'He should feel your pain': Patient insights on patient-provider communication in Rwanda.

BACKGROUND:  Patient-provider communication is an interpersonal interaction between a patient and a health care provider. OBJECTIVE:  This study explored patients' communication preferences and perceptions on what factors influence the patient-provider communication in primary health care settings in Rwanda. METHODS:  In-depth semi-structured interviews with 15 individuals including 8 with limited literacy. A thematic inductive analysis was used. RESULTS:  Patients valued communication with providers and expressed the need for interacting with caring, empathic providers who can share all the information they want and involve them in their own care. Health literacy and power issues were factors that may influence patient-provider communication. Patients with limited literacy appeared to rely highly on health care providers for making decisions about and managing their health care. CONCLUSION:  The expressed preferences, including those of patients with limited literacy, aligned well with the patient-centred care model. There were indications of a power imbalance weighing on the provider's side. Although patients with limited literacy were reliant on providers for decision-making, they were ready to be more involved in the care, suggesting a potential for improved patient involvement even for patients with paternalistic care preferences. These patients' insights can impact policies and curricula to optimise clinical practice. Generated knowledge will contribute to the indispensable yet underdeveloped field of health communication in sub-Saharan Africa. PRACTICE IMPLICATIONS:  Findings call for more inclusion of patient perspectives in the patient-provider encounter. This could require more training of professionals and research on the topic, both in Rwanda and in other regions.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda.

BACKGROUND: The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. METHODS: The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. RESULTS: In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. CONCLUSION: The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

What makes a good clinical student and teacher? An exploratory study.

BACKGROUND: What makes a good clinical student is an area that has received little coverage in the literature and much of the available literature is based on essays and surveys. It is particularly relevant as recent curricular innovations have resulted in greater student autonomy. We also wished to look in depth at what makes a good clinical teacher. METHODS: A qualitative approach using individual interviews with educational supervisors and focus groups with senior clinical students was used. Data was analysed using a "framework" technique. RESULTS: Good clinical students were viewed as enthusiastic and motivated. They were considered to be proactive and were noted to be visible in the wards. They are confident, knowledgeable, able to prioritise information, flexible and competent in basic clinical skills by the time of graduation. They are fluent in medical terminology while retaining the ability to communicate effectively and are genuine when interacting with patients. They do not let exam pressure interfere with their performance during their attachments. Good clinical teachers are effective role models. The importance of teachers' non-cognitive characteristics such as inter-personal skills and relationship building was particularly emphasised. To be effective, teachers need to take into account individual differences among students, and the communicative nature of the learning process through which students learn and develop. Good teachers were noted to promote student participation in ward communities of practice. Other members of clinical communities of practice can be effective teachers, mentors and role models. CONCLUSIONS: Good clinical students are proactive in their learning; an important quality where students are expected to be active in managing their own learning. Good clinical students share similar characteristics with good clinical teachers. A teacher's enthusiasm and non-cognitive abilities are as important as their cognitive abilities. Student learning in clinical settings is a collective responsibility. Our findings could be used in tutor training and for formative assessment of both clinical students and teachers. This may promote early recognition and intervention when problems arise.

The influence of structural and institutional change on teaching and culture in clinical settings: an exploratory study.

OBJECTIVES: Learning in clinical settings is a function of activity, context and culture. Glasgow University's Medical School has undergone significant curricular change in recent years. This has coincided with change to National Health Service consultants' contracts, the introduction of the European Working Time Directive and the Modernising Medical Careers training initiative. We wished to explore teachers' and students' perspectives on the effects of change on our clinical teachers' capacity for teaching and on medical culture. METHODS: A qualitative approach using individual interviews with educational supervisors and focus groups with senior clinical students was used. Data were analysed using a "framework" technique. RESULTS: Curricular change has led to shorter clinical attachments in the senior clinical rotation, which combined with more centralised teaching have had adverse effects on both formal and informal teaching during attachments. Consultants' NHS contract changes the implementation of the European Working Time Directive and changes to postgraduate training have adversely affected consultants' teaching capacity, which has had a detrimental effect on their relationships with students. Medical culture has also changed as a result of these and other societal influences. CONCLUSIONS: The apprenticeship model was still felt to be relevant in clinical settings. This has to be balanced against the need for systematic teaching. Structural and institutional change affects learning. Faculty needs to be aware of the socio-historical context of their institutions.

Testing the validity of a scenario-based questionnaire to assess the ethical sensitivity of undergraduate medical students.

BACKGROUND: Although medical educators acknowledge the importance of ethics in medical training, there are few validated instruments to assess ethical decision-making. One instrument is the Ethics in Health Care Questionnaire--version 2 (EHCQ-2). The instrument consists of 12 scenarios, each posing an ethical problem in health care, and asking for a decision and rationale. The responses are subjectively scored in four domains: response, issue identification, issue sophistication, and values. GOALS: This study was intended to examine the inter-rater and inter-case reliability of the AHCQ-2 and validity against a national licensing examination of the EHCQ-2 in an international sample. METHODS: A total of 20 final year McMaster students and 45 final year Glasgow students participated in the study. All questionnaires were scored by multiple raters. Generalizability theory was used to examine inter-rater, inter-case and overall test reliability. Validity was assessed by comparing EHCQ-2 scores with scores on the Canadian written licensing examination, both total score and score for the ethics subsection. RESULTS: For both samples, reliability was quite low. Except for the first task, which is multiple choice, inter-rater reliability was 0.08-0.54, and inter-case reliability was 0.14-0.61. Overall test reliability was 0.12-0.54. Correlation between EHCQ-2 task scores and the licensing examination scores ranged from 0.07 to 0.40; there was no evidence that the correlation was higher with the ethics subsection. CONCLUSIONS: The reliability and validity of the measure remains quite low, consistent with other measures of ethical decision-making. However, this does not limit the utility of the instrument as a tool to generate discussion on ethical issues in medicine.

'Can you take a student this morning?' Maximising effective teaching by practice nurses.

OBJECTIVES: Little is known about the contribution nurses make to medical student learning. This study set out to explore the nature of practice nurse teaching during the general practice clerkship and to investigate ways in which the teacher and learner (the practice nurse and the medical student) can be best supported to maximise learning. METHODS: Mixed focus groups were conducted with general practitioner educational supervisors and practice nurses. Further focus groups were conducted with students on completion of clerkships. RESULTS: There is wide variation in the delivery, organisation and expectations of practice nurse teaching. Although there is some evidence of a passive learning experience, the learning dynamic and the student-nurse relationship are regarded highly. CONCLUSIONS: Time spent with practice nurses is an important part of the clerkship in general practice. The nature of the practice nurse-medical student relationship differs from that of the educational supervisor-medical student relationship and can be built upon to maximise learning during the clerkship. The experience for the practice nurse, medical student and supervisor can be enhanced through formal preparation for delivering teaching.

Teaching professionalism in the early years of a medical curriculum: a qualitative study.

CONTEXT: Despite the growing literature on professionalism in undergraduate medical curricula, few studies have examined its delivery. OBJECTIVES: This study investigated tutors' and students' perspectives of the delivery of professionalism in the early years of Glasgow's learner-centred, problem-based learning (PBL), integrated medical curriculum. METHODS: A qualitative approach was adopted involving semistructured interviews, on a 1 in 6 sample of tutors involved in teaching in the early curricular years, and 3 student focus groups. The findings were subjected to between-method triangulation. RESULTS: Involvement in teaching raised students' and tutors' awareness of their professionalism. Learning activities promoting critical reflection were most effective. The integration of professionalism across the domains of Vocational Studies (VS) was important for learning; however, it was not well integrated with the PBL core. Integration was promoted by having the same tutor present throughout all VS sessions. Early patient contact experiences were found to be particularly important. The hidden curriculum provided both opportunities for, and threats to, learning. The small-group format provided a suitable environment for the examination of pre-existing perspectives. The portfolio was an effective learning tool, although its assessment should be formalised. CONCLUSIONS: Reflection is integral to professional development. Early clinical contact is an important part of the process of socialisation, as it allows students to enter the community of practice that is the medical profession. Role models can contribute powerfully to students' learning and identity formation. As students move towards fuller participation, the clinical milieu should be controlled to maximise the influence of role models, and opportunities for guided reflection should be sustained.