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Original Research Articles

Mistreatment in Australian medical education: a student-led scoping of experiences

Abstract

Background:
Evidence of bullying and harassment of medical students and junior doctors has existed for over 30 years. However, there has been little attempt to explore the dimensions of this issue in Australia to date. Given the evidence which indicates that experiencing abusive behaviour has a detrimental effect on professional identity formation and on mental health, the Australian Medical Students’ Association (AMSA) undertook a national scoping study to better understand the experiences of Australian medical students.

Methods:
We conducted a mixed methods survey of the 16,959 students enrolled in a medical degree at an Australian university in 2015. An anonymous, voluntary online questionnaire was distributed through AMSA’s social media, email newsletter and website, and medical students’ societies.

Results:
We received 519 responses, including 194 (37%) detailing at least one incident of bullying or harassment. 335 (65%) survey respondents were women and 345 (67%) were in the clinical years of their training. 60% of all respondents reported experiencing or witnessing mistreatment during their medical education. The most common theme in the free text was belittlement of the student’s competence and capacity to be a good doctor. Some gave details about how universities failed to prevent or appropriately respond to students’ experiences of bullying and harassment.

Conclusion:
In line with international data, this study shows that many Australian medical students perceive mistreatment as an important problem that is not always managed well by faculties. Multi-pronged policy and practice responses are needed to instigate cultural change in Australian medical education.

 

Introduction

“How can we care for our patients, man, if nobody cares for us?”
— Chuck the Intern, The House of God, Samuel Shem [1].

Evidence of bullying of medical students and junior doctors has existed for over 30 years in the United States and the United Kingdom [2-7]. In Australia over the past two years, the topics of bullying, teaching by humiliation, and sexual harassment in Australian medical training have attracted attention both from the mainstream news media and within the profession. There is also some formal evidence about the extent of this problem nationally. A recent local study of “teaching by humiliation” found 74% of medical students reported experiencing this practice and 84% witnessed it [5].

Worldwide, similar studies have shown that any student can be affected, regardless of gender or race [8-10]. The most common form of mistreatment reported is covert, mostly in the form of belittling, exclusion or humiliation, rather than overt yelling or violence [4-6,11]. Sexual harassment is the most common form of documented incident [12-14]. The perpetrators of bullying are most commonly senior male clinicians [4,15]. Under-reporting is the norm, especially when the perpetrator of mistreatment is the student’s clinical supervisor, due to fears about the possible impact on career progression [4,10].

There is evidence that experiencing abusive behaviour causes harm both to the student and later, potentially, to their patients (and colleagues). Other research has demonstrated how a student’s developing identity affects their subsequent career progress, employability, and performance [17-19].

Mistreatment may be a contributor to the high levels of psychological distress found among medical students. Studies have shown that rates of such distress are three times higher among medical students than the general population (9.2% and 3.1% respectively), and that female medical students were more likely than male students to have considered suicide in the past twelve months, with 4.5% having attempted suicide. In particular, Indigenous students found bullying to be a substantial source of stress [16].

The exact nature of bullying and discrimination can be difficult to define. Through this research, we determined which incidents students found distressing, and what they considered to be bullying or discriminatory behaviour.

Prompted by an increase in reports of mistreatment from Australian medical students following media attention to the issue, the Australian Medical Students’ Association (AMSA), in association with the Sydney School of Public Health (SSPH), undertook scoping research to better understand the experiences of Australian medical students.

Rather than confirm the prevalence of abuse, demonstrated by previous research and by the Report of the Senate Inquiry into Medical Complaints Processes (2016) [20], we aimed to explore aspects of students’ experiences and their responses.

Methods

Study design and sample
As the only other previous survey of this issue in Australia was distributed to students from two medical schools only [5], our study aimed to reach a wide variety of students from all Australian medical schools and to confirm that previously published findings were generalisable nationally. For this reason, a survey was chosen as the medium for this research as it could be easily disseminated nationally online.

Medical students aged 18 and older who were enrolled in an Australian University between the 25th of August and the 5th of November 2015 were surveyed. The survey was an anonymous, voluntary online questionnaire using REDCap survey software (Vanderbilt University, Tennessee, USA) (see Supplementary Materials online).

The survey link and description were distributed through AMSA’s official Facebook page, Twitter account, website, and email newsletter (“Embolus”). Some medical schools’ student societies, as well as individual participants also shared the survey link.

The questionnaire contained four parts. Part one collected demographic information. In part two, respondents rated their perception of the extent of five categories of mistreatment — “general bullying”, “sexism”, “disability discrimination” (including mental illness), “racism”, and “homophobia” — in Australian medical education, by moving a pointer on a scale from 0 to 100. In part three, respondents rated the attributes of incidents they had witnessed or experienced and were then invited to use free text boxes to describe these incidents. They were also asked about their response to these incidents. In part four, students could describe what actions they felt AMSA could take in response.

The project received ethics approval from the Human Research Ethics Committee (HREC) of the University of Sydney [Protocol number 2015/642].

Data and statistical analysis
Basic demographic information about the respondents was reported, along with the proportions who reported experiencing or witnessing mistreatment. We tested whether experiencing or witnessing mistreatment was associated with gender, age, enrolment, sexuality, and training stage using Fisher’s exact test and Pearson’s chi-squared test. Boxplots were created based on the levels of agreement scales in part two. Differences in levels of agreement between subgroups of respondents were tested using two-sided exact Wilcoxon rank sum tests (gender, enrolment, and sexuality) and Kruskal-Wallis test (age), as the data were negatively skewed (Figure 2). These analyses were performed in R version 3.2.4 [21]. No adjustment has been made for multiple statistical comparisons.

Authors A-KS, EB and KI independently conducted an initial close coding of the open text responses with advice from CH. The taxonomies and categories developed in this process were then reviewed by the research team for comparison and reliability, and a primarily taxonomic thematic coding structure was agreed upon [22,23]. This was then applied to the free text data.

Results

We received 531 completed surveys. Twelve surveys (2%) were excluded as they contained demonstrably unreliable answers or answers unrelated to medical education, leaving a sample of 519 surveys (Figure 1). The respondents were predominantly female (65%), young (median age of 24 years), local students (90%), and at the clinical stage of their training (67%) (Table 1). Each Australian medical school was represented.

Figure 1. Number of surveys included and number of incidents of mistreatment described in check box responses or free text.

It was reported by 60% of all respondents that they had witnessed or experienced adverse treatment (Table 1). Adverse treatment was more likely to be reported by: female than male students (64% vs 53%), older than younger students (79% for 35 years and older vs 55% for 20-24 years), non-heterosexual than heterosexual students (75% vs 58%), and clinical than pre-clinical students (70% vs 40%).

For the five categories of mistreatment (general bullying, sexism, disability discrimination including mental illness, racism, and homophobia), females reported greater problems in medical education than males (p≤0.004) (Figure 2). Non-heterosexuals tended to report greater problems than heterosexuals, particularly regarding homophobia (p<0.001). International students believed mistreatment was less of an issue in medical education than local students for all categories, except racism, though differences were small (p>0.05), and there were no consistent patterns with age (data not presented).

Figure 2. Boxplots of responses of 519 medical students to statements that general bullying, sexism, disability discrimination, racism and homophobia are a problem in medical education.

Information about 301 incidents involving mistreatment was given by 194 students (Figure 1). In 92% of incidents, the victim was a student (Table 2). The respondents nominated consultants as the primary instigator in 46% of the incidents. Belittlement, condescension or humiliation were present in 65% of the incidents. Most students (68%) reported they did not react (that is, take action in response) to the event. Two major reasons for not reacting were not knowing what to do, and fear of repercussions. Most students were bothered by the incident, with only 4% moving the slider scale from “a little” bothered to “not at all”. Over a third moved the slider to the lowest tenth of the scale, described as “very much”.

Table 1. Demographics of 519 survey respondents and the proportion who witnessed or experienced mistreatment in medical education.
Reported p values are for tests of independence between experiencing/witnessing mistreatment and gender, age, enrolment, sexuality and training. Fisher’s exact test was used for gender and training, and Pearson’s chi-squared test for enrolment, sexuality and training.
*There is 1 missing value.

Of the 519 respondents, 168 submitted text descriptions of individual events (Figure 1). Of these, 41 described two events, 14 described three events, and ten described four events. In total, 267 events were described. Themes captured by coding the text responses included the type of event, the perpetrator, the situation and context, aspects that compounded the situation, and any potential outcomes of the event.

The most common theme was the denigration of the student’s competence and capacity to be a good doctor.

“The senior registrar in this instance verbally abused the student regularly, claiming that it was inconceivable that she would one day be a doctor and would cause great harm to potentially anyone she would treat.”

A commonly used framing motif was that the recipient was unworthy, should not have been allowed entry into medical school, or should make way for those who are actually fit to be doctors. The stories included examples of discrimination in all the social categories we investigated. One of the most common was the perceived incompetence or unworthiness of women.

“When we got it wrong, he would tell us we were stupid, we should drop out of medicine because we’d never make a good doctor, or there was no point trying, because we’d quit later to have babies like women should.”

“I was a new mother… and was told by another student I should be at home looking after my child instead of wasting a place at medical school that would have been better off given to someone else.”

A minority of the comments were on non-medical themes such as attractiveness, racial stereotypes, or perceived promiscuousness of the student.
“I would hear jibes about ‘Indians taking over the healthcare system of Australia’ and how ‘No one could understand their curry accent so they shouldn’t be able to work in this country.”

“All the women in our class [were] being scaled on ‘crazy versus hot.’ [The respondent was] followed into a women’s toilet and told to get down on my knees and ‘suck my dick’ while [a male medical student] grabbed his crotch.”

The more the abuse was related to medical practice or competence, the more respondents constructed it as acceptable or understandable.
“The taunts were often unrelated to medicine which made it even more unprofessional.”

Harm and suffering
Implicitly or explicitly, almost all of the 267 free text stories indicated that the recipient(s) of mistreatment were negatively affected as a result. Some accounts directly indicated that teaching by humiliation inhibited rather than enhanced medical learning, decreasing confidence and stopping the student from seeking out further educational opportunities from medical staff.
“Instead of attempting to teach the student in any way, she would harangue the student with increasingly difficult questions — lambasting her further with every question she answered incorrectly… this destroyed the confidence of the student in question quite quickly, to the point where she was afraid and unwilling to go to her clinical placement and learn for fear of the treatment she would receive the next day.”

“I understand that his motivation is to encourage us to be thorough, safe doctors. However, I was so scared at being yelled at for getting an answer wrong in his tutorials that I didn’t learn anything.”

Perpetrators

Students
Of the 38 responses indicating students as perpetrators, the same frame of medical incompetence and unworthiness was common.
“A fellow student kept on telling me that I was stupid and inept and kept saying things like if you don’t know this that (sic) you [don’t] belong in medicine … he threatened to hit me if I continue (sic) doing idiotic things.”

Faculty
We did not include the faculty as perpetrators in our questionnaire. Nevertheless, we received 22 responses citing medical school faculty (including both non-clinical staff and clinical staff in non-clinical roles) as reported perpetrators. These most often related to mishandling of reports of bullying, refusal, or inability to make reasonable allowances for mental illness or disability, and instances of discrimination against students.
“I was told that I was at risk of failing, had my depression called ‘your condition’ the whole time, making me think it was dirty or bad since it couldn’t even be addressed … They said to ask them any questions and the school of medicine would do everything it could to support me, but when I directly asked what they could offer they had nothing.”

Some respondents expressed disappointment and frustration at feeling unsupported by staff.
“The direct inaction by my university nearly led to my suicide … For me the only way I thought the Uni would notice my problem would be if I was to kill myself. Thankfully I pulled myself out of it and am still fighting week in week out to keep myself going.”

Often, students reported faculty promising support to the student, but providing no support or enacting no change. Other responses cited direct bullying or discriminatory action from the faculty towards the student.
“We get mistreated by the very people that are in control of our assessment/progression. How can you complain against the very person that controls your future? It’s just easier to endure it.”


Table 2. Details of 301 incidents of mistreatment reported by 194 medical students.
*The number of incidents with this question answered. **More than one response could be selected therefore the percentages do not sum to 100. *** “Other” includes (from most to least frequently reported) intrusive/unwanted questions, refusal to make reasonable allowance for the needs of others, threatening failure/low grade, receiving lower evaluations/grades, asking to perform personal/inappropriate tasks, spreading malicious rumours, being coerced into unprofessional behaviour, other, and actual/threatened physical punishment. **** “Other” includes (from most to least frequently reported) not there at the time, other, chalked it up to experience, told not to respond, it wasn’t that bad, didn’t have the time, my fault, didn’t care, not intentional, not important, and the data field not being filled in.

Discussion

Our study indicates that a significant proportion of medical students across the country experience or witness mistreatment, extending existing evidence of this issue, which had been previously confined to only two Australian medical schools. In line with other studies [4,11,24], our study shows that bullying and discrimination are commonly “medically themed”, in ways that belittle a student’s core identity and competency. This fits with sociologies of medicine that have shown that surviving humiliating treatment is often a ritual of socialisation into the profession [25]. Our study also extends our understanding of which students are affected and identifies a wider range of perpetrators than had earlier studies [5,14], including professional and support staff in their clinical schools and other students.

A limitation of our study was the sliding response scale for which the default setting was in the middle of the scale. If the respondent did not touch the slider, we could not be sure if they had elected to forego answering the question entirely (because they did not have an opinion or they did not want to answer) or if they were agreeing with the default mid-range answer.
While our low response rate and methods of recruitment mean that our results cannot be regarded as necessarily representative of the whole Australian medical student population, our data strengthen worldwide trends and provides confirmation that Australian medical students often experience serious mistreatment. It also reflects the findings of the Inquiry into Medical Complaints Processes, released in December 2016 [20,26].

Our study underscored that these behaviours can be damaging to students’ mental health. Our data also confirmed the widespread reluctance to disclose, report, or confront mistreatment as students fear direct educational and professional disadvantage as a result.

This research demonstrates that mistreatment is justified by the idea of upholding professional competence in medical students. It has also shown that, for some students, the mistreatment has a negative effect on their mental health and their willingness to perform. While there will be no single intervention solution for this problem, the authors suggest that clinical teaching staff may find an evidence-based short course on adult education and effective and constructive criticism, useful training for teaching medical students. This could include clear guidelines for both staff and students on the difference between effective teaching and bullying. Indeed, as teaching is often considered an integral part of clinical medicine, targeted preparation for this could commence in medical school. This should be paired with effective policies ensuring that staff who have been reported repeatedly for bullying behaviours are removed from teaching positions and receive appropriate training to improve their skills before resuming work.

We also saw that under-reporting is often due to fear of educational and professional disadvantage. We can address this by encouraging the production of university and hospital policies ensuring anonymity and protection for those who report, and providing alternatives such as switching the student to a different rotation.

Another finding was how some students felt that universities were failing to take action to support them. This was particularly linked to students with a disability or mental health conditions. The reports detail either a perceived choice by the university to not support the student or the admission that university staff did not have the ability or resources to support the student.

The authors suggest that universities enact stronger policies with safety nets available for struggling students (such as changing rotations, alternate exam arrangements, or taking time off) and ensure they have the necessary resources to do so. We also suggest the creation of policies that monitor how many students are struggling, detailing the issues, and taking steps to ensure the problem does not continue. The authors suggest that medical school accreditation processes should include a more rigorous examination of institutional performance on this issue.

These recommendations run alongside those handed down by the Inquiry into Medical Complaints Processes, which specifically identified the government, hospitals, colleges, and universities as parties with responsibility for addressing bullying and harassment in the medical profession [26].

Changes in policy and training educators on effective criticism would be strengthened by slowly incorporating cultural change through encouraging positive professionalism training. Such programs use creative techniques such as acting skills to build core professional values and behaviours. They can also reveal the impact of bullying on others without directly shaming perpetrators or exposing victims [27-29].

Further research is required to determine the effectiveness of these approaches to change. It is as yet unknown whether a pre-emptive educational approach or more capacity to remove perpetrators from teaching roles would be most effective in reducing mistreatment. Further qualitative research would better capture the dimensions and effects of mistreatment, which may be experienced differently by male and female students, on the basis of mental health status, or with respect to sexuality or ethnicity. Such research could assist in identifying institutional barriers to managing poor behaviour among teaching and non-clinical staff, and identify the best strategies by which the effects of mistreatment in medical education can be ameliorated.

Acknowledgements
We thank Rita Shackel for her assistance with the ethics approval process.

Conflict of interest
None declared.

Correspondence
A Szubert: anna.szubert64@gmail.com

References

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Categories
Feature Articles

The changing face of cancer in Australian medical schools

A multitude of changes are revolutionising the study and practice of oncology worldwide.   Despite the undeniable importance of cancer education, there is currently no consensus amongst Australian medical schools as to what should be taught regarding oncology practice, nor have the best ways of teaching and learning about cancer been fully elucidated in the literature, or in the clinical realm. There is a lack of important cancer knowledge amongst graduating medical students and variation exists amongst individual Australian medical faculties, between states as well as individual universities from the same state. Furthermore, there is very little teaching here in Australia in relation to emerging genomic technologies within oncology, and in particular, the ever-increasing role of personalised and preventative medicine in cancer care today. Ultimately, there is a clear need for an integrated, overarching national oncology curriculum, embracing a patient-centred approach; national evaluation and assessment; supplementary courses; utilisation of self-directed learning and reflective practice activities; and greater emphasis on emerging technologies. With more research focus on this area, in future there may be a larger evidence-base targeted at providing improvements in Australian Oncology education, assisting graduates in gaining adequate understanding and appreciation of cancer-related scenarios and cancer care. More effective teaching and learning facilitation, with better overall Australian training outcomes, will lead to advancement in cancer diagnosis, treatment, and management as well as ensuring more insightful and valuable patient interactions in the future.

Introduction

A multitude of changes are revolutionising the study and practice of oncology worldwide.  The ways in which oncology and cancer care are incorporated into medical school curricula in Australia is thus of particular interest. Despire the undeniable importance of cancer education, there is currently no consensus amongst Australian medical schools as to what should be taught in regards to oncology practice, nor have the best ways of teaching and learning about cancer and cancer care been fully elucidated in the literature or in the clinical realm [1-4].

In Australia, there is considerable variation in undergraduate and postgraduate teaching of oncology amongst individual medical faculties [8,9] and a lack of important cancer knowledge amongst graduating medical students, between states and between individual universities from the same state [8,9,10]. This inconsistency is compounded by the nature of oncology as a multidisciplinary specialty, with overlap in numerous fields including pathology, surgery, histology, radiology, anatomy, genetics, communication skills, and palliative care [1].

Further, there is very little teaching here in Australia in relation to emerging technologies within oncology and in particular, the ever-increasing role of personalised and preventative medicine in cancer care today. Educators are now presented with the inevitable task of addressing all foundational educational needs in our generation of medical graduates. They must also ensure to incorporate pertinent aspects of such a rapidly progressive field of medicine as it relates, for example, to genetic testing and counselling, the rise of personalised or ‘precision’ medicine, and ongoing development in cancer immunotherapies [11-14].

Variation in oncology education in Australia is compounded by the lack of literature on this subject, which is predominantly qualitative in nature and overall, more difficult to evaluate [30].  Whilst cancer is the number one cause of death in Australia, oncology itself is still not a subscribed part of the medical curriculum, nor is an oncology rotation compulsory in Australian medical schools. There is an ongoing lack of literature regarding oncology-specific teaching and learning methods, as well as a lack of evidence in the effective implementation of compulsory curricula or rotations to engage with foundational and emerging aspects of oncology or palliative care.

The importance of this issue resonates with students, recent graduates, and educators as all medical students will at some point in their career play a role in the management of a cancer patient [5], whether as a resident on an oncology rotation, as a general practitioner at the stage of diagnosis, during long-term follow-up of a cancer survivor [6], as a fully-qualified oncologist, or as a clinical geneticist. Furthermore, with our ageing Australian population, there will be greater numbers of individuals diagnosed with and treated for cancer than ever before as well as an increased number of survivors, making cancer a chronic illness to be managed by a multidisciplinary team [7].

 

How did we get here?

In 1993, the General Medical Council published a detailed review of medical education [15], which led to a major overhaul of medical school oncology training in the United Kingdom, and worldwide [1,16].  A survey of European universities showed that 95% indicated the need for increased cancer education and there was an overwhelming interest in a common European oncology curriculum [17].

In 1999, and again in 2007, the Ideal Oncology Curriculum (IOC) for Medical Students was released here in Australia [18], produced by the Oncology Education Committee of the Cancer Council Australia and endorsed by the Union for International Cancer Control (UICC). It provides an unparalleled example of the evidence-based recommendations required for medical school cancer education, including prescribed clinical experiences and knowledge attainment, which necessitate a patient-centred approach to training methods. In each section, there is detail of prerequisite knowledge, as well as a list of representative questions that illustrate the ‘required depth of knowledge’ for graduating medical students, with attached example answers and multiple-choice question-answer options.

Focus is on the patient rather than the discipline, with topics ranging from public health and cancer biology, to patient management, diagnosis, communication skills, and clinical experiences [18]. More recently, it has been supplemented by a detailed e-Book entitled “Clinical Oncology for Medical Students”, which may be utilised alongside the recommended experiential learning, and acquisition of technical oncology skills, for a more robust understanding of the prescribed IOC material [19].

Moreover, the World Health Organisation and UICC recommend that cancer education be incorporated into oncology modules within an undergraduate curriculum and that medical students spend a minimum of two weeks in oncology training [4,5]. However, despite the superlative example given by the IOC, there has been minimal uptake in Australia, which may be linked to the current lack of a national curriculum, the dearth of literature on effective educational strategies, or the historical absence of oncology content in Australian medical school curricula. This lack of implementation and an inadequate evidence-base makes the feasibility and effectiveness of oncology rotations or uptake of the IOC guidelines incredibly difficult to ascertain, let alone, achieve.

 

Oncology teaching and learning methods

Internationally, there has been a push for an overarching pre-clinical oncology curriculum for medical students incorporating medical knowledge, psychosocial aspects, communication skills training, and utilisation of a variety of teaching methods such as interviews, discussion, reflection, and lectures [1,2,7,20].

There is increased emphasis on a patient-centred approach to teaching [11,13] and learning in oncology education [22,23]. This should extend from the use of standardised patients teaching examination skills to medical students, to the involvement of cancer patients in communication skills teaching and portfolio learning [1,24].

Self-directed learning (SDL) is the educational strategy considered most likely to produce medical graduates who are prepared for lifelong learning and who are able to meet the needs of their patients [26,30]. SDL activities include problem-based learning (PBL), discovery learning, task-based learning, experiential and reflective learning, portfolio-based learning, small group or project-based learning, and peer evaluation with learning contracts [26]. Results from numerous studies have indicated a trend towards improved student performance from SDL assessment, as with the follow-up of a cancer patient over an extended period of time [1,21,23-25]. The use of portfolio assessment and learning journals is also championed as a tool of successful oncology training and for lifelong education [25]. An array of methods may thus be employed in undergraduate oncology training whilst utilising the SDL approach [26-27].

The PBL approach, more specifically, as one of the major aspects of SDL, facilitates a deeper learning style [28] and involves an active search for understanding based on a given scenario. This technique is linked to better clinical problem-solving skills in medical students with higher levels of motivation and stimulation found [27] and superior outcomes in students tested [9,29].

Regarding format, some have argued that an independent block style is more effective in presenting an oncology curriculum [20]. This is as opposed to an integrated model of teaching into other system modules and would be relevant within an Australian-based system. In block format, the curriculum may be presented through oncology-specific technology-based lectures, team-based communication, and clinical skill exercises supplemented by lectures paired with relevant clinically-based scenarios and other activities posted online to be worked through independently [20].

Computer-aided learning [1,21,22,30] may itself have a role to play as supplementation to oncology study though technology-based approaches are not necessarily superior to other learning techniques [1]. Here in Australia, a number of medical schools are already utilising the e-Learning Undergraduate Modules for Australian Medical Schools, accessible via The e-Learning Portal, which is provided by The Australasian College of Dermatologists [31]. This is highly applicable on a national level when considering skin cancer rates in Australia [32]. Overseas, an ‘eDerm’ online curriculum [33] provided to 252 medical students in the United States significantly improved the diagnosis and management of pigmented skin lesions by medical students [33].

In regards to communication skills, suboptimal communication can lead to adverse psychological effects in patients. It can compromise a physician’s ability to treat patients, as well as impacting patient satisfaction, medication compliance and overall clinical outcomes [34]. The use of group presentations, small-group communication skills practice [35], and reflective self-awareness exercises have been shown to improve communication skills. This is particularly true with the use of patient-actors in simulated clinical situations as opposed to role-play alone. There is overwhelming proof that communication skills can be taught and should be delivered through experiential learning methods, which are ultimately more effective than instructional modes to address communication skills development in oncology [36].

Moreover, a primary skill that any medical student can bring to an oncology experience, or rotation is their presence and their time. Medical student training in this burgeoning field [11] must facilitate the development of essential communicative abilities: to be able to listen to a cancer patient’s story during their clinical journey, to be able to connect with this experience, and communicate effectively in response to this scenario [18,34-36].

 

Lessons from abroad

At the University of Wales’ College of Medicine, medical students followed a patient along their cancer journey over a six-month period and were assessed during patient interactions and through a final portfolio. Overall, students found the project rewarding and reported gaining unparalleled insight into the cancer experience [22].

A three-day intensive oncology course has been piloted in Israel, with students feeling more comfortable with cancer-related issues, less afraid of dealing with death, and better able to cope with uncomfortable cancer-related emotional situations as a result [7]. Psychosocial and ethical aspects were presented through student-led presentations and discussions, a psycho-oncology session led by a psychologist, and two presentations by cancer patients describing their personal experiences and offering advice on aspects such as the doctor-patient relationship [7].

In Poland, attempts have been made to improve cancer education through the National Program for Combating Neoplastic Diseases [16]. This was done with a course incorporating computer-learning modules, online tests, portfolio learning, summer school, modules taught by cancer patients, and attachments in oncology and palliative care. Observations highlighted that the introduction of these courses better prepares students for delivering cancer care [16].

Finally, in a novel Brazilian experience, students staffed an oncology clinic, with 77% of students involved in this approach over a ten-year period rating it as the best activity of their course. Findings suggested that attendance at an oncology outpatient clinic can contribute significantly to the cancer education of medical students [24].

 

Future directions for Australian oncology education

There is a clear need for the following in cancer education:

  1. An integrated, overarching national curriculum, with a patient-centred approach
  2. National evaluation and assessment
  3. Summer schools and supplementary courses
  4. Embracing SDL & PBL, with reflective practice activities
  5. Greater emphasis on emerging technologies

 

  1. An oncology curriculum, with a patient-centred approach

 A relevant, integrated oncology curriculum as detailed by the IOC [15,18] should be embraced by all Australian medical schools, with the aim of bringing together requirements regarding essential knowledge, skills, and attitudes about cancer and cancer-related care [2,8,9,10,17]. It should be well-rounded and ideally supported by a coordinating body, with an academic basis of professorships [2].

 As detailed by the IOC [18], there is a need for increased emphasis on clinical interaction and greater time spent with patients [1,2,5,21,37]. As suggested [18], medical students need at least five cancer clinical experiences before graduating:

  • Talking with and examining people affected by all stages of cancer;
  • Talking with and examining people affected by all common cancers;
  • Observing all components of multidisciplinary cancer care;
  • Seeing shared decision-making between cancer patients and their doctors; and
  • Talking with and examining dying people [2,15,18].

 

  1. Assessment

As shown in Australian medical schools, assessment drives performance [2]. Thus, having decided upon a particular patient-centred approach, carrying out formal evaluation of student learning and course content is vital for enhancing training outcomes [18,38], and should inform the prescribed curriculum [2]. In future, this might include the introduction of national assessment, such as a national exit examination [40], with oncology-related scenarios aimed at testing core knowledge levels and ensuring standardisation is maintained across the country [9,39,40].

 

  1. Supplementary courses 

Regarding adjuncts to a proposed national curriculum and module [20] of oncology teaching, summer schools and extra courses [7,16] may be of great use here in Australia [1]. The Vienna Summer School, for example, receives high levels of praise and acceptance rates from European medical students. These students note that these supplementary courses provide them with a greater understanding of oncology and an appreciation of its’ multidisciplinary character [15]. Summer schools may offer educational activities that fill the gaps of an otherwise disjointed oncology training program, as shown by the example of oncology summer schools in Europe [4].

 

  1. Self-directed learning, problem-based learning and reflective practice

Learning in medical school is rarely fully autonomous, with students valuing pedagogic support and often relying on teachers as coordinators and facilitators of their learning environment [41]. Students should be encouraged to recognise the importance of evidence-based medicine, how to critically appraise literature, and the need to constantly update one’s knowledge based on high-quality evidence and guidelines [18]. Furthermore, team-based learning through small scenario or discussion groups has a role to play in the application of basic science knowledge to real-world oncology-related scenarios [35]. This could lead to greater engagement with lecture content and its’ application in daily medical practice.

There is increasing necessity for our medical curriculum to foster the development of sound communication skills. Furthermore, providing students at every level of their education with an opportunity for reflective practice, as individuals and in smaller groups, is also a must. This may serve as an important tool in supporting students who emotionally encounter negative experiences as a result of difficult or uncomfortable clinical encounters. Mentoring, as an extension of this pathway, may be of use in allowing reflection following hospital experiences. It may be of use for medical students to attach themselves to ‘mentor’ clinicians on rotation, staff whom they perceive to be effective teachers for coaching purposes, development of reflective practice, and consolidation of learning [42].

Moreover, students learn more effectively by being actively involved in a PBL strategy, as it facilitates epistemic curiosity through activation and elaboration of prior knowledge [22]. Reflection on experience, followed by evaluation, analysis, and appropriate action, may facilitate further learning and appreciation of curriculum content in the Australian context [1,4,18,21,22,23,25]. Portfolio learning [1,22,23] should thus be employed in a set teaching program [16,23], with reflective exercise  and a compulsory portfolio-based experience, or assessment. This would to facilitate reflection and exploration of the patient experience along their cancer trajectory.

 

  1. Emphasis on emerging technologies

Dramatic advances in genomic technology stand to revolutionise clinical cancer care [13,14]. Personalised (or ‘precision’) medicine is a banner term, describing the use of molecular tools to individualise healthcare through genetic testing, whole genome sequencing, exome, or transcriptome sequencing [13]. While there has been ample research in the area of genetic testing and its’ implications for our future, very little is known about how best to encourage development in understanding of such technologies at the level of medical students or recent graduates.

In the realm of breast cancer in Australia, for example, an individualised cancer care approach is evidenced in the case of genetic testing for BRCA1/2 mutations, which reflect a specific predisposition toward breast and ovarian cancer [43]. About 5% of cases of breast cancer and 10% of ovarian cancer cases, are due to such inherited predisposition [44,45]. With progress towards a more personalised, family-centred model of oncological care in Australia, knowledge of ones’ genetic and genomic information plays a crucial role, from screening and prevention, to individualised surgical treatment, and utilisation of targeted therapies based on a tumours’ molecular signature [46].

In order to fully realise the effective application of personalised medicine into routine Australian cancer care, students and clinicians need a more comprehensive understanding of emerging technologies. In addition, an appreciation of the experiences, and attitudes of cancer patients, and their families is required. Evidence suggests that the majority of cancer patients are willing to undergo genetic and genomic testing during, or following, cancer treatment [11]. More work is needed in this area to provide graduates with a more refined appreciation of how best to communicate genomic concepts to a broad range of patients [11]. Medical graduates must have greater awareness of foundational genetics-based and personalised medicine pathways. This will allow them to alleviate patient misconceptions and ultimately, to empower patients to make more informed cancer care decisions [12-14]. Without this, there may be failure to adequately deliver genetically-guided cancer care, treatment, and management in the future. The issue our educators will now face is how to best integrate this information into a feasible medical student curriculum.

 

Conclusion

More effective teaching and learning strategies in oncology should be aimed at producing Australian medical graduates with adequate and relevant cancer-related knowledge, skills, and attitudes that best meet the needs of their society [2]. The IOC [18] does an exceptional job of demonstrating the requirements and expected knowledge to be attained through a prescribed oncology curriculum here in Australia.

Australian medical students need a well-rounded understanding of oncology concepts and appropriate examination and communication techniques to facilitate aspects of cancer diagnosis, referral, and management in future clinical practice [20]. There must be focus given to developing an awareness of emerging technologies in the realm of cancer care with emphasis on basic concepts related specifically to genetic testing, genetic counselling, and personalised medicine.

The foundational experiences provided by medical school training serve to shape one’s entire career as a doctor. Those students more engaged in their learning through SDL, PBL and reflective practice strategies [26,27], and who have a greater understanding of key concepts are more likely to achieve superior assessment outcomes [2]. They are also more likely to be involved in successful clinical interactions overall [1].

With greater research focus on this area in future, there may be a larger evidence-base targeted at providing overarching improvements in Australian oncology education. This will assist graduates in gaining an adequate understanding and an appreciation of cancer-related scenarios and cancer care. More effective teaching and learning facilitation with better overall Australian training outcomes will ultimately lead to advancement in cancer diagnosis, treatment, and management outcomes as well as ensuring more insightful and valuable patient interactions in our futures [5,12].

 

Conflicts of interest

None declared.

 

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Categories
Original Research Articles

Educational outcomes for children with moderate to severe acquired brain injury

Background: Acquired brain injury (ABI) in childhood can have serious physical, cognitive, and social consequences, although its specific impact on schooling attendance and provision of aid for children is often uncertain. We described educational and neuropsychological outcomes for a population of children with moderate to severe ABI.

 

Methods: A retrospective cohort study of children with moderate to severe ABI attending a paediatric brain injury service at The Children’s Hospital at Westmead between January 2003 and December 2007 was performed. The children were aged 8-16 at time of injury and information on school attendance, provision of aide, and neuropsychological test results were collected at 6, 18, and 30 months post-injury. Children with previous moderate to severe ABI, neurological disorders or learning difficulties were excluded.

 

Results: 104 children were included (mean age 12.4, 62.5% male). 48 had severe ABI (Glasgow Coma Scale ≤ 8 or Post Traumatic Amnesia ≥ 7 days). The proportion having returned to full time schooling improved from 56% to 89.7% between the 6 and 30-month follow-up. A majority of children had an impairment recorded on neuropsychological testing. Regression analysis found that severity of injury and language deficit were predictors of attendance in the first six months post-injury. During the 30-month follow-up, 18% of children attended special classes or received a classroom aide.

 

Conclusion: Time is important in recovery from ABI in children. Neuropsychological deficits influence delivery of classroom aides or modified curricula. Children with severe injury are more likely to have poorer cognitive and educational outcomes.

 

What is already known about this topic

  • Acquired brain injury can lead to serious physical, mental, and social problems for school-aged children
  • These deficits can often extend years after the initial injury
  • Severity of injury is correlated with poorer outcomes

 

What this paper adds

  • An Australian perspective of educational outcomes for children with moderate to severe brain injury
  • Information on deficits experienced by children over two-and-a-half years of follow-up
  • A better understanding of the importance of time, neuropsychological deficits, and physical injuries in transition back to school

 

Introduction

Acquired brain injury (ABI) includes a range of disabilities affecting the brain after birth including traumatic brain injury and haemorrhage. Children with moderate to severe ABI often experience long-term physical, cognitive, or behavioural impairments [1,2]. During discharge planning for these children, families often want to know what to expect from the future. In particular, they worry about the transition from hospital to the home and school environment [3]. Schooling is an important forum for childhood learning, as well as emotional and social development [4]. As such, parents often worry about how and when their children may return to school [5]. These concerns are important to address but are difficult to answer due to the great heterogeneity of outcomes following ABI.

Research has indicated that transition of children with ABI back into school is a challenging time for families. After brain injury, students may need to change their educational and vocational goals to accommodate changes in their abilities [6]. Interviews with children returning to school after ABI raise many issues, including social isolation, missed schoolwork, difficulties adjusting to physical and cognitive changes, and the support provided by schools [7]. Children find it more challenging to participate in school activities than at home and this may be due to the familiarity and greater support provided by the home environment [8].

It has been clearly established by prospective longitudinal studies that severity of injury is associated with poorer physical or cognitive outcomes [1,9-11]. Younger children are also more vulnerable to ongoing consequences of brain injury due to their larger head-to-body ratio, ongoing brain tissue myelination, and their thinner cranial bones [12]. Other factors such as type of injury, socioeconomic status, and provision of family support are also known to affect outcomes following childhood ABI [1,5,7]. Time plays a particularly important role in recovery from ABI however it is useful to note that some deficits may also become more apparent over time.

Neuropsychological testing may also be an early predictor of educational performance and special education requirements: in a study by Kinsella et al., severity of injury and verbal memory and fluency at three months post-injury was a predictor for requirement of special education at 24 months post-injury, Similar findings of the importance of verbal memory influencing educational performance at two years post-injury were made by Catroppa and Anderson as well as Miller and Donders [13,14]. Arnett also found that measures of executive functioning and verbal memory predicted educational competency but did not find these measures predictive of provision of special education [15]. Many studies regarding educational and schooling outcomes for children with ABI do not look specifically at school attendance. Studies of educational outcomes are also limited by small patient numbers and limited follow-up [16].

This study aims to use retrospective data to provide a better understanding of specific neuropsychological and schooling outcomes for children with moderate to severe ABI over a two-and-a-half-year period of follow-up. In particular, the study looks at providing a picture of time for return to schooling and the likelihood of requirement for an aide in the classroom or special education. It also seeks to explore whether neuropsychological factors such as attention, memory, information processing, and executive function, and whether co-morbidities such as fatigue and motor capacity may influence return to school and provision of an aide. This information may enable parents of children with ABI to have a better understanding of what to expect and could improve school engagement in the rehabilitation process [7].

 

Methods

Participants

Eligible cases were identified from the 2003-2007 database of a paediatric brain injury service at The Children’s Hospital at Westmead, New South Wales, Australia.

Inclusion criteria were age at injury of 8-16 years, moderate or severe ABI, and admission to hospital for ABI. Moderate ABI was defined as Glasgow Coma Scale (GCS) ≤ 12 or Post Traumatic Amnesia (PTA) ≥ 1 day. Severe ABI was defined as GCS ≤ 8 or PTA ≥ 7 days [17]. There were eight cases which were judged as representing moderate or severe ABI but there was unclear GCS and PTA data. These cases were included in order to more accurately represent the patient population and were classified as “undefined” in severity.

Exclusion criteria were previous moderate or severe ABI, previously documented behavioural or developmental difficulties, or previously documented special education support.

Medical records were searched and data extracted from neuropsychological and brain injury clinic reports, discharge summaries, and other hospital records. Data were collected for 0-6, 6-18, and 18-30 months post-injury. Data on educational outcomes of school attendance, provision of classroom aide, and whether children changed school were collected. Data on neuropsychological outcomes was taken from reports written by clinical neuropsychologists at the service. Patient demographics were taken from medical notes. Information on co-morbidities was collected primarily from brain injury clinic reports.

 

Measures

The neuropsychological testing variables measured were attention, memory, information processing, and executive functioning. Neuropsychological profile was considered intact when reported as “low average” or above. Where terms such as “difficulty”, “reduced”, “borderline”, or “impaired” were used as descriptors in reports they were coded as a deficit. In cases where children had no deficit on initial neuropsychological testing and were subsequently discharged without further testing, it was assumed that they would not develop deficit later on.

This research also collected data on variables concerning other sequelae of ABI including mood/behavior, fatigue, gross and fine motor deficit, receptive and expressive language deficit, visual impairment, and hearing impairment. These deficits were determined by whether they were mentioned as ongoing issues in clinical letters and other medical notes during the set follow-up periods.

 

Statistical analysis

Quantitative analysis was undertaken using STATA 11 SE.  Where possible, variables were coded dichotomously for analysis using Fisher’s Exact Test to look for a relationship with attendance at school or provision of aide. Ordered logistical regression examined which variables (severity, neurological findings, or co-morbidities) were predictive of school attendance.

 

Ethics approval

Ethics approval was obtained from the Services Improvement Unit at The Children’s Hospital at Westmead, NSW, Australia, approval number: QIE-2011-02-09.

 

Results

Participant demographics (Table 1)

Of the 158 identified cases, 104 cases met the inclusion criteria.  Age at time of injury was between 8-16 years, with the mean age at time of injury being 12.4 years. There were 48 children with severe injury, 48 with moderate injury and 1Table 1.)vehicle accidents. CT/8 with non-traumatic injury, mostly haemorrhage from rupture of arteriovenous malformations. 62.5% were male and three quarters came from urban residencies. 37.5% of injuries were due to falls and 31.7% of children were involved as passengers or pedestrians in motor vehicle accidents. CT and MRI data was collected for 85.6% patients, of which 82% showed abnormalities.

Table 1. Patient demographics of children with moderate to severe acquired brain injury.†
† Note that information is only reported for those cases where it was available.
Undefined cases are cases that were clinically moderate to severe but GCS and PTA were not clearly recorded.

Outcomes

Neuropsychological deficit (Table 2)

Sex and age at onset were not associated with any significant differences in neuropsychological outcomes. As expected, severe ABI has a trend towards more deficits as compared to moderate ABI. Children often had deficits in more than one domain, and children with severe injuries had higher rates of reported deficits. Almost all cases of children who had no deficits on neuropsychological testing were children with moderate ABI. Over time, there was improvement in the numbers of children with reported deficits across attention, memory, information processing, and executive functioning. There was no increase in incidence of deficits over time. Many children with deficits recorded at 0-6 months recovered by 18 or 30 months of follow-up.

Table 2. Number of children with moderate to severe acquired brain injury with neuropsychological deficits at follow up. †Non-traumatic cases had consequences considered to reflect moderate to severe ABI but there was insufficient information on GCS for status to be clearly defined. Note that information is only reported for those cases where it was available. This table therefore does not report on the entire sample of 104. Undefined cases are cases that were clinically moderate to severe but GCS and PTA were not clearly recorded.

Co-morbidities

The most common complaints reported were headache, fatigue, and dizziness. From 0-6 months, 62 children reported fatigue. Mood and behavioural problems were also common, with 61 children reporting problems between 0-6 months, 38 at 6-18 months, and 25 at 18-30 months. Persistence of mood and behavioural problems discussed by parents and children at rehabilitation clinics even two-and-a-half years after injury reflects the ongoing difficulties faced by children with ABI even after physical injuries have healed.

Fine motor deficits were slightly more common than gross motor deficits. For gross motor deficits, from 0-6 months, there were a greater number of children with impaired mobility requiring aid, than those without aide, but between 6-30 months, the majority of children with impaired mobility were able to walk without an aide. Over a fifth of children had initial reports from brain injury clinic reviews describing receptive or expressive language problems, but two thirds of these were resolved by 30 months follow-up. Between 2-8% of children experienced vision or hearing problems after ABI. Except for fine motor deficits, co-morbidities were most frequently recorded during the first 6 months. The frequencies of co-morbidities were recorded at each of the follow-up time points (Table 3).

Table 3. Frequency of co-morbidities reported for children with moderate to severe ABI at follow-up.†
†Note that information is only reported for those cases where it was available for all co-morbidities. This table therefore does not report on the entire sample of 104.

School attendance

Attendance improved over time; most part-time students transitioned into full-time schooling by 18 months (Figure 1). At the end of 18-30 months follow up, 6.9% (n = 87) remained unable to return to full-time schooling.

Figure 1. School attendance for 104 children with moderate to severe brain injury over follow up.

Ordered logistic regression was performed to identify predictors of school attendance. As expected, injury severity was negatively associated with full-time school attendance at 0-6 months post-injury. A child with severe ABI was five times less likely to attend school within six months post-injury than a child with moderate ABI (Table 4). There was a significant difference in school attendance at 18 months post-injury for children with moderate versus severe injury (p < 0.05). No relationship was found at 30 months (p > 0.2). No significant statistical impact of individual neuropsychological measures and attendance of schooling was found.

Table 4. Ordered logistical regression of attendance 0-6 months for 63 children with moderate to severe ABI.†
†SE= Standard Error.
Likelihood Ratio chi2(2) = 24.58 Prob > chi2 = 0.0000
Log likelihood = -52.060058 Pseudo R2= 0.191

Of the co-morbidities measured, it was found that injury severity and language deficit (independently and in combination) were negatively associated with full-time school attendance at 0-6 months post-injury. A child with a receptive or expressive language deficit was ten times less likely to attend school within six months post-injury than a child without a known language deficit.

 

School aide and change of school

Classroom aide was received by 3.3% of children at 0-6 months follow-up, by 12.8% at 6-18 months, and by 13.4% at 18-30 months. There was a significant difference according to injury severity for provision of a teaching aide at 18-30 months (p < 0.03). Special classes or educational programs were provided for 1.1% of children at 0-6 months follow-up, by 5.3% at 6-18 months, and by 7.2% at 18-30 months. There was some overlap with children receiving both aide assistance and attending a special class. During follow-up, seven children required a change of school for reasons relating to their ABI. Of these children, five had experienced severe ABI.

 

Discussion

This study describes the pattern of children in accessing schooling and special education or aide support following ABI.  Extended absences from school are one of the initial challenges facing children after ABI; 17.6% of children in our study population did not attend school in the first six months post-ABI. Whilst hospital and home schooling were sometimes available, this represents a considerable time difference in which children with ABI may fall behind their peers.  This study found that a combination of severity of injury and language deficit were found to be predictive of attendance in the first six months after injury. The involvement of language as a predictive factor is important, as it is modifiable. Language is important to complex learning and adaptation and contributes to understanding shared meanings in contexts such as school [18,19]. Language intervention programs may be able to facilitate earlier transition back to school. This study shows that the great majority (93%) of children with moderate or severe ABI will be able to return to full-time schooling. It also shows that the majority of these children are not given provision of classroom aides, special classes, or educational programs.

Attention to classroom instructions, reasoning and expression of ideas, and self-monitoring are all important features of good reintegration to schooling [20]. Children with severe ABI accounted for a greater proportion of neurological deficits in every domain measured (intellect, attention, memory, executive function, and information processing), and 44 of the 45 children with no reported neuropsychological deficits on testing had only moderate ABI. Our study reinforces that there is great variability in the way that ABI affects children, but severe ABI generally has a poorer prognosis and such children may experience greater challenges when returning to school. It is reassuring to note that time can help reduce the burden of ABI, with prevalence of neuropsychological deficits generally improving during follow-up. Longer-term studies suggest that intellect and personality problems may resolve by adulthood, but that reduced quality of life in relation to education and employment can persist [1]. Further long-term follow-up of these patients may be valuable in investigating this. Our study also found that attendance also improves with time, as 89.7% of children were able to resume full-time schooling by 30 months post-injury.

The presence of a classroom aide and modified learning programs is important in exploring whether the ongoing needs of children with ABI are met by schools. Our study found that 13% were provided with classroom aide during 30 months of follow-up. The provision of aid was found to increase over time. This may be accounted for by the inability of children with severe injuries to return to school early but another possible explanation is that there is a delay in the processing and provision of aid.

Quality of aide provision and the satisfaction children and their families had with the schooling system were not measured in this study. This is a possible avenue for future research, as general school educators and also special education teachers often do not have specialised training for working with children with ABI.  TBI Consulting Team and BrainSTARS are two promising models currently available for improving professional development of educators in caring for children with ABI, but both require further studies to show objective improvement [21].

In our study, some children reported needing to repeat a year of school. Grade repetition is known to be a de-motivating process that can affect homework completion and predict greater amounts of school absence [22]. A possible direction for future research would be to examine how common grade repetition is amongst the ABI population.

 

Strengths and limitations of this study

This study addresses the need for a better understanding of educational outcomes for children with moderate to severe ABI. The follow-up time of 30 months also provides a clearer understanding of how outcomes change over time. Additionally, this study deals specifically with school attendance and provision of aide time, two outcomes which are often overlooked in studies describing participation of children in the community following ABI.

The study also provides important information regarding predictors of attendance in the first six months of schooling. Whilst severity has been a known predictor, language has not been a focus for research previously. This new information may help guide health and education professionals in providing appropriate resources to ensure the best educational outcomes for children with ABI [23].

This study had a number of methodical limitations. Due to the highly variable nature of ABI and the small sample size, subgroup analysis was limited. As the study was retrospective there were a number of missing data fields. The results may underestimate true incidence of neuropsychological deficits as standard clinical practice does not comprehensively test children at all points of follow-up if no changes are expected or testing is not necessary. A larger, prospective study of educational outcomes would provide more data for studies with larger patient cohorts to be undertaken in order to confirm our results [24].

The study did not include a control group so confounders were minimised by excluding children with previous intellectual deficits, moderate to severe brain injury, schooling problems, or behavioural difficulties.

This study was unable to detect differences for children who were previously above average, but dropped into an average category on neuropsychological testing. Unfortunately, pre-morbid capabilities are difficult to quantify without formal testing. This study would not consider these children to have a deficit even though they have experienced a change in abilities. Any changes in abilities should not be discounted as they can still negatively impact the expectations and lifestyle of children and their families.

 

Conclusion

Children with moderate to severe ABI experience a wide range of neuropsychological and physical co-morbidities that can persist for at least 30 months following injury. Greater severity of injury and presence of language deficit are predictive of school attendance of children in the first six months following ABI. 13% of children required additional aide support or involvement in special classes. Over a third of children still reported fatigue and behavioural problems at 30 months follow-up. This study shows that whilst patients and families experience a long and difficult process of recovery, they may be able to expect improvements over time, and children are very likely to have returned to full-time schooling by 30 months post-injury.

 

Acknowledgements

I would like to thank Dr Angela Morrow for her supervision and guidance throughout this research project. I would further wish to express my gratitude to Dr Barzi for great assistance with the statistics and to Julie-Anne Macey, who came up with the research concept. I would also like to thank Dr Patrina Caldwell for her encouragement and invaluable feedback during the editing process.

 

References

[1] Anderson V, Brown S, Newitt H, Hoile H. Long-term outcome from childhood traumatic brain injury: intellectual ability, personality, and quality of life. Neuropsychology. 2011;25(2):176-84.

[2] Anderson V, Le Brocque R, Iselin G, Eren S, Dob R et al. Adaptive ability, behavior and quality of life pre and posttraumatic brain injury in childhood. Disabil Rehabil. 2012.

[3] Aitken ME, Mele N, Barrett KW. Recovery of injured children: parent perspectives on family needs. Arch Phys Med Rehab. 2004;85(4):567-73.

[4] Catalano RF, Oesterle S, Fleming CB, Hawkins JD. The importance of bonding to school for healthy development: findings from the social development research group. J School Health. 2004;74(7):252-61.

[5] Beaulieu CL. Rehabilitation and outcome following pediatric traumatic brain injury. The Surgical Clinics of North America. 2002;82(2):393-408.

[6] Stewart-Scott AM, Douglas JM. Educational outcome for secondary and postsecondary students following traumatic brain injury. Brain Injury. 1998;12(4):317-31.

[7] Sharp NL, Bye RA, Llewellyn GM, Cusick A. Fitting back in: adolescents returning to school after severe acquired brain injury. Disabil Rehabil. 2006;28(12):767-78.

[8] Galvin J, Froude EH, McAleer J. Children’s participation in home, school and community life after acquired brain injury. Aust Occup Ther J. 2010;57(2):118-26.

[9] Anderson V, Catroppa C, Morse S, Haritou F, Rosenfeld J. Functional plasticity or vulnerability after early brain injury? Pediatrics. 2005;116(6):1374-82.

[10] Anderson VA, Catroppa C, Haritou F, Morse S, Rosenfeld JV. Identifying factors contributing to child and family outcome 30 months after traumatic brain injury in children. J Neurol Neurosur PS. 2005;76(3):401-8.

[11] Catroppa C, Anderson VA, Morse SA, Haritou F, Rosenfeld JV. Outcome and predictors of functional recovery 5 years following pediatric traumatic brain injury (TBI). J Pediatr Psychol. 2008;33(7):707-18.

[12] Catroppa C, Anderson V. Recovery in memory function, and its relationship to academic success, at 24 months following pediatric TBI. Child Neuropsychol. 2007 May; 13(3):240-61.

[13] Miller LJ, Donders J. Prediction of educational outcome after pediatric traumatic brain injury. Rehabil Psychol. 2003;48:237–241

[14] Neuroimaging. 2012;22(2):e1-e17.

Arnett AB, Peterson RL, Kirkwood MW, Taylor HG, Stancin T et al, Behavioral and cognitive predictors of educational outcomes in pediatric traumatic brain injury. J Int Neuropsychol Soc. 2013;19(8):881-9.

[15] Pinto PS, Poretti A, Meoded A, Tekes A, Huisman TA. The unique features of traumatic brain injury in children. Review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications and their imaging findings–part 1. J Neuroimaging. 2012;22(2):e1-e17.

[16] Welfare AIoHa. Disability in Australia: trends in prevalence, education, employment and community living. Canberra: AIHW, 2008.

[17] Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4.

[18] Marlowe WB. An intervention for children with disorders of executive functions. Dev Neuropsychol. 2000;18(3):445-54.

[19] Ewing-Cobbs L, Barnes M. Linguistic outcomes following traumatic brain injury in children. Semin Pediat Neurol. 2002;9(3):209-17.

[20] Semrud-Clikeman M. Pediatric Traumatic Brain injury: rehabilitation and transition to home and school. Appl Neuropsychol. 2010;17(2):116-22.

[21] Glang A, Todis B, Sublette P, Brown BE, Vaccaro M. Professional development in TBI for educators: the importance of context. J Head Trauma Rehab. 2010;25(6):426-32.

[22] Martin AJ. Holding back and holding behind: grade retention and students’ non-academic and academic outcomes. Brit Educ Res J. 2010;37(5):739-63.

[23] Hawley CA, Ward AB, Magnay AR, Mychalkiw W. Return to school after brain injury. Arch Dis Child. 2004;89(2):136-42.

[24] Slomine B, Locascio G. Cognitive rehabilitation for children with acquired brain injury. Dev Disabil Res Rev. 2009;15(2):133-43.

Categories
Feature Articles

Personal reflection: how much do we really know?

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“Hurry up with that blood pressure and pulse,” blurts the ED registrar. “And make sure to do it on both arms this time.” Before I can ask him what’s going on, he’s teleported to the next bed. Great. I’m alone again. But I don’t blame him; it’s a Saturday night, and a volunteer medical student is the least of his worries.

I fumble for what seems like an eternity with the blood pressure cuff, but eventually get it on, much to the amusement of a charge nurse eyeballing me from the nurses’ station. Recording the right arm was textbook, so now it was just the left arm to do. I listen hard for the Korotkoff sounds, but there was nothing. I shut my eyes in a squeamish hope that it might heighten my hearing, but nothing again. I can feel the charge nurse staring again; I fluster and break a cold sweat. I feel for the left radial pulse, but it repeatedly flutters away the moment I find it. I remember thinking: Gosh. Am I really that incompetent? Embarrassed, I eventually concede defeat and ask for a nurse who tells me she’ll be there “in a minute.”

Amidst all this confusion, was John—my patient. I’d gotten so caught up with ‘Operation Blood Pressure’ that I completely forgot that he was lying there with a kind of graceful patience. I quickly apologised and introduced myself as one of the students on the team.

“It’s all right. You’re young; you’ll eventually get the hang of it… Have to start somewhere, right?” His voice had a raspy crispness to it, which was quite calming to actually hear against the dull rapture of a chaotic emergency room.

John was one of those lovely elderly persons who you immediately came to admire and respect for their warm resilience; you don’t meet too many gentlemen like John anymore. Despite his discomfort, he gave me a kind smile and reached out with his right hand to reassuringly touch my hand. It was a beautifully ironic moment: There he lay in bed, and there I stood by his bedside. And for a moment, there I was the patient in distress, and there he was the physician offering me the reassurance I so desperately needed.

Patients teach us to be doctors. Whether it is a lesson in humility or a rare diagnostic finding, patients are the cornerstone of our ongoing clinical expertise and development; they are why we exist. The more we see, the more we learn. The more we learn, the better doctors we become. Sir William Osler was perhaps the first one to formally adopt this into modern medical education. After all, the three-year hospital residency program for training junior medicos was his idea, and is now a curriculum so widely adopted that it’s almost a rite of passage all doctors make.

But how much clinical exposure are we really getting nowadays? With the betterment of societal health, there is a reduced prevalence and incidence  for  rarer  diseases.  Epidemiologically  this  is  undoubtedly a good thing, but it does sadly reduce learning opportunities for upcoming generations of doctors. Our clinical accruement is premised on seeing and doing; through experiences that shape our clinical approach. Earlier this year, an African child presented with mild gut disturbances and some paralysis of his lower limbs. The case baffled three residents and a registrar, but after a quick glance from a consultant, the child was immediately diagnosed with polio (which was confirmed later by one of the myriad of tests the panicking residents had ordered earlier). We’d all read about polio, but either through the lack of clinical exposure or careless assumptions that polio was all cured; we were quick to overlook it. We can only diagnose if we know what we are looking for.

It’s not surprising that preceding generations of senior doctors (and those before them) have such perceived superior clinical intellect, not just with the breadth of their clinical knowledge but with their almost Sherlock Holmes senses of acuity to formulate diagnosis based primarily off history taking and physical examination. Traditionally it is advertised in textbooks that 90% of diagnoses should be made from the history and examination alone. Nowadays, with the advent of improving diagnostic technologies in radiology and pathology, it isn’t surprising that a number of us have replaced this fundamental skill with an apparent dependence on expensive invasive tests. In a recent study physicians at their respective levels were assessed on their ability to identify heart murmurs and associate it with the correct cardiac problem. Out of the 12 murmurs: interns correctly identified 5, senior residents 6, registrars 8 and consultants 9. Makes you wonder how long ago it was when physicians could identify all twelve. I remember an ambitious surgical resident saying – Why bother diagnosing murmurs when you can just order an echocardiogram? And I remembered the humbling answer a grandfather consultant had for him – Because I’m a real doctor and I can.

As for poor John, I was still stuck with getting a blood pressure for his left arm. Two hours earlier, I responded with the ambulance to John at his home, a conscious and breathing 68 year old complaining of severe headaches and back pain. John was a war veteran who lived independently and sadly had no remaining family to care for him. He has had a month’s history of worsening headaches and lumbar back pain with associated sensory loss particularly in his lower limbs that has been affecting his walking recently. Physical exam confirmed his story and he was slightly hypotensive at 100/65 mmHg, but otherwise his ECG and vitals were generally unremarkable. He otherwise looked to be a healthy 68 year old with no significant past medical history. Funnily enough, he’d just been sent home from ED earlier in the day for the same complaint.  As far as we could tell, he was just another old guy with a bad headache, back pain, and possibly sciatica. It wasn’t surprising that he was sent home from ED this morning with a script for Celecoxib, Nurofen, and instructions to follow-up with his GP.

I’ll remember from this moment onwards that when a nurse says that they’ll be a minute, it’s actually a metaphor of an ice age. I eventually decide to fess up to the registrar that I couldn’t do the blood pressure properly. He gives me a disappointing look but I concluded that honesty is usually the best option in healthcare — well, at least, over pride. I remembered reading a case earlier that week about a medical student who failed to admit that he was unable to palpate the femoral and left radial pulses in a neonate, and subsequently missed an early diagnosis of a serious aortic coarctation, which in the end was discovered the following morning after the baby had already become significantly blue and cyanosed overnight.

Much to my relief, the registrar couldn’t find the blood pressure either and ruled it as pathologic. He disappeared to have a word with his consultant, with both of them quickly returning to the bedside to take a brief history from the patient. By that point, the nurse had finally arrived along with a couple more students and an intern. John had an audience. It was bedside teaching time.

“So apparently you’re God?” John asked the consultant, breaking the seriousness of the moment. We all simultaneously swivel our heads to face the consultant liked starved seagulls, only we weren’t looking for a fried chip but craving for a smart response to scribble in our notebooks.

“To them,” the consultant looks at us, “I am. As for you, I’m not sure.” “I survived getting shot you know, during the war…it just nicked some major artery in my chest…clean shot, in the front and out the back… army docs made some stitches, and I healed up just fine by the end of the month. I’ve been fit as a fiddle since—well, at least, up until these last few months.”

The rest of the history was similar to what I’d found out earlier, but I was slightly annoyed and almost felt betrayed that he’d failed to mention this to me earlier.

The fictional TV Dr Gregory House has a saying that “everybody lies.” It’s true to an extent, but I don’t think patients do it deliberately. They generally might discount or overlook facts that are actually an essential part of the diagnostic process; they are human after all (and so are we). There are the psychiatric exceptions, but for the most part, patients do have the good faith of wanting to help us to help them get better. While sending a team of residents to break into a patient’s house is not usually the preferable choice (unless you’re Dr House), we usually try and pick up these extra clues by knowing what questions to ask and through the comfortable rapport we build with our patients as we come to understand them as a person. The trick is to do all of this in a 10 to 15 minute consult.

 

The consultant quickly did a physical exam on John. He closed his eyes as he listened to his chest. And then, a very faint smile briefly came across his face — the epiphany of a pitifully murmuring heart.

“We’re probably going to run some tests to confirm this,” he informs John before turning to us, “but I suspect we might have a case of a dissecting aorta.” Of course; why didn’t I think of that? Hindsight’s always 20-20, but I continue to kick myself for missing that murmur, and not making the (now obvious) connection.

The consultant continues to command his lackeys to request an alphabet of tests. Soon enough the CT images return and it’s evident that there was blood dividing into a false lumen of the descending aorta (likely to have torn at the site where his gunshot injury had traumatised the vascular tissues from decades ago). Urgent surgery was booked, a range of cardiac medications commenced, and by the time I returned from documenting the notes, there was now a bunch of tubes sticking out of him.

The next time I see John is after his surgery and before he was transferred to the rehabilitation unit. I treasure our final meeting.

“So I beat the odds,” John threw a beaming smile towards me. He’s a trooper — I’ll definitely give him that. Assuming his initial dissectional tear occurred when he reported the onset of his headaches and lower back pain, he’d survived a dissecting aortic aneurysm for at least one whole month, not to mention a war before that. (The odds of dropping dead from an aortic dissection in the first 24 hours alone it’s 25%, in 48 hours it’s 50%, in the first week it’s 75% and in the first month it’s 90%.)

“Yes, you definitely beat the odds.” I smile back at him with a certain amount of gained confidence. Our eyes meet briefly, and beneath the toughened exterior of this brave man is the all-too-familiar softened reservoir of unannounced fear. Finally, I extend my hand to shake his and gently squeeze it; it is the blessing of trust and reassurance he first showed me as a patient that I am now returning to him as a physician.

Acknowledgements

None.

Conflict of interest

None declared.

Correspondence

E Teo: eteo@outlook.com

Categories
Letters

Surgical hand ties: a student guide

Surgical  hand  ties  are  a  procedural  skill commonly employed in surgery; however, student    exposure    to    practical    surgical experience  is  often  limited.  Students are therefore often excited at the opportunity to learn these skills to practise for themselves. Often the only opportunities to formally learn these skills come in the form of workshops presented at student conferences or run by university special interest groups.

Having attended such surgical skills workshops I have noticed the difficulty demonstrators and students have had in teaching and learning learn and master hand ties.

In addition to being an individual resource, this guide was also created for use in a workshop setting. Ideally, a demonstrator would show the students the basic steps involved in hand ties. The guide could then be used to reinforce this learning, where the student can practise with the sutures in their hands while following the steps using a combination of pictures, text, and memory aids. This would also have the benefit of letting the demonstrator help students with more specific questions on technique, rather  than  repeating  the  same the skill of surgical hand ties. I felt this was the product of two things: the difficulty the tutors had in demonstrating the small movements of the fingers to an audience; and the students’ difficulty with remembering each step later. Therefore, I combined an easy to follow graphic with some helpful memory aids into a simple resource to help medical students demonstration multiple times.

The overall aim of this guide is to make the process of learning and teaching surgical hand ties to students easier, and to improve recall and proficiency for students performing the skill through the use of simplified steps and diagrams.

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Acknowledgements

None.

Conflict of interest

None declared.

Correspondence

J Ende: jesse@ende.com.au