Archive | International

STI Management: Syndromic vs. Laboratory-based Approach

Clinical considerations and ethical deliberations from a rural Caribbean clinic

Dr Josie Reynolds recently contacted RuralGP.com to offer to write about her experiences and observations from rural Jamaica.  We’re delighted to feature the first of these articles here…

As doctors, we are most comfortable with our diagnoses when we have investigative results to confirm them. This is especially true for those trained in high-income countries, as more and more sophisticated laboratory tests and imaging have become part of everyday practice.

But in rural, remote settings, particularly those of low and middle income countries, the practicality and cost of diagnostic testing can become a barrier to treatment. This barrier is intensified in the management of sexually transmitted infections by the taboo and stigma that surround these conditions.

Because of this it has been argued that a syndromic approach to STI management can be more appropriate to tackle the burden of disease. Syndromic management of STIs works by grouping symptoms and signs of disease into syndromes and treating based on the most common causative pathogen(s), e.g. vaginal discharge syndrome, lower abdominal pain and male urethritis syndrome.

This practical approach in the most resource poor environments can help to tackle high burden of disease, therefore reducing significant morbidity, infertility and increasing spread of infection. In these settings there is a strong argument for forgoing the lab tests and treating empirically.

But what about those settings that fall somewhere in the middle?

At what point is it more appropriate to treat following laboratory testing?

Are there any markers that indicate the tip of balance in favour of a laboratory-based approach?

 

Picture a rural Caribbean health clinic. The mountainous community can seem remote based on the terrible conditions of the roads, but in fact as the crow flies there is only 10 miles to the capital city. There is also fairly regular transport by bus to the city Mon – Sat, and a public run clinic in town which provides free STI testing and treatment (all be it slow).

Community members, however, have very little disposable income and primarily lead subsistence lifestyles. With this in mind, working as a primary care physician at the clinic, I was not keen to send people away without treatment in case they did not go to get testing & treatment and the infection continued to spread. Syndromic management, therefore, seemed the way to go…

But the more I thought about syndromic management – STI management without any laboratory testing – the more negative implications I could think of:

  • Contact tracing – this is still possible, but do you treat all sexual contacts even if symptom free? This could expose numerous people to the risk of unnecessary medications when there is no guarantee that they have the disease.
  • Missing concomitant STIs e.g. HIV – it’s not uncommon for STIs to come in pairs and symptoms are frequently vague or non-existent. Treating syndromically without testing misses the opportunity to pick up some of the more serious infections that may be present simultaneously.
  • Contributing to antibiotic resistance – as one of the biggest threats to modern medicine, antibiotic resistance cannot be ignored. Whilst syndromic management may be the pragmatic approach, the greater picture needs to be considered.
  • Relaxed approach – could syndromic management give patients the impression that STIs are not very serious as no testing is required? Could this apparently relaxed approach translate into less incentive to prevent reinfection?
  • The subtle symptoms – for the barn-door cases, where signs & symptoms are clear and fit neatly into the box, this approach is straight-forward. But what about the grey areas? Or the patients which don’t follow the usual pattern?
  • Impact on doctor-patient relationship – with a less evidence-based approach and therefore greater risk of treatment failure, is there a danger of loss of trust or breakdown of relationship between the healthcare provider and patient?
  • Reliable statistics – guidelines for syndromic management often mention adding in treatment for certain infections, e.g. gonorrhoea, if there are high levels in the region. However, in low-middle income settings, the epidemiological data is less likely to be complete and therefore recorded levels may be misleading.

 

I found myself in a struggling health system, but provisions were not non-existent – should I accept the flaws of the approach and treat syndromically or encourage patients to overcome the barriers and receive a better standard of care overall?

I realised too that part of my reserve for syndromic management linked into a deeper notion: by accepting syndromic management as routine are we reinforcing the idea that disadvantaged people deserve second rate healthcare?

Or perhaps my scientific-based training was blinding me to the benefits of syndromic management? Was my personal desire to get to the bottom of the cause preventing me from putting the important things first?

Either way, it appears to me that a more sophisticated set of guidelines is required from the Global Health Sector to reflect the variations in development of health systems worldwide, rather than a binary choice which may work for some, but not for all.

What do you think? What would you do in a similar situation? Which factors would tip the balance in your decision?

References:

http://apps.who.int/iris/bitstream/10665/82207/1/WHO_RHR_13.02_eng.pdf

http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-4-1-eng.php

http://sti.bmj.com/content/80/5/333

http://applications.emro.who.int/aiecf/web79.pdf

http://siteresources.worldbank.org/INTPRH/Resources/STINoteFINAL26Feb08.pdf

http://hetv.org/resources/reproductive-health/rtis_gep/syndromic_mngt.htm

https://www.idealclinic.org.za/docs/National-Priority-Health-Conditions/Sexually%20Transmitted%20Infections_%20Management%20Guidelines%202015.pdf

http://onlinelibrary.wiley.com/doi/10.1046/j.1365-3156.1999.00360.x/full

https://www.hindawi.com/journals/isrn/2014/103452/

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RRH Guide to Getting your work Published

One of the sessions at #ruralwonca was delivered by some of the team at the Journal for Remote & Rural Health.  I was really sorry to miss it, due to presenting in another session, but my tweeted request to make the advice available online was answered quickly and the presentation is now available – see below.

The journal team are keen to encourage and motivate rural healthcare professionals to share their research, and seem genuinely interested in helping budding writers to put pen-to-paper or finger-to-keyboard.

There is a lot of great innovation and problem-solving going on in rural practice.  Rural healthcare professionals tend to know their communities well, are used to dealing with limited resources, and some of the best examples of teamwork are to be found in rural settings.  However ‘being academic does not come easy to everyone, and the process of writing up evaluation and research can sometimes feel tedious and time-consuming.

However, it is now easier than ever to find interested journals, and there seems to be a drive to make the steps to getting work published more accessible.

Watch the presentation below for the RRH team’s top tips on getting your research out to a wider audience.  You can find the guidelines for authors available here.

Also, on the theme of research, here’s a great project that aims to enable rural doctors to develop their research activity through pragmatic and direct support.  Delivered by the Faculty of Medicine at Memorial University in Newfoundland, it’s called the ‘6 for 6’ programme.  Click here for more details or watch the video below.

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AProf Bruce Chater on Dr MacLeod and #ruralwonca

Today RuralGP.com highlighted the tribute speech given by Associate Prof Bruce Chater to the life and work of Dr John MacLeod of Lochmaddy in Scotland.

I was delighted to catch up with Prof Chater after his speech, to ask him more about Dr MacLeod’s work with Rural WONCA, how the WONCA Working Party for Rural Practice is progressing, and also for some advice to younger rural doctors on how to effect change in their own communities.

You can listen to the recording below…

 

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Protective personality traits for LICs

Assoc Professor Diann Eley

Today I attended a session at #ruralwonca which was delivered by Associate Professor Diann Eley from the University of Queensland on the role of personality traits on student experience of Longitudinal Integrated Clerkships.

Diann has gained considerable experience in this area, and specifically on how best to support and mentor students effectively whilst encouraging them to reflect on their own personalities – and how that impacts on their clinical decision-making.

I was delighted that Diann gave me a few minutes of her time after her presentation to discuss this in more detail, particularly as this work is highly relevant to the development of LICs in Scotland.

You can listen to our discussion here:

 

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Clinical courage: an evolving concept crucial to rural practice

I was introduced to the concept of clinical courage when attending an International Rural Research Symposium last year at Tromso University in Norway.  Dr Lucie Walters, of Flinders University in Australia, ran an enthralling workshop about some work that she and her team are doing to quantify and understand what we mean and can learn from clinical courage, particularly in the context of professional isolation and delivery of rural health services.

It’s a concept that seems to resonate easily with rural health practitioners, particularly rural GPs.  Despite this, there is relatively little that I have found to expand on the concept.  Two very helpful resources are a “President’s Message. Clinical Courage” by Dr John Wooton (found in Can J Rural Med 2011; 16(2)) and two comments from Peter Dunlop and Keith MacLellan in the followup issue (found in Can J Rural Med 2011; 16(3)).  The latter comment introduces another concept of ‘learned helplessness’, and I suspect that this will be of increasing importance as debate evolves regarding the fragmentation of undergraduate curriculums and the need to consider generalist undifferentiated training versus teaching in more specialist settings.

So, I was delighted to be asked to participate in an interview run by two of the Flinders University students Ella and Laura who are assisting with the project, whilst here in Cairns at the WONCA World Rural Health Conference.  They interviewed me, and they kindly agreed to me interviewing them!

You can hear about their experiences of medical teaching so far, and also more about the concept of clinical courage in the audio clip below:

 

Ella and Laura, 2nd year medical students at Flinders University

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Voices from #ruralwonca: Day 1

Yesterday I caught up with several delegates attending the WONCA World Rural Health conference being held in Cairns, Australia over the next few days.

Hear more about their backgrounds and why they have come to #ruralwonca by clicking on the interviews… and please don’t be shy if you are asked for a similar clip over the next few days.

Thanks to Dr Minh Le Cong of the Flying Doctors Service, who provided a much-needed-but-forgotten cable to make these interviews possible!

Dr Sophia Åman, Sweden

 


Dr Sergius Onwukwe, South Africa

 


Dr Karen Flegg, Australia

 

 

 

 

 

 

 

 


Dr Pratyush Kumar, India

Pratyush has an important job: he is organising next year’s WONCA World Rural Health conference in New Delhi, in April 2018.  Hear a bit more about how the planning for that is going.  You can visit the website for the conference here.

 

 

 

 

 

 

 


Dr David Hogg, Scotland

Karen decided I should be on the other end of the microphone too, so how could I possibly decline!

 

 

 

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RuralGP.com at #ruralwonca

Today marks the start of the 14th WONCA World Rural Health Conference, being held in Cairns, Australia.

The programme is set to contain a fantastically diverse range of research and workshops covering everything from improvements in patient care, to developing new and effective ways to collaborate across boundaries in rural health.  You can follow the events on twitter using the #RuralWonca hashtag, and already there has been a huge number of comment and links

View the WONCA Rural Conference programme

So far, the vibe at #RuralWonca has been great… benefitting from Cairns hospitality (boosted by a dynamic and helpful team from ACRRM) and a stimulating range of input from stalwart experts in rural medicine, to young, enthusiastic students and young doctors.

Thursday saw a full day of proceedings for the WONCA World Working Party for Rural Health – with the annual Council meeting held in spectacular surroundings of a seminar room looking directly onto rainforest.  As well as hearing about events from the last year, and sorting out logistics for yet another busy year ahead, there was debate about how best to support member organisations and do everything possible to support the growing number of student and young doctor organisations.  The highlight of 2018 is set to be the 15th World Rural Health Conference.  Crumbs, we haven’t even started the 14th conference yet, but for a taster of what’s in store – in New Delhi – see the video below!

Friday brought the World Summit on Rural Generalist Medicine.  The concept and importance of rural generalism in health ecosystems is reaching high levels of resonance now within Australia (where political support for recognising this is higher than ever), and much further afield in both ‘developed’ and ‘developing’ nations.  It is clear that empowering rural generalism within healthcare systems has never been more important, with absolute needs to train future doctors in medical complexity, meet the demands of an ageing population and achieve the levels of health service efficiency that are often more easy to find in the generalist setting.

The Summit also saw the launch of the Japanese Rural Generalist Programme: a major achievement and indicative of the direction that other countries are likely to go too, not least through the inspiration that these developments bring.

You can follow tweets from the Summit meeting using the hashtag #RuralGeneralist

And now for the main event.  This looks set to be a stimulating and busy few days ahead, bringing together an enthusiastic and dedicated group of international confreres giving the opportunity to recognise and drive forward international innovation and collaboration in rural health.  We hope to feature a number of interviews and reports on RuralGP.com over the next few days, like we did with the last conference in Dubrovnik, between a very packed and interesting programme of events.

Follow the WONCA World Rural Health Conference on Twitter:

#ruralwonca

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Setting the right path for Canadian rural practice

Thanks to Dr Douglas Deans for highlighting this recently-published report from a collaborative taskforce in Canada, which has been set up to identify positive actions that are likely to result in a more robust, sustainable and supported rural health service in Canada.  The collaboration comprises the Society of Rural Physicians of Canada (SRPC) and the College of Family Physicians of Canada (CFPC).

The report is refreshingly succinct, relevant and pragmatic, and likely to be of interest to anyone who is trying to work out how to articulate the balance between effective action and strategic direction to influence national policies, in the context of conflicting and difficult policy decision-making.  Many rural GPs and educators will be familiar with the challenge of identifying realistic interventions which can translate into more sustainable recruitment and retention to rural communities, so this road map from Canada is likely to be a welcome read.

Recruiting and retaining family physicians in rural areas through financial incentives alone is not enough.  We need a coordinated and thoughtful alignment of education, practice policies, community involvement, and government support.  Family medicine residents who are educated in rural training sites, who immerse themselves in the communities and who see themselves supported by peers, specialists, health care providers, and evolving distance technologies, are more likely to choose rural and stay rural.

Dr Trina Larsen Soles – SRPC Co-Chair of Taskforce

News Release   Download the Report

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#RuralGPframed – bringing rural healthcare into focus

Check the end of this article for tweets and images that have been posted online since the hashtag went live…

Image from W Eugene Smith’s “A Country Doctor”.  LIFE Magazine, 1948.

the best camera is the one you have with you

1948 saw the beginning of the National Health Service in the UK.  Many of its principles were based on the development of the Highlands & Islands (Scotland) Medical Service which was launched in 1913 following the publication of the Dewar Report into the challenges of rural healthcare in Scotland – and many consider the Dewar Report to be the blueprint of today’s NHS.

1948 was also a key moment in photojournalism, when LIFE Magazine featured the photography of W Eugene Smith. His photoessay of the work of Colorado country doctor Ernest Ceriani became a benchmark for photojournalism, and remains an iconic reference in the power of photography to provide perspective and insight. A YouTube presentation of the article is available too.

Since then, photography and photojournalism has evolved significantly.   Nearly everyone now has a quality camera-phone in their pocket.  The development of digital photography has resulted in the limits of photography being confined only to battery power, memory card space, and creativity.

Dr Greg Hamill (Arran GP) and Dr Stephen Hearns (Consultant, Emergency Medical Retrieval Service) work together using ultrasound-guided vascular access in an acutely unwell patient. (Patient consent obtained).  iPhone; 2017.

And yet, some would argue that this has had the effect of devaluing the art of good photography.  Paradoxically, because photography is within such easy reach, we sometimes fail to document episodes of experience – either as we assume someone else will be, or the immediacy of image capture devalues the art of composition, style and creative depiction.  And because so many images are produced (Facebook estimates that over 300 million photos are uploaded to its website every day), it is likely that great images fail to get the recognition and prominence that they deserve.

In just over a month’s time, I will be running a ‘Practical Tips’ session at the Rural WONCA conference in Cairns, Australia – on The Visible Rural GP: developing an image bank for modern rural practice.  The idea for this evolved through a personal interest in photography and its journalistic role, an interest in ‘how do we represent rural practice to potential rural GPs’ and awareness of projects such as  Document Scotland – just one inspirational project that aims to “photograph the important and diverse stories within Scotland at one of the most important times in our nation’s history”.

A tick that I removed from a patient who presented to our Arran War Memorial Hospital one summer weekend oncall. (Assumed consent from tick).  Canon 60D, with reversed 50mm; August 2016.

Perhaps we should be considering the need for presenting inspiring, accurate visual representations of rural practice today.

And so today, in the run-up to Rural WONCA 2017, I am committing to share (via Twitter, using the hashtag #RuralGPframed) at least one photo per day, from my own images, that depicts an aspect of rural practice.

I would be delighted for others to join me.  The more images that we can collect and share, to represent the stimulation, challenge and professional satisfaction of rural practice, the more insight that others – including potential rural GPs – will have into the opportunities that rural practice can offer.

Dr Kate Dawson (GP, Benbecula) and Dr Charlie Siderfin (GP, Orkney) during a valuable opportunity to get together and discuss research opportunities in rural practice.  Fujifilm XT1; January 2017.

What about video?

‘A picture is worth a thousand words’ but video often allows a narrative and mood to be more easily captured.  Video is important, and submissions of video are welcomed to this project.

Please remember, explicit consent is required for any footage featuring patients or anything related to them. Creativity  is welcomed!

#RuralGPframed

(search Twitter)

4/4/17 Update

Within 24 hours of this post going live, we’ve had an amazing amount of coverage across the world, particularly our Australian confreres.  Keep them coming!  Here’s just a few of the tweets that we’ve picked up on the hashtag…

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