This study highlights the strengths of and challenges imposed by culture to the provision of mentoring relationships at the study institution. It also highlights the central role of culture in mentoring and proposes an updated model for mentoring in academic medicine. This model can inform future research on mentoring and may serve as a model in the larger effort to provide faculty development in mentoring across sub-Saharan Africa.

Objectives: To evaluate whether educating junior doctors and hospital pharmacists about analgesic prescribing improved discharge prescribing of opioids for opioid-naïve patients after surgical admissions. Design: Cluster randomised controlled trial, undertaken during the first half of 2019. Setting: The Alfred Hospital, a major Melbourne teaching hospital with 13 surgical units.

BackgroundThere is a critical shortage of healthcare workers in sub-Saharan Africa, and Malawi has one of the lowest physician densities in the region. One of the reasons for this shortage is inadequate retention of medical school graduates, partly due to the desire for specialization training. The University of Malawi College of Medicine has developed specialty training programs, but medical school graduates continue to report a desire to leave the country for specialization training. To understand this desire, we studied medical students’ perspectives on specialization training in Malawi.MethodsWe conducted semi-structured interviews of medical students in the final year of their degree program. We developed an interview guide through an iterative process, and recorded and transcribed all interviews for analysis. Two independent coders coded the manuscripts and assessed inter-coder reliability, and the authors used an “editing approach” to qualitative analysis to identify and categorize themes relating to the research aim. The University of Pittsburgh Institutional Review Board and the University of Malawi College of Medicine Research and Ethics Committee approved this study and authors obtained written informed consent from all participants.ResultsWe interviewed 21 medical students. All students reported a desire for specialization training, with 12 (57%) students interested in specialties not currently offered in Malawi. Students discussed reasons for pursuing specialization training, impressions of specialization training in Malawi, reasons for staying or leaving Malawi to pursue specialization training and recommendations to improve training.ConclusionsGraduating medical students in Malawi have mixed views of specialization training in their own country and still desire to leave Malawi to pursue further training. Training institutions in sub-Saharan Africa need to understand the needs of the country’s healthcare workforce and the needs of their graduating medical students to be able to match opportunities and retain graduating students.

Significant variation exists in the preparation of intravenous medications across ICUs in Australia and New Zealand. Nationally or regionally coordinated rationalization and standardization could improve safety and efficiency and potentially reduce the barrier of cost.

BackgroundIn many low-income countries, including Malawi, expatriate physicians serve diverse roles in clinical care, education, mentorship, and research. A significant proportion of physicians from high-income countries have global health experience. Despite the well-known benefits of global health experiences for expatriates, little is known about local physician and trainee impressions of their expatriate counterparts. The objective of this study was to explore University of Malawi College of Medicine (COM) physicians' and trainees' impressions of expatriate physicians. Methods We conducted a cross-sectional qualitative study using semi-structured interviews with COM medical students, interns, registrars, and faculty. Through open coding, we developed a codebook that we applied to interview transcripts and used thematic analysis to identify major themes. ResultsWe interviewed 46 participants from across the continuum of medical education at two teaching hospitals in Malawi. Participants discussed themes within the following domains: perceived benefits of expatriate physicians in Malawi, perceived challenges, past contributions, and perceived roles that expatriate physicians should play going forward. Malawian faculty and trainees appreciated the approachability, perspectives, and contribution to education that expatriates have provided, though at times some have been perceived as aggressive, unable to relate to patients and trainees, deficient at adapting to the setting, and self-serving. Potential roles that Malawian physicians and trainees feel expatriates should serve include education, training, capacity building, and facilitating exchange opportunities for local physicians and trainees. Conclusions This study highlights the perceived benefits and challenges that physicians and trainees at the COM have experienced with their expatriate counterparts, and suggests roles that expatriates should play while abroad. These findings can be used to help inform existing global health guidelines, assist with the establishment of host institution expectations for global health programmes, and guide individual expatriate physicians who hope to optimise their roles abroad.

Background: Opioid medications are frequently used effectively for analgesia in acute settings, however, they are associated with dependence and addiction, and were implicated in 47,600 American fatalities in 2017. Evidence suggests that despite guidelines and professional body recommendations, acute prescribing remains highly variable. Educational interventions targeting prescribers have potential to optimize prescribing in-line with evidence-based best practice. Objectives: To identify the objective impacts of education interventions on opioid prescribing in the acute care setting. Study Design: A systematic literature review. Setting: The electronic databases MEDLINE, Embase, and Cochrane for works published until December 31, 2018. Bibliographies of relevant studies and the gray literature were also searched. Methods: Databases were searched for interventional studies (clinical trials and pre- and poststudies). Studies describing an educational intervention delivered to clinicians and reporting at least one objective measure of opioid use in the acute care setting were included. Studies reporting only subjective outcomes and those focused on chronic pain or set in primary care were excluded. Two reviewers (RB, TB) extracted data and assessed the quality of included studies using the Downs and Black Tool. Results: Nine studies met inclusion criteria; all used pre- and postdesigns. Three studies described stand-alone education, and the others described multifaceted interventions. All 9 interventions significantly reduced at least one of the following: high-risk agent use including meperidine use by up to 71%; total or daily dosage of opioids at discharge, including median morphine milligram equivalence (MME) from 90 mg to 45 mg per patient; and quantity of medications such as oxycodone supplied to patients, halved in one study from 6,170 expected to 2,932 supplied tablets. No increase in pain complaints or prescription refill requests were reported in those studies assessing these outcomes. The longest study examined prescribing 15 months after education delivery, reporting sustained practice changes. Limitations: Overall study quality was fair to poor. Significant heterogeneity in settings, patient groups, methodologies, and outcomes prevented pooled quantitative analysis. No studies examined all available opioid agents or formulations. Conclusions: These findings support prescriber education as an effective strategy to reduce opioid use and optimize prescribing in acute settings. Further research, particularly high quality randomized studies, describing the impact of education on all available opioid formulations and total MME is required. Reviewing the existing literature has offered useful models that can be implemented to improve care with opioid prescribing in acute settings. Key words: Opioids, education, physician education, prescriber education, opioid education, opioid prescribing, systematic review, prescriptions, prevention

interviewed, based on inclusion/ exclusion criteria. Twenty-eight clients fully met the criteria at the time of the initial in-person client encounter. Researchers analyzed the data using quantitative methods for the DAS summary scores, with two non-parametric tests to consider scores and client-related factor relationships. Qualitative methods consisted of HOD theme analysis. Findings: Complete DAS key question data were available for 12 female and 16 male clients. Fifteen had non-hemorrhagic cerebrovascular accidents and 13 had other neurologic conditions, mainly spinal cord injury. Analysis of data supported the hypothesis that clients perceived moderate to severe levels of disability. There was one client with no perceived disability, one at the extreme level, and 16 at the moderate to severe levels. There was no relationship with diagnosis or gender. Environmental barriers within homes and surroundings appeared to play a major role in home and community reintegration for those clients with continuing physical challenges to their mobility and function. Interpretation: This small-sample study verified the hypothesis that clients perceived moderate to severe levels of difficulty post rehabilitation discharge. The research results documented the situation at one point in time, verified the literature for similar clients in less-resourced countries, provided programming considerations for Kachere staff with future clients, and supported potential use of the WHO DAS 2.0 for similar research applications. Study limitations included the small sample size and selection convenience, use of a client self-assessment tool with subjectivity from personal and experiential factors. They restrict population generalizability based on the results beyond the focus of this study. The strengths of this study were the integration of the literature with rehabilitation center need, replicable design, use of an interprofessional team approach for the environmental assessment, and the research findings' implementation potential.

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