'I found myself a despicable being!':Medical students face disturbing moral dilemmas

CONTEXT: The psychological realm of medical students` moral experiences is explored tangentially in medical education literature, often in the context of ethics or professionalism education. This study deepens our understanding by (1) investigating the nature of moral dilemmas experienced at the onset of clinical practice, (2) exploring students` emotional response to these dilemmas, and (3) examining how students perceive the influence of these dilemmas on their professional development. METHODS: This is a cross-sectional qualitative study carried out in 2017 that applied Thematic Template Analysis to individual interviews performed with last-year medical students. The interviews followed the drawing of a Rich Picture representing moral dilemmas experienced by medical students at the onset of clinical practice. RESULTS: Moral dilemmas have four intertwined dimensions. The first relates to students` struggle to prioritize, balance and apply conflicting moral values; the second comprises the clash between students` inner motivation and the external constraints that limit the moral action; the third refers to the conflict between students' current attitudes with the desired/idealized attitudes of the doctor they intend to become; the forth corresponds to weighting conflicting ethical principles during the moral decision. Students` emotional responses are intense, long-lasting, and with a remarkable residue effect, particularly when the moral decision does not align with their moral beliefs. Moral dilemmas are impactful experiences that affect the professional development of medical students and can culminate in both detachment or growth in moral courage. CONCLUSION: Moral dilemmas are memorable, complex, and emotionally intense experiences that impact the professional development of medical students. Understanding students` moral dilemmas can help educators to devise pedagogical activities to anticipate and reflect on these experiences. These activities should happen under the guidance of a non-judgmental facilitator, capable of listening and legitimating students' thoughts and feelings while providing insights to nurture their professional development

Triangulating’ AMPATH: Demonstration of a multi-perspective strategic programme evaluation method

Clinical programmes are typically evaluated on operational performance metrics of cost, quality and outcomes. Measures of patient satisfaction are used to assess the experience of receiving care, but other perspectives, including those of staff and communities, are not often sought or used to assess and improve programmes. For strategic planning, the Kenyan HIV/AIDS programme AMPATH (Academic Model Providing Access to Healthcare) sought to evaluate its performance in 2006. The method used for this evaluation was termed ‘triangulation,’ because it used information from three different sources – patients, communities, and programme staff. From January to August 2006, Indiana University external evaluators and AMPATH staff gathered information on strengths, weaknesses and suggestions for improvement of AMPATH. Activities included in-depth key-informant semi-structured interviews of 26 AMPATH clinical and support staff, 56 patients at eight clinic sites, and seven village health dialogues (mabaraza) at five sublocations within the AMPATH catchment area. Data sources included field notes and transcripts of translated audio recordings,which were subjected to qualitative content analysis. Eighteen  recommendations for programme improvement emerged, including ten from all three respondent perspectives. Three recommendations were cited by patients and in mabaraza, but not by staff. Triangulation uncovered improvement emphases that an internal assessment would miss. AMPATH and Kenyan Ministry of Health leadership have deliberated these recommendations and accelerated strategic change actions, including rural satellite programmes, collaboration with village-based workers, and door-to-door village-based screening and counselling

External rotation during elevation of the arm

Background Knowledge about the pattern of rotation during arm elevation is necessary for a full understanding of shoulder function, and it is also useful for planning of rehabilitation protocols to restore range of motion in shoulders in disorder. However, there are insufficient in vivo data available

Professionalism and Evolving Concepts of Quality

For much of the twentieth century, quality of care was defined specifically in terms of physician characteristics and behaviors. High-quality physicians were well trained, knowledgeable, skillful, and compassionate. More recently, quality of care has been defined in terms of systems of care. High-quality organizations develop and adopt practices to reduce adverse events and optimize outcomes. This essay discusses this transformation from physician-based to organization-based concepts of quality and the consequences for patient care and medical professionalism

Makerere University College of Health Sciences’ role in addressing challenges in health service provision at Mulago National Referral Hospital

<p>Abstract</p> <p>Background</p> <p>Mulago National Referral Hospital (MNRH), Uganda’s primary tertiary and teaching hospital, and Makerere University College of Health Sciences (MakCHS) have a close collaborative relationship. MakCHS students complete clinical rotations at MNRH, and MakCHS faculty partner with Mulago staff in clinical care and research. In 2009, as part of a strategic planning process, MakCHS undertook a qualitative study to examine care and service provision at MNRH, identify challenges, gaps, and solutions, and explore how MakCHS could contribute to improving care and service delivery at MNRH.</p> <p>Methods</p> <p>Key informant interviews (n=23) and focus group discussions (n=7) were conducted with nurses, doctors, administrators, clinical officers and other key stakeholders. Interviews and focus groups were tape recorded and transcribed verbatim, and findings were analyzed through collaborative thematic analysis.</p> <p>Results</p> <p>Challenges to care and service delivery at MNRH included resource constraints (staff, space, equipment, and supplies), staff inadequacies (knowledge, motivation, and professionalism), overcrowding, a poorly functioning referral system, limited quality assurance, and a cumbersome procurement system. There were also insufficiencies in the teaching of professionalism and communication skills to students, and patient care challenges that included lack of access to specialized services, risk of infections, and inappropriate medications.</p> <p>Suggestions for how MakCHS could contribute to addressing these challenges included strengthening referral systems and peripheral health center capacity, and establishing quality assurance mechanisms. The College could also strengthen the teaching of professionalism, communication and leadership skills to students, and monitor student training and develop courses that contribute to continuous professional development. Additionally, the College could provide in-service education for providers on professionalism, communication skills, strategies that promote evidence-based practice and managerial leadership skills.</p> <p>Conclusions</p> <p>Although there are numerous barriers to delivery of quality health services at MNRH, many barriers could be addressed by strengthening the relationship between the Hospital and MakCHS. Strategic partnerships and creative use of existing resources, both human and financial, could improve the quality of care and service delivery at MNRH. Improving services and providing more skills training could better prepare MakCHS graduates for leadership roles in other health care facilities, ultimately improving health outcomes throughout Uganda.</p

Engaging communication experts in a Delphi process to identify patient behaviors that could enhance communication in medical encounters

<p>Abstract</p> <p>Background</p> <p>The communication literature currently focuses primarily on improving physicians' verbal and non-verbal behaviors during the medical interview. The Four Habits Model is a teaching and research framework for physician communication that is based on evidence linking specific communication behaviors with processes and outcomes of care. The Model conceptualizes basic communication tasks as "Habits" and describes the sequence of physician communication behaviors during the clinical encounter associated with improved outcomes. Using the Four Habits Model as a starting point, we asked communication experts to identify the verbal communication behaviors of patients that are important in outpatient encounters.</p> <p>Methods</p> <p>We conducted a 4-round Delphi process with 17 international experts in communication research, medical education, and health care delivery. All rounds were conducted via the internet. In round 1, experts reviewed a list of proposed patient verbal communication behaviors within the Four Habits Model framework. The proposed patient verbal communication behaviors were identified based on a review of the communication literature. The experts could: approve the proposed list; add new behaviors; or modify behaviors. In rounds 2, 3, and 4, they rated each behavior for its fit (agree or disagree) with a particular habit. After each round, we calculated the percent agreement for each behavior and provided these data in the next round. Behaviors receiving more than 70% of experts' votes (either agree or disagree) were considered as achieving consensus.</p> <p>Results</p> <p>Of the 14 originally-proposed patient verbal communication behaviors, the experts modified all but 2, and they added 20 behaviors to the Model in round 1. In round 2, they were presented with 59 behaviors and 14 options to remove specific behaviors for rating. After 3 rounds of rating, the experts retained 22 behaviors. This set included behaviors such as asking questions, expressing preferences, and summarizing information.</p> <p>Conclusion</p> <p>The process identified communication tasks and verbal communication behaviors for patients similar to those outlined for physicians in the Four Habits Model. This represents an important step in building a single model that can be applied to teaching patients and physicians the communication skills associated with improved satisfaction and positive outcomes of care.</p

The impact of hyperbaric oxygen therapy on serological values of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF)

<p>Abstract</p> <p>Background</p> <p>Hyperbaric oxygen (HBO) therapy is an effective adjunct treatment for ischemic disorders such as chronic infection or chronic wounds. It combines hyperoxic effects with the stimulating potential of post-therapeutic reactive hypoxia. As its crucial effects, stimulation of fibroblast growth, induction of collagen synthesis and the initiation of angiogenesis are discussed. Angiogenesis is a multistage process resulting in the growth of blood vessels. It includes degradation of extracellular matrix, proliferation and migration of different cell populations and finally formation of new vessel structures. This complex chain of procedures is orchestrated by different cytokines and growth factors. Crucial mediators of angiogenesis are basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF); their <it>in-vivo </it>function is still not fully understood.</p> <p>Methods</p> <p>Forty-three patients suffering from sudden sensorineural hearing loss or tinnitus were treated with HBO. The therapy included 10 sessions of 90 minutes each, one session a day. Serological levels of bFGF and VEGF were assessed by enzyme-linked immunosorbent assays performed according to the manufacturer's instructions on day 1, 2, 5 and 10 of HBO therapy and were compared to mean values of the control group, related to the patient's age and sex, and their development observed over the ten days of HBO.</p> <p>Results</p> <p>There was no sex- or age dependency of bFGF observed in the present study, whereas under HBO our results showed a significant mitigation of the bFGF concentration. In the present data, there was no connection between the VEGF concentration and the patients' ages. Women showed significantly higher levels of VEGF. There was no significant change of VEGF concentration or the VEGF/bFGF ratio during HBO. All scored results varied within the range of standard values as described in the current literature.</p> <p>Conclusions</p> <p>A significant effect of HBO on serum concentrations of bFGF and VEGF was not verified in the present study. Additional application of exogenous growth factors in conjunction with HBO was not obviously linked by a coherent cause-and-effect chain as far as wound healing is concerned.</p