1286 IS VIRTUAL ADVANCE CARE PLANNING SIMULATION AS EFFECTIVE AS FACE-TO-FACE LEARNING?

Introduction

Advance care planning (ACP) is about what matters to patients, enabling their wishes to be respected, even when they become unable to engage in decision-making. Evidence shows ACP improves end of life care for patients and reduces relatives’ bereavement reactions (Detering KM et al. BMJ. 2010; 340:1345). A simulation course for multidisciplinary healthcare professionals, using actors, was developed to improve understanding of ACP, and confidence in having these conversations. In response to the COVID-19 pandemic, the course was adapted to an online format.

Method

Participants were asked about their ACP confidence and understanding pre- and post-course, using a Likert scale (1-Not at all to 5-Very confident). Data between 2018-2022 was analysed to compare face-to-face and online course responses. Free-text responses to ‘How do you feel about attending the course online?’ were analysed qualitatively. Ethics approval was not required.

Results

Five face-to-face and five virtual sessions trained 128 and 133 attendees respectively. Confidence in having ACP discussions improved significantly following the course in both cohorts; from a mean Likert rating of 2.77 (95% CI 2.60-2.94, n=132) to 4.11 following face-to-face training (95% CI 3.97-4.25, n=128), and from 2.79 (95% CI 2.66-2.91, n=149) to 4.11 following the online course (95% CI 4.01-4.21, n=133). Additionally, 97% (n=132) of face-to-face attendees and 99.2% (n=133) of virtual attendees said their practice would change because of the course. Following the training, 100% of participants across both cohorts reported that they ‘fully understood’ what was meant by ACP, from a baseline of 77.3% (n=132) in the face-to-face cohort and 81.9% (n=149) of virtual participants. Free-text analysis highlighted the convenience of attending online (n=22, 21%), and only a minority reported technical difficulties (n=8,8%).

Conclusion

This course was successfully adapted to a virtual format, improving participants’ ACP confidence and understanding as effectively as in-person training, whilst being more accessible.

Remote consultations in primary care across low-, middle- and high-income countries: Implications for policy and care delivery

The COVID-19 pandemic mandated a substantial switch in primary health care delivery from an in-person to a mainly remote telephone or video service. As the COVID-19 pandemic approaches its third year, limited progress appears to have been made in terms of policy development around consultation methods for the post-acute phase of the pandemic. In September 2020, the International Primary Care Respiratory Group convened a global panel of primary care clinicians - including family physicians, paediatricians, pharmacists, academics and patients - to consider the policy and health management implications of the move to remote consultations in the primary care setting. The group gave special consideration to how and how far remote consultations should be integrated into routine primary health care delivery. Remote consultations can be a useful alternative to in-person consultations in primary care not only in situations where there is a need for viral infection control but also for the routine delivery of chronic disease management. However, they may not be more time efficient for the clinician, and they can add to the workload and work-related stress for primary care practitioners if they remain the dominant consultation mode. Remote consultations are also less appropriate than in-person consultations for new disease diagnosis, dealing with multiple issues and providing complex care. Ensuring health care professionals have the appropriate skill set to effectively deliver remote consultations, administrative and/or IT support and appropriate reimbursement will be key to achieving optimal integration of remote consultations into routine clinical practice. Addressing digital access and digital literacy issues at a societal level will also be essential to ensure individuals have fair and equitable access to the internet and sufficient security for exchange of personal and health-related data.

Implications of telehealth services for healthcare delivery and access in rural and remote communities: perceptions of patients and general practitioners

BACKGROUND

Accelerated by the coronavirus disease 2019 (COVID-19) pandemic, Australia has shifted towards greater use of telehealth to deliver care for rural and remote communities. This policy direction might risk a shift away from the traditional model of informed person-centred care built around care relationships to a technology-mediated health transaction. Potential opportunity costs of widespread telehealth services on the quality of care for rural and remote communities remain understudied.

METHODS

A qualitative study was conducted in three local health districts of rural New South Wales, Australia. Data were collected through in-depth interviews. A total of 13 participants was interviewed. Data were analysed using thematic analysis.

RESULTS

Patient participants perceived telehealth as an alternative when specialist care was limited or absent. Both patients and clinicians perceived that the deeper caring relationship, enabled through face-to-face interactions, could not be achieved through telehealth services alone, and that telehealth services are often superficial and fragmented in nature. Patients in this study contended that virtual consultations can be distant and lacking in personal touch, and risk losing sight of social circumstances related to patients' health, thereby affecting the trust placed in healthcare systems.

CONCLUSIONS

Simply replacing face-to-face interactions with telehealth services has the potential to reduce trust, continuity of care, and effectiveness of rural health services. Telehealth must be used to assist local clinicians in providing the best possible care to rural and remote patients within an integrated service delivery model across diverse rural contexts in Australia.

The RECHARGE-IPCRG ‘Teach the Teacher’ programme: building capacity for pulmonary rehabilitation in low- and middle-income countries

Introduction

Chronic respiratory diseases are the most common causes of morbidity and mortality globally. Pulmonary rehabilitation (PR) is a low-cost, high-impact intervention with patient education and exercise at its core. Although supported by a well-established evidence base, demand greatly exceeds capacity in low- and middle-income countries (LMIC), including limited workforce training opportunities to support PR development and implementation. The International Primary Care Respiratory Group’s (IPCRG) Teach the Teacher (TtT) is an established education programme designed to build sustainable local clinical teaching and delivery capacity.

Methods

A collaboration between the National Institute for Health and Care Research (NIHR) funded Global RECHARGE Group for PR and IPCRG to deliver a ‘Teach the Teacher’ (TtT) programme for PR capacity building. Our Tier 1 TtT programme combined educational and PR service development concepts with core clinical content adapted for RECHARGE partners in India (Pune and Delhi), Sri Lanka, Kyrgyzstan and Uganda. Due to the severe acute respiratory syndrome coronavirus-2 (SARS‑CoV‑2) pandemic, the programme was adapted to a digital environment using online platforms such as Zoom video conferencing and Google Classroom. We used an adapted framework to evaluate professional learning and its impact.

Findings

Fifteen Tier 1/local leader participants attended a sixteen-hour online programme in September-October 2021. Participants included nurses, physiotherapists, doctors and early career health professionals/researchers. As local leaders in PR, participants created a tiered teaching programme for developing a critical mass of PR expert teachers, contextualised to their local healthcare systems and cultures. Participants also explored how to engage and influence multiple professional groups and stakeholders to support the widespread sustainable implementation of PR.

Conclusions

The RECHARGE-IPCRG TtT programme provided a clear education and service development framework to support PR capacity development in LMIC. We address a lack of empirical evidence concerning capacity-building initiatives by being explicit about the programme’s learning design, management and evaluation. A whole system perspective to PR allowed consideration of health systems, culture, referral pathways and scalability. Sustainable national PR education programmes will require additional resources and a long-term strategy, potentially aligning with the TtT three-tier cascade model.

Do General Practitioners in a Visiting Medical Officer Arrangement Improve the Perceived Quality of Care of Rural and Remote Patients? A Qualitative Study in Australia

Background: In rural and remote Australia, general practitioners (GPs) provide care across the continuum from primary to secondary care, often in Visiting Medical Officer (VMO) arrangements with a local hospital. However, little is known about the role of GP-VMOs in improving the perceived quality of care and health outcomes for rural and remote communities. Methods: We collected qualitative data from three GP-VMOs (all aged >55 years) and 10 patients (all aged over 65 years) in three local health districts of New South Wales, Australia. Thirteen in-depth interviews were conducted between October 2020 and February 2021. We employed thematic analysis to identify key roles of GP-VMOs in improving the perceived quality of care and health outcomes of rural and remote patients. Results: Our study advances the current understanding regarding the role of GP-VMOs in improving the perceived quality of services and health outcomes of rural and remote patients. Key roles of GP-VMOs in improving the perceived quality of care include promoting the continuity of care and integrated health services, cultivating trust from local communities, and enhancing the satisfaction of patients. Conclusions: GP-VMOs work across primary and secondary care creating better linkages and promoting the continuity of care for rural and remote communities. Employing GP-VMOs in rural hospitals enables the knowledge and sensitivity gained from their ongoing interactions with patients in primary care to be effectively utilised in the delivery of hospital care.

Effects of employing primary care doctors in hospital to improve the quality of care and health outcomes of rural patients: A systematic scoping review

OBJECTIVE

To describe effects of employing primary care doctors in hospital care and their roles in improving the quality of care and health outcomes of rural and remote patients.

DESIGN

A systematic scoping review.

SETTING

Peer-reviewed publications were sourced from 3 online journal databases (PUBMED, SCOPUS and Web of Science).

PARTICIPANTS

All study designs from peer-reviewed journals that discussed effects of employing primary care doctors in hospital care Interventions: employing primary care doctors in hospital care.

MAIN OUTCOME MEASURES

Positive and negative consequences of employing primary care doctors in hospital care, and the roles of primary care doctors in improving the quality of care and health outcomes.

RESULTS

A total of 12 articles met the inclusion and exclusion criteria. Positive outcomes included improved access to specialised treatment, improved continuity of care, reduced waiting list and admission rates, improved skills, competence and confidence of primary care doctors, and increased satisfaction from both health providers and patients/families. Negative consequences reported included increased prescriptions and poorly documented history and physical examinations.

CONCLUSION

Employing primary care doctors in hospital care can fill the gaps in the delivery of acute care, emergency medicine and maternity care. Primary care doctors bring advanced clinical skills and a patient-centred approach to the hospital care. They also improve the quality of referrals leading to freed-up clinical capacity of tertiary hospitals to treat more serious conditions. The provision of acute or emergency care and secondary care in rural and remote areas should be directed towards patient-oriented not provider-oriented policies.

Performance of commercial PCR assays to detect toxigenic Clostridioides difficile in the feces of puppies

Clostridioides difficile is an important enteric pathogen that causes significant morbidity and mortality in humans. With community‐acquired infections on the rise, it is important to identify reservoirs of the pathogen. Companion animals can be asymptomatic carriers of C. difficile and may therefore represent a reservoir, but epidemiological studies of C. difficile within the pet‐owner unit are needed, along with validated methods to detect C. difficile in both people and animals. The goal of this study was to assess the performance of commercial qPCR assays and a multiplex PCR for C. difficile compared to toxigenic culture. These assays were tested on up to 103 fecal samples from puppies, a population in which the prevalence of C. difficile is the highest. The sensitivities, specificities, positive predictive values and negative predictive values were respectively 84.2%, 87.7%, 61.5%, and 95.9% for the Cepheid GeneXpert; 66.7%, 66.7%, 29.6%, and 90.9% for the DiaSorin Simplexa; and 94.4%, 85.0%, 65.4%, and 98.1%, for the multiplex qPCR. The agreement was highest between the GeneXpert and the multiplex PCR (90.1% agreement, with a kappa statistic of 0.77). For diagnostic purposes, the positive predictive values of the assays were low. However, the high sensitivities of the assays could render them useful for epidemiologic purposes.

Companion animals might be a reservoir of Clostridioides difficile. Diagnostic assays that are validated in both people and pets are needed to conduct epidemiological investigations within the pet‐owner unit. We found that at least one commercial PCR assay to detect C. difficile in people is also highly sensitive in dogs and could therefore be used for epidemiological purposes within the pet‐owner unit.

467 FRAILTY IN SITU SIMULATION

Introduction

The ability to recognise and manage frailty and its associated presentations is variable among acute hospital staff. Patients living with frailty who are admitted to hospital are more likely to suffer adverse effects than those without. We created an inter-professional in-situ simulation programme designed to improve recognition and management of frailty and its common adverse events. The programme objectives align with recommendations from the British Geriatric Society’s ‘Frailty Hub’ and Royal College of Physicians’ ‘Acute Care Toolkit’ for frailty.

Method

Over a two month period, seven sessions were completed on the Older Persons Unit (OPU) at St Thomas’ Hospital. These comprised a simulated scenario followed by facilitated debrief—including technical skills and human factors highlighted by the scenario. Quantitative data was collected through pre and post session questionnaires using the Human Factors Skills for Healthcare Instrument (HuFSHI) and frailty based questions. Post session qualitative data was also collected.

Results

30 participants attended the sessions (nursing, medical and allied health professional). All participants completing the post course questionnaire found the sessions useful. When comparing pre and post session data, participant confidence in 10/12 sections of the HuFSHI and 8/9 frailty based questions demonstrated improvement. The qualitative data showed common learning themes around improved communication, teamwork and escalation. Participants found that the sessions were a valuable ‘opportunity to reflect’ and ‘debrief’, and learn together as a multidisciplinary team.

Conclusion

In-situ simulation is an effective tool for improving knowledge and confidence in managing frail patients. It increases awareness and understanding of human factors, which are key to the multidisciplinary approach frail patients require. The course is being expanded across the OPU and now has funding for a departmental manikin. The programme can be disseminated to other units to help improve the care and safety of those with frailty in hospital.

Residency match interview scheduling: quantifying the applicant experience

BACKGROUND

The process of offering and scheduling residency interviews varies widely among programmes. Applicants report distress and have advocated for reform. However, there is a paucity of quantitative data to characterise applicant concerns.

OBJECTIVE

We quantified the interview scheduling experience for US allopathic medical students in the 2020 main residency match.

METHODS

An anonymous, 13 question survey was sent to student representatives from each Association of American Medical Colleges member institution. Recipients were asked to forward the survey to their entire fourth-year class.

RESULTS

Of 4314 applicants to whom the survey was sent, 786 (18.2%) responded. Overall, 20.4% reported missing the opportunity to interview at a programme because they did not have adequate time to respond to an invitation; applicants into surgical specialties were significantly more likely than their non-surgical peers to report this experience (26.4% vs 18.4%, p<0.05). Most (57.4%) respondents scheduled an interview knowing they would likely cancel it in the future. The most commonly cited reason for this behaviour was concern that applicants would not receive invitations from other programmes (85.6%). A majority (56.4%) of respondents did not believe the match interview process functions based on equity and merit.

CONCLUSIONS

About one in five respondents missed the opportunity to interview at a programme because they did not respond to an invitation in time. Most respondents scheduled interviews knowing that they were likely to cancel them in the future. Standardisation of the interview invitation timeline would address these concerns.

Evaluation of a real-time RT-PCR panel for detection of SARS-CoV-2 in bat guano

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease 2019 (COVID-19), which is an ongoing global health concern. The exact source of the virus has not been identified, but it is believed that this novel coronavirus originated in animals; bats in particular have been implicated as the primary reservoir of the virus. SARS-CoV-2 can also be transmitted from humans to other animals, including tigers, cats, and mink. Consequently, infected people who work directly with bats could transfer the virus to a wild North American bat, resulting in a new natural reservoir for the virus, and lead to new outbreaks of human disease. We evaluated a reverse-transcription real-time PCR panel for detection of SARS-CoV-2 in bat guano. We found the panel to be highly specific for SARS-CoV-2, and able to detect the virus in bat guano samples spiked with SARS-CoV-2 viral RNA. Our panel could be utilized by wildlife agencies to test bats in rehabilitation facilities prior to their release to the wild, minimizing the risk of spreading this virus to wild bat populations.

Cumulative dispensing of high oral corticosteroid doses for treating asthma in Australia

OBJECTIVE

To estimate the level of dispensing of oral corticosteroids (OCS) for managing asthma in Australia, with a particular focus on the cumulative dispensing of doses associated with long term toxicity (≥ 1000 mg prednisolone-equivalent).

DESIGN

Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data.

PARTICIPANTS, SETTING

People aged 12 years or more treated for asthma during 2014-2018, according to dispensing of controller inhaled corticosteroids (ICS).

MAIN OUTCOME MEASURES

Number of people dispensed OCS for managing asthma during 2014-2018; proportion who were cumulatively dispensed at least 1000 mg prednisolone-equivalent. The secondary outcome was the number of people dispensed at least 1000 mg prednisolone-equivalent during 2018, stratified by inhaler controller dose and use.

RESULTS

124 011 people had been dispensed at least two prescriptions of ICS during 2014-2018 and met the study definition for asthma, of whom 64 112 (51.7%) had also been dispensed OCS, including 34 580 (27.9% of the asthma group) cumulatively dispensed 1000 mg prednisolone-equivalent or more. Of 138 073 people dispensed OCS at this level, 68 077 (49%) were patients with airway diseases. Dispensing of diabetes and osteoporosis medications was more common for people cumulatively dispensed 1000 mg prednisolone-equivalent or more. During 2018, 4633 people with asthma using high dose ICS controllers were dispensed 1000 mg prednisolone-equivalent or more, for 2316 of whom (50%) controller use was inadequate.

CONCLUSIONS

Cumulative exposure to OCS in Australia reaches levels associated with toxicity in one-quarter of patients with asthma using ICS. Cumulative dispensing of potentially toxic OCS amounts often accompanies inadequate inhaler controller dispensing. Better approaches are needed to improve adherence to controller therapy, improve outcomes for people with asthma, and to minimise the use and toxicity of OCS.

Rural clinical school students do come back: But it may take time

BACKGROUND AND OBJECTIVES

Rural clinical schools (RCSs) help address Australia’s rural workforce shortfall, but they require an investment by rural clinicians and communities. Our objective was to determine the location of RCS graduates as one measure of the effectiveness of RCSs.

METHOD

This cross-sectional study obtained work location data for Australian National University Medical School (ANUMS) graduates and analysed both RCS and non-RCS data.

RESULTS

The percentage of graduates working in rural areas after their fifth postgraduate year (PGY6–11: 34.7%) was significantly greater than that of graduates in PGY1–5 (15.2%, P <0.001).

DISCUSSION

Many graduates who trained in rural sites spend time in cities before returning to work in rural areas. This is encouraging for rural clinicians and communities, but it can take time for graduates to return.

The Australian Rural Clinical School (RCS) program supports rural medical workforce: evidence from a cross-sectional study of 12 RCSs

INTRODUCTION

Many strategies have been implemented to address the shortage of medical practitioners in rural areas. One such strategy, the Rural Clinical School Program supporting 18 rural clinical schools (RCSs), represents a substantial financial investment by the Australian Government. This is the first collaborative RCS study summarising the rural work outcomes of multiple RCSs. The aim of this study was to combine data from all RCSs' 2011 graduating classes to determine the association between rural location of practice in 2017 and (i) extended rural clinical placement during medical school (at least 12 months training in a rural area) and (ii) having a rural background.

METHODS

All medical schools funded under the RCS Program were contacted by email about participation in this study. De-identified data were supplied for domestic students about their gender, origin (rural background defined as having lived in an Australian Standard Geographic Classification-Remoteness Area (ASGC-RA) 2-5 area for at least 5 years since beginning primary school) and participation in extended rural clinical placement (attended an RCS for at least 1 year of their clinical training). The postcode of their practice location according to the publicly available Australian Health Practitioner Regulation Agency (AHPRA) register was collected (February to August 2017) and classified into rural and metropolitan areas using the ASGC 2006 and the more recent Modified Monash Model (MMM). The main outcome measure was whether graduates were working in a 'rural' area (ASGC categories RA2-5 or MMM categories 3-7) or 'metropolitan' area. Pearson's χ2 test was used to detect differences in gender, rural background and extended placement at an RCS between rural and metropolitan practice locations. Binary logistic regression was used to determine odds of rural practice and 95% confidence intervals (CIs) were calculated.

RESULTS

Although data were received from 14 universities, two universities had not started collecting origin data at this point so were excluded from the analysis. The proportion of students with a rural background had a range of 12.3-76.6% and the proportion who had participated in extended RCS placement had a range of 13.7-74.6%. Almost 17% (16.6%) had a principal practice postcode in a rural area (according to ASGC), range 5.8-55.6%, and 8.3% had a principal practice postcode in rural areas (according to MMM 3-7), range 4.5-29.9%. After controlling for rural background, it was found that students who attended an RCS were 1.5 times more likely to be in rural practice (95%CI 1.2-2.1, p=0.004) using ASGC criteria. Using the MMM 3-7 criteria, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (95%CI 1.8-3.8, p<0.001) after controlling for rural background. Regardless of geographic classification system &#40;ASGC, MMM&#41; used for location of practice and of student background (metropolitan or rural), those students with an extended RCS had an increased chance of working rurally.

CONCLUSION

Based on the combined data from three-quarters (12/16) of the Australian medical schools who had a graduating class in 2011, this suggests that the RCS initiative as a whole is having a significant positive effect on the regional medical workforce at 5 years post-graduation.

The induction of core pluripotency master regulators in cancers defines poor clinical outcomes and treatment resistance

Stem cell characteristics have been associated with treatment resistance and poor prognosis across many cancer types. The ability to induce and regulate the pathways that sustain these characteristic hallmarks of lethal cancers in a novel in vitro model would greatly enhance our understanding of cancer progression and treatment resistance. In this work, we present such a model, based simply on applying standard pluripotency/embryonic stem cell media alone. Core pluripotency stem cell master regulators (OCT4, SOX2 and NANOG) along with epithelial–mesenchymal transition (EMT) markers (Snail, Slug, vimentin and N-cadherin) were induced in human prostate, breast, lung, bladder, colorectal, and renal cancer cells. RNA sequencing revealed pathways activated by pluripotency inducing culture that were shared across all cancers examined. These pathways highlight a potential core mechanism of treatment resistance. With a focus on prostate cancer, the culture-based induction of core pluripotent stem cell regulators was shown to promote survival in castrate conditions—mimicking first line treatment resistance with hormonal therapies. This acquired phenotype was shown to be mediated through the upregulation of iodothyronine deiodinase DIO2, a critical modulator of the thyroid hormone signalling pathway. Subsequent inhibition of DIO2 was shown to supress expression of prostate specific antigen, the cardinal clinical biomarker of prostate cancer progression and highlighted a novel target for clinical translation in this otherwise fatal disease. This study identifies a new and widely accessible simple preclinical model to recreate and explore underpinning pathways of lethal disease and treatment resistance.

Evaluating the Health "Hubs and Spokes" interprofessional placements in rural New South Wales, Australia

Australia has been relatively slow in adopting interprofessional learning (IPL) to prepare health professional students for future collaborative professional practice. A collaborative project between two universities placed senior health professional students in IPL teams in rural southeast New South Wales, Australia, to work on small, locally relevant projects with guidance from locally appointed IPL facilitators. This paper reports on the initial stages of an evaluation of this rural-based IPL intervention using the modified Freeth/Kirkpatrick's 4-level evaluation model.

METHODS

Students' responses were collected using a debriefing questionnaire, the Interprofessional Education Perception (IEPS) and Team Performance (TPS) scales. An audience feedback questionnaire was structured around project objectives.

RESULTS

Seventy-nine students participated in 33 IPL teams during the evaluation period included in this study. IEPS scores increased with participation (t=2.803; p=0.007). The TPS showed a statistically significant difference between teams (ANOVA, F(31,45) = 1.982, p=0.018( and a trend toward agreement with audience perceptions of team performance.

CONCLUSIONS

The evaluation demonstrated positive short-term outcomes suggesting benefits of this applied approach in preparing students to work interprofessionally.

Learning trajectories in longitudinal rural medical school placements

BACKGROUND

Rural longitudinal placements are now a key part of clinical medical education, and are part of workforce strategies to enhance the rural medical workforce. Learning trajectories (a map to guide student learning) have been recommended as a means of maximising student learning on placements, and have the potential to assist long-term rural students and supervisors in adapting to a longitudinal clerkship.

CONTEXT

This study focuses on year-3 medical students in rural longitudinal clinical placements at an Australian graduate-entry medical school.

INNOVATION

This article reports the outcomes of working with current rural supervisors and students to develop a learning trajectory across the rural stream year, for implementation in future years.

IMPLICATIONS

Students and supervisors identified incremental learning goals in keeping with Dreyfus's model of progressive skill development. Students offered tips to future students to adjust to variations in learning experiences across rural sites. Some supervisors were reluctant to have a learning trajectory, fearing it would be seen as proscriptive and reduce student ambition for varied rich experiences. Future research will focus on the impact of the rural learning trajectory.

The learner's perspective in GP teaching practices with multi-level learners: a qualitative study

BACKGROUND

Medical students, junior hospital doctors on rotation and general practice (GP) registrars are undertaking their training in clinical general practices in increasing numbers in Australia. Some practices have four levels of learner. This study aimed to explore how multi-level teaching (also called vertical integration of GP education and training) is occurring in clinical general practice and the impact of such teaching on the learner.

METHODS

A qualitative research methodology was used with face-to-face, semi-structured interviews of medical students, junior hospital doctors, GP registrars and GP teachers in eight training practices in the region that taught all levels of learners. Interviews were audio-recorded and transcribed. Qualitative analysis was conducted using thematic analysis techniques aided by the use of the software package N-Vivo 9. Primary themes were identified and categorised by the co-investigators.

RESULTS

52 interviews were completed and analysed. Themes were identified relating to both the practice learning environment and teaching methods used.A practice environment where there is a strong teaching culture, enjoyment of learning, and flexible learning methods, as well as learning spaces and organised teaching arrangements, all contribute to positive learning from a learners' perspective.Learners identified a number of innovative teaching methods and viewed them as positive. These included multi-level learner group tutorials in the practice, being taught by a team of teachers, including GP registrars and other health professionals, and access to a supernumerary GP supervisor (also termed "GP consultant teacher"). Other teaching methods that were viewed positively were parallel consulting, informal learning and rural hospital context integrated learning.

CONCLUSIONS

Vertical integration of GP education and training generally impacted positively on all levels of learner. This research has provided further evidence about the learning culture, structures and teaching processes that have a positive impact on learners in the clinical general practice setting where there are multiple levels of learners. It has also identified some innovative teaching methods that will need further examination. The findings reinforce the importance of the environment for learning and learner centred approaches and will be important for training organisations developing vertically integrated practices and in their training of GP teachers.

Under the hood of satellite empirical chlorophyll a algorithms: revealing the dependencies of maximum band ratio algorithms on inherent optical properties

Empirically-based satellite estimates of chlorophyll a [Chl] (e.g. OC3) are an important indicator of phytoplankton biomass. To correctly interpret [Chl] variability, estimates must be accurate and sources of algorithm errors known. While the underlying assumptions of band ratio algorithms such as OC3 have been tacitly hypothesized (i.e. CDOM and phytoplankton absorption covary), the influence of component absorption and scattering on the shape of the algorithm and estimated [Chl] error has yet to be explicitly revealed. We utilized the NOMAD bio-optical data set to examine variations between satellite estimated [Chl] and in situ values. We partitioned the variability into (a) signal contamination and (b) natural phytoplankton variability (variability in chlorophyll-specific phytoplankton absorption). Not surprisingly, the OC3 best-fit curve resulted from a balance between these two different sources of variation confirming the bias by detrital absorption on global scale. Unlike previous descriptions of empirical [Chl] algorithms, our study (a) quantified the mean detrital:phytoplankton absorption as ~1:1in the global NOMAD data set, and (b) removed detrital (CDOM + non-algal particle) absorption in radiative transfer models directly showing that the scale of the remaining variability in the band ratio algorithm was dominated by phytoplankton absorption cross section.

Managing glaucoma in those with co-morbidity: not as easy as it seems

PURPOSE

To identify the extent of use of medicines recommended to be used with caution in glaucoma patients with specified comorbidities and to determine evidence of associated harm. Retrospective cohort analysis from administrative claims data and prescription/event sequence symmetry analysis.

PARTICIPANTS

Australian Government Department of Veterans' Affairs treatment card holders dispensed glaucoma eye-drops.

MAIN OUTCOME MEASURES

Proportion of veterans with glaucoma and diabetes, airways disease, heart failure, ischemic heart disease or depression, dispensed glaucoma eye drops which should be used with caution. For harms, outcome measures were hospitalizations for airways disease and heart disease.

RESULTS

The cohort analysis included 25,984 veterans. Of these, 88% with airways disease were dispensed glaucoma eye drops with the potential to aggravate airways disease, 43% with heart failure were dispensed topical beta-blockers and 49% with depression received glaucoma eye drops which should be used cautiously in those with depression. We found increased risk of initiation of inhaled beta-agonist following timolol (adjusted sequence ratio (ASR) 1.48, 99% CI 1.22-1.78) and latanoprost (ASR 1.24, 99% CI 1.11-1.38) initiation. We found increased risk of inhaled corticosteroid initiation following initiation of timolol (ASR 1.43, 99% CI 1.13-1.81). There was increased risk of antidepressant initiation following timolol initiation (ASR 1.24, 99% CI 1.07-1.43), and latanoprost (ASR 1.16, 99% CI 1.03-1.31). There was also increased risk of hospitalization for bradycardia following timolol initiation (ASR 2.22,99% CI 1.15-4.31).

CONCLUSION

Use of glaucoma eye drops recommended to be used with caution in co-morbidities is common and was associated with adverse outcomes. Awareness of co-morbidities is required in the selection and prescription of glaucoma eye drops.

Maximising student preparation for clinical teaching placements

BACKGROUND

With the increasing emphasis on ambulatory health care, clinical educators need to ensure that students are sufficiently prepared to maximise learning opportunities during placements in ambulatory settings.

CONTEXT

This study focuses on third-year medical students entering urban or rural clinical placements at an Australian graduate entry medical school.

INNOVATION

All rural and a subset of urban students received intensive training in taking Papanicolaou (Pap) smears prior to starting the clinical placement. Training involved gynaecological teaching associates, active practice and real-time feedback. Evaluation included workshop feedback, reflection on effectiveness during the placement, and comparison of trained and untrained students' recorded clinical experience of taking Pap smears.

IMPLICATIONS

Students given pre-placement training praised their learning experience, and on average took more Pap smears during their placement than did their untrained peers. The difference, however, did not reach statistical significance. The pre-placement teaching workshop on a difficult skill was popular and worthy of further study regarding other challenging clinical skills.

Initial evaluation of rural programs at the Australian National University: understanding the effects of rural programs on intentions for rural and remote medical practice

INTRODUCTION

Rural health workforce issues are a priority area for the Australian Government and substantial funding has been provided for rural education programs to address health workforce disparities across Australia's rural and remote communities. The Australian Government established a Rural Health Strategy in 2001 and as a result there are now 14 rural clinical schools in Australia. The 2008 Urbis Report highlighted the lack of research on rural programs and workforce outcomes, essential to ensuring that educational efforts, resources and funding are being concentrated appropriately. This study examined the Australian National University (ANU) Medical School's 4 year rural program to identify the impact of elective and compulsory program components on student intentions to practice in a rural and remote location post-graduation. The study also explores factors that affect student decisions to apply for year-long rural placements. METHODS; ANU Medical School's graduating cohort of 2008 fourth year medical students completed an anonymous and voluntary online survey questionnaire. Survey sections included student demographics, compulsory and elective components of the ANU rural program, and an overall evaluation of the ANU rural curriculum. The survey contained a mixture of forced-answer questions and open-ended commentary. Quantitative data were analyzed for descriptive and frequency statistics using EpiInfo V3.5.1 (<a href='http://wwwn.cdc.gov/epiinfo/' target='_blank'>http://wwwn.cdc.gov/epiinfo/). Qualitative data were reviewed and consistent themes among responses extracted.

RESULTS

In total, 40 students from a cohort of 88 (45%) responded, with 26 respondents (65%) indicating that at medical school commencement they considered working in a rural or remote area. At the end of their medical education, 33 respondents (82%) indicated their intention to spend some time in their careers working in a rural or remote area. Students from non-rural backgrounds had greater positive change in their intentions to practice rurally as a direct effect of ANU rural programs when compared with students from rural backgrounds. More than 70% of students believed the amount of rural focus in the curriculum was correct, 75% believed that they will be better medical practitioners because of the program, and 85% found the curriculum was delivered effectively. Students who undertook elective rural programs such as a year-long rural placement were more likely to have future rural career intentions when compared with students undertaking compulsory rural components. Compulsory components, however, had a strong influence on students applying for elective programs. Regarding application for the year-long rural placement, students reported clinical exposure was the most encouraging factor, and time away from family and friends, and lack of spousal and family support were the most discouraging factors.

CONCLUSION

Rural programs at the ANU, and medical school exposure to rural health experiences is important in influencing students' perceptions of a career in rural and remote health. This study provides evidence that both compulsory and elective components contribute to a successful holistic rural program which nurtures the rural interest of all students. Overall, students at the ANU medical school were satisfied with the rural curriculum. The results confirm that there is difficulty in recruiting students with family commitments into year-long rural placement programs, despite incentives. Those students who select long-term rural study for reasons other than an interest in a career in rural health end the program with positive rural intentions.

Making the 2007-2010 Action Plan work for women in family medicine in the Asia Pacific

The Wonca Working Party for Women and Family Medicine (WWPWFM) was organized in 2001 with the following objectives: to identify the key issues for women doctors; to review Wonca policies and procedures for equity and transparency; to provide opportunities to network at meetings and through the group's listserve and website; and to promote women doctors' participation in Wonca initiatives.In October 2008, at the Asia Pacific Regional conference, the Wonca Working Party on Women in Family Medicine (WWPWFM) held a preconference day and conference workshops, building on the success and commitment to initiatives which enhance women's participation in Wonca developed in Ontario, Canada (2006) and at the Singapore World Congress (2007). At this meeting fifty women workshopped issues for women in Family Medicine in the Asia Pacific. Using the Action Plan formulated in Singapore (2007) the participants identified key regional issues and worked towards a solution.Key issues identified were professional issues, training in family medicine and women's health. Solutions were to extend the understanding of women's contributions to family medicine, improved career pathways for women in family medicine and improving women's participation in practices, family medicine organizations and academic meetings.