Melbourne Medical School Collected Works - Theses
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ItemExploring the qualities of Electronic Health Record medical student documentation( 2016)Written communication within the health professions has been rapidly changing over the last decade. Implementation of Electronic Health Records (EHR) in health services is now widespread. Medical student teaching and learning of the skills specifically required for EHRs has lagged behind the implementation. Very few original studies have focused on EHR skills and there are no validated measures by which to assess any of the EHR skills students are expected to develop. Our study explored the attributes of quality EHR documentation recorded by medical students, with the purpose of the EHR documentation being the communication between health care professionals to share or transfer the clinical care of a patient. Recently there have been published validated instruments for measuring quality in physician EHR documentation, one being Physician Documentation Quality Instrument (PDQI-9). The purpose of this study was to explore the attributes of quality of EHR documentation written by first-year clinical medical students by building upon existing literature. The PDQI-9 was used as a basis for defining the attributes of quality in EHR documentation as a foundation for assessing and providing feedback on the performance of documentation to medical students. With the focus on assessment, and providing a content validated test domain for assessment in quality EHR documentation, we utilised Kane’s framework for validity to structure the study and a mixed method study design to achieve the depth of exploration required to examine the performance of quality documentation fully. The study was conducted in two stages. In the first stage of the study, an expert panel of assessors applied the PDQI-9 to existing EHR data recorded by first clinical year medical students in a graduate entry program. The assessors both scored the records and justified their grading. Descriptive statistics and thematic analysis were undertaken on the data collected, and the findings triangulated with the literature review. The second stage employed explanatory semi-structured interviews with the expert assessors to better understand the findings of the first stage and reach consensus on a test domain for assessing quality documentation recorded by medical students. Outcomes from our study indicated that the PDQI-9 in its current format was not valid in a medical student setting, however most of the attributes assessed by the PDQI-9 were deemed relevant and meaningful to assess if their interpretations were clarified. In addition, Professionalism of documentation was regarded as a quality attribute. Consensus was reached on modifications that have the potential to improve the validity of the assessment of quality documentation recorded by medical students. Further studies need to complete Kane’s framework of validity for an assessment instrument and collect evidence to broaden the validity of the scoring, the generalization of the assessment items, the extrapolation to the real world and the implications of this assessment for students and health services.
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ItemExploring the use of eLearning resources and preparedness of medical students transitioning to hospital internship( 2015)The increasing use of online technology in medical education and junior doctor training raises questions about the efficacy of this approach to improve the preparedness of medical students transitioning to internship. This study examined the use of eOrientation resources for hospital and ward orientation by medical students during transition from medical school to internship, with the aim of determining what attributes make an online resource useful and what effect an eOrientation program can have on preparedness for hospital practice. More specifically, the research questions focussed on how intern preparedness changed following implementation of eOrientation, which resources were most and least used, which were found to be most and least useful and what common themes could be found with respect to the type of resources interns found most useful. A mixed method case study approach was used to explore the use of eLearning resources and preparedness of medical students transitioning to internship. The Preparation for Hospital Practice questionnaire was administered to a cohort of 74 interns at a metropolitan teaching hospital before they had undertaken any form of hospital orientation. The questionnaire was then readministered at the conclusion of their second hospital unit rotation. Learning management system data was used to examine resource usage, supplemented by personal interviews to extract detail rich information regarding which resources were found most useful. The study found that interns initially felt well prepared for internship with a minor increase in preparedness over time. Resources which were interactive, role relevant and assisted in application of identity formation tasks were deemed most useful. eOrientation was found to be a useful supplement to the suite of teaching and learning methods used for transition to internship. Findings from the study suggest that the value of eOrientation can be further enhanced when resources are directed to interns, interactive and role relevant while also considering the temporality of a resource. Resources made by or with input from interns were also found to be particularly useful, leading to a recommendation of utilising instructional designers in medical education teams in order to assist in managing stakeholder input, assess content suitability across the transition curriculum and design interactive resources. eOrientation can be an effective teaching and learning method if a considered and holistic approach to transitional curriculum development is adopted.
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ItemConsiderations for surgical intervention in metastatic cancer to the spine: evaluation of risk factors for pathologic fracture and spinal cord compression, and analysis of pre-operative scoring systems for the prognostication and treatment of patients with spinal metastases( 2014)The spine has structural load bearing and neural-protective functions, and tumour growth and bony destruction caused by spinal metastases results in pathologic fracture and cord compression, causing pain, neurological deficit, impaired function and quality of life. Surgery is the only method to immediately stabilise the spine and decompress the spinal cord. Survival prognosis is one of the key factors in selecting patients for surgery, and there are a number of scoring systems aimed at prognostication and treatment decision making for patients with spinal metastases, however these differ in the parameters assessed and prognostic value. The ability to predict those patients with spinal metastases most likely to progress to pathological fracture or develop spinal cord compression may simplify the surgical decision-making process and enable earlier surgical intervention, with the potential to prevent permanent neurological deficit and disability and maintain function and quality of life for the remainder of the patient's life. This thesis considers the complexities of treatment decision making for patients with spinal metastases, with two major aims: 1) An evaluation of patient risk factors and radiological parameters associated with pathological fracture and metastatic epidural spinal cord compression, and 2) Validation of survival prognostication of current pre-operative prognostic scoring systems, in order to optimise the treatment decision-making process. The methodology involved retrospective assessment of clinical and radiological parameters of 72 patients with spinal metastases who had undergone decompressive and/or stabilisation surgery for pathological fracture and/or metastatic epidural spinal cord compression or nerve root compression. The items assessed for association with pathological fracture or metastatic epidural spinal cord compression were: tumour size, location, type and lesion morphology, disease burden, pain and function. Pre-operative scores were calculated for each patient, and the prognostic value of each scoring system evaluated by comparison of predicted and actual survival. The results showed that tumour size within the vertebral body, vertebral endplate and three-column involvement, tumour growth rate, multiple vertebral metastases, and pain were associated with increased risk for pathological fracture. Vertebral posterior element and costovertebral joint involvement by tumour, primary tumour growth rate and presence of visceral metastases were associated with metastatic epidural spinal cord or nerve root compression. All patients with pathological fracture had at least one of three risk factors – pain; >25% tumour occupancy of vertebral body; and endplate or 3-column involvement – and incidence of pathological fracture increased with higher number of risk factors. The Revised Tokuhashi, Bauer, Modified Bauer, and Tomita scoring systems were the most reliable for survival prediction. It is concluded that these risk factors should be considered in the decision-making process for surgery for spinal metastases. Patients with spinal metastases causing pain, greater than 25% occupancy of the vertebral body and involving the vertebral endplate or all three columns should be considered for prophylactic or therapeutic decompressive and stabilization surgery. As a component of comprehensive treatment planning, we recommend the use of Revised Tokuhashi, Modified Bauer, and Tomita scoring systems due to their favourable survival prognostic accuracy and clearly outline of treatment strategy according to prognostic group.