Help,I’m losing patient‐centredness! Experiences of medical students and their teachers

Medical Education 2010: 44 : 662–673 Objectives Despite all educational efforts, the literature shows an ongoing decline in patient‐centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient‐centredness in order to gain a better understanding of the factors that determine its development. Methods We conducted 11 focus groups on the subject of learning and teaching about patient‐centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the ‘sensitising concepts’ provided by the Attitude–Social Influence–Self‐Efficacy (ASE) model. Results Although students express positive attitudes towards patient‐centredness and acquire patient‐centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today’s challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient‐centred skills. However, when students lack self‐efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non‐patient‐centred role models and are overwhelmed by powerful experiences, they lose their patient‐centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self‐awareness and self‐care are important qualities of the central phenomenon of the ‘doctor‐as‐person’, which is identified as a missing concept in the ASE model. The student–supervisor relationship is found to be key to learning patient‐centredness and has several functions: it facilitates the direct transmission of patient‐centred skills, knowledge and attitudes; it provides social support of students’ patient‐centred behaviour; it provides support of the ‘student‐as‐person’; it mirrors patient‐centredness by being student‐centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student‐centred education and guidance be offered, self‐awareness be fostered and more opportunities to encounter patients be created, including more time in general practice. Conclusions Supportive student–doctor relationships, student‐centred education and guidance that addresses the needs of the doctor‐as‐person are central to the development of patient‐centredness. Medical education requires patient‐centred, self‐caring and self‐aware role models.     

Assessing detoxification of a complex hazardous waste,using the Microtox™bioassay

Research has demonstrated the usefulness of the Microtoxbioassay in assessing the acute toxicity of organic compounds. Recently, the use of the Microtoxbioassay has been extended to applications in hazardous waste management. The rapidity of the test, low sample requirements, and low cost provide several advantages over chemical analysis, especially for complex waste mixtures. Microtoxbioassay results correlate closely with results from rainbow trout bioassays, and are more sensitive to inhibitory chemicals than activated sludge organisms. An experimental approach using batch reactors and soil columns was implemented in the laboratory to evaluate the detoxification and mobility of a toxic complex hazardous waste in soil. The objective of the study reported here was to quantify the extent and rate of detoxification of a complex hazardous waste as affected by soil type and waste application rate. The extent and rate of detoxification was directly related to waste loading rate for both soil types investigated, in both batch reactors and soil column reactors. Analysis of the toxicity of aqueous soil extracts at incremental depths through soil columns and of soil columnn leachate indicated a low leaching potential for the complex petroleum refinery waste.     

‘More shades of grey in my answers’: an interview study revisiting attitude erosion during clerkships

Context Small declines in patient‐centred attitudes during medical education have caused great concern. Although some of the self‐report scales applied have solid psychometric foundations, validity evidence for the interpretation of attitude erosion during clerkships remains weak. Objectives We sought to address this gap in a qualitative study of the relationships between scores on four commonly used attitude scales and participants’ experiences and reflections. Our aim was to gain a better understanding of the score changes from the participants’ perspectives. Methods We conducted semi‐structured interviews with 15 junior doctors from a cohort (n = 37) that had previously shown a small decline in patient‐centred attitudes during clerkships, measured on four self‐report scales. In the interviews, we explored interviewees’ experiences of their development of patient‐centredness and subsequently discussed their scale scores, particularly for those items that contributed to a rise or decline in scores. We analysed the data using a process of constant comparison among personal experiences, scale scores and participants’ explanations of score changes, applying the coding techniques of grounded theory. Results The analysis revealed important response distortions that might be responsible for small declines in scores during clerkships separately from changes in attitudes. The drastic alterations to the participants’ frame of reference, attributable to the transition to clinical practice, represented the most prominent cause of distortion. More nuanced, context‐specific, patient‐centred reasoning resulted in more neutral responses after clerkships, paradoxically causing a decline in scores. In addition to response distortions, the interviews revealed shortcomings in content validity such as an ‘extreme’ construct of patient‐centredness. Conclusions This study calls into question the validity of the interpretation of attitude erosion during clerkships. The findings suggest that small declines in scores on self‐report attitude scales are related to a recalibration of trainees’ understandings of patient‐centredness as they grow more clinically experienced. The evolved construct of patient‐centredness and the way attitudes are measured require special attention in the development of future instruments.     

The epidemiology of acute hepatitis A in north Queensland, 1996-1997.

Details on all cases of hepatitis A notified in North Queensland in 1996 and 1997 were prospectively collected. There were two substantial outbreaks and a total of 225 cases during this period. The total incidence rate (per 100,000) was 11.0 in 1996 and 27.0 in 1997. Aborigines and Torres Strait Islanders constituted 29% of cases and had incidence rates of 75.2 and 62.7 per 100,000 for 1996 and 1997 respectively. Thirty-nine cases (17.3%) were admitted to hospital for a total of 202 bed-days and a 4 year old died with fulminating hepatitis. A probable source of infection was identified for 69% of cases. The common risk categories for infection were: living in or visiting a rural Aboriginal or Torres Strait Islander community, injecting drug use, contact with a known case of hepatitis A, and travel to countries with endemic hepatitis A.     

What matters to users of services? An explorative study to promote shared decision making in health care

Background Involving service users and carers in decisions about their health care is a key feature of health‐care practice. Professional health and social care students need to develop skills and attributes to best enable this to happen. Aims The aims were to explore service user and carer perceptions of behaviours, attributes and context required to enable shared decision making; to compare these perceptions to those of students and academic staff with a view to utilizing the findings to inform the development of student assessment tools. Methods A mixed methods approach was used including action learning groups (ALG) and an iterative process alongside a modified Delphi survey. Participants The ALGs were from an existing service user and carer network. The survey was sent to sixty students, sixty academics and 30 service users from 16 different professional disciplines, spanning four Universities in England. Results The collaborative enquiry process and survey identified general agreement that being open and honest, listening, showing respect, giving time and being up to date were important. The qualitative findings identified that individual interpretation was a key factor. An unexpected result was an insight into possible insecurities of students. Conclusions The findings indicate that distilling rich qualitative information into a format for student assessment tools could be problematic as the individual context could be lost, it is therefore proposed that the information could be better used as a learning rather than assessment tool. Several of those involved identified how they valued the process and found it beneficial.     

Evaluating Uncertainty to Strengthen Epidemiologic Data for Use in Human Health Risk Assessments

Background: There is a recognized need to improve the application of epidemiologic data in human health risk assessment especially for understanding and characterizing risks from environmental and occupational exposures. Although there is uncertainty associated with the results of most epidemiologic studies, techniques exist to characterize uncertainty that can be applied to improve weight-of-evidence evaluations and risk characterization efforts.Methods: This report derives from a Health and Environmental Sciences Institute (HESI) workshop held in Research Triangle Park, North Carolina, to discuss the utility of using epidemiologic data in risk assessments, including the use of advanced analytic methods to address sources of uncertainty. Epidemiologists, toxicologists, and risk assessors from academia, government, and industry convened to discuss uncertainty, exposure assessment, and application of analytic methods to address these challenges.Synthesis: Several recommendations emerged to help improve the utility of epidemiologic data in risk assessment. For example, improved characterization of uncertainty is needed to allow risk assessors to quantitatively assess potential sources of bias. Data are needed to facilitate this quantitative analysis, and interdisciplinary approaches will help ensure that sufficient information is collected for a thorough uncertainty evaluation. Advanced analytic methods and tools such as directed acyclic graphs (DAGs) and Bayesian statistical techniques can provide important insights and support interpretation of epidemiologic data.Conclusions: The discussions and recommendations from this workshop demonstrate that there are practical steps that the scientific community can adopt to strengthen epidemiologic data for decision making.Citation: Burns CJ, Wright JM, Pierson JB, Bateson TF, Burstyn I, Goldstein DA, Klaunig JE, Luben TJ, Mihlan G, Ritter L, Schnatter AR, Symons JM, Yi KD. 2014. Evaluating uncertainty to strengthen epidemiologic data for use in human health risk assessments. Environ Health Perspect 122:1160–1165; http://dx.doi.org/10.1289/ehp.1308062     

罗格列酮单用或者与阿伐他汀联合使用对于2型糖尿病患者心血管疾病的非传统标志物的作用

背景和目的:罗格列酮与阿伐他汀联合疗法已经被证实对于2型糖尿病患者的血糖控制以及脂质水平都有益处。本试验将通过检测罗格列酮与阿伐他汀联合疗法对于2型糖尿病患者的生物标记水平的作用来研究该联合疗法对血管炎的作用。方法:30例患有2型糖尿病和高脂血症的患者被纳入治疗。对这些患者给予罗格列酮单一疗法4mg/d,持续3个月,然后在接下来的3个月中给予这些患者阿伐他汀10mg/d作为联合疗法。在研究开始时,罗格列酮单一疗法之后以及罗格列酮与阿伐他汀联合治疗之后测量炎性生物标记物,包括高敏C-反应蛋白(hs-CRP)、基质金属蛋白酶9(MMP…     

Measurements of contact currents in radiofrequency fields

Radiofrequency electromagnetic fields can affect human health not only by direct interactions but indirectly through induction of charges on isolated or poorly grounded conductive (metallic) objects located in these fields. A person who touches such an object may perceive a tingling or prickling sensation or heat, or experience pain or electric shock. For sufficiently large objects, these phenomena can occur at field strengths that are relatively low and below the health protection limits based on direct interactions. We describe a method and circuitry developed to evaluate steady-state contact currents that may flow through a person touching conductive objects and give a summary of experimental tests performed. The method is simple and viable for field tests aimed at preventing pain, shock, and burn hazards in radiofrequency electromagnetic fields except those related to spark discharges. The method is applicable up to about 30 MHz.