Tag: University of Tasmania

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Case Reports

Medication-induced acute angle-closure glaucoma: a case study

Acute angle-closure glaucoma, is an uncommon condition. It is an emergency associated with the potential for significant vision loss and unilateral blindness if not diagnosed and treated promptly. This case describes a classic presentation of angle-closure glaucoma, highlighting the potential of certain medications to precipitate acute angle-closure glaucoma in at-risk individuals. Although the incidence is uncertain, it is thought that a significant number of cases may be medication-induced, and so it is important to be aware of what medications may precipitate acute angle-closure and have a plan for assessing and managing this small but real risk. In addition, patients should be warned of possible ocular symptoms and advised to seek urgent medical attention if they occur. In a presentation of acute angle-closure glaucoma, the key management is urgent reduction of intraocular pressure and ophthalmology referral

Case

A 65-year-old female presented to her general practitioner with a painful, red left eye associated with blurred vision and nausea. She had commenced paroxetine for management of depression three weeks prior. On examination, best-corrected visual acuity was 6/19 in the left eye, 6/6 in the right. The left pupil was mid-dilated and fixed. Examination was otherwise normal. An urgent ophthalmology review was organised and a diagnosis of acute angle-closure glaucoma was made.

Though uncommon in Australia, acute angle-closure glaucoma (AACG) is a medical emergency that requires rapid diagnosis and reduction of intraocular pressure to prevent permanent vision loss. [1,2]

Discussion

Epidemiology

Glaucoma is the second leading cause of vision loss worldwide, with an estimated 79.6 million people to be affected in 2020. Though approximately 74% of cases worldwide are open-angle glaucoma, it is projected that 5.3 million people will be legally blind due to AACC in 2020, comparable to the 5.9 million estimated to be blind due to open-angle glaucoma. [2]

Pathogenesis

Overwhelmingly, the most common cause of angle closure crisis is pupillary block. Aqueous humour normally flows between the pupil and lens, from the posterior chamber to the angle of the anterior chamber of the eye, where it then drains across the trabecular meshwork. When the pathway between the lens and iris is blocked, aqueous accumulates behind the iris, pushing it anteriorly and blocking the trabecular meshwork, thus preventing aqueous drainage. [3] When this occurs, intraocular pressure (IOP) rapidly becomes elevated, frequently reaching pressures greater than 60 mmHg, rapidly causing glaucomatous optic neuropathy if untreated. [4] Eyes with pre-existing anatomic narrow angles are predisposed to acute angle-closure.

Medication-induced angle-closure

Medication-induced angle-closure has been reported to cause a significant proportion of AACC cases in developed countries. [5] Consequently, it is important to be aware of the risk when prescribing implicated medications. The underlying mechanism may be due to pupil dilatation (mydriasis) as a medication side effect, or due to choroidal effusion, causing swelling of the ciliary body and forward movement of the lens and iris towards the chamber angle. [4,6]

Ophthalmic mydriatics are a well-known precipitant of angle-closure crisis, but other medications with mydriatic effects also carry risk. Importantly, this includes several classes of antidepressants: selective-serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and serotonin–noradrenaline reuptake inhibitors. [7] Visual disturbance has frequently been a cause of SSRI withdrawal and it has been suggested that SSRI-induced intraocular pressure elevation may be underestimated. [8]

Any medication with sympathetic or anticholinergic effects has theoretical potential to precipitate angle-closure in at-risk eyes. Other drugs implicated include phenothiazine antipsychotics, antihistamines, benzhexol, over-the-counter medications containing phenylephrine, nebulised ipratropium bromide and salbutamol. [4,9]

Topiramate, an anticonvulsant commonly used to treat epilepsy and for migraine prophylaxis, has commonly been reported as a precipitant of AACC in the literature due to choroidal effusion. A report suggested topiramate may be the most common cause of AACC in individuals under the age of 40. [11] The risk is thought to be due to the sulfur component of the drug. Other sulfur-containing medications, including acetazolamide, have been reported as precipitants, though only rarely, so should therefore not be used to treat topiramate-induced angle-closure. [6,9,10]

Drug-induced acute angle-closure usually develops soon after initiation of treatment, and generally within 30 days. Whilst AACC classically presents with a unilateral red eye with pain and reduced vision, bilateral presentations may occur and are more common in medication-induced cases. If symptoms are consistent with angle-closure crisis, a high index of suspicion must be maintained. [11,12]

Clinical implications

Clinicians should be aware of medications associated with increased risk of angle-closure glaucoma, and consider and warn the patient of this small possibility when initiating these medications. [13] The risk of causing angle-closure when dilating pupils is very low (estimated 1 in 20 000) and mydriatics should always be used when performing a complete fundus examination. A good choice of medication to minimise risk is tropicamide 0.5%. [14]

It would be impractical for an ophthalmologist to review every patient before prescribing many of the associated medications, however, a brief history of ocular symptoms should be taken and the risk profile of the patient stratified. [9]

Acute angle-closure risk factors include:

  • Advanced age
  • Asian ethnicity
  • Severe hyperopia (beware of the patient wearing thick glasses)
  • Known shallow anterior chamber, or occludable angle
  • Family history of blindness suspicious for angle-closure glaucoma

The oblique flashlight test, a simple way to estimate anterior chamber depth, should be performed (Figure 1). A light is shined onto the temporal iris. If the anterior chamber is deep, the iris will be uniformly illuminated. Shadowing of the nasal iris indicates the anterior chamber may be shallow, increasing risk of anterior chamber angle occlusion. The test is only 45.5% specific, but is 82.7–91.7% sensitive and may be performed rapidly. [15,16]

Figure 1. Oblique Flashlight Test. Uniform illumination of the iris indicates a deep anterior chamber
Figure 1. Oblique Flashlight Test. Uniform illumination of the iris indicates a
deep anterior chamber

Patients should be warned of ocular symptoms and their significance at first prescription of implicated medications, particularly if identified to be at high risk. If at high risk, an ophthalmology referral should be considered to evaluate the degree of openness of the angle that is prone to angle-closure. [9,13] On review after initiating implicated medications, it is important to ask patients whether they have experienced any ocular symptoms. [17]

It is important to note that open-angle glaucoma is a separate condition and patients with this condition should not be denied medications associated with angle-closure glaucoma. [18]

Treating angle-closure glaucoma

Immediate treatment goals are rapid reduction of intraocular pressure and symptomatic relief. Intravenous mannitol 5–10 mL/kg of 20% solution, given over 30 minutes, will cause a rapid, temporary reduction in intraocular pressure. [19] Intravenous or oral acetazolamide may also be required. Topical medications, including timolol, prednisolone, and brimonidine, may be used. [10] A miotic, such as pilocarpine, is used to constrict the pupil. This will pull the peripheral iris away from the angle, thereby opening drainage through the trabecular meshwork. Antiemetics and analgesics should be given as needed, and the patient should be supine, in an attempt to prevent further anterior movement of the lens. Any medications possibly contributing should be ceased. [5,12]

Definitive treatment is laser iridotomy, performed by an ophthalmologist. An opening is made in the peripheral iris, allowing free flow of aqueous between posterior and anterior chambers, allowing equilibration of pressure between the chambers, thus preventing the occurrence of pupillary block. Both eyes are treated, even in unilateral presentations, as the fellow eye is likely to have the same narrowed angles, which increases the risk of angle-closure. [3,11]

Consent

Informed consent was obtained from the patient for publication of this case report. Informed consent was obtained from individuals photographed for the purposes of this report.

Conflict of Interest

None declared.

References

[1] Wensor M, McCarty C, Stanislavsky Y, Livingston P, Taylor H. The prevalence of glaucoma in the Melbourne Visual Impairment Project. Ophthalmology. 1998;105(4):733-9.

[2] Quigley H, Broman A. The number of people with glaucoma worldwide in 2010 and 2020. Brit J Ophthalmol. 2006;90(3):262-7.

[3] Masselos K, Bank A, Francis IC, Stapleton F. Corneal indentation in the early management of acute angle closure. Ophthalmology. 2009;116(1):25-9.

[4] Subak-Sharpe I, Low S, Nolan W, Foster PJ. Pharmacological and environmental factors in primary angle-closure glaucoma. Brit Med Bull. 2010;93:125-43.

[5] Lachkar Y, Bouassida W. Drug-induced acute angle closure glaucoma. Curr Opin Ophthalmol. 2007;18(2):129-33.

[6] Chen T, Chao C, Sorkin J. Topiramate induced myopic shift and angle closure glaucoma. Brit J Ophthalmol. 2003;87(5):648-9.

[7] de Guzman M, Thiagalingam S, Ong P, Goldberg I. Bilateral acute angle closure caused by supraciliary effusions associated with venlafaxine intake. Med J Australia. 2005;182(3):121-3.

[8] Costagliola C, Parmeggiani F, Sebastiani A. SSRIs and intraocular pressure modifications: evidence, therapeutic implications and possible mechanisms. CNS drugs. 2004;18(8):475-84.

[9] Razeghinejad M, Pro M, Katz L. Non-steroidal drug-induced glaucoma. Eye (Lond). 2011;25(8):971-80.

[10] Ybarra M, Rosenbaum T. Typical migraine or ophthalmologic emergency? Am J Emerg Med. 2012;30(5):831.

[11] Pokhrel P, Loftus S. Ocular emergencies. Am Fam Physician. 2007;76(6):829-36.

[12] Amerasinghe N, Aung T. Angle-closure: risk factors, diagnosis and treatment. Prog Brain Res. 2008;173:31-45.

[13] Cackett P. Funduscopy: to dilate or not? Other drugs can cause partial pupil dilatation. Brit Med J. 2006;332(7534):179.

[14] Liew G, Mitchell P, Wang JJ, Wong TY. Fundoscopy: to dilate or not to dilate? Brit Med J. 2006;332(7532):3.

[15] Yu Q, Xu J, Zhu S, Liu Q. A role of oblique flashlight test in screening for primary angle closure glaucoma. Yan Ke Xue Bao. 1995;11(4):177-9.

[16] He M, Huang W, Friedman D, Wu C, Zheng Y, Foster P. Slit lamp-simulated oblique flashlight test in the detection of narrow angles in Chinese eyes: the Liwan eye study. Invest Ophth Vis Sci. 2007;48(12):5459-63.

[17] Lai J, Gangwani R. Medication-induced acute angle closure attack. Hong Kong Med J. 2012;18(2):139-45.

[18] Razeghinejad M, Myers J, Katz L. Iatrogenic glaucoma secondary to medications. Am J Med. 2011;124(1):20-5.

[19] Mannitol. Australian Medicines Handbook [internet]. 2013 [cited 2014 March 1] Available from: http://www.amh.net.au/online/

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Letters Articles

End-of-life issues in the emergency department

In AMSJ Vol. 3, Issue 2, Michael Li provided an insightful and personal dissertation on the futility of medical treatments and the potential of students to relate to and support patients and their families. [1] Li’s article captures one of the most confronting situations faced by all health professionals, in acknowledging the futility of aiming for a cure, and instead allowing the patient to succumb to their illness. In these situations, clinicians may experience thoughts of frustration, feelings of being powerless, guilt, a sense of professional or personal failure, and an awakened sense of human fragility and mortality. [2] However, the challenges posed by end-of-life decision making across the divergent fields of medicine are not identical. Emergency medicine has long been held as a field of medicine centred upon recognising, treating and stabilising patients with acute illness before they receive definitive care. This is now changing and emergency physicians are experiencing an increasing responsibility for patients with acute, sometimes terminal, exacerbations of chronic, incurable disease.  [3,4] Awareness of the values pertinent to end-of-life care, specifically within the emergency department setting, is critical to maintaining patient dignity and preventing unnecessay distress to the patient and their families.

The 24/7 availability of emergency departments and their functioning as the point of access to a range of hospital services, both therapeutic and diagnostic, often result in emergency doctors being the first medical personnel confronted by new or worsening symptoms in patients with advanced or terminal medical conditions. [3,5] Rosenwax et al. (2011) illustrated that emergency providers feature prominently in the care of patients with terminal illness, with 70%  of a Western Australian cohort of 1071 patients with terminal illness visiting the emergency department at least once in their last year of life and 4% on their final day of life. [4] Such exposure provides emergency physicians the opportunity to apply the tenants of palliative care in relation to patients with incurable, terminal disease, who are clearly suffering.[3] Despite its need, the decision regarding the extent of treatment appropriate is often a challenging one to make in the emergency setting. Emergency medicine is a field characterised by limited continuity of care and a highly mobile patient population, as highlighted by the national four-hour benchmark. [6] Consequently, emergency physicians rarely have the advantage of knowing a patient or their family and lack the background knowledge and unique rapport of a long-term therapeutic relationship. Physicians must also struggle against some ingrained cultural aspects and expectations tied to emergency medicine, where when in doubt aggressive resuscitation is the default. [7,8]

Strategies to increase the ability and confidence of emergency departments to manage patients nearing the end of life include increasing training and protocols around end-of-life care, improving the utilisation of palliative care services and improving access to palliative management information for novel situations. [3,9] Tasmania has recently instituted the Healthy Dying Initiative, a state-wide policy that includes ‘Goals of Care’ documentation. [10] A patient’s Goals of Care are documented on admission and range from ‘for all active treatment measures’ to ‘terminal’, with a range of medical and surgical management options in between. They aid after-hours patient management, clearly outlining treatment expectations and goals, and provide a link between hospitals and the community. As always, clear communication between medical practitioners, patients, families and allied health professionals is an essential component of providing good medical care.

In some situations, treating with curative intent may be futile, even harmful, but emergency doctors still have a major role to play in optimising patients’ overall quality of life and relieving suffering. Worthwhile goals that may outweigh the simple prolongation of life include reducing pain or preserving a patient’s independence, dignity or good neurological functioning. As Australian medical students, we are always progressing towards the moment when we take the lead responsibility for our patients. Considering how we can best benefit patients and their families when a cure is no longer an option and death appears imminent is a vital, if challenging, aspect of medical training. The emergency department is a setting we will all encounter during some stage of our training. While there may be unique challenges to achieving optimal end-of-life care in the emergency environment, awareness of these challenges and of the continuing importance of symptom relief across all domains of medicine will aid our practice as we endeavour to provide the best possible care and achieve the best possible outcome for each and every patient.

Conflict of interest

None declared.

Correspondence

C Ellis: cellis2@utas.edu.au

References

[1] Li, M. Dealing with futile treatment: A medical student’s perspective. AMSJ. 2012; 3(2): 8-60.

[2] Meier, D, Back, A, Morrison, R. The inner life of physicians and care of the seriously ill. JAMA. 2001; 286(23):3007-14.

[3] Forero, R, McDonnell, G, Gallego, B, McCarthy, S, Mohsin, M, Shanley, C, Formby, F & Hillman, K. A Literature Review on Care at the End-of-Life in the Emergency Department. Emerg Med Int. 2012; 2012

[4] Rosenwax, L, McNamara, B, Murray, K, McCabe, R, Aoun, S &Currow, D. Hospital and emergency department use in the last year of life: a baseline for future modifications to end-of-life care. MJA.  2011; 194(11): 570-73.

[5] O’Connor, A, Winch, S, Lukin, W & Parker, M. Emergency medicine and futile care: Taking the road less travelled. Emerg Med Australs. 2011; 23: 640-43.

[6] Indraratna, P &Lucewicz, A. In and out in four hours: The effects of the four-hour emergency department target on patients, hospitals and junior doctors. AMSJ. 2011; 2(2): 9-10.

[7] Smith, A, Fisher, J, Schonberg, M, Pallin, D, Block, S, Forrow, L, Phillips, R, MCCarthy, E. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med. 2009; 54(1):86-93

[8] Marco, CA. Ethical issues of resuscitation: an American perspective. Postgrad Med Journ.  2005; 81(959):608-12.

[9] Grudzen, C, Stone, S & Morrison, R. The palliative care model for emergency department patients with advanced illness. J Palliat Care Med. 2011; 14(8): 945-50.

[10] Department of Health and Human Services. Goals of care plan. http://www.dhhs.tas.gov.au/palliativecare/health_professionals/goals_of_care (accessed 8 March 2013).

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Letters Articles

International medical electives: time for a rethink?

International medical electives (IMEs) are rapidly growing in popularity. A recent study by Law and colleagues [1] conducted across Australia reported that 53% of graduate entry program students and 35% of high school entry students undertook IMEs, of which just over half were in developing countries. In some medical schools the majority of students head overseas for their electives. [2] This phenomenon is not restricted to Australia; in the United Kingdon (UK) and United States (US) roughly 40% of students reported having spent some time in developing countries. [3,4] Many universities across Australia now have global health interest groups, and an increasing proportion of graduating medical students report having some experience in overseas health. [4] Traditionally, these electives are unstructured and arranged on an ad hoc basis between local partners and medical students.

There are undeniable benefits to practicing medicine in an unfamiliar, foreign setting. Students often describe IMEs as one of the highlights of their time at medical school, and it can be an opportunity for unparalleled personal and professional development. On a personal level, students report increased confidence, broadened perspectives, increased cultural competence, and improved communication skills. [5] Professionally, students benefit from being exposed to uncommon conditions and the opportunity for more hands-on experience. [6,7] IMEs also have the potential to influence future practice, with students more likely to enter public service, serve underprivileged populations, and participate in volunteering. [8,9]

However, the results of the aforementioned studies have to be interpreted with caution. Unlike other aspects of the medical course, IMEs tend to be student driven and lack a structured curriculum. Therefore many of the outcome measures are highly subjective and were assessed with unvalidated questionnaires. Given the observational nature of these studies, it is difficult to establish a causative relationship between IMEs and outcome measures. There is also the potential for selection bias (for example, where IME participants were chosen based on their commitment to global health) and publication bias in this area. [8,10] Given the subjectivity of the current literature, it remains unclear if there are indeed any long-term benefits for medical students.

Of note, much of the research on IMEs has revolved around medical students from OECD (Organisation for Economic Cooperation and Development) nations instead of host institutions or patients. Given the short term, transient nature of many IMEs, it seems unlikely that there will be any long term benefits to the local institution. There is potential for limited, temporary benefits such as increased supply of resources, incorporation of new teaching ideas, and positive support from local communities. [5] However, even this can turn out to be a double edged sword, as local institutions develop reliance on visiting medical students. Furthermore, there are cases where the donated equipment end up draining more of the hospitals resources in the long run, or are unable to be maintained. This is not to say that there are not examples of IMEs that have had a positive impact. [11] However, these programs tend to be structured, continuous partnerships between hosts and visiting students with a clear long-term goal.  Unfortunately, the vast majority of IMEs lack such a structure.

A significant proportion of IMEs involve students from developed countries heading to less developed countries. These include pre-clinical students with little to no practical medical training. As students they require proper supervision and this puts added strain on already scarce resources in developing countries. In addition to this problem, many students perceive electives as a holiday, tending to be ill-prepared both culturally and medically for the experience. [3] In worst case scenarios, the student may be placed in a position where he expected to take on the role of a qualified physician and is given responsibility for their own patients. [12] There are several reports in the literature of junior medical students being asked to participate in potentially risky procedures such as lumbar puncture and tubal ligation. [13] Students often try to rationalise this by adopting a utilitarian viewpoint, arguing that no one would look after these patients if they did not step up to the plate. The moral boundaries in these situations are vague and to date there are few established guidelines. However medical students must bear in mind that practicing beyond one’s competency is a serious breach of medical ethics. Students risk doing more harm than good, particularly when they may not be fully aware of the complexities associated with unfamiliar medical conditions and treatments.

To further aggravate this problem, patients in developing countries tend to be vulnerable and greatly disadvantaged. The risk of students developing their skills at the expense of vulnerable patients is a very real one that is probably under-reported in the literature. [14] Anecdotally, we often hear of medical students speak proudly about having been able to perform surgeries or risky procedures on their own with little supervision. There is often a lack of critical reflection surrounding this phenomenon, and clear ethical guidelines should be developed for students.

The motivation behind IMEs is slowly evolving. Traditionally, altruistic reasons were often quoted as the driving factor in medical students pursuing IMEs where students had a genuine interest in serving resource poor areas. [15,16] However, gaining a competitive advantage with the increasing demand for experiences in developing countries has become an important motivating factor. Global health programs look good on a CV and with training programs becoming more competitive, the proportion of students participating in IMEs for this reason will increase.

The threat to medical students’ well-being during electives is often an aspect that is overlooked. Medical students are often drawn by the sense of adventure, opportunity for travel, and the chance for a unique experience different to that back home. At the turn of the century, there was strong concern due to the lack of preparation by visiting British medical students to areas with a high prevalence of HIV. [17] There are often reports of a range of infectious diseases, ranging from schistosomiasis, thyphoid fever, malaria, and dysentery. [2] Literature now demonstrates that adverse events go beyond the risk of HIV and other infectious diseases. Deaths and serious injury have occurred due to risks associated with overseas travel (such as road traffic accidents), suicide, crime and political issues. [18] Aside from physical harm, psychological trauma has also been reported. [18]

Numerous studies encourage pre-departure training as a way to increase awareness of  ethical issues, encourage critical self-reflection, and practical preparation. [13,19] In spite of the physical dangers and ethical dilemmas that are sometimes posed by IMEs, studies have shown that basic practical and ethical preparations for students travelling abroad was low. [20] Only three quarters of Australian medical schools offer pre-departure training, however only half of these are mandatory. [1] The average duration of pre-departure training was 4.7 hours. Only half of Australian medical schools offered post-elective debriefing, out of which roughly half was mandatory. [1] The average duration of post-elective debriefing was 1.2 hours. [1] Medical schools have a duty of care towards medical students and it seems surprising that there is a significant lack of preparation for what is often a unique and unusual experience.

With the increasing ease and affordability of international travel, IMEs will continue to have a growing appeal to medical students. However there is a dangerous lack of critical thought and reflection in terms of the ethical aspect of IMEs, as well as the possible threat to student well-being. Given the strong consensus in the literature for more structured global health education, medical schools should consider developing training programs aimed at enabling students to conduct considered, structured and sustainable IMEs.

Acknowledgement

Saion Chatterjee for his assistance and feedback in editing the draft manuscript.

Conflict of interest

None declared.

Correspondence

Y Foong: Yichao.Foong@utas.edu.au

References

[1] Law IR, Worley PS, Langham FJ. International medical electives undertaken by Australian medical students: current trends and future directions. The Medical journal of Australia. 2013;198(6):324-6. Epub 2013/04/03.

[2] Goldsmid JM, Sharples N, Bettiol SS. A Preliminary Study on Travel Health Issues of Medical Students Undertaking Electives. Journal of Travel Medicine. 2003;10(3):160-2.

[3] Dowell J, Merrylees N. Electives: isn’t it time for a change? Medical Education. 2009;43(2):121-6.

[4] Association of American Medical Colleges. Medical School Graduation Questionnaire Report: 2000. Washington, DC: October 2000.

[5] Mutchnick IS, Moyer CA, Stern DT. Expanding the Boundaries of Medical Education: Evidence for Cross-Cultural Exchanges. Academic Medicine. 2003;78(10):S1-S5.

[6] Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on US and Canadian medical students and residents: a literature review. Academic Medicine. 2003;78(3):342-7.

[7] Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global Health Training and International Clinical Rotations During Residency: Current Status, Needs, and Opportunities. Academic Medicine. 2009;84(3):320-5 10.1097/ACM.0b013e3181970a37.

[8] Ramsey AH, Haq C, Gjerde CL, Rothenberg D. Career influence of an international health experience during medical school. Fam Med. 2004;36(6):412-6. Epub 2004/06/08.

[9] Matar WY, Trottier DC, Balaa F, Fairful-Smith R, Moroz P. Surgical residency training and international volunteerism: a national survey of residents from 2 surgical specialties. Canadian journal of surgery Journal canadien de chirurgie. 2012;55(4):S191-9. Epub 2012/08/03.

[10] Imperato PJ. A third world international health elective for U.S. medical students: the 25-year experience of the State University of New York, Downstate Medical Center. Journal of community health. 2004;29(5):337-73. Epub 2004/10/09.

[11] Vora N, Chang M, Pandya H, Hasham A, Lazarus C. A student-initiated and student-facilitated international health elective for preclinical medical students. Medical education online. 2010;15. Epub 2010/02/27.

[12] Banatvala N, Doyal L. Knowing when to say “no” on the student elective: Students going on electives abroad need clinical guidelines. BMJ: British Medical Journal. 1998;316(7142):1404.

[13] Petrosoniak A, McCarthy A, Varpio L. International health electives: thematic results of student and professional interviews. Medical Education. 2010;44(7):683-9.

[14] Radstone SJ. Practising on the poor? Healthcare workers’ beliefs about the role of medical students during their elective. Journal of medical ethics. 2005;31(2):109-10. Epub 2005/02/01.

[15] Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. Journal of the American College of Surgeons. 2009;208(2):304-12.

[16] Huish R. The Ethical Conundrum of International Health Electives in Medical Education. Journal of Global Citizenship & Equity Education. 2012;2(1).

[17] Wilkinson D, Symon B. Medical students, their electives, and HIV. BMJ (Clinical research ed). 1999;318(7177):139-40. Epub 1999/01/15.

[18] Tyagi S, Corbett S, Welfare M. Safety on elective: a survey on safety advice and adverse events during electives. Clinical medicine (London, England). 2006;6(2):154-6. Epub 2006/05/13.

[19] Dharamsi S, Osei-Twum J-A, Whiteman M. Socially responsible approaches to international electives and global health outreach. Medical Education. 2011;45(5):530-1.

[20] Bozorgmehr K, Schubert K, Menzel-Severing J, Tinnemann P. Global Health Education: a cross-sectional study among German medical students to identify needs, deficits and potential benefits (Part 1 of 2: Mobility patterns & educational needs and demands). BMC Medical Education. 2010;10(1):66.

 

Categories
Feature Articles Articles

Burdens lifted, hopes restored

During the summer break of our third year of medicine at the University of Tasmania, we decided to embark on an elective at Padhar in India. The country of India fascinated us as an opportunity to experience a very different health care system and to learn more about the Indian culture.

Padhar is a small town located in Madhya Pradesh in the central highlands of India. It appealed to us because of its rural location. This tiny town boasts a 200 bed multispecialty missionary hospital, which initially started out in 1958 as a clinic. The hospital is often the first point of contact for many patients from surrounding states, including the Gond and the Korku tribals, and some patients travel for days to seek medical help here.

After fifteen hours of flying and an eventful 26 hour train ride, we arrived at Itarsi Junction, a two hour bumpy drive away from Padhar.

Padhar is declared endemic for malaria so we came ‘armed’ with insect repellents and mosquito coils. Despite our best efforts, we were not spared the wrath of the mosquitoes. We couldn’t help but feel paranoid when we got our first mosquito bites even though we took our doxycycline regularly.

Tuberculosis (TB) is a serious and common health problem in Padhar. We had not expected such a high prevalence to the extent that, for doctors in Padhar, the first differential diagnosis for a cough and a cold was often TB until proven otherwise. It was not uncommon to see the sorts of chest X-rays with cavitating lesions that we had previously only seen in textbooks.

Another difference we observed during our elective was the vastly differing attitudes to hygiene. In Australia we are well familiarised with the hand hygiene posters plastered all over hospital walls. In Padhar, in place of our ‘5 moments of hand hygiene’ signs are signs that read, ‘Gloves are useful but not necessary.’ The sanitation practices were also very rudimentary as basins of water and lemon replaced the sinks and chlorhexidine we had previously taken for granted.

Textbook photographs of patients with late presentations of cancer came to life in Padhar. Geographical barriers, as well as the habit of betel nut and tobacco chewing, often result in patients presenting with large tumours of the oral cavity. One of the cases we saw was that of a 45 year old man who presented for a surgical resection of a large squamous cell carcinoma on the left side of his tongue. The skilled surgeons at Padhar performed a COMMANDO Procedure (COMbined MANDibulectomy and Neck Dissection Operation). The surgeons are particularly skilled at this procedure as it is commonly performed. This is because late presentations of cancer are common here due to the lack of preventative screening, as well as geographical barriers and poverty. It saddened us to see that there is a huge health disparity between a developed and developing country.

However, despite disparities in health care systems, we found that generosity knew no boundaries. There were many charming patients and helpful medical staff whom we encountered during our time in Padhar. In particular, we met a pair of omphalophagus conjoined twins, who were four months old at the time of our visit. Their parents were poor farmers who were devastated when their twins were born, as they did not have the means to care for them. Therefore, they did what they thought was best for the twins, by returning home without them and leaving them in the hospital. Won over by the twins’ infectious smiles, the hospital staff decided to take them into their care. The current plan is to wait for the twins to reach ten kilograms before separating them. However, the amount needed to separate the twins is more than US$150,000, much more than the hospital can afford. In addition, the hospital would need to cover the cost of raising the twins. However, they are determined to raise the twins and provide them with the best life that they can have. The twins were constantly surrounded by nurses, doctors and other hospital staff. The care and love shown by the team in Padhar certainly tugged at our heartstrings.

We also saw other cases that taught us some fundamental rules about diagnosis and history taking. One was a sixteen year old girl who presented to the emergency department complaining of a five day history of progressively worsening generalised abdominal pain.. She had a background of trauma after a fall whilst collecting water from a well. Although injury to the jejunum is common after blunt force trauma, [1] the medical team had ruled it out as it would be expected to cause very significant pain, usually leading to immediate hospital presentation. Thus it came as a surprise when a perforated jejunum was found on X-Ray. This case reminded us that clinical presentations, though incredibly useful, can still be deceiving.

One of the highlights of the trip was being a part of the team involved in the Mobile Clinic under the Rural Outreach Program, which was an initiative of Padhar Hospital. The Mobile Clinic services the surrounding villages that have limited access to healthcare due to geographical barriers. More often than not, it would have been months or even years since the villagers engaged with the healthcare system.

The makeshift clinic attracted many people from the village and surrounding villages as people of all ages with a myriad of diseases lined up patiently to seek medical help. The most common presentation was scabies and we quickly ran out of Permethrin cream. As Padhar Hospital has always been passionate about contributing towards the fight against human immunodeficiency virus (HIV) we also took bloods from patients to test for HIV and educated them about the disease and the importance of safe sexual practices.

On the last few days of our trip, we were very lucky to be a part of Padhar’s celebration of World Aids Day. The prevalence of HIV/AIDS in India in 2009 was 2.4 million out of a population of 1.2 billion. [2] It was the aim of Padhar Hospital to raise awareness of HIV and AIDS in conjunction with this day. In the morning church service conducted in the hospital compound, testimonials were shared from HIV patients as well as doctors who had clinical contact with them. During the lunch break, the hospital invited school children from nearby primary schools as part of the awareness program. One of the interesting things they had in store for them was a parody of the stereotypes against HIV patients. It is good to see that, unlike for many in the older generations, these young minds were receptive to the idea that HIV is not a deadly infectious disease that spreads through touch. The children were educated about safe sex practices as well as informed about the availability of free needles.

Whilst seeing plenty of patients and medical staff gave us opportunities and insights into medicine, our elective was also a culturally enriching experience. Generally, people were curious about our backgrounds and it was good to be able to share our culture with them and learn about theirs too. It gave us a glimpse into a very different way of life to our own. We experienced firsthand the gracious hospitality of the locals; we were invited to be a part of one of the doctors’ daughter’s wedding, despite the fact that we have never met the bride before.

We also loved seeing the sights and sounds of the town and outskirts, from people bathing and doing their laundry in rivers to women in bright coloured sarees carrying urns twice the size of their heads. We also saw families of five piled onto motorcycles. We were touched by the hospitality that was shown by the villagers, despite the fact that we were foreigners who did not speak their language. Many villagers opened their homes to us and we had a chance to see how they live their life, which contrasted immensely to what we were used to. They cooked with firewood and had to walk a fair distance to collect water from wells. What touched our hearts was the fact that everyone seemed satisfied with what they had. Their voices and faces seemed to echo the old adage, “Happiness is not having what you want, but appreciating what you have.”

It was a humbling experience, and reminded us to be grateful for everything around us. It is sad to think that in this day and age, there are many people who are still living in poverty and unable to access healthcare. Hospitals like Padhar Hospital have certainly made a difference in terms of rural healthcare provision. When it was time for us to go, we left with a heavy heart but knowing that we will always do our best to uphold the hospital’s motto, ‘Burdens lifted, hopes restored.’

Acknowledgements

Sharene Chong and Niyanta D’souza for making the trip memorable. Dr Choudrie and the amazing team in Padhar for their hospitality. Pictures taken by Tiffany Foo.

Conflict of interest

None declared.

Correspondence

A Lim: jnalim@utas.edu.au

T Foo: sytfoo@utas.edu.au

References


[1]Langell J. Gastrointestinal perforation and the acute abdomen. The Medical Clinics of North America 2008;92(3):599-625.
[2] USAID, HIV/AIDS health profile [Internet]. 2010 [updated 2010 Dec; cited 2012 April 30]. Available from: http://www.usaid.gov/our_work/global_health/aids/ Countries /asia/india.html

Categories
Feature Articles Articles

Student-led malaria projects – can they be effective?

Introduction
In this article we give an account of establishing a sustainable project in Uganda. We describe our experiences, both positive and negative, and discuss how such endeavours are beneficial to both students and universities. The substantial work contributed by an increasing group of students at our university and around Australia demonstrates an increasing push towards a greater national contribution to global health. Undoubtedly, student bodies have the potential to become major players in global health initiatives, but first we must see increased financial and academic investment by universities in this particular area of medicine.

Background
There are an estimated three billion people at risk of infection from malaria, with an estimated one million deaths annually. The greatest burden of malaria exists in Sub-Saharan Africa. [1,2] Amongst the Ugandan population of 26.9 million, malaria is the leading cause of morbidity and mortality, with 8 to 13 million episodes reported. [3] The World Malaria Report estimated that there were 43 490 malaria-related deaths in Uganda in 2008, ranking it third in the world behind Nigeria and the Democratic Republic of Congo. [4] In 2011, the situation remained alarming, with 90% of the population living in areas of high malaria transmission. [5]

The focus of this report is the Biharwe region of south-west Uganda. Due to a lack of reliable epidemiological data regarding the south-west of Uganda, it is difficult to evaluate the effectiveness of current malaria intervention strategies. However, Uganda is a country with relatively stable political and economic factors, [6] making it a strong candidate for the creation of sustainable intervention programs.

Insecticide Treated Nets (ITN)
Insecticide treated nets are a core method of malaria prevention and reduce disease-related mortality. [5] The World Health Organisation (WHO) Global Malaria Programme report states that an insecticide-treated net is a mosquito net that repels, disables and/or kills mosquitoes that come into contact with the insecticide. There are two categories of ITNs: conventionally treated nets, and long-lasting insecticidal nets (LLINs). The WHO recommends the distribution of LLINs rather than conventionally treated nets as LLINs are designed to maintain their biological efficacy against vector mosquitoes for at least three years in the field under recommended conditions of use, removing the need for regular insecticide treatment. [7]

Long-lasting insecticide nets have been reported to reduce all-cause child mortality by an average of eighteen percent in Sub-Saharan Africa (with a range of 14-29%). This implies that 5.5 lives could be saved per 1000 children under five years of age per year. [8] Use of LLINs in Africa increased mean birth weight by 55 g, reduced low birth weight by 23%, and reduced miscarriages/stillbirths by 33% in the first few pregnancies when compared with a control arm in which there were no mosquito nets. [9]

Use of LLINs is one of the most cost-effective interventions against malaria. In high-transmission areas where most of the malaria burden occurs in children under the age of five years, the use of LLINs is four to five times cheaper than the alternate strategy of indoor residual spraying. [10] Systematic delivery of LLINs through distribution projects can be a cost-effective way to make a significant impact on a local community. This makes the distribution of LLINs an ideal project for student-led groups with limited budgets.

Our experience implementing a sustainable intervention project in Uganda
This article comments on student-led research performed in Biharwe, which aimed to evaluate the Biharwe community’s current knowledge of malaria prevention techniques; to assess how people used their ITNs and to investigate from where they sourced their ITNs. We also aimed to alleviate the high malaria burden in Biharwe through the distribution of ITNs. We fundraised in Tasmania, with financial support being garnered from local Rotarian groups and student societies. Approximately five thousand dollars was raised which we used to purchase ITNs. Simultaneously we began contacting a local non-governmental organisation (NGO) and a student body from Mbarara University, the largest university in south-west Uganda. We felt we had laid the foundation for a successful overseas trip.

Our endeavours suffered initial setbacks due to the observation of a local organisation we were working with misusing the funds of other projects. We felt that in order to avoid a similar fate we would need to cut ties, and decided to seek out other local groups. We made contact with the Mbarara University students and they pointed us towards the Biharwe sub-county as a region of particular neglect with regards to previous government and NGO ITN distribution programs. At their recommendation we travelled to villages in the area. Access to these villages was obtained through respectfully approaching the village representatives and their councils, and asking their permission to engage with the local community.

Despite all our preparations before heading to Uganda, we were still not fully prepared for the stark realities of everyday life in East Africa. One problem we encountered was the misuse and misunderstanding of the ITN distribution program by locals. We also encountered local ‘gangs’ who would collect free ITNs from our distribution programs and then sell them at the market place for a profit; people who used their ITNs as materials to build their chicken coups; and widespread myths about the effects of ITNs. To combat this we sought the advice of a local priest who requested that the village heads put together a list of households as a means of minimising the fraudulent distribution of our nets. While not ideal, this approach did give us greater confidence when distributing the ITNs. As Uganda is a religious nation the support of a well-respected local priest made local leaders more receptive to our program.

It became apparent that we had to strengthen our understanding of local attitudes towards and usage of ITNs if we were to create a long-term, meaningful relationship with people in the area. At the suggestion of Mbarara University students, we commissioned DEKA Consult Limited, a local research group, to conduct qualitative epidemiological research in villages in these communities. Data collected was useful in identifying the scope of the problem. It identified that community members already had a significant amount of knowledge on the use of ITNs and that those who owned mosquito nets had purchased them from local suppliers. Local ethics approval and permission for access to local community members was gained by DEKA Consult Limited.

Evaluating local knowledge on malaria prevention
The study commissioned addressed community attitudes towards malaria prevention by surveying two distinct groups living in the Biharwe sub-county of south-west Uganda. Through questionnaires and focus group discussions, local researchers gathered information concerning attitudes towards and usage of mosquito nets in the area. One of the key findings was that ITNs were nominated as the main preventative technique by the respondents (33.3%). This is congruent with previous data indicating an increase in awareness of ITNs in Uganda following the Roll Back Malaria Abuja Summit. [11] A majority of respondents indicated some knowledge of the appropriate use of these mosquito nets (83.3%), meaning though that one in six of the Biharwe community members were unsure of how to correctly use ITNs. The research also explored common reasons why people neglected to sleep under ITNs in the Biharwe sub-county. Common misperceptions such as ITNs causing impotence and leading to burns were identified as barriers to people using their mosquito nets, and were issues that would need to be addressed in future education seminars. The findings indicate that assessment of existing knowledge and perceptions of a community are crucial in identifying obstacles that must be overcome during the implementation of an effective intervention project. Activities promoting education can then be moulded around the particular culture and social dynamic of a community, which will lead to maximal project impact. [12, 13] We believe this data indicates that the distribution of ITNs would be improved if it was accompanied by robust educational initiates that are tailored to local community needs.

Our way forward
In the summer of 2011-2012 another group of students from UTAS implemented an LLIN distribution project in the south-west of Uganda. They furthered the work outlined in this report. Our experiences and connections provided an excellent foundation for them to implement expanded projects. A further group of UTAS students has been assembled and is planning to travel to Uganda this coming summer, once again with the aim of building on the previous two visits. With the generous assistance of the Menzies Institute and UTAS School of Medicine, plans for a more robust epidemiology project have been formulated in order to measure the efficacy of future projects in Uganda. We believe the sustainability and effectiveness of these programs relies on both the development of a long-term relationship between our student organisation and the local community, as well as appropriate evaluation of all our projects.

Free distribution or subsidised LLINs
The majority of the malaria burden exists in the poorest, most rural communities, yet it is these regions that are often neglected in widespread ITN distribution programs. [14]

Our data indicates that only a minority of the households in the rural Biharwe sub-county own ITNs (11.1%), and that all of these ITNs have been purchased through the commercial sector. Again methodological disparities need to be addressed in order to confirm the validity of these results. However it does raise the important question of whether the commercial sector, rather than the public/non-governmental organisation (NGO) sector, would be better placed to serve their local communities.

Our dilemma serves as a microcosm for a much larger debate that has been occurring over the last decade regarding the most effective means of delivering ITNs in order to achieve the greatest national coverage.[15] Free distribution of ITNs is far more equitable and effective at reaching the poor. [16] However, utilisation of the commercial sector through subsidies, vouchers or a stratification model [17] is more sustainable, because a portion of the losses may be recovered. Populations, including those in the rural Biharwe sub-region, that have been neglected from ITN schemes such as Roll Back Malaria, [5] may stand to benefit from free targeted distribution of nets. Collaborations with both local and international students are well placed to combine local knowledge and financial support to best implement such initiatives.

The role of students in malaria prevention and international development projects
Organisations such as the World Health Organisation, when involved in widespread ITN distribution, [5] have far greater capabilities than any student-led project. However, due to shortfalls in funding and co-ordination, these schemes will not be able to reach all at-risk populations, particularly the poorest rural areas. [5] Small scale and independently funded student-led projects can fill a void in this neglected population. In order to achieve the maximal impact with a malaria intervention project, students should identify areas with a low rate of household ITN ownership, as well as areas with a low percentage of the owned ITNs being donated. It is these areas that ultimately stand to make the greatest progress in terms of ITN coverage amongst vulnerable individuals, resulting in a decrease in morbidity and mortality from malaria. [18] With locally-specific research, strong relationships with the community and the community leaders, and appropriate evaluation processes in place, students can make the maximal impact on reducing morbidity and mortality from malaria with limited funds. [19]

The aim should always be for a long-term partnership between the community [19] and student-led organisations who are willing to promote sustainability. This has the greatest opportunity to provide long-term benefits for both parties. Our experience is that medical students provide a continuous stream of like-minded youth who have been able to rise to the challenge and continue the work of previous students. Through bilateral exchanges between students and overseas partners, trust and friendship are able to be fostered, which further encourages participation in the project upon returning. Important information regarding the social hierarchy is also gained, which greatly helps with gaining access to the local decision makers. In turn, this creates greater understanding of the health problems, culture and reasons why particular communities have been left behind. Student-led organisations are perfectly placed to deliver these educational programs, as they constitute a long-term pool of motivated, altruistic skilled workers who are able to learn from their predecessors. Individual students also stand to benefit through increased cultural understanding, application of learned skill sets and an opportunity which can enhance their career paths. [19] Through appropriate long-term trial, error and proper evaluation, systems of program implementation can be formulated which may then be applied to similar communities elsewhere.

The Role of Universities
Preparing students for a leadership role in global health and its related fields is critical. University curricula should reflect today’s problems and those that are likely to be present in the coming decades. [20] It is our opinion that students are increasingly becoming aware and more willing to be involved in providing solutions, no matter how small, to current international issues, thanks mainly to a surge in the exposure to social media. When universities do not explore such issues deeply in their curricula, and do not provide the support for active student involvement, it may lead students to perceive that universities are about something other than the realities of the world. [21] Encouraging participation in international health projects has been reported to encourage students to better examine cross cultural issues, to improve their problem solving skills and to help improve the delivery of healthcare for under-privileged people. [22] These are transferable skills that are vital in the Australian health care system.

North American and European universities continue to lead the way; however, Australian universities are starting to become more involved with global health issues. The Australian Medical Students Association’s Global Health Committee aims to link and empower groups of students from each Australian medical school. [23] The Melbourne University Health Initiative, which oversees the Victorian Student’s Aid Program, aims to help students make a difference in health issues on a local and international level by running events on campus to promote awareness about several health issues, and by organising public health lectures to promote awareness in the community. [24] The Training for Health Equity Network (THEnet) is a composition of ten schools from around the world, including James Cook and Flinders Universities, who have committed to ensure that teaching, research and service activities address priority health needs, using a focus on underserved communities. [25] A focus of THEnet is on social accountability, with a framework to assess whether the schools are contributing to the improvement of health conditions within their local communities. [26]

In our view, there is no doubt that there needs to be more penetration of such initiatives into each of the universities’ curriculum. Should this occur, Australia may be able to produce a generation of graduates who will be well placed to address the numerous complex global health issues we are facing today, and that we will inevitably face in the future.

Conflict of interest
None declared.

Correspondence
B Wood: benjaminmwood88@gmail.com

References
[1] Greenwood BM, Bojang K, Whitty CJM, Targett GAT. Malaria, The Lancet. 2005 Apr 23-29; 365 (9469): 1487-98.
[2] Snow RW, Guerra CA, Noor AM, Myint HY, Hay SI. The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature. 2005 Mar 2010; 434 (7030): 214-7.
[3] Uganda. Uganda Ministry of Health. Uganda Malaria Control Strategic Plan 2005/06 – 2009/10: Roll Back Malaria; 2003.
[4] Aregawi M, Cibulskis R, Williams R. World Malaria Report 2008. Switzerland: World Health Organisation; 2008.
[5] Aregawi M, Cibulskis R, Lynch M, Williams R. World Malaria Report 2011. Switzerland: World Health Organisation; 2011.
[6] Yeka A, Gasasira A, Mpimbaza A, Achan J, Nankabirwa J, Nsobya S, et al., Malaria in Uganda: Challenges to control on the long road to elimination: I. Epidemiology and current control efforts. Acta Tropica. 2012 Mar; 121 (3); 184-95.
[7] Fifty-eighth World Health Assembly: Resolution WHA58.2 Malaria Control [Internet Article]. Geneva: World Health Organisation; May 2005 [cited 2012 12th April]. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA58-REC1/english/A58_2005_REC1-en.pdf
[8] Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database of Systemic Review (Online). 2004; 2: CD000363.
[9] Gamble C, Ekwaru JP, Ter Kuile FO. Insecticide-treated nets for preventing malaria in pregnancy. Cochrane Database of Systematic Reviews (Online). 2006 April 19; 2: CD003755.
[10] Yukich J, Tediosi F, Lengeler C. Comparative cost-effectiveness of ITNs or IRS in Sub-Saharan Africa. Malaria Matters (Issue 18). 2007 July 12: pg. 2-4.
[11] Baume CA, Marin MC. Gains in awareness, ownership and use of insecticide-treated nets in Nigeria, Senegal, Uganda and Zambia. Malaria J. 2008 Aug 7; 7: 153.
[12] Williams PCM, Martina A, Cumming RG, Hall J. Malaria prevention in Sub-Saharan Africa: A field study in rural Uganda. J Community Health. 2009 April; 34:288-94.
[13] Marsh VM, Mutemi W, Some ES, Haaland A, Snow RW. Evaluating the community education programme of an insecticide-treated bed net trial on the Kenyan coast. Health Policy Plan. 1996 Sep; 11(3): 280-91.
[14] Webster J, Lines J, Bruce J, Armstrong Schellenberg JR, Hanson K. Which delivery systems reach the poor? A review of equity of coverage of ever-treated nets, never-treated nets, and immunisation to reduce child mortality in Africa. Lancet Infect Dis. 2005 Nov; 5(11): 709-11.
[15] Sexton A. Best practices for an insecticide-treated bed net distribution programme in sub-Saharan eastern Africa. Malaria J. 2011. Jun 8; 10:157.
[16] Noor AM, Mutheu JJ, Tatem AJ, Hay SI, Snow RW. Insecticide-treated net coverage in Africa: mapping progress in 2000-07. Lancet. 2009 Nov 18; 373 (9657): 58-67.
[17] Noor AM, Amin AA, Akhwale WS, Snow RW. Increasing coverage and decreasing inequity in insecticide-treated bed net use among rural Kenyan children. PLoS Medicine. 2007 Aug 21; 4(8): e255.
[18] Cohen J, Dupas P. Free distribution or cost-sharing? Evidence from a randomized malaria prevention experiment. The Quarterly Journal of Economics. 2010; 125 (1): 1-45.
[19] Glew RH. Promoting collaborations between biomedical scholars in the U.S. and Sub-Saharan Africa. Experimental Biology and Medicine. 2008 Mar; 233(3): 277-85.
[20] Bryant JH, Velji. Global health and the role of universities in the twenty-first century,.Infect Dis Clin North Am 2011 Jun; 25(2): 311-21.
[21] Crabtree RD. Mutual empowerment in cross-cultural participatory development and service learning: Lessons in communication and social justice from projects. J Appl Commun Res. 1998; 26 (2): 182-209.
[22] Harth SC, Leonard NA, Fitzgerald SM, Thong YH. The educational value of clinical electives. Medical Education. 1990 Jul; 24 (4) :344–53.
[23] Murphy A. AMSA Global Health Committee [Internet]. 2012 [cited 2012 April 10]. Available from: http://ghn.amsa.org.au/
[24] Melbourne University Health Initiative [Internet]. 2012 [cited 2012 April 3]. Available from: http://muhi-gh.org/about-muhi
[25] THEnet. Training for Health Equity Network [Internet]. 2012 [cited 2012 March 30]. Available from: http://www.thenetcommunity.org/
[26] The Training for Health Equity Network. THEnet’s Social Accountability Evaluation Framework Version 1. Monograph I (1 ed.). The Training for Health Equity Network, 2011.

Categories
Articles Editorials

Medical students in the clinical environment

Introduction

It is common amongst medical students to feel apprehension and uncertainty in the clinical environment. It can be a daunting setting, where medical students can sometimes feel as if they are firmly rooted to the bottom of the pecking order. However, there are many ways medical students can contribute to their respective healthcare teams. Whilst students are not able to formally diagnose patients or prescribe medications, they remain an integral part of the healthcare landscape and culture. The step from being ‘just’ a medical student to being a confident, capable medical professional is a big step to take, but an important one in our development from the textbook to the bedside. By being proactive and committed, students can be of great help and achieve improved outcomes in a clinical setting. Through this editorial we hope to illustrate several methods one can employ to ease this transition.

Concerns of medical students

When faced with the clinical environment, most medical students will have some form of reservation regarding various aspects of clinical practice. Some of the concerns listed in the literature revolve around being accepted as part of the team, [1] fatigue, [2, 3] potential mental abuse, [4, 5] poor personal performance and lifestyle issues. [6, 7] These points of concern can mostly be split up into three parts: concern regarding senior clinicians, concern regarding the clinical environment, and concern regarding patient interaction. [1] Practicing clinicians hold the key to effective medical education and their acceptance of medical students is often crucial for a memorable learning experience. [1] Given the hierarchical nature of most medical organisations, senior clinicians being the direct ‘superiors’, are given the responsibility of assessing students. Concerns regarding the clinical environment refer to the demands on students during clinical years, such as on calls, long hours, early starts and the pressure to gain practical knowledge. Anecdotally, it’s common to hear of medical students becoming consumed by their study of medicine and rarely having the time to pursue other interests in life.

Patient-student interaction is another common source of anxiety, as medical students are often afraid to cause harm to real-life patients. Medical students are often encouraged to perform invasive practical skills (such as venipuncture, intravenous cannulation, catheterisations, suturing, invasive clinical exams, nasogastric tube insertion, airway management, arterial blood gases) and to take sensitive histories. We have the ability to physically or psychologically hurt our patients, and Rees et al. [8] have recently reported the performance of intimate examinations without valid consent by Australian medical students. This has to be balanced against our need to learn as students so that we avoid making errors when we eventually enter clinical practice. These are all pertinent points that have to be addressed to ensure that the average medical student can feel comfortable and contribute to the team in an ethical manner.

Attitudes towards medical students

Despite the concerns of medical students regarding the attitudes of clinicians, allied health professionals and patients towards them, most actually take a positive view on having students in the clinical environment. Most studies have shown that the majority of patients are receptive to medical students and had no issues with disclosing personal information or being examined. [9-11] In particular, patients who were older and had prior admissions tended to be more accepting of student participation in their care. [9, 12] These findings were consistent across a number of specialties, even those dealing with genitourinary issues. [13] On a cautionary note, students should bear in mind that a sizable minority of patients prefer to avoid medical student participation, and under these circumstances it is important to respect patient autonomy and refrain from being involved with their care. [14] Graber et al. [14] have also reported that patients are quite apprehensive regarding having medical students perform procedures on them, particularly more invasive procedures such as central line placement or lumbar puncture. Interestingly, a sizable minority (21%) preferred to never have medical students perform venipuncture, [14] a procedure often considered minor by medical professionals. It is a timely reminder that patient perspectives often differ from ours and that we need to respect their opinions and choices.

Ways we can contribute

As aspiring medical professionals our primary objective is to actively seek ways to learn from experienced colleagues and real-life patients about the various conditions that they face. Being a proactive learner is a crucial aspect of being a student and this in itself can be advantageous to the clinical team by sharing new knowledge, promoting academic discussion or as a source of motivation for senior clinicians. However as medical students we can actively contribute to the healthcare team in a variety of practical ways. These methods include formulating a differential diagnosis, assisting in data collection, preventing medical errors and ensuring the emotional well-being of patients. These are simple yet effective ways of fulfilling one’s role as a medical student with potentially meaningful outcomes for patients.

Preventing medical errors

As medical students, we can play an important role in preventing patient harm and picking up medical errors. Medical errors can be caused by a wide variety of reasons, ranging from miscommunication to a loss of documentation to the lack of time on the part of physicians. [15-18] These are all situations where medical students can be as capable as medical professionals in noticing these errors. Seiden et al. [19] reports four cases where medical students prevented medical errors and ensured patient safety, ranging from ensuring sterile technique in surgery to correcting a medication error to respecting a do not resuscitate order. These are all cases within the circle of competence of most medical students. Anecdotally, there are many more cases of situations where a medical student has contributed to reducing medical errors. Another study has shown that up to 76% of second-year medical students at the University of Missouri-Columbia observed a medical error. [17] However, only 56% reported the error to the resident-in-charge. Various factors contribute to this relatively low percentage: inexperience, lack of confidence, hesitancy to voice opinions, being at the bottom of the medical hierarchy and fear of conflict. [17] Whilst medical students should not be relied upon as primary gatekeepers for patient safety, we should be more forthcoming with voicing our opinions and concerns. By being involved and attuned to the fact that medical errors are common, we can make a significant difference to a patient’s well-being. In recognition of the need to educate medical students about the significance of medical errors, there have been efforts to integrate this formally into the medical student curriculum. [20, 21]

Assistance with collecting data

Physicians in clinical environments are notoriously limited with time. Average duration of consultations may range from eight to nineteen minutes, [22-24] which is often insufficient to take a comprehensive history. There are also a range of administrative duties that reduce patient interaction time, such as ordering investigations, filling out drug charts, arranging referrals or finding a hospital bed. [25,26] Mache et al. [25,26] have reported that pediatricians and surgeons spent up to 27% and 21% of their time on administrative duties and documentation. Medical students tend to have less administrative duties and are thus able to spend more time on individual patients. Medical students can be just as competent at taking medical histories or examining patients, [27,28] and they can uncover crucial pieces of information that had gone unnoticed, such as the presence of a ‘Do Not Resuscitate’ order in a seriously ill patient. [19] Students are also often encouraged to try their hand at practical skills such as venipuncture, history taking or clinical examination, all of which saves physician time and contribute to the diagnostic process as well.

Emotional well-being of patients

Due to the unique nature of the hospital environment, patients often have a range of negative emotions, ranging from anxiety to apprehension and depression. [29-31] A patient’s journey in the hospital can be an unnerving and disorientating experience, where he/ she is referred from unit to unit with several different caregivers at each stage of the process. This issue is further compounded by the fact that clinicians simply do not always have sufficient patient contact time to soothe their fears and emotional turmoil; studies have shown that direct patient contact time represented a small proportion of work time, as little as 4% in some cases. [25,26,32,33] Most patients feel comfortable and enjoy their interactions with medical students and some even feel that they benefit from having medical students in the healthcare team. [9,10,12,14,34] By being empathetic and understanding of our patient’s conditions, we can often alleviate the isolating and disorientating nature of the hospital environment. [12,35]

International health

Most medical students, particularly earlier in the course are motivated by idealistic notions of making a difference to the welfare of our patients. [36,37] This often extends to the less fortunate in developing countries and students often have a strong interest in global health and overseas electives (38, 39). This can be a win-win situation for both parties. Healthcare systems in developing countries stand to benefit from the additional help and expertise provided by students and students gain educational benefits (recognising tropical conditions, public health, alternative medicine), enhanced skills (clinical examination, performing investigations), cultural exposure and fostering certain values (idealism, community service). [38] However, it is important to identify our limits as medical students and learn how to turn down requests that are beyond our scope of knowledge, training and experience. This is an ethical dilemma that many students face whilst on electives in resource-poor areas, and it is often a fine line to tread between providing help to those in desperate need and inappropriate abuse of one’s position. We have the potential to do more harm than good when exceeding our capabilities, and given the lack of clear guidelines it comes down to the student to be aware of these ethical dilemmas and draw the line between right and wrong in these situations. [40,41]

Student-run clinics and health promotion activities

In other countries, such as the United States, student-run medical clinics play a crucial role in the provision of affordable healthcare. [42- 45] These clinics number over 120 across the country and have up to 36 000 visits nation-wide. [43] In these clinics, students from a variety of disciplines (such as medicine, nursing, physiotherapy, dentistry, alternative medicine, social work, law and pharmacy) collaborate to manage patients coming from disadvantaged backgrounds. [46] Whilst this concept is still an emerging one in Australia (the first student run clinic was initiated by Doutta Galla Community Health and the University of Melbourne this year, culminating in the REACH clinic – Realising Education, Access and Collaborative Health), [47] there has been a strong tradition of medical students being heavily involved with health promotion projects in their respective local communities. [48] It is not uncommon to hear of students being actively involved in community health promotion clinics, blood donation drives or blood pressure screening, [49] all of which have practical implications on public health. Through modifying our own health behaviours and active participation in local communities, students can have a tangible impact and influence others to lead a healthier lifestyle.

Note of caution

Whilst medical students should actively participate and be an integral part of a medical team, care must be taken to not overstep the professional boundaries of our role. It is always important to remember that our primary aim is to learn how to care for patients, not to be the principle team member responsible for patient care. There have been several ethical issues surrounding the behavior of medical students in clinical settings in recent times. A prominent example of this is the lack of valid consent whilst observing or performing intimate examinations. This report by Rees et al. [8] generated widespread controversy and public outrage. [50] The study showed that most medical students complied with the instructions of more senior clinicians and performed sensitive examinations without explicit consent, sometimes whilst patients were under anaesthesia. There were a variety of reasons leading up to the action, ranging from the lack of similar opportunities to the presumed pressure from supervising doctors. This is not a new issue; a previous study by Coldicott et al. [51] had also highlighted this as a problem. As emerging medical professionals we must avoid getting carried away by the excitement of clinical practice and ignore the vulnerability of our patients.

Conclusion

The clinical environment offers medical students limitless potential to develop their clinical acumen. As medical students we have the opportunity to participate fully in all stages of patient care, from helping formulate a diagnosis to proposing a management plan. Holistic care for our patients goes beyond the physical aspect of disease and medical students can play an important role in ensuring that the psychosocial wellbeing of patients is not ignored. Our impact is not just restricted to a hospital setting; we are only limited by our imagination and determination. By harnessing the idealism unique to medical students we are able to come up with truly inspirational projects that influence local or overseas communities. Through experiencing a full range of clinical scenarios in different environments we can develop a generation of doctors that are not only clinically astute, but also well- rounded individuals with the ability to connect to patients from all backgrounds. As medical students we have the potential to contribute in a practical manner with tangible outcomes, and we should aspire to that as we make the fifth cup of coffee for the busy registrar on call.

Acknowledgements

Michael Thompson for his feedback and assistance in editing draft manuscripts.

Conflict of interest

None declared.

Correspondence

f.chao@amsj.org

 

Categories
Feature Articles Articles

Immunology beyond a textbook: Psychoneuroimmunology and its clinical relevance for psychological stress and depression

Our medical studies encompass many areas of medical science, and immunology is an example of just one. Traditionally, we have been taught that our immune system exists to protect us from pathogens; however, in recent years, this romantic view of the immune system has been challenged and it is now well recognised that it is also involved in whole-body homeostasis and cross talks to other regulating systems of the body. This is the notion of psychoneuroimmunology (PNI). This text will briefly review the current understanding of PNI and how it features prominently in clinical practice as a part of the ‘whole person’ model of patient care and, especially, in terms of stress and depression. With this in mind, PNI is an emerging medical discipline that warrants integration and consideration in future medical care and practice.

Introduction

At first glance, immunology may be viewed by some as an esoteric medical science that simply provides us with the molecular and cellular mechanisms of disease and immunity. It is a subject that all medical students have to face and no doubt can find quite challenging as well. Yet, in recent times, its role in helping us understand mental health and why individuals behave in certain ways has become increasingly appreciated. [1,2] The novel area of study that attempts to explain this intricate and convoluted relationship between the mind, behaviour, nervous system, endocrine system and finally the immune system is, quite appropriately, termed psychoneuroimmunology (PNI) or sometimes psychoendoneuroimmunology. [3] This was probably something that was never mentioned during our studies because it is quite radical and somewhat ambiguous. So what, then, is PNI all about and why is it important?

Many of us may have come across patients that epitomise the association between mental disturbances and physical manifestations of disease. Indeed, it is this biopsychosocial model that is well documented and instilled into the minds of medical students. [4-7] The mechanism behind this, although something best left to science, is nonetheless interesting to know and appreciate as medical students. This is PNI.

The basic science of psychoneuroimmunology

History

The notion that behaviour and the manifestation of disease were linked was probably first raised by Galen (129-199 AD) who noticed that melancholic women were more likely to develop breast cancer than sanguine women. [8] The modern push for PNI probably began in the 1920s to 1930s when Metal’nikof and colleagues conducted several preliminary experiments in various animals showing that the immune system can be classically conditioned. [9] New interest in this area was established by Solomon et al. who, in 1964, coined the term ‘psychoimmunology’ [10]; however, the concept of PNI was firmly established by the American behavioural scientist Dr Robert Ader in his revolutionary 1981 book, ‘Psychoneuroimmunology.’ This book described the dynamic molecular and clinical manifestations of PNI through various early experiments. [11,12] In one initial experiment, Ader and fellow researchers successfully demonstrated that the immune system can be conditioned, similarly to Metal’nikov. After pairing saccharin with the immunosuppressive agent, cyclophosphamide, and administering this to some rats, they found that saccharin administration alone, at a later date, was able to induce an immunosuppressive state marked by reduced titres of haemagglutinating antibodies to injected sheep erythrocytes. [13]

The authors postulated that non-specific stress associated with the conditioning process would have elicited such a result. By extension and based on earlier research, [14] the authors believed psychological, emotional or physical stress probably act through hypothalamic pathways to induce immunomodulation which manifests itself in various ways. [13]

Stress, depression and PNI

A prominent aspect of PNI focuses on the bi-directional relationship between the immune system and stress and depression, where one affects the other. [4,15] The precise mechanisms are complicated but are ultimately characterised by the stress-induced dysregulation, (either activation or depression), of the hypothalamic-pituitaryadrenal (HPA) and sympathetic-adrenal-medullary (SAM) axes. [16] Because of the pleiotropic effects of these hormones, they can induce a dysfunctioning immune system partly through modulating the concentration of certain cytokines in the blood. [15] Endocrine and autonomic pathways upregulate pro-inflammatory cytokines (such as interleukin (IL)-1β, IL-6 and tumour necrosis factor-α (TNF-α)) that can exert their effects at the brain through direct (i.e., circumventricular organs) and indirect access ports (via aff erent nerve fi bres). [17,18] Such pro-inflammatory cytokines therefore stimulate the HPA axis and activate it leading to the rapid production of corticotropin-releasing hormone. [19-21] Eventually, cortisol is produced which, in turn, suppresses the pro-inflammatory cytokines. Interestingly, receptors for these cytokines have also been found on the pituitary and adrenal glands, thereby serving the ability to integrate neuroendocrine signals at all three levels of the HPA axis. [21,22] Cortisol also has significant eff ects on mood, behaviour and cognition. On a short-term basis, it may be beneficial; making an animal more alert and responsive. However, increased periods of elevation may give rise to impaired cognition, fatigue and apathy. [23]

In the brain, an active role is played by the once-thought insignificant glial cells which participate at the so-called tripartite synapse (glial cell plus pre- and post-synaptic neurons). [24] It is this unit that is fundamental to much of the central nervous system activity of the PNI system. Pro-inflammatory cytokines like interferon (IFN)-α and IL-1β released from peripheral and central (microglia and astrocytes) sources can alter dopaminergic signals, basal ganglial circuitry, hippocampal functioning and so on. Consequently, this induces behavioural changes of anhedonia, memory impairment and other similar behaviours. [18,25] Since IFN-α receptors have been found on microglia in the brain, [26] IFN-α likely also causes further local inflammation and further disruption of dopaminergic signals. Excessively activated microglia by a range of inflammatory cytokines can therefore cause direct neurotoxicity and neuropathology. [27] Additionally, these cytokines can induce activity of the indoleamine 2,3-dioxygenase enzyme (found in astrocytes and microglia) which metabolise the precursor of serotonin, tryptophan. The result is a reduction of serotonin and the production of various products, including quinolinic acid, an NMDA (N-methyl-D-aspartate) receptor agonist which leads to excess glutamate and neurodegeneration. These mechanisms are postulated to contribute to the pathogenesis of depression; however, the precise mechanisms of which are yet to be fully elucidated. [28-30]

Recent research into behavioural epigenetics has also provided an additional interesting link whereby stressors to the psychosocial environment can modulate gene expression within the neuroimmune, physiological and behavioural internal environments. This may account for the long-term aforementioned changes in immune function. [31]

Depression has also been shown to activate the HPA and SAM axes as well through inflammatory processes, [28,32] which in turn exacerbates any pre-existing depressive behaviours. [33] This inflammatory theory of depression sheds light onto the complicated pathophysiology of depression, adding to the already well-characterised theory of serotonergic neurotransmission deficiency. [28,33] Interestingly, proinfl ammatory cytokines have been shown to modulate serotonergic activity in the brain as well, [34,35] which provides further insight into this complex disorder. There is question as to whether or not this may have its roots with evolution where the body diverts energy resources away from other areas to the immune system for the promotion of anti-pathogenic activity during stress and depression. [17] For instance, with threat of an injury or wound in an acute situation (the stressor), cortisol (a natural immunosuppressant) would be released via the HPA axis. This aids in energy conservation which in turn, and paradoxically, attempts to minimise the non-helpful effect of immunosuppression in times of infection risks. [17] Depressive behaviour such as lethargy has also been said to have stemmed from the need to conserve energy to promote fever and inflammation. [2] Ultimately, the evolutionary aspects of PNI are under current speculation and investigation to elicit the precise links and relationships. [36]

The alterations of the immune system in stress and depression have implications for other areas of medicine as well. Though conclusive clinical experiments are lacking, it has been strongly hypothesised that this imbalanced immune state can contribute to a plethora of medical ailments. Depression, characterised by a general pro-inflammatory state with oxidative and nitrosative stress, [33,37] can contribute to poor wound healing; and exacerbate chronic infections and pain. [38,39] Stress similarly entails a dysregulated immune system and may contribute to the aforementioned conditions plus cardiovascular disease and minor infectious diseases such as the common cold. [40- 44] The link with cancer is somewhat more controversial but both may, in some way, predispose to the development of it through numerous mechanisms such as reduced immune surveillance by immune cells (cytotoxic T cells and natural killer cells), general inflammation and genomic instability. [45,46]

Highlighting the bidirectionality of the PNI paradigm, secondary inflammation caused by a myriad of neurological diseases (e.g., Huntington’s disease, Alzheimer’s disease) and local and systemic disorders (e.g., systemic lupus erythematosus, stroke, cardiovascular disease and diabetes mellitus) may very well contribute to the pathogenesis of co-existing depression. [47] This may account for the close association of depression and such diseases. Underlying neurochemical changes have been observed in many of these diseases—especially the neurological disease examples—and it has been suggested that depression vulnerability is proportional to how well one can ‘adapt’ to said neurochemical imbalances. [48,49]

Through an immunophysiological point-of-view, these links certainly makes sense; but it is important to note that there could be other confounding factors, such as increased alcohol consumption and other associated behaviours that accompany stress and depression that can contribute to pathology. [50] The question therefore remains as to how much the mind plays in the pathogenesis of physical ailments. Figure 1 summarises the general PNI model as it relates to stress and depression.

Implications

Having explored the discipline of PNI, what is the importance of this for clinical practice? Because of the links between stress and depression; altered immunity; other ill-effects and behaviour, [3,12] it seems fitting that if we can address a patient’s underlying stress or depression, we may be able to improve the course of their illness or prevent, to a certain extent, the onset of certain diseases by correcting immune system dysregulation. [43]

Simply acknowledging the relationship between stress and their role in the pathogenesis, maintenance and susceptibility of diseases is certainly not enough, and healthcare professionals should consider the mental state of mind for every patient that presents before them. It is fortunate, then, that a myriad of simple stress-management strategies could be employed to improve their mental welfare, depending on their individual circumstances. Such strategies include various relaxation techniques, meditation, tai chi, hypnosis and mindfulness practice. These have, importantly, proven cost-eff ective and lead to self-care and self-efficacy. [51,52]

As an example, mindfulness has received considerable attention in its role of alleviating stress and depression. [52] Defined as the increased awareness and attention to present, moment-to-moment thoughts and experiences, mindfulness therapy has shown remarkable efficacy in the promotion of positive mental states and quality of life. [52-54] This is particularly important in this age of chronic diseases and their associated unwelcomed psychological consequences. [54] Furthermore, and in light of the discussion above on PNI, there is evidence that mindfulness practice induces physiological responses in brain and immune function. [55,56] This suggests that its benefits are mediated, at least in part, through such positive immunological alterations that modulate disease processes.

With the growing understanding of the cellular and molecular mechanisms behind stress, depression and other similar psychiatric disorders, a host of novel pharmacological interventions to target the previously discussed biological pathways are actively being researched. Most notably is the proposition of the role of anti-inflammatories in ameliorating such conditions where patients present in an increased inflammatory state. This is largely based on experimental work where antagonists to pro-inflammatory cytokines and/or their receptors improve sickness behaviours in animals. [17] As an example, the cholesterol-lowering statins have been found to have intrinsic anti- inflammatory and antioxidant properties. In a study of patients taking statins for cardiovascular disease, it was found that statins had a substantial protective effect on the risk of developing depression. This suggests that the drug acts, at least in part, to decrease systemic inflammatory and oxidative processes that characterise depression. [57] Other drugs being researched aim to tackle additional pathways such as those involving neurotransmitters and their receptors.

Of the neuroendocrine arm of PNI, current research is looking at ways to reverse HPA axis activation. [20] Some tested drugs that act on specific parts of the HPA axis seem to show promise; however, a major problem is tailoring the correct drug to the correct patient, for not all patients will present with the same neuroendocrine profile. [58,59] Neuroendocrine manipulation can also be used to treat or act as an adjunct to other non-HPA axis-mediated diseases. For example, administration of melatonin and IL-2 was able to increase the survival time in patients with certain solid tumours. [60] Needless to say, a great amount of research is further warranted to test and understand possible pharmaceutical agents.

Discussion and Conclusion

The exciting and revolutionary field of PNI has now provided us with the internal links of all the major regulating systems of the human body. The complex interactions that take place is, indeed, a tribute to the complexity of our design, and has provided a basis or mechanism of how our mind and behaviour can infl uence our physical health. As a result, serious stressors—be them emotional, mental or physical—can wreak havoc on our delicate internal environment and predispose to physical ailments, which can further exacerbate the inciting stressors and our mental state. For said psychological stress or depression, it seems appropriate that if healthcare professionals can ameliorate the severity of these, they may be able to further improve the physical health of an individual. How much so is a matter of debate and further investigation. Conversely, as demonstrated by the bi-directionality model of PNI, addressing or ‘fi xing’ the organic pathology may be conducive to the mental state of patients’ minds.

Whilst clinical approaches have been sharply juxtaposed to a very theoretical and scientific review of PNI, this has been deliberately done to hopefully demonstrate how mind-body therapies can exert their physical benefits. Accordingly, valued mind-body therapies deserve as much attention as the scientific study of molecular pharmacology. It is also important to note that even these two approaches (pharmacology and mind-body therapies) are almost certainly the tip of the iceberg; for there is certainly a vast amount more to be further explored in our therapeutic approach to medical conditions. For example, how does a practitioner-patient relationship fit into this grand scheme of things, and how much of a role does it play? No doubt a decent part for sure. Furthermore, whilst the PNI framework provides good foundations for which to explain, (at a basic level), the mechanisms behind the development of stress, depression and associated ailments, further insight is needed into the biological basis of these. For example, a symphony of intricate factors (such as the up-regulation of inflammation-induced enzymes, neurotransmitter changes, dysfunction of intracellular signalling, induced autoimmune activity, neurodegeneration and decreased serum levels of antioxidants and zinc) are at play for the signs and symptoms of depression. [61,62] Thus, the complex pathogenesis of psychological stress and depression begs for further clinical and scientific research into unravelling its mysteries. Nevertheless, with a sound basis behind mindfulness, other similar mind-body therapies and novel pharmacological approaches, it seems suitable for these to be further integrated into primary care [54] and other areas of medicine as an adjuvant to current treatments. If we can achieve this, then medicine undoubtedly has more potent tools in its armamentarium of strategies to address and alleviate the growing burden of chronic disease.

Acknowledgements

My thanks go to Dr E Warnecke and Prof S Pridmore for their support.

Conflicts of interest

None declared.

Correspondence

A Lee: adrian.lee@utas.edu.au

Categories
Review Articles

On the nature of the alcohol-based hand rub and its use for hand hygiene in medicine and healthcare

Abstract

Hand hygiene (HH) is today recognised as being the most important factor in preventing the spread of infections; however, adequate compliance with this remains unacceptably low amongst healthcare workers (HCWs). One of the leading products in the push for successful HH is the alcohol-based hand rub (ABHR), which currently exists as a ubiquitous item in healthcare facilities. This review amalgamates the current understanding of ABHRs, presenting an overview of important issues including its correct usage and insights into HH. Aimed at Australian HCWs and students, a small yet significant amount of attention is devoted to Hand Hygiene Australia – one of the leading authorities in this subject area. It may be concluded that the ABHR is an effective hand disinfectant that also improves HH compliance, and is thus highly recommended for use in healthcare settings.

Categories
Feature Articles

The good, the bad and the ugly of mobile phone use in clinical practice

Act 1

Scene: at the bedside

Enter stage: registrar, intern, medical student, Mrs. Thompson

Registrar: “Hi Mrs. Thompson, how are you travelling?”

Mrs. Thompson: “Not too well dear, I’ve had a pounding headache since last night.”

Registrar: “Really? Well you are recovering from a stroke, but I wonder if we have overlooked something. Maybe we should scan your head again?”

Medical student (to the rescue!): “We changed Mrs. Thompson’s aspirin to Asasantin yesterday and it says here on my mobile phone application that Asasantin can cause headache. Should we try stopping it to see if her headache resolves before we zap her brain again?”

Act 2

Scene: outpatient clinics

Enter stage: consultant, medical student, Mr. McLeod

Consultant: “We seem to have your COPD under control with your current medications. It has been a while now since you’ve been hospitalised with an exacerbation.”

Mr. McLeod: “Yeah I feel…”

Ring, ring (interruption by consultant’s mobile phone)

Consultant: “Yes, it’s me speaking. Go ahead…”

Conversation between consultant and his registrar regarding Mrs. Vince, a current inpatient; during conversation it is revealed to all present in the room that Mrs. Vince’s bowel habits have been erratic and now she has PR bleeding; consultant recommends a gastro consult

Consultant: “Now, what were we saying?”

Act 3

Scene: at the bedside

Enter stage: consultant, registrar, intern, medical student

Mr. Walker’s biopsy report has confirmed squamous cell carcinoma of the lung; it is now time to break the news to him

Consultant: “Hi Mr. Walker, how did you sleep?”

Mr. Walker: “Didn’t get much sleep last night. I’m very anxious about the result.”

Consultant: “Well, the result has come back and I’m afraid the news is not as good as we would have hoped for. Is your wife here with you today?”

Mr. Walker: “No she’s just stepped out to run some errands. That’s ok though, just give it to me straight. I want to know exactly what’s going on.”

Consultant: “Ok Mr. Walker. Well the biopsy reveals that you do have cancer. It is a type of lung cancer called squamous…”

Ring, ring (interruption by consultant’s mobile phone)

Consultant: “Hold on Mr. Walker, I need to take this call. I will be back in a moment.”

Registrar, intern and medical student standing around the patient’s bed looking at each other and feeling rather awkward about the…

Categories
Letters

‘Bull-dogging’ for the RACP exams

The Royal Australasian College of Physicians’ (RACP) Clinical Examination takes a full day and for medical registrars is the barrier between basic and advanced training, including subspecialty training. My experience was as an ‘examination assistant’ (or ‘bulldog’ in colloquial terms) for the candidates. I had been on my general medicine rotation and the consultant of my medical unit was looking for volunteers.

The clinical examination day comprises a morning and an afternoon session. Each session is comprised of two short cases and one long case. Short cases each take fifteen minutes. Candidates have three minutes before they enter the station to read one sentence which provides the name of the patient, presenting complaint and body system to examine. The candidate introduces themselves, examines the patient, presents their findings, is questioned by two examiners and walks out at the bell, remembering to wash their hands before they leave. In contrast to medical school OSCEs, candidates do not speak to the examiners while examining the patient. Instead they present afterwards, which is when they start scoring marks. My candidate asked me to signal him at six minutes (by tapping on my watch, coughing or clearing my throat) so he could spend the next nine minutes presenting and thus scoring marks. The examiners can also ask for investigations to be interpreted. For example, “What would you like to order for his murmur?” or, “You said ECG, tell us about this ECG and chest x-ray.” Fortunately, the short cases are assessed ‘blind’ by the examiners who have not examined the patients themselves. This is not so for the long cases.

For the long case, the candidate spends one hour alone with the patient. During this time, they take a thorough history, perform an examination, determine the patient’s medical and psychosocial issues and construct a management plan. After this, candidates have ten minutes before seeing the examiners. In these ten minutes, the candidate can think of potential questions and collect their thoughts. The long case assessment occurs over 25 minutes with two examiners. The candidate begins by presenting the case followed by non-stop questioning on anything from the history (“What were the circumstances of the fall you mentioned?”), physical examination (“What do you mean by nerve compression, what level?”), investigations (“How do you determine if the asthma is mild, moderate or severe?”), and management (“What if this person were to go to surgery?” or, “How might you educate this patient?”).

While the examination represents an artificial construct, particularly in respect to the short cases, the format does allow for assessment of a candidate’s ability to perform at a physician level, to analyse, interpret information and to deal with the inevitable dilemmas presented by real patients. “Under the pressure of the exam, candidates generally revert to their normal level of everyday practice,” says successful candidate Dr Luke Vos of Launceston General Hospital.

He advises budding physicians, “Preparation for clinical examinations really begins as soon as you enter physician training. The essential elements of history taking, physical examination, construction of a differential diagnosis and the establishment of a plan for the investigation and management of each clinical problem are skills you can continue to refine from day one. While somewhat daunting, a willingness to expose yourself to constructive criticism from colleagues and mentors will help improve your approach and can prove invaluable. The skills you develop in preparation for the clinical exams will continue to serve you throughout your career.”

From a bulldog’s perspective, I could see how medical school trains us for these types of exams, but also prepares us for days when we just need to remain calm and focused on the next patient. And given that the clinical examination fee was $3,780 this year, there was definitely good motivation to pass!

More information can be found at the RACP PREP Basic Training Program website: http:// www.racp.edu.au/page/basic-training / examinations/clinical-examination.