The views of medical students on professionalism in South Africa

An article on medical professionalism was published in the Annals of Internal Medicine in February 2002 outlining a charter, and the fifth-year medical students of the Medical School of the University of Pretoria were asked to comment on the charter. The question was asked whether the principles and responsibilities as set out in the charter could also be applied to the South African context. The responses of the students could be divided into three groups with overlapping themes: 15,64% of the students felt that the charter was not at all applicable to our country because of its diverse cultures and languages and the variety of social classes and religions; 24,02% of the students felt that the charter was a universally acceptable document; and 60,34% of the students felt that, to a great extent, the charter was the ideal and the goal to strive for, although they only accepted some of the principles and responsibilities while having serious doubts and criticism of others. In conclusion, the majority of the medical students felt that the charter was noteworthy and commendable in principle, but not totally applicable in our country with its unique problems and challenges. Our challenge is to take what resources we have and use it to the benefit of all. Keywords: Medical Professionalism, Patient welfare, Autonomy, Social justice, Continued medical education, Confidentiality and privacy, Financial considerations, Rights of doctors, Cultural differences, Government support For full text, click here:SA Fam Pract 2004;46(1) :28-3

Crystal structure of the Large Type III Glutamine Synthetase from Bacteroides Fragilis

Glutamine synthetases are one of the most ancient functioning enzymes in existence and these large oligomeric complexes are found in all extant forms of life where they play a critical role in nitrogen metabolism. Over the past five decades, extensive biochemical studies together with structural investigations have helped build a picture of the mechanism of functioning and regulation in the GSI and GSII families. The most divergent GSIII family, however, is poorly characterized and has only recently been recognized. Structural studies, using both cryo-EM and X-ray crystallography, were undertaken on the type III GS, GlnN, from the opportunistic human pathogen, Bacteroides fragilis, with a view to better understanding the GSIII family in the light of the known structure functionrelationships of the other GS enzymes, and to investigate the potential for the design of selective inhibitors against the divergent family. A low-resolution (16 Ã) reconstruction of GlnN was first determined by single particle cryo-EM and image processing. This structure revealed that GlnN was a double-ringed dodecamer with D6 symmetry and the arrangement of active sites within the hexameric rings closely matched the GSI structure. Following the design of a rapid purification protocol and improvements to the stability and solubility of GlnN, conditions were discovered for the production of diffraction quality inhibitor-bound crystals. A second better diffracting crystal form was also produced following proteolytic processing. The crystal structure of GlnN was solved to near atomic resolution (3.0 Ã) following phase extension of low-resolution SAD phases, taking into account the cryo-EM structure. The higher resolution of the crystal structure revealed that, surprisingly, the orientation of the hexameric rings in GlnN is inverted in comparison to other families. These results have raised interesting questions surrounding the mechanism and driving forces responsible for the evolution of quaternary structure in the GS enzymes and have suggested that the GSI and GSII structure arose following truncation of a large GSIII-like ancestor. Despite the differences in higher order assembly, the GlnN monomer displayed a high degree of similarity with the GSI and GSII structures in the core active site region, thus, suggesting a conservation of reaction mechanism. Structure-based multiple sequence alignment showed that the residues forming the nucleotide binding pocket are the least conserved in the GS superfamily, and several residue positions, which represent altered modes of ligand binding, were suggested as potential avenues for the design of selective inhibitors against GlnN

Pretoria medical students' perspectives on assessable attributes of Professionalism

Background Professionalism forms an important aspect of medicine's contract with society, and it is therefore important that it should be assessed and developed in medical schools. For the effective assessment of medical students' professionalism, clear objectives, or outcomes based on a clear definition of professionalism, have to be accepted by society, the faculty and the students. A Physician's Charter, ‘Medical Professionalism in the New Millennium‿, was published by the Annals of Internal Medicine in February 2002. Fifth-year medical students of the University of Pretoria were challenged to comment on the applicability of this Charter's principles and responsibilities in the South African context. The majority of the students did not fully agree with the principles and responsibilities. A following cohort of fifth-year students was requested to define professionalism and describe attributes that could be included in an assessment tool. Methods A qualitative design was employed to explore the students' perceptions. An analysis of the scripts was performed using qualitative content analysis. All the scripts were read twice and the emergent themes (attributes of professionalism) were identified by two researchers. The scripts were reviewed and coded independently to enhance reliability. Investigator triangulation, involving researchers with diverse research backgrounds, was done to validate the identified attributes. The themes were organised into categories (domains of professionalism). The authors discussed differing concepts with the other members of the Professional Attitude Development and Assessment Committee (PADAC) to arrive at a consensus. In the second stage of analysis, the identified themes were compared to the Charter. This was supported by quotations taken from the students' perceptions, as well as from the relevant literature. Tabulations were used to determine the frequencies of the different themes. Results The attributes used to describe professionalism were grouped under four main domains: attitude and personal conduct, teamwork, patient care and professional competence. These correspond, to some extent, with the Charter. Most of the students, however, stressed the humanistic attributes of professional behaviour, which are not mentioned in the Charter. These attributes include empathy, interpersonal relationships, integrity, respect, maturity and teamwork. Conclusion The students' perceptions of professionalism differed from that described in the Charter. The fact that the students value the humanistic part of professionalism could possibly be ascribed to the following factors: • Teaching of professionalism at the University of Pretoria focuses on the humanistic attributes, which form an important part of patient consultations and teamwork. • Medical students are not actively involved in the social contract that is prominent in the Charter. They have very little influence regarding social justice, access to care, distribution of resources and conflict of interest. • The Charter is considered vague and open to interpretation It is recommended that a universally acceptable charter be developed for the Medical School of Pretoria by involving faculty members to validate and accept the students' perspectives. It is also recommended that these mutually accepted attributes then be used as the assessment criteria of a professionalism assessment tool. This should also encourage faculty members to act as good role models. South African Family Practice Vol. 49 (4) 2007: pp.1

Do we assess what we set out to teach in obstetrics: An action research study

Background. Medical education empowers students to transform theoretical knowledge into practice. Assessment of knowledge, skills and attitudes determines students’ competency to practice. Assessment methods have been adapted, but not evaluated, to accommodate educational challenges. Objectives. To evaluate whether assessment criteria align with obstetrics learning outcomes. Methods. We conducted a collaborative action research study, in which we reviewed and analysed learning outcomes and assessments according to Bigg’s model of constructive alignment. Data were analysed as per levels of Bloom’s taxonomy. Results. Final-year students have two 3-week modules in obstetrics, with 75% overlap in learning outcomes and assessments. Ninety-five percent of learning outcomes were poorly defined, and 11 - 22% were inappropriately assessed. Summative assessments were comprehensive, but continuous assessments were rudimentary without clear educational benefit. There is a deficiency in assessment of clinical skills and competencies, as assessments have been adapted to accommodate patient confidentiality and increasing student numbers. The lack of good assessment practice compromises the validity of assessments, resulting in assessments that do not focus on higher levels of thinking. Conclusion. There was poor alignment between assessment and outcomes. Combining the obstetrics modules, and reviewing learning outcomes and assessments as a single entity, will improve the authenticity of assessments

The infl uence of banks’ internal performance on market performance: a non-parametric approach

The purpose of the study is to determine the degree to which banks’market performance, as measured by market value ratios, is aff ectedby their internal performance. Annual fi nancial statement reportswere used to determine the internal and market performance oflisted banks on the JSE Limited over a ten-year period. The internalperformance measures used are the profi tability ratios in the DuPont analysis and two Data Envelopment Analysis (DEA) models toestimate effi ciency. Income statement data were included as theoutput of the fi rst model to determine banks’ operating effi ciency,and balance sheet data were included as the output of the secondmodel to determine banks’ fi nance and investment effi ciency. Thestudy concluded that market value ratios correlate better withprofi tability ratios than the income statement output-based andbalance sheet output-based effi ciencies. This study is the fi rst tocompare two DEA models and profi tability ratios with market valueratios. The value of the study is therefore that it indicates thatprofi tability ratios should be used as a proxy for market value ratiosrather than effi ciency measures that focus separately on incomestatement data and balance sheet data

A strategic analytics methodology

University of Technology, Sydney. Faculty of Information Technology.Commercial organisations are dependent on generating profit from competitive advantage. Central to this approach, is the Strategic Planning Cycle (SPC). SPC converts new information and new subject matter expertise into competitive knowledge, and then converts that knowledge into executable solutions best suited to the organisation’s internal and external circumstances and resources. SPC also maintains the relevance and efficiency of the executed solutions over time. In order to optimise competitiveness, organisations seek to improve SPC in a number of ways. First, they improve the quality of the informational inputs to SPC. Second, they improve the quality of the knowledge which they develop from that information. Third, they optimise the executibility of the solutions, which were based on the knowledge, for the organisation’s particular circumstances and resources. Four, they improve the solutions over time, maintaining competitiveness. All four ways of improving SPC are supported by data analytics. It is therefore a necessity ever to improve the integration of data analytics with SPC. Data mining is an advanced analytics approach, which has been shown to support SPC. Recognising the complexity of integrating data analytics with the business at the turn of the 21st century, the analytics community developed data mining project methodologies to facilitate the integration. The most widely published methodology is CRISP-DM. SAS Institute’s SAS Data Mining Projects Methodology (SDMPM) is a second, albeit proprietary, methodology which is also widely used. Despite the availability of packaged data mining software and project methodologies for more than a decade now, organisations are still finding the integration of data mining with the SPC process complex and daunting. The current situation is that business leaders and data analysts often express the need for better integration of data analytics with SPC and business goals. The researcher hypothesized that the data mining project methodologies may be a major contributor to the above situation. The researcher therefore formulated the research objective of evaluating data mining methodology for its support of the SPC process. The CRISP-DM methodology was chosen for evaluation because it is in the public domain and therefore available to other researchers. (The researcher has evaluated SDMPM in a separate paper.) The research method chosen was Participatory Action Research, specifically that of action science or expert reflection-in-action. The research was industry-based, using data from a real-life Telco customer retention management problem. The researcher and the Telco formulated a data analytics project using CRISP-DM. The project was in support of the Telco’s strategic initiative drastically to reduce customer churn in their consumer business. The data mining project would support the initiative in three ways. First, it would predict customer churn behaviour within an upcoming time window. Second, it would segment the most at-risk customers in strategic marketing dimensions. Third, it would profile the segments in dimensions required for retention campaign re-design. Using expert reflection-in-action, we evaluated the operating and strategic outcome for the Telco, from the project that was formulated using CRISP-DM as the project methodology. The research findings were that the project based on CRISP-DM would be limited in its executibility and strategic impact. This would severely restrict the competitive advantage realisable from the project. Our research identified six key limitations of CRISP-DM in the SPC environment: diagnostic technique for defining the project’s business goals or business deliverables. This is about defining the required informational and marketing components required for the strategic initiative; introduction of new business and analytics subject matter expertise into the project environment. This relates to increasing the understanding of the business problem and its possible solutions through new marketing and data mining subject matter expertise; mapping technique between the project’s business deliverables and the supporting data mining plan. This is about assuring that the data analytics best support the project’s business deliverables; knowledge management activities required by SPC for assessing discovered information against business deliverables, environmental and circumstantial factors, for adapting the information, and for developing competitive, executable business solutions; monitor and control of business and data mining solutions over time for effectiveness and efficiency; and a number of soft project and business solution implementation issues. The main research goal, which flowed from the above finding, was to develop a new, more potent data mining project methodology for the SPC environment. In developing this methodology, the researcher used concepts from the Business, Knowledge Discovery, and Data Mining literature, also drawing on his previous corporate management experience and MBA qualification. The researcher called the new method Strategic Analytics Method (SAM). Essentially SAM is the integration of data analytics project methodology and a proven SPC tool, which is known as Strategic Planning Method (SPM). SPM is a generic decision-making process designed for producing competitive outcomes under conditions of uncertainty and limited resources. SPM is widely used in various guises by business, software engineering, the military, and many other applications. SAM presents a major departure from CRISP-DM’s data centricity, to a project centered on the project’s business deliverables. SAM is targeted at data miners and data analysts working in a commercial environment, and at business intelligence practitioners. Practically SAM contributes the following to data mining projects methodology: omoving the focus from data-related activities to business deliverables; insights about the restrictive impact of the pre-project status quo on the results of the project, the dimensions of the status quo which must be defined into a business problem, and how to achieve that definition; technique for injecting new business and analytics subject matter into the stale business environment, to enable competitive breakthrough; technique for developing business deliverables or goals for the project, which will be competitive. This includes considering the new subject matter, and overcoming the restrictions presented by the current understanding of the status quo; mapping technique between the project’s business deliverables and the data mining plan, which assures the data mining outputs optimally supporting the attainment of the business deliverables; technique for assessing discovered information for its relevance to the business deliverables; knowledge management activities for developing the discovered information into competitive business solutions which are executable under the organisation’s limited resources and limiting circumstances; substantial qualitative and quantitative technique for developing monitor and control plans for both the analytics and the business solution; activities, which pro-actively manage soft issues before they impact on the project negatively. For instance, we reframe data preparation activities as a process, which gradually reduces project risk associated with the data. This offers more understandable and acceptable justification to the business audience about this resource-intensive part of data mining projects; insights for distinguishing between iteration and repetition of activities on advanced SPC projects, and technique for knowing when to start and stop iterating, or repeating. This distinction provides contextual vocabulary for communicating with the business about required project effort. The research validates SAM on the same Telco ABC problem, which was used for evaluating CRISP-DM. The validation came through being able to formulate a project using SAM in which we: assisted Telco ABC in breaking through their limited pre-project marketing perceptions and expectations, to formulate business deliverables based on new marketing and analytics subject matter, which constituted competitiveness in customer retention management; formulated and executed a data mining project which produced the information required by the business deliverables; improved the Telco’s calculation of the extent of the problem; developed knowledge from the discovered information which complemented applicable new marketing subject matter; developed the knowledge into a competitive retention management solution executable under the Telco’s limiting circumstances and limited campaign resources. We presented the solution as new marketing objectives and strategies, and developed these into a retention campaign strategy with various key components; developed a comprehensive monitor and control plan for the campaigns and the operationalised data analytics solution; quantified the project ROI as about 187 times the investment

The prevalence of the diagnosis of increased intra-ocular pressure in a general practice

Glaucoma is one of the main causes of blindness.1 The disease occurs in 3% to 4% of all people over the age of 70 years.1 As many as 50% of patients suffering from this disease are unaware of their condition until a comparatively late stage, due to the asymptomatic nature of the disease.2 Of the objective signs of primary open angle glaucoma, the loss of visual field and pathological cupping would generally have reached an advanced stage before they could be recognised by a general practitioner, and aqueous flow can only be measured with the use of specialised equipment. However, increased intra-ocular pressure can easily be detected by tonometry performed by a general practitioner.3For full text, click here:SA Fam Pract 2006;48(3):16-1

An investigation of the perceptions of South African students with regards to accelerated learning courses

The cost of repeating a module has both financial and social implications. The social implications include increased workloads when repeating a module and students often not being able to graduate within the prescribed minimum course period. A possible solution for this is the use of accelerated learning courses, in the form of summer or winter schools. These schools provide students with another opportunity to pass a module, during the summer or winter recess, using an accelerated learning mode, and consequently complete modules with prerequisites of failed modules in the following year. Using an accelerated learning approach, a summer or winter school covers a large portion of the content in semester or year modules in a shortened timeframe outside the normal academic period. Using a questionnaire approach, the various perceptions of first year students at the end of the academic year regarding the use of these schools were obtained and analysed. The timing of the end of the academic year allows students to familiarise themselves with the various accelerated learning courses offered to them throughout the academic year. The findings suggest that students have a positive perception of these schools despite most of them not having had previous experience of completing an accelerated learning course. Although previous literature has indicated that students are hesitant to complete finance-related modules in an accelerated learning format versus traditional semester and year modules, the perceptions indicate that students are willing to engage in financial modules, with the students identifying that the benefits of these accelerated learning courses exceed the cost. The findings suggest that students who are presented with various non-academic obstacles throughout the traditional module are able to use summer or winter schools as a way to reduce exposure to these obstacles and complete an accelerated learning course. The use of these schools therefore presents an area for module developers to consider when implementing these schools as a way to improve throughput rates, thereby contributing in a positive way to students’ financial and social health

Scaling up HIV testing in resourceconstrained settings: Debates on the role of VCT and Routine ‘Opt-in or Opt-out\' HIV Testing

Scaling up of the numbers of people voluntarily undergoing HIV testing has become vital, especially in resource-constrained settings, where the need for knowledge of HIV status for both prevention and care is critical. The reality is that for most people in Africa, access to HIV testing and to voluntary counselling and testing (VCT) has been very limited, and this has human rights implications – missing the opportunity to be diagnosed with a disease that is now well understood, manageable and treatable means certain death. The key challenge in our current context is how scaling up of HIV testing should be done. In responding to this challenge, we are guided by Gruskin and Loff,1 who state that ‘A human rights approach mandates that any public strategy, whether or not rights are to be restricted, be informed by evidence and widely debated. This approach protects against unproved and potentially counterproductive strategies, even those motivated by the genuine despair in the face of overwhelming public health challenges.\' This article describes the arguments and discussion raised during a session on models for increasing access to HIV testing at the 2nd National Conference on HIV/AIDS held in Durban in June 2005. It describes the legal framework for HIV testing in South Africa, frames the issues at the heart of the debate, and describes and discusses the various models of HIV testing, routine HIV testing, VCT and mandatory or compulsory HIV testing, within the context of HIV prevention and care. It concludes with recommendations. Southern African Journal of HIV Medicine Vol. 6 (3) 2005: pp. 45-4

Household food security and HIV status in rural and urban communities in the Free State province, South Africa

Higher socioeconomic status impacts profoundly on quality of life. Life-event stressors, such as loss of employment, marital separation/divorce, death of a spouse and food insecurity, have been found to accelerate disease progression among people with human immunodeficiency virus (HIV). The objective of this study was to determine significant independent sociodemographic and food security factors associated with HIV status in people from rural and urban communities in the Assuring Health for All study, which was undertaken in rural Trompsburg, Philippolis and Springfontein and urban Mangaung, in the Free State Province of South Africa. Sociodemographic and food security factors associated with HIV status were determined in 886 households. Logistic regression with forward selection (p < 0.05) was used to select significant independent factors associated with HIV status. Variables with a p-value of < 0.15 were considered for inclusion in the model. Adults 25–64 years of age were eligible to participate. Of the 567 rural participants, 97 (17.1%) were HIV-infected, and 172 (40.6%) of the 424 urban participants. A relatively high percentage of respondents had never attended school, while very few participants in all areas had a tertiary education. The unemployment rate of HIV-infected adults was higher than that of HIV-uninfected adults. A high percentage of respondents in all areas reported running out of money to buy food, with this tendency occurring significantly more among urban HIV-infected than HIV-uninfected respondents. In all areas, a high percentage of HIV-infected respondents relied on a limited number of foods to feed their children, with significantly more HIV-infected urban respondents compared to their uninfected counterparts reporting this. Most participants in all areas had to cut the size of meals, or ate less because there was not enough food in the house or not enough money to buy food. During periods of food shortage, more than 50% of respondents in all areas asked family, relatives or neighbours for assistance with money and/or food, which occurred at a higher percentage of HIV-infected rural participants compared to HIV-uninfected rural participants. More than half of all participants reported feeling sad, blue or depressed for two weeks or more in a row. HIV infection was negatively associated with being married (odds ratio 0.20 in rural areas and 0.54 in urban areas), while church membership decreased the likelihood of HIV (odds ratio 0.22 in rural areas and 0.46 in urban areas). Indicators of higher socioeconomic status (having a microwave oven and access to vegetables from local farmers or shops) decreased the likelihood of HIV in rural areas (odds ratios 0.15 and 0.43, respectively). Indicators of lower socioeconomic status such as spending less money on food in the rural sample (odds ratio 3.29) and experiencing periods of food shortages in the urban sample (odds ratio 2.14), increased the likelihood of being HIV-infected. Interventions aimed at poverty alleviation and strengthening values can contribute to addressing HIV infection in South Africa.Keywords: HIV, poverty, food securit