The International Partner as Invited Guest: Beyond Colonial and Import-Export Models of Medical Education

The dominant model of international collaboration in medical education, both currently and in the past two centuries, is one of foreign (i.e., Euro-American) ownership and control. In this Invited Commentary, the authors provide a brief selected history of such international partnerships. They then focus on recent partnership models that have alternative structures. One of these is the collaborative partnership between Addis Ababa University (AAU) and the University of Toronto. This partnership is known as the Toronto Addis Ababa Academic Collaboration (TAAAC). From the inception of this partnership, the TAAAC has aimed to be relational and has firmly placed ownership of the codeveloped curriculum at AAU. Other explicit aims of the TAAAC are to help AAU develop culturally appropriate programming that is sustainable with local resources and to develop capacity-building, coteaching models. In seeking potential precedents to the TAAAC, the authors have explored archives in Ethiopia, Canada, and the United Kingdom. They found that invited foreign guests have played a role in the development of educational systems in Ethiopia since the 1940s. The authors believe that by paying close attention to the language used to describe the nature of a relationship, medical educators may be able to move toward more collaborative, capacity-building international partnerships.

Toronto Addis Ababa Academic Collaboration: A Relational, Partnership Model for Building Educational Capacity Between a High- and Low-Income University

Educational partnerships between academic health sciences centers in high- and low-resource settings are often formed as attempts to address health care disparities. In this Perspective, the authors describe the Toronto Addis Ababa Academic Collaboration (TAAAC), an educational partnership between the University of Toronto and Addis Ababa University. The TAAAC model was designed to help address an urgent need for increased university faculty to teach in the massive expansion of universities in Ethiopia. As TAAAC has developed and expanded, faculty at both institutions have recognized that the need to understand contextual factors and to have clarity about funding, ownership, expertise, and control are essential elements of these types of collaborative initiatives. In describing the TAAAC model, the authors aim to contribute to wider conversations and deeper theoretical understandings about these issues.

Stethoscope of the 21st century: dominant discourses of ultrasound in medical education

CONTEXT

In recent years, point-of-care ultrasound (POCUS) has become a widely used clinical tool in a number of clinical specialties. In response, POCUS has been incorporated into medical curricula across the learning continuum, bolstered by enthusiastic appraisals of the technology's benefits for learners, clinicians and patients. In this project, we have sought to identify and understand the effects of dominant discourses influencing the integration of POCUS into medical education.

METHODS

We conducted a Foucauldian critical discourse analysis (CDA) to identify and analyse discourses that legitimise and privilege the use of POCUS in medical education. We assembled an archive of 473 texts published between 1980 and 2017. Each article in the archive was analysed to identify frequently occurring truth statements (expressing concepts whose truths are unquestioned within particular discourses) that we used to characterise the major discourses that construct representations of POCUS in medical education.

RESULTS

We identified three dominant discourses: (i) a visuo-centric discourse prioritising the visual information as truth over other clinical data; (ii) a utilitarian discourse emphasising improvements in patient care; and (iii) a modernist discourse highlighting the current and future needs of clinicians in our technological world. These discourses overlap and converge; the core discursive effect makes the further elevation of POCUS in medical education, and the resulting attenuation of other curricular priorities, appear inevitable.

CONCLUSIONS

The three dominant discourses identified in this paper engender ideal conditions for the proliferation of POCUS in medical education through curricular guidelines, surveys of adherence to these guidelines and authoritative position statements. By identifying and analysing these dominant discourses, we can ask questions that do not take for granted the assumed truths underpinning the discourses, highlight potential pitfalls of proposed curricular changes and ensure these changes truly improve medical education.

Understanding health advocacy in family medicine and psychiatry curricula and practice: A qualitative study

BACKGROUND

We explored understanding and experiences of health advocacy among psychiatry and family medicine residents and faculty and the implications for clinical care and teaching through the lens of relationship-centred care.

METHODS

This qualitative study was conducted in the psychiatry and family medicine departments at a large urban university. We interviewed 19 faculty members and conducted two focus groups with 18 residents. Semi-structured questions explored the relational meaning of health advocacy, how residents and faculty learned about the role and ethical considerations involved in incorporating advocacy work into clinical practice within a relationship-centred care framework.

RESULTS

Four themes emerged from the interviews and focus groups: 1) health advocacy as an extension of the relationship to self; 2) health advocacy and professional boundaries in the physician-patient relationship; 3) health advocacy within a team-based approach; and 4) health advocacy and the physician-community/organization relationship. Participants described implications for practice of the challenges of health advocacy, including perceived institutional risks, professional boundaries and the appropriation of patient voice.

CONCLUSIONS

Our study provides insights into the relational complexities of the health advocate role in residency curriculum and clinical practice. All participants described health advocacy as a broad spectrum of actions that are guided by relationships among patients, health care professionals and communities. Our analysis revealed that some challenges that participants identified with a health advocacy role could be addressed by anchoring the role within a specific theoretical framework. This would better enable us to create a culture of advocacy in the training and development of physicians.

Medical Trainees' Experiences of Treating People With Chronic Pain: A Lost Opportunity for Medical Education

PURPOSE

Evidence suggests that physicians' opinions about patients with chronic pain become progressively negative over the course of medical training, leading to decline in empathy for these patients. Few qualitative studies have focused on this issue, and thus the experiences shaping this process remain unexplored. This study addressed how medical trainees learn about chronic pain management through informal and formal curricula.

METHOD

This study adopted a constructive qualitative approach informed by the theoretical lens of the hidden curriculum. Thirteen open-ended interviews were conducted with medical students and residents at various training stages; interviewees had experience treating patients with chronic pain, shadowing the care of these patients, or both. Interviews elicited information about stage of medical training, general descriptions of work, and concrete experiences of managing patients with chronic pain. All interviews were collected in Toronto between June and August 2015.

RESULTS

Most interviewees described the management of chronic pain as challenging and unrewarding and attributed this at least in part to their perception that pain was subjective. Trainees also recounted that their inability to cure chronic pain left them confused about how to provide care, and voiced a perception that preceptors seemed to view these patients as having little educational value.

CONCLUSIONS

Specifically because chronic pain is subjective and incurable, listening and communication become crucial for patient care. Instead of sheltering trainees, medical educators should be offered the opportunity to reflect on the skills that are required to provide patient-centered care for this population. This approach has the potential to greatly benefit both trainees and patients.

Back from basics: integration of science and practice in medical education

CONTEXT

In 1988, the Edinburgh Declaration challenged medical teachers, curriculum designers and leaders to make an organised effort to change medical education for the better. Among a series of recommendations was a call to integrate training in science and clinical practice across a breadth of clinical contexts. The aim was to create physicians who could serve the needs of all people and provide care in a multitude of contexts. In the years since, in the numerous efforts towards integration, new models of curricula have been proposed and implemented with varying levels of success.

SCOPE OF REVIEW

In this paper, we examine the evolution of curricular integration since the Edinburgh Declaration, and discuss theoretical advances and practical solutions. In doing so, we draw on recent consensus reports on the state of medical education, emblematic initiatives reported in the literature, and developments in education theory pertinent to the role of integrated curricula.

CONCLUSIONS

Interest in integration persists despite 30 years of efforts to respond to the Edinburgh Declaration. We argue, however, that a critical shift has taken place with respect to the conception of integration, whereby empirical models support a view of integration as pertaining to both cognitive activity and curricular structure. In addition, we describe a broader definition of 'basic science' relevant to clinical practice that encompasses social and behavioural sciences, as well as knowledge derived from biomedical science.

Taking presentations seriously: Invoking narrative craft in academic talks

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Ultrasound in undergraduate medical education: a systematic and critical review

CONTEXT

The use of point-of-care ultrasound (POCUS) in clinical care is growing rapidly and advocates have recently proposed the integration of ultrasound into undergraduate medical education (UME). The evidentiary basis for this integration has not been evaluated critically or systematically.

OBJECTIVES

We conducted a critical and systematic review framed by the rationales enumerated in academic publications by advocates of ultrasound in UME.

METHODS

This research was conducted in two phases. First, the dominant discursive rationales for the integration of ultrasound in UME were identified from an archive of 403 academic publications using techniques from Foucauldian critical discourse analysis (CDA). We then sought empirical evidence in support of these rationales, using a critical synthesis methodology also adapted from CDA.

RESULTS

We identified four dominant discursive rationales with different levels of evidentiary support. The use of ultrasound was not demonstrated to improve students' understanding of anatomy. The benefit of ultrasound in teaching physical examination was inconsistent and rests on minimal evidence. With POCUS, students' diagnostic accuracy was improved for certain pathologies, but findings were inconsistent for others. Finally, the rationale that ultrasound training in UME will improve the quality of patient care was difficult to evaluate.

CONCLUSIONS

Our analysis has shown that the frequently repeated rationales for the integration of ultrasound in UME are not supported by a sufficient base of empirical research. The repetition of these dominant discursive rationales in academic publications legitimises them and may preclude further primary research. As the value of clinical ultrasound use by medical students remains unproven, educators must consider whether the associated financial and temporal costs are justified or whether more research is required.

Posterior urethral valves: Metabolic consequences in a cohort of patients

BACKGROUND

Despite the improvements in diagnosis and management of posterior urethral valves (PUVs), about one third of patients develop chronic kidney disease (CKD). Children with PUVs might have abnormal calcium, phosphorus, vitamin D and parathyroid hormone levels, which could affect their bone growth and overall health.

OBJECTIVE

The aim was to determine the relationship between kidney function, vitamin D deficiency and secondary hyperparathyroidism in children with PUVs.

PATIENTS AND METHODS

Sixty-four children with PUVs were followed for a period of 3.64 ± 2.50 years after their initial presentation and management. Their laboratory parameters were compared with 20 age-, gender- and race-matched children in a control group, including: serum calcium, phosphorus, intact parathyroid hormone (iPTH), 25-hydroxyvitamin D levels, and kidney function.

RESULTS

Children with PUVs had significantly lower estimated kidney function (P = 0.006) and vitamin D levels (P < 0.001) and higher iPTH levels (P = 0.042). There were no significant between-group differences in serum calcium, phosphorus, alkaline phosphatase, sodium, potassium, and bicarbonate levels. There was a strong correlation between the degree of vitamin D deficiency and hyperparathyroidism and the degree of kidney dysfunction (r = 0.52 and -0.52, respectively) in the PUV group. On a multivariate analysis, the kidney dysfunction was the only independent predictor of vitamin D deficiency (ρ = 0.271, P < 0.001), while kidney dysfunction, serum calcium and alkaline phosphatase were independent predictors for hyperparathyroidism (ρ = 0.925, P<0.001, ρ = 0.933, P<0.001 and ρ = 0.913, P < 0.001, respectively).

DISCUSSION

The prevalence of CKD in children with PUVs ranges from 30 to 60%. Patients with CKD are more likely to have vitamin D deficiency and display more-prominent hyperparathyroidism. Compared with a control group with normal kidney function, the present cohort had lower 25-hydroxyvitamin D and higher iPTH serum levels. Abnormal kidney function was a major predictor for both serum levels. In this cohort, there were no significant differences in serum calcium and phosphorus between children with PUVs and the control group, and also between those with and without CKD. On the contrary, vitamin D level decreased early in the disease and progressively declined thereafter, while iPTH was the opposite. These findings were comparable to previous studies. This study had some limitations because it was a single center cross-sectional non-randomized study. However, the findings in this study can be extrapolated to children with PUVs and CKD from other origins because the unit is considered as a referral center in the Middle East region.

CONCLUSION

Abnormal kidney function, vitamin D deficiency, and secondary hyperparathyroidism are prevalent in children with PUVs. Kidney function is the main determinant of vitamin D and parathyroid hormone levels. Efforts should be directed toward managing CKD, and controlling vitamin D deficiency and hyperparathyroidism in children after ablation of PUV.

A scoping review of medical education research in family medicine

BACKGROUND

Little is known about the state of education research within family medicine. As family medicine education models develop, it is important to develop an understanding of the current state of this research and develop ways to advance the field.

METHODS

We conducted a scoping review of family medicine education research to describe 1) research topic areas and 2) the methodologies and methods used to study these topics. MEDLINE, Social Sciences Abstracts and ERIC electronic databases were searched. 817 full text articles from 2002 to 2012 were screened; 624 articles were included in the review.

RESULTS

The following research topic areas were identified: continuing education, curriculum development, undergraduate education, teaching methods, assessment techniques, selection of entrants, non-clinical skills, professional and faculty development, clinical decision-making and resident well-being. Quantitative studies comprised the large majority of research approaches; overall minimal methodological details were provided.

CONCLUSIONS

Our review highlights an overall need for increased sophisticated in methodological approaches to education research in family medicine, a problem that could be ameliorated by multiple strategies including better engagement of methodologists throughout the research process. The results provide guidance for future family medicine education research programs.