Integrating two measures of quality practice into clinical and practical legal education assessment: good client interviewing and effective community legal education

This paper will examine, through two case studies (an undergraduate clinical program and a Practical Legal Education (PLE) advice clinic) the scope for indicators developed by Curran to assess the outcomes, effectiveness and quality of legal assistance service in Australia to be used in clinical assessment. This article will explore how two particular indicators evaluated as fundamental in that research might be utilised to assess students so as to enhance the quality of their clinical participation. Clinical Legal Education is seen by its adherents as ‘a premier method of learning and teaching. Its intensive, one-on-one or small group nature can allow students to apply legal theory and develop their lawyering skills to solve client legal problems. Its teaching pedagogy is distinguished by a system of self-critique and supervisory feedback enabling law students to learn how to learn from their experiences’. In many senses it is a form of experiential learning through engagement with the practice of law.It aims to contextualise the study of law and draw on student learning in other courses to guide and support them in identifying, developing and applying ethical legal practice skills. But its scope is much wider than simply ‘skills’, it also aims to develop students’ critical understanding of approaches to legal practice, to their understanding of the roles of lawyers in relation to individual clients and social justice issues and to encourage and as a means to validate student aspirations to promote access to justice and equality through the law. We suggest ways to assess the quality of such engagement by clinical students, focusing on Curran’s core quality measures of ‘a good client interview’ and ‘quality community legal education’. The value of utilising these two indicators to assess the quality of student engagement is that they themselves are core to the activities in which students are involved in clinic

A Literature Review of Possible Barriers and Knowledge Gaps of General Practitioners in Implementing Advance Care Planning in Ireland: Experience from Other Countries

Background: An Advance Care Plan (ACP) is a decision-making process concerning end-of-life care that embodies a patient’s values and preferences, for a time when patients are unable to make such choices on their own. ACPs have been employed into medical practices worldwide; however, they remain largely uncompleted by general practitioners (GPs), regardless of their benefits to patients and their families with respect to end of life (EOL) care. Furthermore, ACPs will soon be implemented into clinician practices across Ireland, as part of the Assisted Decision Making (Capacity) Act 2015. This review aims to explore the literature to examine challenges GPs may face in employing ACPs into clinical practice. Methods: An electronic search was performed through three databases: PubMed, MEDLINE, and CINAHL Plus, through which a total of eleven studies met the selection criteria. Additionally, three studies were provided by experts in the field. Thus, a total of fourteen studies were condensed and critically appraised through CASP (Critical Appraisal Skills Program), which concluded that the quality of the studies was high. Conclusion: Through this review, knowledge gaps and barriers for GPs regarding ACPs were identified. Barriers for implementing ACPs into practice were categorized into three major themes: barriers for the GPs, barriers in the healthcare system, and barriers regarding the patient. These included insufficient time, complexity of the ACP documents themselves, uncertainty of the disease prognosis, and the ultimate fear of inducing anxiety and loss of hope in patients

Dementia care: the view from general practice

Dementia is a topic of major concern internationally because of increasing prevalence rates, rising costs to healthcare systems and the considerable impact that dementia has on the lives of patients and their families. There are currently approximately 46 million people living with dementia worldwide, a figure that is expected to almost treble to 131.5 million by 2050

Teaching professionalism in legal clinic – what new practitioners say is important

Anecdotal evidence suggests new lawyers may struggle as they begin legal practice. Little is known empirically about their actual experiences. This paper provides some insights into what occurs in this transition. It reports on a qualitative study currently underway tracking new lawyers through their first year of practice. Preliminary analysis of data from interviews and from workplace observations suggests clinical legal education can play a significant role in smoothing the transition and helping new lawyers develop their sense of professionalism. into their vocational training year. We track new lawyers in the context of their post-admission practice with a small cohort of recently admitted lawyers interviewed and observed in their day to day practice.We describe what these new lawyers say is important to an effective transition – developing autonomy, learning to deal with uncertainty and finding an accommodation between their developing professional values and those modelled by their firm and colleagues. Clinical programs offer opportunities for an early reflective exposure to these experiences

Developing and piloting a resource for training assessors in use of the Mini-CEX (mini clinical evaluation exercise).

The assessment of undergraduate medical students in the clinical setting has become a key priority for medical educators. Facilitating the successful translation of undergraduate theoretical knowledge into safe and appropriate postgraduate clinical practice represents a challenge in medical education [1]. Poor clinical performance of newly qualified doctors has been highlighted as a major issue relating to patient safety [2]. Performance based assessment in the undergraduate setting may assist in addressing this issue by assessing ‘doing’ rather than ‘knowing’. The mini clinical evaluation exercise (Mini-CEX) is a formative assessment used to assess the performance of medical students in a clinical context. It incorporates assessment by, and feedback from, an assessor, based on the direct observation of a student–patient consultation [3]. Conducted in a series of stages, the Mini-CEX allows focused assessment of key competencies (see Box 1) [3]

'Working away in that Grey Area...' A qualitative exploration of the challenges general practitioners experience when managing behavioural and psychological symptoms of dementia

Background: general practitioners (GPs) have identified the management of behavioural and psychological symptoms of dementia (BPSD) as a particularly challenging aspect of dementia care. However, there is a paucity of research on why GPs find BPSD challenging and how this influences the care they offer to their patients with dementia. Objectives: to establish the challenges GPs experience when managing BPSD; to explore how these challenges influence GPs’ management decisions; and to identify strategies for overcoming these challenges. Design: qualitative study of GPs experiences of managing BPSD. Methods: semi-structured interviews were conducted with 16 GPs in the Republic of Ireland. GPs were purposively recruited to include participants with differing levels of experience caring for people with BPSD in nursing homes and in community settings to provide maximum diversity of views. Interviews were analysed thematically. Results: three main challenges of managing BPSD were identified; lack of clinical guidance, stretched resources and difficulties managing expectations. The lack of relevant clinical guidance available affected GPs’ confidence when managing BPSD. In the absence of appropriate resources GPs felt reliant upon sedative medications. GPs believed their advocacy role was further compromised by the difficulties they experienced managing expectations of family caregivers and nursing home staff. Conclusions: this study helps to explain the apparent discrepancy between best practice recommendations in BPSD and real-life practice. It will be used to inform the design of an intervention to support the management of BPSD in general practice

Clopidogrel discontinuation and platelet reactivity following coronary stenting.

Aims: Antiplatelet therapy with aspirin and clopidogrel are recommended for 1 year after drug-eluting stent (DES) implantation or myocardial infarction. However, the discontinuation of antiplatelet therapy has become an important issue as recent studies have suggested a clustering of ischaemic events within 90 days of clopidogrel withdrawal. The objective of this investigation was to explore the hypothesis that there is a transient \u22rebound\u22 increase in platelet reactivity within three months of clopidogrel discontinuation. Methods and Results: In this prospective study, platelet function was assessed in patients taking aspirin and clopidogrel for at least 1 year following DES implantation. Platelet aggregation was measured using a modification of light transmission aggregometry in response to multiple concentrations of adenosine diphosphate (ADP), epinephrine, arachidonic acid, thrombin receptor activating peptide and, collagen. Clopidogrel was stopped and platelet function was reassessed 1 week, 1 month and 3 months later. Thirty-two patients on dual antiplatelet therapy were recruited. Discontinuation of clopidogrel increased platelet aggregation to all agonists, except arachidonic acid. Platelet aggregation in response to ADP (2.5, 5, 10, 20 μM) and epinephrine (5, 20 μM) was significantly increased at 1 month compared to 3 months following clopidogrel withdrawal. Thus, a transient period of increased platelet reactivity to both ADP and epinephrine was observed 1 month after clopidogrel discontinuation. Conclusions: This study demonstrates a transient increase in platelet reactivity 1 month after clopidogrel withdrawal. This phenomenon may, in part, explain the known clustering of thrombotic events observed after clopidogrel discontinuation. This observation requires confirmation in larger populations

Development of a tool for monitoring the prescribing of antipsychotic medications to people with dementia in general practice: a modified eDelphi consensus study

Background: Despite their adverse effects, antipsychotics are frequently used to manage behavioral and psychological symptoms of dementia. Regular monitoring of antipsychotic prescribing has been shown to improve the appropriateness of prescribing. However, there is currently no consensus on what the components of such a monitoring tool would be. Aim: The aim of this study was to use an expert consensus process to identify the key components of an antipsychotic repeat prescribing tool for use with people with dementia in a general practice setting. Methods: A modified eDelphi technique was employed. We invited multidisciplinary experts in antipsychotic prescribing to people with dementia to participate. These experts included general practitioners (GPs), geriatricians and old age psychiatrists. The list of statements for round 1 was developed through a review of existing monitoring tools and international best practice guidelines. In the second round of the Delphi, any statement that had not reached consensus in the first round was presented for re-rating, with personalized feedback on the group and the individual’s response to the specific statement. The final round consisted of a face-to-face expert meeting to resolve any uncertainties from round 2. Results: A total of 23 items were rated over two eDelphi rounds and one face-to-face consensus meeting to yield a total of 18 endorsed items and five rejected items. The endorsed statements informed the development of a structured, repeat prescribing tool for monitoring antipsychotics in people with dementia in primary care. Conclusion: The development of repeat prescribing tool provides GPs with practical advice that is lacking in current guidelines and will help to support GPs by providing a structured format to use when reviewing antipsychotic prescriptions for people with dementia, ultimately improving patient care. The feasibility and acceptability of the tool now need to be evaluated in clinical practice

Leading entrepreneurial e-learning development in legal education: a longitudinal case study of ‘universities as learning organisations'

Purpose The study aims to review the entrepreneurial and educational innovations in technology-enabled distance education in practical legal education (PLE) accomplished by a unit “on the periphery” of a strong research-led university. It also aims to examine the learning organisation (LO) attributes associated with this initiative. Design/methodology/approach This is a longitudinal case study based on interviews and reflective analysis, and reviewed using three “models” drawn from the literature: breaking the “iron triangle” (containing costs; widening access; enhancing quality); a tailored version of distance education appropriate for research-intensive universities; a strategy for successful adoption of disruptive technologies in higher education. Findings Entrepreneurialism yielded growth (PLE student numbers went from 150 to 2,000 in 15 years) and diversification (two new programmes established). The PLE programme advanced in two “waves”: the first centred on widening access and the second, on enhancing quality. Costs were contained. Both the presence and absence of LO attributes are identified at three different organisational levels. Research limitations/implications Challenges to academic identity may act to inhibit educational change, especially in research-strong settings. Practical/implications Business logic, and the creation and institutionalisation of educational development support – an “internal networking” group, were keys to success. “Organisational learning” in complex institutional environments such as universities involves understandably lengthy timescales (e.g. decades or more). Practical/implications Technology-enabled disruption in higher education appears relentless. While institutional and individual performance metrics favour research, proven cases of “how to do things differently” in education may well not get exploited, thus opening the market to alternative providers. Originality/value This is the only empirical example of a tailored version of distance education appropriate for research-intensive universities that we know about

Dementia diagnosis and referral in general practice: a representative survey of Irish general practitioners

Aims: Most of those with a memory problem or concern over cognition present to their General Practitioner (GP) in the first instance. Despite this, the current diagnostic and referral patterns of Irish GPs remains unclear. Methods: A survey was distributed to three separate cohorts of GPs (n=692) Results: Ninety-Five (14%) responded. Most personally diagnose 1-3 (69%; 65/95) or 4-6 (21%; 20/95) patients with dementia per year. Two-thirds (62%; 59/95) refer >80% of those with possible dementia for further assessment/support, most commonly to support/clarify a diagnosis (71%; 67/95) and most frequently to a geriatrician (79%; 75/95). In half of cases (51%; 48/95), referral is to a professional working as part of an established memory clinic. One-fifth reported receiving dementia-specific postgraduate training (19%; 18/95) and over four-fifths (82%; 78/95) would welcome further training. Discussion: Further attention to the ongoing establishment of memory clinic services and dedicated referral pathways, as well as increasing emphasis on dementia assessment and diagnosis in medical curricula, is warranted