Adoption of Problem-Based Learning in Medical Schools in Non-Western Countries: A Systematic Review

Phenomenon: In recent decades, medical education practices developed in Western countries have been widely adopted in non-Western countries. Problem-based Learning (PBL) was first developed in North America and it relies on Western educational and cultural values, thereby raising concerns about its 'lift and shift' to non-Western settings. Approach: This review systematically identified and interpretively synthesized studies on students' and teachers' experiences of PBL in non-Western medical schools. Three databases (ERIC, PsycINFO, and MEDLINE) were searched. Forty-one articles were assessed for quality using the Critical Appraisal Skills Program (CASP) checklist and synthesized using meta-ethnography. The final synthesis represented over 5,400 participants from 18 countries. Findings: Findings were categorized into three different constructs: Student Engagement, Tutor Skills, and Organization and Planning. Our synthesis demonstrates that medical students and teachers in non-Western countries have varied experiences of PBL. Students engage variably with PBL, consider knowledge to be better acquired from authoritative figures, and deem PBL to be ineffective for assessment preparation. Student participation is limited by linguistic challenges when they are not native English speakers. Teachers are often unfamiliar with the underlying philosophical assumptions of PBL and struggle with the facilitation style needed. Both students and teachers have developed modifications to ensure that PBL better fits in their local settings. Insights: Given the significant adjustments and resource requirements needed to adopt PBL, medical school leaders and policy makers in non-Western countries should carefully consider possible consequences of its implementation for their students and teachers, and proactively consider ways to 'hybridize' it for local contexts.

#Anatomynotes: A temporal content analysis of anatomy education posts on Instagram

Social media platforms such as Instagram are becoming increasingly popular sources for students to access anatomy educational resources. This review used content analysis to examine posts under the hashtag #anatomynotes and is the first to map the characteristics of anatomy education posts on Instagram and determine any temporal changes. Sample posts were gathered from April 2019 and April 2021 and categorized according to the technical format, purpose and author credentials. Engagement was recorded in the form of likes and comments. Overall, posts depicting illustrations remained the most popular format within both time periods. Three-dimensional models saw an increase in popularity with a 62.5% rise. Students remained the most common author type throughout and increased further in 2021 by 25%. Clinician authors and posts focusing on clinical education also increased in 2021 by 17.9% and 227%, respectively. Humor-based posts saw the greatest increase among the post purposes, with 1000% more recorded in 2021. Engagement overall saw a decline with notably significant reductions in average likes per post among all text-based posts (-72%, p < 0.0001), all illustrative posts (-51%, p = 0.0013), and a decline in the presence of comments among all text-based posts (-65.1%, p = 0.0158). These findings highlight that Instagram is a popular platform for facilitating near-peer teaching while increasingly providing a space where students and clinicians can interact. Additionally, it highlights the benefits of the platform for visually focused learners. However, future research should seek to determine whether Instagram can facilitate deeper learning and have an impact on academic and clinical performance.

Fit for purpose: Ensuring robust, contextually appropriate global accreditation practices

The authors comment on the need for research to account for how political and power dynamics are embedded in accreditation systems to explore their unintended consequences.

The art of reinvention: The remarkable longevity of the OSCE

This commentary delves into the theatre and performances of OSCEs. Join us in exploring their 50‐year journey of reinvention and how they continue to hold the stage in medical assessments.

Moving Together, Apart: Impacts of Travel Restrictions on a UK-Egypt Collaboration in Health Profession Education

Objective

University College London (UCL) and Newgiza University (NGU) have been in an academic collaboration since 2016 to establish undergraduate healthcare programmes in Egypt with an underlying ethos of capacity building and co-development. We explored impacts of pandemic-related travel restrictions on staff across both organisations.

Methods

We conducted 30 semi-structured interviews with academic and professional services staff from UCL and NGU schools of medicine, dentistry, and pharmacy. Data were jointly coded using reflexive thematic analysis and categorised according to the American Council on Education's Comprehensive Internationalisation Framework.

Results

Nine themes were identified, which related to each of the six components of the framework. In addition to mobility, participants' experiences also spread across the other five components (institutional commitment, leadership, curriculum, faculty support, and partnerships). Successful adaptations were made and staff felt able to 'keep the show on the road'. However, staff remained keen to keep in-person engagement a priority when possible, especially for quality management site visits.

Conclusions

Travel restrictions can have widespread impacts on all aspects of international collaborations. In this well-established relationship, there was sufficient resilience to withstand these impacts and, many positive unintended consequences emerged. A hybrid engagement model should be prioritised in future partnerships.

Examining the WFME Recognition Programme at 10 years

BACKGROUND

In 2012, the World Federation for Medical Education (WFME) evaluated and formally recognized the first agency in its Recognition Programme (RP). The RP was developed to review accrediting authorities in response to a 2010 policy by the Educational Commission for Foreign Medical Graduates (ECFMG) to require international medical graduates (IMGs) seeking to practice in the U.S. to graduate from an appropriately accredited medical school. By the end of 2022, WFME had recognized 33 accrediting bodies and received applications from another 16, which accounted for over three-quarters of the world's medical schools. In 2023, WFME leadership changed hands, and the ECFMG will take its first steps toward implementing its Recognized Accreditation Policy.

APPROACH

In this article, we look back at the genesis of the RP and describe its first decade as informed by the limited existing peer-reviewed literature and the emerging activities of accrediting agencies that could have significant implications for the quality of medical education internationally.

CONCLUSIONS

The rapidly growing influence of WFME on medical education worldwide has largely occurred without significant awareness or scrutiny, and there is a need for the WFME to demonstrate greater transparency, proactively engage its stakeholders, and support research and evaluation.

Reconsidering a Global Agency for Medical Education: Back to the Drawing Board?

Issue: The World Federation for Medical Education (WFME) was established in 1972 and in the five decades that followed, has been the de facto global agency for medical education. Despite this apparently formidable remit, it has received little analysis in the academic literature. Evidence: In this article, we examine the historical context at the time WFME was established and summarize the key decisions it has taken in its history to date, highlighting particularly how it has adopted positions and programmes that have seemingly given precedence to the values and priorities of countries in the Global North. In doing so, we challenge the inevitability of the path that it has taken and consider other possible avenues that such a global agency in medical education could have taken, including to advocate for, and to develop policies that would support countries in the Global South. Implications: This article proposes a more democratic and equitable means by which a global organization for medical education might choose its priority areas, and a more inclusive method by which it could engage the medical education community worldwide. It concludes by hypothesizing about the future of global representation and priority-setting, and outlines a series of principles that could form the basis for a reimagined agency that would have the potential to become a force for empowerment and global justice in medical education.

Implementation of virtual OSCE in health professions education: A systematic review

INTRODUCTION

The Objective Structured Clinical Examination (OSCE) has been widely used in health professions education since the 1970s. The global disruption caused by the COVID-19 pandemic restricted in-person assessments and medical educators globally sought alternative means to assess and certify students and trainees to meet the acute demand for health-care workers. One such solution was through virtual OSCE (vOSCE), which modified traditional in-person OSCE using videoconference platforms. This meta-ethnography sought to synthesise qualitative literature on candidates' and assessors' experiences of vOSCE to evaluate whether it may have a role in future assessment practices.

METHODS

In June 2022, we systematically searched PsycINFO, Medline and ERIC for peer-reviewed qualitative and mixed-methods articles that described candidates' and assessors' experiences of virtual OSCE in health professions education. Of 1069 articles identified, 17 were synthesised using meta-ethnography.

RESULTS

The final synthesis represented 1190 candidates and assessors from faculties of medicine, dentistry, nursing, pharmacy and osteopathy. We developed our findings into four key concepts. 'Strengthening confidence in a virtual environment' highlighted attempts to overcome and mitigate concerns associated with transitioning from in-person to virtual assessment. 'Understanding the scope of use as an assessment' reflected on the suitability of vOSCE in assessing various skills. 'Refining operational processes' emphasised the technical challenges of implementing vOSCE and impacts on accessibility and resources. 'Envisioning its future role' considered the applicability of vOSCE in the climate of rapid development in telehealth.

CONCLUSION

This meta-ethnography highlighted that although vOSCE was primarily considered a temporary and crisis response, candidates and assessors recognised positive, as well as negative, consequences of the transition towards them. Moving forward, medical education policymakers should carefully consider the extent to which elements of vOSCE could be incorporated into assessment systems, particularly in light of the rise of telehealth in clinical practice.

Enhancing family medicine training to build capacity in Pakistan: a call for action

A high-performing, integrated, primary healthcare system is essential to achieve universal health coverage (UHC) goals and improve health indicators. There is enough evidence that healthcare is cost-effective with significantly better outcomes in countries where primary care is delivered through trained family physicians. The concept of "Family Practice approach" is relatively new in developing countries like Pakistan, where majority of basic healthcare is provided by doctors without a formal postgraduate training. The intention to adopt this approach in primary care has increased in recent years in an effort to attain UHC, yet implementation requires a paradigm shift with intervention at multiple levels. There is an opportunity to learn from better developed primary care models for example in UK and Australia to develop a pragmatic and collaborative approach to develop the specialty of family medicine in primary care. This calls for academic interventions at multiple levels, such as mandating family medicine inclusion in undergraduate medical curricula, and ensuring quality of postgraduate training by investment in developing primary care sites for training, curricula, assessment, and quality assurance structures. Encouraging medical students and general practitioners to pursue a post graduate qualification in family medicine would also require promoting family medicine as a worthwhile career and developing a higher esteem for qualified family physicians than the conventional GPs in public and private sector healthcare institutions. These interventions would help evolution of locally grounded solutions to improve the quality of primary care, hence the health outcomes of the larger population of Pakistan.

Is West Really Best? The Discourse of Modernisation in Global Medical School Regulation Policy

Phenomenon: In 2012, the World Federation for Medical Education (WFME) established a recognition programme to evaluate medical school regulatory agencies across the world, in response to a new U.S. accreditation policy. Given the predominantly Western origins and Eastern impacts of the WFME programme, this article deconstructs tensions in the programme using postcolonial theory. Approach: Critical discourse analysis examines the intersections of language, knowledge, and power relations to highlight what can or cannot be said about a topic. We employed it to delineate the dominant discourse underpinning the WFME recognition programme. We drew on the theoretical devices of Edward Said, whose work is foundational in postcolonial thinking but has not been widely used in medical education scholarship to date. An archive of literature about the WFME recognition programme dating back to 2003, when WFME first released global standards for medical education, was analyzed. Findings: In the globalization of medical school regulation, the discourse of modernization can be conceptualized as a means of holding knowledge and power in the West, and enacting this power on those in the East, playing on fears of marginalization in the event of non-engagement. The discourse allows these practices to be presented in an honorable and heroic way. Insights: By uncovering the representation of the WFME recognition programme as being modern and modernizing, this article explores how such conceptualisations can close off debate and scrutiny, and proposes further examination of this programme through a lens that recognizes the inherent inequities and geopolitical power differentials that it operates within.

How should we do equity, diversity and inclusion work in health professions education?

This is an editorial for the special collection on equity, diversity and inclusion (EDI) for MedEdPublish. In this article, the guest advisors of this collection first reflect on the paradoxes in EDI in health professions education (HPE), then on the importance of recognising the existence of multiple authenticities on the basis of different contexts and settings, and finally encourage authors and readers to reflect on their position on the continuum of EDI work. They conclude the editorial by outlining the direction they wish to set for articles in the collection.

Respect and reflexivity: international education partnerships in primary care

The UK general practice model has been described as the 'jewel in the crown' of the National Health Service and is widely respected and emulated around the world. In recent years, there has been a particular interest in the UK approach to primary care medical education, including at undergraduate and postgraduate levels, leading to a number of international education partnerships designed to draw on the best of UK experience and expertise in this area. Drawing on the limited academic literature in this area, and the authors' personal experiences of working across many international partnership projects with countries around the world, this article reflects on the central importance of respect and reflexivity when engaging in such work. A respectful approach relies on a genuine and deep curiosity for the local context, and a desire to empower partners to build their own solutions that are contextually authentic. A reflexive approach, meanwhile, relies on those engaging in partnerships to understand themselves as 'invited guests' and to remain mindful of current and historical power differentials and inequities when framing their engagement, looking both inwardly and outwardly as they conduct themselves. As primary care education around the world develops and expands, there may be a greater role for international partnerships and it is critically important that those engaging in such partnerships bring a thoughtful and scholarly lens to this work.

Editing the editors: Aims and priorities of health professions education journals

PURPOSE

Although health professions education (HPE) scholarship has flourished in recent decades, the influence of HPE journals has received little attention. This study examines the editorial policies and priorities of leading HPE journals.

METHODS

Fourteen HPE journals with the highest impact factors were reviewed for their editorial aims, scope, intended readership, and priority topic areas. Text from journal websites was coded using thematic analysis.

RESULTS

10/14 HPE journals included in this study were linked to regional or national education societies. Two focussed predominantly on medicine, one on dentistry, one on nursing, one on nutrition, and the remaining nine on general HPE. Although journals differed in their projected aims and proposed readerships, four overarching editorial themes were identified: (1) methodological and theoretical rigor; (2) impact on practice; (3) global relevance; (4) advancing knowledge.

CONCLUSIONS

Leading HPE journals share a number of priority areas and principles, implying some cohesion and consensus amongst the HPE scholarly community. These journals prioritise impact at the level of individual practitioners. Given the importance of policy level change in the development and reform of HPE around the world, the relative lack of focus on policy impact in HPE journals is worthy of further exploration.

Altruism or nationalism? Exploring global discourses of medical school regulation

BACKGROUND

Although medical school regulation is ubiquitous, the extent to which it should be based on global principles is unclear. In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) announced that from 2023, overseas doctors would only be eligible for certification to practise in the United States if they had graduated from a medical school that was accredited by a 'recognised' agency. This policy empowered the World Federation for Medical Education (WFME) to create a recognition programme for regulatory agencies around the world, despite a lack of empirical evidence to support medical school regulation.

METHODS

This study employs critical discourse analysis, drawing on the theoretical perspectives of Michel Foucault and Edward Said, to identify discourses that enabled this 'globalising' policy decision to take place. The dataset includes a series of 250 documents gathered around three key events: the Edinburgh declaration by WFME in 1988, the first set of global standards for medical schools by WFME in 2003 and the ECFMG ruling about medical school accreditation in 2010.

FINDINGS

Two discourses, endorsement and modernisation, were dominant throughout this entire period and framed the move to globalise medical school regulation in terms of altruism and improving medical education worldwide. A discourse of resistance was present in the earlier period of this study but faded away as WFME aligned itself with ECFMG after 2010. Two further discourses, protection and control, emerged in the later period of this study and framed the ECFMG ruling in terms of nationalism and protecting American interests.

DISCUSSION

This study proposes a new conceptualisation of the relationship between ECFMG and WFME in light of the apparently contradictory policy motivations of altruism and nationalism. It goes on to consider the implications of this association for the legitimacy of WFME as an organisation that represents all of the world's medical schools.

English Language Medical Schools in China: An Analysis of International Medical Graduates Practicing in the UK

OBJECTIVES

From 2006, the Ministry of Education in China has approved universities to provide undergraduate medical training in English, targeting fee-paying international students. Students on these courses can face challenges in their clinical training, particularly in the domains of communication and professionalism. This study examines the proportion of doctors qualified from such medical schools who are currently listed on the UK medical register.

METHODS

The UK General Medical Council register of medical practitioners was searched to identify doctors qualified from 33 Chinese medical schools who provide education in the English language.

RESULTS

As of February 2022, 502 doctors whose primary medical qualification is from a university offering English language education in China were registered on the UK medical register. Four hundred twenty-five (84.7%) of these doctors were aged 39 and under, approximately double the proportion of doctors in this age bracket overall. Three hundred forty nine (69.5%) were staff grade and associate specialist doctors, 109 (21.7%) were doctors in training, 36 (7.2%) were on the General Practitioner (GP) register, and 20 (4.0%) were on the specialist register. Among doctors in training, the most common specialty areas were in general practice and psychiatry that are both facing recruitment shortages in the UK at present.

CONCLUSION

A small but significant number of graduates whose medical training was in the English language in China are practicing medicine in the UK. These doctors are in younger age groups than the overall medical workforce, and are less likely to be in training, and specialist or GP posts. Among those in training, a high proportion are in GP and psychiatry training and could contribute to alleviating UK medical workforce shortages. Policymakers and educators should be mindful of the growing numbers of doctors qualified from these schools, and the additional support they may require considering the unique training environments they have encountered.

Breaking Boundaries: Interdisciplinary Workshops to Write Integrated Medical School Assessments

Although integrated medical school curricula have been widely adopted and examined, there has been comparatively less attention on the challenges associated with developing integrated assessments. Working with medical schools around the world, we have developed a writing workshop format that unites teachers from different disciplines to produce integrated assessment items.

Hyperglobalist, sceptical, and transformationalist perspectives on globalization in medical education

PURPOSE

Globalisation has been hotly debated in recent decades and has seemingly had a profound impact on medical education. This review synthesises the medical education literature using key perspectives from globalisation theory by Holton (Making globalisation).

METHODS

Holton (Making globalisation) recognised three key perspectives in globalisation theory-hyperglobalist, sceptical, and transformationalist. This article critically reviews the literature on globalisation in the field of medical education using this theoretical framework.

RESULTS

Hyperglobalist and sceptical perspectives dominated early periods of medical education literature on globalisation, projecting it either as a mainly positive or mainly negative force, respectively. Most forecasts grounded in these perspectives have not materialised in medical education policy and practice. Since 2010, the volume of scholarship about globalisation has increased and has been predominantly transformationalist in perspective, recognising a reality that has both positive and negative consequences.

CONCLUSIONS

The medical education literature has mirrored the broader social science literature, in moving over time from hyperglobalist and sceptical positions, towards a 'third wave' of globalisation thinking that is transformationalist. Medical education practitioners and policymakers should be mindful of these perspectives and trends as they navigate the opportunities and challenges presented by globalisation.

Sharing is caring: an analysis of #FOAMed Twitter posts during the COVID-19 pandemic

PURPOSE

Free Open Access Medical Education (FOAMed) is a worldwide social media movement designed to accelerate and democratise the sharing of medical knowledge. This study sought to investigate the content shared through FOAMed during the emerging COVID-19 pandemic.

STUDY DESIGN

Tweets containing the #FOAMed hashtag posted during a 24-hour period in April 2020 were studied. Included tweets were analysed using the Wiig knowledge management cycle framework (building knowledge, holding knowledge, pooling knowledge and using knowledge).

RESULTS

1379 tweets contained the #FOAMed hashtag, of which 265 met the inclusion criteria and were included in the analysis. Included tweets were posted from 208 distinct users, originated from each world continent and were in five different languages. Three overarching themes were identified: (1) signposting and appraising evidence and guidelines; (2) sharing specialist and technical advice; and (3) personal and social engagement. Among 12 subthemes within these groupings, 11 aligned to one of the four dimensions of the Wiig knowledge management cycle framework, and the other focused on building and managing social networks. Almost 40% of tweets related directly to COVID-19.

CONCLUSION

#FOAMed tweets during the COVID-19 pandemic included a broad range of resources, advice and support. Despite the geographical, language and disciplinary variation of contributing users and the lack of organisational structure uniting them, this social media medical community has been able to construct, share and use emerging technical knowledge through a time of extraordinary challenge and uncertainty for the global medical community.

Understanding impacts of accreditation on medical teachers and students: A systematic review and meta-ethnography

PURPOSE

Accreditation is widely used by medical schools around the word to evaluate their curricula and educational processes, although its impacts on those involved in the 'frontline' of medical education receive little attention. This study systematically identified and synthesised qualitative studies that have explored medical teachers' and students' experiences of accreditation.

METHODS

Four databases (Pubmed, EMBASE, ERIC, and PsychINFO) were searched for relevant published articles. Synthesis was performed using meta-ethnography.

RESULTS

Eighteen articles were included in the final synthesis with 1017 individual participants from 10 countries. Findings were categorised into four domains, including navigating power differentials, evaluating credibility, influencing medical programmes, and culture and behaviour. The synthesis demonstrates divergent views on the value of accreditation in medical schools from students and staff including both positive and negative impacts on medical education programmes and stakeholders.

CONCLUSIONS

Although accreditation is perceived to have many benefits, it also has a number of unintended consequences, including on staff morale, student-teacher relationships, and teacher workloads. Medical teachers also have a number of concerns about the credibility of accreditation standards, assessors, and processes. Regulators and policymakers should consider the views of teachers and students as they seek to improve current accreditation practices.

For Students, by Students: a Peer-Led Entrepreneurship Course for Medical Students

Recognising the growing importance of clinical leadership and entrepreneurship to implement innovative healthcare solutions, final year UK medical students developed a near-peer elective module for first- and second-year students. To date, five cohorts have completed the module and developed skills in the fields of medical technology, quality improvement, and leadership.

Analysis of Preparatory Courses for the Practical Component of the PLAB Exam for International Medical Graduates in the UK

BACKGROUND

Medical workforce shortages are a major threat to the future of the UK National Health Service (NHS) and countless other healthcare systems globally. Reliance on international medical graduates is likely to continue and may increase, although these doctors face many educational and professional challenges. The Professional and Linguistic Assessment Board (PLAB) test, delivered by the General Medical Council (GMC), is the "gateway" exam that doctors must pass through in order to practice in the UK. Despite the central importance of this exam, no official or accredited training courses are provided or approved by the GMC.

METHODS

This study used online and social media searches to identify and categorise preparatory courses available for the practical (clinical) component of the PLAB assessment.

RESULTS

A total of 13 courses were identified, delivered predominantly in the cities of Manchester and London, ranging from 1 to 28 days in duration and from £24.99 to £649.99 in cost. Most courses were organised by previous PLAB candidates and websites focussed on testimonials from previous participants rather than educational credentials or professional clinical experience of teachers running the courses. Courses were all provided by private education companies, and none were delivered by universities or National Health Service organisations.

DISCUSSION

A variety of preparatory services and courses exist for the PLAB assessment, although the public information about them is variable and limited. Further research is required to examine the quality of these courses and the potential for alternative avenues of training for international medical graduates preparing to practice in the UK.

What Will It Mean for Me? Perceptions of the ECFMG 2023 Accreditation Requirement from an Online Forum

In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) announced that as of 2023, physicians applying to train and practice in the United States will be required to graduate from a medical school that has been accredited using criteria such as those developed by the World Federation for Medical Education. This study analyzed posts on the Student Doctor Network (SDN) online forum that refer to this accreditation requirement to investigate how it has been perceived and understood by current and prospective medical students. A keyword search of relevant terms was used to identify posts discussing the accreditation requirement on the SDN online forum, which were subjected to thematic analysis. There were a total of 83 posts from 49 distinct user accounts between May 2012 and January 2020. Seven themes were identified in total; four whose overall purpose was to seek or offer advice and three whose overall purpose was commentary. Themes relating to advice included applications and admissions, future career planning, personal circumstances, and countryspecific issues. Themes relating to commentary included the accreditation requirement policy itself, the potential implications of the requirement, and the educational quality of non-U.S. medical schools. Only half of web links on these posts were to the ECFMG website for official information about the requirement. Although a variety of different perspectives about the ECFMG accreditation requirement were expressed on an online forum for student doctors, the overall number of posts was low, which suggests that the requirement has not been a frequent topic of discussion on this platform. The insights gained from posts suggest personal opinions about the requirement and consequences for individual student application and career choices were the main areas of interest. Signposting to official information channels may help to raise awareness about the requirement and tackle areas of uncertainty and confusion about its implementation.

Public availability of information from WFME-recognized accreditation agencies

The World Federation for Medical Education (WFME) Recognition Programme was created to ensure the comparability of medical school accrediting agencies, so that the schools accredited by those agencies would have similar educational quality. WFME explicitly values transparency and has recognition criteria that relate to agencies making information publicly available. Our study examined 20 WFME-recognized agencies' transparency by reviewing agency websites for 27 information elements related to accreditation standards, procedures, and processes. We contacted agencies as needed for information that we could not find on their websites. We were only able to retrieve additional information from 3 of the 12 agencies that we attempted to contact. We found that while 12 agencies had over 90% of expected information elements available, 6 agencies had less than 50%. Our findings illustrate barriers for those who wish to better understand medical school accreditation in some regions and raise questions about how comparable WFME-recognized agencies are.

Editorial diversity in medical education journals

BACKGROUND

In recent years, the field of medical education has sought to amplify the voices of those from traditionally marginalised groups and medical education journals have sought to become more accessible and diverse. This study sought to examine the gender and geographical representation of editors and editorial board members in medical education journals.

METHODS

Information about individual editors and editorial board members of 10 medical education journals was retrieved from their websites in January 2021, including their gender and the country in which they were based. Countries were categorised according to World Bank Income Classification and World Bank Geographical Regions. We then calculated the Composite Editorial Board Diversity Score for each journal.

FINDINGS

Of 488 editors and editorial board members, 283 (58.0%) were male, 452 (92.6%) were based in high-income countries and 322 (66.0%) were from the four countries with greatest representation (the United States, the United Kingdom, Australia and Canada).

DISCUSSION

The composition of medical education journals' editorial leadership teams remains dominated by males and those from higher income and Western countries. Strikingly, little change has taken place since this was last examined 17 years ago despite the field becoming apparently more globalised. As medical education strives to become a more inclusive and diverse discipline, developing policies to create more globally representative editorial leadership teams should now be an urgent priority.

"Doctor, teacher, translator:" International medical students' experiences of clinical teaching on an English language undergraduate medical course in China

Background

Like many Chinese universities, Ningbo University (NBU) has two undergraduate medical courses - one taught in Mandarin for domestic students, and one taught in English for international students. This study examines the experiences of medical students who recently completed the English language program that has a particular focus on clinical placements.

Methods

In-depth, face-to-face, semi-structured interviews were conducted with 10 final year medical students at NBU in April 2019. Transcripts were analyzed using inductive thematic analysis.

Results

All medical student participants were non native English speakers and had a limited grasp of Chinese. Their clinical teachers were all fluent in Chinese and had variable command of English. The large majority of patients in the teaching hospitals where placements took place spoke only in Chinese. Despite the obvious challenges arising from this, students still had predominantly positive experiences of clinical placements. Although students recognized that their clinical teachers' English proficiency was variable, they felt that other attributes, such as enthusiasm, interactivity, and a desire to teach were more important factors to their learning experiences.

Discussion

Despite challenging linguistic circumstances, non native English-speaking students were able to navigate the challenges of studying clinical medicine from teachers with limited English language skills and with patients who spoke virtually no English. Further studies should explore the perceptions of teachers of the program, and graduate outcomes when these students enter the workplace. Educators involved in supporting international medical students should note that non technical curricular areas such as professionalism may require greater attention where language barriers exist.

Efficacy of F-75 & F-100 Recipes in theTreatment of Severe Acute Malnutrition: A Randomized Controlled Trial

Severe malnutrition is an important cause of death in children. According to new WHO-growth chart 2006, the proportion of children with severe wasting is 3.1% thus the total number being 4, 65000 (BDHS 2014). Overall risk of death among children with severe acute malnutrition (SAM) is 9 times more than well nourished children. The death rate among hospitalized children of SAM was as high as 15%. Once properly treated, severely malnourished children would grow up leading a normal life. Severe malnutrition in children can be successfully treated by using WHO guidelines that have been shown to be feasible and sustainable even in small district hospital with limited resources. A randomized controlled trial was conducted at department of Pediatrics, Dhaka Medical College Hospital, Dhaka, Bangladesh from July 2014 to September 2015. The trial enrolled 92 SAM patients (46 cases + 46 controls) aged 06 months to 59 months of either sex who meet the inclusion criteria consecutively. Enrolled children were randomized by lottery method into two groups, Group I and Group II. Patients in Group I was treated with F-75 and F-100 recipes and managed in two phases, initial stabilization phase with F-75 recipes then subsequently rehabilitation phase by F-100 recipes. Patients in Group II was treated with prepackaged F-75 & F-100 formulae and feeding was given in two phases i.e. initial stabilization phase and subsequently rehabilitation phase according to national guidelines for the management of severe malnourished children. Then play therapy was given for half an hour daily with red colored toy in Ashic play centre Dhaka Medical College Hospital for patients of both groups. The time (days) taken to return of appetite (mean±SD) was 5.1±1.16 and 4.8±1.34 in Group I and Group II respectively, disappearance of edema (mean±SD) 4.8±1.53 in and 4.9±1.05 for Group I Group II respectively, to gain target weight (mean±SD) 13.8±2.20 days and 13.5±1.74 days in Group I and Group II respectively, rate of weight gain (mean±SD) 17.70±7.07gm/kg/day for Group I and 16.20±4.63gm/kg/day for Group II. The side effects, diarrhea was equal in both group, vomiting was more in Group II, combined diarrhea and vomiting was more in Group I but the differences were not statistically significant. The treatment cost (mean±SD) was higher in Group II (97.2±78.24 BDT/child/day) than in Group I (58.5±54.36 BDT/child/day). Return of appetite and disappearance of oedema and target weight gain were similar in both groups but treatment cost was higher in Group II than Group I, which was statistically significant.

Comparison of Ultrasonogram of Brain Findings of Asphyxiated and Non-Asphyxiated Baby Admitted in Neonatal Ward in a Tertiary Level Hospital

Perinatal asphyxia is a major cause of neonatal mortality and morbidity in developing countries. A significant portion of patient with perinatal asphyxia is admitted with complications. Cerebral complications are the most devastating and the child may be left with lifelong neurological impairment. Therefore, the high index of suspicion, prompt recognition and thorough understanding of common sonographic abnormalities are necessary to ensure timely intervention, management and counseling. A hospital based case control study was conducted in the neonatal unit of Mymensingh Medical College Hospital, Mymensingh, Bangladesh. Study period was six months (June 2012 to December 2012). This study was done to compare the ultra sonogram of brain findings of admitted asphyxiated babies with admitted non-asphyxiated babies. A total of 30 asphyxiated (case) and another 30 non-asphyxiated (control) neonate of this department were enrolled in the study. Necessary information was collected by taking detailed history, clinical examination and also close follow up of the neonates according to pre-designed questionnaire. The main outcome variable was abnormality in cranial ultrasound. Among case group (30 neonates), ultrasonogram of brain findings were abnormal in 9(30.0%) cases. Among them most common was ventricular dilatation 5(16.6%), followed by Intraventricular hemorrhage (IVH) 1(3.0%), intracranial hemorrhage 1(3.0%), HIE 1(3.0%) and cerebral edema in 1(3.0%) cases. On the contrarary, among asphyxiated control group all 30 cases had normal ultra sonogram of brain. In case group 22 babies had normal birth weight and 08 had low birth weight. Among the 22 normal birth weight neonates in case group total 6(27.2%) cases had abnormal ultra sonogram findings. Among normal birth weight cases 3(13.6%) had ventricular dilatation, 1(4.5%) Intracranial hemorrhage (ICH), 1(4.5%) HIE, 1(4.5%) cerebral edema. Among 08 low birth weight neonates in case group total 3(37.5%) cases had abnormal ultrasonogram of brain finding. Among low birth weight cases 2(25%) had ventricular dilatation, 1(12.5%) IVH. Ultrasonogram brain findings difference between two groups was statistically significant. Abnormal findings were also common in low birth weight babies than normal birth weight babies. So, early detection of abnormal brain changes can help us for proper management and counseling.

Diagnostic Performance of RBC Indices in Beta Thalassaemia Trait

Beta thalassaemia trait is one of the most common forms of thalassaemia in Bangladesh. This clinical entity usually remains undiagnosed because they present with mild anaemia or sometimes no anaemia. Determination of trait is the mainstay of prevention of thalassaemia. RBC indices can provide valuable diagnostic tool for beta thalassaemia trait. This was a hospital based cross-sectional, analytical study, done at Department of Paediatrics, Rangpur Medical College Hospital, Rangpur, Bangladesh from July 2014 to June 2016. A total of 150 anaemic children, aged 1-15 years from inpatient and outpatient department were included by purposive sampling. Blood samples were collected and sent to the Department of Biochemistry, Rangpur Medical College to determine the value of RBC indices. Out of 150 anaemic children 37(24.66%) children were diagnosed as E-trait, 9(9%) E-disease 6(4%) as E-Beta thalassaemia, 1(0.66%) had error in the report, a total of 53 children were excluded from the study. Finally, 32(21.3%) children, diagnosed as beta thalassaemia trait and 65(43.33%) children, diagnosed as normal Hb variant, so a total of 97 children were enrolled in this study. Age of the children was 1-15 years. Their mean age was 6.4 years. Male female ratio was 1.15:1. There was significant difference of HbA₂ between BTT and non BTT group of participants (p value <0.001). Value of MCV and MCH were significantly greater in BTT than non BTT group (p value <0.05). Sensitivity, Specificity, Positive predictive value, Negative predictive value and Youden index of MCV were 81.25%, 90.76%, 81%, 90% and 71 respectively. Sensitivity, Specificity, Positive predictive value, Negative predictive value and Youden index of MCH were 84.37%, 92.30%, 84%, 92% and 76 respectively.

Growth performance of local and genetically improved chicken of Bangladesh

The experiment was conducted to compare the growth performance among four genotypes of indigenous chicken namely Non-descriptive Native (ND), genetically Improved Native (IN), Hilly (HC) and Naked Neck (NN) of Bangladesh under free-range rearing system.  A total of 288 day old chicks (DOC) from four genotypes were divided into four treatments having eight replications of each for a period of 12 weeks under free-range system with supplementation of commercial broiler diet. During first 4 weeks, all chicks were kept together, whereas chicks of ND was brooded in the same room but separated by a partition. At 5 weeks of age chicks were randomly distributed to the selected farmers. Growth parameters were recorded to determine the comparative growth performance among four genotypes of chicken. The highest body weight (1110.76 g/bird) was achieved by HC, followed by IN (900.63 g/bird) and NN (831.13 g/bird) at 12 weeks of age. The lowest body weight (734.13 g/bird) however was found in ND chicken. During the growing period under free range rearing (5-12 weeks), HC group consumed the highest amount of feed (2697.02 g/bird) with an average FCR of 3.06 while the lowest feed consumption (2666.13 g/bird) with the highest FCR of 4.90 was observed in ND. IN consumed (2674.63 g/bird) feed with an average FCR of 3.92 and BLRI improved NN consumed (2668.13 g/bird) feed with an average FCR of 4.19. Live weight gains in all the four genotypes of indigenous chicken were changed almost in a similar pattern. Significant differences were observed in live weight, dressing percentage, breast meat, drumstick, thigh meat among the four genotypes of chicken. The HC was superior to other genotypes of indigenous chicken including ND in terms of growth performance, meat yield characteristics and net returns. Bang. J. Anim. Sci. 2018. 47 (2):76-84

Bt Eggplant Project in Bangladesh: History, Present Status, and Future Direction

The purpose of this article is to provide information on the history, accomplishments, and future direction of the Bt brinjal (eggplant) program in Bangladesh, formerly under the Agricultural Biotechnology Support Project II, now the South Asia Eggplant Improvement Partnership (SAEIP). The India-based Maharashtra Hybrid Seed Company (Mahyco) developed an eggplant expressing Cry1Ac (EE-1) for control of the eggplant fruit and shoot borer (EFSB). In a partnership among Mahyco, USAID, Sathguru Management Consultants and Cornell University EE-1 was provided to the Bangladesh Agricultural Research Institute (BARI) who bred it into local varieties. After regulatory approval, four varieties were distributed to 20 farmers who harvested Bt brinjal in 2014. Adoption in subsequent years has increased rapidly so that, in 2018, 27,012 farmers used this technology. This article provides background information on the process leading up to current adoption levels, the level of control of EFSB achieved and the economic benefits of Bt brinjal. Efforts on stewardship, farmer training and communication are discussed. In order to ensure the long-term future of the partnership, we discuss the need to enhance involvement of the private sector in the production and stewardship of Bt eggplant. Bt brinjal is the first genetically engineered crop to be commercially released in Bangladesh, and other GE crops are in the pipeline. Hence, success of the Bt brinjal partnership is likely to affect the future of other GE crops in Bangladesh, as well as other parts of the world where biotechnology is needed for food security and environmental safety.

Socio-economic performance of Bt eggplant cultivation in Bangladesh

A study was conducted in 35 districts of Bangladesh during 2016-17 winter season for assessing the farm level performance of Bt eggplant in reducing pesticide use, cultivation cost and increase farm income. Five hundred five Bt eggplant farmers were selected purposively and 350 non-Bt eggplant farmers were selected randomly for the study. Net returns per hectare were Tk. 179,602/ha for Bt eggplant as compared to Tk. 29,841/ha for non-Bt eggplant. Pesticides were applied 11 times to Bt eggplant where as it was 41 times to non-Bt eggplant for controlling sucking pests. The Bt eggplant farmers saved 61 percent of the pesticide cost compared to non-Bt eggplant farmers, experienced no losses due to fruit and shoot borer, and received higher net returns. The experience with Bt eggplant technology was good for most of the locations and up to the mark and off course this technology will be significantly improved to their socio-economic conditions in future as reported by the Bt respondents. All Bt and 86% non-Bt farmers wanted to cultivate Bt eggplant in the next year if they can obtain the seeds/seedlings from the research station. For getting higher yield and economic benefits, in the course of technology dissemination, the importance of good production practices must be emphasized.Bangladesh J. Agril. Res. 43(2): 187-203, June 2018

What advice is given to newly qualified doctors on Twitter? An analysis of #TipsForNewDocs tweets

CONTEXT

Twitter is a social media platform on which users post very brief messages that can be rapidly communicated across wide geographical areas and audiences. Many doctors use Twitter for personal as well as professional communications and networking. The #TipsForNewDocs hashtag is used on Twitter to give advice to newly qualified doctors as they commence their careers. This study explores the nature and focus of such advice.

METHODS

An analysis of Twitter activity containing the #TipsForNewDocs hashtag was performed using Symplur health care analytics software. Tweets sent during a peak 48-hour period in 2016 (immediately preceding the first day of work for newly qualified UK doctors) were studied. The geographical locations and professional backgrounds of participants were categorised and the content of tweets was subjected to thematic analysis. During 1 and 2 August 2016, 661 unique #TipsForNewDocs tweets were posted. A total of 621 (94.0%) were posted by people in the UK; 522 (79.0%) were posted by doctors, and the remainder by allied health care professionals and patients.

RESULTS

The majority of included tweets focused on aspects of professional development, improving personal or professional knowledge, particularly tacit knowledge, and developing 'know-how'. These aspects of professional knowledge have previously been described as fundamental to professional education and training. However, a significant subset of tweets focused on accelerating socialisation into the profession, an essential step in joining a professional community. The tweets relating to socialisation were often humorous and colloquial in nature.

CONCLUSIONS

Despite their brief and often jocular nature, #TipsForNewDocs tweets provided meaningful advice for newcomers to the profession, often focusing on tacit learning and professional socialisation. Hashtag-driven enquiries can be a valuable and time-efficient way of accessing and sharing tacitly held knowledge. Social media content analysis can provide valuable insights into key educational issues.

What are the implications for practice that arise from studies of medication taking? A systematic review of qualitative research

Background

Despite several decades of evidence supporting the benefits of taking medications in various diseases and healthcare settings, a significant proportion of prescribed treatments are not taken. This review sought to synthesise qualitative research exploring experiences of medication taking around the world, and to determine whether there were consistent messages arising from these studies.

Methods and findings

5 databases (MEDLINE, PsycINFO, EMBASE, SCOPUS, CINAHL) were systematically searched to identify published research papers using qualitative methodologies, which explored medication-taking experiences in patients, citizens, carers, relatives and clinicians. Data were extracted independently by at least two clinician reviewers. Implications for practice from individual papers were charted and coded using thematic content analysis. These were then cross-tabulated with research paper categories to explore emergent patterns with particular implications for practice. 192 papers from 34 different countries were included in the review. Implications for practice fitted into 11 categories: increase family involvement, increase clinician involvement, promote personalised management, address practical barriers, provide ongoing support, promote self-management, adopt a patient-centred approach, improve patient education, address system barriers, increase access to non-prescribing clinicians and improve clinician training. These implications for practice were generally evenly spread across research paper categories.

Conclusions

Implications for practice from the published qualitative literature exploring medication-taking are notably consistent across research methods, disease categories and geographical settings. More recent clinical trials of interventions to improve adherence have started to draw on these findings by focussing on improving clinical interactions and involving patients in healthcare decisions. Promoting patient education and self-management have been widely advocated, and improvements at a system level have been frequently cited in studies from developing countries and those relating to communicable diseases. Regardless of the setting, clinicians and policymakers around the world can focus efforts to improve medication-taking by considering a number of consistently emerging findings.

Differential effects of experimental hyperthyroidism on declined immunity of broiler chicken

Thyroid hormones (THs) are involved in the development of lymphoid organs and regulation of immune function in birds. However, their role as an immune-modulator in the hyperthyroid state is still debatable. To explore the interrelationship of thyroxine (T₄ ) and the immune system, chicks were divided into three groups. Group I was comprised of control birds, who received the basal diet while group II and III were given diets supplemented with 5 μg and 10 μg thyroxine/kg feed, respectively, from 15 to 28 days of age. Cell-mediated immune response was evaluated through in vitro abdominal macrophage phagocytosis assay, macrophage nitric oxide (NO) production, heterophil-to-lymphocyte (H:L) ratio and delayed-type hypersensitivity response against phytohemagglutinin (PHA). Humoural immune response was assessed through serum IgG and IgM antibody production against sheep red blood cells (SRBCs) and antibody production against infectious bronchitis virus (IBV). Sampling was carried out at 7, 14 and 21 days of treatment. Results have shown higher levels (p < .001) of circulating T₄ in both treatment groups compared to the control group. There was a lower (p < .05) macrophage engulfment percentage, an increase in H:L ratio (p < .001) in treated birds, while their NO production remained higher (p < .05) in thyroxine supplemented groups after bacterial lipopolysaccharide stimulation. The humoural immune response revealed a significant decline (p < .001) in IgG, IgM antibody production against SRBCs but IBV circulating antibodies increased with age. In conclusion, hyperthyroidism has a strong co-relation with decreased immune performance of birds.

Response of antioxidant enzymes in Mythimna separata (Lepidoptera: Noctuidae) exposed to thermal stress

The oriental army worm Mythimna separata (Lepidoptera: Noctuidae) is a migratory pest in Eastern Asia and China. Seasonal high temperatures in Southern China and low temperatures in Northern China are pressures favouring the annual migration of this species, while cold tolerance determines the northern limit of its overwintering range. A number of physiological stress responses occur in insects as a result of variations in temperature. One reaction to thermal stress is the generation of reactive oxygen species (ROS), which can be harmful by causing oxidative damage. The time-related effects (durations of 1, 4 and 7 h) of thermal stress treatments of M. separata at comparatively low (5, 10, 15 and 20°C) and high (30, 35, 40 and 45°C) temperatures on the activities of antioxidant enzymes, including superoxide dismutase (SOD), catalase (CAT), peroxidase (POX) and glutathione S-transferases (GSTs), and total antioxidant capacity (T-AOC) were determined. Thermal stress resulted in significant elevation of the activities of SOD, CAT and GSTs, indicating that these enzymes contribute to defence mechanisms counteracting oxidative damage caused by an increase in ROS. However, at high-temperatures, POX and T-AOC were also found to contribute to scavenging ROS. Our results also indicate that extreme temperatures lead to elevated ROS production in M. separata. The present study confirms that thermal stress can be responsible for oxidative damage. To overcome such stress, antioxidant enzymes play key roles in diminishing oxidative damage in M. separata.

Primary Angioplasty for the Treatment of Acute ST Elevated Myocardial Infarction: Single Centre Experience

Worldwide primary angioplasty is a recommended strategy of reperfusion in patient with acute myocardial infarction as because it ensures reperfusion of the infarct-related vessels more than 90% whereas, with thrombolytics it is only 60-70%. This retrospective observational study includes all patients treated with primary angioplasty at United Hospital from Between March 2007 to January 2011. Total 114 consecutive patients with acute myocardial infarction were treated with primary angioplasty included. Those presented beyond 12 hours of onset of chest pain, in cardiogenic shock, resuscitate and intubated before the procedure were excluded from the study. Majority (89%) of the patient were male, age was minimum 30 years and maximum 90 years, 41.5% were diabetics, 58.4% were hypertensive, 43.5% were dyslipidaemic, 17% were smoker, 29.3% with positive family history. Fifty seven percent patients presented with anterior MI , 42 % with inferior MI and 1% with lateral MI. Left anterior descending (LAD) is the most common vessel involved (57%), followed by Right coronary artery (RCA) 31%, Left circumflex artery (LCX) 8 %, Ramus 1.3% and Graft vessel 2.7%. Our door to balloon time was minimum 23 min, maximum 184 min. We used drug eluting stents for most of the patients, GP IIb- IIIa receptor blockers used in 50% cases and thrombus suction device were used when indicated. We faced complications like arrhythmias in 24%, hypotension in18%, no flow or slow flow in 45%, cardiac arrest in 3% and coronary perforation in 1%. Our overall survival was 97.9%. Primary angioplasty is an emerging area in context of our country. Many of the new centers start this novel strategy which helps to save many lives Primary angioplasty is feasible and safe method of reperfusion in patient with acute myocardial infarction in our center. With the help of our initial experience we can perform PAMI with confidence to those who can afford and who need most.

The role of general practitioners in medical school admission interview panels in the UK (2012-2014): a national survey

Objective

Recent primary care workforce pressures in the UK have prompted national reviews. Recommendations to increase the proportion of medical students entering general practice have led to interest in the role of medical schools in career choices. This study sought to identify the career backgrounds of admissions leads at UK medical schools and the proportion of general practitioners on admission interview panels.

Design

A national survey using a proforma circulated to all UK medical school admission leads via the Medical Schools Council.

Setting

UK medical schools.

Participants

UK medical schools.

Main outcome measures

Prevalence of assessment lead and panel members' professional groups.

Results

Responses were received from 18 (54.5%) of the 33 UK medical schools. General practitioners led the admissions process in 2 (11%) of these. Fifteen schools were able to furnish detailed data about interview panel composition, having held a combined total of 876 distinct interview panels during the 2012–2013 and 2013–2014 admission years; 683 panels (78%) included a secondary care physician, but only 261 panels (29.8%) included general practitioners. General practitioner representation ranged from 3.8% to 100% of individual schools’ panels; however, eight schools (about half the respondents able to offer numbers of participants) omitted general practitioner representation in more than half of their interview panels.

Conclusions

Despite the UK policy focus to increase the proportion of medical students becoming general practitioners, doctors from this clinical background are not proportionately represented as admissions leads or on admissions interview panels. Increasing general practitioner involvement in admissions processes may be one way in which medical schools can support general practice as a career aspiration.

Voiceless Bangla vowel recognition using sEMG signal

Some people cannot produce sound although their facial muscles work properly due to having problem in their vocal cords. Therefore, recognition of alphabets as well as sentences uttered by these voiceless people is a complex task. This paper proposes a novel method to solve this problem using non-invasive surface Electromyogram (sEMG). Firstly, eleven Bangla vowels are pronounced and sEMG signals are recorded at the same time. Different features are extracted and mRMR feature selection algorithm is then applied to select prominent feature subset from the large feature vector. After that, these prominent features subset is applied in the Artificial Neural Network for vowel classification. This novel Bangla vowel classification method can offer a significant contribution in voice synthesis as well as in speech communication. The result of this experiment shows an overall accuracy of 82.3 % with fewer features compared to other studies in different languages.

Analgesic and antidepressant activities of Brassica rapa subspecies chinensis (L.) Hanelt on Swiss-albino mice model

Bangladesh being a subtropical country provides varieties of herbs and vegetables. Brassica is a broad genus available in Bangladesh and it encompasses a lot of nutritive herbs. Among these, Brassica rapa subspecies chinensis (L.) Hanelt (Family-Brassicaceae) is popular in many parts of the world. In the quest of medicinal property, this plant was investigated here for observing analgesic and antidepressant activities in Swiss-albino mice model. The herb was extracted well with methanol and then assayed by acetic acid-induced writhing and tail immersion methods for analgesic action. Besides, thiopental sodium induced sleeping time test, tail suspension test and forced swim test were conducted for the evaluation of its antidepressant activity. The plant extract was orally administered to the mice at 200 and 400 mg/kg body weight and it exhibited significant analgesic and antidepressant activities in compare to the controlled groups. This is the first time comprehensive report for analgesic and antidepressant activities of this plant.

First Metatarsalphalangeal Joint Arthrodesis: A Retrospective Comparison of Two Methods of Fixation

First metatarsalphalangeal joint arthrodesis is a well established and successful treatment; however there still remains controversy over the best choice of construct. We performed a retrospective study of patients undergoing first metatarsalphalangeal fusion over eighteen months (n=52) using either dorsal non-locking plate with additional compression lag screw fixation or dorsal non-locking plate alone. We found when assessing clinical criteria, patients with dorsal non-locking plates and additional compression lag screw fixation had a significantly higher rate of fusion (100% vs 77.8%), significantly higher rate of fusion within the first two months (55.6% vs 83.3%), significantly earlier time to fusion (52.2 days vs 75.6 days), and significantly lower rate of non-union (0% vs 22.2%). When blindly assessing radiographic criteria, the patients treated with the plate and compression screw had a significantly higher rate of fusion and lower rate of non-union (0% vs 33%). There was no statistically significant difference between the frequencies of complications in the groups. We believe that the interfragmentary compression is a crucial factor in achieving good union rates and recommend the use of non-locking pre-contoured plating with additional interfragmentary compression screw as the fixation method of choice for these procedures.