Emergency medicine and general practice

Emergency Medicine and Immediate Medical Care are relatively new specialties. In Malta, there is quite a considerable area of overlap between these specialties and general practice. Indeed, the family physician is confronted with some sort of medical emergency quite regularly. The brief of this article is to go through recent developments in Emergency Medicine as applied to General Practice. The areas considered are Basic Life Support, Head Injury, Asthma, Anaphylaxis, Community Acquired Pneumonia, Burns and Controlled Hypotensive Resuscitation. Whenever possible, distinct practical guidelines will be suggested as an aid in the clinical management of emergency situations which the family physician may encounter. This overview of new developments is by no means comprehensive but serves to highlight the increasing importance given to the role of the first-line medical practitioner in the emergency situation.peer-reviewe

A seven-year review (2011-17) of the work-based assessment component of Malta’s Specialist Training Programme in Family Medicine

Background: Work-based assessment (WBA) within Malta’s Specialist Training Programme in Family Medicine is recorded using the ‘One-to-One Appraisal’ form in the General Practitioner (GP) Trainee Educational ePortfolio. -- Objectives: The postgraduate training coordinators in family medicine review the above annually to see where the WBA is operating well and to identify where improvements are required. -- Method: The ‘One-to-One Appraisal’ involves the completion of a scoring system (selecting one score from ‘needs further development’: 1-2-3; ‘competent’: 4-5-6; and ‘excellent’: 7-8-9) for twelve competency areas. The educational portfolio is reviewed using objective requirements listed in the form ‘Review of the GP Trainee Educational Portfolio’. -- Results: The review of educational portfolios revealed commendable practices including detailed educational plans and case-logs, a general trend of adherence to time frames, and high attendance rates for group-teaching sessions. While One-to-One Appraisal documents were filled in satisfactorily, the issue of remarkably high average scoring was encountered. Moreover disparities were seen between scores and comments in some of the ‘GP trainee interim review by GP trainer’ forms. Deficiencies were outlined in clinical supervision time, mainly during family medicine government placements, while incomplete adherence to placement requirements was noticed. -- Conclusion: A significant amount of quality work was carried out by the GP trainees under their trainers’ supervision. Two main areas of improvement were however outlined – the need for refining the GP trainers’ score allocation and the importance of regular review of the portfolio by both trainees and trainers, with the prompt flagging of persisting unresolved issues to the training coordinators.peer-reviewe

Work-based assessment within Malta’s specialist training programme in family medicine

The Specialist Training Programme in Family Medicine (STPFM) – Malta was drawn up by the Malta College of Family Doctors in 2006, approved by Malta’s Specialist Accreditation Committee, and launched in 2007 by the Primary Health Care Department and the Malta College of Family Doctors. This article regarding the work-based assessment of specialist training in family medicine in Malta was prepared by consulting various local / international documents and publications that are related to general practice / family medicine and its teaching, appraisal and assessment. Assessment of family doctors should consider their actual performance of different tasks in diverse settings of daily practice; this is carried out on-site by direct observation of the practitioner at the work-place (work-based assessment) using different methods.peer-reviewe

Specialist training in family medicine in Malta during 2007-2012 : a comparative evaluation of the first and fifth years of the programme

As a result of Malta’s entry to the European Union in 2004, Family Medicine was recognised as a speciality and subsequently a three-year programme of Specialist Training was launched in 2007 by the Primary Health Care Department and the Malta College of Family Doctors. By 2012, three cohorts of GP trainees had completed the training programme. Evaluation is important in ensuring quality and success in provision of teaching programmes in general, and family-doctor training in particular. While evaluation and improvement of the programme is performed on an ongoing basis, a comparison of the trainees’ evaluations of the first (2007-8) and fifth (2011-2) years of the training programme was carried out in order to identify areas where consolidation or further improvement was needed. Evaluation forms are completed by trainees after each post in family or hospital practice and after each group-teaching session. The information from these forms is transcribed into MS Excel to enable quantitative and qualitative analysis. The feedback given during the period 2007 – 2008 was compared with that given during 2011 – 2012. During the first and fifth years of the training programme, GP trainees were 80-90% satisfied with the effectiveness of the training provided during the family practice posts, and over 90% satisfied with the presentation, content and relevance of the teaching provided during the group teaching sessions. Their overall satisfaction with the effectiveness of training in the other specialities improved from 53-92% to 65-95%. While GP trainees’ satisfaction with their training generally remained high or improved, specific areas were identified in family medicine and hospital placements where changes for improvement are merited.peer-reviewe

Empowering the continuing professional development of general practitioner trainers in Malta through educational needs assessment

Background It has been recommended that GP trainers in Malta undergo continuing professional development (CPD) in education and assessment through participation in regular meetings. Aim To encourage GP trainers to organise on-going CPD activities, and thus improve the training they provide, through an assessment of their educational needs. Method In 2015, two UK questionnaires used to evaluate specialist training provided by GP trainers were consulted in the development of online surveys for completion by current and recent GP trainees and trainers in Malta. The information collected was presented to two small groups of trainers for categorisation using an ‘urgent/important/ less urgent/less important’ grid. Results In reply to the question ‘What are your current development needs?’, the top answers from trainers included developing teaching skills, keeping abreast with medical knowledge, and regular meetings with other GP trainers to discuss problems and share experiences. The trainees’ top answers to the question ‘What should the GP trainer do differently?’ were ‘nothing’, being up-to-date regarding guidelines, and providing “examoriented” feedback. The most important and urgent recommendations made during the trainers’ small group meetings included regular peer-support meetings between GP trainers to share teaching experiences and discuss problems, regular updates regarding guidelines and protocols recommended for exams, and more examoriented training to be provided to trainees. Conclusion The educational needs assessment carried out provided useful information that enabled the set-up of regular CPD meetings for GP trainers in Malta, thus meeting their educational needs and hopefully benefiting the quality of training provided to GP trainees.peer-reviewe

Quality improvement through evaluation of GP trainers’ continuing professional development in Malta

BACKGROUND: Mandatory trainer continuing professional development (CPD) sessions were held during 2019 for each GP trainer actively involved in the Specialist Training Programme in Family Medicine – Malta.OBJECTIVE: GP trainer CPD sessions were evaluated to improve the quality of the provided CPD that was intended to refine their assessment skills.METHOD: Participants were sent a link to an electronic feedback form to complete anonymously using Google Forms. The responses were exported into Microsoft Excel to enable analysis, both quantitatively and qualitatively using item content analysis.RESULTS: Twenty-six GP trainers completed the feedback questionnaire, giving a response rate of 46%. Positive comments were made regarding the relevance and group dynamics of the sessions (marked as 3 or more out of 5) and the ensuing discussion and interaction (81%). Moreover, 42% stated that they would not change anything about the CPD sessions, while 23% gave different comments about their timing. Educational needs identified by participants ranged from technical help (42%) to providing trainee guidance (35%) and self-development (12%). While 38% of respondents wanted further training in assessment and marking, 27% wished to broaden training to include other teaching topics.CONCLUSION: Since the 2019 trainers’ CPD sessions were well-received, it was proposed that in 2020 the topic of assessment should be tackled in more depth, with fine-tuning made of the sessions’ facilitation and timing. Trainer CPD sessions to be held after 2020 could incorporate further recommended topics that are set at different levels for participants with varying levels of knowledge and skills.peer-reviewe

Preparing an interdisciplinary guidance for the management of generalised paediatric status epilepticus

BACKGROUND: A guidance was created to assist family doctors in managing generalized paediatric status epilepticus (GPSE) at Primary HealthCare (PHC) clinics.AIM: The article aims to discuss the process by which the GPSE guidance was prepared.OBJECTIVES: The authors intend to provide information on how the literature review was carried out, what clinical threshold was decided as appropriate for the administration of rescue medication, and what treatments may be used in PHC.METHOD: An initial search and guidance draft was forwarded to a Joint Working Group (JWG) composed of professionals working at PHC and Mater Dei Hospital (MDH). The names of benzodiazepines and their formulations available at PHC clinics were forwarded to the JWG by the clinical Chairperson of Primary HealthCare. A Pubmed search was carried out for the terms “status epilepticus,” “children”, and “prehospital”, filtering for free full text publications, humans, English language, and dating from 1999 to 2019, yielding seventeen results in the English language. Eight were relevant. A second Pubmed search for “diazepam use in paediatric seizures” and “midazolam use in paediatric seizures” yielded fifty-five results, filtering for English and dating from 2010-2019. Two were relevant. Several guidelines and literature were directly referenced. The literature review process and results were summarised and modified into a flowchart.RESULTS: An interdisciplinary approach was used to decide how GPSE should be treated. Consensus was agreed that if a seizure lasts more than five minutes, benzodiazepines midazolam and diazepam available at PHC clinics, may be used. Intramuscular, intranasal, buccal, or rectal routes are preferred per the child’s weight; and time the duration of seizure activity.CONCLUSION: GPSE may terminate during the first five minutes of ictal activity. Midazolam and diazepam may be administered by different methods if seizures persist, depending on the clinical scenario.peer-reviewe