Context: Human trafficking is a human rights violation prevalent globally. Current guidelines highlight healthcare professionals' key role in responding to human trafficking, emphasizing the importance of medical education in raising awareness of trafficking. Objective: To assess pre-clerkship medical students' awareness of human trafficking and attitudes towards learning about trafficking in the medical curriculum at Canada's largest medical school. Methods: An anonymous, classroom-based questionnaire was designed, piloted and administered to first- and second-year medical students at one large Canadian medical school with a diverse student population. The questionnaire sought demographic data and information on students' self-perceived awareness of human trafficking and interest in learning about trafficking and other community health issues. Results: 262 medical students completed the questionnaire (70.0% response). Most participants reported that they were not knowledgeable (48.5%) or only somewhat knowledgeable (45.4%) about human trafficking. 88.9% of participants were not familiar with signs and symptoms of trafficked persons. While students' responses indicated that they prioritized other social issues, a majority of participants (76.0%) thought that trafficking was important to learn about in medical school, especially identifying trafficked persons and their health needs. Conclusions: These medical students of one Canadian medical school demonstrated limited familiarity with the issue of human trafficking but largely felt that they should be taught more about this issue during their medical education. This assessment of early medical students' awareness of human trafficking is relevant to medical educators and the organizations that could develop the required educational curricula and resources.

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Introduction: Many health professions students who treat Spanish-speaking patients in the United States have little concept of their culture and health related traditions. The lack of understanding of these concepts may constitute major barriers to healthcare for these patients. International service-learning experiences allow students to work directly in communities from which patients immigrate and, as a result, students gain a better understanding of these barriers. Objective: This article describes the implementation of an international, multidisciplinary, service-learning program in a dental school in the United States. Program Description: The Indiana University International Service-Learning program in Hidalgo, Mexico began in 1999 as an alternative spring break travel and clinical experience for medical students, focusing on the treatment of acute health problems. Travel-related preparatory sessions were offered, and no learning or service objectives had been developed. The program has evolved to include a multidisciplinary team of dental, medical, nursing, public health and social work students and faculty. The experience is now integrated into a curriculum based on the service-learning model that allows students to use their clinical skills in real-life situations and provides structured time for reflection. The program aims to enhance teaching and foster civic responsibility in explicit partnership with the community. Preparatory sessions have evolved into a multidisciplinary graduate level course with defined learning and service objectives. Program Evaluation Methods: In order to assess the program's operation as perceived by students and faculty and to evaluate student's perceptions of learning outcomes, evaluation tools were developed. These tools included student and faculty evaluation questionnaires, experiential learning journals, and a strengths, weaknesses, opportunities and threats analysis. Findings: Evaluation data show that after program participation, students perceived an increase in their cultural awareness, crosscultural communication skills and understanding of barriers and disparities faced by Latinos in the United States. Faculty evaluations offer insights into the lessons learned through the implementation process. Conclusion: The development of a service-learning based curriculum has posed challenges but has enriched international service experiences.

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Context: A key element of the doctor-patient relationship is to understand the patient's and doctor's perceptions of quality care. Objectives : To assess the perceptions of good and bad doctors among first-year medical students and local community members in a semi-urban, African setting. Methods: Using open-ended and closed dichotomous questions, 115 first-year medical students in Beira, Mozambique were surveyed regarding their perceptions of a 'good' and 'bad' doctor. Students then surveyed 611 community members in a predominately poor, semi-urban neighbourhood. Results: Answers to open-ended questions provided by both groups produced the same four most important positive characteristics, with good diagnostic and therapeutic skills and dedication ranked highest. Closed-ended questions revealed that local community members felt that being concerned/considerate and diagnosing well were equally important (19.5% and 17.5%, respectively) compared to students (17.5% and 41.2%, respectively). The most important negative characteristics to the open-ended question for both groups were discrimination and contemptuous behaviour: 29.3% for community members and 27.4% for medical students. The biggest difference between groups was poor attending skills: 17.3% by community members and 3.9% by medical students. Conclusion: This study highlights differences and similarities between the perceptions of medical students and community members concerning a 'good' and a 'bad' doctor. Our data suggest that perceptions are guided by the experiences and values of those interviewed. Results indicate that medical education in developing countries should focus on patient-centered care, including communication skills and attitudes, besides training knowledgeable doctors.

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Context: The relevance of healthcare student training in communication skills has led to the development of instruments for measuring attitudes towards learning communication skills. One such instrument is the Communication Skills Attitude Scale (CSAS), developed in English speaking students and adapted to different languages and cultures. No data is available on the performance of CSAS with South European students. The aims of the present study were to translate the CSAS into the Catalan language and study its psychometric properties in South European healthcare students. Methods: A total of 569 students from the School of Medicine of the Universitat Autònoma de Barcelona (UAB) participated. Students completed a Catalan version of the CSAS and provided demographic and education information. Findings: Principal component analysis with oblimin rotation supported a two-factor original structure with some modifications. In general, internal consistency and test-retest reliability of the scales were satisfactory, especially for the factor measuring positive attitudes. Relationships of student responses on the two factors with demographic and education variables were consistent with previous work. Students with higher positive attitudes tended to be female, to be foreign students and to think that their communication skills needed improving. Students with higher negative attitudes tended to be male and to have parents that were doctors or nurses. Conclusions: These data support the internal validity of a Catalan version of the CSAS and support its use in future research and educational studies related to attitudes towards learning communication skills for South European students who speak Catalan.

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Context: The increasing global mobility of physicians and severe physician shortages of many countries has led to an increasing reliance on International Medical Graduates (IMGs) by countries including Australia and Canada. Objectives:A web-based comparison of licensing policies for IMGs in Australia and Canada to inform and improve policies in each country. Methods: The research involved identification of relevant government and medical regulatory bodies' official websites documenting information on the licensing process for IMGs from each respective country; in-depth examination and comparison of the licensing processes outlined on these sites; and compilation of a comprehensive list of similarities and differences. Findings: While difficult entry requirements are imposed in Canada, once full registration is achieved IMGs have the same membership rights as Canadian medical graduates and their separate status (nominally) ends. In Australia, IMGs are allowed relatively easy access to temporary or conditional licenses, especially in designated underserviced areas or areas of need in order to fulfil resource demands. However IMGs are predominantly restricted to practise in limited and less prestigious positions within the medical hierarchy. Discussion: The Canadian process for recertifying IMGs can be characterized as being based on the integration/assimilation of IMGs with domestically trained doctors. In contrast, Australia has pursued a different strategy of parallelism of its IMGs. Conclusions: The findings provide insights into how each country balances national licensing requirements with physician shortages in a globalized environment in order to provide healthcare for its citizens.

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Context and Objectives: The communication of patient prognosis is an essential component of modern healthcare. Previous research has focussed on clinician-to-patient communication only, while the interaction between different professionals in a clinical setting remains relatively unexplored. The research reported here investigated how multidisciplinary clinicians (nursing, medicine and allied health) communicated prognosis information in these professional groups in an acute care setting. Methods: A case series method was utilised with a sample of patients with haematological malignancies in an acute haematology ward in a metropolitan city of Australia. Data were provided by clinician interviews (nursing, medical and allied health) and patient notes. The data were examined in three individual case studies, which were then collectively analysed as an overarching case series. Results: Thematic analysis of the case series resulted in three major findings for the study. The second finding that 'Clinicians are unprepared to discuss prognosis' was the focus of this paper. Identified barriers to prognosis communication were role delineations and a lack of shared values between disciplines. The state of unpreparedness has serious implications for how members of the staffing groups interact with patients and their families. Conclusion: Overall, the findings offer support for the need for educational strategies to prepare pre-service health students (future clinicians) to discuss prognosis in clinical settings. Medical, nursing and allied health clinicians tend to discuss prognosis from either a psychosocial or scientific viewpoint. Pre-service health students may benefit from increased communication and teamwork skills, familiarity with framing devices to understand and discuss prognosis and increased understanding of the roles and values of other health professions, in order to bridge communication gaps.

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Context: The Canadian Medical Education Directions for Specialists identifies health advocacy as an essential role for physicians. Health advocacy is also an integral part of the principles of family medicine. It relates to the physician's responsibility to identify and respond appropriately to the social determinants of health and the healthcare needs of vulnerable and marginalized populations. The competencies related to health advocacy are regarded by medical educators as difficult to integrate into residency training. Objectives: This qualitative study investigates what family medicine residents, educators and physicians perceive inspires them to engage in health advocacy, and explores how best to incorporate related competencies into medical training. Methods: In-depth, semi-structured interviews conducted with a purposive sample of four family medicine residents, three physicians and two educators who self-identified or were identified by peers as health advocates. Interviews were recorded, transcribed and analyzed using framework analysis. Transcripts were made available to the participants to ensure transcript accuracy. Findings: Early exposure to social injustice, parental influences, role modeling and internal motivators were seen as important inspirations for health advocacy. Conclusion: Creating an enabling and nurturing environment prior to and during residency training may be necessary to sustain the motivation to engage in health advocacy. Findings from this study suggest possibilities for a resident-guided participatory curriculum development process around health advocacy. Recommendations for promoting health advocacy in postgraduate training include effective integration of health advocacy in the curriculum by providing protected time and resources, providing experiential learning opportunities and fostering a community of practice for physician health advocates.

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Context: There is a need for studies specifically addressing the barriers to empathy training from the perspective of medical students. The objective of this study was to evaluate attitudes of 3rd and 4th year medical students regarding their training in clinical empathy at a public teaching hospital and medical school. Methods: A questionnaire assessing students' satisfaction with, and opinions on, empathy training, as well as barriers to training, was distributed during the last quarter of the year. Results: Of 188 eligible participants, 157 (84%) responded. Approximately one-half of the respondents said empathy could be taught. Eighty-one percent of respondents felt that their empathy had increased or stayed the same during their training. When asked about barriers for learning empathy, the majority of respondents chose time pressure and lack of good role models. Respondents rated breaking bad news, talking to patients about medical mistakes and taking care of dying or demanding patients as areas in need of more empathy-related training. Conclusions: Although the majority of students were satisfied with their training of clinical empathy, our study highlights the need for innovative methods to address concerns regarding barriers to practicing empathy, as well as the need for more training in how to demonstrate empathy in challenging clinical situations.

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Context: In developing countries, messages on maternal health are often developed and conveyed without due regard to the literacy and cultural context of communities. Culturally-acceptable approaches are, however, necessary to increase awareness on women's health issues, especially in cultures where oral tradition is important. Objective : To describe the processes adopted to engage church-based women support groups to develop innovative culturallybased strategies for communicating women's health matters. Methods : We utilized an activity-oriented workgroup discussion methodology to engage 30 participants from 15 churches (two per church) in a two-day workshop located in an urban community in southeast Nigeria. The recruitment process included initial visits to 25 churches with an expression of interest form, followed by an invitation letter to the 15 churches that completed and returned the form. Participants were female church leaders, 26 years of age and older, from different occupations and educational levels. They attended a 16-hour (two-day) small group workshop, conducted in an adult-learning format. Results: Six groups of five participants each used the Women and Health Learning Package (WHLP) to create and develop a dialogue on adolescent health, a drama on violence against women, a song on nutrition and women's health, a story on use of medicines by women, a quiz on cervical cancer and a poster on family planning. Thirteen of the 15 churches submitted a written report of the workshop to their local churches one month after the workshop as well as a copy to the workshop facilitator. Of the 13 churches, three organized a workshop to increase awareness on women's health issues in their local churches within three months of the workshop. Conclusion: Activity-oriented workshops can be a useful way of developing culturally- appropriate communication strategies for increasing awareness on women's health issues among church-based women groups.

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Context: As the body of literature on rural health has grown, the need to develop a unifying theoretical framework has become more apparent. There are many different ways of seeing the same phenomenon, depending on the assumptions we make and the perspective we choose. A conceptual and theoretical basis for the education of health professionals in rural health has not yet been described. Approach: This paper examines a number of theoretical frameworks that have been used in the rural health discourse and aims to identify relevant theory that originates from an educational paradigm. The experience of students in rural health is described phenomenologically in terms of two complementary perspectives, using a geographic basis on the one hand, and a developmental viewpoint on the other. The educational features and implications of these perspectives are drawn out. Discussion: The concept of a 'pedagogy of place' recognizes the importance of the context of learning and allows the uniqueness of a local community to integrate learning at all levels. The theory of critical pedagogy is also found relevant to education for rural health, which would ideally produce 'transformative' graduates who understand the privilege of their position, and who are capable of and committed to engaging in the struggles for equity and justice, both within their practices as well as in the wider society. Conclusion: It is proposed that a 'critical pedagogy of place,' which gives due acknowledgement to local peculiarities and strengths, while situating this within a wider framework of the political, social and economic disparities that impact on the health of rural people, is an appropriate theoretical basis for a distinct rural pedagogy in the health sciences.

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Introduction: It is widely accepted that medical undergraduate and postgraduate education should address issues related to human diversity. Despite the growth of guidelines and training resources, little is known about primary healthcare professionals' perceptions about their work with patients from diverse communities. Objective: This research explored GP Registrars' views of their learning needs in relation to delivering effective healthcare to ethnically and culturally diverse patient populations. Methods: The study was based on a naturalistic inquiry design, involving qualitative methods. Current GP Registrars of the postgraduate GP Western Training Programme, Galway, Ireland, were invited to participate in focus groups. Three different focus groups were conducted with a total of 31 GP Registrar participants. A thematic analysis following the principles of framework analysis was applied. Results: GP Registrars reported considerable professional uncertainty and occupational stress when consulting with patients from diverse communities. They perceived their training in relation to healthcare for patients from diverse backgrounds as inadequate and desired more training. They identified concrete learning needs, which were mainly related to factual knowledge, with less emphasis on communication skills and attitude awareness. Conclusions: Educators should take GP Registrars' views into account in the development of diversity training in medical education. GP Registrars' attention to specific knowledge related to human diversity may, nonetheless, be too narrow. This training should also encourage acknowledgment of the doctor's professional uncertainty, awareness of the doctor's own attitudes, and development of generic skills such as a patient-centred approach to best meet the needs of diverse population groups.

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Context: Studies of HIV care in Pune, a high-HIV-prevalence city in India, have shown that a significant proportion of practitioners were not adhering to national guidelines due to inadequate awareness and understanding. Objectives: This study examined the effectiveness of a pilot Internet-based continuing medical education course in increasing knowledge of pediatric HIV diagnosis and treatment among providers in Pune. The study also explored perceived factors limiting the effectiveness of the pilot course. Methods: The mixed methods evaluation design consisted of quantitative pre- and post-course knowledge assessments, and qualitative focus groups and in-depth interviews conducted on site with healthcare providers with experience treating HIV to explore the barriers to optimal course utilization, the applicability of the course content, and the systemic barriers to the implementation of physician knowledge. Findings: There were significant increases (p<0.05) in mean knowledge scores on the global knowledge assessment and for two of five individual course modules. Perceived barriers to optimal course utilization were identified as being related to Internet access. The course content was reported to be generally useful, although certain guidelines and information were described as not congruent with local resource availability. Participants reported that the major barriers to implementing their knowledge were stigma that prevented patients from seeking care and financial resource limitations affecting physician practice. Discussion and Conclusions: This course resulted in a modest increase in pediatric HIV knowledge among Pune healthcare providers. Identification of perceived factors limiting the effectiveness of the course provides guidance for improving future Internet-based courses.

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Context: Facets of reasoning competence influenced by an explicit insight into cognitive psychology features during clinical reasoning seminars have not been specifically explored. Objective: This prospective, controlled study, conducted at the University of Geneva Faculty of Medicine, Switzerland, assessed the impact on sixth-year medical students' patient work-up of case-based reasoning seminars, bringing them explicit insight into cognitive aspects of their reasoning. Methods: Volunteer students registered for our three-month Internal Medicine elective were assigned to one of two training conditions: standard (control) or modified (intervention) case-based reasoning seminars. These seminars start with the patient's presenting complaint and the students must ask the tutor for additional clinical information to progress through case resolution. For this intervention, the tutors made each step explicit to students and encouraged self-reflection on their reasoning processes. At the end of their elective, students' performances were assessed through encounters with two standardized patients and chart write-ups. Findings: Twenty-nine students participated, providing a total of 58 encounters. The overall differences in accuracy of the final diagnosis given to the patient at the end of the encounter (control 63% vs intervention 74%, p=0.53) and of the final diagnosis mentioned in the patient chart (61% vs 70%, p=0.58) were not statistically significant. The students in the intervention group significantly more often listed the correct diagnosis among the differential diagnoses in their charts (75% vs 97%, p=0.02). Conclusion: This case-based clinical reasoning seminar intervention, designed to bring students insight into cognitive features of their reasoning, improved aspects of diagnostic competence.

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