To be or not to be: a critical realist exploration of factors motivating doctors in their commitment to improve their teaching practice in a clinical setting in Oman

Adopting a critical realist framework, this study explored how medical doctors come to understand and espouse, or resist, their roles as teachers in clinical settings and how they seek to become more proficient in that role. This work builds on earlier research on doctors’ professional development as teachers and extends it into the particular cultural context of medical practice and education in the Sultanate of Oman. A qualitative approach was adopted. Data were collected in 2016 through semi-structured in-depth interviews with 27 senior clinicians and by the examination of relevant institutional policy documents. Interviews were conducted in two hospital settings: the Sultan Qaboos University Hospital (SQUH) and the Royal Hospital (RH), which is a Ministry of Health Hospital (MoHH). The findings suggest that Omani medical doctors’ orientation to their roles as teachers and their understanding of their responsibility to prepare the next generation of medical professionals have been transformed by three main events over the last 3 decades. First was the establishment of Sultan Qaboos University College of Medicine and Health Sciences (CoMHS) in 1986. Next came the governmental authorities’ decision to train medical doctors in the overseas hospitals that have structured postgraduate clinical training since the 1990s. Thus, while the senior doctors contributing to this study had received some or all of their medical training outside of Oman, they were helping to build a medical education system which sought to raise the next generations of doctors at home. Finally came the establishment of the Oman Medical Speciality Board (OMSB) in 2006 as the official body responsible for the graduate medical education in Oman. However, due to a lack of clear policy regarding their teaching roles, the Ministry of Health (MoH) doctors felt that they, as compared to their colleagues in the university teaching hospital (SQUH), were being expected to make an extra effort to teach in their clinical setting. All respondents, whether recruited from RH or SQUH, recognised the influence their own experience of being taught had on their personal development as clinical teachers on their return to Oman. Respondents’ exposures to different teaching and learning cultures and styles contributed to their motivation to teach and learn about teaching. In particular, many respondents believed that the religious culture of the country contributed to a pervasive attitude of altruism in the orientation of doctors to both their patients and their students. However, demotivators such as the health system’s hierarchical structure, unclear educational roles, lack of resources—time, human and suitable facilities—for teaching in their hospitals are significant challenges in accomplishing their multiple roles and developing themselves for their educational roles. What emerged as a fundamental challenge for the RH respondents was the lack of any clear policy regarding the doctor’s role as a teacher. The respondents believed that having a clear policy would empower the doctors and give them the support they need for their multiple roles in the clinical setting. Such policy would also guide the administrators and decision-makers in the support and resourcing that they provide to doctors, which they believed were so essential to ensure the next generation of doctors developed according to Oman’s mission and vision. This study’s findings show clearly the need to establish and standardise national medical education policy and procedures for the MoH doctors, thus giving them a clarity of roles and responsibilities they believe to exist for their SQUH colleagues. Having such national standards and policy is an essential part of a health organisation, and hence its implication for the doctors will be to provide them with the road map for the day-to-day management of their multiple complex roles. It is also clear that the Ministry of Health and the educational institutions (governmental and private at both the undergraduate and the postgraduate levels) need to collaborate and cooperate to establish an integrated medical education system for clinical settings, not just for the learners but also for the doctors who teach them, and thus to establish a stable teaching and learning environment. The presence of such a national policy for medical education will have a positive impact upon the quality of medical education, patient care, and upon junior doctors’ willingness to pursue careers as medical educators in clinical settings

Lateral condylar fractures in thoroughbred racehorses: investigation of premonitory radiographic changes in distal metacarpal III

Reasons for performing this study: Metacarpal/metatarsal III condylar fractures are the most common type of fracture associated with Thoroughbred horseracing in the UK, and the most common reason for euthanasia on the racecourse. Prediction of fracture through quantification of exercise-related radiographic changes could enable modification of horse management to prevent this injury, improving animal welfare and reducing wastage. Objectives: The general aims were to validate objective radiographic measurement of exercise-related modelling in distal metacarpal III of Thoroughbred racehorses and to explore their utility for fracture prediction by comparing measurements from horses that sustained a fracture of the lateral condyle of distal metacarpal III with those from controls. The initial objective was to establish methods to measure objectively the following variables in distal metacarpal III: condyle opacity, cortical thickness and metaphyseal angle. Radiographic measurements were correlated with equivalent measurements derived from computed tomography (CT) to determine their accuracy. The second objective was to explore the ability of the radiographic measurements to identify horses at risk of fracture. This was done initially by comparing measurements made from radiographs taken at a single time point between Thoroughbred racehorses with and without a lateral condylar fracture, and subsequently by analysis of measurements from series of radiographs obtained prior to and at diagnosis of lateral condylar fracture as part of routine clinical practice. For the final objective, the maximum density of the palmar condyles of distal metacarpal III was determined using a quantitative CT-based technique. Maximum density was compared between horses with fractures and those without, and comparison made with the maximum opacity measured from radiographs, to investigate whether these measurements could be used to identify horses at risk of fracture. Materials and Methods: Fifty-five metacarpal III bones obtained from Thoroughbred racehorses euthanized on UK racecourses (age range 3-11 years) were divided in to three groups: control (no distal limb fracture, n=30), non-fractured (contralateral limb lateral condylar fracture, n=11) and fractured (lateral condylar fracture, n=14). All limbs were subjected to radiography and computed tomography for measurement of diaphyseal cortical thickness 2.5cm distal to the nutrient foramen (expressed as dorsal cortex:medulla width) and metaphyseal angle (deviation of the metaphysis relative to the diaphysis). Measurement of radiopacity of the medial and lateral condyles was calibrated using an aluminium phantom i (condyle:phantom ratio). Correlation between radiography and CT measurements and comparison of radiography measurements between groups was performed. For the longitudinal study, medical records of the Singapore Turf Club were reviewed. Thoroughbred racehorses diagnosed with a lateral condylar fracture that had also been radiographed in the previous 24 months were identified and placed in the ‘high risk’ group (n=16). Horses radiographed and then raced for a minimum of 2 years without suffering a fracture were placed in the ‘low risk’ group (n=15). Twenty-seven metacarpal III bones obtained from Thoroughbred racehorses euthanized on UK racecourses (age range 3-10 years) were used in the investigation of maximum density of the palmar condyles. They were divided in to three groups: control (no distal limb fracture, n=10), non-fractured (contralateral limb lateral condylar fracture, n=8), and fracture (lateral condylar fracture, n=9). Computed tomography measurement of condyle density was calibrated using a potassium phosphate phantom to enable comparison between age-matched bones. Results: Diaphyseal cortical thickness and metaphyseal angle measurements made by radiography and CT were significantly correlated (r=0.74, 0.73; p=0.007, 0.004) but there was no significant difference in measurements between groups. Radiopacity of medial and lateral condyles was significantly greater in non-fracture (0.67±0.04, 0.68±0.04) and fracture (0.82±0.07, 0.68±0.09) groups than the control (0.59±0.08, 0.57±0.09) group (p=0.003). The medial condyle (0.82±0.07) was significantly more radiopaque than the lateral condyle (0.68±0.09) in the fracture group only (p=0.001). In the longitudinal study, the dorsal cortex was thicker in high risk than low risk horses, the mean ± SD cortical thickness ratio of the high and low risk groups was 1.36 ± 0.26 and 1.08 ± 0.19 respectively (p=0.008). Metaphyseal angle measurement displayed a similar pattern and the difference was statistically significant, the mean ± SD metaphyseal angle of the high and low risk groups was 9.65° ± 2.21 and 6.95° ± 1.65 respectively (p=0.000). Computed tomography measurement of maximum density of distal metacarpal III, found no significant difference in maximum density of the lateral and medial palmar condyle between groups. There was a significant correlation between age and maximum density of the lateral condyle (r=0.44, p=0.019) and medial condyle (r=0.54, p=0.003). ii Conclusions: Objective measurement of dorsal cortical thickness and metaphyseal angle of distal metacarpal III can be performed accurately and precisely using radiography in Thoroughbred horses. Radiographic measurement of condyle opacity was precise but conclusions about the accuracy of this measurement await comparison with an appropriate reference standard. Increased radiopacity of the distal condyles was identified in horses that sustained lateral condylar fracture. However, this finding was not reflected by data from the horses represented by the clinical radiographs, suggesting that this measurement may not be useful in identifying horses at risk of fracture. Evidence supportive of this conclusion was provided by maximum density measurements made by CT. Significant differences in dorsal cortical thickness and metaphyseal angle were found between horses that sustained a lateral condylar fracture and horses that underwent radiography for clinical reasons but subsequently raced without fracture, suggesting that these variables could be of value in determining the risk of fracture and merit further investigation

Standardization of fetal ultrasound biometry measurements: improving the quality and consistency of measurements.

OBJECTIVE: To assess whether a standardization exercise prior to commencing a fetal growth study involving multiple sonographers can reduce interobserver variation. METHODS: In preparation for an international study assessing fetal growth, nine experienced sonographers from eight countries participated in a standardization exercise consisting of theoretical and practical sessions. Each performed a set of seven standard fetal measurements on pregnant volunteers at 20-37 weeks' gestation, and these were repeated by the lead sonographer; all measurements were taken in a blinded fashion. After this the sonographers had hands-on practice and feedback sessions on other volunteers. This process was repeated three times. Measurement differences between sonographers and the lead sonographer, expressed as a gestational-age-specific Z-score, between the first and third scans were compared using the Wilcoxon signed ranks test, and variance was assessed using Pitman's test. Interobserver agreement was also assessed using the intraclass correlation coefficient (ICC), and all images were scored for quality in a blinded fashion. RESULTS: At baseline the level of agreement and image scoring were high. A significant reduction in the differences between sonographers and the lead sonographer were seen for fetal biometry overall (head circumference, abdominal circumference and femur length) between the first and third scans (median Z-scores, 0.46 and 0.24; P = 0.005), and a reduction in the variance was also observed (P < 0.001). The ICCs for measurement pairs for every fetal measurement showed a clear trend of increasing ICC (better agreement) with consecutive training scan sessions, although no improvement in image scores was seen. CONCLUSION: Even for experienced sonographers, a standardization exercise before starting a study of fetal biometry can improve consistency of measurements. This could be of relevance for studies assessing fetal growth in multicenter sites