No healthcare coverage, big problem: lack of insurance for older population associated with worse emergency general surgery outcomes.

Introduction: Older populations, being a unique subset of patients, have poor outcomes for emergency general surgery (EGS). In regions lacking specialized medical coverage for older patients, disparities in healthcare provision lead to poor clinical outcomes. We aimed to identify factors predicting index admission inpatient mortality from EGS among sexagenarians, septuagenarians, and octogenarians. Methods: Data of patients aged >60 years with EGS conditions defined by the American Association for the Surgery of Trauma at primary index admission from 2010 to 2019 operated and non-operated at a large South Asian tertiary care hospital were analyzed. The primary outcome was primary index admission inpatient 30-day mortality. Parametric survival regression using Weibull distribution was performed. Factors such as patients' insurance status and surgical intervention were assessed using adjusted HR and 95% CI with a p-value of <0.05 considered statistically significant. Results: We included 9551 primary index admissions of patients diagnosed with the nine most common primary EGS conditions. The mean patient age was 69.55±7.59 years. Overall mortality and complication rates were 3.94% and 42.29%, respectively. Primary index admission inpatient mortality was associated with complications including cardiac arrest and septic shock. Multivariable survival analysis showed that insurance status was not associated with mortality (HR 1.13; 95% CI 0.79, 1.61) after adjusting for other variables. The odds of developing complications among self-paid individuals were higher (adjusted OR 1.17; 95% CI 1.02, 1.35). Conclusion: Lack of healthcare coverage for older adults can result in delayed presentation, leading to increased morbidity. Close attention should be paid to such patients for timely provision of treatment. There is a need to expand primary care access and proper management of comorbidities for overall patient well-being. Government initiatives for expanding insurance coverage for older population can further enhance their healthcare access, mitigating the risk of essential treatments being withheld due to financial limitations. Level of evidence: III.

Undergraduate Medical Education Curriculum Reforms in Pakistan: A Mixed Methods Study of Academic Leadership Perspectives.

PURPOSE: Periodic revision of undergraduate medical education (UGME) curricula is an essential part of evidence-based educational practices. Pakistan's national UGME curriculum, last updated in 2005, was reviewed, and recommended updates were made in 2022. The authors explore academic medical school leaders' perspectives about the proposed reforms, gaps within the existing curriculum, and how to ensure the reform implementation is effective, collaborative, and feedback-driven. METHOD: Using a mixed methods approach, data were collected from April-July 2022. Academic leadership (principals, who could designate vice principals or medical educators) at all medical schools across Pakistan (n = 117) were invited. Agreement with each of 20 proposed reforms was measured via a survey employing a Likert scale. A semi-structured interview guide expanded on the survey questions with probes. RESULTS: Eighty-eight survey responses, from private (59; 67.0%) and public (29; 33.0%) institutions, were obtained (75.2% response rate). Participants recommended most of the proposed reforms. The 3 reforms that received the highest agreement were teaching professionalism as an integral part of the curriculum (83; 94.3%), mandating bedside procedural skills training (80; 90.9%), and including patient safety in the UGME curriculum (79; 89.8%). Including multidisciplinary tumor boards and surgical oncology had the lowest agreement (26; 29.5%). Fifteen interviews were conducted, which revealed 3 major themes: perceptions about changes to the curricular content; limitation of human and financial resources as barriers to reform implementation; and recommendations for effective implementation of an updated curriculum. CONCLUSIONS: The findings reflect an overall positive attitude of academic medical school leadership toward the 20 proposed UGME curriculum reforms, which could aid with on-the-ground implementation. However, major limitations, such as a lack of trained faculty and financial resources, must be addressed. The authors propose future research on the resources required for implementing UGME reforms and the reforms' impact after national implementation.

Disparities in patient-resident physician communication and counseling: A multi-perspective exploratory qualitative study.

Effective communication between physicians and patients plays an integral role in clinical care. Gaps in a physician's ability to ensure effective communication, especially with patients from diverse backgrounds, are known causes of medical errors. This study explores the potential biases and disparities in patient-resident communication, which may influence a patient's quality of care. This exploratory qualitative study was conducted at the largest academic medical center in Pakistan. Purposive sampling was used to approach participants from surgery, medicine, obstetrics and gynecology, pediatrics and family medicine. Faculty, fellows and residents working in these departments and medical students in their fourth and fifth years of undergraduate education with prior experience of at least one month in these specialties during their clinical rotations were included. Focus group discussions (FGDs) lasting 45-60 minutes were conducted with each cohort of healthcare professionals separately, using a semi-structured interview guide. Sixty participants (19 males and 41 females, mean age: 32.9, SD: 10.9) took part in the study. Thematic analysis revealed five major themes. Four themes focused on residents' biases and patient disparities hindering patient-resident communication: (1) patient-resident gender discordance (2) ethnicity and language barriers, (3) differing social class of the patient, and (4) challenging patient-resident interactions (patients resistant to treatment, exceedingly inquisitive and those with multiple attendants, etc.). The fifth theme identified the need for a communication skills curriculum in postgraduate medical education. Opposite gender and discordant socioeconomic/cultural backgrounds of patients pose a challenge to effective patient-physician communication. Self-identification and awareness of residents' biases when interacting with patients can ensure their active elimination and improve their communication skills. Integrating these components in a standardized curriculum within postgraduate programs can enable resident-physicians to provide the same level of care and communicate more efficiently with patients of all backgrounds.

Leveraging the vantage point - exploring nurses' perception of residents' communication skills: a mixed-methods study.

INTRODUCTION: Effective communication is key to a successful patient-doctor interaction and improved healthcare outcomes. However, communication skills training in residency is often subpar, leading to inadequate patient-physician communication. There is a dearth of studies exploring the observations of nurses - key members of healthcare teams with a special vantage point to observe the impact of residents' communication with patients. Thus, we aimed to gauge the perceptions of nurses regarding residents' communication skills expertise. METHODS: This study employed a sequential mixed-methods design, and was conducted at an academic medical center in South Asia. Quantitative data was collected via a REDCap survey using a structured validated questionnaire. Ordinal logistic regression was applied. For qualitative data, In-depth interviews were conducted with nurses using a semi-structured interview guide. RESULTS: A total of 193 survey responses were obtained from nurses hailing from various specialties including Family Medicine (n = 16), Surgery (n = 27), Internal Medicine (n = 22), Pediatrics (n = 27), and Obstetrics/Gynecology (n = 93). Nurses rated long working hours, infrastructural deficits, and human failings as the main barriers to effective patient-resident communication. Residents working in in-patient settings were more likely to have inadequate communication skills (P-value = 0.160). Qualitative data analysis of nine in-depth interviews revealed two major themes: existing status-quo of residents' communication skills (including deficient verbal and non-verbal communication, bias in patient counselling and challenging patients) and recommendations for improving patient-resident communication. CONCLUSION: The findings from this study highlight significant gaps in patient-resident communication from the perception of nurses and identify the need for creating a holistic curriculum for residents to improve patient-physician interaction.

Development, outcome and costs of a simulation-based neurosurgery bootcamp at the national level.

INTRODUCTION: With a growing interest in simulation-based training to develop clinical proficiency, bootcamps have been utilized for imparting basic skills to medical trainees. While considerable research on the topic exists in high income countries, no such neurosurgical teaching standards have been employed in Low- and Middle-Income Countries. METHODS: We conducted a cross-sectional study to explore the effectiveness of first low-cost, multi-center regional neurosurgery bootcamp in South Asia. Twenty-two participants attended the bootcamp and practiced 12 hands-on skills over the course of 2 days. Burr-holes and craniotomies were done on 3D printed skulls. Lumbar drain insertion was practiced on a purpose-built lumbar puncture mannequin. For laminectomy, we used an in-house designed simulation. The modified Objective Structured Assessment of Technical Skills tool was utilized for skills Assessment. Feedback from faculty and residents was collected via a standard 5-point Likert scale. RESULTS: Only one participant (4.55%) had previously attended a neurosurgical skills workshop. Comparison of outcomes on 1st and 3rd attempts of cranial and spinal skills showed a significant improvement in all 14 domains assessed (p <0.05). Positive feedback was received ranging from 3.9 up to 4.8 on a 5-point Likert scale. Overall cost per participant culminated to $145, significantly lower than previously reported data. CONCLUSION: Our findings report the effectiveness of sustainable, low-cost training models which can be easily reproduced elsewhere. These indigenously designed simulators can be modified for variable difficulty level and serve as an effective educational strategy in improving learners' skills, knowledge and confidence.