Specialist approach to childhood asthma: does it exist?

Twenty six paediatricians and 21 consultant physicians concerned in the care of children with asthma answered a postal questionnaire on various aspects of the management of asthma, attitudes to referral, and the nature of advice given to parents and children. The 47 specialists had considerable differences in opinion for more than half the questions, including the role of allergen skin tests and the use of "breathing exercises." In addition, the paediatricians disagreed with the responses of the non-paediatricians on common issues such as whether to use aminophylline suppositories and whether swimming helps children grow out of asthma. These results have disturbing implications for the advice that specialists give to general practitioners, children, and parents.     

Globalisation: what is it and how does it affect health?

The term "globalisation" tends to be misused and overused. We need greater clarity in our understanding of the globalisation process, including the distinct changes involved and their relation to human health. The health impacts of globalisation are simultaneously positive and negative, varying according to factors such as geographical location, sex, age, ethnic origin, education level, and socioeconomic status. Globalisation is not an unstoppable force. Our key challenge is to create socially and environmentally sustainable forms of globalisation that provide the greatest benefits and least costs, shared more equitably than is currently the case. The health community must engage more directly in current research and policy debates on globalisation and encourage values that promote human health. At the same time, those at the helm of globalisation processes must recognise that attending to health impacts will strengthen the long-term sustainability of globalisation.     

Career choices of today’s medical students: where does surgery rank?

Introduction

The national junior doctor recruitment crisis prompts an appraisal of medical student attitudes to different career pathways. The purpose of this study was to perform a national review of surgical career intentions of Irish final year medical students.

Methods

Ethical and institutional approval was obtained at each study location. A questionnaire was designed and distributed to final year students. Domains assessed included demographics, career plans and reasons associated. Anonymised responses were collated and evaluated. Categorical data were compared with Fisher’s exact test.

Results

Responses were obtained from 342 students in four medical schools of whom 78.6 % were undergraduates. Over half (53 %) were Irish, with Malaysia, Canada and the USA the next most common countries of origin. Only 18 % of students intended to pursue surgery, with 60 % stating they did not plan to, and 22 % undecided. Of those who plan not to pursue surgery, 28 % were unsure about a speciality but the most common choices were medicine (39 %), general practice (16 %) and paediatrics (8 %). Reasons for not picking a career in surgery included long hours and the unstructured career path. Suggestions to improve uptake included earlier and more practical exposure to surgery, improved teaching/training and reduction in working hours.

Conclusions

In this study 18 % of final year medical students identified surgery as their chosen career pathway. Although lifestyle factors are significant in many students’ decision, perceived quality and duration of surgical training were also relevant and are modifiable factors which, if improved could increase interest in surgery as a career.     

Problem based learning and medical malpractice: does how you've been trained make a difference?

Testing the hypothesis that physicians trained in problem based learning formats versus traditional lecture based formats develop equally strong physician-patient relationships, the rates of malpractice filings against graduates trained in each format at the John A. Burns' School of Medicine were compared. With the graduation of 10 more PBL classes, statistically significant differences between the two groups could be obtained.     

Portfolios in Saudi medical colleges: Why and how?

Over recent decades, the use of portfolios in medical education has evolved, and is being applied in undergraduate and postgraduate programs worldwide. Portfolios, as a learning process and method of documenting and assessing learning, is supported as a valuable tool by adult learning theories that stress the need for learners to be self-directed and to engage in experiential learning. Thoughtfully implemented, a portfolio provides learning experiences unequaled by any single learning tool. The credibility (validity) and dependability (reliability) of assessment through portfolios have been questioned owing to its subjective nature; however, methods to safeguard these features have been described in the literature. This paper discusses some of this literature, with particular attention to the role of portfolios in relation to self-reflective learning, provides an overview of current use of portfolios in undergraduate medical education in Saudi Arabia, and proposes research-based guidelines for its implementation and other similar contexts.A portfolio in education is a collection of evidence that learning, or more generally, an effort to the achievement of a goal, has taken place. In medical education, the concept and practical uses of portfolio have evolved over the last 2 decades, under the influence of various theories of adult and experiential education.1 This evolution has encompassed workbooks, log books, reflective learning and competence based learning tools, typically with feedback and reflective writing as essential parts of the collection and process that a portfolio both represent and derives from. Currently, portfolios are used in various forms and for diverse purposes in medical education in many parts of the world, and their uses are widely accepted as complementary to other conventional methods of learning and assessment.2,3 This paper is a part of Ministry-funded project for development and implementation of portfolio in undergraduate medical education. The purpose of this paper is to highlight the strengths and limitations of portfolios as learning and assessment tool in this context, to provide an account of its current use in King Abdulaziz University (KAU), Saudi Arabia, and to propose evidence-based guidelines for its implementation and other similar contexts.

Portfolios and adult learning theory

Portfolio-based learning has shown to be consistent with the principles of andragogy, which was developed by Malcom Knowles beginning in the 1990’s4 as a theory of adult learning with mature learners as the primary target. The theory suggests on the notion that adult learners have to discover why they should be learning something and on the belief that, for these learners, understanding the relevance of material and concepts is essential. Also, central to andragogy are the notions that adult learners are self-directed individuals who are capable of taking responsibility for their learning experientially, and through problem solving is key to success.5

The role of portfolios in learning and teaching

A portfolio is widely regarded as a multipurpose tool that can positively impact learners’ and educators’ attitudes to learning, teaching, and assessment, as well as increasing their sense of hands-on connection to their work.6,7 Indeed, portfolio-based learning provides a combination of processes that function interactively to enhance learning, a benefit that may not be achieved through any other single learning tool. These processes include, and contribute to the learner’s capacity for, autonomous learning and reflective practice.Reflection is a metacognitive procedure that creates a better understanding of the self as well on the situation so that future actions can be informed by this understanding. Self-regulated and lifelong learning depend on reflection as an important aspect. Self-reflection, moreover, is also key to developing both a therapeutic relationship and professional expertise.8 Developing reflective practice, which is an essential feature of portfolio based education, encourages students to think on their experiences, actions, performance, and shortcomings; thereby, preparing them to become independent professionals and to use their learning abilities effectively in postgraduate studies.9 The benefits of portfolio; however, are not limited to student learning. Student feedback on the learning process provides educators with a basis upon which to reflect on and improve their teaching methods and their methods of discharging their professional responsibilities. This process can improve student-teacher relationships and can provide support for students as they face personal, emotional, and educational challenges of completing their medical education.10

The role of portfolios in assessment

The commonly heard phrase “assessment drives learning” refers to the phenomenon by which students tend to learn in ways that are influenced or determined by how their assessment is planned and implemented.11 In light of this expectation, assessment by portfolio is necessary in order to validate portfolios as a learning tool. Nonetheless, portfolios can add distinctive elements to the overall evaluation of medical students’ progress. In particular, assessment by portfolio adds a subjective element of evaluation of students’ learning through experience and reflection. Moreover, as an assessment tool, portfolio can be broad-based, encompassing material that is formative and summative, qualitative, and quantitative as well as considered highly individualized.12,13Although subjective in nature, the credibility (validity) and dependability (reliability) of the portfolio-based assessment process can be safeguarded using established methods.5 The benefits of portfolio-based assessment build on the value that it adds to the learning process through student-centered, self-directed, thought provoking, responsibility-building approach to professional development.

Importance of portfolios in Saudi Arabian medical education

In 2010, the competence framework for medical graduates in Saudi Arabia known as the Saudi-Meds was established to guide curriculum development and assessment, as well as to ensure that Saudi medical education adapts to the changing needs of current times. These competencies were organized into 7 broad fields and subdivided into 30 areas.14 The Phase II consultation document consolidated the framework into 6 fields, which are further subdivided into 16 competencies. The National Commission for Academic Accreditation and Assessment (NCAAA),15 in order to achieve accreditation and quality assurance, requires these to be further classified into 5 domains: knowledge, cognitive skills, interpersonal skills, communication skills, and psychomotor skills, which are known collectively as the National Qualification Framework.15Although traditional tools of learning and assessment can account for most of these domains and competencies, the current trend in Saudi medical colleges to teach subjects such as medical ethics and professionalism primarily through didactic lectures does not provide an effective means of modifying students’ behavior in ways that promote patient care and professionalism.16 Promoting such change requires thoughtful reflection on clinical and other encounters during students’ hospital learning experience, with supervised discourse involving peers and effective feedback from faculty. Portfolios, in this scenario, can be an effective tool in tracking, demonstrating, and assessing reflective learning experiences. The portfolio process, moreover, can provide opportunities for students to collect evidence of their leadership roles and their involvement in patient and peer education, as well as to improve their writing skills, all of which are fields that have been emphasized by the Saudi-Meds and by The National Commission for Academic Accreditation and Assessment (NCAAA), but that are nevertheless largely overlooked in the course of traditional methods of teaching and assessment.

Guidelines for implementing portfolio-based learning and assessment in medical colleges in Saudi Arabia

The Association of Medical Education in Europe (AMEE) has published explicit guidelines for implementing portfolios in learning and in assessment for medical students.1 The following guidelines were developed in accordance with the 6-point schema (Figure 1), which represents a modification of the Association of Medical Education in Europe (AMEE) guidelines, which is designed to fit with current Saudi educational needs and practices.Open in a separate windowFigure 1Guidelines for implementing portfolio-based learning and assessment in medical colleges in Saudi Arabia.

Develop a general consensus

Portfolios and reflective learning may be completely novel concepts for most stakeholders in Saudi medical education; therefore, before implementing these practices, it is necessary to develop a consensus among administrators and faculty regarding the need to include them along with tools currently in use. Doing so may require presentations, workshops, and the piloting of portfolio use on an experimental basis. At King Abdulaziz University (KAU), Jeddah, Saudi Arabia, a planned awareness was created among faculty members by portfolio working group, which discussed their experiences with implementation of portfolios formatively within their modules, in different faculty meetings and seminars.

Select an appropriate place in the curriculum

In order to gain the maximum benefit from portfolios, the competencies, and learning objectives to be achieved through this method must be selected with care. Decisions will therefore need to be made regarding the placement of portfolio in the curriculum map. Introduction of portfolios in early years of medical school can prepare the students’ for later years when they have more clinical experience to reflect upon, and maximize their learning through reflection and feedback. Another consideration to be kept in mind is that Saudi students may initially have difficulty in writing their thoughts due to limitations of writing skills in English language. Therefore, students at KAU were initially given the option to write in their native (Arabic) language, if they had difficulty in explaining themselves in English. Students’ writing skills and language improved with time and so did their reflections.

Select an appropriate support group

Motivated faculty members, who are willing to put in the time and effort needed to develop students’ learning competencies in ways that will ultimately help them to become better professionals, will be indispensable in the process of implementing portfolio-based learning and assessment. Faculty enthusiasm can be enhanced by rewarding innovative and progressive activities. In our experience, selecting the initial group to initiate the process is most difficult; however, once the “ball starts to roll” many faculty members get motivated to join the group.

Develop the portfolio

Once the appropriate competencies and other objectives are set, the team can determine the material that can be used to gather proper evidence of student learning. There is almost no limit on creativity while choosing the modalities that can be used in a portfolio. From feedback, reports, reflective write ups on incidents to pictures and video recordings, all can be a part of the portfolio. The availability of resources and feasibility of their use will guide the faculty in deciding on the right directions in which to develop portfolio as an effective tool for promoting positive behavior change in Saudi medical students. A plan for how the collected material will be used for students’ assessment should also be developed at this point. In our opinion, limitations of time, and human resource required for assessment process often become a factor in limiting the collectables in portfolios.

Orientation of students

Students must be informed, from the outset, regarding the methods to be used in portfolio-based learning and assessment. They should also receive written guidelines that explain the learning methods, content, assessment process, marking system, and benefits that pertain to the use of portfolio. If they are well informed on what to expect, students are less likely to feel anxious or threatened; thereby, increasing the likelihood of a successful and enjoyable learning experience.

Designing the assessment plan and evaluation process

This process must encompass decisions regarding the nature of assessment (formative or summative) for students at various levels as well as regarding marking criteria for the content of portfolios, training for examiners, and the time, place and methods to be used for assessment. The process of evaluation for improvement and quality assurance in place at the start of implementation not only secures a smooth-running process, it also instills stakeholders, and observers with confidence.

Limitations of portfolios

A number of limitations with the use of portfolios have been reported including students and faculty finding it time-consuming, less important or distractive from other forms of learning, and, at times, inability of students to understand the purpose of the whole exercise.12 These limitations can be tackled with a thoughtfully prepared plan for development and implementation of the process.The authors acknowledge that there still are unanswered questions regarding the use of portfolios in Saudi Arabian culture of medical education, implementation process details, assessment criteria, and standard setting. We are hopeful that these issues will be better understood once we have the results of local implementation of the portfolios, the KAU portfolio project.In conclusion, we believe implementation of portfolios as a method for learning and assessment requires careful consideration and understanding of the tool, careful selection of the topics and competencies that can maximally benefit from this relatively complex modality, and buy-in of the involved stakeholders for the painstaking process of change. We recommend that portfolios, at least in the initial phase of implementation, should only be used to achieve selected competencies, particularly those that are not typically achievable through other, less multi-faceted, and more easily implemented means of education.     

Prevocational medical training in Australia: where does it need to go?

The workplace remains the most important learning environment for junior doctors in their postgraduate years. There is no national curriculum to guide the education of prevocational doctors. The apprenticeship model is under threat, and is not sustainable in the future without significant changes to the system. Supervision is crucial for junior doctors' learning and for safe, quality patient care.     

Assessing clinical competency in medical senior house officers: how and why should we do it?

Most consultants are involved in the training and assessment of several grades of doctors in training especially senior house officers (SHOs) and specialist registrars. In the medical and other specialties there is an increasing trend towards assessing junior doctors' competency using the record of in-training assessment process for specialist registrars and using the Royal College of Physicians folder to record competences of medical SHOs. It is necessary to consider why there is a need to assess competency, how it may be done practically, and the advantages and disadvantages of this system of assessment. There are considerable hurdles to the implementation of this system in the medical specialties within today's NHS and the organisation may need to undergo fairly radical change to facilitate this system.     

Attitudes of preclinical medical students towards caring for chronically ill and dying patients: does palliative care teaching make a difference?

Introduction: Students entering medical school today will encounter an ageing population and a higher incidence of diseases affecting the elderly—for example, chronic respiratory and cardiac disease and malignancy. Purpose: This study was carried out to determine the attitudes of preclinical medical students towards the care of patients for whom a cure is not possible. Methods: All students were invited to complete a 23 item questionnaire prior to initial teaching and again following the second teaching session in palliative care. Results: Overall, 149 of the 186 students (80%) completed the pre-teaching questionnaire (59 males and 90 females; median age 20 years, range 19–27 years), and 66 students (35%) completed the post-teaching questionnaire. Attitudes towards chronically ill and dying patients were generally positive. It was found that increasing age was associated with a more positive view of caring for patients with chronic or terminal illness, a more positive view of listening to patients reminisce, and a more positive view of patients dying at home (p = 0.014). The only notable result was that after palliative care teaching students had a significantly more positive view of hospices. Conclusion: Caring for patients at the end of life can be one of the most rewarding aspects of being a doctor. This study suggests that the majority of medical students have a positive attitude towards patients with chronic incurable illness, and the trend for encouraging older students to enter medicine may be an influencing factor.     

The epidemic of asthma: too much allergen or not enough infection?

Asthma has generally been thought to result from exposure to allergens in infancy leading to atopy, and eventually to airway hyperresponsiveness. There is now evidence that implicates absence of childhood infections as a factor in development of asthma. Childhood infections seem to be important in normal maturation of the immune system, with asthma a manifestation of a persistent "immature" immune system.     

The consent process for cadaveric organ procurement: how does it work? How can it be improved?

CONTEXT: Understanding the consent process that organ procurement organizations (OPOs) use is crucial to improving the process and thereby reducing the number of individuals who die each year for want of an organ transplant. However, no data exist on OPOs' current consent practices. OBJECTIVE: To assess whose wishes OPOs follow when procuring solid organs from deceased individuals and whether advance directives and computerized registries might improve the consent process for solid organ procurement. DESIGN, SETTING, AND PARTICIPANTS: Telephone survey conducted from June to August 1999 of all 61 active OPOs. MAIN OUTCOME MEASURES: Responses to the 49-question survey addressing consent practices in specific scenarios of deceased and next of kin wishes. RESULTS: Widespread divergence exists in OPOs' consent practices for cadaveric solid organ procurement. Regarding overall consent practices, 19 (31%) OPOs reported that they follow the deceased's wishes, 19 (31%) follow the next of kin's wishes, 13 (21%) procure organs if neither party objects, 8 (13%) procure organs if either party consents or neither objects, and 2 (3%) do not follow any of these 4 overall practices. These differences appear to be traceable to implicit ethical disagreements about whose wishes should be followed. A total of 29 (48%) OPOs reported having an official policy to address whether they follow the family's or deceased's wishes. Regarding factors that influence OPOs' choice of consent practice, 29 (48%) respondents ranked impact on the deceased's family as the most important factor, 13 (21%) ranked state law as most important, and 7 (11%) ranked the priority of the deceased's wishes as most important. Durable power of attorney appeared to have substantial weight in OPOs' decisions; for example, in the scenario in which the deceased supported organ donation and the next of kin opposed it, 34 (56%) OPOs reported they were likely to procure organs based on the consent of the holder of the deceased's durable power of attorney, whereas only 7 (11%) reported they were likely to procure organs based on a document of gift (a living will, donor card, or driver's license). CONCLUSIONS: Expanding the legal scope of living wills to cover individuals' organ donation preferences would likely have little impact on procurement rates. In contrast, expanding the legal scope of durable powers of attorney for health care may have a significant impact. A national discussion should take place addressing the underlying ethical issues that appear to account for much of the divergence among OPOs' consent practices for cadaveric solid organ procurement.     

Self-management in adolescents with chronic illness. What does it mean and how can it be achieved?

The concept of self-management is based on the notion that it will improve wellbeing and strengthen self-determination and participation in health care, while reducing health care utilisation and health costs. Increasing self-management is a desirable goal for the 15%-20% of children and adolescents who have a significant ongoing health care need related to a chronic health condition. Promoting self-management in young people with chronic illness can be difficult for parents and health care practitioners. Doctors can help parents recognise the potentially competing aspects of the parenting role--protecting young people's health while supporting their growing independence and autonomy. Optimal care may or may not be achievable, depending on a young person's level of development. As children mature through adolescence, they increasingly want their own voice to be heard, as well as the right to privacy and confidentiality in health care consultations. As well as listening to parents and supporting their roles, doctors should see young people alone for part of the consultation, taking a psychosocial history and carefully maintaining confidentiality.     

Intensive glycaemic control in type 2 diabetes mellitus: does it improve cardiovascular outcomes?

With growing urbanization and economic development, there is a rapid increase in the incidence of type 2 diabetes mellitus (T2DM) in India. T2DM is associated with 2-4 times higher risk for cardiovascular disease (CVD), including coronary artery disease, stroke and peripheral vascular disease. Several studies have shown the benefit of intensive glycaemic control in reducing the frequency of diabetic microvascular complications such as retinopathy and nephropathy. Results of long term follow up of patients with diabetes, who were enrolled in earlier trials, have shown that initial intensive glycaemic control led to a reduction in CVD outcomes when compared with standard therapy. However, it is unclear if intensive glycaemic control, aiming to reduce haemoglobin A1c to levels even lower than the current goal of <7%, will similarly lead to reduction in the rates of CVD. Recently, the results of 3 large, randomized controlled trials have been published, which suggest that in established T2DM with previous CVD or high risk of CVD, the benefits of intensive glycaemic control when compared with conventional good control, are minimal with regards to reduction of cardiovascular outcomes. Intensive therapy increases the risk of side-effects such as severe hypoglycaemia and weight gain. The implementation of such a therapy, with rigorous attention to frequent monitoring of blood glucose and visits to the physician, is not likely to be possible on a large scale, especially in a developing country such as India. The aim of management of patients with established T2DM should be to achieve the goal of good glycaemic control (haemoglobin A1c<7%), with avoidance of hypoglycaemia. It is equally, if not more important, to control other risk factors of CVD by paying greater attention to lifestyle measures (weight loss if overweight or obese, regular exercise, cessation of smoking), rigorous control of blood pressure (<130/80 mmHg) and low density lipoprotein (LDL) cholesterol (<100 mg/dl or <70 mg/dl if already diagnosed with CVD) and the prophylactic use of low dose aspirin as per current recommendations. A multifactorial approach targeting multiple cardiovascular risk factors is likely to be most effective in reducing CVD outcomes in T2DM.