Medical Education - Research Publications
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ItemNo Preview AvailableMore than another pair of hands? The impact of medical student placements on the healthcare service(AMEE, 2018)Background: Clinical placements are key to developing work-ready graduates. To date, the literature on workplace learning has focussed on learner-as-consumer, rather than learner-as-contributor. This study aimed to identify the impact of medical student clinical placements for multiple stakeholders in healthcare services. Method: This study was conducted at a large outer metropolitan healthcare service. Qualitative data collection included: observation of students on placement; activity profiling of supervisors and students; student and supervisor focus groups; and interviews with clinicians, academic and hospital leaders, and patient advocates. The data were analysed using Braun and Clarke’s (2006) thematic analysis. Results: The effects of medical students on the healthcare service were categorised into two higher order themes: ‘impact on workflow’; and ‘student presence amplifying quality of care’. In terms of affecting workflow, students in their earlier years reportedly absorbed clinicians’ time on account of direct teaching, task selection, and supervision of activities. As they approached graduation, students began to take on tasks independently (e.g. history taking, data entry, and coordinating patient discharge). Amplifying quality of care was observed through students’ prompting clinicians to reflect on their own practice. Students attended to different aspects of care, often responding to patient or family questions in the specialist’s absence. As one supervisor reported, “students often form an important, informed, but lay, connection between the patient and the medical staff so they can identify a mismatch of expectations.” Discussion: The results suggest that although students require an upfront investment of supervisor energy on clinical placement, they add value along a number of dimensions, particularly in the final year of their program. These contributions are beyond being “another set of hands”. The presence of students encouraged clinicians to reflect on their practice. Conclusion: The presence of students prompted clinicians to adopt a more critical gaze on their own work, and students focussed on humanistic elements of care – elements that can be missed or deprioritised when there is an attending expert only. The role of students as a bridge between patients and experienced staff, and how this can be optimised, warrants further exploration,
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ItemNo Preview AvailableGathering evidence for medical students’ contribution to health services: A communities of practice informed methodology(Australian & New Zealand Association for Health Professional Educators, 2018)Introduction: Immersion in clinical environments is key to developing work-ready graduates. Workplace learning literature has focused on the benefits of clinical placements for students and the burden for health services, such as the cost of supervisor time away from patient care. There has been little focus on mapping the benefits (obvious and hidden) of clinical placements to multiple stakeholders. Aim: To develop a methodology for capturing the benefits of clinical placements for multiple stakeholders. Methods: Using ethnographic methods of observation and interviews, as well as surveys, and drawing from the concept of legitimate peripheral participation within a Community of Practice, we charted student activities on clinical placements at an outer metropolitan health service. Results: The multiple data collection methods helped to identify how students learn through work as their expertise develops. The activity logs, survey and interviews prior to the observation phase, helped sensitise researchers to the less visible student contributions. Students in their final year contributed like a junior team member: taking patient histories, completing discharge planning and taking on ‘busy jobs’ that freed up senior team members. Discussion: The multiple data collection methods and variety of stakeholder participants allowed for triangulation of the findings, and the phased approach sharpened the focus for the student observations. Capturing the patient perspective presents challenges, as does taking into account differences in student year levels, and different levels of student engagement. Conclusions: A multi-phased, mixed methods approach can identify bi-directional benefits, mapping student contributions along a number of dimensions.
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ItemNo Preview AvailableBurden or bonus? The impact of medical student placements on health services(Australian & New Zealand Association for Health Professional Educators (ANZAHPE), 2018)Introduction: Workplace learning plays a key role in developing work-ready medical graduates. The literature has focussed on how students learn in these complex settings with little research exploring the costs and benefits of student placements for different stakeholders. Aim: This study identified the perceived costs and benefits of medical student clinical placements for multiple stakeholders in the healthcare system. Methods: The study, funded by the Medical Deans of Australia and New Zealand, was conducted at a large outer metropolitan healthcare service. Data collection included observation of students, activity profiling, focus groups, and interviews with a range of stakeholders. Quantitative data were analysed using descriptive statistics and qualitative data were thematically analysed. Results: Multiple data sets identified the time cost in hosting medical students including briefing and debriefing with students, questioning/explanation, and more formalised teaching such as tutorials. Benefits identified included students contributing to clinical work, increasing reflective practice of clinicians, workforce recruitment, and improving patient experience through education. The extent of student contribution depended on clinical domain, student proactivity and level of experience. Discussion: The degree to which medical students contribute to healthcare depends on the characteristics of the clinical context, as well as the experience and engagement of learner and supervisor. Further research across programs and contexts is warranted, including extended ethnographic approaches to capture the less visible contributions. Conclusions: This multi-phased study identified that students do more than complete ‘busy tasks’ on clinical placements. Their presence as observers was reported to heighten clinicians’ reflective practice.
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ItemNo Preview AvailableCommunity engagement programs and socially accountable medical education(The Australian & New Zealand Association for Health Professional Educators, 2016)
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ItemNo Preview AvailableFactors associated with readmission after chronic obstructive pulmonary disease related hospitalisation(WILEY, 2018-03)Introduction/Aim: Acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD) are associated with increased morbidity and mortality. Readmission within 30 or 60 days of discharge remains common. The purpose of this study was to identify factors in COPD admissions that are associated with readmission at two Melbourne teaching hospitals. Methods: Admissions where COPD was the principal diagnosis between August 1st and December 31st 2016 were retrospectively reviewed through the electronic database of Western Health. Information pertaining to the patient, COPD severity and treatment, as well as to the admission itself was recorded. Admissions were not recorded if they were incomplete, if follow-up was not possible, or if the admission concluded with death. Data was analysed through STATA (v14.2). Results: 211 admissions were included. The outcome 30-day readmission occurred 39 times (19.0%) and the outcome 60-day readmission occurred 60 times (28.4%). Patients who were readmitted were generally older and male. Univariate analysis demonstrated that the risk of 30-day readmissions was higher in patients with more previous COPD or total admissions, lower FEV1, higher bicarbonate levels, abnormal chest x-rays, admissions to Footscray Hospital, higher number of regular medications, and a recent history of pulmonary rehabilitation or Hospital Admission Risk Program participation. Multivariate analysis showed that a higher number of regular medications, a recent COPD admission, a higher white blood cell count, and higher bicarbonate levels on admission were associated with 30-day readmissions (corrected for age, sex, and hospital site). Similar associations were observed for 60-day readmission. Conclusion: Readmission within 30 and 60 days of discharge after admission for AECOPD are common in the Western Health population. Several factors were significantly associated with readmission, in particular those related to COPD severity.
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ItemNo Preview AvailableQuality of communication regarding patient care in the Intermediate Respiratory Care Unit (ircu)(WILEY-BLACKWELL, 2016-04)Introduction/Aim: Intermediate Respiratory Care Units (IRCU) are commonly used to facilitate management of patients in respiratory failure requiring a period of non-invasive ventilation (NIV) who can be managed in the ward (non-intensive care) setting. At Western Health, these patients are admitted under the Respiratory unit or an alternative unit (for example General Medicine). Patients requiring NIV are managed collaboratively by their admitting unit and the Respiratory unit with support from allied health and nursing staff. Clear delineation of responsibility and good communication is essential between those managing IRCU patients to ensure timely decision making and optimal patient care. There is anecdotal evidence that the communication between specialties managing these patients is often suboptimal. An objective assessment of the limitations in understanding and communication will allow delivery of appropriate and meaningful education to those involved in IRCU patient care. Methods: Staff involved in the management of patients admitted to the IRCU at Footscray Hospital were surveyed to assess their understanding of the role of the Unit and their responsibilities with regard to shared management of patients in the unit. Additionally, the inpatient records of all patients admitted to the unit over three non-consecutive months in 2014 were reviewed to assess the quality of written communication between the Respiratory unit, home unit (where applicable), nursing staff and allied health using a standard assessment form. Results: Preliminary review of survey responses reflects a reported good understanding of the role of IRCU and the indications/contraindications for management of patients in IRCU. There was a less satisfactory understanding of appropriate lines of communication and division of responsibility between specialties. We expect in-depth review of the survey responses to elicit clear areas that need further education. Analysis of the inpatient records will provide objective evidence of quality of written communication regarding patient care and decision making. Conclusion: Ongoing analysis of inpatient notes and survey responses will provide a clear picture of areas requiring further education and improvement. This will enable the improvement of current guidelines for the management of patients in IRCU and an education package to improve understanding of staff managing these patients. This will ultimately result in improvement in quality of patient care in the Unit.
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ItemNo Preview AvailablePrevalence of illegal inhalant use among patients undergoing respiratory function tests at Western Health(WILEY, 2017-03)Introduction/Aim: In 2014, 75% of Victorian Illicit Drug Reporting System participants reported recently using methamphetamine (75%), significantly higher than in 2013 (55%, p < 0.001). Cannabis lifetime use was 97%, with 75% recent users and 47% daily users. Lifetime use of E-cigarettes was 27% and recent use was 23%, with a median frequency of use of two days. (IDRS 2014)1 Little is known about the prevalence of illicit inhalant use in Melbourne's Western suburbs. Footscray and Sunshine Hospitals serve the most disadvantaged areas of Melbourne with the highest rates of unemployment. It has been found that the unemployed population is 1.6 times more likely to use cannabis and 2.4 times more likely to use methamphetamines. (AIHW 2014)2 The purpose of this study is to identify the prevalence of illegal inhalant use among patients undergoing respiratory function tests at Western Health. Methods: This study is a prospective audit and involves the completion of an anonymous questionnaire by patients performing respiratory function tests over three months. The questionnaire explores recent and current usage of inhaled methamphetamine, marijuana and tobacco via E-cigarettes and standard cigarettes. The questionnaire is available in multiple languages. The anticipated dataset is 300–500 patients. Voluntary completion of the survey is requested from all adult patients (>18 years) with implied consent. Results: Data collection has commenced across two laboratories. We anticipate the data will corroborate anecdotal reports of high drug use amongst the Western Health patient population. Conclusion: Counselling regarding the use of illicit inhalants represents an important and under-emphasised aim for patients at Western Health. Through demonstrating the prevalence of illicit inhalant use within our population, we hope to increase awareness of this issue amongst our doctors. Concurrent education on topics such as street names and modes of delivery will enable doctors to elicit a more thorough illicit drug history.
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ItemNasal Resistance Is Elevated in People with Tetraplegia and Is Reduced by Topical Sympathomimetic Administration(AMER ACAD SLEEP MEDICINE, 2016)STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is common in individuals with tetraplegia and associated with adverse health outcomes. The causes of the high prevalence of OSA in this population are unknown, but it is important to understand as standard treatments are poorly tolerated in tetraplegia. Nasal congestion is common in tetraplegia, possibly because of unopposed parasympathetic activity. Further, nasal obstruction can induce OSA in healthy individuals. We therefore aimed to compare nasal resistance before and after topical administration of a sympathomimetic between 10 individuals with tetraplegia (T) and 9 able-bodied (AB) controls matched for OSA severity, gender, and age. METHODS: Nasal, pharyngeal, and total upper airway resistance were calculated before and every 2 minutes following delivery of ≈0.05 mL of 0.5% atomized phenylephrine to the nostrils and pharyngeal airway. The surface tension of the upper airway lining liquid was also assessed. RESULTS: At baseline, individuals with tetraplegia had elevated nasal resistance (T = 7.0 ± 1.9, AB = 3.0 ± 0.6 cm H2O/L/s), that rapidly fell after phenylephrine (T = 2.3 ± 0.4, p = 0.03 at 2 min) whereas the able-bodied did not change (AB = 2.5 ± 0.5 cm H2O/L/s, p = 0.06 at 2 min). Pharyngeal resistance was non-significantly higher in individuals with tetraplegia than controls at baseline (T = 2.6 ± 0.9, AB = 1.2 ± 0.4 cm H2O/L/s) and was not altered by phenylephrine in either group. The surface tension of the upper airway lining liquid did not differ between groups (T = 64.3 ± 1.0, AB = 62.7 ± 0.6 mN/m). CONCLUSIONS: These data suggest that the unopposed parasympathetic activity in tetraplegia increases nasal resistance, potentially contributing to the high occurrence of OSA in this population.
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ItemRelationship between autonomic cardiovascular control and obstructive sleep apnoea in persons with spinal cord injury: a retrospective study.(Springer Science and Business Media LLC, 2018)STUDY DESIGN: Retrospective study. OBJECTIVE: To determine if there is an association between obstructive sleep apnoea (OSA) and blood pressure (BP) pattern or heart rate variability (HRV) in people with spinal cord injury (SCI). SETTING: A state-based spinal cord service in Victoria, Australia. METHODS: We identified 42 subjects who had ambulatory BP monitoring (ABPM) within 6 months of a diagnostic sleep study at Austin Hospital between 2009 and 2014. Markers for autonomic function, including circadian BP pattern and HRV were extracted from the ABPM study database. Apnoea/hypopnoea index (AHI), arousals/hour and oxygen desaturation index were extracted from the sleep study database. Subjects with a nocturnal systolic BP dipping more than 10% of daytime value were defined as dippers, between 10 and 0% were non-dippers and those with a higher night than day systolic BP were reverse dippers. Severity of OSA is classified as non-OSA (AHI < 5), mild (AHI 5-15), moderate (AHI 15-30) and severe (AHI > 30). RESULTS: Subjects (n = 42) were predominantly male (85.7%), aged 44 ± 15.4 (mean ± SD), with a BMI of 24.4 ± 5.7 (mean ± SD) and mainly tetraplegic (92.9%). There was no difference in AHI, oxygen desaturation index or arousals/hour between dippers, non-dippers and reverse dippers. None of the HRV parameters differed between dippers, non-dippers and reverse dippers. No differences were found in 24 h, night-time, daytime or nocturnal dip in BP between subjects with non-OSA, mild, moderate and severe OSA. CONCLUSION: We found no relationship between BP pattern or HRV and the severity of OSA in persons with SCI.
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ItemDiacetylbis(N(4)-methylthiosemicarbazonato) Copper(II) (CuII(atsm)) Protects against Peroxynitrite-induced Nitrosative Damage and Prolongs Survival in Amyotrophic Lateral Sclerosis Mouse Model(AMER SOC BIOCHEMISTRY MOLECULAR BIOLOGY INC, 2011-12-23)Amyotrophic lateral sclerosis (ALS) is a progressive paralyzing disease characterized by tissue oxidative damage and motor neuron degeneration. This study investigated the in vivo effect of diacetylbis(N(4)-methylthiosemicarbazonato) copper(II) (CuII(atsm)), which is an orally bioavailable, blood-brain barrier-permeable complex. In vitro the compound inhibits the action of peroxynitrite on Cu,Zn-superoxide dismutase (SOD1) and subsequent nitration of cellular proteins. Oral treatment of transgenic SOD1G93A mice with CuII(atsm) at presymptomatic and symptomatic ages was performed. The mice were examined for improvement in lifespan and motor function, as well as histological and biochemical changes to key disease markers. Systemic treatment of SOD1G93A mice significantly delayed onset of paralysis and prolonged lifespan, even when administered to symptomatic animals. Consistent with the properties of this compound, treated mice had reduced protein nitration and carbonylation, as well as increased antioxidant activity in spinal cord. Treatment also significantly preserved motor neurons and attenuated astrocyte and microglial activation in mice. Furthermore, CuII(atsm) prevented the accumulation of abnormally phosphorylated and fragmented TAR DNA-binding protein-43 (TDP-43) in spinal cord, a protein pivotal to the development of ALS. CuII(atsm) therefore represents a potential new class of neuroprotective agents targeting multiple major disease pathways of motor neurons with therapeutic potential for ALS.