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Background At Deakin University School of Medicine, compulsory formal teaching in Surgery occurs in year 3. This may occur as part of a rural longitudinal integrated clerkship (LIC), or in a traditional teaching hospital block rotation (BR). The purpose of this study was to compare these groups’ exposure to surgical common conditions and their academic outcomes. Methods Part I: This was a survey of students’ encounters with patients with common surgical conditions between 2016 and 2018. Self-reported data were collected describing the nature of the encounters and their clinical settings. Part II: All third year Surgery MCQ and OSCE results from 2011 to 2017 were analyzed. Students were deidentified and grouped according to whether they were in the LIC or BR programme. Results Part I: Thirty-eight third year students (20 LIC, 18 BR) submitted data for a total of 188 clinical encounters. Both groups encountered all nominated common surgical conditions, but the settings in which this occurred were different. BR students saw most patients as hospital inpatients whereas LIC student encounters were distributed across multiple clinical sites. Part II: A total of 942 (121 [26%] LIC and 821 [74%] BR) students’ assessment results were analyzed. The groups performed similarly in the MCQ (p = 0.21) and OSCE (p = 0.16) examinations. Conclusions Students who were taught surgery in a LIC program performed similarly to on their final exams to their peers in traditional clerkships, with self-reported student data indicating both groups encountered a similar range of conditions.

To provide a structured understanding of rural hospital-based emergency care facility workforce and resources.The resources of regional training hubs were used to survey eligible emergency care facilities in their surrounding region.Rural emergency care facilities manage more than one third of Australia's emergency presentations. These emergency care facilities include emergency departments and less-resourced facilities in smaller towns.Hospital facilities located outside metropolitan areas that report emergency presentations to the Australian Institute of Health and Welfare.A survey tool was sent by email.Presence of human, diagnostic and other resources as reported on a questionnaire.A completed questionnaire was received from 195 emergency care facilities. Over 60% of Small hospitals had on-call doctors only. General practitioners/generalists and nurses with extended emergency skills were found in all hospital types. Emergency physicians were present across all remoteness areas, but more commonly seen in larger facilities. All Major/Large facilities and most Medium facilities reported having onsite pathology and radiology. Point of care testing and clinician radiography were more commonly reported in smaller facilities. Among Small hospitals, Very Remote hospitals were more likely than Inner Regional hospitals to have an onsite doctor in the emergency care facility and/or a high dependency unit.Smaller and more remote facilities appear to adapt by using different workforce structures and bedside investigations.

Clinicians’ experiences inform my work in medical education. Oliver’s suggestions for post-covid hospital visiting restrictions, allowing clinicians uninterrupted space to do their best work, made me pause for thought.1 Workplace stress for my clinical colleagues is enormous, but we need to question our responses and have them questioned by others. Covid-19 has made students anxious and uncertain about clinical exposure and developing competence. Already feeling starved of “hands-on” experience, they are eager to develop their expertise, and Oliver’s suggestion would influence that. Abused patients need …

To compare the participation of rural Longitudinal Integrated Clerkship (LIC) and rural Block Rotation (BR) students in surgical clinical activities.Third-year medical students from Deakin University's Rural Clinical Schools were invited to record their participation during clinical encounters with ten common surgical conditions, using a descriptive five-point progressive entrustment scale. Participation levels of LIC and BR students were compared for differences, according to clinical task and context.LIC students recorded greater active participation across all clinical tasks.Highest levels of active participation occurred in General Practice, a setting only LIC students were exposed to at this course stage. BR students recorded the majority of their surgical encounters in the hospital inpatient setting, where their involvement was predominantly observational. Both groups recorded high levels of participation in the Emergency Department.Active participation in clinical encounters with surgical patients was enhanced by participation in a LIC program and cannot be attributed to the rural context alone. Student participation is influenced by clinical context, presenting the opportunity to reconsider the design of clerkships to include models that facilitate active student participation. Further research is required to investigate the learner, supervisor and contextual factors influencing entrustment decisions within clerkships.

Disruption of circadian rhythm has a significant impact on the physical, psychosocial, and professional lives of night shift nurses. How night shift nurses learn the coping techniques they employ to adapt to this disruption was examined in a qualitative, cross-sectional survey of 42 nurses. A template analysis technique was used to categorize the responses, which were then compared to industry "best practices" in fatigue countermeasures. Results documented the variety of sleep/wake routines nurses employ to cope with circadian disruption as well as a wide-ranging variety of behaviors related to driving while fatigued.

Background: Academically bright and ambitious medical students must cope with a combination of curriculum, assessment, career choice, personal, family and social pressures. Many seek support, and some present complex problems that consume substantial resources. A few continue unresolved into postgraduate life and may affect future professional performance. Early intervention may be helpful in minimising the impact on both individual students and school resources. Aim: To develop a broad classification framework for personal problems presented by medical students to student support services. Methods: We report a study of more complex student problems presenting to student support services. A three stage iterative process, involving student support faculty from several international medical schools, discussed case scenarios based on pooled experience and developed a framework for categorising and considering management. Results: Seven profiles of student problems were developed, based on composites of unidentified cases drawn from participants’ experiences, reflecting: immaturity; learning skills; organisational skills; health or personal issues and poor insight. Broad characteristics and brief prognostic comments are provided for each profile. Discussion: While profiles may overlap and each student may have a unique set of issues, there appears to be similarities that allow some categorisation for management strategies and prognostic features in both undergraduate and postgraduate medical education. Further work is needed to develop ‘diagnostic’ assessments that might guide intervention. Conclusion: This classification may assist early intervention into personal problems presented by medical students to student support services.

This paper describes how the development of critical reflection in student teachers has been made an explicit part of a teacher education programme. Using a rubric presented by Ward and McCotter, (2004) and supported by an online discussion forum, the rubric was used in a meta-analysis activity where students identified the quality of critical reflection in their lesson evaluations. The evidence suggests that the activity can result in a qualitative improvement in the nature of critical reflection. The intervention also appeared to generate a growing acknowledgement by students that writing lesson evaluations, is a valuable process which can enhance their practice.

Background Many UK medical schools have modified their curricula to meet the requirements of the General Medical Council and other external agencies. In particular, efforts have been focused on increasing integration and reducing factual overload through the definition of a core curriculum. Various approaches to curriculum change have been adopted in an attempt to meet such demands. Purpose This paper describes a curriculum development process, which commences with a clear vision, adopts an outcome-based approach and identifies clear statements of learning outcomes. The process led to the development of an outcome-focused core curriculum structured around clinical problems, which is available to all students and staff. Conclusion A model of curriculum development has evolved which is relatively simple in concept, and appears to be easy to comprehend by students, teaching staff and visitors from other institutions. It provides a practical framework for managing the difficult problems of integration and factual overload. It should be of general interest and applicability to other schools with health professional programmes looking for a realistic and acceptable way of defining a core curriculum.

Objective:To evaluate the feasibility and effectiveness of shared learning of clincal skills for medical and nursing students at the University of Manchester.Design:Medical and nursing students learned clinical skills in either uniprofessional or multiprofessional groups. These groups rotated through skills stations taught by multiprofessional facilitators. The groups stayed together for a series of 3 sessions held at weekly intervals (an induction meeting follwed by 2-3 hour teaching sessions). Both quantitative and qualitative methods were used to evaluate the project.Context:A total of 113 Tear 3 students registered on the Medical (n=41), Bachelor of Nursing (Honours) (n=43) or the Diploma for Professional Studies in Nursing (n=29) courses participated in the project which was set in the clincial skills unit of a teaching hospital.Results:Pre- and post self-evaluation of confidence levels for the taught skills revealed a statistically significant increase for all skills. The primary reason students gave for participation in the project was to learn or consolidate skills. An additional inducement for participation was the opportunity to share knowledge and observations between professional groups. Tutors also evaluated the experience favourably, particularly with regard to small group discussions. The indicated that the programme provided an opportunity to standardise clinical skills teaching.Conclusion:Collaborative learning opportunities for nursing and medical students are feasible and add value to the learning experience. Data indicate positive outcomes of learning in multiprofessional groups, comprising increased confidence levels, increased understanding of others' professional roles and personal development.

This paper describes one possible model for e-learning in undergraduate medical education with an emphasis on supporting and managing curriculum development. The University of Sheffield School of Medicine is undergoing a major revision of its undergraduate medical curriculum, prompted by requirements of the professional regulatory body, the General Medical Council (GMC), and the Quality Assurance Agency for Higher Education (QAA). A computer-based system was developed to provide more efficient administration of the current course and more effective delivery of educational materials to students. The Sheffield Networked Learning Environment (NLE) has been developed in collaboration with other medical schools. A new 'revised' curriculum, due to start in 2003, will be intensively supported by an NLE which has been extensively tested and modified through pilot studies in the current curriculum.

Recent increases in day case surgery offer new opportunities for medical student learning, whilst the reduction in surgical beds and length of hospital stays has reduced opportunities in traditional inpatient settings. To establish the extent and nature of undergraduate medical education in day surgery units in the UK, the authors undertook a postal questionnaire survey. Of the 227 units which replied, 45% are used for teaching. In 83% of these, students attend only single operating lists, and only 7% of units take students for more than 1 day per week. This suggests that students have very limited teaching in day surgery units. Diagnosis, common surgical procedures and rehabilitation are increasingly carried out in outpatient, day case and community settings. These may be missed by students unless educational programmes are responsive to trends in health care delivery. Day surgery units could play an increased role in medical education.

Atrial natriuretic peptide (ANP) which alters sodium balance, blood volume and vascular tone represents an important candidate for investigating the genetic basis of essential hypertension (EH). Accordingly, we have studied Bgl1 and Xho1 restriction fragment length polymorphisms (RFLPs) of the ANP gene in 147 hypertensive, 141 normotensive and 67 population-based control subjects from a homogenous population of West African origin from St Vincent and the Grenadines. We found no association of either Bgl1 and Xho1 RFLPs with EH. This study suggests that the ANP locus may not exert a major gene effect on EH amongst the black people of St Vincent and the Grenadines.

The renin-angiotensin system regulates blood pressure and sodium balance. The angiotensinogen gene which encodes the key substrate within this system has been linked to essential hypertension in White Europeans. It has been suggested that people of West African ancestry may have a different genetic basis for hypertension. In this study we have tested whether there is linkage of the angiotensinogen gene to essential hypertension in African Caribbeans from St. Vincent and the Grenadines. DNA from 63 affected sibling pairs with hypertension was tested for linkage by analyzing whether there was excess allele sharing among siblings genotyped using an angiotensinogen dinucleotide repeat sequence. There was significant support for linkage (T = 3.07, P = 0.001) and association of this locus to hypertension (chi 2 = 50.2, 12 degrees of freedom, P << 0.001). A DNA polymorphism which alters methionine to threonine at position 235 (M235T) within the angiotensinogen peptide has been associated previously with hypertension. However, we found no association of this variant with hypertension in this study. These findings provide support for linkage and association of the angiotensinogen locus to hypertension in African Caribbeans and suggest some similarities in the genetic basis of essential hypertension in populations of different ethnicity.

The first year of practice after medical school is considered to be an essential part of becoming a medical practitioner in Australia. Previous qualitative investigations have investigated a number of significant aspects of this early stage of professional development. This qualitative study explores experiences and developing professional identities during internship. Thirty interns and six intern supervisors were interviewed from three different Australian states. Grounded theory techniques were used to develop three key themes: internship-as-participation, internship-as-progression, and conflicts, parallels, disturbances and outliers. Key findings were: the important balance between support from colleagues and development through taking independent responsibility; and the strength of the view of internship as part of a 'natural progression', an inevitable evolution through the stages of medical training.

Summary The effects of ketoprofen on frusemide-induced diuresis, natriuresis and renin release were studied in 12 healthy male volunteers. Each received frusemide 40 mg once daily with either ketoprofen 100 mg twice daily or placebo for two periods of 5 days separated by a treatment-free period according to a randomized, double-blind, cross-over study design. Ketoprofen significantly reduced frusemide-induced diuresis on Day 1 but not on Day 5 of treatment. The natriuresis induced by frusemide on Day 1 or Day 5 of treatment did not differ significantly whether ketoprofen or placebo was administered, although the mean urinary sodium excretion values were consistently lower following ketoprofen. Ketoprofen did not affect the kaliuretic response to frusemide on Day 1 or Day 5 of treatment. The increase in plasma renin activity after frusemide was inhibited by ketoprofen on both Day 1 and Day 5. These results suggest that ketoprofen reduces the diuresis and renin release induced by frusemide, but that the reduction in diuretic response may become less important after their repeated coadministration.

This chapter describes the development and implementation of an ePortfolio to support the Graduate Certificate in Health Professional Education (GCHPE) at Monash University, Australia. The GCHPE addresses the skills and knowledge of teachers working in health, and encourages the development of a professional approach to teaching practice. The ePortfolio was developed primarily to enable the preparation and sharing of reflective tasks and assessment items constructed from the workplace of the course participants, and to facilitate written peer and tutor feedback. The first interprofessional cohort completed the course in 2003. In this chapter, the development process, evaluation methods, and results of the first year of implementation will be summarized. Problems experienced in the development and implementation process are identified along with recommendations for further action.

When considering implementing integrated curriculum models, such as problem-based learning (PBL), concerns may be expressed about the need for increased staff resources required to deliver tutor-led small group PBL. Less staff intensive ways of supporting PBL need to be explored. We compared the outcomes of a PBL module conducted in a large class format within a lecture theatre with a module having the same defined learning outcomes delivered in small group PBL format, both supported by e-learning resources. The pre-existing 27 small groups within the whole class (n = 246) of first year students undertaking a cardiovascular basic science module at Sheffield undergraduate medical school, UK, were randomized to 22 groups undertaking the large class Integrated Learning Activity (ILA) and 5 groups to traditional small group facilitated PBL sessions. Outcome measures were: a pre-post knowledge based test, a student educational effectiveness questionnaire, and assessment of student group work and presentations. There seemed to be no significant differences in learning outcomes between the methods although it is recognized that students would prefer the small group teaching format. Within institutions where resources to support small group PBL are limited, the large group ILA format supported with e-learning techniques may be a useful alternative approach.

Objectives To promote safe prescribing and administration of medicines in the pre-registration house officer (PRHO) year through a programme of structured teaching and assessment for final year medical students. Design Forty final year medical students from two medical schools were randomly allocated either to participate in a pharmacist facilitated teaching session or to receive no additional teaching. Teaching comprised five practical exercises covering seven skills through which students rotated in small groups. One month later, a random sample of 16 taught and 16 non-taught students participated in a nine-station objective structured clinical examination (OSCE) to assess the impact of the teaching. Setting Manchester School of Medicine (MSM), and Kings College School of Medicine and Dentistry (KCSMD). Participants Final year medical student volunteers. Main outcome measures The need for teaching as indicated by student prior experience; questionnaire rating of student acceptability of teaching and assessment; self-rating of student confidence post-assessment, and student performance assessed by OSCE. Results The study demonstrated that the taught group achieved higher scores in eight OSCE stations. Four of these were statistically significant (P

The focus of palliative care is to relieve human suffering; however, about 90% of patients with advanced cancer will experience severe pain. Intolerable human suffering may be defined in the healthcare setting as symptoms that cannot be tolerated or endured for any length of time. If the patient is unable to communicate, the family or identified decision maker for the patient may decide when symptoms cannot be endured any longer. All dimensions (i.e., physical, psychological, social, emotional, and spiritual) of the symptom causing suffering must be evaluated.

Indomethacin, a non-steroidal anti-inflammatory drug is known to increase the efficacy and toxicity of methotrexate, the widely used anti-cancer drug in man. The mechanism for this interaction has not been clearly established. However, since these drugs bind with albumin, a possible displacement of methotrexate by indomethacin from albumin might explain this interaction. To investigate the possible interaction an in-vitro protein-binding displacement study was carried out in 17 normal volunteers and in two groups of eight cancer patients. One group of patients had active disease and the other was in complete clinical remission. Serum samples were obtained and protein levels estimated. The protein binding of methotrexate was measured alone and with indomethacin using equilibrium dialysis. Statistical analysis of results suggested that the binding of methotrexate is not influenced by indomethacin, confirming that methotrexate is not displaced by indomethacin.

Background Traditional clinical clerkships have been based on the apprenticeship model of learning, with opportunistic teaching by doctors on presenting patients. Students at King’s College School of Medicine, London had expressed concern that they were receiving inequitable experiences in different clerkships. This had become more apparent since the introduction of a school-wide end-of-year skills assessment. We decided to assess the consistency of delivery of the surgical syllabus. Method A multistage questionnaire survey was undertaken with third-year (first clinical year) undergraduate medical students on surgical clerkships. The questionnaire required students to record topics about which they had been taught, and practical skills on which they had been supervised, from the surgical syllabus pertaining at the time. Results 194 (46·4%) questionnaires were returned. A low level of consistency was reported in the teaching of theoretical topics and practical skills across surgical clerkships in eight different locations. There were substantial differences, both in overall coverage of the syllabus and in the priority given to different topics. There were no overall differences between teaching hospital- and district general hospital-based clerkships. Discussion Students in so called ‘parallel’ clerkships did not receive comparable teaching. The traditional opportunistic nature of clinical teaching led, in effect, to individual curricula within each clerkship. The General Medical Council has called for a core curriculum to be delivered across different clinical sites within each medical school. To achieve this, medical schools may need to introduce guidelines to direct teaching in the same way that clinical protocols have been developed to achieve greater standardization in clinical practice.

Medical schools are having to adapt their teaching in response to the reduction in inpatient availability and the increase in outpatient and community care. A surgical course for first clinical-year undergraduate medical students was established in the day surgery unit at King's College School of Medicine and Dentistry in 1995. It was considered desirable because of the shift to day-case surgery, and proved feasible to run (Seabrook et al. 1997a). The course is taken by one-third of the annual intake of 120 students. A formal evaluation was undertaken comprising comparison of student performance in end-of-year clinical and multiple choice examinations and of acceptability to students, teachers and managers. The results showed no significant differences in performance between students who had taken the day-surgery course and those on other surgical attachments. Students' satisfaction with the course was significantly higher on nine individual criteria and lower on four criteria. The teaching was positively viewed by teachers and managers, despite having costs as well as benefits. We conclude that day-surgery centres can be used successfully to teach medical undergraduates. Experience in both inpatient and day-case environments should benefit students by reflecting more closely the reality of current surgical care.

The renin-angiotensin system is a powerful pressor system with a major influence on salt and water homeostasis. Angiotensinogen (also called renin substrate) is a key component of this system; it is cleaved by renin to yield angiotensin I, which is then cleaved by angiotensin-converting enzyme to yield angiotensin II. The observation that plasma angiotensinogen levels correlate with blood pressure and track through families suggests that angiotensinogen may have a role in essential hypertension. We therefore investigated whether there is linkage between the angiotensinogen gene on chromosome 1q42-43 and essential hypertension.Samples of DNA from 63 white European families in which two or more members had essential hypertension were tested for linkage of the angiotensinogen gene to this disorder. Affected cousins, nephews, nieces, and half-siblings were included when possible. To test for linkage, we used as a marker a dinucleotide-repeat sequence flanking this gene, and we employed the affected-pedigree-member method of linkage analysis. Two molecular variants of the angiotensinogen gene, one encoding threonine instead of methionine at position 235 (M235T) and the other encoding methionine rather than threonine at position 174 (T174M), were also tested for possible association with essential hypertension.We found significant linkage (t = 5.00, P0.001) and association (chi-square = 53.3, P0.001) of the angiotensinogen-gene locus to essential hypertension in the 63 multiplex families. This linkage was consistently maintained in the subgroup of subjects with diastolic pressure above 100 mm Hg and in the subgroups classified according to sex. It has been proposed previously that T174M and M235T are associated with essential hypertension. However, we found no association in our population between either polymorphism and this disorder.This study provides strong and consistent support for the linkage to essential hypertension of regions within or close to the angiotensinogen gene. Precisely how mutations in this region may result in hypertension remains to be determined.

This study was designed to assess the prevalence and nature of autonomic dysfunction (AD) in 34 patients with systemic sclerosis (SSc).Patients were questioned for current symptoms possibly related to AD. Five noninvasive cardiovascular autonomic function tests and sequential plasma catecholamine estimations at rest, during standing, and during sustained handgrip were performed. Seven patients with manometrically documented esophageal involvement and high resting plasma adrenaline levels were treated with clonidine (75 to 375 micrograms/d). One month later, resting plasma catecholamine estimations and esophageal motility studies were repeated.Autonomic testing revealed AD in each patient, while symptoms were experienced by 33 of them. Findings on two of the three heart rate tests and both blood pressure tests were significantly impaired as compared with those in 25 matched control subjects. Mean resting plasma adrenaline levels were 18 times higher than in 10 matched controls (p less than 0.001). Plasma catecholamine (adrenaline, noradrenaline, and dopamine) concentrations and mean arterial blood pressures fluctuated inappropriately during standing and sustained handgrip in 28 (82%) of the patients. The presence of headaches correlated significantly with sympathetic overactivity and instability (p less than 0.05). Resting plasma adrenaline concentrations correlated inversely with disease duration (p less than 0.05). Significant suppression of sympathetic overactivity and increases in resting lower esophageal sphincter pressures were observed in the seven patients treated with clonidine.AD is extremely common in SSc. It is characterized by parasympathetic impairment and marked sympathetic overactivity, particularly in early disease. The potential role of AD in the pathogenesis of SSc deserves further study.

Metronidazole concentrations in plasma were measured by h.p.l.c. in 12 healthy female volunteers after single and repeated vaginal administration of 500 mg metronidazole pessaries. The area under the plasma concentration-time curve (AUC(0,12 h) was 8.4 +/- 3.9 micrograms ml-1 h (mean +/- s.d.) on day 1 and 20.6 +/- 7.1 micrograms ml-1 h (mean +/- s.d.) on day 5. The peak plasma drug concentration on day 1 was 1.2 +/- 0.6 micrograms ml-1 (mean +/- s.d.) and on day 5 it was 2.0 +/- 0.7 micrograms ml-1 (mean +/- s.d.). The plasma concentration of metronidazole at steady state was above the minimum inhibitory concentration (MIC) for anaerobic Streptococci and Clostridium tetani. These results demonstrate much lower systemic exposure than after oral administration.