Facilitating best practice : transferring the lessons of the Clinical Support Systems program

The Clinical Support Systems Program (CSSP) includes the management of clinical practice using clinical and consumer pathways, outcome and performance indicators, clinical measurement and review in a continuous improvement cycle using the best available extant evidence. The Royal Australasian College of Physicians is testing the CSSP model through four consortia around Australia. There are 17 project sites in three States. The funded projects address major clinical problems including congestive heart failure and acute coronary syndromes, acute stroke management, and colorectal cancer care. There is some early evidence of the CSSP influencing change in areas beyond the bounds of the project settings and the College has developed a plan to promote wider adoption of best practice. This approach recognises the College’s role in providing Fellows with the practical tools of quality improvement, the means to collect data and compare their practice to other clinicians, while traversing the appropriate educational framework.

General practice : contribution to health and equity

The evidence that a primary health approach enhances health outcomes, increases system effectiveness and is cost effective gives a new impetus for general practice within the continuum of health services. At the same time, in Australia the establishment of the Divisions of General Practice and their continued support has led to a new found confidence in general practice.

Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice

While diagnosis has traditionally been viewed as an essential concept in medicine, particularly when selecting treatments, we suggest that the use of diagnosis alone may be limited, particularly within mental health. The concept of clinical case formulation advocates for collaboratively working with patients to identify idiosyncratic aspects of their presentation and select interventions on this basis. Identifying individualized contributing factors, and how these could influence the person's presentation, in addition to attending to personal strengths, may allow the clinician a deeper understanding of a patient, result in a more personalized treatment approach, and potentially provide a better clinical outcome.

Facilitating students' reflective practice in a medical course: literature review

Introduction:
Reflection and reflective practice is of increasing importance in medical education curricula. The aim of this review is to summarise the literature published around facilitating refection in a medical course, and to answer the question: What is the current evidence regarding learning and development moments across the medical curriculum in developing students' reflective practice?

Methods:
A review of the literature was undertaken using defined databases and the search terms 'medical students', 'medical education', 'reflection', 'reflect*' and 'medicine'. The search was limited to peer-reviewed published material in English and between the years 2001 and 2011, and included research, reviews and opinion pieces. Results: Thirty-six relevant articles were found, identifying enhancing factors and barriers to effectively teaching reflective practice within medical curricula, relating to: The breadth of the meaning of reflection; facilitating reflection by medical educators; using written or web-based portfolios to facilitate reflection; and assessing the reflective work of students.

Discussion:
A variety of reflective purposes was found in this literature review. Evidence indicates that, if students are unclear as to the purpose of reflection and do not see educators modelling reflective behaviours, they are likely to undervalue this important skill regardless of the associated learning and development opportunities embedded in the curriculum.

Are individuals more accepting of the internet than mobile phone apps being used in clinical practice?

Background: New technology such as the internet and mobile phone applications (“apps”) are increasingly being used in clinical practice. However, little is known in regards to individual’s attitudes towards medical professionals using the internet and apps in the context of their own medical care. The aim of the present study was to examine and compare individual’s attitudes towards the use of medically related internet sites and apps in clinical practice. 

Healthcare professionals’ use of mobile phones and the internet in clinical practice

Background: Over the last few years mobile phone applications have been designed for healthcare professionals. However, little is known in regards to healthcare professionals’ use of and attitudes towards using smartphones (and applications) within clinical practice. Thus the aims of the present study were to enumerate the number of healthcare professionals that use mobile phones within clinical practice and their attitudes towards using them. Furthermore, given that the internet preceded smartphones, we also established healthcare professionals’ attitudes towards internet use in clinical practice as a comparison.

Method: Forty-three healthcare professionals from a range of disciplines and specialities who were predominantly working in Australia completed an anonymous online survey. 

Enriching interdisciplinary connections : student engagement in theory and practice in higher education programs in Australia and the UK

This paper provides insight into how postgraduate students in two pre-service disciplines, namely medicine and education, identify and make meaning of their circumstances in the globalised era of tertiary education.
Drawing on elements of Giddens’ theory of structuration, we discuss some of the tensions students have reported encountering in an era which is characterised by greater internationalisation of the student body and more globalised curricula.

Using patients' experiences of adverse events to improve health service delivery and practice: protocol of a data linkage study of Australian adults age 45 and above

Evidence of patients' experiences is fundamental to creating effective health policy and service responses, yet is missing from our knowledge of adverse events. This protocol describes explorative research redressing this significant deficit; investigating the experiences of a large cohort of recently hospitalised patients aged 45 years and above in hospitals in New South Wales (NSW), Australia.

Evidence-based psychiatric practice: doctrine or trap?

Medical practice has rapidly shifted towards an 'evidence-based' approach. While there are acknowledged clear benefits to this, a number of pitfalls are frequently not appreciated. Perhaps the most important limitation is the extent to which the current body of data is inadequate for many common clinical decisions. Algorithms risk being developed, frequently by third parties, without acknowledgement of these limitations and with substantial implications for clinical independence and the quality of patient care. This paper discusses potential problems of the evidence-based approach and suggests possible guidelines for the management of clinical decisions given the limitations of data-based guidelines.

Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital

Objective: The present study aimed to describe the characteristics and outcomes of intubation occurring in the ICU and ED of an Australian tertiary teaching hospital. Methods: This was a prospective observational study of intubation practice across the Geelong Hospital over a 6 month period from 1 August 2012 to 31 January 2013. Data were entered by the intubating team through an online data collection form. Results: There were 119 patients intubated and 134 attempts at intubation in the ED and ICU over a 6 month period. The first-pass success rate was 104/119 (87.4%), and all but a single patient was intubated by the second attempt. Propofol, fentanyl, midazolam and suxamethonium were the most common drugs used in rapid sequence induction. AEs were reported in 44/134 (32.8%) of intubation attempts, with transient hypoxia and hypotension being the most common. A significant adverse outcome, namely aspiration pneumonitis, occurred in one patient. There were no peri-intubation deaths. Conclusion: The majority of airways are managed by ICU and ED consultants and trainees, with success rates and AE rates comparable with other published studies. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

A longitudinal analysis of self-prescribed complementary and alternative medicine use by a nationally representative sample of 19,783 Australian women, 2006-2010

BACKGROUND: Complementary and alternative medicine (CAM) use is increasingly popular amongst general populations around the world with women constituting substantial CAM users. However, self-prescribed CAM use does raise potential safety concerns and so it is important to identify those risk factors associated with self-prescribed CAM use. METHODS: Data was obtained from the Australian Longitudinal Study on Women's Health (ALSWH). Longitudinal data analyses were conducted on questionnaire data from the 1973-78 cohort (n=9,145) and the 1946-51 cohort (n=10,638), collected over the period 2006-2010. RESULTS: In the 1973-78 cohort, use of self-prescribed CAM was 73.2% in 2006 and 75.3% in 2009. For the 1946-51 cohort, use of self-prescribed CAM was 73.9% in 2007 and 74.7% in 2010. There were similar levels of use of individual self-prescribed CAM, with the exception that the use of herbal medicine was much higher among the 1946-51 cohort (20% vs. 27%). There was a substantial increase over three years in the use of vitamins/minerals in both cohorts (21% and 19%, respectively). In contrast, there was a considerable decline over three years in use of aromatherapy oils in both cohorts (34% and 28%, respectively). CONCLUSION: Self-prescribed CAM use is popular amongst women in Australia and it is important that conventional practitioners providing women's health care be cognizant of such use amongst their patients. In order to ensure effective practice, there is a need for further research to explore women's decision-making and experiences around self-prescribed CAM use.

"Cancer 2015": a prospective, population-based cancer cohort-phase 1: feasibility of genomics-guided precision medicine in the clinic

"Cancer 2015" is a longitudinal and prospective cohort. It is a phased study whose aim was to pilot recruiting 1000 patients during phase 1 to establish the feasibility of providing a population-based genomics cohort. Newly diagnosed adult patients with solid cancers, with residual tumour material for molecular genomics testing, were recruited into the cohort for the collection of a dataset containing clinical, molecular pathology, health resource use and outcomes data. 1685 patients have been recruited over almost 3 years from five hospitals. Thirty-two percent are aged between 61-70 years old, with a median age of 63 years. Diagnostic tumour samples were obtained for 90% of these patients for multiple parallel sequencing. Patients identified with somatic mutations of potentially "actionable" variants represented almost 10% of those tumours sequenced, while 42% of the cohort had no mutations identified. These genomic data were annotated with information such as cancer site, stage, morphology, treatment and patient outcomes and health resource use and cost. This cohort has delivered its main objective of establishing an upscalable genomics cohort within a clinical setting and in phase 2 aims to develop a protocol for how genomics testing can be used in real-time clinical decision-making, providing evidence on the value of precision medicine to clinical practice.

The construction of power in family medicine bedside teaching: a video observation study

INTRODUCTION: Bedside teaching is essential for helping students develop skills, reasoning and professionalism, and involves the learning triad of student, patient and clinical teacher. Although current rhetoric espouses the sharing of power, the medical workplace is imbued with power asymmetries. Power is context-specific and although previous research has explored some elements of the enactment and resistance of power within bedside teaching, this exploration has been conducted within hospital rather than general practice settings. Furthermore, previous research has employed audio-recorded rather than video-recorded observation and has therefore focused on language and para-language at the expense of non-verbal communication and human-material interaction. METHODS: A qualitative design was adopted employing video- and audio-recorded observations of seven bedside teaching encounters (BTEs), followed by short individual interviews with students, patients and clinical teachers. Thematic and discourse analyses of BTEs were conducted. RESULTS: Power is constructed by students, patients and clinical teachers throughout different BTE activities through the use of linguistic, para-linguistic and non-verbal communication. In terms of language, participants construct power through the use of questions, orders, advice, pronouns and medical/health belief talk. With reference to para-language, participants construct power through the use of interruption and laughter. In terms of non-verbal communication, participants construct power through physical positioning and the possession or control of medical materials such as the stethoscope. CONCLUSIONS: Using this paper as a trigger for discussion, we encourage students and clinical teachers to reflect critically on how their verbal and non-verbal communication constructs power in bedside teaching. Students and clinical teachers need to develop their awareness of what power is, how it can be constructed and shared, and what it means for the student-patient-doctor relationship within bedside teaching.

Promoting clinical reasoning in general practice trainees: role of the clinical teacher

BACKGROUND: Clinical reasoning requires knowledge, cognition and metacognition, and is contextually bound. Clinical teachers can and should play a key role in explicitly promoting clinical reasoning.

CONTEXT: The aim of this article is to relate the clinical reasoning literature to the general practice or family medicine context, and to provide clinical teachers with strategies to promote clinical reasoning.

INNOVATION: It is important that the clinical teacher teaches trainees the specific skills sets of the expert general practitioner (e.g. synthesising skills, recognising prototypes, focusing on cues and clues, using community resources and dealing with uncertainty) in order to promote clinical reasoning in the context of general practice or family medicine. Clinical teachers need to understand their own reasoning processes as well as be able to convey that knowledge to their trainees. They also need to understand the developmental stages of clinical reasoning and be able to nurture each trainee's own expertise. Strategies for facilitating effective clinical reasoning in trainees include adequate exposure to patients, offering the trainees opportunity for reflection and feedback, and coaching on the techniques of reasoning in the general practice context.

IMPLICATIONS: The journey to expertise in clinical reasoning is unique to each clinician, with different skills developing at different rates, depending on content, context and past experience. Doctors enter into general practice training with the building blocks of biomedical and clinical knowledge and a desire to learn how to be a general practitioner. Clinical teachers are integral in the process of helping trainees learn how to 'think like a general practitioner'.