Melbourne Medical School Collected Works - Theses
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ItemWhat is the clinical placement experience of prevocational doctors in Victorian health services compared with the defined curriculum, and how may this have been shaped by contemporary healthcare delivery?( 2015)Medical training in Australia and comparable countries internationally is based on an apprenticeship model of training. However this has been challenged by contemporary healthcare practices as well as the limited training capacity of the acute care settings where medical training is largely undertaken. While this impacts all phases of medical training, it is the prevocational phase in Australia that is most vulnerable as its training outcomes are poorly defined and not routinely measured. Similarly, while a twelve‐month rotation‐based internship has existed in Australia for decades, the effectiveness of this model in providing core training and clinical competencies for prevocational doctors has not been rigorously evaluated, and is currently being questioned. This research seeks to better understand the clinical placement experience of prevocational doctors in Victorian Health Services, and to consider how this may be affected by contemporary healthcare delivery. The research has been designed as a mixed –methods study, where data obtained from a broad‐based survey of exposure to a range of clinical curriculum‐based activities of junior doctors from seven Victorian health services was explored by groups of junior doctor supervisors and managers. These research findings have concurred with limited previous literature, noting that prevocational trainees have limited exposure to a number of curriculum areas, particularly within the curriculum domains of procedures and emergency management, as well as teaching and learning activities, and other more complex patient management and interaction activities. It has identified that particular intern core terms and PGY2 clinical streams may provide better access to curriculum experiences than others, and that there may be particular curriculum strengths and weaknesses of prevocational training in metropolitan versus regional areas. It has also suggested that the current prevocational curriculum framework is variably understood by health service supervisors and managers, and that these findings have potentially significant implications for the trainees themselves, for length of training, and for the confidence and competence of the end practitioner. Essentially a key finding from this research is that acute health services are increasingly performing high‐risk activities within constrained environments, resulting in changes to healthcare teams and individual roles – and the legitimate peripheral participation of junior doctors in clinical care has decreased in proportion to the acuity and specialisation of the activity involved. While local educational initiatives to overcome this challenge are currently being variably utilised by health services, they do not ensure ongoing repeated curriculum exposure and therefore curriculum mastery. Instead, system‐wide issues require to be addressed by a system wide approach. Lave and Wanger’s Situated Learning theory (1991) provided a framework through which the research results were viewed, and provides a lens through which recommendations can be conceptualised. Essentially, this thesis recommends reform of prevocational training ‐ that redefines its role; that addresses curriculum ambiguity; that enhances junior doctor access to legitimate peripheral participation; and that re‐establishes communities of practice. These medical training reforms need to be undertaken within a clear, integrated governance model, and supported by ongoing evaluation and innovation.
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ItemParticipatory health through social media in chronic disease: a framework for research and practice( 2015)As participatory health develops, healthcare as a whole continues to cautiously embrace social media and the vast possibilities they can bring. They may be useful to transform the management of people living with chronic disease by enabling them to be more active participants and shared-decision makers in their own care. Unfortunately, limited definitive evidence exists indicating that social media use can improve health outcomes, nor is research mature enough to have established stringent methodologies for examining social media in this context. Unlike a variety of evidence-based guidelines suggesting best practice for an array of chronic diseases, evidence that could underpin guidelines for use of social media remains inadequate. There are many unknowns, for example: How social media are used as part of self-management, what mechanisms underpin social media’s therapeutic potential, the health outcomes and other effects most likely to be impacted by social media, and whether social media can form an effective part of management in the clinical setting. The key challenge addressed by this thesis is whether criteria and methods for generating and evaluating evidence about health outcomes from social media use can be defined. A framework for research and practice has been developed, tested and refined to address this challenge. With further research using the framework across a range of conditions and contexts, evidence about patient-reported outcomes from social media use will grow. This will improve evidence-based decision-making about social media and ultimately benefit a variety of stakeholders: patients, clinicians, health researchers and health informaticians.
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ItemProfessional roles and relationships in health models of care: a study of insulin initiation in Australian general practice( 2015)Background: The majority of care for people with type 2 diabetes occurs in general practice in Australia, yet insulin initiation is often delayed in this setting and many people are referred to specialists (endocrinologists and registered nurse credentialed diabetes educators (RN-CDEs)). Stepping Up (SU) is a new model of care supporting insulin initiation in general practice which includes an enhanced role for practice nurses (PNs) with support and mentoring from a SU RN-CDE. Successful implementation of this model of care is likely to be shaped by interprofessional roles and relationships. Relational Coordination (RC) theory provides a conceptual framework to study key factors underpinning effective interprofessional work. Aim: To explore the roles and relationships between health professionals involved in insulin initiation, how these are affected by models of care and whether, within the Stepping Up model of care, they are associated with improved clinical outcomes. Methods: I conducted five related sub-studies utilising RC theory. The first two sub-studies were exploratory and utilised a survey and interviews to explore current levels of RC between endocrinologists, RN-CDE, General Practitioners (GPs) and PNs for the task of insulin initiation, perceived appropriateness of this task in general practice and contextual factors influencing RC. The last three sub-studies were nested within a randomised controlled trial testing the effectiveness of SU. I analysed a baseline cross sectional survey exploring characteristics of participating GPs, PNs and general practices associated with RC for the task of insulin initiation. I explored how GPs and PNs perceived that SU had impacted on professional roles and RC using qualitative methods. Finally, I performed a quantitative analysis to determine whether RC was a partial mediator of the effect of SU on glycaemic outcomes. Results: There was agreement from all four health professional groups that general practice-based initiation of insulin was appropriate. Potential barriers to achieving this in practice included a lack of communication and relationships between health professionals across secondary/specialist and primary care, with weak RC reported between PNs and RN-CDE. Specialists had concerns about the competence and capacity for PNs to have a role in insulin initiation. Factors associated with stronger RC included PN qualifications in diabetes education, PN prior experience with insulin initiation, younger PN age and increasing rurality of general practices. Dedicated space and protected time for PNs to participate in insulin initiation and RN-CDE mentoring were identified as important facilitators for an expanded PN role. While SU was associated with improved glycaemic outcomes, this was not mediated by RC with RN-CDE reported by PNs. Conclusion: SU was explicitly designed to change professional roles to support insulin initiation in general practice. SU was associated with stronger inter-professional relationships, particularly between PNs and the SU RN-CDE, and improved clinical outcomes for patients. Other important factors in normalising the SU model of care into Australian general practice include achieving interprofessional consensus on the role of PNs in insulin initiation, funding structures to support the PN and SU RN-CDE roles and organising general practice to support expanded PN roles.
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ItemVitamin D and HIV: exploring determinants of 25-hydroxyvitamin D and altered vitamin D metabolism in HIV-infected adults( 2015)Background: Vitamin D deficiency is a widespread global problem of particular importance for people with HIV. Vitamin D is an important hormone for endocrine and extra-endocrine functions, including modulating the immune system. Vitamin D deficiency is associated with reduced bone mineral density and infectious diseases, both common in people with HIV. Maintaining optimal vitamin D levels may help to reduce the risk of developing these diseases. The overall research questions for this thesis are: Firstly, which factors influence vitamin D metabolites, and secondly, what effect does vitamin D status have on bone and immunological outcomes, in people living with HIV infection? Method: To answer these questions, five studies were performed: 1. Cross-sectional comparison of 25(OH)D levels in HIV-infected and uninfected individuals in southern Australia. 2. Cross-sectional analysis of the determinants of 25(OH)D in people with HIV in Queensland and Melbourne, Australia. 3. Cross-sectional analysis of parathyroid hormone levels in antiretroviral-treated individuals. 4. Cross-sectional analysis of the effect of 25(OH)D on bone mineral density in antiretroviral-treated individuals. 5. Longitudinal analysis of CD4 cell count trajectory in antiretroviral-untreated individuals. Results: 1. People with HIV were more likely to be vitamin D deficient when compared with people without HIV in southern Australia. 2. Determinants of 25(OH)D levels: a. UV index and location are important determinants of 25(OH)D levels in people with HIV in Australia. b. Antiretroviral therapy impacts 25(OH)D levels: i. Efavirenz is associated with lower 25(OH)D levels, particularly in those with dyslipidaemia. ii. Protease inhibitors are associated with higher 25(OH)D levels. 3. The effect of tenofovir on parathyroid hormone levels depends on sex and ethnicity; parathyroid hormone levels were higher in non-white males using tenofovir. 4. Influence of ART and 25(OH)D on 1,25(OH)2D levels and bone mineral density: a. People using tenofovir have higher 1,25(OH)2D levels and people using protease inhibitors have lower 1,25(OH)2D levels. b. There is an interaction between tenofovir and 25(OH)D status on 1,25(OH)2D levels and bone mineral density. Vitamin D deficiency increases the odds of low bone mineral density only in those not using tenofovir. 5. Vitamin D deficiency may reduce the time to CD4 decline to <350 cells/μL in people living with HIV and untreated with antiretroviral therapy. Conclusions: Traditional risk factors for vitamin D deficiency and bone mineral density appear to be more important than HIV-related factors in people with HIV. In spite of this, antiretroviral therapy clearly alters vitamin D and bone metabolism. Understanding the mechanisms behind these alterations may assist in modifying the negative effects of vitamin D deficiency.
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ItemPost-test feedback: knowledge acquisition & learning behaviours( 2015)This study, situated within the conceptual framework of assessment for learning, was motivated by the desire to find a practical way of providing informative and useful post-assessment feedback to medical students. The work was informed by the theories of test-enhanced learning and the principles of good feedback. It employed mixed methods to explore the impact of the study interventions on learning behaviour and knowledge acquisition. Set within an authentic medical educational setting, this study modelled an innovative method for production and distribution of individualised feedback reports following written multiple choice assessment. Year two students in a graduate entry medical program received four modified progress tests during their academic year and were randomised into three feedback groups. Feedback formats were selected to provide information about performance and guidance for learning without requiring release of test questions and answers. All feedback groups received test scores and some form of instruction based elaboration. Two groups were provided with variations of item level verification and instruction based elaboration, while the other group received normative data with general (rather than item level) instruction based elaboration. Outcomes of interest included study diaries, progress test scores, summative examination results, questionnaires and semi-structured interviews. Triangulation of the research data was used to interpret results. Outcomes from this study suggest there was a learning benefit from the test and feedback interventions. It appears that this benefit was achieved through direct interaction with the tests, and through the ability to self-monitor levels of knowledge and evaluate the effectiveness of study activities. Behaviour changes identified as a result of the study interventions included general study prior to tests, increased study following tests and feedback, and altered study behaviours involving different content, techniques and study aids. Of the three feedback types provided in this experiment, feedback consisting of grades, general instruction based elaboration and normative comparison appeared to be most easily interpreted and provided motivation for study, but resulted in inferior performance for students in the lower quartile of the cohort. This experiment demonstrates that it is feasible to produce and distribute individualised post-test feedback reports following paper based clinical vignette MCQ tests within a clinical learning environment. It highlights the potential of regular formative assessment to play an important role in directing focus of study and clarification of expectation of study depth and breadth. Medical students are often considered a relatively homogenous and high achieving cohort, yet results of this study suggest their responses to feedback are influenced both by the type of feedback information provided and the students’ relative ability within their learning cohort.