Rapid Implementation of a Novel Embedded Senior Medical Student Program, as a Response to the Educational Challenges of COVID-19

As with many OECD countries, graduating medical students have been choosing specialist careers at a greater rate than ever before. Generalism in the form of family (general practice) and more generalist medical specialties have been trending down resulting in distributional geographic challenges. With the advent of COVID-19 in March 2020, medical schools and in particular the Joint Medical Program situated in a regional and rural area in NSW Australia had the unique opportunity to rethink the penultimate year curriculum when the previous rapid rotation model through numerous medical specialities became untenable. The need to vision a new practical pragmatic curriculum spurred a rapid revaluation of assessment, placement length and model with a pivot to an “embedded senior student placement” agnostic of discipline and supported by a competency-based learning portfolio. This article explores the barriers and enablers and identifies the potential elements of this type of placement which can be adapted to community and smaller rural sites. The positive student and supervisor experience also enabled an employment model to be woven into the students learning and ensured on hand medical student workforce for hospitals throughout the rural footprint. The capacity of these placements to celebrate variation in experience and support students to learn on the job have now caused a revision of the penultimate year with expectation of gains in students’ satisfaction and in employability. It has also opened up options to deliver and increase the inherent value of generalist placements with likely long term workforce benefit.

Insights into the complexity of presentation and management of patients: the Sport and Exercise Physician’s perspective

ObjectivesSport and Exercise Physicians represent a relatively new specialty focusing on exercise in complex diseases including musculoskeletal diseases. Our objective was to describe the characteristics, type and complexity of patient presentations, their management strategies and referral information in Australian practice.MethodsA cross-sectional study including a cohort of 11 senior Sport and Exercise Physicians in Australia studied all new patient consultations within an 8-week period. Data were analysed relating to presentation, referral source, follow-up referrals, and patient management strategies.ResultsData from 419 patients were recorded. The majority, 97% (n=406), had musculoskeletal conditions, 53% (n=222) had one or more associated comorbidities and 47% (n=195) had ongoing symptoms for >12 months. Most patients, 82% (n=355), were referred by general practitioners. Prior consultations included physiotherapy 72% (n=301) and orthopaedic 20% (n=85). A multidisciplinary network of referrals from Sport and Exercise Physicians was observed, including 210 referrals to 9 allied health specialities and 61 referrals to 17 medical specialities. Over 74% (n=311) of patients received exercise-based intervention as part of the treatment plan, including 57% (n=240) physician managed exercise interventions.ConclusionOur work shines a light on the nature and complexity of the role of Sport and Exercise Physicians in an Australian practice context. Findings will assist in implementing measures to promote patient care at the community level in managing musculoskeletal conditions. Sport and exercise medicine stakeholders and government policy makers can use this information in developing appropriate programmes to support patients and create integrated sport and exercise medicine services for the community.

Integrated patient network and genomic plasmid analysis reveal a regional, multi-species outbreak of carbapenemase-producing Enterobacterales carrying both blaIMP and mcr-9 genes

The incidence of carbapenemase-producing Enterobacterales (CPE) is rising globally, yet Imipenemase (IMP) carbapenemases remain relatively rare. This study describes an investigation of the emergence of IMP-encoding CPE amongst diverse Enterobacterales species between 2016 and 2019 in patients across a London regional hospital network. A network analysis approach to patient pathways, using routinely collected electronic health records, identified previously unrecognised contacts between patients who were IMP CPE positive on screening, implying potential bacterial transmission events. Whole genome sequencing of 85 Enterobacterales isolates from these patients revealed that 86% (73/85) were diverse species (predominantly Klebsiella spp, Enterobacter spp, E. coli) and harboured an IncHI2 plasmid, which carried both blaIMP and the putative mobile colistin resistance gene mcr-9. Detailed phylogenetic analysis identified two distinct IncHI2 plasmid lineages, A and B, both of which showed significant association with patient movements between four hospital sites and across medical specialities. Combined, our patient network and plasmid analyses demonstrate an interspecies, plasmid-mediated outbreak of blaIMPCPE, which remained unidentified during standard microbiology and infection control investigations. With whole genome sequencing (WGS) technologies and large-data incorporation, the outbreak investigation approach proposed here provides a framework for real-time identification of key factors causing pathogen spread. Analysing outbreaks at the plasmid level reveals that resistance may be wider spread than suspected, allowing more targetted interventions to stop the transmission of resistance within hospital networks.

Indian psychiatrists in the Australian workforce – From brain drain to brain exchange

Worldwide doctors have been migrating from low- and middle-income countries to high-income countries for decades. This contributes to dearth of doctors, especially psychiatrists, in low- and middle-income countries – often referred to as ‘brain drain’. Australia has a fair share of psychiatrists of Indian origin in its workforce. This article endeavours to re-formulate the migration phenomenon as ‘brain exchange’ through the experiential insight of the authors along with published literature and discusses the contribution of substantial number of psychiatrists of Indian origin to the Australian society. Furthermore, the article highlights the potential for the Royal Australian and New Zealand College of Psychiatrists to be a leader in this area by facilitating globally responsible practice by giving back to countries from which psychiatrists originate. The key observations and recommendations are transferrable to other similar countries and equally to other medical specialities.

A critical review on altmetrics: can we measure the social impact factor?

Altmetrics measure the digital attention received by a research output. They allow us to gauge the immediate social impact of an article by taking real-time measurements of how it circulates in the Internet. While there are several companies offering attention scores, the most extensive are Altmetric.com (Altmetric Attention Score—AAS) and Plum X (Plum Print). As this is an emerging topic, many medical specialities have tried to establish if there is a relationship between an article’s altmetric data and the citations it subsequently receives. The results have varied depending on the research field. In radiology, the social network most used is Twitter and the subspeciality with the highest AAS is neuroimaging. This article will review the process involved from the start when an article is published through to finally obtaining its altmetric score. It will also address the relationship between altmetrics and more traditional approaches focusing on citations in radiology and will discuss the advantages and limitations of these new impact indicators.

Utrametric diffusion equation on energy landscape to model disease spread in hierarchic socially clustered population

We present a new mathematical model of disease spread reflecting some specialities of the covid-19 epidemic by elevating the role of hierarchic social clustering of population. The model can be used to explain slower approaching herd immunity, e.g., in Sweden, than it was predicted by a variety of other mathematical models and was expected by epidemiologists; see graphs Fig. \ref{fig:minipage1},\ref{fig:minipage2}. The hierarchic structure of social clusters is mathematically modeled with ultrametric spaces having treelike geometry. To simplify mathematics, we consider trees with the constant number $p>1$ of branches leaving each vertex. Such trees are endowed with an algebraic structure, these are $p$-adic number fields. We apply theory of the $p$-adic diffusion equation to describe a virus spread in hierarchically clustered population. This equation has applications to statistical physics and microbiology for modeling {\it dynamics on energy landscapes.} To move from one social cluster (valley) to another, a virus (its carrier) should cross a social barrier between them. The magnitude of a barrier depends on the number of social hierarchy's levels composing this barrier. We consider {\it linearly increasing barriers.} A virus spreads rather easily inside a social cluster (say working collective), but jumps to other clusters are constrained by social barriers. This behavior matches with the covid-19 epidemic, with its cluster spreading structure. Our model differs crucially from the standard mathematical models of spread of disease, such as the SIR-model; in particular, by notion of the probability to be infected (at time $t$ in a social cluster $C).$ We present socio-medical specialities of the covid-19 epidemic supporting our model.

Resident-as-teacher to provide multidisciplinary online medical education on Instagram

Implication Statement Instagram is an easy-to-use smartphone-based program and an increasingly popular platform for medical education. A total of 17 weekly structured resident-led education sessions that cover 15 different medical specialities were hosted on an Instagram account (@medskldotcom) to publish clinical “pearls” – short pieces of free standing, evidence-based, clinically relevant information designed specifically for medical students. With the cancellations of out-of-province clerkship electives during COVID-19 pandemic, the number of resident-led Instagram accounts to promote residency programs have increased. Our initiative can be easily adapted by residents or even clinicians to provide medical education to medical students, showcase residents, and attract followers on Instagram.

Hyperprolactinaemia: audit of practice and new guidance

AimsHyperprolactinaemia is a problem secondary to antipsychotic use. Current management guidelines are heterogeneous and impractical. We aimed to assess coherence to common themes monitoring and intervention, reasons for failure, and to design new guidance for both general use Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) and beyond.We hypothesised that performance would be poor and new guidance warranted.BackgroundHyperprolactinaemia is defined as blood prolactin of >530 miu/L in females and >424 miu/L in males, with 49.9% is due to medication. Several agents are deemed higher risk Symptom profiles and risk are idiosyncratic and there are adverse long-term outcomes. Treatment is based on symptom profile and severity and cause. Current guidance is trust specific or advised through The Maudlsey Prescribing Guidelines.Comprehensive and practical guidance reflecting front-line limitations is lacking. There is no clear delineation of a risk stratified pathway.MethodWe wished to ascertain data on surveillance, aetiology and signpost opportunities for service improvement. We also designed ‘risk strata’ to guide intervention.A random sample (n30) was selected from Enfield South Locality Team and data captured using local records. No ethical considerations were raised.A number of audit standards (95%) were developed based on previous guidance and agreed within the team and included frequency of monitoring, time to review and need for further referral.New guidance was developed based on results, MDT agreement and consultation with medical specialities.ResultData (n 30) showed predominant male bias to sample (66%) and average age of 48.87 yrs. Predominant diagnoses were Paranoid Schizophrenia (53.33%) and Schizoaffective disorder (33.33%.) Only 7/30 (23.33%) had undergone testing within the last year.Of those sampled, 2 (6.667%) had a new diagnoses of Hyperprolactinaemia, one on routine monitoring, one incidentally on admission to hospital. Both were on high risk agents. Both were reviewed and treated within one month. No audit standards were met, but no further referrals were required.Reasons for failure varied, but included loss to follow-up, no test requested or appointments missed.ConclusionBased on these data it was noted that monitoring was poor and reasons for failure varied. New Guidance was developed in response. The scope and validity of this guidance was agreed by MDT and awaits formal ratification.Re-audit will occur in 2020, and if successful the guidance submitted to other Trusts and RCPSYCH for national use.No financial interests to declare.

The perception of behaviour associated with dementia in the acute hospital

AimsGeneral hospital based Health Care Professionals (HCPs) use very varied language to describe behaviour in dementia. Lessons from medicine and other professions tell us that non-uniform communication is a source of error and subsequent poor decision making. Knowing how HCPs communicate behaviour in dementia in a hospital setting may help better understand these potential sources of communication error and identify training needs.BackgroundAround 25% of hospital beds occupied with people living with dementia. Hospitalised patients with dementia have a high prevalence of distressing symptoms (pain 70%, delirium 66%, depression 35%, anxiety 34%, hallucinations 14% delusions 11%). These symptoms often displayed as behaviour can be challenging for HCPs to interpret. Variations in communicating behaviour may lead to inconsistent understanding of the need, with the potential for missing treatable conditions that drive the behaviour. Standardizing communication and documentation have the potential to improve the quality of information handed over between HCPs which may improve the quality of care and patient outcomes.MethodQualitative methodology including photo elicitation was used. A purposive sample of 59 HCPs was selected. This was identified from a range of professional backgrounds, experience levels and medical specialities. They were presented with a photograph and case vignettes depicting 4 behaviours associated with distress (aggression, depression, delirium and psychosis). HCPs were asked to respond to the scenarios as if they were handing over to colleagues or documenting in the medical record. Data were analysed by thematic analysis.Result59 HCPs were interviewed with photo-elicitation. Participants recorded their responses in limited time to reflect time constraints in a busy ward environment. 2 HCPs declined to participate in research.When describing behaviour associated with aggression and depression HCPs were consistent with the language used (49/57). When presented with a delirium less consistency was observed (31/47). While describing psychosis each HCP chose either paranoia or suspiciousness among other descriptions.ConclusionOverall there has been consistency in describing the distress experienced by the patient even though HCPs came from very different roles and specialities. Doctors, Nurses, CSWs and dieticians all described the behaviour alike. Newer staff were more accurate which could be due to dementia training within National Dementia Action Alliance.

Service user experience of remote consultations during COVID-19 in an older adult community mental health setting

AimsThe COVID-19 pandemic has had a significant effect on our ability to communicate face-to-face with patients freely. Similar to other medical specialities and general practice (1), to continue providing a service for our service users, we employed other means of communication including telephone and video consultations (although face-to-face consultations were available for high clinical concern and/or identified risk). We set out to explore the acceptability of remote consultation for service users of an older adult (>65 years) Community Mental Health Team (CMHT).Reference: BMJ 2020;371:m3945MethodA total of 34 service users were selected randomly from the CMHT caseload (9% of total 372 caseload). 4 clinicians were involved in collecting data between July and October 2020. We used our trust's (East London Foundation Trust) standard questionnaire on patient satisfaction and contacted individuals by telephone to complete the survey.ResultFor both questions of ‘I felt listened to by the team’ and ‘I feel I have been given enough information regarding my care’ 17 (50%) responders ‘agreed’ with this statement and an additional 13 (38%) ‘strongly agreed’ (total of 88%). For the statement ‘I feel involved in decisions about my care’ 16 (47%) responders ‘agreed’ and a further 11 (32%) responders ‘strongly agreed’ with this statement. The statement ‘The professionals involved in my care talk to each other and we all work as a team’ had 15 (44%) responders ‘agree’ and 13 (38%) responders ‘strongly agree’. When asked ‘If you experienced telephone/video sessions, were these helpful?’ 31 responders said ‘yes’.ConclusionOverall most responders agreed or strongly agreed that they felt listened to, were given enough information about their care, felt involved in decisions about their care and that they worked as a team with the professionals involved in their care. 91% of responders felt that the video/telephone sessions had been helpful. These data have provided reassurance that telemedicine methods were a useful substitute for face-to-face consultations during the early stages of the pandemic. However this was a small scale study. This study cannot tell us about the experience after the initial 6 months of the pandemic, how often it would be optimal for people have face to face reviews, or whether satisfaction with telemedicine altered over a longer period. We were also not able to tell whether the experience varied for those who had less robust and longstanding relationships with their clinicians.