A new breed of doctor? Lessons learned and changes made to library services for the MBBS program at the University of Queensland

November 2000 saw the graduation of the first cohort from the new MBBS Program at The University of Queensland. The fully integrated problem-based curriculum has provided many challenges and opportunities for The University of Queensland Library such as servicing an extensive remote student population, information technology issues and customer demand. In October 2000 all four years of the MBBS Program completed a survey on related issues such as the library's collection, web-based resources, information skills and evidence-based medicine. This paper focuses on the results of the survey, and the future directions of the library to ensure that the new doctors graduating from this program gain the essential attributes of life-long learning, information management and evidence-based principles.

Comparison of ASAS improvement criteria for ankylosing spondylitis with clinically relevant improvement according to an expert panel

Objective: To investigate whether the recently developed (statistically derived) "ASsessment in Ankylosing Spondylitis Working Group" improvement criteria (ASAS-IC) for ankylosing spondylitis (AS) reflect clinically relevant improvement according to the opinion of an expert panel. Methods: The ASAS-IC consist of four domains: physical function, spinal pain, patient global assessment, and inflammation. Scores on these four domains of 55 patients with AS, who had participated in a non-steroidal anti-inflammatory drug efficacy trial, were presented to an international expert panel (consisting of patients with AS and members of the ASAS Working Group) in a three round Delphi exercise. The number of (non-) responders according to the ASAS-IC was compared with the final-consensus of the experts. The most important domains in the opinion of the experts were identified, and also selected with discriminant analysis. A number of provisional criteria sets that best represented the consensus of the experts were defined. Using other datasets, these clinically derived criteria sets as well as the statistically derived ASAS-IC were then tested for discriminative properties and for agreement with the end of trial efficacy by patient and doctor. Results: Forty experts completed the three Delphi rounds. The experts considered twice as many patients to be responders than the ASAS-IC (42 v 21). Overall agreement between experts and ASAS-IC was 62%. Spinal pain was considered the most important domain by most experts and was also selected as such by discriminant analysis. Provisional criteria sets with an agreement of greater than or equal to 80% compared with the consensus of the experts showed high placebo response rates (27-42%), in contrast with the ASAS-IC with a predefined placebo response rate of 25%. All criteria sets and the ASAS-IC discriminated well between active and placebo treatment (chi(2) = 36-45; p < 0.001). Compared with the end of trial efficacy assessment, the provisional criteria sets showed an agreement of 71-82%, sensitivity of 67-83%, and specificity of 81-88%. The ASAS-IC showed an agreement of 70%, sensitivity of 62%, and specificity of 89%. Conclusion: The ASAS-IC are strict in defining response, are highly specific, and consequently show lower sensitivity than the clinically derived criteria sets. However, those patients who are considered as responders by applying the ASAS-IC are acknowledged as such by the expert panel as well as by. patients' and doctors' judgments, and are therefore likely to be true responders.

Embodied expertise: women's perceptions of the contraception consultation

This research, based on qualitative interviews and non-participant observation, emerges from a larger study investigating what factors influence the ‘contraceptive careers’ of British women in their 30s. The women informants recognized that contraceptive products often impacted on their health, but viewed them as distinct from ‘medical matters’. Rather than doctors being seen as having expertise, it was women health professionals, be they nurses, midwives, health visitors or doctors, who were perceived as the ones who ‘know’ about contraception, through an assumption that they are contraception users.This embodied knowledge is valued by the women above their formal medical training. I will also show how general practice surgeries and family planning clinics were viewed as gendered spaces, which altered the expectations and experiences of the women during contraceptive consultations. This study found that as ‘real’ expertise over contraception stems from embodied rather than textual knowledge, the women’s choices were grounded by a gendered sense of trust.

An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital

Aims: To determine the incidence of unintended medication discrepancies in paediatric patients at the time of hospital admission; evaluate the process of medicines reconciliation; assess the benefit of medicines reconciliation in preventing clinical harm. Method: A 5 month prospective multisite study. Pharmacists at four English hospitals conducted admission medicines reconciliation in children using a standardised data collection form. A discrepancy was defined as a difference between the patient's preadmission medication (PAM), compared with the initial admission medication orders written by the hospital doctor. The discrepancies were classified into intentional and unintentional discrepancies. The unintentional discrepancies were assessed for potential clinical harm by a team of healthcare professionals, which included doctors, pharmacists and nurses. Results: Medicines reconciliation was conducted in 244 children admitted to hospital. 45% (109/244) of the children had at least one unintentional medication discrepancy between the PAM and admission medication order. The overall results indicated that 32% (78/244) of patients had at least one clinically significant unintentional medication discrepancy with potential to cause moderate 20% (50/244) or severe 11% (28/244) harm. No single source of information provided all the relevant details of a patient's medication history. Parents/carers provided the most accurate details of a patient's medication history in 81% of cases. Conclusions: This study demonstrates that in the absence of medicines reconciliation, children admitted to hospitals across England are at risk of harm from unintended medication discrepancies at the transition of care from the community to hospital. No single source of information provided a reliable medication history.

Patients and doctors working together in partnership:Birch v UCL Hospital NHS Foundation Trust [2008] EWHC 2237 (QB)

Of the myriad of pressing topics current in medical law and ethics, the issue of informed consent appears to be the ‘plainer sibling’. The decision by Cranston J in Birch v UCL Hospital NHS Foundation Trust in 2008 has brought into sharp relief that which many commentators already held to be true. Far from being the ‘plainer sibling’ when weighed against other prominent issues in medical law and ethics, the doctrine of informed consent, is one of the most significant principles to emerge in recent years.

Images of pharmacy as a career: a survey among groups of year 12 students at school

To explore the images and perceptions of pharmacy with potential applicants to undergraduate pharmacy education. There is currently considerable interest in the UK in studying aspects of the pharmacy profession because of the changing pharmacy agenda and the need to understand the workforce and its motivations. Aim: To explore the images and perceptions of pharmacy with potential applicants to undergraduate pharmacy education. Design: Four interactive focus groups involving 40 volunteer year 12 students (age 17). The focus group theme plan was designed after a review of relevant literature. A novel approach was employed using photographic images of pharmacists and doctors in varied settings. Subjects and setting: The research was carried out in six schools in the West Midlands, UK. Results: The students presented a rather negative image of pharmacy as a boring occupation in a laboratory or the back of a shop. Most had little idea of what pharmacists actually do. Unlike nursing, they were unaware of positive role models in the media. The small number who did have a realistic idea of pharmacy based it on their previous work experience in pharmacy. Conclusions: The focus group technique is useful for exploring hitherto untapped perceptions of the profession. Undertaking research with year 12 students provided some useful insights into the ways in which pharmacy as a profession is perceived. Although no claims to generalisability are made here, the results were fed into the design of quantitative surveys. The somewhat negative image presented suggests that the profession has more work to do in marketing itself to young people as a potential career choice.

Use of complementary and alternative medicine and self-tests by coronary heart disease patients

Background: Coronary heart disease patients have to learn to manage their condition to maximise quality of life and prevent recurrence or deterioration. They may develop their own informal methods of self-management in addition to the advice they receive as part of formal cardiac rehabilitation programmes. This study aimed to explore the use of complementary and alternative medicines and therapies (CAM), self-test kits and attitudes towards health of UK patients one year after referral to cardiac rehabilitation. Method: Questionnaire given to 463 patients attending an assessment clinic for 12 month follow up in four West Midlands hospitals. Results: 91.1% completed a questionnaire. 29.1% of patients used CAM and/or self-test kits for self-management but few (8.9%) used both methods. CAM was more often used for treating other illnesses than for CHD management. Self-test kit use (77.2%,) was more common than CAM (31.7%,) with BP monitors being the most prevalent (80.0%). Patients obtained self-test kits from a wide range of sources, for the most part (89.5%) purchased entirely on their own initiative. Predictors of self-management were post revascularisation status and higher scores on 'holism', 'rejection of authority' and 'individual responsibility'. Predictors of self-test kit use were higher `holism' and 'individual responsibility' scores. Conclusion: Patients are independently using new technologies to monitor their cardiovascular health, a role formerly carried out only by healthcare practitioners. Post-rehabilitation patients reported using CAM for self-management less frequently than they reported using self-test kits. Reports of CAM use were less frequent than in previous surveys of similar patient groups. Automatic assumptions cannot be made by clinicians about which CHD patients are most likely to self-manage. In order to increase trust and compliance it is important for doctors to encourage all CHD patients to disclose their self-management practices and to continue to address this in follow up consultations.

Self monitoring of blood glucose in type 2 diabetes:Longitudinal qualitative study of patients' perspectives

Objective: To explore views of patients with type 2 diabetes about self monitoring of blood glucose over time. Design: Longitudinal, qualitative study. Setting: Primary and secondary care settings across Lothian, Scotland. Participants: 18 patients with type 2 diabetes. Main outcome measures: Results from repeat in-depth interviews with patients over four years after clinical diagnosis. Results: Analysis revealed three main themes - the role of health professionals, interpreting readings and managing high values, and the ongoing role of blood glucose self monitoring. Self monitoring decreased over time, and health professionals' behaviour seemed crucial in this: participants interpreted doctors' focus on levels of haemoglobin A1c, and lack of perceived interest in meter readings, as indicating that self monitoring was not worth continuing. Some participants saw readings as a proxy measure of good and bad behaviour - with women especially, chastising themselves when readings were high. Some participants continued to find readings difficult to interpret, with uncertainty about how to respond to high readings. Reassurance and habit were key reasons for continuing. There was little indication that participants were using self monitoring to effect and maintain behaviour change. Conclusions: Clinical uncertainty about the efficacy and role of blood glucose self monitoring in patients with type 2 diabetes is mirrored in patients' own accounts. Patients tended not to act on their self monitoring results, in part because of a lack of education about the appropriate response to readings. Health professionals should be explicit about whether and when such patients should self monitor and how they should interpret and act upon the results, especially high readings.

Assessing the effectiveness of business support services in England:evidence from a theory based evaluation

In England, publicly supported advice to small firms is organized primarily through the Business Link (BL) network. Using the programme theory underlying this business support, we develop four propositions and test these empirically using data from a new survey of over 3000 English SMEs. We find strong support for the value to BL operators of a high profile to boost take-up. We find support for the BL’s market segmentation that targets intensive assistance to younger firms and those with limited liability. Allowing for sample selection, we find no significant effects on growth from ‘other’ assistance but find a significant employment boost from intensive assistance. This partially supports the programme theory assertion that BL improves business growth and strongly supports the proposition that there are differential outcomes from intensive and other assistance. This suggests an improvement in the BL network, compared with earlier studies, notably Roper et al. (2001), Roper and Hart (2005).

The genius of Erasmus Darwin

The Genius of Erasmus Darwin provides insight into the full extent of Erasmus Darwin's exceptional intellect. He is shown to be a major creative thinker and innovator, one of the minds behind the late eighteenth-century industrial revolution, and one of the first, if not the first, to perceive the living world (including humans) as part of a unified evolutionary scenario. The contributions here provide contextual understandings of Erasmus Darwin's thought, as well as studies of particular works and accounts of the later reception of his writings. In this way it is possible to see why the young Samuel Taylor Coleridge was moved to describe Darwin as 'the first literary character in Europe, and the most original-minded man'. Erasmus Darwin, Charles Darwin's grandfather, was one of the leading intellectuals of eighteenth-century England. He was a man with an extraordinary range of interests and activities: he was a doctor, biologist, inventor, poet, linguist, and botanist. He was also a founding member of the Lunar Society, an intellectual community that included such eminent men as James Watt and Josiah Wedgwood. Contents: Introduction; Setting the scene, Jonathan Powers; Prologue 'Catching up with Erasmus Darwin in the New Century', Desmond King-Hele. Section 1: Medicine: Physicians and physic in 17th and 18th century Lichfield, Dennis Gibbs; Dr Erasmus Darwin MD FRS (1731–1802): England's greatest physician?, Gordon Cook; William Pale (1743–1805) and James Parkinson (1755–1824): two peri-Erasmatic thinkers (and several others), Christopher Gardner-Thorpe; The vertiginous philosophers: Erasmus Darwin and William Charles Wells on vertigo, Nicholas Wade. Section 2: Biology: The Antipodes and Erasmus Darwin: the place of Erasmus Darwin in the heritage of Australian literature and biology, John Pearn; Erasmus Darwin on human reproductive generation: placing heredity within historical and Zoonomian contexts, Philip Wilson; All from fibres: Erasmus Darwin's evolutionary psychobiology, C.U.M. Smith; Two special doctors: Erasmus Darwin and Luigi Galvani, Rafaella Simili. Section 3: Education: But what about the women? The lunar society's attitude to women and science and to the education of girls, Jenny Uglow; The Derbyshire 'Darwinians': the persistence of Erasmus Darwin's influence on a British provincial literary and scientific community, c.1780–1850, Paul Elliot. Section 4: Technology: Designing better steering for carriages (and cars); with a glance at other inventions, Desmond King-Hele; Mama and papa: the ancestors of modern-day speech science, Philip Jackson; Negative and positive images: Erasmus Darwin, Tom Wedgwood and the origins of photography, Alan Barnes; Section 5: Environment: Erasmus Darwin's contributions to the geological sciences, Hugh Torrens; The air man, Desmond King-Hele; Erasmus Darwin, work and health, Tim Carter; Section 6: Literature: The progress of society: Darwin's early drafts for the temple of nature, Martin Priestman; The poet as pathologist: myth and medicine in Erasmus Darwin's epic poetry, Stuart Harris; 'Another and the same': nature and human beings in Erasmus Darwin's doctrines of love and imagination, Maurizio Valsania. Epilogue: 'One great slaughter-house the warring world': living in revolutionary times, David Knight; Coda: Midlands memorabilia, Nick Redman; Appendix: The Creation of the Erasmus Darwin Foundation and Erasmus Darwin House, Tony Barnard; Index.

Study of management decision making by ward sisters in a hospital and the effects on decision making after the implementation of a decision support sytem

This thesis considers management decision making at the ward level in hospitals especially by ward sisters, and the effectiveness of the intervention of a decision support system. Nursing practice theories were related to organisation and management theories in order to conceptualise a decision making framework for nurse manpower planning and deployment at the ward level. Decision and systems theories were explored to understand the concepts of decision making and the realities of power in an organisation. In essence, the hypothesis was concerned with changes in patterns of decision making that could occur with the intervention of a decision support system and that the degree of change would be governed by a set of `difficulty' factors within wards in a hospital. During the course of the study, a classification of ward management decision making was created, together with the development and validation of measuring instruments to test the research hypothesis. The decision support system used was rigorously evaluated to test whether benefits did accrue from its implementation. Quantitative results from sample wards together with qualitative information collected, were used to test this hypothesis and the outcomes postulated were supported by these findings. The main conclusion from this research is that a more rational approach to management decision making is feasible, using information from a decision support system. However, wards and ward sisters that need the most assistance, where the `difficulty' factors in the organisation are highest, benefit the least from this type of system. Organisational reviews are needed on these identified wards, involving managers and doctors, to reduce the levels of un-coordinated activities and disruption.

Control of antibiotic prescribing in UK NHS hosptials. Available in 2 volumes.

This thesis is an evaluation of practices to control antibiotic prescribing in UK NHS hospitals. Within the past ten years there has been increasing international concern about escalating antibiotic resistance, and the UK has issued several policy documents for pmdent antibiotic prescribing. Chief Pharmacists in 253 UK NHS hospitals were surveyed about the availability and nature of documents to control antibiotic prescribing (formularies, policies and guidelines), and the role of pharmacists and medical microbiologists in monitoring prescribers' compliance with the recommendations of such documents. Although 235 hospitals had at least one document, only 60% had both an antibiotic formulary and guidelines, and only about one-half planned an annual revision of document(s). Pharmacists were reported as mostly checking antibiotic prescribing on every ward whilst medical microbiologists mostly visited selected units only. Response to a similar questionnaire was obtained from the Chief Medical Microbiologists in 131 UK NHS hospitals. Comparisons of the questionnaires indicated areas of apparent disagreement about the roles of pharmacists and medical microbiologists. Eighty three paired-responses received from pharmacists and medical microbiologists in the same hospital revealed poor agreement and awareness about controls. A total of 205 institutional prescribing guidelines were analysed for recommendations for the empirical antibiotic prescribing of Community-Acquired Pneumonia (CAP). Variation was observed in recommendations and agreement with national guidance from the British Thoracic Society (BTS). A questionnaire was subsequently sent to 235 Chief Pharmacists to investigate their awareness of this new guidance from the BTS, and subsequent revision of institutional guidelines. Documents had been revised in only about one-half of hospitals where pharmacists were aware of the new guidance. An audit of empirical antibiotic prescribing practices for CAP was performed at one hospital. Although problems were experienced with retrieval of medical records, diagnostic criteria were poorly recorded, and only 57% of prescribing for non-severe CAP was compliant with institutional guidelines. A survey of clinicians at the same hospital identified that almost one-half used the institutional guidelines and most found them useful. However, areas for improvement concernmg awareness of the guidelines and ease of access were identified. It is important that hospitals are equipped to react to changes in the hospital environment including frequent movement of junior doctors between institutions, the employment of specialist "infectious diseases pharmacists" and the increasing benefits offered by information technology. Recommendations for policy have been suggested.