Miscellaneous

Introduction

Organ transplantation is an effective therapy for end-stage organ failure and is widely practiced around the world. According to World Health Organization (WHO), kidney transplants are carried out in 91 countries. Around 66,000 kidney donations, 21,000 liver donations and 6000 heart transplants were performed globally in 2005. ¹ In India the rate of organ donation is only 0.16 per million populations, compared to America's 26 and Spain's 35.² The shortage of organ is virtually a universal problem. Though many efforts were undertaken by the government to motivate the public towards donation of organs, the rate of organ donors has not paralleled the growing waiting list³,⁴, ⁵ and inadequate organ donation in India remains a major limiting factor for transplantation. There are several factors which could facilitate and hinder the general public to donate a organ. Identifying these factors could help in planning effective strategies to combat the problem. Hence the present study was conducted with the aim to explore the general publics perceived barriers and facilitating factors of organ donation.

Materials and methods

The present study was a cross sectional, exploratory survey conducted among the general public of Puducherry U.T, India. 400 eligible subjects who fulfilled the following criteria were included a) Subjects aged 18 and above, and b) who understand either the local language Tamil or English. Subjects with intellectual, psychiatric and emotional disturbances that could affect the reliability of their responses were excluded from the study. The population registry in the primary health centers of the selected community area was used as a sample frame to select subjects randomly. Every eligible subject was explained about the purpose of the study and signed a written consent form. Formal ethical clearance was obtained from the institute ethics committee before actual data collection procedure.

Preparation of the questionnaire

An extensive literature review was carried out to understand the possible barriers and facilitators reported in the past. Reported barrier and facilitating factors in the literature were included in constructing the questionnaire, including specific cultural and religious oriented items specific to Indians. Subject’s intention to donate the organ was assessed using a single dichotomous question (yes or no). For assessing the barriers and facilitators related to organ donation a questionnaire with a total of 18 items (9 items each) was prepared in the form of closed ended question i.e. yes or no. Along with closed ended questions, an open ended question i.e. any other? was also included for obtaining an extended response apart from the framed questions. As knowledge is an important factor which could serve both as a barrier and facilitator for organ donation, 8 items related to knowledge were also included as a part of the questionnaire. Knowledge items of the questionnaire were evaluated by assigning a score of 1 for each correct response with a maximum possible score of 8. Interpretation of the knowledge component was also done by categorizing the knowledge as follows - Below 50% of the total score - Inadequate knowledge, 51 – 75% - Moderately adequate knowledge, above 75% - Adequate knowledge, for ease of understanding. The draft tool was validated for its content by 10 experts from the field of surgery, medicine, nursing, anthropology and psychology for its appropriateness. After appropriate modification the content validity index for the tool was calculated and it was found to be highly valid (0.98). The reliability of the tool was estimated by a test re-test reliability method among 10 subjects with an interval of 2 weeks from the first and second time of administration of the questionnaire. It was found to be highly reliable with reliability coefficient of 0.91. A face to face interview method was used to collect data from each subject. Collected data was analyzed using SPSS for windows version 14 (SPSS Inc., Chicago, Il, USA) with appropriate descriptive and inferential statistics. A probability value of < 0.05 was set as the level of significance

Results

Basic Demographic details

Of the total 400 subjects enrolled the majority were male (56%), between the age group of 31-40 years (48%), and followed Hinduism (68%) at the time of interview. Most of the subjects were literate (70%) with education up to high school and resided in a rural area (53%).

Knowledge regarding organ donation

The mean knowledge score of the subjects regarding organ donation was 4.74 1.45 score which ranged from a minimum score of 1 to a maximum score of 8. Most subjects responded correctly to questions related to organ matching (85.3%) and consent procedure (84.7%). Details of different aspects of knowledge regarding organ donation of the subjects can be found in Table 1. When subjects were asked about the source of information regarding organ donation, 51.3% of the subjects reported that they gained knowledge through television, 23% from health personnel, and 12% from friends and 7% through books and internet (Figure1). Whilecategorizing knowledge scores the majority of the subjects (38.6%) had inadequate knowledge, 50.6% had moderate knowledge and only 10.6% had adequate knowledge regarding organ donation.

Intention to donate organs: Barriers and Facilitators

Of the total 400 subjects interviewed 69.75% of the subjects reported that they wish to donate their organs, whereas the remaining 30.25% reported that they will not donate their organs either during their life or after their death. Subsequently the factors for barriers and facilitators were also analyzed using the pretested questionnaire. The most common barriers perceived by the subjects related to organ donation were as follows, ‘family opposition’ (82.8%), ‘complicated organ donation procedure’ (69%), ‘fear that donation affects their future’ (58.36%), and ‘misuse of organs’ (55.2%). More information about barriers is detailed in Table 2.The most important facilitating factors of organ donation as reported by the subjects were ‘thought of saving someone’s life’ (95.9%), ‘feeling of improved sense of humanity’ (95%), ‘to save the life of a close relative’, ‘thought that their organ live after their death (92.6%) and ‘being a role model for others’ (77.7%). More details of facilitating factor can be seen in Table 3

While associating the subject’s intention to donate organs with demographic variables like age, gender, residence, education, religion, marital status, type of family and knowledge; only educational level had a significant association with the subject’s intention to donate organ. Specifically graduate people are more likely to report intention to donate organ their organs than others (p<0.001).

Figure 1: Distribution of source of information regarding organ donation among the subjects.


Table 1: Item wise distribution of different aspects of knowledge regarding organ donation (n=400)

Table 2: Perceived Barriers towards organ donation (n=121)

Table 3: Perceived Facilitators towards organ donation (n=279)

Discussion

The current study was conducted with the aim to explore the general publics intention towards organ donation and to identify the perceived barriers and facilitators. The present study revealed that 69.7% of the subjects have an intention to donate their organs either during their life or after their death, which is similar to the finding of Chung et al⁶ and Shahbazian H et al⁷. Similar to the previous studies⁸ the current study also confirmed a positive association between public intentions to donate their organ with their educational status. Though many studies in the past reported attitudes⁹,¹⁰ of public towards organ donation, the present study was the first of its kind to analyze specifically the barriers and facilitators of organ donation among the general public, this adds strength to this study. The most common barrier reported in the present study was ‘opposition form family in donating their organs’; these findings were similar to a previous study.⁶ Illegal organ donation and misuse of organ is a major problem in India for the low organ donation rate among public¹¹, this fact was reflected even in the current study as 55.2% of the subjects reported misuse of an organ as barrier to organ donation. The most important facilitating factors of organ donation reported in the present study was ‘thought of saving someone’s life’ (95.9%), ‘feeling of improved sense of humanity’ (95%), ‘to save the life of a close relative’ (92.9%), these finding were similar to the findings of Neelam et al conducted in India¹². The majority of the respondents in this study reported "lack of information" about organ donation and transplantation. These findings are comparable with those reported from previous studies, which all indicate the importance of public education about the importance of organ donation¹³,¹⁴,¹⁵,¹⁶. Our study identified that the principle respondents' source of information about organ donation was the television (TV). The contribution of other sources of information in providing respondents with knowledge about organ donation was minimal. Generally, studies had shown the importance of visual media in increasing the awareness of the public about organ donation. ¹⁷,¹⁸

Conclusion

Better knowledge may ultimately translate into the act of donation. Effective measures should be taken to educate people with relevant information with the involvement of media, doctors and religious scholars.

Isaac Asimov famously said: ‘The only constant is change.’ (Cited in Hartung, 2004).

So why is it so difficult for most of us to understand, manage, or embrace change?

Coping with change can be challenging for many and, depending on the change and what the impact or outcome of the change means to the individual, will depend upon how well they embrace and accept it. Should a person be fearful of change then it is natural that they will attempt to resist it which in turn can cause high levels of stress and anxiety.

Understanding how we typically react to change also helps us to cope better and manage change. The Kubler-Ross (2009) Model of Change is perhaps one of the best known and most applied models within clinical environments (her original work being around the five stages of grief) which is now also applied to businesses and organisations when looking at changes in the work place such as loss or change of job.

The five stages she refers to are:

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

A common example used to explain this model is to understand how we would typically respond to an unexpected change such as a dead car battery.

The dead car battery

Just imagine it is a cold winter day and you are dashing to get to work already running late…

You jump into the car, place the key in the ignition and turn it on.

Nothing happens, the battery is dead.

Applying the Kubler Ross Model to this situation, this is how a person may typically react:

1. Denial - This cannot be happening! Try again. And again! Check the other things in the car are working such as the lights and radio. Try again but still nothing.
2. Anger - Arrrrgh you stupid car!!! I’m sick of this car!! Why is this happening today of all days!! Slamming a hand against the steering wheel.
3. Bargaining - (realising that  it really isn’t going to start and that you're going to be late for work)..., Oh please car, if you will just start one more time I promise I'll buy you a brand new battery and keep you clean and tidy. Please just start this one time.
4. Depression - Oh no! What am I going to do? I'm going to be late for work. I give up. I don't really care any more. What's the use?
5. Acceptance - Right I need to do something. It is not going to start. I need to call the breakdown service and ring into work.

The above example is a simple example yet I’m sure most of us have experienced it or something similar quite often. If you apply this to a situation where the stakes are far higher such as a sudden loss or change of a job, bereavement, house, relationship etc which may impact upon so many things including stability of finances, family, health and other forms of security, then you may be able to see the harsh effect this could have on an individual during this time.

Often individuals add to their stress by expecting themselves to be able to cope with such events. It is important to understand it is not about strength or weakness but about human nature to react by demonstrating the signs of loss and grief. Organisations, managers and individuals need to be understanding and supportive when situations like this happen.

Another way of understanding and coping with change is to consider what goes on in the mind of the individual at the time of the change and what it ‘means’ to them. Some people see risk and uncertainty as exciting and embrace change (depending on the change), whereas others can be fearful of any change, even those perceived to be minor changes, as for them any change is seen as a risk and takes them out of their comfort zone.

The comfort zone

Your comfort zone is where you are fully able, competent and comfortable. The job that you can do with your eyes shut or routines of life where you know exactly what you are doing. You may feel slightly challenged now and then, but there’s nothing you cannot easily handle. 

When invited to step outside their comfort zone – or if they’re pushed outside of it - many people react with resistance. This is because of the human fear of failure which, when you look into it more deeply, comes from a desire to be accepted, liked and even loved. When most people ‘fail’ they feel embarrassed, ashamed, silly or stupid because they feel they can’t or couldn’t do whatever it was they tried.

So it’s understandable if at work, or any area of life where there is change, people react with resistance. Change is the unknown, and if you don’t know whether you can do something – especially if you have a ‘Be Perfect’ driver – you could have fears over whether you can do it, can be a success or even cope. Everyday changes such as new computers or telephone systems, new staff, new jobs, new routines and procedures, new management, merging of departments, sections or whole companies or, on a personal level, exams, weddings, divorce, births, deaths, moving house and so on, are all high on the list of stressors due to change.  

How big is your zone?

Are you resistant to change? If you are, you’re causing yourself stress. Imagine what size a child’s comfort zone would be compared to an adult’s. Children do not have inhibitions and fears; it’s only as we grow older that we learn to feel fear, that we learn what embarrassment is and how to feel silly or stupid – that is, we learn to have an ego. This restricts our ability to have the freedom to learn, grow and be open to change, as we are nervous about asking questions for fear of looking silly, or trying new things for fear of failure, and we avoid doing anything that may cause us to feel embarrassed.

By being more fluid and open to change, accepting any fear and dealing with it effectively, you would not only grow your confidence and self-esteem, but you will be free to develop your life with more happiness and less stress. 

By looking at change differently (for example, recognising that change can also be a good thing; focusing on the possible positives from a situation rather than being quick to look at the negatives from a point of fear and therefore resistance) stress can be greatly reduced.

Choose to flow with change rather than resist; choose to step out of your comfort zone and grow the size of your comfort zone daily. Aim to have a comfort zone the size of a child’s where nothing can faze or worry you, and you will notice a huge difference to the amount of stress you have in your life.

‘The greatest discovery of my generation is that a human being can change their life by altering their attitude of mind.’ William James (cited in Maxwell, 2007).

Remember – the only failure is not trying again. If we fail at something at least we know what NOT to do next time!

Identifying your zones and being rational

Following are three simple exercises you can complete to help you to gain a rational perspective on understanding how you cope with change and also being solution focused when embracing change.

The zones of change help us to understand the different levels of comfort or ‘risk’ and where changes may sit in terms of their percieved meanings to the individual.

Zones of change

Exercise 1

Think back to a significant change in your life or work (something from the past).

• What were your perceived risks at the time?

…………………………………………………………………………………

…………………………………………………………………………………

• What did you lose?

…………………………………………………………………………………

…………………………………………………………………………………

• What did you gain?

…………………………………………………………………………………

…………………………………………………………………………………

This exercise demonstrates that our ‘perceived risks’ at the time of a change were often far different than the reality of how the change occurred. It is also common for an individual to notice that their ‘gains’ can be larger than their ‘losses’ (time can play a factor in this too, often a change can seem a disaster at the time but over time a person can look back and be glad it happened in comparison to how their life is now.)

Exercise 2

Think of a change that you are currently undergoing.

• What aspects of the change are in your ‘comfort zone’?

…………………………………………………………………………………

…………………………………………………………………………………

• What aspects are in your ‘risk zone’?

…………………………………………………………………………………

…………………………………………………………………………………

• What aspects are in your ‘high risk zone’?

…………………………………………………………………………………

…………………………………………………………………………………

• What do you need to make the ‘high risk’ into ‘risk’ and the ‘risk’ into ‘comfort’?

…………………………………………………………………………………

…………………………………………………………………………………

This exercise is excellent for considering a current change and how it may affect a person.

Actually listing in categories the level of ‘risk,’ or even drawing the zones on a piece of paper and writing in each change in the place on the zone where the person believes it sits, will give a rational perspective.

Once all the ‘risks’ are highlighted then that is the time to minimize ‘risk’ and find solutions for the individual to cope or manage that change. This is good for action planning and allowing a person to take control to embrace a change rather than being reactive once the change has occurred.

Exercise 3

Think of a life or work change which is going to occur in the future.

Blockers

• What I’d be sorry to lose.

…………………………………………………………………………………

…………………………………………………………………………………

• My fears and concerns.

…………………………………………………………………………………

…………………………………………………………………………………

Drivers

• Benefits of the change.

…………………………………………………………………………………

…………………………………………………………………………………

• What I’d be glad to leave behind.

…………………………………………………………………………………

…………………………………………………………………………………

Answering these questions assists a person to determine how much resistance they may feel/have towards a change. Listing potential blockers will identify fears and concerns of the change as well as the levels of risk and loss. Listing drivers will encourage the individual to consider the benefits of the change, the gains, and that change can also be a good thing.

Typically, whichever list is the longest or has the most meaning/impact will be the strongest for that person. If this is the blockers they will resist the change and cause themselves pressure and stress. Therefore addressing the zones of change and looking for ways to reduce risk would be a good strategy in action planning to manage the change well. Should the drivers be the strongest for the person then they are likely to embrace the change more readily although they may still need to address their thoughts and rationale for any blockers listed.

Change tips:

• Embrace change, as if you don’t accept it someone will push you into it.
• Take every opportunity to grow your comfort zone.
• Have the attitude that there is no failure and only learning and development – when we ‘fail’ we know what NOT to do next time.
• The worst rarely happens, so why waste energy focusing on it and enforcing irrational fears?
• Change CAN be a good thing.
• There is always a solution, it may take time for you to see it, but if you look, you will find it.

INTRODUCTION

The widespread use of office-software in general practice makes the idea of simple, automatic computerised support an attractive one.  Different tools for different diseases have been tested with mixed results, and in 2009 a Cochrane review¹ concluded that “Point of care computer reminders generally achieve small to modest improvements in provider behavior. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude”.  One year later another review² reached similar conclusion: “Computer reminders produced much smaller improvements than those generally expected from the implementation of computerised order entry and electronic medical record systems”.   Despite this, simple, non-expensive, automatic reminders are frequently part of GPs’ software, even if their real usefulness is seldom tested in real life.

Repeated hospitalisation for heart failure is an important problem for every National Health System; it is estimated that about half of all re-hospitalisation could be avoided³. Adherence to guidelines can reduce re-hospitalisation rate⁴, and pharmacotherapy according to treatment guidelines is associated with lower mortality in the community⁵. In 2004 a software commonly used in Italian primary care implemented a simple reminders’ system to help GPs to improve prescription of drugs recommended for heart failure. We evaluated if this could lead to a decrease in re-hospitalisation rate.

METHODS

In 2003, using Millewin ®, a software commonly used by Italian GPs, we showed that appropriate prescription could increase using a simple pop-up reminders⁶; a year later, using the Italian General Practitioners database ‘Health Search – CSD Patient database (HSD) (www.healthsearch.it), we observed a lower than expected prevalence of codified diagnosis of heart failure and of prescription of both beta-blockers and ACE-Inhibitors/ARBs (data on file). Therefore in 2004 Millewin® embedded a simple reminder system to help heart failure (HF) management. The first reminder aimed to identify patients with HF, but without codified diagnosis: in case of loop diuretic and/or digoxin prescription without codified HF diagnosis a pop-up told the GP that the patients could be affected by HF and invited the physician to verify this hypothesis and eventually to record the diagnosis. The second reminder appeared when a patient with codified HF diagnosis had no beta-blocker and/or ACE-inhibitor/ARB prescription: a pop-up invited the GP to prescribe the missing drug. This reminder system was already activated in the 2004 release of the software, but required voluntary activation in the successive releases. This is a common choice in real life, where positive choices in clinical practice by software-house neither are welcomed nor accepted by GPs. We had no possibility to know who decided to keep using the reminders.

We examined the 2004-2009 HF hospitalisations in Puglia, a Southern Italian Region with a population of over 4000000, and with high HF hospitalisation rate compared with the Italian mean⁷.  We compared the hospitalisations for patients cared for by GPs who used Millewin® in 2004 to those of the patients cared for by GPs who never used Millewin®. Data were provided by the local Health Authority, and were extracted from the administrative database. 

RESULTS

We identified 64591 patients (mean age 76 y, sd 12; 49.9% men) with one or more HF hospitalisation; 17810 had > 2 hospitalisations, and were analysed for the current study.

Figure 1 - Selection process leading to the identification of the patients with > 2 HF hospitalisations

The selection that led to this group is summarised in figure 1. There was no statistically significant difference between patients cared for GPs using or non using Millewin® software as far as age and gender are concerned. The re –hospitalisation rate according to the use or non-use of  Millewin® of patients’ GPs is summarised in table 1.

Table 1: Re-hospitalisation rate of patients cared by Millewin® users and non-users

MW = Millewin®, N.S = Not significant

The mean time before the first re-hospitalisation was 108.5 day +/- 103.3 for Millewin® non-users and 116.4 +/- 107.5 for users (p < 0.05).

DISCUSSION

Even if reasonable and clinically sound, the availability of computerised reminders aimed to help GPs to identify HF patients and to prescribe them with recommended drugs didn’t reduce re-hospitalisation rate. The first possibility to explain this result is that, after the first year, GPs didn’t re-activate the reminders’ system. Unfortunately we couldn’t verify this hypothesis, but it is known that the level of use of such a system may be low in usual care⁸; furthermore providers may agree with less than half of computer generated care suggestions from evidence-based CHF guidelines, most often because the suggestions are felt to be inapplicable to their patients or unlikely to be tolerated⁹.  Epidemiological studies have shown that heart failure with a normal ejection fraction is now a more common cause of hospital admission than systolic heart failure in many parts of the world^10-11. Despite being common, this type of heart failure is often not recognised, and evidence based treatment—apart from diuretics for symptoms—islacking¹². It is therefore possible that increasing ACE-I/ARBs and beta-blockers use in these patients doesn’t influence the prognosis and hospitalisation rate. Unfortunately administrative databases do not permit to distinguish the characteristic of HF. We must also consider that the use of appropriate drugs after HF hospitalisation could spontaneously increase in the last years; a survey in Italian primary care showed that 87% of HF patients used inhibitors of the renin-angiotensin system, and 33% beta-blockers¹³. A further relevant increase in ACE-I/ARBS is therefore unlikely, while a improvement is clearly needed for beta-blockers.   Could more complex and information-providing reminders be more useful? This is unlikely since adding symptom information to computer-generated care suggestions for patients with heart failure did not affect physician treatment decisions or improve patient outcomes¹⁴.  Furthermore, consultation with a cardiologist for starting beta-blocker treatment is judged mandatory by 57% of Italian GPs¹³, thus reducing the potential direct effect of reminders on prescription. Finally we must remember that part of the hospitalisation due to HF worsening can be due to non-cardiac disease, such as pneumonia, anemia, etc; all these cause cannot be affected by improved prescription of cardiovascular drugs.

Albeit simple and inexpensive, computerised reminders aren’t a neutral choice in professional software. Too many pop-ups may be disturbing and may lead to systematic skipping the reminders’ text. This can be a problem, since computerised reminders have proved to be useful for other important primary-care activity, such as preventive interventions¹⁵. In our opinion, at the moment, a computerised reminder-system should be proposed only as a part of a more complex strategy, such as long-term self or group audit and/or pay for performance initiative.

CONCLUSIONS

Availability of computerised automatic reminders aimed to improve detection of heart-failure patients and prescription of recommended drugs doesn’t decrease repeated hospitalisation; these tools should be probably tested in the context of a more complex strategy, such as a long-term audit.

Introduction

Assessment and evaluation are the foundations of learning; the former is concerned with how students perform and the latter, how successful the teaching was in reaching its objectives. Case based discussions (CBDs) are structured, non-judgmental reviews of decision-making and clinical reasoning¹. They are mapped directly to the surgical curriculum and “assess what doctors actually do in practice” ¹. Patient involvement is thought to enhance the effectiveness of the assessment process, as it incorporates key adult learning principles: it is meaningful, relevant to work, allows active involvement and involves three domains of learning²:

1. Clinical (knowledge, decisions, skills)
2. Professionalism (ethics, teamwork)
3. Communication (with patients, families and staff)

The ability of work based assessments to test performance is not well established. The purpose of this critical review is to assess if CBDs are effective as an assessment tool.

Validity of Assessment

Validity concerns the accuracy of an assessment, what this means in practical terms, and how to avoid drawing unwarranted conclusions or decisions from the results. Validity can be explored in five ways: face, content, concurrent, construct and criterion-related/predicative. 

CBDs have high face validity as they focus on the role doctors perform and are, in essence, an evolution of ‘bedside oral examinations’³. The key elements of this assessment are learnt in medical school; thus the purpose of a CBD is easy for both trainees and assessors to validate¹. In terms of content validity, CBDs are unique in assessing a student’s decision-making and which, is key to how doctors perform in practice. However, as only six CBDs are required a year, they are unlikely to be representative of the whole curriculum. Thus CBDs may have a limited content validity overall, especially if students focus on one type of condition for all assessments.

Determining the concurrent validity of CBDs is difficult as they assess the pinnacle of Miller’s triangle – what a trainee ‘does’ in clinical practice (figure1)⁴. CBDs are unique in this aspect, but there may be some overlap with other work based assessments particularly in task specific skills and knowledge. Simulation may give some concurrent validity to the assessment of judgment. The professional aspect of assessment can be validated by a 360 degree appraisal, as this requests feedback about a doctor’s professionalism from other healthcare professionals¹.

Figure 1: Miller’s triangle⁴

CBDs have high construct validity, as the assessment is consistent with practice and appropriate for the working environment. The clinical skills being assessed will improve with expertise and thus there should be ‘expert-novice’ differences on marking³. However the standard of assessment (i.e. the ‘pass mark’) increases with expertise – as students are always being assessed against a mark of competency for their level. A novice can therefore score the same ‘mark’ as an expert despite a difference in ability.

In terms of predictive validity performance-based assessments are simulations and examinees do not behave in the same way as they would in real life³. Thus, CBDs are an assessment of competence (‘shows how’) but not of true clinical performance and one perhaps could deduct that they don’t assess the attitude of the trainee which completes the cycle along with knowledge and skills (‘does’)⁴. CBDs permit inferences to be drawn concerning the skills of examinees that extend beyond the particular cases included in the assessment³. The quality of performance in one assessment can be a poor predictor of performance in another context. Both the limited number and lack of generalizability of these assessments have a negative influence on predictive validity³. 

Reliability of Assessment

Reliability can be defined as “the degree to which test scores are free from errors of measurement”. Feldt and Brennan describe the ‘essence’ of reliability as the “quantification of the consistency and inconsistency in examinee performance” ⁵. Moss states that less standardized forms of assessment, such as CBDs, present serious problems for reliability⁶. These types of assessment permit both students and assessors substantial latitude in interpreting and responding to situations, and are heavily reliant on assessor’s ability. Reliability of CBDs is influenced by the quality of the rater’s training, the uniformity of assessment, and the degree of standardization in examinee.

Rating scales are also known to hugely affect reliability – understanding of how to use these scales must be achieved by all trainee assessors in order to achieve marking consistency. In CBD assessments, trainees should be rated against a level of completion at the end of the current stage of training (i.e. core or higher training) ¹. While accurate ratings are critical to the success of any WBA, there may be latitude in the interpretation of these rating scales between different assessors. Assessors who have not received formal WBA training tend to score trainees more generously than trained assessors^7-8. Improved assessor training in the use of CBDs and spreading assessments throughout the student’s placement (i.e. a CBD every two months) may improve the reliability and effectiveness of the tool¹.

Practicality of Assessment

CBDs are a one-to-one assessment and are not efficient; they are labour intensive and only cover a limited amount of the curriculum per assessment. The time taken to complete CBDs has been thought to negatively impact on training opportunities⁷. Formalized assessment time could relieve the pressure of arranging ad hoc assessments and may improve the negative perceptions of students regarding CBDs.

The practical advantages of CBDs are that they allow assessments to occur within the workplace and they assess both judgment and professionalism – two subjects on the curriculum which are otherwise difficult to assess¹. CBDs can be very successful in promoting autonomy and self-directed learning, which improves the efficiency of this teaching method⁹. Moreover, CBDs can be immensely successful in improving the abilities of trainees and can change clinical practice – a feature than is not repeated by other forms of assessment⁸.

One method for ensuring the equality of assessments across all trainees is by providing clear information about what CBDs are, the format they take and the relevance they have to the curriculum. The information and guidance provided for the assessment should be clear, accurate and accessible to all trainees, assessors, and external assessors. This minimizes the potential for inconsistency of marking practice and perceived lack of fairness^7-10. However, the lack of standardization of this assessment mechanism combined with the variation in training and interpretation of the rating scales between assessors may result in inequality.

Formative Assessment

Formative assessments modify and enhance both learning and understanding by the provision of feedback¹¹. The primary function of the rating scale of a CBD is to inform the trainee and trainer about what needs to be learnt¹. Marks per see provide no learning improvement; students gain the most learning value from assessment that is provided without marks or grades¹². CBDs have feedback is built into the process and therefore it can given immediately and orally. Verbal feedback has a significantly greater effect on future performance than grades or marks as the assessor can check comprehension and encourage the student to act upon the advice given^1,11-12. It should be specific and related to need; detailed feedback should only occur to help the student work through misconceptions or other weaknesses in performance¹². Veloski, et al, suggests that systemic feedback delivered from a credible source can change clinical performance⁸.

For trainees to be able to improve, they must have the capacity to monitor the quality of their own work during their learning by undertaking self-assessment¹². Moreover, trainees must accept that their work can be improved and identify important aspects of their work that they wish to improve. Trainee’s learning can be improved by providing high quality feedback and the three main elements are crucial to this process are ¹²:

1. Helping students recognise their desired goal
2. Providing students with evidence about how well their work matches that goal
3. Explaining how to close the gap between current performance and desired goal

The challenge for an effective CBDis to have an open relationship between student and assessor where the trainee is able to give an honest account of their abilities and identify any areas of weakness. This relationship currently does not exists in most CBDs, as studies by Veloski, et al⁸and Norcini and Burch⁹ who revealed that only limited numbers of trainees anticipated changing their practice in response to feedback data. An unwillingness to engage in formal self-reflection by surgical trainees and reluctance to voice any weaknesses may impair their ability to develop and lead to resistance in the assessment process. Improved training of assessors and removing the scoring of the CBD form may allow more accurate and honest feedback to be given to improve the student’s future performance. An alternative method to improve performance is to ‘feed forward’ (as opposed to feedback) focusing on what students should concentrate on in future tasks¹⁰

Summative Assessment

Summative assessments are intended to identify how much the student has learnt. CBDs have a strong summative feel: a minimum number of assessments are required and a satisfactory standard must be reached to allow progression of a trainee to the next level of training¹. Summative assessment affects students in a number of different ways; it guides their judgment of what is important to learn, affects their motivation and self-perceptions of competence, structures their approaches to and timing of personal study, consolidates learning, and affects the development of enduring learning strategies and skills^12-13. Resnick and Resnick summarize this as “what is not assessed tends to disappear from the curriculum” ¹³. Accurate recording of CBDs is vital, as the assessment process is transient, and allows external validation and moderation.

Evaluation of any teaching is fundamental to ensure that the curriculum is reaching its objectives¹⁴. Student evaluation allows the curriculum to develop and can result in benefits to both students and patients. Kirkpatrick suggested four levels on which to focus evaluation¹⁴:

Level 1 – Learner’s reactions
Level 2a – Modification of attitudes and perceptions
Level 2b – Acquisition of knowledge and skills
Level 3 – Change in behaviour
Level 4a – Change in organizational practice
Level 4b – Benefits to patients

At present there is little opportunity within the Intercollegiate Surgical Curriculum Project (ISCP) for students to provide feedback. Thus a typical ‘evaluation cycle’ for course development (figure 2) cannot take place¹⁵. Given the widespread nature of subjects covered by CBDs, the variations in marking standards by assessors, and concerns with validity and reliability, an overall evaluation of the curriculum may not be possible. However, regular evaluation of the learning process can improve the curriculum and may lead to better student engagement with the assessment process¹⁴. Ideally the evaluation process should be reliable, valid and inexpensive¹⁵. A number of evaluation methods exist, but all should allow for ongoing monitoring review and further enquiries to be undertaken.

Figure 2: Evaluation cycle used to improve a teaching course¹⁵

Conclusion

CBDs, like all assessments, do have limitations, but we feel that they play a vital role in development of trainees. Unfortunately, Pereira and Dean suggest that trainees view CBDs with suspicion⁷. As a result, students do not engage fully with the assessment and evaluation process and CBDs are not being used to their full potential. The main problems with CBDs relate to the lack of formal assessor training in the use of the WBA and the lack of evaluation of the assessment process Adequate training of assessors will improve feedback and standardize the assessment process nationally. Evaluation of CBDs should improve the validity of the learning tool, enhancing the training curriculum and encouraging engagement of trainees.

If used appropriately, CBDs are valid, reliable and provide excellent feedback which is effective and efficient in changing practice. However, a combination of assessment modalities should be utilized to ensure that surgical trainees are facilitated in their development across the whole spectrum of the curriculum. 

Introduction

Nosocomial pneumonia in patients receiving mechanical ventilation, also called ventilator-associated pneumonia (VAP), is an important nosocomial infection worldwide which leads to an increased length of hospital stay, healthcare costs, and mortality.^(1,2,3,4,5) The incidence of VAP ranges from 9% to 27% with a crude mortality rate that can exceed up to 50%.  ^(6,7,8,9) Aspiration of bacteria from the upper digestive tract is an important proposed mechanism in the pathogenesis of VAP.^{(9, 10)}  The normal flora of the oral cavity may include up to 350 different bacterial species, with tendencies for groups of bacteria to colonize different surfaces in the mouth. For example, Streptococcus mutans, Streptococcus sanguis, Actinomyces viscosus, and Bacteroides gingivalis mainly colonize the teeth; Streptococcus salivarius mainly colonizes the dorsal aspect of the tongue; and Streptococcus mitis is found on both buccal and tooth surfaces.⁽¹¹⁾ Because of a number of processes, however, critically ill patients lose a protective substance called fibronectin from the tooth surface.  Loss of fibronectin reduces the host defence mechanism mediated by reticuloendothelial cells. This reduction in turn results in an environment conducive to attachment of microorganism to buccal and pharyngeal epithelial cells.⁽¹²⁾ Addressing the formation of dental plaque and its continued existence by optimizing oral hygiene in critically ill patients is an important strategy for minimizing VAP.⁽¹³⁾ Two different interventions aimed at decreasing the oral bacterial load are selective decontamination of the digestive tract involving administration of non absorbable antibiotics by mouth, through a naso-gastric tube, and oral decontamination, which is limited to topical oral application of antibiotics or antiseptics.⁽¹⁴⁾ Though meta-analysis of antibiotics in decontamination of digestive tracts have found positive results⁽¹⁵⁾ , the use of this intervention is, however, limited by concern about the emergence of antibiotic resistant bacteria.⁽¹⁶⁾ One alternative to oral decontamination with antibiotics is to use antiseptics, such as chlorhexidine which act rapidly at multiple target sites and accordingly may be less prone to induce drug resistance.⁽¹⁷⁾ Recently a meta-analysis of four trials on chlorhexidine failed to show a significant reduction in rates of ventilator associated pneumonia⁽¹⁸⁾  but, subsequent randomised controlled trials, however, suggested benefit from this approach.⁽¹⁹⁾ Current guidelines from the Centres for Disease Control and Prevention recommend topical oral chlorhexidine 0.12% during the perioperative period for adults undergoing cardiac surgery (grade II evidence). The routine use of antiseptic oral decontamination for the prevention of ventilator associated pneumonia, however, remains unresolved.⁽⁸⁾ Despite the lack of firm evidence favouring this preventive intervention, a recent survey across 59 European intensive care units from five countries showed that 61% of the respondents used oral decontamination with chlorhexidine. As the emphasis on evidence based practice is increasing day by day, integrating recent evidence by meta-analysis could greatly benefit patient care and ensure safer practices. Hence we carried out this meta-analytic review to ascertain the effect of oral decontamination using chlorhexidine in the incidence of ventilator associated pneumonia and mortality in mechanically ventilated adults.⁽²⁰⁾

Methods

Articles published from 1990 to May 2011 in English which were indexed in the following databases were searched: CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, EMBASE, CENTRAL, and Google search engine. We also screened previous meta-analyses and the references lists from all the retrieved articles for additional studies. Further searches were carried out in two trial registers (www.clinicaltrials.gov/ and www.controlled-trials.com/) and on web postings from conference proceedings, abstracts, and poster presentations.

Articles retrieved were assessed for inclusion criteria by three independent reviewers from the field of nursing with masters degrees. The inclusion criteria set for this meta-analysis were as follows:
a) VAP definition meeting both clinical and radiological criteria
b) Intubation for more than 48 hours in ICU.  

We excluded the studies where clinical pulmonary infection score alone was considered for diagnosing VAP. Thereafter the articles were evaluated for randomisation, allocation concealment, blinding techniques, clarity of inclusion and exclusion criteria, outcome definitions, similarity of baseline characteristics, and completeness of follow-up.  We considered randomisation to be true if the allocation sequence was generated using computer programs, random number tables, or random drawing from opaque envelopes. Finally, based on the above characteristics, only 9 trials which fulfilled the inclusion criteria was included for the pooled analysis. A brief summary of the 9 trials were listed in Table 1. The primary outcomes in this meta-analysis were incidence of VAP and mortality rate.

Table 1: Brief summary of trials

NA-Not available; C-Control group; E- Experimental group

Data analysis

Meta-analysis was performed in this study by using Review Manager 4.2 (Cochrane Collaboration, Oxford) with a random effect model. The pooled effects estimates for binary variables were expressed as a relative risk with 95% confidence interval. Differences in estimates of intervention between the treatment and control groups for each hypothesis were tested using a two sided z test. We calculated the number of patients needed to treat (NNT, with 95% confidence interval) to prevent one episode of ventilator associated pneumonia during the period of mechanical ventilation. A chi-squared test was used to assess the heterogeneity of the results. A Forest plot graph was drawn using Stats direct software version 2.72 (England: Stats Direct Ltd. 2008). We considered a two tailed P value of less than 0.05 as significant throughout the study.

Results

Effect of Chlorhexidine in reducing the Incidence of VAP

A total of nine trials were included in this meta-analysis^{(19,21,22,23,24,25,26,27,28)}. Pooled analysis of the nine trials with 2819 patients revealed a significant reduction in the incidence of VAP using chlorhexidine (Relative risk 0.60, 0.47 to 0.76; P< 0.01) (Figure 1). In relation to the Number Needed to Treat (NNT), 21 patients would need to receive oral decontamination with Chlorhexidine to prevent one episode of Ventilator associated pneumonia (NNT 21, 14 to 38).

Figure 1: Forest Plot showing the effect of Chlorhexidine oral decontamination in preventing the incidence of ventilator-associated pneumonia. Test for heterogeneity:χ² =15.5, df =8, p < 0.01. Test for overall effect: z =4.33, p <0.05.

Effect of Chorhexidine in overall mortality rate

For assessing the outcomes in terms of mortality, only seven out of nine trials were included, since the other two^(23,27) did not report the mortality rate. Pooled analysis of the seven trials with 2253 patients revealed no significant effect in reducing the overall mortality rate in patient who received chlorhexidine oral decontamination.(Relative risk 1.02, 0.83 to 1.26; P= 0.781 (Figure 2).

Figure 2: Forest plot showing the effect of Chlorhexidine oral decontamination in reducing overall mortality rate. Test for heterogeneity:χ² =0.05, df =6, p = 0.81. Test for overall effect: z =0.27, p = 0.78

Discussion

The effectiveness of oral decontamination to prevent VAP in patients undergoing mechanical ventilation has remained controversial since its introduction, due to partly discordant results of individual trials. In the present meta-analysis nine trials were included to estimate the pooled effect size; the results revealed a significant reduction in the incidence of VAP among patients who were treated with oral chlorhexidine. But, it had no effect in reducing the overall mortality rate among these patients. There is a firm body of evidence that oropharyngeal colonization is pivotal in the pathogenesis of VAP. More than 25 years ago, Johanson et al described associations between increasing severity of illness, higher occurrence of oropharyngeal colonization, and an increased risk of developing VAP .^(29,30)Subsequently, cohort and sequential colonization analyses identified oropharyngeal colonization as a important risk factor for VAP. ^(31,32,33)  Our finding confirms the pivotal role of Oro- pharyngeal colonization in the pathogenesis of VAP , since this meta-analysis indicates that oral decontamination may reduce  the incidence of VAP. Chlorhexidine was proven to have excellent antibacterial effects, with low antibiotic resistance rates seen in nosocomial pathogens, despite long-term use⁽³⁴⁾.  Previous meta-analyses examining the effect of prophylaxis using selective decontamination of the digestive tract reported a significant reduction in the incidence of ventilator associated pneumonia^(35,36,37). The most recent meta-analysis indicated that such an intervention combined with prophylactic intravenous antibiotics reduces overall mortality⁽³⁸⁾. In comparison our review suggests that oral antiseptic prophylaxis alone can significantly reduce the incidence of ventilator associated pneumonia, but not mortality. A similar result was documented by Ee Yuee Chan et al (2007)⁽¹⁴⁾ who performed a meta-analysis with seven trials with a total of 2144 patients and found a significant result (Odds ratio 0.56, 0.39 to 0.81). Another comparable finding in the present study was,  Mortality rate was not influenced by use of Chlorhexidine use,  which was in line with the findings of Ee Yuee Chan et al (2007)⁽¹⁴⁾ . Our meta-analysis on Chorhexidine differs from the findings of Pineda et al, who pooled four trials on chlorhexidine  and did not report lower rates of ventilator associated pneumonia (odds ratio 0.42, 0.16-1.06; P=0.07)⁽¹⁸⁾ . Our results also extend those of Chlebicki et al, who did not find a statistically significant benefit using the more conservative random effects model after pooling seven trials on chlorhexidine (relative risk 0.70, 0.47- 1.04; P=0.07), although their results were significant with the fixed effects model⁽³⁹⁾. Our meta-analysis included larger data set with a total of 9 trials including recent trials⁽²⁸⁾ which further adds strength to our analysis.

Limitations

Though our literature search was comprehensive, it is possible that we missed other relevant trials. Electronic and hand searches do not completely reflect the extent of research outcomes. For example, trials reported at conferences are more likely than trials published in journals to contain negative reports. In addition, more positive than negative results tend to be reported in the literature. This failure to publish more studies with negative outcomes is probably more due to authors’ lack of inclination to submit such manuscripts than to the unwillingness of editors to accept such manuscripts. Furthermore, many studies not published in English were not included e.g. a study by Zamora Zamora F (2011).⁽⁴⁰⁾ These limitations may lead to a risk for systematic reviews to yield a less balanced analysis and may therefore affect the recommendations resulting from the reviews.  In addition, the heterogeneity which we found among the trials with respect to populations enrolled, regimens used, outcome definitions, and analysis strategies, may limit the ability to generalize results to specific populations.

Conclusion

The finding that chlorhexidine oral decontamination can reduce the incidence of ventilator associated pneumonia could have important implications for lower healthcare costs and a reduced risk of antibiotic resistance compared with the use of antibiotics. These results should be interpreted in light of the moderate heterogeneity of individual trial results and possible publication bias. It may not be prudent to adopt this practice routinely for all critically ill patients until strong data on the long term risk of selecting antiseptic and antibiotic resistant organisms are available. Nevertheless, Chlorhexidine oral decontamination seems promising. Further studies are clearly needed in testing the effect of Chlorhexidine in specific populations with standard protocols (which includes specific concentration, frequency, and type of agents) to generalize the findings. Studies also may be done to test the effect of different oral antiseptics in reducing VAP, so as to enrich the body of knowledge within this area.

An 86-year-old lady was admitted from her residential home with acute on chronic confusion, new symptoms of expressive and receptive dysphasia, dysphagia, vacant episodes and urinary incontinence. She had a previous significant history of haemorrhagic stroke with residual right sided weakness, atrial fibrillation, hypertension, and moderate dementia. Following a CT head, this lady was started on acyclovir for encephalitis. She failed to respond to treatment, and developed constipation. With careful consideration of her poor prognosis and quality of life, this lady was placed on the End of Life Pathway. She was catheterised for comfort. Nine days after initial insertion of the urinary catheter, purple urine was noted in the catheter bag with yellow urine in the tubing leading to the bag. Urine dipstick showed Blood ++, Protein ++, Leuc +, Nit –ve, Glu -ve, Ketone +, pH 8.0. Urine microscopy showed: WCC 454, RBC 279, epithelial cells 52, no casts. Urine culture revealed heavy mixed growth with multiple organisms. 

Question: What is the diagnosis?

Answers:

1. Porphyria
2. Propofol infusion syndrome
3. Purple urine bag syndrome
4. Blue diaper syndrome    

Differential diagnoses: Discoloration of urine can be caused by trauma if blood stained, urinary tract infections, ingestion of dye (methylene blue), medications (amitriptyline, indomethacin, triamterene, flutamide, and phenol).

Explanation:

Porphyria usually presents with severe pain with neuropsychological symptoms or photosensitivity, and urine discoloration is likely to occur from initial onset of disease.   

Propofol is an anaesthetic agent, excreted in the urine as phenol derivatives which can cause a green urine discolouration¹. This medication is unlicensed for End of Life Pathway. Propofol infusion syndrome is associated with prolonged high dose infusion, but is not always accompanied by urine discoloration.

Blue diaper syndrome is an inherited metabolic disorder of tryptophan with presentation at infancy^2-3.

Correct answer

Purple urine bag syndrome (PUBS)

Purple urine bag syndrome (PUBS)

PUBS is an uncommon condition with purple discoloration of the urine catheter system. This phenomenon is due to the presence of indigo and indirubin in the collected urine. PUBS was first published in 1978⁴. Some academics would argue that PUBS was reported even earlier historically as an observation in Sir Henry Halford's bulletin in 1811^5-6. Two recent literature reviews suggested the prevalence of PUBS is as high as 9.8% in institutionalized patients with long-term urinary catheterisation^{8-9, 12}. 

A triad of key factors are suggested as cause of PUBS:

1. high level of tryptophan in the gut due to diet intake or bowel stasis
2. long term catheterisation⁸
3. urinary tract infection (UTI) with bacteria possessing indoxyl phosphatase and sulphatase enzymes, commonly Providencia stuarttiand rettgeri, Pseudomonas auruginosa, Proteus mirabilis, Escherichia coli, Klebsiella pneumoniae, Morganella, Citrobacter species, Group BStreptococci and Enterococci^{8, 13}.

It is understood that bowel stasis causes accumulation of tryptophan, which leads to an increase in urinary indoxyl sulphate (UIS). In the presence of indoxyl phosphatase and sulphatase enzyme activities, whilst collected in the catheter system, UIS is degraded to form a mixture of indigo and dissolved indirubin in the plastic¹¹, coating the catheter system with a purple appearance. Intensity of discoloration is deeper the longer the urine is in contact with the catheter plastic^{7, 10-12}. The urine does not appear purple prior to entering the catheter.

Recent literature^7-8 also suggested female gender, alkaline urine, bed bound debilitated patient population, PVC material⁷ and institutionalization are further predisposing factors of PUBS. 

Management of PUBS requires catheter change and treatment of underlying UTI.

Good catheter hygiene and shorter duration of catheterisation can reduce PUBS¹.

Introduction:

On discharge from hospital, secondary care providers have a duty and obligation to communicate with primary care provides – particularly the general practitioner – to give information regarding the reasons for admission, results of investigations, procedures performed, treatment instigated and importantly follow-up management. Therefore the transition of information between secondary and primary care is vital for care management and hence patients’ safety.

This information is shared in the form of a ‘discharge summary’. It is the responsibility of the secondary care team to provide this. The level of detail given has been found to vary not just between different NHS trusts or hospital but also between different wards and individual doctors completing the discharge summary – this can create many problems as communication plays a pivotal role in patient care.

The information given in the discharge summary is all that a patients’ GP knows in regards to their hospital admission and management. A discharge summary is effectively a form of ‘handover’. A hospital physician may instruct the GP to do certain things in regards to follow-up; for example check blood results, review results of investigations arranged as outpatients or simply review the patient clinically. The more information that is transferred across from secondary to primary care the more awareness the GP has to what has happened and what needs to happen, which leads to better patient care.

A discharge summary can also be a valuable document for when a patient is admitted to hospital; if their notes are not available a past discharge summary will provide useful information (re. past medical history and drug history in particular) to the medical team who may have no prior knowledge of the patient, this is invaluable if it not possible to take a history from a patient and is also useful in directing investigations if a patient has been admitted with the same complaint(s). Of course this depends on the patient having a copy of the discharge summary with them on admission or the ability to access previous discharge summaries electronically.

Good documentation is vital in the healthcare setting. All documentation, no matter in what form, must be clear, accurate and legible. Any type of document is useless if it cannot be read. The GMC and Royal College of Physicians stress the importance of documentation^{1, 2}.

The importance of the discharge summary has been highlighted in the last few years. There has been a move from the traditional hand-written discharge summary – commonly referred to as the TTA (to take away) – to the use of computer software providing an electronic discharge summary (EDS). The latter not only provides more detail but also aims to deliver it to the primary care setting in a timelier manner; for example, in the future, once all EDSs are completed at Barking, Havering and Redbridge University Hospitals NHS Trust there are plans for them to be automatically emailed to a patients GP surgery – currently this scheme is being trailed at certain GP surgeries. This complies with the requirement and recommendations made to secondary care trusts to provide the GP with a discharge summary within 24hrs of a patients’ discharge from hospital – consequently reducing previous financial penalties when not achieved and thus being more cost efficient.

The advent of the EDS has impacted the daily working of the junior doctor, who is commonly, the individual on the secondary care team whose role it is produce the discharge summary. Previously with a TTA a patient could be discharged home without all the constituents on the form being completed and so a GP would be provided with an incomplete discharge summary. At BHR University Hospital NHS Trust in order to produce a finished EDS - and essentially discharge the patient - all constituent sections have to be completed before it can be electronically sent to pharmacy so that the patient sent home with their medications (the discharge summary acts as a prescription). Therefore producing an EDS is more time consuming in comparison to a TTA.  However an EDS does have advantages (see Table 1).

Table 1: Comparison of EDS and TTA

Any form of discharge summary is user dependent; what is written is determined by the individual doctor producing the document therefore there is no guarantee that they have documented everything that occurred during admission.  In the case of the TTA user dependence also refers to the legibility of the writing, the durability of the carbon copies produced, as well as the level of detail of the discharge summary produced.

In 2008 Newham University Hospital Trust introduced the EDS, the trust audited this process and found it to be successful³. 2010 saw the introduction of the EDS at BHR University Hospital NHS Trust. The EDS was piloted on Sunrise B ward of Queen’s Hospital, Romford. The purpose of this audit is to establish if the introduction of the EDS at BHR University Hospital NHS Trust has been successful. The audit aims to determine if the EDS method is superior to that of the traditional TTA – this will be achieved by comparing the completion rates for specific criteria of the discharge summary. This audit also aims to identify areas of improvement and recommendation for the EDS. 

Design and Method:

An opportunistic sample of 50 TTAs and 50 EDSs were selected from the patients admitted to Sunrise B (‘Care of the elderly’) ward, Queen’s Hospital, Romford in a two-month period (January to February 2011). Thus this is a retrospective audit. No exclusion criteria for selection of discharge summaries was set. For each discharge summary completion rates for the different fields of the discharge summary were recorded. Table 2 shows the criteria fields included in each type of discharge summary.

Table 2: Comparison of EDS and TTA criteria

The Royal College of Physicians have published their recommendations for the structure and content of the discharge summary. Section headings include

• GP details - name, address, practice code
• Patient details – surname, forename, date of birth, gender, NHS number, address, telephone number
• Admission details – method of admission, source of admission, hospital site, trust, date of, time of
• Discharge details – date of, time of, discharge destination, discharging consultant, specialty
• Clinical information – diagnosis at discharge, operations/procedures, reason for admission/presenting complaint, allergies, investigations and results, treatments, discharge medications, medication changes
• Advice, recommendations and future plan – hospital/GP/community
• Person completing summary – doctors name, grade, specialty, signature, date of completion⁴

This audit establishes which method of discharge summary is more compliant with these recommendations.

Data analysis was mainly descriptive. Data collected was tabulated and represented as percentages. Graphical representation of the data was performed using Microsoft Excel. Due to the nature of the study and data collected more sophisticated statistical analysis, such as that requiring the use of SPSS software, was not warranted.

Results:

Results demonstrate significant differences between the TTA and EDS completion rates for criteria of the discharge summary. Table 2 presents the data as percentages in a tabulated form. Compared to the TTA, the EDS had a higher rate of the following six criteria of the discharge summary documented; diagnosis, co-morbidities, investigations, drug history, discharge destination and instructions for GP.

Table 3: Summary table of data

•  Patient details and admission date.

The TTA had lower completion rates for these fields than the EDS. The EDS software automatically enters these fields therefore it is not possible for this criterion to be incomplete. The correct patient details ensure continuity of care and patient safety. If patient details – i.e. full name, date of birth, hospital number and address - are not present those with similar names could be mixed up.

Diagnosis.

The TTA performed poorly on documenting diagnosis. The EDS had a completion rate significantly higher than that of the TTA (EDS completion rate = 88%, TTA completion rate = 48%). Figure 1 represents these findings. The main objective of a discharge summary is to inform primary care of the diagnosis to enable healthcare management, therefore it is crucial and pivotal information, for it not to be included in the discharge summary is illogical.

Co-morbidities.

Neither TTAs nor EDSs documented co-morbidities well. However the EDS, yet again, outperformed the TTA. See Figure 1. Documenting co-morbidities has important repercussions for clinical coding and financial incentives (see below).

Investigations.

Coincidently, 62% of TTAs did not document investigations that the patient had had in contrast to 62% of EDSs that did. See Figure 1. There is no guarantee for either discharge method that all investigations are listed; it is dependent upon the doctor who is producing the discharge summary.

Figure 1: Graphical representation of data

Drug history.

As previously mentioned, EDS has to have a completed drug history before the patient can be discharged and hence they have to have a 100% completion rate for this criterion. TTAs only achieved a 64% completion rate as Table 3 demonstrates.

Review of case.

This is not a criteria field on the TTA document. Therefore 86% of TTAs provided no review. 88% of EDSs did provide a case review. Just fewer than 10% of EDSs were incomplete for this item.

Discharge date.

Like the admission date, a discharge date is automatically completed on an EDS thus the completion rate is 100%. However, this date is the date in which the EDS is completed and may not be the actual day the patient leaves hospital because sometimes the EDS is completed (and so the medications dispensed) the day prior to discharge or patient discharge may be delayed. The TTA achieved a 66% completion rate.

Discharge destination.

This is not a criterion present on the TTA and thus 100% of TTAs did not fulfil this requirement. EDSs had a 98% completion rate.

Follow-up arrangements.

The majority of EDSs documented the follow-up plans for a patient (88% in total, 70% specifically for GP follow-up). 46% of TTAs documented patient follow-up required, specifically 44% for hospital follow-up. 54% of TTAs documented no follow-up. In summary, 88% of EDSs documented follow-up in comparison to 46% of TTAs. These findings may be a limitation of the study i.e. patient selection rather than failings in documentation.

Instructions for GP and functional status.

Coincidently, 92% of TTAs did not document ‘instructions for GP’ in contrast to 92% of EDSs that did. ‘Instructions for GP’ is not a criterion on the TTA document.

Functional status.

‘Functional status’ is also not a criterion on the TTA document and so all TTAs were not complete for this. 64% of EDS had a completion rate for documenting ‘functional status’. Functional status indicates a patient’s mobility status, self-care abilities, hearing and sight impairment.

Discussion:

This audit has established that the EDS has a higher completion rate for criteria on the discharge summary, significantly so for documenting diagnosis, co-morbidities, investigations, drug history and instructions for the GP.

One major concern that has been highlighted in performing this audit is the documentation of co-morbidities. Due to variations in training many doctors are unaware of how and where to enter this information on the EDS – there is a specific window that opens on the software program to input this information. Junior doctors were documenting patients’ past medical history under the field of ‘diagnosis’. Co-morbidities should not be listed under ‘diagnosis’ - this infers a new diagnosis - as they are not the acute problem.

The coding of the diagnosis [the acute problem], in context of a patients co-morbidities, results in a condition specific ‘fee’ being paid to secondary care. For example the ‘fee’ received for a patient diagnosed with a respiratory tract infection is different for that when the patient is diagnosed with a respiratory tract infection on the background of dementia. Inaccuracies in diagnosis lead to incorrect coding and measures of incidence. Co-morbidity is ‘any condition which co-exists in conjunction with another disease’. It is a requirement of the discharge summary to document certain co-morbidities – as determined by the Clinical Coding Co-morbidity Working Group (CCCWG)⁵. Although the discharge summary is not the recommended source documents for use in clinical coding – patients medical notes are used instead – it can help direct and inform those responsible for clinical coding. In should be borne in mind that it is the treating clinicians’ responsibility to document co-morbidities relevant to the current admission. Accurate and correct clinical coding will result in financial gains. Clinical coding has more important purposes other than just financial; it allows the monitoring of health services, epidemiological research, NHS planning of provisions, as well as clinical audit and governance⁶.

The amount of information documented is user dependent; the level and amount of detail written is subjective.  For example there is no guarantee that all the investigations that a patient had are documented. One doctor may provide a whole paragraph to summaries [‘review of case’] whereas another may just write one sentence. Educating those whose task it is to complete the discharge summary about how vital and important it is, along with the role it serves in healthcare management, may influence the effort and time dedicated to producing an EDS. The principles of clear, complete and concise documentation should be applied to both the patients’ discharge summary and their medical notes.  

Other healthcare professionals should also contribute to producing the discharge summary, in particular occupational therapists and physiotherapists who are more aware of a patients ‘functional status’ than the doctors. More accurate completion of this item could be achieved with their input. 

At the moment with the EDS software system used at BHR University Hospital Trust once an EDS has been printed there is no means of changing any of the information. It cannot be re-accessed to document new or change existing details. Often an EDS will be finalized and so printed for a patient to be discharged home on that day for the discharge then to be delayed. The discharge date document on the EDS should be the actual date the patient is discharged from hospital. Therefore it should be possible to be able to re-access and change details on the EDS.

The results of this audit show that the EDS system used at BHR University Hospital Trust is better then the EDS system audited at Newham in 2008. The Newham audit did not focus on all the criteria fields of the discharge summary or compare with a hand-written discharge summary method, however there is place for comparison with the results of this audit.

Table 4: Comparison of results with findings of Newham audit

This audit has established that the EDS method provides a discharge summary more compliant with the Royal College of Physician’s recommendations on the structure and content of discharge summary in comparison to the TTA.

The EDS will inevitably replace the TTA in time. However it should be remembered that there is still a place for the TTA in clinical practice e.g. locums do not have passwords to access the software programme, if computers are not working, fail or are unavailable. At the end of the day, a discharge summary is better than no discharge summary.

Conclusion:

The findings of this audit show that the EDS is a far superior method of producing a discharge summary than the TTA. The EDS provides a more informative and detailed discharge summary, which is always legible. The discharge summary is often the only source of information a GP is given in regards to a hospital admission and therefore secondary care providers have an obligation to provide clear, complete and concise information.

This audit does highlight that there are areas for improvement and recommendation:

• The importance of a discharge summary should be highlighted to all individuals whose responsibility it is to complete them. This could promote better compliance at completing all items and completing them more thoroughly.
• EDS training should make users aware of the ‘co-morbidity’ section. Past medical history should not be listed under new diagnosis. This should be a compulsory part that has to be completed before an EDS can be finished.
• Occupational therapists and physiotherapists should be able to complete the ‘functional status’ criterion. This should be expanded to give more information and details to primary care providers.
• The documentation of certain co-morbidities (those determined by the CCCWG) should be done by ‘tick list’ selection therefore it will not rely upon the individual doctor to remember to document such co-morbidities. All the co-morbidities that should be documented could be listed and the user selects those that the patient has. This will improve the trusts performance in regards to the financial rewards linked to discharge summaries.
• The audit should be performed again in 12 months to access if EDS are maintaining high completion rates, to identify further improvement in completion rates and identify any further areas for improvement or recommendation.
• Discussion of both TTA and EDS could be a part of the regular weekly supervision of junior medical staff by their prospective consultants.
• A discharge summary should also be checked by nursing or clerical staff prior to letting the patient leave the ward to see if all components are completed.

Interest in cross-species transplantation has recently been rekindled¹. This is due to many developments including the shortage of donor organs, advances in transplant medicine, investment in biotechnology research, and the non-availability of more ethically suitable alternatives to human organs. Increasing success rates in allotransplantations (organs from different member of the same species) has increased the demand on donor organs^{1, 2}. Other types of transplantation include autotransplants (a person’s own organs or tissues are used for transplantation) and isotransplants (organs from one person are transplanted into another genetically identical person, like an identical twin). These options are limited in terms of body parts used and numbers.

Good facts inform good ethics. It is therefore obligatory to look into the current research knowledge about xenotransplants (organs from one species to another, for example animal to human) in more detail. The advocates of xenotransplantation argue that it could provide organs “relatively quickly” and hence save more lives.  If animal organs were easily available for transplantation most eligible recipients would receive the transplantation much earlier on in their illness. It is argued that this may decrease distress and suffering. Whilst xenotransplantation may theoretically increase the survival time, it is unclear, however, whether the negative impact on recipients’ quality of life due to long-term immunosuppressant therapy and the risk of zoonotic infections would in fact worsen the overall long-term outcome³. Recent research suggests that xenotransplantation may be associated with the transmission of pig microorganisms including viruses, bacteria, fungi, and parasites. Because of the recipient’s likely immunosuppressed state, infection and pathologic consequences may be more pronounced. Transmission of most microorganisms with the exception of the porcine endogenous retroviruses may be prevented by screening the donor pig and qualified pathogen-free breeding. However, porcine endogenous retroviruses represent a special risk as they are present in the genome of all pigs and infect human cells in vitro. Until now, no porcine endogenous retrovirus transmission was observed in experimental and clinical xenotransplantations as well as in numerous infection experiments⁴. Nevertheless, strategies need to be developed to prevent their transmission to humans. It is equally possible that many eligible recipients may be denied having a trial of xenotransplantation by doctors who believe that there is an unfavourable risk-benefit ratio. The limited long-term data on outcomes of xenotransplants thus renders ethical analysis difficult.

There is some evidence to suggest that the recipients of animal organ donation may develop a different self image with possible consequences for their identity^5,6.  This happens with human organs at times, but may be a more significant problem with animal organs, as the recipient knows that they have been given a non-human organ. Loss of identity jeopardises the core principle of autonomy, which underpins all medical treatment.

The risk of zoonosis to the recipient and to the wider society cannot be accurately estimated⁷. Hence there is a requirement for vigilant post-operative monitoring⁵ with a possibility of engaging article5 and 8 of the European Convention of Human Rights (for England and Wales: Human Rights Act 1998)^†. Article 12 may also be engaged as the recipients may be restricted from having physical relationships, carrying out their routine day to day activities and socialisation. This is because the prevention of possible risk to the wider public from zoonosis may require the recipient to be put under restrictions with regard to their engagement with others. This may include restrictions to go out, which can result into de facto temporary detentions at home. Hence consenting to xeno-transplantation would be “binding and contractual” over a long period of time. The subject may not have the right to withdraw. This is entering into a de facto contract with potential restrictions or even deprivation of human rights. This would restrict the ability to give informed consent even for a well informed patient, as it is difficult to be fully appreciative of future restrictions of one’s liberty.

Autonomous decision making and thus informed consent may also be put at risk by other factors surrounding xenotransplantation. The decision to embark on xenotransplantation may be primarily driven by an instinctual wish to survive due to a lack of other viable alternatives. Patients in these circumstances may have little or no consideration to medium and long-term effects on themselves and society. However, it is the consideration of such long-term consequences that make a truly autonomous decision, and differentiate it from a decision that is purely based on immediate instinct. Whilst the wish to survive is legitimate it is difficult to make decisions free of the pressure to survive when there is a lack of alternatives.

It also brings up an even more important question: Can any person ever consent to a future restriction or deprivation of their liberty or other human rights? Even if there were an option to define acceptable future restrictions it would be likely that patients could still challenge the legality of any such agreements. They could quite reasonably argue that they have agreed to the restrictions under duress because of a lack of viable alternatives to their xeno-transplants.

Xenotransplantation touches questions of utilitarianism (greatest good for the greatest numbers) and public protection². Utilitarianism takes into account the reasonable interests of society in good outcomes, fairness in the distribution of resources, and the prevention of harm to others. The Nuffield council on bio-ethics embraces a utilitarian approach. However, there are limits to the utilitarian argument for xenotransplants. Even if they were widely available, the treatment would be immensely expensive. Production of a pathogen free donor organ would involve rearing animals in strictly controlled environments, subjecting them to rigorous standards of examination and surveillance. The additional costs of developing a sustainable work force to provide transplantation and post-transplant surveillance of the patient and the community would be high.  The insurance providers may not cover expenses of a xenotransplant. Public health care providers may decline to provide this treatment as it may not be recommended by expert groups as cost effective. Xenotransplantation may commence in the developing world where the regulations are lax and the poor can be more easily exploited⁸. Patients who would potentially benefit from xenotransplantation may not be able to afford it due to its cost with serious implications for fairness.

Xenotransplantation also raises other ethical questions in relation to the wider community.  We have seen that consent of an individual to a xenotransplant has significant bearing on the protection of society⁷. Should the members of a community therefore be consulted if there were any xeno-transplantation experiments in their region? The risk is primarily due to the risk of zoonotic infections, the need for surveillance, and possible quarantine of contacts^7,9.  In addition, if health authorities were to fund expensive experimental interventions like xenotransplantation, other routine treatments of greater potential benefits to society may be jeopardised. Society may also have views about particular animals being used as donor animals¹⁰.  For example religions like Islam and Judaism may feel that pigs are ‘ritually unclean’. They may therefore not approve of certain animals to be used for donation, and more worryingly may fail to socially accept recipients with such ‘unclean’ transplants¹¹.

From a deontological perspective (this judges the morality of an action based on the action's adherence to a ruleor principle) some authors assert that animals have rights similar to those considered appropriate for humans^12,13. The protection of animals has legal status in many countries. Consequentialists may view the suffering and death of an animal as acceptable for the betterment of a human patient, as they would judge the morality of an action primarily by its end result. They would argue that potential benefits and improvement in human welfare arising from xenotransplantation may justify the loss of animal life. However, this will never satisfy the animal rights lobby; especially as whilst minimising the risk of acquired infections, the animals have to forgo greater suffering in the form of isolation, monitoring and investigations. Furthermore, genetic modification can have both immediate and long-term negative effects on animals.

In summary, xenotransplantation has significant ethical consequences. On an individual level, there are the questions of pressure to consent that may negate autonomy and the validity of that consent as well as the difficulties that arise when patients are asked to consent to future restrictions of their human rights. On a societal level there are questions of cost and benefit analysis as well as risks from zoonotic infections. In addition, questions of animal rights need to be addressed before any programs are likely to go ahead.

^†Appendix of articles of the Human Rights Act.

• Article 8 of the Human Rights Act 1998 (The right to respect for private and family life, home and correspondence)
• Article 5 (The right to liberty).
• Article 12 (The right to marry and found a family)

“The more we care for the happiness of others, the greater our own sense of well being becomes.”  The Medicine of Altruism: Dalai Lama

Introduction

The fundamental mission of any medical school is to select those individuals who possess the qualities and personality traits best suited to becoming a good doctor. The first part of this article takes a critical look at how United Kingdom (UK) medical schools select doctors, which can vary considerably, and asks whether it can be improved. The qualities needed to be a good doctor are discussed and asks whether work experience illustrates at least some of these personal qualities and should therefore be an essential prerequisite for applying to medical school. Such experience helps the student to make an informed career choice and exploring it at interview can reflect student motivation to study medicine. My experience in Ghana gave me the opportunity to find out at first hand if I had what it takes to become a doctor. The trip was totally inspirational. It made me realise that medicine is much more than being master of all sciences. In Ghana I saw many of the qualities one needs to be a doctor, how this contrasts with the current selection criteria in the UK, and made me wonder whether the UK system offers our society the best practice available.

Critique of UK medical school selection           

Applying to medical school has become increasingly competitive. Selection into medical schools is not an exact science but one assumes that best available evidence is being used. The present system almost certainly turns away students who would make good doctors and accepts some who are mediocre or poor or even drop out of medicine altogether. The selection criteria for entry into medicine have to be accurate. However, no system is fool proof and the number of drop-outs in UK training stands at 6.8 – 12%.^1,2,3 I believe that better selection criteria would reduce the drop-out rate and save personal distress among those who made an unwise choice. This makes economic sense. There is widespread agreement that we should select medical students on wider criteria than scores of academic success,^{4, 5} though in practice many medical schools have valued academic scores at the expense of other considerations.^{6, 7} A Levels alone should not be sufficient to gain a place at medical school. True communication calls for some shared life experiences and empathy with others. I believe that students who are totally absorbed in their studies to the exclusion of almost everything else are less likely to make good doctors. In one study, a ten-year follow-up after entry into medical school showed no correlation between academic score at entry and drop-out rate, but significant correlation between low interview scores and later drop-out.⁸ Reasons for drop-out were a variety of personal reasons including lack of motivation for study or for medicine. In a medical school that carefully evaluates applicants, empathy and motivation to be doctors were found to be particularly important in predicting both clinical and academic success.⁹

Another major study, looking at the dropping out from medical schools in the UK over a ten year period (1990-2000), ¹⁰ showed that drop-out rates increased during this period and concluded that the probability of dropping out of medical school is 20% lower for students with a parent who is a doctor. The authors comment that this may be the result of greater commitment or better preparation and insight before starting the course. Ethnic background of students was recorded only between 1998-2000. The study found that Indian females were around 1.9% less likely to drop out compared with white females, whereas Indian males were no different from white males. Other ethnic groups were less likely to drop-out by around 0.8%.  A concerning fact in this paper was the degree to which drop-out rates varied between different medical schools. No study to date has been done to find the reasons for these differences. Surely potential applicants need to be aware of these results. The differences could be accounted for by variable selection processes among the medical schools.¹¹ Some medical schools shortlist for interview only on predicted academic performance or the number of A* GCSEs or decide by the UK Clinical Aptitude Test (UKCAT) / BioMedical Admissions Test (BMAT) scores. Some use information presented in the candidate’s personal statement and referee’s report while others ignore this because of concern over bias. In some cases candidates fill in a supplementary questionnaire. Interviews vary in terms of length, panel composition, structure, content, and scoring methods. Some schools do not interview.

The commonest reasons cited in many papers for dropping out of medical school were because it is not for them, they found it boring, they did not like patients, the work environment was not what they want to spend their time on, or they did not like responsibility.¹² Essentially they had realised too late that Medicine was not for them. They had failed to find out what they were letting themselves in for before applying and the medical school had failed to pick this up. There is a strong argument for pooling resources so that applicants get one good assessment instead of four poor ones.                  

A levels, used for medical selection, do not indicate any personality attributes of the candidate and are affected by socio-economic bias. The UKCAT was introduced to level the playing fields. This test doesn’t examine acquired knowledge and candidates can’t be coached to pass, so in theory it should provide a fairer assessment of aptitude than A level grades. It was also thought that the various components of the UKCAT, namely verbal reasoning, quantitative reasoning, abstract reasoning, and decision making, could help to pick the students who have the personality attributes to make good doctors. Unfortunately, a recent paper suggests that the UKCAT does not provide any more assessment of aptitude than A levels.¹³ However, an inherent favourable bias towards students from well-off backgrounds or from grammar and independent schools was also found. Moreover the test does not compensate for talented candidates whose education has been affected by attending a poor school. Another paper looked at the predictive validity of the UKCAT.¹⁴ This showed that UKCAT scores did not predict Year 1 performance at two medical schools. Although early prediction is not the primary aim of the UKCAT, there is some cause for concern that the test failed to show even the small-to-moderate predictive power demonstrated by similar admission tools.   

There is no doubt that potential doctors must have enough intellectual capacity to do the job but they must also possess other important traits (Table 1):

What patients rate highly among the qualities of a good doctor are high levels of empathy and interpersonal skills.¹⁵ Personality traits such as conscientiousness have been positively associated with pre-clinical performance.¹⁶ 

The criteria being used more and more by admission tutors include the candidate’s insight into medicine including as evidenced from work experience.¹⁷Surprisingly, very little has been written on work experience and the value placed on it varies considerably between medical schools. Many would regard this experience as a prerequisite for entry into medical school. It enables a student to experience at first hand what he/she is letting him/herself in for. Some find the experience fascinating and challenging while others may find it is not for them. Work experience should not be seen as a hurdle to climb, but part of the decision-making process in determining whether medicine really is for you. I fear that another contributing factor to the increase in drop-out rates from medical schools is the increasing difficulty in obtaining work experience. Gone are the days when students could join theatre staff and watch an exciting operation or shadow doctors in Accident and Emergency (A&E). Useful work experience is so important and it is becoming harder and harder to get, but is still possible. Therefore considerable desire, commitment and motivation by the student are required to obtain it. The work does not need to be medically related, but work experience in any care setting is essential. These placements can be used to illustrate at least some of the personal qualities that are sought after in a good doctor including: appreciation of the communication skills required of a doctor; a thorough awareness of the realities of medicine and the National Health Service (NHS); an understanding of teamwork; an ability to balance commitments; and observation of the caring and compassionate nature of the doctors. Furthermore, as demonstrated in general practice,¹⁸ personal experiences can have a highly positive influence on an individual’s attitude to a particular speciality. Encouraging school students to experience general practice would therefore not only increase their awareness of the life to which they are about to commit, but could aid recruitment to general practice as a speciality.

My Ghana Experience

I decided that, as part of my work experience, I would go to Ghana with a charity organisation (Motec UK Life). The reason was not to impress medical admissions tutors, but to discover if I had what it takes to become a doctor. I realised how comfortably we live in our small bubble, with little appreciation of what goes on in the rest of the world. Ghana is a third world country, which not only has great poverty and malnutrition but also has many deadly diseases such as Acquired Immunodeficiency Syndrome (AIDS)/Human Immunodeficiency Virus (HIV), malaria, hepatitis, typhoid and sickle cell disease. My trip was demanding as I was stripped of my luxuries and removed from my comfort zone, but it helped me to understand the real values in life through helping the most needy and vulnerable people. I felt the suffering and the pain they went through, day in and day out, but knew that making even the slightest difference to their lives motivated me and enabled me to persevere through my time there.

One of the hospitals we stayedwas Nkawkaw, which was in the middle of a shantytown with houses made of metal sheets. Yet, despite the presence of great poverty and disease, I did not find a single person who was not extremely kind and welcoming and always smiling. It made me think of the contrasting situation back home in the UK where people were relatively well off, and yet so unhappy. I spoke to as many people as possible, not realising that I was developing my people- and communication-skills. I played football with the children and made them smile. I was able to visit the AIDS/HIV clinic and gained a first-hand account of how this devastating disease was controlled and dealt with in a third-world country. The pain, grief and suffering were immense and difficult to comprehend unless one was actually there witnessing it. AIDS here hurts everyone, but children are always the most vulnerable. The children were born with HIV from their mothers, or infected through breast milk, or in the past infected by unsafe medical treatments. They were often orphaned and destitute, having to build their own homes, grow their own food, and care for younger brothers and sisters. That is the cruel reality.

Equally heartbreaking was seeing so many people in the HIV clinic who could

not afford the anti-retroviral drug that would improve the quality and duration of life. This feeling of helplessness motivated me even further to pursue a career in medicine in order to help people at their most vulnerable. On this trip I was greatly impressed by the dedication, commitment and professionalism shown by the doctors in difficult situations. I saw doctors working with little supervision and little equipment, and yet they seemed confident, well organised, and adapted themselves well to the conditions. Their enthusiasm and compassion never waned despite working long hours.

I saw many types of operation being performed including joint replacements, hernia repairs and caesarean sections. On one particular day, I observed the team performing many knee and hip joint replacements. The deformities of the joints were much more severe than seen in the UK. I enjoyed and appreciated the skills of the orthopaedic surgeons in carrying out these operations, which were being done under spinal anaesthesia, and so I was able to talk to the patients and comfort them. Throughout the day, after seeing many operations, I did not flinch or feel queasy at the sight, and this further encouraged me to believe that I could handle a career in medicine. On watching the caesarean sections, the excitement of bringing new life into the world was overwhelming. Seeing another baby being born with severe hydrocephalus marred this. No treatment facilities for this condition were available for hundreds of miles and the baby was too ill to be transferred such a large distance. I witnessed the doctors conveying the heartbreaking news to the family with compassion. It became clear to me that there are negative aspects to this career. There is a great deal of emotion and stress to cope with in such circumstances but I believe that, given training, I would be mentally stronger to take control of these situations.

I was always allowed to follow the doctors on their ward rounds, and was encouraged to ask questions and make comments, so that I often felt that I was being treated as a medical student, which was strange in some ways but also very gratifying. On this trip I was involved in teaching and in helping to set up a workshop, which lasted for a whole day for doctors from all over Ghana. This involved lectures as well as demonstrating the latest surgical and theatre equipment. I was impressed by the teamwork and organisation shown by the group. The communication skills of the group had to be of the highest quality in order to get the message across. I found that teaching about the devastating effects of HIV, in a local school in Ghana, was particularly challenging as some of the students before me were sufferers and so I found it difficult to look them in the eye, knowing that although they were being taught the safety precautions, many did not have much of a future. This reinforced my feeling of helplessness but, although this situation was heartbreaking, I remained enthusiastic for the children, to keep their morale high in order to prepare them for their inevitable future.

Conclusion    

My trip was totally inspirational. It made me realise that medicine is much more than being a master of all sciences. In Ghana I observed in doctors the real passion and drive needed for medicine as well as many other essential qualities I believed doctors needed. This contrasts with the current selection criteria in the UK; sadly we are missing out on too many good doctors because of our obsession with grades rather than looking for real qualities that are going to make a difference to our patients.I discovered that seeing the immense suffering, and the close bond of doctors and patients in an entirely different social and economic context, helped me to evaluate and shape my own emotions and personal values. My motivation in wanting to become a doctor has increased tremendously since this trip. My trip to Ghana also inspired me to create a medical journal in my school as a fund-raising initiative. I brought together a group of fellow students to write articles about common teenage problems (teenage drinking, anorexia, obsessive compulsive disorder (OCD), stress, smoking, sexually transmitted diseases (STDs)) as well as articles on euthanasia and assisted suicide, stem cell research and the NHS. I wrote about my personal experiences in Ghana in addition to editing and publishing the school journal. All the funds raised from the school medical journal will be going to the HIV victims in Ghana.

Background:

Controlled teaching environment can be provided to undergraduate medical students for learning certain basic clinical skills through using manikins or models before they have to perform them on real patients. Many medical schools in the United Kingdom now have clinical skills laboratories which are equipped with a large host of such learning resources. Many medical schools promote their clinical laboratories and have dedicated lead consultants to teach, monitor and develop clinical skills. Furthermore, a wide variety of skills can be taught in these laboratories. For example, the University of Leeds Medical school offers teaching to second year undergraduate medical students in basic life support, vital signs, injections, blood glucose monitoring, cannulation and venepuncture while third year medical students are taught fundoscopy, rectal examination, urinary bladder catheterisation, doing an ECG and examination of the breast. Similarly, simulators have also been used in postgraduate medical teaching, for example, Colonoscopy simulators have been used to calculate efficiency ratio of learners. ¹

However not all places in the world have clinical skills laboratories. Alternatively, some institutions teach the undergraduate medical students various basic skills in clinical supervised settings before they take up their first job as physicians. Some have assessed the level of training that their institutions have thus offered and tried to improve upon deficits. Mario Sicaja et al ² from Zagreb University evaluated 252 students using a questionnaire asking the students to self assess their abilities on nine groups of skills and asked 129 faculty teachers to simultaneously assess the minimum necessary level of skills they expected from the graduating students. They concluded that the teachers expected higher level of clinical skills from students than that assessed by the students. Similarly, in postgraduate teaching, the students’ learning needs have been assessed by determining the difference in expectation of trainers and the trainees. ³

Effectiveness of basic clinical skills training programmes has been documented and it has been suggested that longitudinal skills training offers superior preparation for abilities during the clerkship ⁴. It has also been suggested that whereas students from medical schools using traditional curriculum may not differ in their knowledge based performance, (demonstrated by Multiple Clinical Questions i.e. MCQ scores) from students at medical schools with clinical skills training, the later perform better on clinical examination (measured by Objective Structured Clinical Examination i.e. OSCE). ⁵

However, in many other medical schools worldwide, which implement the traditional undergraduate medical curriculum, there are no clinical skills teaching sessions for undergraduate medical students. The students get to learn this first time when they are doing internship and are in direct contact with the patients. It was the same situation in Liaquat University of Medical and Health Sciences (LUMHS) in Hyderabad, Pakistan. This is a large medical school which is based in the second largest city of Sindh province of Pakistan. The first author was invited from United Kingdom to review and advise on the undergraduate medical curriculum at LUMHS. The professor of plastic surgery (second author) had started to run a voluntary clinical skills course in his department covering some general basic clinical skills and provided his data to the first author for analysis and review.

This study was devised to analyse the views of participating students regarding the course and determine their learning needs. Based on the learning needs, one could identify which resources are needed and what the University should aim to provide.  Furthermore, there are no such published studies from Pakistan. This study was aimed at providing scientific information on the learning needs of undergraduate medical students from the developing world, which may be deemed to be different from the medical students in the western world.

Methods:

All medical students from fourth and final year at LUMHS were invited to attend four weeks of clinical skills course at the plastic surgery department voluntarily. The students had to attend the department after their normal working hours. There were dedicated junior doctors in the department who were given the responsibility to teach the attendees hands on clinical skills in a structured manner. The skills included  history taking, organising blood tests, vene-puncture, giving intravenous and intra-muscular injections, intravenous cannulation, urinary bladder catheterisation, passing naso-gastric tube, dressing of surgical wounds, basic pre-operative assessment, basic post-operative assessment including haemo-dynamic stability, surgical theatre mannerism, principles of sterilization, identification of common surgical instruments and equipment and identification of types of drugs used in anaesthesia. The students were provided a questionnaire asking for feedback on the course which they had to fill at the end. The study was approved by the University Research and Ethics Committee. The data was computerised and statistically analysed using a statistical package. It involved all students who went through the course during consecutive sixteen months commencing from October 2008 and ending in January 2010.

Results:

90 students were recruited to the study. Students were from both sexes and both fourth year and final year. There were 32 male (35.6%) and 58 female (64.4%) students. Of the total 90 students, 62 (68.9%) were from 4^th year while 28 (31.1%) students were from final year. They were all volunteers who were willing to attend the course after their normal working hours and were allocated seats on a first come first serve basis. No student was refused entry to the course and all participants were provided questionnaire on feedback at the time of completion of the course. The response rate was 100% although this may be because students were actively encouraged by the teaching staff to ensure that feedback questionnaires were filled in. 

History taking and laboratory investigations were deemed least important by students, perhaps because these are taught to them during normal attachments in all wards for clinical teaching.

The Friedman mean rank was highest for catheterisation of urinary bladder (11.66) and passing of a naso-gastric tube (12.44). The students felt the greatest need to learn these two basic clinical skills perhaps because they are not taught elsewhere. This was followed by anaesthesia, sterilisation and passing an intravenous cannulation. The students ranked learning of the learning of the following skills  in the middle: giving injections, taking blood, providing pre or post-operative care and being able to identify surgical instruments. Taking history and arranging laboratory investigations were both ranked the lowest at 6.22. The Friedman asymptotic significance was high (p<0.000). Despite being a good sample size, Monte Carlo significance at confidence interval of 99% was very high (p<000.0). Table below summarises the statistics

Our study has shown that undergraduate medical students from the developing world greatly value a basic clinical skills course, and are particularly keen on being taught naso-gastric intubation and urinary bladder catheterisation. They seem to get enough exposure in the wards on history taking and arranging laboratory tests, but identify learning needs in other clinical skills.

This study is limited to data collection from one large medical university, but the sample size has been large, observation has been over a period of one year, statistical significance has been very high and response rate has been extremely good. The teaching staff actively encouraged the students to fill the feedback questionnaires, and this could arguably lead to some response bias.

There are no such previous studies from Pakistan to compare our findings with. This study therefore can make a good baseline for local institutions to further develop and build upon. Roy Remmen’s group compared four medical schools on clinical skills of students, and demonstrated positive effect of both longitudinal skill training as well as utilisation of problem based approach in these skill courses. Our study did not provide any longitudinal data and problem based learning approach was not utilised either. Our data is a cross sectional study.

There seem to be three levels of engagement in learning basic clinical skills. One side of the spectrum has structured teaching in clinical skills laboratories with simulation, models and manikins, while the other has no teaching of clinical skills at all, until the physician starts to work with real patients. In the middle is the model of teaching clinical skills on the wards, before graduating as doctors. The former model with clinical skills laboratories requires the most resource. Which model of teaching is adopted by any individual medical university may be dependant upon the local resources, as well as the demands of the local regulatory bodies.  During this study, we were able to realise the pattern of clinical skills teaching at some other medical universities in Pakistan, India and Bangladesh as random examples of southeast Asia. We learned that most institutions in this part of the world do not undertake any formal clinical skills teaching, and certainly there are hardly any clinical skills laboratories. This voluntary attempt by the professor of plastic surgery at LUMHS is therefore commendable. 

This study has also identified the keenness of students to learn some specific skills through such courses prior to graduation. With a move to more globalisation of medical protocols and guidelines, a greater uniformity should also emerge in the ways in which doctors in the east or the west hemisphere of the world learn medical knowledge, attitudes and skills. There may thus be need for researchers in medical education to encourage and push for adoption of clinical skills teaching courses prior to medical graduation in the developing world.

Furthermore this study has yet again reiterated that student’s views should form a key part in the curriculum design when considering development of a clinical skills course, and resources should be geared to meet these learning needs of students.

Introduction:

Problem based learning (PBL) has been an important development in health professions education in the latter part of the twentieth century. Since its inception at McMaster University¹ (Canada), it has gradually evolved into an educational methodology being employed by many medical schools across the globe^2,3. PBL presents a paradigm shift in medical education, with a move away from ‘teacher centered’ to ‘student centered’ educational focus. The assumptive difference between a pedagogy learner and an androgogy learner (Table 1) was summarised by Knowles⁴, and the androgogy approach underpins PBL. This shift has redefined the role of a teacher in the PBL era, from being a teacher to a facilitator.

It is well known that implementing PBL as an educational methodology required additional resources compared to a traditional lecture based curricula⁵. In addition, there was a need to recruit and train a large number of tutors to facilitate the PBL process⁶.Training PBL tutors is an important component of a successful curriculum change, and is a continuous process. Training workshops and role plays were employed to train conventional teachers, but challenges were faced in developing them into effective PBL tutors⁵.

The aim of this paper is to evaluate the literature for any evidence supporting the theory that a PBL background student may develop into an effective PBL tutor. The Medline, EMBASE and CINHAL databases were searched to look for any pre-existing literature or research supporting this theory.

Results:

To the best of my knowledge, there has been no reported evidence supporting this theory. With limited literature evidence, this paper aims to identify common grounds between a PBL student and a PBL tutor, and whether being a PBL student may contribute to the overall development as a PBL tutor. The discussion evolves around the following domains:

1. Teaching Styles:

The ideal teaching style of a PBL tutor is a facilitative-collaborative style, which augments and supplements the PBL process. The teaching style inventory developed by Leung et al⁷ hypothesised four domains of teaching styles: the assertive, suggestive, collaborative and facilitative styles. Though a PBL tutor assumes himself in possessing this style (facilitative), it does not necessarily match with the students perceptions, as reported by Kassab et al⁸.

Some of the characteristics of being a PBL student may foster the development of a collaborative teaching style. Being a student, you are expected to be a collaborative learner which is critical for achieving and improving group performance⁹. Initial years as a student in PBL may contribute to developing attributes required to develop a preferential teaching style.

2. Facilitating critical thinking:

PBL is grounded in cognitive psychology and is set out to stimulate curiosity and build durable understanding. One of the roles of the tutor is to foster critical thinking and enhance the group’s ability to analyse and synthesise the given information. This attribute stems from the tutors ability to facilitate, rather than teach. Irby¹⁰ opined that clinical teachers tended to teach as they themselves were taught using traditional approaches, which may affect the process of stimulating critical thinking among the students.

A tutor from a PBL background would have the ability to think critically, through a process of developing thoughtful and well-structured approach to guide their choices¹¹. Tiwari et al¹² showed in their study that PBL students showed significantly greater improvement in critical thinking compared to traditionalist courses. Hence, prior exposure to a certain learning style can create a cognitive psychology that can contribute to tutor development.

3. Group dynamics:

One of the prime roles of a PBL tutor is to facilitate the PBL process by keeping the group focused on tasks, and guiding them to achieve their goals. Tutors who are skilled in group dynamics are evaluated more highly than those who are not so skilled^11,13 . Tutors need to develop sound appreciation of the group dynamics, failing which may lead to fostering uncertainty with in the group. Bowman et al¹³ commented about the lack of consideration on the emotional implications placed on prospective PBL tutors when tutoring small groups, especially the skills required to balance between short term anxieties and potential serious problems. This imbalance which usually serves as unconscious incompetence may affect group dynamics.

PBL students would have experience of group dynamics and the pressures of working within it. They would have developed a model of working with members with varying attributes. Blighet al¹⁴ showed in their study that students from a PBL curriculum rated themselves better in team working and motivation compared to conventional course peers. This highlights the fact that an apprenticeship model may be necessary in developing the right skills to be an effective tutor.

The characteristics of a student that may foster ideal attributes in a PBL tutor are briefly summarised in Table 2, and has evolved from the work of Samy Azer^9,11 .

Table 2: Common ground

4. Tutor training

Considerable resources are exhausted in teaching new tutors the art of facilitating a PBL group⁶, and the usual cohort is teachers from a conventional taught background. The shift from didactic expertise to facilitated learning is difficult for those tutors who feel more secure in their expert role. Finucane et al⁵ published their study which showed that only a minority of staff had volunteered to be PBL tutors, possibly reflecting the fact that absence of prior exposure to PBL style of learning may have contributed to this. In spite of tutor training workshops, they could only retain 73% at the end of two years.

Prior exposure as a student may help negate much of the stigma associated with PBL. They would have observed and learnt from their PBL tutors, and would have analysed their contribution to the PBL process. They could reflect on their experience and evolve into an ideal PBL tutor. This would help in minimising resource expenditure and contribute towards retention of staff.

5. Tutor comfort zones:

PBL contextualises learning to practical situations, with integration across disciplinary boundaries. Dornan et al¹⁵ reported on how some teachers felt PBL to be a frustrating drain on time as it did not fit their educational style, and was a distraction from clinical teaching, demonstrating the ‘conditioning effect’ of prior experiences. This further fuels the debate between content vs. process expertise, but prior knowledge of the process would benefit the students and the PBL process.

6. Role modeling:

Role models have long been regarded as important for inculcating the correct attitudes and behaviors in medical students. Being an ideal role model is considered as one of the prime requisites of a teacher. In a recent study, Mclean et al¹⁶ showed that PBL students tended to have a higher percentage of role models compared to students from a traditional programme (73% vs. 64%). In an ideal setting, a “content and process expert” would be the perfect role model for the PBL students, but this may not be realised in all settings.

Paice et al¹⁷ commented on the resistance to change within the medical profession, and highlighted the need for training to emphasise the values and attitudes required. This puts an added emphasis on the tutor to demonstrate tenacity and virtues to be an effective role model, avoiding ‘cognitive clouding’ from previous experiences.

As a PBL student, they would be exposed to variety of PBL tutors. They would have incorporated the good points of an effective PBL tutor, and would have reflected on the negative aspects. Reflective practice enables them to develop the right attributes. Though these attributes may be difficult to develop through training workshops, having a background of PBL education may help mould the tutor characteristics.

Conclusion:

As PBL continues to be employed across different specialties, there would be increased emphasis on the medical schools to match the resources needed to implement it. There is an argument for developing an apprenticeship model or recruiting tutors from PBL background, which would help in reducing the cost in training new tutors, along with nullifying the negative influences a new tutor may bring. The biggest limitation in the present setting is finding a cohort of PBL background tutors, but an apprenticeship model may benefit teachers from conventional background. A prospective research study exploring the attributes of tutors, successful and less successful, from traditional, PBL and hybrid curricula and those who have crossed the Rubicon from traditional to PBL can effectively answer this question.

(A Poem written by a doctor about ADHD)