Decision-making tips for patients with dementia.

BACKGROUND: When patients with advanced dementia lose capacity to make medical decisions for themselves, a 'best interests' determination is usually made on their behalf by the responsible clinician. Where possible, this should be made in consultation with members of the multiprofessional team and the family, consistent with ethical and legal norms. This paper is about multidisciplinary approaches to education and practice in dementia care, using a framework. APPROACH: At a UK multiprofessional workshop in 2020, delegates discussed ethical and legal issues that arise when making decisions for patients with advanced dementia. After an initial presentation, providing context and background, delegates broke into small groups. They were tasked with responding to questions arising from anonymised cases based on real-life scenarios. During plenary discussion afterwards, feedback was shared, and points of best practice were discussed. The authors took notes, and following positive evaluations after the event, they did further work on the framework with the intention of making it available for other health care professionals and clinical educators. EVALUATION: Based on contemporaneous notes summarising the feedback, plus further reflections, the framework was developed into a 12-point plan to assist health care teams and educators address difficulties in making 'best interests' determinations. IMPLICATIONS: Promoting understanding of ethics and law pertaining to 'best interests' should benefit patients and families, with the potential to reduce the need for cases to be decided in court. To help promote good clinical practice, educators may want to consider running case-based workshops at their institution, using the framework as a scaffold for learners.

Improving global access to medical ethics education: a free self-paced online course on the Peoples-uni website.

In an attempt to increase global access to education about medical ethics, a free fully online course was developed on the Peoples-uni Open Online Courses site. Students came from 60 countries and were more likely to be medical practitioners, have come from the global North, and to have heard about the course through the web than other students enrolled in the Peoples-uni Open Online Courses site. Students scored high marks on the five quizzes. A third of the students gained a certificate of completion. Course feedback was overwhelmingly positive. Students stated that they learned the most from the lesson on professionalism, while other topics such as patient rights and autonomy, legal issues, and healthcare organisation and public health were also frequently mentioned. The course is an example of how open online courses can play a role in increasing awareness of medical ethics. Based on its analysis, the study identifies a need to attract interest in this area from low- and middle-income countries.

Structured medical electives: a concept whose time has come?

BACKGROUND: Most international electives in which medical students from high-income countries travel abroad are largely unstructured, and can lead to problematic outcomes for students as well as sending and receiving institutions. We analyse the problems of unstructured medical electives and describe the benefits of an elective experience that includes more organisation and oversight from the sending medical school. RESULTS: A number of structured elective programmes have been developed, including those at the Medical School for International Health, Israel and the University of Dundee, United Kingdom. These programmes provide significant pre-departure training in global health and the ethical dimensions of electives, support and monitoring during the elective, and post-elective debrief. Crucially, the programmes themselves are developed on the basis of long-term engagement between institutions, and have an element of reciprocity. We further identify two major problems in current medical electives: the different ethical contexts in which electives take place, and the problem of 'voluntourism', in which the primary beneficiary of the activity is the medical student, rather than the receiving institution or health system. These two issues should be seen in the light of unequal relations between sending and receiving institutions, which largely mirror unequal relations between the Global North and South. CONCLUSION: We argue that more structured elective programmes could form a useful corrective to some of the problems identified with medical electives. We recommend that medical schools in countries such as the UK strongly consider developing these types of programmes, and if this is not possible, they should seek to further develop their pre-departure training curricula.

Responding to unprofessional behaviours.

BACKGROUND: Medical educators sometimes have to respond to inappropriate behaviours from doctors in training that have the potential to endanger their future careers and affect the safety and well-being of their patients. The authors led workshops at international meetings using case-based discussion and plenary wrap-ups to reinforce and share the learning outcomes. This paper summarises key points of difference and common themes about how to manage challenging professional behaviours presented by doctors in training that may be of value to tutors and clinical educators. CONTEXT: Although the problems encountered had elements in common, experiences varied between countries, schools and programmes as regards processes, procedures and thresholds for launching an investigation. Whereas variations are not unexpected it is important to consider the context and background against which decisions are made. Appropriate responses must take account of professional, legal and ethical guidelines, where they exist. IMPLICATIONS: Major inconsistencies in hearings and investigations may not be in anyone's best interests: fairness is core to most notions of justice, whether from the perspective of a doctor in training, clinical educator or member of the public. Therefore, schools and programmes need to take this into account when reviewing processes and procedures. Although the career of a doctor in training is important, it is not the only consideration. If systems fail the public has a right to be concerned, and striving to ensure that medical students graduate to become safe, professional doctors is something of concern to all clinical educators.

An introduction to the 2011 National Multicultural Conference & Summit keynote addresses.

This article provides and introduction to the 2011 National Multicultural Conference & Summit Keynote Addresses. The authors explain that they chose to focus on the tension and possibilities within multicultural psychology at the seventh biennial National Multicultural Conference & Summit (NMCS), which was held on January 27-28, 2011, at The Westin-Seattle Hotel. During the 2-day conference, nearly 900 attendees engaged with one another and heard from experts in the field as we focused on the theme, "Unification through Diversity: Bridging Psychological Science & Practice in the Public Interest. Two key sets of presentations are highlighted.

Cultural aspects of primary healthcare in india: A case- based analysis.

Delivering quality primary care to large populations is always challenging, and that is certainly the case in India. While the sheer magnitude of patients can create difficulties, not all challenges are about logistics. Sometimes patient health-seeking behaviour leads to delays in obtaining medical help for reasons that have more to do with culture, social practice and religious belief. When primary care is accessed via busy state-run outpatient departments there is often little time for the physician to investigate causes behind a patient's condition, and these factors can adversely affect patient outcomes. We consider the case of a woman with somatic symptoms seemingly triggered by psychological stresses associated with social norms and familial cultural expectations. These expectations conflict with her personal and professional aspirations, and although she eventually receives psychiatric help and her problems are addressed, initially, psycho-social factors underlying her condition posed a hurdle in terms of accessing appropriate medical care. While for many people culture, belief and social norms exert a stabilising, positive influence, in situations where someone's personal expectations differ significantly from accepted social norms, individual autonomy can be directly challenged, and in which case, something has to give. The result of such challenges can negatively impact on health and well-being, and for patients with immature defence mechanisms for dealing with inner conflict, such an experience can be damaging and ensuing somatic disturbances are often difficult to treat. Patients with culture-bound symptoms are not uncommon within primary care in India or in other Asian countries and communities. We argue that such cases need to be properly understood if satisfactory patient outcomes are to be achieved. While some causes are structural, having to do with how healthcare is accessed and delivered, others are about cultural values, social practices and beliefs. We note how some young adult women are adversely affected and discuss some of the ethical issues that arise.

Deconstructing multicultural counseling competencies research: comment on Owen, Leach, Wampold, and Rodolfa (2011).

The present article offers a commentary and critique of the research presented by J. Owen, M. M. Leach, B. Wampold and E. Rodolfa (2011). Given the complexity of the research methodology, findings, and conclusions, the authors provide a concise summary of findings, study limitations, and conclusions followed by a detailed critique of the study. The authors respect and appreciate the ambitious efforts made by Owen et al. to address gaps in the literature regarding outcome research using client ratings of counselors' multicultural counseling competencies (MCCs). The authors provide a critical analysis of some of J. Owen et al.'s specific conclusions and offer alternative conclusions based on conceptual and methodological bases. The authors use the opportunity to comment on this study as a means of advancing recommendations regarding future research on MCCs that might contribute to substantive revisions to the long-standing theoretical foundation in this area.

Development, reliability, and validity of the Measure of Sexual Identity Exploration and Commitment (MOSIEC).

Four studies were conducted on the development and validation of the Measure of Sexual Identity Exploration and Commitment (MoSIEC). Exploratory factor analysis of an initial item pool yielded a 22-item measure with 4 distinct factors assessing commitment, exploration, sexual orientation identity uncertainty, and synthesis/integration. Exploratory factor analysis findings support the argument that sexual identity is a broad, multidimensional construct and that the MoSIEC assesses the construct of sexual identity in a manner consistent with J. E. Marcia's (1966) model of identity development. Confirmatory factor analyses demonstrated the stability of the MoSIEC factor structure, providing evidence of construct validity. Test-retest stability, internal consistency, and validity coefficients supported the use and continued development of the MoSIEC. Significant differences in levels of exploration and sexual orientation identity uncertainty were found among different sexual orientation identity groups, establishing the criterion-related validity of the MoSIEC. Implications for further development and use of the MoSIEC are discussed.