Post-COVID-19: can digital solutions lead to a more equitable global healthcare workforce?

An unintended consequence of the COVID-19 pandemic has been the exponential growth of telemedicine, with automation of healthcare becoming more common. Face-to-face meetings and training events have been replaced relatively seamlessly with online versions, taking clinical or academic expertise to distant parts of the world and making them more accessible and affordable. The wide reach of digital platforms offering remote healthcare offers the opportunity of democratising access to high-quality healthcare, However, certain challenges remain: (a) clinical guidance developed in one geographical area may need adaptation for use in others; (b) regulatory mechanisms from one jurisdiction need to offer patient safety across other jurisdictions; (c) barriers created by disparity in technology infrastructure and the variation in pay for services across different economies, leading to brain drain and an inequitable workforce. The World Health Organization's Global Code of Practice on the International Recruitment of Health Personnel could offer the preliminary framework on which solutions to these challenges could be built.

Learners' Perspectives of Professionalism: Protocol for a Mixed Methods Systematic Review.

BACKGROUND: Professionalism has come to be associated with competence in medical education, with the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served. Recent studies indicate students should have the opportunity to observe the application of knowledge and skills by their mentors to improve patient health and safety. A noticeable detail that needs implementation into the curriculum is the inclusion of student perspectives. This review will explore students' understanding and experience of professionalism in undergraduate medical education (UME). OBJECTIVE: This paper presents the protocol for a review that aims to develop an integrated synthesis of qualitative and quantitative studies resulting in recommendations for medical school curricula to incorporate the learners' perspectives in teaching professionalism in UME. METHODS: We will take an integrated approach to synthesis. Data will be extracted from the included studies, and quantitative data will be "qualitized." PubMed (Medline), Embase, PsycInfo, and ERIC (Education Resources Information Center) will be searched for studies published in English from 2010 to 2021. Studies will be screened and critically appraised for methodological quality using the Mixed Methods Appraisal Tool by 2 researchers, with disagreements resolved by a third researcher. Qualitative, quantitative, and mixed methods studies will be considered. Our population of interest is undergraduate medical students; hence, studies on medical residents and graduate medical students will be excluded. We will consider studies that explore how concepts of professionalism are understood, experienced, and taught in undergraduate medicine and on how medical students understand and develop the identified constructs of professionalism. RESULTS: This study is in the screening phase; therefore, no results are available at this time. However, we had initiated the searches, screening, and are currently in the critical appraisal stage. We will commence preparation to clean and convert the data for coding in July 2022, and analysis will be ongoing from the end of July 2022 until submission for publication in November 2022. CONCLUSIONS: This research will contribute to the student perspectives on professionalism in medical education literature. The findings will aid in the creation of a checklist to guide the development of a curriculum on professionalism in UME. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37473.

Use of a novel assay to measure pre- to posttraining palpatory skills of first-year osteopathic medical students.

CONTEXT: Although palpation is a central skill in the practice of osteopathic medicine, few data are available on factors affecting the development of palpatory skills. OBJECTIVE: To use a novel palpatory skills assay to assess the role of training and practice in the development of palpatory skills in an osteopathic medical student population. METHODS: The palpatory skills of first-year osteopathic medical students were assessed using a simple, objective palpation assay that consisted of locating a dime placed under sheets of copy paper at depths of 50, 100, 150, 200, 300, and 400 sheets. Two trials were performed at each depth. The assay was performed at the beginning and at the end of the students' first term. To determine whether practice with the assay impacted participant performance, a third assay was conducted to compare the performance of students who completed the assays at the beginning and at the end of the term with that of students who had never completed the assay. RESULTS: Sixty-three participants completed the assays at the beginning and end of the term. Fifty-seven of those 63 participants and 192 participants who had not previously completed the assay completed the third assay. A wide variability in number of correct responses per participant was observed at both the beginning (range, 0-11 correct) and the end (range, 2-12 correct) of the term. The mean (SD) number of correct responses per participant increased from the beginning (5.49 [2.78]) to the end (7.17 [2.27]) of the term. Analysis using the generalized estimating equation model demonstrated that both paper depth and experience (ie, beginning vs end of the term) were statistically significant determinants of the number of correct responses (P<.001). The Kaplan-Meier method indicated that the median paper depth at which participants first scored no correct responses increased from 200 sheets (95% CI, 171-229) at the beginning of the term to 300 sheets (95% CI, 232-367) at the end of the term (P<.001). In the third assay, no significant differences were noted in the performance of students who had completed the 2 previous assays vs participants who had not completed the previous assays (P=.136). CONCLUSION: Participants' palpatory skills improved from the beginning to the end of the term. The range of participants' palpatory skills at the beginning of the term suggests that other factors in addition to training influenced participants' palpatory skill level. Additional research is needed to identify and investigate factors that influence the development of palpatory skills.

Osteopathic manipulative treatment as a useful adjunctive tool for pneumonia.

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 2007 (1) and resulted in the hospitalization of 1.1 million patients (2). With an average length of in-patient hospital stay of five days (2), pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 2005 (3). Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence (4). (Figure 1) Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients' length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone (5). The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians (6). When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems(7,8, 9, 10). The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: (1) Rib Raising, (2) Thoracic Pump, (3) Doming of the Thoracic Diaphragm, and (4) Muscle Energy for Rib 1.

The anatomical and functional relation between gluteus maximus and fascia lata.

There is not full agreement regarding the distal insertions of the gluteus maximus muscle (GM), particularly the insertions into the iliotibial band and lateral intermuscular septum. 6 cadavers, 4 males and 2 females, mean age 69 yr, were dissected to evaluate the insertions of the GM into the iliotibial band, fascia lata, lateral intermuscular septum and femur. The iliotibial band is a reinforcement of the fascia lata and cannot be separated from it. Its inner side is in continuity with the lateral intermuscular septum, which divides the quadriceps from the hamstring. In all subjects the gluteus maximus presented a major insertion into the fascia lata, so large that the iliotibial tract could be considered a tendon of insertion of the gluteus maximus. The fascial insertion of the gluteus maximus muscle could explain the transmission of the forces from the thoracolumbar fascia to the knee.

Impact of osteopathic manipulative treatment on secretory immunoglobulin a levels in a stressed population.

CONTEXT: High levels of human secretory immunoglobulin A (sIgA) have been shown to decrease the incidence of acquiring upper respiratory tract infections. Osteopathic manipulative treatment (OMT) has been shown to improve cardiac indices, increase lymph flow rates through the thoracic duct, and decrease sympathetic tone in postoperative patients and those in intensive care. Therefore, we hypothesized that OMT may also increase sIgA levels in people under high levels of emotional and psychological stress, thereby enhancing immunity and potentially preventing subsequent infections. OBJECTIVE: To determine if OMT increases sIgA levels in highly stressed individuals. METHODS: Twenty-five second-year osteopathic medical students were randomly assigned to an experimental group (n=12) or a control group (n=13). All participants were scheduled to take their national board examination (Comprehensive Osteopathic Medical Licensing Examination-USA) within 2 to 3 weeks after the experiment. After each participant submitted a saliva sample for a baseline sIgA level assessment, the experimental group received 20 minutes of OMT while the control group sat quietly and relaxed in a separate area for 20 minutes. Participants in both groups rested quietly for 1 hour after the 20-minute session and then submitted a second saliva sample. RESULTS: A 2 × 2 repeated measures analysis of variance revealed that the experimental group displayed a statistically significant greater increase in postintervention sIgA levels than the control group (F1,23), 5.92; P<.025). CONCLUSION: This study demonstrates the positive effect of OMT on sIgA levels in persons experiencing high stress. Results suggest that OMT may then have therapeutic preventive and protective effects on both healthy and hospitalized patients, especially those experiencing high levels of emotional or physiological stress and those at higher risk of acquiring upper respiratory tract infections.