Tuesday, May 27, 2014

New Papers from the Biomed Central Family

Muller A. Teaching lesbian, gay, bisexual and transgender health in a South African health sciences faculty: addressing the gap. BMC Medical Education 2013, 13:174  doi:10.1186/1472-6920-13-174
Background: People who identity as lesbian, gay, bisexual and transgender (LGBT) have specific health needs. Sexual orientation and gender identity are social determinants of health, as homophobia and heteronormativity persist as prejudices in society. LGBT patients often experience discrimination and prejudice in health care settings. While recent South African policies recognise the need for providing LGBT specific health care, no curricula for teaching about LGBT health related issues exist in South African health sciences faculties. This study aimed to determine the extent to which LGBT health related content is taught in the University of Cape Town’s medical curriculum.

Methods: A curriculum mapping exercise was conducted through an online survey of all academic staff at the UCT health sciences faculty, determining LGBT health related content, pedagogical methodology and assessment.
Results: 127 academics, across 31 divisions and research units in the Faculty of Health Sciences, responded to the survey, of which 93 completed the questionnaire. Ten taught some content related to LGBT health in the MBChB curriculum. No LGBT health related content was taught in the allied health sciences curricula. The MBChB curriculum provided no opportunity for students to challenge their own attitudes towards LGBT patients, and key LGBT health topics such as safer sex, mental health, substance abuse and adolescent health were not addressed.

Conclusion: At present, UCTs health sciences curricula do not adequately address LGBT specific health issues. Where LGBT health related content is taught in the MBChB curriculum, it is largely discretionary, unsystematic and not incorporated into the overarching structure. Coordinated initiatives to integrate LGBT health related content into all health sciences curricula should be supported, and follow an approach that challenges students to develop professional attitudes and behaviour concerning care for patients from LGBT backgrounds, as well as providing them with specific LGBT health knowledge. Educating health professions students on the health needs of LGBT people is essential to improving this population’s health by providing competent and non-judgmental care.

Weijer C, Peterson A, Webster F, Graham M, Cruse D, Fern├índez-Espejo D, Gofton T, Gonzalez-Lara L, Lazosky A, Naci L, Norton L, Spoeechley K, Young B, Owen A. Ethics of neuroimaging after serious brain injury BMC Medical Ethics 2014, 15:41  doi:10.1186/1472-6939-15-41

Background: Patient outcome after serious brain injury is highly variable. Following a period of coma, some patients recover while others progress into a vegetative state (unresponsive wakefulness syndrome) or minimally conscious state. In both cases, assessment is difficult and misdiagnosis may be as high as 43%. Recent advances in neuroimaging suggest a solution. Both functional magnetic resonance imaging and electroencephalography have been used to detect residual cognitive function in vegetative and minimally conscious patients. Neuroimaging may improve diagnosis and prognostication. These techniques are beginning to be applied to comatose patients soon after injury. Evidence of preserved cognitive function may predict recovery, and this information would help families and health providers. Complex ethical issues arise due to the vulnerability of patients and families, difficulties interpreting negative results, restriction of communication to “yes” or “no” answers, and cost. We seek to investigate ethical issues in the use of neuroimaging in behaviorally nonresponsive patients who have suffered serious brain injury. The objectives of this research are to: (1) create an approach to capacity assessment using neuroimaging; (2) develop an ethics of welfare framework to guide considerations of quality of life; (3) explore the impact of neuroimaging on families; and, (4) analyze the ethics of the use of neuroimaging in comatose patients.

Methods/Design: Our research program encompasses four projects and uses a mixed methods approach. Project 1 asks whether decision making capacity can be assessed in behaviorally nonresponsive patients. We will specify cognitive functions required for capacity and detail their assessment. Further, we will develop and pilot a series of scenarios and questions suitable for assessing capacity. Project 2 examines the ethics of welfare as a guide for neuroimaging. It grounds an obligation to explore patients’ interests, and we explore conceptual issues in the development of a quality of life instrument adapted for neuroimaging. Project 3 will use grounded theory interviews to document families’ understanding of the patient’s condition, expectations of neuroimaging, and the impact of the results of neuroimaging. Project 4 will provide an ethical analysis of neuroimaging to investigate residual cognitive function in comatose patients within days of serious brain injury.

Henschke N, Harrison C, McKay D, Broderick C, Latimer J, Britt H, Maher C. Musculoskeletal conditions in children and adolescents managed in Australian primary care. BMC Musculoskeletal Disorders 2014, 15:164  doi:10.1186/1471-2474-15-164

Background: Primary care settings play a vital role in the early detection and appropriate management of musculoskeletal conditions in paediatric populations. However, little data exist regarding these conditions in a primary care context or on the presentation of specific musculoskeletal disorders in children. The aim of this study was to estimate the caseload and describe typical management of musculoskeletal conditions in children and adolescents presenting to primary care in Australia.

Methods: An analysis of data from the Bettering the Evaluation and Care of Health (BEACH) study was performed. The BEACH study is a continuous national study of general practice (GP) activity in Australia. We identified all GP encounters with children and adolescents over the past five years and extracted data on demographic details, the problems managed, and GP management of each problem. SAS statistical software was used to calculate robust proportions and after adjustment for the cluster, the 95% confidence intervals (CIs).
Results: From the period April 2006 to March 2011, there were 65,279 encounters with children and adolescents in the BEACH database. Of the 77,830 problems managed at these encounters, 4.9% (95%CI 4.7% to 5.1%) were musculoskeletal problems. The rate of musculoskeletal problems managed increased significantly with age, however there was a significant decrease for girls aged 15–17 years. Upper and lower limb conditions were the most common, followed by spine and trunk conditions. Spine and trunk conditions were significantly more likely to be managed with medication, but less likely to receive imaging, than upper or lower limb problems.

Conclusions: Musculoskeletal problems in children and adolescents present a significant burden and an important challenge to the primary health care system in Australia. There is variability in rates of presentation between different age groups, gender and affected body region.


Monday, May 19, 2014

Communicating with Students using Apps

The latest issue of the wonderful little publication Online Cl@ssroom  [May 2014;14(5):2,5] offers a short article in which the author (Rob Kelly) provides the reader with information about various apps that you could use for communicating with your students. Some of the apps he lists include:

Smore (www.smore.com/): this app acts as a kind of a class blog that you can send to the students of a given class. And it can be sent in various formats, such as a text message or as an email. The article notes that one instructor uses this as a newsletter to send congratulatory information out to the class.
Edmodo (www.edmodo.com): Edmodo is actually now being used extensively in the Quad City Professional Development Network for its Excellence in Teaching program. It acts in ways akin to Facebook, but it allows you to do polls, offer assignments and embed video clips. Students can post to the site as well, so what they post can be shared with the class.

GroupMe (https://groupme.com/): this is a program that gives you the ability to send a text to up to 50 people at the same time. It also allows people to respond to your text so that everyone in the network can see what is posted in response. It operates outside of college LMSs.
LiveBinders (www.livebinders.com): This is a program that allows people to organize their resources on a topic-by-topic basis. Consider how this might benefit a chiropractic student- a binder on anatomy, another on physiology, etc. Given their reliance now on technology, all the resources are now in one location and easy for them to find.

Monday, May 12, 2014

A Little Bit on Bioethics

I know that most of us are by now fairly conversant in research bioethics. We are aware of the need to submit an IRB application for all human subject research, and we know that consent is a critically important aspect of all human research projects. But this is just one area of bioethics, and there are others, each with their own specific approaches and requirements. This is a brief overview of 4 of these sub-disciplines in bioethics.

Research Bioethics: As noted above, we are all pretty aware of research ethics. This discipline is focused on the protection of human subjects in scientific research. It grew from discoveries made in World War II related to unwilling use of prisoners in concentration camps, as well as purely American findings related to Tuskegee and to Willowbrook Hospital. The movement here is toward autonomy, leading to the need for informed consent and risk-benefit analysis in scientific research. An entire edifice has been erected under our laws: 45CFR46 (The Common Rule) and 21CFR56; these govern the use of human subjects in research and the composition and function of institutional review boards.
Clinical Bioethics: This branch of ethics governs how we obtain consent from patients to treat them. Again, informed consent is important, but it takes on a different flavor in the clinical setting. Before we can treat a patient, we need to let them know of the risks of treatment so that they can decide whether or not they wish to be treated. In our country, patients have a right to accept or refuse a doctor’s recommendation. Some of the thorniest issues in medical ethics arise in the clinical setting. How do we decide what to do if a patient cannot provide us guidance on treatment, and has left no record of what they might wish? Or if their children argue and disagree on a course of care? Ethics consultation is an important sub-branch of clinical bioethics.

Public Health Ethics: This is an area that seems to upend research and clinical bioethics, because it does not focus on the primacy of the individual and his or her individual rights. Instead, public health focuses on community health, and was developed in response to and anticipation of large-scale medical crises. Current examples of public health ethics is the fact that in certain occupations you may be required to have a flu shot- if you work in critical care hospital settings or, as my wife does, in early childhood development, for example. This is required in order to secure the safety of the community. You can opt out, but you will lose your job should you do so. Consider this question: how should the government respond if there is a deadly disease outbreak, such as an airborne influenza virus? Could it curtail travel, or force confinement? We have even had movies, such as Outbreak and Contagion, to look at this question.
Professional Ethics: This governs our behavior as members of a profession and as business people. We all follow professional codes of ethics. These tell us to keep our patients’ confidences, to treat patients with respect, to help others, etc. We should never take advantage of our patients, upsell them services, and we should always act in their best interest, not ours. Our role as a practitioner is sort of sacred and it differs from others businesses where maximizing profit is all that matters.

Each of these 4 branches has a wealth of literature and each is fascinating in its own right. Each is worth studying and applying to our daily life as a faculty member.

Monday, May 5, 2014

Palmer College of Chiropractic West Homecoming

I’ve just returned from helping celebrate Homecoming at PCCW. In addition to all the instructional courses that doctors and students could attend, there was also a visit, for a “meet and greet,” with National Football League Hall-of-Famer Jerry Rice. Mr. Rice, an engaging and friendly man, also spent an hour with 35 prospective students, making it a college visit it is not likely they will forget.

But what struck me, and it struck me hard, was to finally realize how far we have come in so short a time.  I began my chiropractic studies in 1976, and I graduated in 1979. I began my career as an educator in 1980. At the time I did so I could not have conceived, and I am not sure that anyone else could have either, where we would be professionally in 2014. This was brought home in 3 sessions that I attended.
The first was with our own Dr. Christine Goertz. It was not so much her topic, which was how to use scientific date to talk to policy makers. It was more that Dr. Goertz began her career as a program officer at NIH. And from that, she has become a tremendously powerful force in our profession, working for both PCORI (Patient-Centered Outcomes Research Institute) and for a AMA committee on health policy. Here we have a chiropractor working within the AMA- a past enemy- and at a high governmental level.

I then heard my former student Dr. Brian Justice speak. He spoke about primary spine care as a real-world approach to chiropractic practice in an evolving healthcare system. He did so as the medical director for Excellus/Blue Cross Blue Shield of upstate New York. Yes, he now heads a BCBS program and directs not just DCs but other professionals as well. And he argues that it is all about the patient as he goes about modelling effective care pathways.

And finally, I listed the estimable Dr. Bill Moreau. Bill is the medical director overseeing medical care delivered through the United States Olympic Committee. Thus, a chiropractor heads all medical services our elite athletes receive from the USOC.
Other speakers were involved with major league baseball, football and basketball teams. Some worked the America Cup in yacht racing. None of this could have been foreseen back in 1980.

It made me proud of what we have accomplished. And it starts here, in the classroom- you all made it happen!