The use of point-of-care, evidence-based tools is becoming increasingly popular. They can provide easy-touse, high-quality information which is regularly updated and has been shown to improve clinical outcomes. Integrating such tools into clinical practice is an important component of improving the quality of health care. However, because such tools are rarely used in resource-limited settings, there is limited research on uptake especially among medical students.This paper explores the uptake of one such tool, Up-To-Date, when provided free of cost at a medical school in Africa.In partnership with the Better Evidence at Ariadne Labs free access to UpToDate was granted through the MakCHS IP address. On-site librarians facilitated training sessions and spread awareness of the tool. Usage data was aggregated, based on log ins and content views, presented and analyzed using Excel tables and graphs.The data shows evidence of meaningful usage, with 43,043 log ins and 15,591 registrations between August 2019 and August 2020. The most common topics viewed were in obstetrics and gynecology, pediatrics, drug information, and infectious diseases. Access occurred mainly through the mobile phone app.Findings show usage by various user categories, but with inconsistent uptake and low usage. Librarians can draw upon these results to encourage institutions to support uptake of point-of-care tools in clinical practice. Digital point-of-care tools can provide easy-to-use, high-quality information that is regularly updated in line with the science and have been shown to improve diagnostic accuracy and promote quality, efficient careUpToDate is a clinical decision support resource that can be used on or offline and provides evidence-based information for medical doctors. It can be accessed on digital devices such as computers, tablets, or mobile smart phones in hospitals, clinics, or homes. The tool is authored by 7,100 physicians who continuously synthesize the most recent medical information across specialties into evidence-based recommendations that can support point-of-care decisions. UpToDate is used in over 190 countries and by 90% of US academic medical centersRecent research demonstrates that the use of UpToDate was associated with improved quality of care, shorter lengths of stay, and lower mortality rates over a three-year periodThe tool covers a range of information areas and tools, including: topic updates by specialty, clinical calculators, drug interaction checkers, and search functionality  with filter options . While users can search UpToDate in many languages, the content is available only in English. With the emergence of the COVID-19 pandemic, UpToDate has added new open-access information covering clinical topics, questions, patient education and society guidelines. The pace of discovery and science related to the COVID-19 pandemic as well as the spread of misinformation, coupled with shortages of health workers have only hastened the need for clinicians to have evidence-based and trusted resources to which they can turn for clinical information.UpToDate is a commercial product available for purchase. Better Evidence, a group at Ariadne Labs – a joint center for health systems innovations at Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital – works to facilitate access to evidence-based clinical resources to health providers serving vulnerable populations who couldn't otherwise afford them. A pilot study run by Better Evidence demonstrated the utility of Up-To-Date among medical students at University of Rwandawww.uptodate.com) on the institutional local area network (LAN) and register for an individual account that will allow them to access UpToDate outside the LAN and download the content for use offline. The ability to use the tool offline is a valuable feature in developing countries.With an institutional license, users can access UpToDate .The university transitioned from the faculty-based to the collegiate system in 2011. As of July 2014, it includes 10 constituent colleges including the School of Law, all operating as semi-autonomous units Makerere University College of Health Sciences was transformed from a Faculty of Medicine into a College in 2013. It is comprised of 4 schools  and 27 departments, with a total population of 3,018 students, 249 academic staff, who double as lecturers and health workers, mainly stationed at the Mulago National Referral and Teaching Hospital. It is this population, together with other health researchers who are affiliated to the College that utilizes the UpToDate subscription facilitated by Better Evidence to support clinical practice This paper explores the uptake of UpToDate among medical students and faculty at Makerere University College of Health Sciences.After being approved for participation in the Better Evidence for training program, MakCHS entered into a contract with UpToDate. UpToDate established access to the product through the LAN at the university and its affiliated training facilities in August 2019. Better Evidence team members aided librarians, students, and faculty at MakCHS in learning how to access, register for, and use the tool. The MakCHS librarians then communicated about the tool and built awareness of the tool in their respective institutions through training sessions on campus and messaging.UpToDate tracked aggregate usage and searches by registered, logged-in users or users on campus and shared this data with the school through the Better Evidence program every two months. Usage of the open-access information on COVID-19 was not tracked if users were offsite and not logged in. No institutional review board approvals were needed given the nature of this work and the aggregate nature of the data that did not allow any individuals to be identified.Trending topics sorted by most views—topics that increased in popularity from the prior two month periodMethods used to access the topics—whether users accessed UpToDate via the website on a computer or via the UpToDate app on their smart phones, tablets or iPadsRoles of the users that accessed UpToDateTop five medical topics by views —the most frequently visited topic cards during each two-month periodTop five medical specialties viewed – what specialties the topics viewed fall intoTotal usage by month—how many searches were doneThe data presented here captured usage information from August 2019 to August 2020 on the following:We used Excel to organize the data into tables and graphs to enable us to look at the trends and usage patterns over time. We then grouped the relevant data based on trending topics, access methods, user roles, topic specialties by views, medical topics by views and total usage of the tool by month. Reporting periods are labeled by when the report was received. UpToDate provided reports every two months.Usage via the appwas consistently about two to three times more common than usage via the website but both forms of usage followed approximately the same trends. The February 2020 report showed the most usage via both the web  and the app  while the December 2019 report showed the lowest usage of any two-month period.The topics viewed fall into different specialty areas. The top five topic specialties viewed from October 2019 to August 2020 are shown in Pediatrics, obstetrics and gynecology & women's health registered the most topic hits over the course of the year, while gastroenterology and herpetology received a lot of views during two reporting periods.The top five most viewed medical topics by reporting period are shown in Total usage of the tool by month is shown in The discussion of findings is presented according to the subheadings discussed in the results section:Access methods data shows that users primarily accessed UpToDate on mobile devices rather than computers. This suggests that users are able and willing to access the digital tool while on the go and not only in a static location. This is promising given the relevance of the tool for clinical care use at the patient bedside where there are often no computers. This also suggests that people are willing to use their own personal devices for learning and consulting the evidence given the school does not provide mobile devices. Furthermore, hospitals in Uganda, where the students and residents do ward rounds do not necessarily have internet connection, so the fact that use occurred on mobile devices suggests that users may have been able to download the UpToDate content and use the offline feature of the tool. The ability to use the tool offline is likely make the use of UpToDate on mobile devices more appealing and could be an important feature when considering use of digital tools in limited-resource settings.User role data is promising and it shows those in their training years at the institution used Up-To-Date most. This finding is encouraging as these are critical years for establishing habits for practice for the years ahead. It is important to note however that the denominator for the various groups users groups varies, which may explain why some user groups appear to use the tool less. For example, the college has only three librarians compared to 2,700 students.The beginning of the semester is characterized by exams and tests, and that is the time when lectures are gaining momentum. Students are therefore usually busy and this could have affected usage. The month of March 2020 was further affected by the lockdown and closure of institutions of higher education in Uganda due to the COVID 19 pandemic. This, coupled with the beginning of semester schedules, could have further affected usage.Medical specialties and topics by views data shows that pediatrics, obstetrics and gynecology, infectious diseases, drug information, and gastroenterology and herpetology registered many and continuous viewers throughout the period indicated. While the increased views of the infectious diseases specialty during the month of February 2020 could be attributed to the COVID-19 pandemic, the various topic specialties viewed suggest just how one point-of-care tool can be used in a variety of situations that benefit various categories of users. The data also suggest that these few specialties are especially keen on using information that is up to date to facilitate the application of evidence-based medicine in daily clinical practice. The ability to access COVID-19 information without logging in also may have impacted the data on topics and specialties viewed.Total usage by month data variation can mostly be explained by outside situational factors. For example, MakCHS received access to Up-To-Date in July 2019. Therefore, in August, most potential users were just becoming aware of the availability of the tool, and trainings were just starting. After being introduced to the tool, users started accessing it more. Between July and September, usage increased substantially. Trainings were conducted weekly during this period, suggesting a clear impact between training and usage. Usage then clearly decreased during the holiday break but came back up once classes resumed. In March 2020, MakCHS went into lockdown due to the COVID-19 pandemic and as of August 2020, the students were still under lockdown, although remote work had been eased for a few members of staff. The big difference between usage in February and June 2020 was therefore likely a result of the lockdown and closure of the university, due to the COVID-19 pandemic. There were no trainings or awareness campaigns creation during that time, and students were likely to have less internet access while remote as well.It is probable that, had it not been for the lockdown due to the COVID-19 pandemic at the end of March, usage would have been higher than it was. However, even in the lockdown, the tool is still being accessed and used, though to a smaller extent. This suggests that those who had registered for the tool before the lockdown have continued to use it off campus, likely having formed the habit of use.Data suggests that though UpToDate is used in a variety of ways by a variety of user types at the university, usage remains relatively low considering the total number of students, faculty, and potential searches. Therefore, there is a need for continued advocacy and capacity building for the various users of the tool and others like librarians, who promote its uptake and usage. As for the librarians, who promote the uptake and usage of the tool, there is need for further capacity building and awareness. The usage trend, however, suggests that, irrespective of what method of access used to access the tool, users had started embracing the tool before the COVID-19 pandemic and closure of institution. Continued use in such difficult times suggests that there is potential for increased and more consistent use in the future.Increased capacity building and promotion is expected to go a long way in increasing usage of evidence-based digital tools. The Better Evidence for Champions program, launched in August 2020, in which local librarians, faculty members, and ICT professionals are trained to aid in promoting uptake, is one possibility for increasing uptake via trained local advocates. As bi-monthly data collection will continue, further analysis after the launch of the Champions program will be conducted. This project and other similar efforts that aim to promote the use of evidence in clinical care will be critical to improving the quality of care and health outcomes for patients for decades to come.The demographic characteristics of the respondents were not captured because of the nature of the study. The data was remotely captured based on log ins in the system, and this could not allow for the capture of data, other than the number of log ins and the topics viewed.


In orthopedics, we tend to classify and quantify different traumas in order to focus our efforts and resources on the specific areas of need. To gain a perspective, we use epidemiology as a fallback instead of trusting on our own feelings of prevalence. There are several ways to access the analysis performed in epidemiological studies. For example, hospital discharge registries are usually nationwide or form part of a subsample of a larger area patient cohort; they give a reliable overview of the data attained. There are, however, several problems with such registries. One major problem is the inability to access patient-level information. This leads to only the overall numbers of incidences and rates of interventions being provided, and a subsequent lack of incident classification and patient reported outcome measures (PROMs). Another way to attain the data is a cohort sample of the catchment population of a specific area. The problem with this method is the relative rarity of the specific cases . In addition, it is time consuming to accumulate a large enough cohort for analysis. Furthermore, the data provided are usually retrospective in nature and can lead to deficiencies and heterogeneity of the dataset.The study by Court-Brown et al.  reportedThe study raised several important issues. For example, the fractures that occurred in young patients were mainly related to sports or high velocity injuries, whereas those that occurred in patients 30 years and older were mostly caused by falling from a standing height. The authors could show the peak incidence for older patients, which was also associated with more severe fracture patterns than in younger patients. Furthermore, they were able to classify all the patients using the Neer and AO classification systems Neer . Of the “Neer three- and four-part fractures and fracture dislocations and the AO type C fractures occurred with an incidence of 13% and 6%, respectively, indicating that the literature does not adequately respect the spectrum of proximal humeral fractures”In our smaller, retrospective cohort study from year 2015, we found a similar rate of fractures classified with Neer for three- and four-part fractures with an incidence of 19% and 7%, respectively (Launonen et al. The Court-Brown study has aged well, and it can still be considered as a benchmark of proximal humeral fracture epidemiology with large prospective patient cohorts. In the clinical and research field, we need detailed epidemiological data so that we can focus on the key issues. However, the data provided in the study need an update since the age distribution has changed over time, which may affect the fracture distribution. Although the epidemiology and fracture classification do not help us decide on the best treatments for patients, they do help us to understand the disparity between the common and the rare and act as a baseline in the guidelines (Brorson et al. Department of Orthopaedics and Traumatology,Tampere University Hospital, Teiskontie, Tampere, FinlandE-mail:antti.launonen@pshp.fiAntti P Launonen


Healthcare facilities are facing huge challenges due to the outbreak of COVID-19. Around the world, national healthcare contingency plans have struggled to cope with the population health impact of COVID-19, with healthcare facilities and critical care systems buckling under the extraordinary pressures. COVID-19 has starkly highlighted the lack of reliable operational tools for assessing the level sof flexibility of a hospital building to support strategic and agile decision making. The aim of this study was to modify, improve and test an existing assessment tool for evaluating hospital facilities flexibility and resilience. We followed a five-step process for collecting data by (i) doing a literature review about flexibility principles and strategies, (ii) reviewing healthcare design guidelines, (iii) examining international healthcare facilities case studies, (iv) conducting a critical review and optimization of the existing tool, and (v) assessing the usability of the evaluation tool. The new version of the OFAT framework (Optimized Flexibility Assessment Tool) is composed of nine evaluation parameters and subdivided into measurable variables with scores ranging from 0 to 10. The pilot testing of case studies enabled the assessment and verification the OFAT validity and reliability in support of decision makers in addressing flexibility of hospital design and/or operations. Healthcare buildings need to be designed and built based on principles of flexibility to accommodate current healthcare operations, adapting to time-sensitive physical transformations and responding to contemporary and future public health emergencies. Healthcare systems and their hospital facilities are facing huge challenges since the outbreak of COVID-19, in regards to the management of healthcare settings and building layouts , environFlexibility in architectural design can be defined as the ability of a building to adapt to changed spatial requirements and functional solutions according to short, medium or long-time perspectives ,17. FlexThe coronavirus crisis revealed that many modern hospitals and healthcare organizations lack the flexibility to accommodate sudden surges of patients due to unexpected healthcare situations. There is a lack of operative tools for assessing the levels of flexibility and resiliency of hospital buildings . It is nThe aim of this research was to modify, improve and test an assessment tool that provides guidance for hospital designers to improve their proposed designs, and to be applied to existing hospitals offering deeper understanding of how the facilities satisfy the criteria and concepts of flexibility.The research plan followed a five-step process by collecting data through: (i) detailed literature review about flexibility principles and strategies, (ii) review of healthcare design guidelines, (iii) evaluation of international healthcare facilities case studies, (iv) critical review and optimization of an assessment tool for healthcare flexibility, and (v) usability testing method to check and compare the new with the original assessment tools see .Scoping reviews are a traceable method of ‘mapping’ areas of research and highlighting gaps in the literature for future research. Scoping reviews are a useful tool in the ever-increasing arsenal of evidence synthesis approaches and require rigorous and transparent methods to ensure that the results are trustworthy and reproducible ,25. ThisThe objective of the scoping review was to map key concepts as a basis for a deeper understanding of the effects of facility flexibility on hospital readiness and performance while identifying gaps in our current knowledge to inform design of future hospitals .The initial search was undertaken on studies published between January 2000 and June 2021. The review of the literature was conducted by identification of search string keywords and appropriate Boolean operators  in databases Scopus, PubMed (including Medline), Researchgate with supplementary searches on Google Scholar. The databases were selected to be comprehensive and to cover a broad range of disciplines. Definitions and principles of flexibility were collected. In the stage of literature review see , the keyThe study’s initial selection for inclusion was based on the title and abstract of the studies that were reviewed to preclude waste of resources in procuring articles that did not meet the minimum inclusion criteria. Two of the authors (W.E. and A.G.) reviewed titles, references and abstracts generated by the original search against the agreed inclusion and exclusion criteria. In case of disagreement, a third researcher (A.B.) revised the items. When the title and abstract provided insufficient information to determine the relevance, a full-text copy of the article was retrieved and reviewed. For the final selection, a full-text copy of each study was examined to determine if it fulfilled the inclusion criteria.U.K. ;Australia ;Canada ;International guidelines ;Facilities Guidelines Institute Design Guidelines (FGI).A different combination of keywords  was usedOne of the limitations encountered in the process was the unavailability of a free version of the design guidelines of the U.S. (FGI), hence it was excluded and only four guidelines were examined.A third set of keywords was selected to identify practical examples of hospital facilities to be analyzed. We choose case studies with a promising level of future-proofing that were recently completed or under construction. The case studies were chosen across varied geographies and different scales and evaluated with a critical lens focusing on flexibility and resiliency .Seven case studies  of recent healthcare facilities were selected and analyzed with regard to flexibility and future-proofing approach, the architectural design and spatial organization/layout as well as general information such as the location, client, year of start and completion, collaborators, area and budget to establish a detailed overview for each one of the case studies.Case study 1 (CS1): Hospital Südspidol, Esch sur Alzette, Luxembourg;Case study 2 (CS2): Massachusetts General Hospital (Lunder Building), Boston, MA, USA;Case study 3 (CS3): Machala Fluid Hospital, Machala, Ecuador;Case study 4 (CS4): The Sammy Ofer Heart Building, Tel Aviv, Israel;Case study 5 (CS5): New Karolinska Hospital, Stockholm, Sweden;Case study 6 (CS6): Aarhus University Hospital, Aarhus, Denmark;Case study 7 (CS7): New Martini Hospital, Groningen, Netherlands.The seven selected case studies were:We used the Open Building Assessment Tool (OBAT), a widely used evaluation tool to evaluate each case study in terms of eight evaluation parameters: shape, structure, facade, building plant, expandability, restrictions and technologies with a grading system that allows for each parameter a score between 0 and 10 points ,28. The The modified assessment tool was developed through a critical review of the OBAT framework to highlight the strengths and weaknesses of each parameter of the original version. The review was conducted at the evaluation parameter level as well as on the measurement variable levels. Our analysis resulted in a modified version of the tool—Optimized Flexibility Assessment Tool (OFAT).The OFAT framework was tested on two case studies of selected healthcare facilities to validate the updated instrument. The aim was to check the usability and simultaneously compare the scores of each evaluation parameter on both the original tool and the modified tool versions.The initial literature search identified several articles for full-text review after meeting the eligibility and inclusion criteria and underwent a full-text abstraction. Because of the heterogeneity of the study designs, participants and outcome measures, a meta-analysis was not feasible. The full list of articles from identification to final inclusion is represented by 28 papers reported in flexibility of space in healthcare facilities, strategies of flexibility and its impact on hospitals. Flexibility was the most emerging and trending principle in healthcare facilities including a detailed explanation of the levels and types. In addition, we extracted from the literature the typological-spatial strategy from the different levels and types of projects.The search focused on the following issues: Pati et al. found that flexibility in healthcare design depends on the perspectives patients, managers and administrators, and professionals . PatientPati and colleagues define the three aspects of flexibility are adaptability, convertibility, and expandability . A similPatient safety and staff efficiency are two of the essential factors for integrating space standardization and flexibility . Pati etPrevious studies have noted that “through a better analysis of the hospital facility it is possible to identify four levels of flexibility depending on the scale of the building . For each scale it is also possible to highlight possible types of flexibility  achievable solely through specific typological-spatial strategies” . AdditioWe developed an analysis matrix to determine which strategies are used most in a healthcare facility and to highlight which levels and types of flexibility. The matrix highlights the most common requirements for converting healthcare spaces into four levels of flexibility: from the territorial scale to an individual room.The matrix is designed according to four levels of flexibility based on different scales as follows: hospital complex, building entity, functional unit, and individual room see . For eacWe developed the “Flexibility principles matrix for healthcare guidelines” for an overall comparison see  and extrThe comparative matrix highlights the most common flexibility considerations, which are planning models, adaptability, expandability, standardization, modular design, room utilization, accessibility, and overflow design, as they are treated in some detail in the four healthcare guidelines. However, structural loading capacity, construction flexibility, equipment flexibility, interstitial floor, ceiling height, and facade design are scarcely addressed in the healthcare guidelines as they are each present in only one design guideline.The assessment for Open Building flexibility total scores;The extent one of the evaluation parameters is fulfilled, and the points deducted due to lacking information; and,The range/category (out of five) of the healthcare facility, indicating whether or not they satisfy the requirements to be considered an Open Building.None of the case studies in our analysis and evaluation scored higher than 80%, except for one healthcare facility (CS4) out of the seven case studies that was considered an ideal Open Building.A comparative histogram based on the analytical framework applied to the case studies and our results conducted from the assessment tool for Open Building flexibility, are shown in The most common type of shape parameters was 50% compact or linear, although the compact shape allows flexibility. The most applied strategy in the structure parameter is the oversized structural elements as it maximizes the building’s structural capacity to accommodate future expansion. Considering facade design, the most applied principle was having a modular facade and then comes the curtain wall system. For the building plant, the most applied strategies were spreading out plant infrastructure in false ceilings and minimizing the ratio of the total surface area of shafts-to-floor surface area to be less than 0.01. Internal equipped spaces are the most important and also the most applied in terms of expandability. As for restrictions, drainpipes placed in service shafts are the most applied strategy. Modular and prefabricated internal partitions are applied the most evenly though the dry assembly technique is a more fundamental strategy when it comes to technology parameters. The exchangeability of large equipment was achieved through one method, the disassembly of facade panels.We conducted a critical review of the Open Building Assessment Tool (OBAT) in this section in order to understand the classification of the evaluation and analyses parameters, and the methods of evaluation and scoring for each parameter. We proposed modifications to each parameter, based on the critical review of the evaluation parameters our literature review. Each parameter is explained and a clear definition for each is generated with the assigned score according to its value in terms of flexibility for each healthcare facility.The original tool OBAT identified eight elements as evaluation parameters: shape, structure, facade, building plant, expandability, restrictions, technology, exchangeability of large equipment. Each of them is taken into consideration independently and is given an overall summary score with a range that varies between 0 and 10. Therefore, each of the indicators was assigned a value that expresses the degree of compliance with the flexibility characteristics of the Open Building framework for that specific aspect of the project.(i)Shape parameter critical reviewThe main criterion for defining the efficiency of building shape/morphology is based on achieving flexibility, convenience, and cost-effectiveness, yet with the presence of significant ambiguity in the way the designers or users of the assessment tool would perceive such analysis parameters . As for compact classification, the main criterion for assigning scores is “compactness percentages”. What is meant by this term and the borderlines between each of the three identified compactness levels are not defined. In addition, the parameters merge different typological classifications such as 70% compact with vertical and 50% compact with linear. Although the vertical building gets a high score as the building plant’s main components are vertically stacked and placed in the shafts, how to determine verticality is not mentioned, and the same applies to the case of linearity. On the other hand, in the case of 50% compact, articulated, and detached classifications, there are no definitions.(ii)Structure parameter critical reviewThe assessment tool aims to determine the flexibility of the building structure, regarding its capacity to accommodate extra loads concerning adding heavy medical equipment and/or vertical future expansion. The analysis parameter for structural spans is clearly defined and classified into three categories with a specific score each, which are , corresponding with the literature, healthcare design guidelines and selected case studies. While regular structural modulation is considered as an advantage in terms of flexibility, there should be tolerance as there might be some constraints that require breaking the regularity . This tolerance should be also taken into consideration in the case of the squared analysis parameter, to avoid inflexible assessment that might negatively impact the total evaluation. As for the oversized elements, it should also consider the vertical expansion if needed in the future. The analysis parameter prefab slab “predalles” is not commonly used, and is not mentioned in the literature or the healthcare design guidelines.(iii)Facade parameter critical reviewThe assessment tool’s main criteria for defining the efficiency of building facade is based on flexibility, neglecting the architectural articulation and technical aspects, yet without differentiating with intermediate categories between the completely opposite cases of the building being completely glazed “curtain wall”, and solid facades  with openings. Although curtain walls can allow total independence from the building structure, they neglect different cases of hybrid facades which combine solid and glazing with different proportions, causing uncertainties for designers and evaluators.(iv)Building plant parameter critical reviewThe assessment tool’s main criteria for defining the efficiency of the building plant are capacity, distribution, and capability of adapting to future alterations or expansion. The analysis parameter of plant distribution is clearly defined and classified into three categories with specific score each, which are  and technical interfloor). The analysis parameters of distribution in raised floors and in view when advisable are both useful strategies in supporting functions such as laboratories and pharmacies. In the case of a plant tower, the mechanical floor should not be neglected considering its wide mention in literature and applied in the analyzed healthcare projects. Even though one of the main criteria for defining the building plant evaluation parameter is the capability to adapt to future hospital needs, the redundancy of the building plant is totally neglected. As for the distance between shafts analysis parameter, it is well defined based on the complexity of connections of the technical network and categorized into three classifications, and a score of (+4) is assigned to the first category as a distance less than 30 m creates a more efficient distribution of the service network. However, there are other elements that are equally important.(v)Expandability parameter critical reviewThe assessment tool’s main criteria for defining the possibility of expanding the healthcare facilities is the availability of excess spaces to accommodate certain elements that facilitate the mass itself to expand within the existing structure. However, it neglects expandability through creating physical extensions which is a significant strategy for future-proofing of the facility. The expandability evaluation parameter is classified into two main categories, internal and external. Although the internal spaces are well defined, yet other equally important strategies are neglected, even though they are mentioned in literature and in healthcare design guidelines, such as providing soft spaces that can be retrofitted into service spaces, and open-ended corridors that allow horizontal expansion without sacrificing existing and functioning spaces. As for the internal expandability, only one external strategy is identified: volumes “hanging” from the facade, and a score of (+2) is assigned, even though it is not of great advantage when it comes to external expandability. We did not find other strategies for external flexibility.(vi)Restrictions parameter critical reviewThe assessment tool’s main criteria for defining the structural restrictions that constrain future alterations of the healthcare facility is the percentage of the fixed vertical elements in the building plant that exist in several or all building floors. The restriction evaluation parameter is well defined and classified into five categories that are include only fixed vertical elements (connections and service shaft), up to 10%, up to 30%, up to 50%, up to 70%, respectively. With the lower percentage of fixed elements in the building, the more guaranteed is the level of space flexibility. Having minimal fixed elements is recommended. Although the classifications are well defined, the hierarchy of percentages and their respective scores are relatively unbalanced. Extra points are assigned to placement of draining techniques such as drainpipes placed in service shafts and drainpipes that run next to pillars. Since drainage pipes are considered complex elements of the hospital ward floors, combining them with either pillar or service shafts would significantly reduce the vertical constraints in the floor plans.(vii)Technology parameter critical reviewThe assessment tool’s main criteria for defining the flexibility of building technology is the assembly and fabrication techniques of the interior walls/partitions. The analysis parameter of assembly techniques is well defined and classified into three categories according to the construction technique used that are: dry assembly technique, mixed assembly technique, and, wet assembly technique) respectively. Although internal partitions with specific analysis parameter characteristics such as modularity and embedded plant infrastructure have considerable scoring weight, other essential aspects such as movable/retractable partitions and using framed construction techniques are neglected, even though they are present in literature and the healthcare design guidelines.(viii)Exchangeability of large equipment parameter critical reviewThe assessment tool’s main criterion for defining the possibility of exchanging large equipment because of technological and medical advancements in the future is carrying out the process with minimal intervention, no demolition, and in considerably short time. The analysis parameter of complexity of exchangeability of large equipment is well defined and classified into three categories according to the nature of intervention that is: only needs disassembly of facade panels, disassembly of facade panels and internal partitions, and partial demolitions, respectively. Although (+2) is assigned to large equipment located on the ground floor, it can miss the case of having the equipment located on a floor that is in direct contact with the outside. Considering future-proofing strategies, the equipment spaces should be designed with redundancy to accommodate equipment that may require extra storage areas.The parameter modifications are shown in We identified and extracted the flexibility principles related to functionality that play a vital role in guaranteeing future-proofing of the building based on the literature search, review of the healthcare design guidelines and a review of recent healthcare projects. Accordingly, a new evaluation parameter “functionality” offers a more comprehensive and precise evaluation for the healthcare facility, as seen in Functionality is an essential principle for the building, both from an efficiency and future-proofing points of view, since it considers adaptability, versatility, refit-ability, convertibility and expandability, as instrumental aspects that must be achieved. The functionality evaluation parameter contains six measurable variables: generic/universal rooms, space standardization, double function, overflow design, loose fit, furniture/equipment flexibility.The assessment tool was designed to determine the degree of fulfillment of the essential principles of the flexibility concept. It was developed to evaluate flexibility in healthcare facilities during the design and planning phases and provides a control benchmark for the designer to enhance their proposals. Applying it to existing facilities helps to better appreciate to what extent the building satisfies the criteria, concepts of flexibility and hence what needs to be modified if needed.The new tool consists of nine evaluation parameters, with each parameter subdivided into measurable variables with a score range varying between 0 and 10 (see Text S1 for the full list and scoring). Each evaluation parameter achieves a specific score that reflects the level of application of flexibility principles. Five score ranges were identified using this weighing system, and which correspond to five different levels of compliance with the flexibility criteria, thus helping to determine to what extent the building is flexible.We tested the revised tool on two selected healthcare facilities from the previously evaluated case studies . We checked the viability of the optimized tool and simultaneously compared the scores of each evaluation parameter using both versions of the original and revised tools.For each of the two case studies, we compiled results from the optimized assessment generated along with a critical comparison with the results from the original assessment. We drew diagrams to recap the results of the final score from the optimized assessment tool and compared them to see to what extent each evaluation parameter was applied. We also classified the building according to its assessment score and to determine whether it satisfied the criteria for an Open Building and to what extent.The new assessment tool was applied to the healthcare facility CS1 and the total assigned score was 75% (64/85), hence it was classified as a flexible building, but with some aspects to be improved. The final results show that the total assigned score from the original assessment tool was 72%, and 75%, using the modified tool.The new assessment tool was applied to the healthcare facility and the total assigned score was 73% (63/86), hence it was classified as a flexible building, but with some aspects to be improved. The final results show that the total assigned scores from the original assessment tool were 69% and 73%, using the modified one. A detailed comparison between the two cases is provided in Healthcare facilities are complex structures with a mixture of social, cultural, economic, technological, and architectural aspects. For healthcare facilities to fulfill their roles, it is essential that they should be planned and designed for the present and the future. Hospitals should be flexible to changing needs. John Weeks in 1954 highlighted the importance of multifunctional potential for interconnecting examination and consulting rooms and how the workflow of nurses can be modified in the interests of improved patient care . It was While emphasizing the importance of the building’s flexibility it is important to highlight other areas of improvement. Several alterations can indeed be carried out on the operational level of the facility without any change at the physical level while other changes are made by adapting the users to maximize their experience of the given environment. It is necessary to evaluate how such changes would affect the overall operation and performance of the facility and impact on the provider’s workflow. Hospital buildings should have the capability to accommodate alteration of functions and not just designed rigidly to serve a specific purpose. In fact, such approaches can only be addressed if a participatory design and multidisciplinary cooperation between different fields, disciplines and professions is in place ,49. The Our multi-method research approach addressed both contemporary and innovative approaches in healthcare design that are divided into multiple levels which are not only physical but also operational, such as architectural, structural, engineering, technological and functional levels. Flexibility is the essential principle in contemporary and futuristic hospitals, and designers must prepare for changing needs. Implementing an easy-to-use tool applicable to different design stages can improve the effectiveness of project flexibility, both in the product and process dimensions, by reducing the cost of unplanned changes during advanced construction, refurbishment and operation phases ,52,53.The flexibility principle is not commonly considered nor used by practitioners, however it is used in various hospitals worldwide without intentionally aiming for flexibility ,49. We dThe new assessment tool (OFAT) is designed to improve the degree of fulfillment of the essential flexibility principles including the Open Building concept both in design and operation phases. We found that, in two case studies, applying the OFAT led to a more comprehensive assessment when compared to the old tool.COVID-19 affected all segments of the health care industry; some effects will be temporary, but others are likely to have profound long-term consequences , such asWe optimized the evaluation tool, OFAT, to provide a benchmark and monitoring system for healthcare designers to improve their proposed flexibility during the design and planning phases, as well as being applicable for existing facility designs. The COVID-19 pandemic has required health care systems to undergo a paradigm shift and be prepared for new emergencies . ImplemeFirstly, as mentioned above one of the limitations encountered in the design guidelines review process was the unavailability of a free version of the USA design guidelines (FGI). Secondly, the limited application to two pilot case studies underscores the need to further expand the testing phase. Further study is needed to consider the potential effects of applying the assessment tool to a wider sample of facilities and geographic locations.We used a five-step research methodology that included a literature review, review of design guidelines, case studies evaluation, improved assessment tool, and a revised final tool test, the new Optimized Flexibility Assessment Tool (OFAT). The OFAT is well suited and robust for assessing the flexibility of healthcare facilities. Increasing the flexibility and adaptability of physical structures and services, both at the levels of facility itself and its network, are urgently needed. Ensuring rapid, efficient, and high-quality interventions are needed even under exceptional conditions .While our results are exploratory and further long-term research is needed, our findings resulted in the development of the OFAT assessment tool, OFAT, to evaluate the extent to which a healthcare facility meets the principles of flexibility.


The Clinical Research Mentorship Programme (CRMP) is a collaborative initiative created by the University of Toronto Department of Radiation Oncology, Princess Margaret Cancer Centre, delivered in collaboration with LMIC radiation oncology residency programmes with the primary goal of enriching the research experience of LMIC oncology trainees. It was inspired by observing a need, an enthusiasm to collaborate and some seed funding that supported the idea. At the heart of the programme is a formalised relationship, a triad, between a LMIC oncology trainee, their local supervisor and a mentor from Toronto. Within the collaborative environment created between the LMIC and high income country (HIC) institutions, enabled by remote learning technologies, a 12-week research methods seminar kick starts a year-long mentorship for the trainee on their research question. The goal is to enrich the quality of the research experience for the trainee, resulting in dissemination of research findings in international conferences and publications. A standard evaluation package is used  6 919–928)). In this paper, through a description of our collaboration, we will highlight how a distant mentorship programme was used to enhance clinical research mentorship skills for radiation oncology trainees in Africa. We hope the format we have chosen will continue to demonstrate effectiveness for our trainees, sustainability for our faculty and institutions and will serve as one mechanism to build radiation capacity for LMIC through collaboration, mentorship and research.Research skills are mandatory for all oncology residency training programmes. Creating the environment to foster skills and passion can be a challenge in all settings, and a unique challenge in low and middle income countries (LMICs). Tremendous clinical workload places exceptional demand on clinician teachers, research infrastructure and access to research collaborators with diverse methodological skill sets can be limited. International collaborations, and in particular relationship partnerships (Whitehead  Inequities in health research contribute towards inequities in health , 5. TeacPrincess Margaret Cancer Centre is the largest cancer centre globally under one roof. It is the first cancer hospital in Canada and one of the five clinical sites that calls the Department of Radiation Oncology, University of Toronto her academic home. Each year, approximately 22 radiation oncology residents and 30 fellows are in training here supported by over 70 radiation oncologists across the department. Guided by our mission to prepare radiation medicine leaders for the future , and motThe Clinical Research Mentorship Programme (CRMP) is a collaborative initiative created by the Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto delivered in collaboration with LMIC radiation oncology residency programmes with the primary goal of enriching the research experience of LMIC oncology trainees. It was inspired by observing a need, an enthusiasm to collaborate and some seed funding that supported the idea.The collaborations are only possible with highly collaborative colleagues, and their trainees, willing to experiment and explore. Our inaugural partner in 2016 was the National Center for Radiotherapy, the premier training centre in Ghana. Our second collaborator in 2018 was the Parirenyatwa Hospital Radiotherapy Centre, the largest tertiary referral cancer treatment centre in Zimbabwe and the University of Zimbabwe clinical training hospital. It is the only institution in the country that has an oncology residency programme and has served as a regional training centre for clinical oncologist since its inception in the early 90s. For 2020, our upcoming cohort will launch in partnership with The Association of Clinical and Radiation Oncologist of Nigeria, the voice of oncologists in Nigeria and their trainees. There are four fully accredited oncology residency programmes in Nigeria with more centres in the process.In this paper, we will provide a high level overview of a brief history behind the programme, structure of the programme, guidance to mentors, brief description of the past and upcoming evaluation plan, design, our experience to date and sustainability plan for the future. A new component, designed to enhance mentoring skills for the mentors and supervisors, that will be launched and evaluated in 2020–21, and future directions.In 2015, Dr Joel Yarney (JY) joined Princess Margaret as a visiting fellow. This sets the stage for Dr Rebecca Wong (RW) visiting Ghana for the first time, as a speaker at the African Radiation Oncology Group meeting. Here the opportunity to meet with many of their residents planted the idea and inspired the programme. Supported for the first 2 years by a grant from the Princess Margaret Cancer Centre Capacity Building Fund, the first year long clinical research mentorship programme was offered in 2016 supporting two residents from the Korle Bu Cancer Hospital in Ghana. This was followed in 2018 where the programme was offered to two residents at the Parirenyatwa Group of Hospitals in Harare, Zimbabwe. In 2020, we plan to support a new cohort of participants from Nigeria through a collaboration with the Association of Radiation and Clinical Oncologists of Nigeria. We invite a new programme each year to collaborate, hoping to learn, through a standardised evaluation strategy, how to adapt to different collaborating environments and collaborating needs and styles, while growing the network, and its capacity to pass on the philosophy.Details of the training programme, from how the resident research projects were evaluated, selected, programme implementation, evaluation, evaluation metrics and the lessons learned from the first year has been published .In brief, the clinical research mentorship programme is a 1-year programme with four key design features . First, Second, all trainees, whether mentors were assigned or not, are invited to participate in the 10-week seminar series and encouraged to complete their projects with their supervisors. The seminar series is designed to cover a different topic each week from ‘asking the right question’ to setting up a database to research ethics. Sessions employ a flipped classroom approach and use the trainees’ research questions to illustrate the application of the topic. All seminars are delivered using videoconferencing technologies, and informal discussions using predominantly emails.Third, the mentee, supervisor and mentor triad is at the core of the mentorship programme . The supFourth, a modest stipend is made available to support in part their travel to a conference to present their results and conduct their research.Mentors assigned to the trainees are selected for their scientific expertise, experience as teachers and mentors for trainees entering into clinical research, and their interest and willingness to work with colleagues with our said objectives. Mentors see themselves as invited guests by our host faculty , providiPrior to the start of the programme, an evaluation plan was envisioned. We hypothesise that by using a consistent approach to evaluate learnings from each collaboration, each environment, will be accumulative, translating into greater efficiency and effectiveness with each offering. The evaluation programme consists of pre-programme discussions with our collaborators (and trainees) to understand the learning goals, evaluation surveys post seminars, use of a validated tool to measure critical appraisal skills  and postThe programme is designed to enhance skills development in clinical research methods through collaboration. In addition to willingness for all participants to find the time to participate, resources are needed in terms of infrastructure and human resources. These include faculty time for teaching, mentoring, videoconferencing tool subscription, project coordination, evaluation and stipend for knowledge dissemination for the trainee. Outcome metrics are critical for sustainability of the programme. They not only serve to guide improvement of the programme, but are also critical in sustaining collaborator interest, mentees, supervisors and mentor alike, and to support grant applications for funding support.Due to limitations in funding, faculty commitment and the pilot nature of the project, two mentees were paired with a mentor at each iteration to date. Seven residents submitted proposals in 2016, and only the two senior residents were selected by their programme to submit proposals in 2018. All mentees who participated in the 2016, and 2018 from Ghana  and ZimbEarly programme evaluation (from Ghana trainees) suggests a high level of engagement and effective learning of critical appraisal and clinical research skills. One manuscript has been published  and one A qualitative study designed to understand the reasons for participation, other experience in mentorship programmes, perception of the programme, enablers and barriers, suggestions for improvement. Past programme applicants, mentees, supervisors, programme directors and mentors are invited to participate. The study is currently ongoing. Initial findings from this study suggest there were strong engagement by all the participants, the program had enriched the research experience of participating residents, and aligns well with the mentees' formal residency training program objectives. Suggestions for the future include a call for the program to support more trainees within each training programs as well as across more training programs. This will allow communities to emerge that will support each other, grow future generation of mentors and ultimately research capacity.et al [et al [The concept of mentorship is steeped in tradition with the earliest reference to a mentor figure in the literature appearing in Homer's ‘The Odyssey’ in the 15th century in the form of the character called ‘Mentor’. It means a trusted friend, counsellor or teacher, an experienced adviser and supporter = somebody, more experienced, who advises and guides a younger, less experienced person. What it means, looks like, when does it begin and end, expectations and perceived effectiveness vary widely. Many different models of mentorship have been described. The most commonly cited models are the traditional dyad mode (i.e. one on one mentoring), peer and facilitated peer mentoring, group mentorship  and netwet al  providedl [et al  providedHow to create an effective mentorship relationship is a subject of many scholarly works. Mismatch in perception of what is mentorship between mentors and mentees has been described , 24 and Finding a good research topic is often not easy and represents an important barrier to scholarly productivity for learners. The difficulty in landing with a good research question contrasts with the belief by education programme leaders that research possibilities in busy clinical environments are abundant . Asking et al [et al [Successful mentoring can be learned. Pfund et al  conductel [et al  describeHow can it be learned? Many scholarly works, courses , handbooks  and instWe selected a 1-year mentorship programme format allowing mentors, in collaboration with the supervisors, to support their trainee through the course of their research project. This format has the advantage of supporting trainees who are earlier on in their research career where research problem solving skills require nurturing. This format allows the mentor to gain a better understanding of the challenges and enablers of the trainee within the learning environment and contribute to problem solving in ways that more focused programmes will be less adapted to respond. Indeed, the short intense research methods courses , 35 and Our early experience supported our hypothesis that a distant mentorship relationship and a local supervisor–distant mentor–mentee triad are efficacious. Despite limited Internet connectivity and technical challenges at times, the clinical research mentorship programme enriched the learners’ experiences as it did, also for the mentors and supervisors. The collaborative spirit for the participants continues to expand beyond the year, with a growing network of CRMP alumni and potentially, future mentors in the making.The clinical research mentorship programme format is entering into its third offering. Early success encouraged us to broaden our collaborations and expand our structure into encouraging the development of mentorship skills through a short, structured curriculum. We hope the format we have chosen will continue to demonstrate effectiveness for our trainees, be sustainable for our collaborating faculty and serve to enrich radiation capacity building through collaborative mentorship and research.The authors have no conflicts of interest to declare relevant to the content of this manuscript.


The relevance of communication in medical education is continuously increasing. At the Medical Faculty of Hamburg, the communication curriculum was further developed and optimized during this project. This article aims to describe the stakeholders’ perceived challenges and supporting factors in the implementation and optimization processes.The initial communication curriculum and its development after a one-year optimization process were assessed with a curricular mapping. A SWOT analysis and group discussions were carried out to provide information on the need for optimization and on challenges the different stakeholders faced.The curricular mapping showed that the communication curriculum is comprehensive, coherent, integrated and longitudinal. In both the implementation and the project-related optimization processes, support from the dean, cooperation among all stakeholders and structural prerequisites were deemed the most critical factors for successfully integrating communication content into the curriculum.The initiative and support of all stakeholders, including the dean, teachers and students, were crucial for the project’s success.Although the implementation of a communication curriculum is recommended for all medical faculties, their actual implementation processes may differ. In a “top-down” and “bottom-up” approach, all stakeholders should be continuously involved in the process to ensure successful integration. Communication competencies are highly relevant in daily communication between doctors and patients and among hospital staff. Research has shown that good medical communication skills positively impact patients’ well-being, satisfaction, cooperation and health –7. FurthIn recent years, different policies have highlighted the importance of communication in medical studies in Germany . In 2012However, the implementation and factors that support the successful implementation of communication curricula have not yet been sufficiently researched. Consequently, in a multicenter study, the model communication curriculum was implemented at the Medical Faculties of Hamburg, Heidelberg, Mainz, and Magdeburg with financial support from the German Ministry for Health . InformaThe present study aims to describe stakeholders’ perspectives on the curriculum. Therefore, the degree of implementation of the communication curriculum at baseline and after an optimization process is quantified, which was carried out on the basis of the results of the baseline measurement. Furthermore, the factors that enable the successful implementation of longitudinal communication curricula and the strengths and weaknesses of the curricula will be identified.Within the framework of a design-based research project, we involved both quantitative and qualitative methods , 26, 27.Although the study scope exempted it from German requirements for formal ethical review by an institutional review board, all procedures performed in this study involving human participants were in accordance with the ethical standards of the institutions and with the WMA Declaration of Helsinki. Prior, written informed consent was obtained from the individual participants involved in the curricular mapping. Verbal informed consent was obtained from all participants involved in the voluntary interviews.The first survey was distributed to all departments and institutes involved in medical teaching at the Medical Faculty of Hamburg at the end of 2017 and beginning of 2018 (premeasurement). In total, 90 clinics and institutes were identified, 67 were contacted for the survey and teachers from 51 respective clinics and institutes were interviewed in regards to their communication-related courses. The majority of teachers was physicians or psychologists with lectureship at the medical faculty. The number of departments involved had to be adjusted during the interview process, as there was new information about cooperation between the departments. SPSS Statistics 24 was used to analyze the results and present the descriptive analysis. The survey results were compared to the following two objectives: (1) the curriculum completely covers the learning objectives listed in chapter 14 c of the NKLM  and (2) For the overall goal of identifying supporting factors and challenges for the implementation and optimization of a communication curriculum, a strengths, weaknesses, opportunities, and threats (SWOT) analysis was carried out in September and October 2018. SWOT analyses are a standard tool for analyzing strategies in medical education –30. ReprReflections on both the initial implementation and the optimization process of the communication curriculum were collected with group discussions , 32. TheAnother group discussion was carried out in July 2018. The sessions lasted about one hour. Three psychologists, one medical specialist in psychosomatic medicine and one student worker took part. One psychologist and one sociologist moderated the discussions with the help of an interview guide. The guide contained open-ended questions on the faculty’s strengths and weaknesses related to the implementation of the communication curriculum, institutional readiness, and both planned implementation measures and those that have already been carried out, along with relevant difficulties and facilitating factors –35. In pAfter the conclusion of the optimization process, a third group interview was conducted in October 2019 with one medical specialist in psychosomatic medicine, two lecturers and a deanery representative. A psychologist moderated the discussion. The interview guide’s subject was the retrospective evaluation of the communication curriculum and assessment of the optimization process. The discussion lasted approximately one and a half hours, and the evaluation was based on discussion transcripts. A researcher analyzed the group interviews by summarizing the findings and examining themes of meaning within the data. Finally, the findings were communicated to the participating institutes in order to comment or revise them.Analysis of the quantitative data showed that the communication curriculum at baseline was longitudinal and centrally coordinated. There was also a central pool of simulation persons and staff for its management and training. The communication examinations were organized centrally and included multiple-choice questions, open questions, written patient reports, patient presentation and objective structured clinical examinations (OSCEs). No new examinations were introduced during the optimization process. There were no changes in the infrastructural equipment available for communication teaching or the organization. Throughout the entire degree program, communication classes were offered, with the most classes occurring in the second, third and fourth years. In 2019, there were both more courses with communication-related content and more teaching units than in 2017/18 see . After tAll interviewees stated that communication was embedded in clinical content. The SWOT analysis focused on the initial implementation process of the communication curriculum see . This reOne positive aspect of the curriculum was related to the longitudinal character of the communication curriculum throughout the whole degree program. The introduction to clinical medicine, anamnesis and conversation courses in the first semesters begin to address communication. In the last year of the study–the practical year–the integration of communication is often not as consistent as in the other years because academic hospitals are not well informed about the communication curriculum. “Learning spirals”–methods for independent and individualized learning–were another enabling factor mentioned for integrating communication into the curriculum. The relevance of communication is highlighted by examination formats such as OSCEs throughout the program. However, the relevance of communication in examinations is not entirely clear to teachers, and part of the examined subjects are taught in previous years. Additionally, examiners perceived that they are not always appropriately trained.The presence of motivated lecturers with competencies in communication and the teaching-learning research conducted at the university were other enabling factors for integrating communication content in the curriculum. Some participants were unaware of the proportions of teaching units on communication offered by subjects within different institutes. The decentralized teaching organization, in which the individual subject areas are independently responsible for implementing communication teaching, was perceived as an impediment for a fully integrated communication curriculum and thus as leading to incomplete coordination and redundancies.The interviewees attributed immense importance to the faculty members’ attitudes towards and support of the communication curriculum (“top-down”). Notably, in the beginning, there were only a few qualified lecturers, and the development and implementation mainly fell them. Additionally, it was suspected that teachers did not always use their available resources to the full extent. Therefore, participants recognized the need for training lecturers on the learning objectives and the implementation of the content in their teaching.Furthermore, students can practice both everyday and unusual situations with actors or other students within a pleasant environment to generate feedback and self-reflection. An extensive and professional program for actors is available in which actors are prepared for many roles and varying situations. In addition, extracurricular activities are offered for student tutors . Challenges include the lack of knowledge and unequal interest and willingness among teachers and students to practice competencies. Not all students are interested, and the same individuals often participate in and profit from training situations.The interdisciplinary cooperation between groups and regular exchanges between departments contributed to the coordination between both departments and subjects. For example, an anamnesis scheme was jointly developed and distributed as posters and small booklets. Additionally, interdisciplinary and interprofessional teams began teaching courses . Participants mentioned establishing an interdisciplinary working group on clinical examination methods and medical communication as one enabling factor. The strengths associated with this lie mainly in the competences built up through this. Since 2018, the group has been integrated into the annual medical faculty teaching conference, leading to the further institutionalization of communication content. The group discussions with the stakeholders, including project leaders, teachers, students, and deanery representatives, confirm the SWOT analysis’s major findings, including the integration of communication content into the curriculum. There was a generally positive attitude towards communication teaching, even if not everyone was interested in being actively involved. Many communication teaching competencies were gained, particularly among Master of Medical Education (MME) graduates and current students. Additionally, extensive teaching and communication research areas were mentioned. However, the participants discussed the difficulty of implementing more events because the curriculum is relatively rigidly defined, and the students’ workload limits must be considered. Coordination concerning concrete learning objectives should be further developed and optimized.In addition to the retrospective group discussions, the project leader summarized that the communication curriculum was developed during the study reform as an integral part of the model study program. This structure enabled concerted support for intensive and financially supported curriculum development. The particularly favorable conditions in terms of institutional readiness, such as established interdisciplinary cooperation, great teaching competence at the faculty and an overall good organization, were helpful.The focus of the optimization process in 2018 and 2019 was on better interlinking the individual subjects and integrating the communication content into the clinical subjects. Furthermore, regular meetings between teachers, information events and meetings for fine-tuning between departments and lecturers were established in the optimization process with the aim of using a common concept. The group discussions in 2019 revealed that the participants viewed the continuous project meetings triggered by the premeasurement as one of the most important factors in optimizing the communication curriculum. Further, the faculty is committed to the project since communication is already a part of the curriculum. The dean and other stakeholders showed enormous support for further developing the communication curriculum. For the group discussions participants, it was crucial that the dean and other stakeholders within the faculty initialized the project with a top-down approach. The coordination group then created opportunities for the participation of other stakeholders, including students and teachers, in the optimization process in line with a bottom-up approach. However, it was mentioned that teachers did not always have the opportunity to implement their ideas and courses because the curriculum is already very extensive. The students’ feedback was mainly positive. The courses on behavior change counseling and motivational interviewing were further developed and optimized based on student feedback, among other things.Competencies in communication teaching at the faculty, meetings among teachers, continuous coordination processes and the simulation person program also facilitated the optimization process. Barriers included a lack of separate teaching positions for communication and the financing for the curriculum implementation coming from the regular budget. A criticism that arose during the lecturers’ discussions was the desire and the need for supervision and communication training. The implementation of new approaches required restructuring the curriculum, as the curriculum did not easily allow for extensions. In the future, the integration of new content should be planned with a focus on interprofessionality. The perceptions regarding the changes were generally positive, even if not everyone was interested in being actively involved. The project leader summarized that the support and communication curriculum at baseline enabled development during the implementation process.The study results show that there is a comprehensive, coherent and longitudinal communication curriculum integrated into the main curriculum at the Medical Faculty of Hamburg. Additional differentiated structures were developed during the project and throughout the optimization process, and communication is now a more prominent part of the faculty’s self-image than it was before the project. The optimization process in 2018 and 2019 was successful due to the dean’s support for the project and the excellent baseline conditions, such as research conducted at the university . AnotherThe results show that one great benefit of the new curricula of model programs is the integration of relevant competencies and practical skills from the beginning. Developing modern curricula requires much consideration but enables a high degree of integration of relevant topics such as communication, as shown at the Medical Faculty of Hamburg. Curricular mapping is essential for identifying the strengths and weaknesses of a curriculum. One strong advantage of this project’s approach is that all different groups were included since all stakeholders were crucial for the development process. The project sought to combine both top-down and bottom-up approaches. Decisions for the development of the curriculum were primarily top-down, ensuring efficiency and supervision. The dean’s support paved the way for meetings and for curriculum adaptation. On the other hand, it is also crucial to boost bottom-up capacity through the extensive integration and involvement of all stakeholders. Lecturers and students were motivated to participate and to improve the teaching at the faculty.The comparison to the NKLM showed that some competences are better covered than others. These shortcomings have to be identified, e.g., with a curricular mapping, communicated and discussed. Then the curriculum or existing courses should be revised accordingly. Although the optimization process resulted in an improved curriculum, development is ongoing and must provide for adaptations to new demands and needs. Simultaneously, it is necessary to ensure that taught material is understood and can be implemented by medical students. Practical examination formats, such as OSCE, have proven their usefulness in this context , 38, 41.Limitations of this study include that the analysis focuses on one curriculum at one medical faculty only, and the generalizability of the findings is therefore limited. However, it is a fascinating example that shows that communication content can be integrated into a curriculum within a relatively short period of time. The model program had different framework conditions than traditional courses of study in the sense that the model character allows for more scope for design and innovation , 42. FurThe importance of communication competences for doctors is recognized worldwide, particularly at the Medical Faculty of Hamburg. A comprehensive, coherent and longitudinal communication curriculum was integrated into the curriculum and optimized during the project through the cooperation of different status groups. In this way, the medical faculty set the course for a successful start to the students’ careers, as future doctors can benefit from learning communication skills during their studies.Our study shows that there are many prerequisites for the successful implementation of communication curricula. These factors may differ from university to university and across countries depending on the structural conditions and maturity of the curricula. Before implementing a project similar to ours, the baseline conditions should be evaluated (premeasurement). Quantitative surveys help identify developments during the project phase (pre- and postmeasurement), and qualitative discussions with all stakeholders are necessary to identify specific challenges and ways to overcome these challenges.Based on our results, it is evident that whenever possible, communication content should be integrated into the development of a curriculum from the beginning. Second, the dean needs to support such development and ensure the support of faculties’ employees. Third, the cooperation of all stakeholders and regular working group meetings are crucial. Last, the development of (communication) curricula should be ongoing.


Descriptive analysis will be conducted to assess the level of ageism in the study sample. The ageism levels between the two groups will be compared using the t-student test, and two Structural Equation Modeling will be developed to evaluate the predictors of ageism. Assessing ageism is necessary to allow healthcare professionals and policymakers to design and implement strategies to solve or reduce this issue. Findings from this study will generate knowledge relevant to healthcare and medical courses along with anti-ageism education for the Portuguese population.Ageism refers to stereotyping (how we think), prejudice (how we feel), and discrimination (how we act) against people based on their age. It is a serious public health issue that can negatively impact older people’s health and quality of life. The present protocol has several goals: (1) adapt the Ambivalent Ageism Scale for the general Portuguese population and healthcare professionals; (2) assess the factorial invariance of the questionnaire between general population vs. healthcare professionals; (3) evaluate the level of ageism and its predictors in the general population and evaluate the level of ageism and its predictors in healthcare professionals; (4) compare the levels of ageism between groups and the invariance between groups regarding the explanatory model of predictors of ageism. This quantitative, cross-sectional, descriptive, observational study will be developed in partnership with several Healthcare Professional Boards/Associations, National Geriatrics and Gerontology Associations, and the Universities of the Third Age Network Association. The web-based survey will be conducted on a convenience sample recruited via various social media and institutional channels. The survey consists of three questionnaires: (1) Demographic data; (2) Ambivalent Ageism Scale; (3) Palmore-Neri and Cachioni questionnaire. The methodology of this study will include translation, pilot testing, semantic adjustment, exploratory and confirmatory factor analysis, and multigroup analysis of the Ambivalent Ageism Scale. Data will be treated using International Business Machines Corporation (IBM The demographic aging of the population is one of humanity’s greatest triumphs and challenges. By 2050 the number of people aged 60 or older is expected to rise from 962 million in 2017 to 2.1 billion in 2050 and 3.1 billion in 2100 [In the European Union, Portugal has the fourth-highest percentage age of older people . In 2000Aging becomes a problem when society is not prepared for its own aging, presenting negative attitudes towards this stage of life .Ageism, a term first coined by Robert Butler, refers to stereotyping (thoughts), prejudice (feelings), and discrimination (actions or behavior) against people by their age , has beeAgeism can have different targets, as it can be directed towards others or oneself . In addiDefinitions of ageism refer to older people, aging, and the aging process as being seen in an undesirable fashion. Ageist attitudes are of great complexity as they fit the paternalistic stereotype. Older adults are seen as warm but incompetent, ending in hostile and benevolent forms of prejudice ,10. BecaNumerous studies have verified that ageism negatively impacts older people in several distinct dimensions such as memory and cognitive performance ,12, healWhile negative representations of older adults may lead to exclusion, hostile attitudes and behaviors ,9, and sIt is common to find ageism in many sectors of society, including those providing health and social care. Considering healthcare systems, older adults represent a significant group of users, and their care has a crucial impact on the overall financial costs . HoweverThe research will have two phases. Phase 1 aims to evaluate ageism in Portuguese healthcare professionals and identify its predictors. In Phase 2, we will expand the study to a representative sample of the Portuguese population.We chose the Ambivalent Ageism Scale to evaluate ageism because it is a useful tool for researchers to measure attitudes toward older adults, allowing us to assess different elements of ageist attitudes and benevolent and hostile ageism .(a)What is the level of ageism in Portuguese healthcare professionals?(b)What are the predictors of ageism in Portuguese healthcare professionals?(c)What is the level of ageism in the Portuguese population?(d)What are the predictors of ageism in the Portuguese population?Given the research questions mentioned above, the study goals are: (a) adapt the Ambivalent Ageism Scale for the general Portuguese population and for healthcare professionals; (b) assess the factorial invariance of the questionnaire between both groups ; (c) evaluate the level of ageism and its predictors in the general population; (d) evaluate the level of ageism and its predictors in healthcare professionals; (e) compare the levels of ageism between groups and the invariance between groups regarding the explanatory model of predictors of ageism.A quantitative, cross-sectional, descriptive, observational study conducted based on a web-based survey.January 2022–June 2024 .The study population consists of Portuguese citizens.Portuguese health care professional’s ;Willingness to participate in the study.Portuguese population;People aged 18 years and above;Willingness to participate;Ability to understand, provide informed consent and comply with all the proceedings.Target population under the age of 18, and an unwillingness/inability to understand, provide informed consent, or comply with all the proceedings.The total sample consists of 168 participants, which will be divided into 2 groups . The sample size was obtained based on a power calculation (5% level of significance) indicating that a total sample size of 140 will have 95% power, for a small effect size (0.25). Therefore, sample size was increased to 168 participants to accommodate a 20% of exclusions.In Phase 1, the study will be conducted in collaboration with the Board of Nurses, Board of Physiotherapists, Board of Psychologists, Board of Medicine, and the Portuguese Association of Exercise Physiologists.These partners will use their database to forward an email (with a link to access the survey), inviting their members/associates to participate in the study. At the same time, we will create a campaign to publicize the study on different social media channels to maximize the number of respondents.In phase 2 the study will be conducted in collaboration with the National Association of Social Gerontology, the Portuguese Society of Geriatrics and Gerontology, and the Universities of the Third Age Network Association. In addition, we will start a campaign to publicize the study on different social media channels to maximize the number of respondents.Data collection will be carried out through the application of the web-based survey using Qualtrics. Participants will answer the survey. At the end of all the questionnaires, participants can see the contact details of the researchers for any questions or comments, as well as links to other organizations that provide information or intervention in the area of ageism. The survey’s first page will clarify the objectives and procedures of the study and the guarantee to ensure the confidentiality and anonymity of the data. Before completing the survey, informed consent will be obtained from all study participants.Part 1—Demographic data: Multiple choice and quick answer questions are presented to allow the sociodemographic characterization of the sample. Participants will report information such as gender, age, nationality, education, professional status, frequency, and quality of intergenerational contact.Part 2—Ambivalent Ageism Scale: To assess the presence of benevolent and hostile ageism, we will use the Ambivalent Ageism Scale developed by Cary, Chasteen, and Remedios . ParticiPart 3—Palmore-Neri and Cachioni questionnaire: To assess the level of knowledge concerning aging, we will use the Palmore-Neri and Cachioni questionnaire . The queAgeism and level of knowledge are constructs that can be influenced by social desirability. Therefore, to control for social desirability bias, we will include a short text before the presentation of the questionnaires . In addThe Ambivalent Ageism Scale will be translated in accordance with World Health Organization best practice guidelines .The translation process will be performed through different stages, namely: forward translation, an expert panel, back-translation, pre-testing, and cognitive interviewing. Our team has already gained permission by email correspondence to use and translate the Ambivalent Ageism Scale. Translation and cultural validation will take place between May 2022 and September 2022.The translation of the questionnaire from the original English version into the Portuguese language will be accomplished by two independent bilingual translators. One translator will be an expert on Ageism, providing a translation that more closely resembles the original instrument. The other will be a naïve translator, who is unaware of the questionnaire’s aim, producing another translation so that subtle variances in the original questionnaire might be perceived. Any divergences in the translation will be debated and resolved between the two translators or, if needed, a third unbiased translator fluent in both languages. With the forward translation, we aim to translate the questionnaire and determine its conceptual equivalence in Portuguese, reflecting the nuances of the target language.The back-translation will be performed independently from the forward translation to ensure the accuracy of the translation. This stage will be done independently by two further translators fluent in both Portuguese and English. Following the best practice recommendation, these two translators will not have previous exposure to the original questionnaire. As in the previous stage, any divergences in the translation will be debated and resolved between the two translators or, if needed, a third unbiased translator. In this stage, we aim to reveal any misunderstandings or unclear wording in the initial translation.The translated version will be applied to a small , randomly selected sample of men and women to discuss the items’ understanding and arrive at the final translation of the Portuguese version of the questionnaires Ambivalent Ageism Scale. The Ambivalent Ageism Scale will be pilot tested through a think-aloud protocol  as per tSubsequently, researchers will apply the instruments to the general and healthcare samples within the scope of the investigation protocol.®, v.27.0, IBM® Corp, Armonk, NY, USA) and Analysis of Moment Structures (AMOS®) . To assess the construct validity of the Ambivalent Ageism Scale, exploratory factor analyses (EFA) will be performed. The principal components method will be used for the extraction of common factors and the Varimax rotation for the factor rotation [Data will be treated using Statistical Package for the Social Sciences (SPSS) software  SPSS Statisticsrotation . Confirmrotation . Model irotation . After tThis research will be conducted in accordance with the Helsinki Declaration (as revised in 2013) and will seek approval from the Egas Moniz Ethics Committee.All the participants must complete an informed consent question embedded on the first page of the questionnaire. It will state that participation is entirely voluntary. Participants are also free to not reply to some questions, change or review their responses, or voluntarily quit at any time. Consent will be obtained before proceeding to the next page if participants answer “YES” to the form’s first question, agreeing to participate in the study. Participants who answer “NO” to the informed consent question will be directed to the end of the survey. Data will be conducted in compliance with ethical principles guaranteeing the participants’ anonymity. Therefore, no individual answers to the questionnaire will be accessible.In this study, all data collected from participants will be strictly anonymous and confidential. Researchers are not interested in individual responses. Only the project managers will have access to all data. Essential documents will be archived in a way that ensures that they are readily available, upon request, to the competent authorities. All paper copies will be stored in a locked file. Data collected from the survey will be coded and stored on a password-protected and backed-up computer drive. For five years, all data will remain locked in a file cabinet at Egas Moniz University. The project managers will destroy all data when this retention period is complete.This study represents a starting point to change the narrative around age and aging among the Portuguese population. Up to now, there has been no significant study that addresses ageism in Portugal. Ageism can harm members of society individually and collectively, with negative consequences for their health and wellbeing, being responsible for a heavy economic burden on society. For example, in the United States of America, age stereotypes led to excess annual costs of US$63 billion for the eight most expensive health conditions . Ageist There are several scales designed to measure hostile ageism, potentially making it difficult for clinicians to decide which to choose for better practices. Notably, the Ambivalent Ageism Scale is the first dedicated to measuring both hostile and benevolent ageism since hostile and benevolent ageist attitudes exist and do not predict the same outcomes . This scThe data collected in this study may play a central role in raising awareness of ageism among the Portuguese population, with a particular focus on healthcare professionals. After its completion, it is expected that the team of researchers will work with key partners to develop content related to ageism and share this content on various social media platforms to raise awareness of this problem.Assessing ageism is the first step that allows healthcare professionals and policymakers to develop and implement strategies  to solve this issue. Previous studies investigated strategies to combat ageism. For example, research developed in Canada addressed the effect of educational programs on nursing students’ knowledge and ageist behaviors. Researchers concluded that education had a positive impact on the way students view older adults .Other studies also show that increased aging knowledge was significantly correlated with reduced ageist behaviors ,35,36. TIn addition, previous studies have shown that a high level of encounters in the right setting decreases ageism, so multidisciplinary intervention to promote intergenerational contact should be promoted ,38,39. TThis study protocol presents our aims, methodological approach, and plan to operationalize the research. The findings are expected to have direct relevance to several healthcare and medical courses across Portugal, along with anti-ageism education for the general public.It is necessary to develop the capacity to challenge, rather than perpetuate, stereotypes, prejudice, and discrimination against people by their age. Therefore, this study is of vital importance.This study has the advantage of contributing to a more complete representation of ageism among the Portuguese population. Nevertheless, we emphasize that the study has limitations. The first is the possibility that participants might deny or minimize their ageist behaviors if they recognize them as incorrect or socially undesirable. Alternatively, if participants perceive it to be socially desirable, they might overstate the frequency of their behavior, increasing the frequency of the positive items. Second, by relying upon recruiting participants via various social media, we may not generalize the survey result to the population as a whole as there is the possibility of under-or over-representation.