Clinical teaching: Maintaining an educational role for doctors in the new health care environment

Context and objectives: Good clinical teaching is central to medical education but there is concern about maintaining this in contemporary, pressured health care environments. This paper aims to demonstrate that good clinical practice is at the heart of good clinical teaching. Methods: Seven roles are used as a framework for analysing good clinical teaching. The roles are medical expert, communicator, collaborator, manager, advocate, scholar and professional. Results: The analysis of clinical teaching and clinical practice demonstrates that they are closely linked. As experts, clinical teachers are involved in research, information retrieval and sharing of knowledge or teaching. Good communication with trainees, patients and colleagues defines teaching excellence. Clinicians can 'teach' collaboration by acting as role models and by encouraging learners to understand the responsibilities of other health professionals. As managers, clinicians can apply their skills to the effective management of learning resources. Similarly skills as advocates at the individual, community and population level can be passed on in educational encounters. The clinicians' responsibilities as scholars are most readily applied to teaching activities. Clinicians have clear roles in taking scholarly approaches to their practice and demonstrating them to others. Conclusion: Good clinical teaching is concerned with providing role models for good practice, making good practice visible and explaining it to trainees. This is the very basis of clinicians as professionals, the seventh role, and should be the foundation for the further development of clinicians as excellent clinical teachers.

Futility and the law: Knowledge, practice and attitudes of doctors in end of life care

Despite the potential harm to patients (and others) and the financial cost of providing futile treatment at the end of life, this practice occurs. This article reports on empirical research undertaken in Queensland that explores doctors’ perceptions about the law that governs futile treatment at the end of life, and the role it plays in medical practice. The findings reveal that doctors have poor knowledge of their legal obligations and powers when making decisions about withholding or withdrawing futile treatment at the end of life; their attitudes towards the law were largely negative; and the law affected their clinical practice and had or would cause them to provide futile treatment.

What does “futility” mean? An empirical study of doctors’ perceptions

Objective(s) To describe how doctors define and use the terms “futility” and “futile treatment” in end-of-life care. Design, Setting, Participants A qualitative study using semi-structured interviews with 96 doctors across a range of specialties who treat adults at the end of life. Doctors were recruited from three large Australian teaching hospitals and were interviewed from May to July 2013. Results Doctors’ conceptions of futility focused on the quality and chance of patient benefit. Aspects of benefit included physiological effect, weighing benefits and burdens, and quantity and quality of life. Quality and length of life were linked, but many doctors discussed instances when benefit was determined by quality of life alone. Most doctors described the assessment of chance of success in achieving patient benefit as a subjective exercise. Despite a broad conceptual consensus about what futility means, doctors noted variability in how the concept was applied in clinical decision-making. Over half the doctors also identified treatment that is futile but nevertheless justified, such as short-term treatment as part of supporting the family of a dying person. Conclusions There is an overwhelming preference for a qualitative approach to assessing futility, which brings with it variation in clinical decision-making. “Patient benefit” is at the heart of doctors’ definitions of futility. Determining patient benefit requires discussions with patients and families about their values and goals as well as the burdens and benefits of further treatment.

An investigation of contact transmission of methicillin-resistant staphylococcus aureus

Hand hygiene is critical in the healthcare setting and it is believed that methicillin-resistant Staphylococcus aureus (MRSA), for example, is transmitted from patient to patient largely via the hands of health professionals. A study has been carried out at a large teaching hospital to estimate how often the gloves of a healthcare worker are contaminated with MRSA after contact with a colonized patient. The effectiveness of handwashing procedures to decontaminate the health professionals' hands was also investigated, together with how well different healthcare professional groups complied with handwashing procedures. The study showed that about 17% (9–25%) of contacts between a healthcare worker and a MRSA-colonized patient results in transmission of MRSA from a patient to the gloves of a healthcare worker. Different health professional groups have different rates of compliance with infection control procedures. Non-contact staff (cleaners, food services) had the shortest handwashing times. In this study, glove use compliance rates were 75% or above in all healthcare worker groups except doctors whose compliance was only 27%.

General practitioners’ experiences of the psychological aspects in the care of a dying patient

Objective: General practitioners (GPs) play an integral role in addressing the psychological needs of palliative care patients and their families. This qualitative study investigated psychosocial issues faced by GPs in the management of patients receiving palliative care and investigated the themes relevant to the psychosocial care of dying patients. Method: Fifteen general practitioners whose patient had been recently referred to the Mt. Olivet Palliative Home Care Services in Brisbane participated in an individual case review discussions guided by key questions within a semistructured format. These interviews focused on the psychosocial aspects of care and management of the referred patient, including aspects of the doctor/patient relationship, experience of delivering diagnosis and prognosis, addressing the psychological concerns of the patients' family, and the doctors' personal experiences, reactions, and responses. Qualitative analysis was conducted on the transcripts of these interviews. Results: The significant themes that emerged related to perceived barriers to exploration of emotional concerns, including spiritual issues, and the discussion of prognosis and dying, the perception of patients' responses/coping styles, and the GP's personal experience of the care (usually expressed in terms of identification with patient). Significance of results: The findings indicate the significant challenges facing clinicians in discussions with patients and families about death, to exploring the patient's emotional responses to terminal illness and spiritual concerns for the patient and family. These qualitative date indicate important tasks in the training and clinical support for doctors providing palliative care.

Staff perspectives of a cardiology short stay unit

Objective To evaluate staff perceptions about working environment, efficiency and the clinical safety of a cardiovascular intervention short stay unit (SSU) during the first year of operation. Design Postal questionnaire. Setting Cardiac catheterisation laboratory (CCL), coronary care unit (CCU), general cardiology ward (GCW) and the short stay unit (SSU) of a tertiary referral hospital situated in the mid coastal region of NSW. Subjects Cardiologists (including visiting medical officers [VMO]), cardiology fellows, cardiology advanced trainees and nurses. Results Responses on the working environment of the SSU and the discharge process were statistically significant. A substantial proportion of both nurses and doctors had concerns about patient safety, even though no adverse events were formally recorded in the database. Conclusions Though the participants of the survey agree on the efficiency of the SSU in providing beds to the hospital, they disagree on aspects that are important in the functioning of the SSU, including the working environment, patient selection and clinical safety. The results highlight potential issues that could be improved or addressed and are relevant to the rollout of SSUs across NSW.

Getting creative in health care

Health care accounts for a substantial and growing share of national expenditures, and Australia’s health-care system faces some unprecedented pressures. This paper examines the contribution of creative expertise and services to Australian health care. They are found to be making a range of contributions to the development and delivery of health-care goods and services, the initial training and ongoing professionalism of doctors and nurses, and the effective functioning of health-care buildings. Creative activities within health-care services are also undertaken by medical professionals and patients. Key functions that creative activities address are innovation and service delivery in information management and analysis, and making complex information comprehensible or more useful, assisting communication and reducing psycho-social and distance-mediated barriers, and improving the efficiency and effectiveness of services.

Engaging with the promises of education : African refugee students in Australian secondary schools

The research reported in this paper investigated the engagement of students who arrived in Australian secondary schools as refugees from Africa. Enrolment of large cohorts of refugees from Africa is a relatively new phenomenon in the English-speaking West. The literature provides evidence that emotional engagement with the promises of schooling is strong for many of the young African refugees. Students envision successful professional careers as doctors, engineers, lawyers, and IT experts; they envision returning to their country as professionals able to help the people. The question investigated in this paper is: How does schooling in Australia impact on young African refugees’ education and career aspirations? Engagement is understood in Bourdieuian terms as dispositions to be and to become an educated person. This is a disposition which entails fundamental belief in the value of the stakes of schooling. The data analysed in the paper were produced in a study undertaken in the state of Queensland where 5000 of the 39 000 African refugees who have arrived in Australia since 2000 have settled. Semi-structured interviews were conducted with students and their parents and teachers after arrival in an intensive language school, and then after transition to a regular secondary school. The findings show both the durability and malleability of educational dispositions in conditions of dramatic social change occasioned by refugee experience. Engagement in the stakes of schooling is both built and eroded as students flee their homelands for countries of refuge. Previously unimaginable educational dreams are possible for some; but for others, long-held dreams become unattainable. The paper concludes with recommendations for better supporting young people through this re-shaping of self.

Breastfeeding experiences of Japanese women living in Perth, Australia

The aim of this study was to document the breastfeeding practices of Japanese-Australian mothers living in Perth. A cross-sectional survey of mothers who had delivered babies in Japan or Australia or both was carried out on a sample of 163 mothers recruited through Japanese social and cultural groups in Perth and by a 'snowball' technique. Factors involved in the decision to breastfeed were analysed using multivariate regression analysis. The main outcome measures were the initiation and duration of breastfeeding and cultural beliefs about breastfeeding. Breastfeeding initiation rates of the Japanese- Australian mothers in Japan and in Australia were higher than for other Australians and are consistent with breastfeeding rates in Japan. In Australia, 65% of Japanese-Australian mothers were still breastfeeding at six months. The most common reason for the decision to cease breastfeeding was 'insufficient breastmilk'. The significant factors in breastfeeding duration were 'the time the infant was introduced to infant formula', 'the time when the feeding decision was made', 'doctors support breastfeeding' and 'the mother received enough help from hospital staff'; these were positively associated with the duration of breastfeeding. Japanese mothers take a lot of notice of advice given by health professionals about infant feeding practices.

Introduction

The title of this book, Hard Lesson: Reflections on Crime control in Late Modernity, contains a number of clues about its general theoretical direction. It is a book concerned, fist and foremost, with the vagaries of crime control in western neo-liberal and English speaking countries. More specifically, Hard Lessons draws attention to a number of examples in which discrete populations – those who have in one way or another offended against the criminal law - have become the subjects of various forms of stare intervention, regulation and control. We are concerned most of all with the ways in which recent criminal justice policies and practices have resulted in what are variously described as unintended consequences, unforeseen outcomes, unanticipated results, counter-productive effects or negative side effects. At their simplest, such terms refer to the apparent gulf between intention and outcome; they often form the basis for considerable amount of policy reappraisal, soul searching and even nihilistic despair among the mamandirns of crime control. Unintended consequences can, of course, be both positive and negative. Occasionally, crime control measures may result in beneficial outcomes, such as the use of DNA to acquit wrongly convicted prisoners. Generally, however, unforeseen effects tend to be negative and even entirely counterproductive, and/or directly opposite to what were originally intended. All this, of course, presupposes some sort of rational, well meaning and transparent policy making process so beloved by liberal social policy theorists. Yet, as Judith Bessant points out in her chapter, this view of policy formulation tends to obscure the often covert, regulatory and downright malevolent intentions contained in many government policies and practices. Indeed, history is replete with examples of governments seeking to mask their real aims from a prying public eye. Denials and various sorts of ‘techniques of neutralisation’ serve to cloak the real or ‘underlying’ aims of the powerful (Cohen 2000). The latest crop of ‘spin doctors’ and ‘official spokespersons’ has ensured that the process of governmental obfuscation, distortion and concealment remains deeply embedded in neo-liberal forms of governance. There is little new or surprising in this; nor should we be shocked when things ‘go wrong’ in the domain of crime control since many unintended consequences are, more often than not, quite predictable. Prison riots, high rates of recidivism and breaches of supervision orders, expansion rather than contraction of control systems, laws that create the opposite of what was intended – all these are normative features of western crime control. Indeed, without the deep fault lines running between policy and outcome it would be hard to imagine what many policy makers, administrators and practitioners would do: their day to day work practices and (and incomes) are directly dependent upon emergent ‘service delivery’ problems. Despite recurrent howls of official anguish and occasional despondency it is apparent that those involved in the propping up the apparatus of crime control have a vested interest in ensuring that polices and practices remain in an enduring state of review and reform.

Romance and Reconciliation : The secret life of indigenous sexuality on Australian television drama

This article examines the representation of Indigenous sexuality on Australian television drama since the 1970s, suggesting the political importance of such representations. In 1976 Justine Saunders became the first regular Indigenous character on an Australian television drama series, as the hairdresser Rhonda Jackson in Number 96. She was presented as sexually attractive, but this was expressed through a rape scene after a party. Twenty five years later, Deborah Mailman starred in The Secret Life of Us, as Kelly, who is also presented as sexually attractive. But her character can be seen in many romantic relationships. The article explores changing representations that moved us from Number 96 to The Secret Life of Us, via The Flying Doctors and Heartland. It suggests that in representations of intimate and loving relationships on screen it has only recently become possible to see hopeful models for interaction between Indigenous and non-Indigenous Australians.

Teaching cause-of-death certification : lessons from international experience

The accuracy of cause-of-death statistics substantially depends on the quality of cause-of-death information in death certificates, primarily completed by medical doctors. Deficiencies in cause-of-death certification have been observed across the world, and over time. Despite educational interventions targeting to improve the quality of death certification, their intended impacts are rarely evaluated. This review aims to provide empirical evidence that could guide the modification of existing educational programs, or the development of new interventions, which are necessary to improve the capacity of certifiers as well as the quality of cause-of-death certification, and thereby, the quality of mortality statistics.

Determinants of health costs due to farmers’ exposure to pesticides : an empirical analysis

It is now well known that pesticide spraying by farmers has an adverse impact on their health. This is especially so in developing countries where pesticide spraying is undertaken manually. The estimated health costs are large. Studies to date have examined farmers’ exposure to pesticides, the costs of ill-health and their determinants based on information provided by farmers. Hence, some doubt has been cast on the reliability of such studies. In this study, we rectify this situation by conducting surveys among two groups of farmers. Farmers who perceive that their ill-health is due to exposure to pesticides and obtained treatment and farmers whose ill-health have been diagnosed by doctors and who have been treated in hospital for exposure to pesticides. In the paper, cost comparisons between the two groups of farmers are made. Furthermore, regression analysis of the determinants of health costs show that the quantity of pesticides used per acre per month, frequency of pesticide use and number of pesticides used per hour per day are the most important determinants of medical costs for both samples. The results have important policy implications.

Where have all the workers gone? Exploring public sector workforce planning

Governments undertake extensive planning of many services and functions, but tend to neglect planning of public service workforces. Disruptions to public service delivery, such as shortages of nurses and doctors, have rejuvenated interest in workforce planning, but many organisations struggle to do it effectively. This historical study examines the capacity of central personnel agencies to predict workforce risks and support workforce planning, using a study of the Queensland public service. It identifies lack of workforce data as a barrier to effective workforce planning, as a result of factors such as changes in the direction of the central personnel agency, lack of appreciation for the value of comprehensive central workforce data, and limited agency human resource (HR) skills or capacity.

Interaction and mediation in preadmission clinics : implications for the design of a telehealth stethoscope

A telehealth stethoscope would make it possible for doctors to perform physical examinations on patients at great distances. In order to develop a useful and usable telehealth stethoscope we have conducted fieldwork observations of existing anaesthetic preadmission clinics to understand how stethoscopes are currently used. Both face-to-face consultations and videoconference consultations have been studied. Our results indicate that the stethoscope plays a minor role in the consultation and that consultations are mediated by the administrative work that is the reason for the consultation. We suggest that a stethoscope plays an infrastructural role in the consultation. The implications of considering stethoscopes as infrastructure are explored and considered in the context of a future telehealth stethoscope.