Development and validation of an instrument to assess and improve clinical consultation skills

Context: Development of medical students’ consultation skills with patients is at the core of the UK General Medical Council’s 'Tomorrow’s Doctors' guide (2009). Teaching and assessment of these skills must therefore be a core component of the medical undergraduate curriculum. The Calgary Cambridge guide to the medical interview and the Leicester Assessment Package (LAP) provide a foundation for teaching and assessment, but both have different strengths. Objective: To develop and validate a comprehensive set of generic consultation competencies. Design: The Calgary Cambridge guide to the medical interview was revised to include ‘clinical reasoning’, ‘management’, ‘record keeping’ and ‘case presentation’. Each section was populated with competencies generated from Tomorrow’s Doctors (2009), the LAP and the Calgary Cambridge guide to the medical interview. A Delphi validation study was conducted with a panel drawn from hospital and general practice clinical tutors from eight UK medical schools. Main outcome measures: A priori consensus standards for inclusion (or exclusion) of an element were: at Stage 1 =70% agreement (or disagreement) that the item should be included; at Stage 2 =50% agreement (or disagreement) that the item should be included. If more than 10% of respondents suggested a thematically similar new item (or rewording of an existing item) in Stage 1, it was included in Stage 2. Results: The design stage resulted in a set of 9 categories of consultation skills with 58 component competencies. In the Delphi study all the competencies reached 70% agreement for inclusion, with 24 suggested amendments, all of which achieved consensus for inclusion at Stage 2. Conclusion: We have developed a Generic Consultation Skills assessment framework (GeCoS) through a rigorous initial development and piloting process and a multi-institutional and multi-speciality Delphi process. GeCoS is now ready for use as a tool for teaching, formative and summative assessment in any simulated or workplace environment in the hospital or community clinical setting

What is stirring in the reservoir? Modelling mechanisms of henipavirus circulation in fruit bat hosts

Pathogen circulation among reservoir hosts is a precondition for zoonotic spillover. Unlike the acute, high morbidity infections typical in spillover hosts, infected reservoir hosts often exhibit low morbidity and mortality. Although it has been proposed that reservoir host infections may be persistent with recurrent episodes of shedding, direct evidence is often lacking. We construct a generalized SEIR (susceptible, exposed, infectious, recovered) framework encompassing 46 sub-models representing the full range of possible transitions among those four states of infection and immunity. We then use likelihood-based methods to fit these models to nine years of longitudinal data on henipavirus serology from a captive colony of Eidolon helvum bats in Ghana. We find that reinfection is necessary to explain observed dynamics; that acute infectious periods may be very short (hours to days); that immunity, if present, lasts about 1–2 years; and that recurring latent infection is likely. Although quantitative inference is sensitive to assumptions about serology, qualitative predictions are robust. Our novel approach helps clarify mechanisms of viral persistence and circulation in wild bats, including estimated ranges for key parameters such as the basic reproduction number and the duration of the infectious period. Our results inform how future field-based and experimental work could differentiate the processes of viral recurrence and reinfection in reservoir hosts. This article is part of the theme issue ‘Dynamic and integrative approaches to understanding pathogen spillover’

Salmonella pyomyositis complicating sickle cell anemia: a case report

<p>Abstract</p> <p>Introduction</p> <p>Pyomyositis is a bacterial infection of skeletal muscle and a rare complication of sickle cell anemia. It may present a difficult problem in diagnosis, leading to delay in appropriate treatment and development of complications including abscess formation and osteomyelitis.</p> <p>Case presentation</p> <p>We report the case of a 44-year-old Afro-Caribbean woman with homozygous sickle cell disease who presented with chest crisis and later developed pyomyositis of her hip and pelvic muscles. <it>Salmonella agbeni </it>was isolated from blood cultures and magnetic resonance imaging confirmed the diagnosis in this case. It is noteworthy of this case that there were no antecedent signs of gastroenteritis. Drainage was not appropriate and she was treated with intravenous antibiotics for six weeks.</p> <p>Conclusions</p> <p>Focal Salmonella infections are uncommon in soft tissue. Pyomyositis should be considered in patients with sickle cell anemia that continue to have muscle pain and high fevers, despite initial management of their sickle cell crisis. Radiological imaging, particularly magnetic resonance imaging, is a crucial tool in establishing the diagnosis.</p

Eliciting and prioritising determinants of improved care in multimorbidity: A modified online Delphi study.

BACKGROUND: Multimorbidity is a major challenge to health and social care systems around the world. There is limited research exploring the wider contextual determinants that are important to improving care for this cohort. In this study, we aimed to elicit and prioritise determinants of improved care in people with multiple conditions. METHODS: A three-round online Delphi study was conducted in England with health and social care professionals, data scientists, researchers, people living with multimorbidity and their carers. RESULTS: Our findings suggest a care system which is still predominantly single condition focused. 'Person-centred and holistic care' and 'coordinated and joined up care', were highly rated determinants in relation to improved care for multimorbidity. We further identified a range of non-medical determinants that are important to providing holistic care for this cohort. CONCLUSIONS: Further progress towards a holistic and patient-centred model is needed to ensure that care more effectively addresses the complex range of medical and non-medical needs of people living with multimorbidity. This requires a move from a single condition focused biomedical model to a person-based biopsychosocial approach, which has yet to be achieved

Double differentiation in a cross-national comparison of populist political movements and online media uses in the United States and the Netherlands

In a context of highly visible and politically influential populist movements, this study considers the online self-representation of the Tea Party Patriots (TPP) in the United States and the Party for Freedom (PVV) in the Netherlands. A multi-methodological approach was adopted to compare the discursive manifestation of key populism concepts: leadership characteristics, adversary definition and mobilizing information. Analyses reconstruct and account for similarities and differences in discursive framing strategies of 'double differentiation' through which both movements attempt inclusion in and exclusion from the political establishment, and, in doing so, mobilize communities of support. Altogether, this study advances the understanding of what constitutes 'unmediated' content that is presented through user-generated media production, and how self-determined media spaces have facilitated shifts in populist media legitimation and political representation in two politically unique countries

Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania

Health care systems are faced with the challenge of resource scarcity and have insufficient resources to respond to all health problems and target groups simultaneously. Hence, priority setting is an inevitable aspect of every health system. However, priority setting is complex and difficult because the process is frequently influenced by political, institutional and managerial factors that are not considered by conventional priority-setting tools. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority setting in district health management were studied. This review is based on a PhD thesis that aimed to analyse health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness (A4R) approach to priority setting in Tanzania. A qualitative case study in Mbarali district formed the basis of exploring the sociopolitical and institutional contexts within which health care decision making takes place. The study also explores how the A4R intervention was shaped, enabled and constrained by the contexts. Key informant interviews were conducted. Relevant documents were also gathered and group priority-setting processes in the district were observed. The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. The study also found that while the A4R approach was perceived to be helpful in strengthening transparency, accountability and stakeholder engagement, integrating the innovation into the district health system was challenging. This study underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context is imperative in fostering sustainability. Additionally, the study stresses the need to deal with power asymmetries among various actors in priority-setting contexts

Education and transfer of water competencies: An ecological dynamics approach

© The Author(s) 2020. To cope in various aquatic environments (i.e. swimming pools, lakes, rivers, oceans), learners require a wide repertoire of self-regulatory behaviours such as awareness of obstacles and water properties, floating and moving from point to point with different strokes, decision making, emotional control and breathing efficiently. By experiencing different learning situations in stable indoor pool environments, it is assumed that children strengthen aquatic competencies that should be transferable to functioning in open water environments, where prevalence of drowning is high. However, this fundamental assumption may be misleading. Here, we propose the application of a clear, related methodology and theoretical framework that could be useful to help physical education curriculum specialists (re)shape and (re)design appropriate aquatic learning situations to facilitate better transfer of learning. We discuss the need for more representativeness in a learning environment, proposing how the many different task and environmental constraints on aquatic actions may bound the emergence of functional, self-regulatory behaviours in learners. Ideas in ecological dynamics suggest that physical educators should design learning environments that offer a rich landscape of opportunities for action for learners. As illustration, three practice interventions are described for developing functional and transferrable skills in indoor aquatic environments. It is important that aquatic educators focus not just upon ‘learning to swim’, but particularly on relevant transferable skills and self-regulatory behaviours deemed necessary for functioning in dynamic, outdoor aquatic environments

Education and transfer of water competencies: An ecological dynamics approach

© The Author(s) 2020. To cope in various aquatic environments (i.e. swimming pools, lakes, rivers, oceans), learners require a wide repertoire of self-regulatory behaviours such as awareness of obstacles and water properties, floating and moving from point to point with different strokes, decision making, emotional control and breathing efficiently. By experiencing different learning situations in stable indoor pool environments, it is assumed that children strengthen aquatic competencies that should be transferable to functioning in open water environments, where prevalence of drowning is high. However, this fundamental assumption may be misleading. Here, we propose the application of a clear, related methodology and theoretical framework that could be useful to help physical education curriculum specialists (re)shape and (re)design appropriate aquatic learning situations to facilitate better transfer of learning. We discuss the need for more representativeness in a learning environment, proposing how the many different task and environmental constraints on aquatic actions may bound the emergence of functional, self-regulatory behaviours in learners. Ideas in ecological dynamics suggest that physical educators should design learning environments that offer a rich landscape of opportunities for action for learners. As illustration, three practice interventions are described for developing functional and transferrable skills in indoor aquatic environments. It is important that aquatic educators focus not just upon ‘learning to swim’, but particularly on relevant transferable skills and self-regulatory behaviours deemed necessary for functioning in dynamic, outdoor aquatic environments

A demonstration of 'broken' visual space

It has long been assumed that there is a distorted mapping between real and ‘perceived’ space, based on demonstrations of systematic errors in judgements of slant, curvature, direction and separation. Here, we have applied a direct test to the notion of a coherent visual space. In an immersive virtual environment, participants judged the relative distance of two squares displayed in separate intervals. On some trials, the virtual scene expanded by a factor of four between intervals although, in line with recent results, participants did not report any noticeable change in the scene. We found that there was no consistent depth ordering of objects that can explain the distance matches participants made in this environment (e.g. A > B > D yet also A < C < D) and hence no single one-to-one mapping between participants’ perceived space and any real 3D environment. Instead, factors that affect pairwise comparisons of distances dictate participants’ performance. These data contradict, more directly than previous experiments, the idea that the visual system builds and uses a coherent 3D internal representation of a scene