Warwick Medical School: A four dimensional curriculum

Medical curricula vary hugely across the world. Notions of horizontal and vertical integration and spiral curricula are present in many modern curricula although true integration happens to a varying degree. By seeing the development of a curriculum as fundamentally about integration, rather than as a process of seeking to integrate separate elements, we have developed a program that prepares students well for the complexities and rate of change of practice. The risks inherent in bringing forward the point at which learners need to deal with such substantive and fundamental complexity produces challenges. Such challenges are ones that our students have shown they can not only deal with, they are often better equipped than faculty to provide solutions for themselves, their peers and those who follow them. We present the three dimensions of integration in the Warwick Medical School curriculum and note the fourth dimension provided by our students, being student led teaching and support far beyond what is normally found in medical courses.

Evaluating qualitative papers in a multidisciplinary evidence-based journal club: a pilot study

Journal clubs have traditionally been important means by which clinicians, academics and trainees appraise research that relates to their field. In recent years the evidence-based style has become more prevalent, allowing knowledge gleaned from research to be applied to clinical situations. Currently, the main approach of evidence-based journal clubs is quantitative. This paper describes the evaluation of a modified journal club format, developed in an academic department of a medical school and combining the appraisal of both qualitative and quantitative papers.

Mystery Shopper Lecture Feedback Programme – a collaborative project between staff and students at a graduate entry medical school

The pilot study described is an innovative model which ensures that lecturers receive relevant and tailored feedback from students in order to improve their delivery of lectures, ultimately improving student education.The current method of lecture feedback at Warwick Medical School asks students to comment on a whole term’s worth of lectures at once – consequently feedback is often non-specific and unconstructive.This project has been rolled out by a collaborative team of four medical students and one Faculty member. The project team designed a training event to instruct 10-15 students from each year group to deliver constructive and useful feedback to lecturers. The project team designed the online feedback form, which is completed by the trained students after observing a lecture. Students sign up to review lectures via a digital platform managed by the project team. Once the feedback form is submitted, it is quality-control-assessed by a Faculty member before being sent anonymously to the lecturer.This project allows medical students to provide lecturers with meaningful information about what they did well and how they can improve. Initial feedback from lecturers has been positive; they have valued the constructive criticism and the suggestions they have been given for improving future lectures.

Factors influencing career intentions on completion of general practice vocational training in England: a cross-sectional study

OBJECTIVES

General practice is experiencing a growing crisis with the numbers of doctors who are training and then entering the profession in the UK failing to keep pace with workforce needs. This study investigated the immediate to medium term career intentions of those who are about to become general practitioners (GPs) and the factors that are influencing career plans.

DESIGN

Online questionnaire survey, with quantitative answers analysed using descriptive statistics and free text data analysed using a thematic framework approach.

SETTING AND PARTICIPANTS

Doctors approaching the end of 3-year GP vocational training in the West Midlands, England.

RESULTS

178 (57.2%) doctors completed the survey. Most participants planned to work as salaried GPs or locums rather than entering a general practice partnership for at least the first 5 years post-completion of training; others failed to express a career plan or planned to leave general practice completely or work overseas. Many were interested in developing portfolio careers.The quality of general practice experience across undergraduate, foundation and vocational training were reported as influencing personal career plans, and in particular perceptions about workload pressure and morale within the training practices in which they had been placed. Experience of a poor work-life balance as a trainee had a negative effect on career intentions, as did negative perceptions about how general practice is portrayed by politicians and the media.

CONCLUSION

This study describes a number of potentially modifiable factors related to training programmes that are detrimentally influencing the career plans of newly trained GPs. In addition, there are sociodemographic factors, such as age, gender and having children, which are also influencing career plans and so need to be accommodated. With ever-increasing workload in general practice, there is an urgent need to understand and where possible address these issues at national and local level.

The general practitioner workforce crisis in England: a qualitative study of how appraisal and revalidation are contributing to intentions to leave practice

Background

The general practice (GP) workforce in England is in crisis, with declining morale and job satisfaction, increasing early retirement and declining interest in training to become a GP. We recently reported on factors that are influencing this, with appraisal and revalidation emerging as an unexpected finding; 28.6 % of GPs stating an intention to leave general practice within the next 5 years included this as ‘very important’ or ‘important’ to their decision. In this study we undertook a secondary analysis to identify how the experience of appraisal and revalidation might be influencing intentions to leave general practice.

Methods

Qualitative analysis of free text comments made by GPs in a survey of career intentions. All comments that included mention of appraisal or revalidation were extracted. Emergent themes were identified and a coding framework devised.

Results

Forty-two participants made comments that related to appraisal and revalidation. Compared to all 1192 participants who completed the main survey, they were older (76.2 % compared to 46.2 % aged 50 years and older), with more years’ general practice experience (80.0 % compared to 48.0 % with >20 years’ experience) and more likely to state an intention to retire within 5 years (72.2 % compared to 41.9 %).

Key themes were appraisal and revalidation as: a bureaucratic, inflexible exercise that added to an already pressured workload; an activity that has little educational value, relevance to professional development or quality of care; and an issue that contributes to low morale, work-related distress and intentions to leave general practice. Revalidation was depicted as a cumbersome tick-box exercise that had little to do with quality of care or protecting patients. There were no comments that countered these negative views.

Conclusions

While the representativeness of these comments to the experience of GPs as a whole cannot be judged, it is likely that that they reflect the concerns of GPs whose experience of appraisal and revalidation is influencing their intention to leave general practice. Through its impact on GP morale and burnout, the current appraisal and revalidation system in England appears to be contributing to the workforce crisis. The findings indicate that the appraisal system may be in urgent need of re-design to increase its relevance to individual GPs’ experience and seniority, clinical activities being undertaken and professional development needs.

Registered report: A chromatin-mediated reversible drug-tolerant state in cancer cell subpopulations

The Reproducibility Project: Cancer Biology seeks to address growing concerns about reproducibility in scientific research by conducting replications of selected experiments from a substantial number of high-profile papers in the field of cancer biology. The papers, which were published between 2010 and 2012, were selected on the basis of citations and Altmetric scores (Errington et al., 2014). This Registered Report describes the proposed replication plan of experiments from “A chromatin-mediated reversible drug-tolerant state in cancer cell subpopulations” by Sharma and colleagues, published in Cell in 2010 (Sharma et al., 2010). Sharma and colleagues demonstrated that prolonged exposure of cancer cells to TKIs give rise to small populations of “drug tolerant persisters” (DTPs) (Figure 1B-C) that were reversed during subsequent maintenance under drug-free conditions (Figures 1E, 2B and 2E). DTPs exhibited reduced histone acetylation and sensitivity to HDAC inhibitors (HDIs) (Figure 4A-B). Drug sensitivity was restored with co-treatment of either HDIs or an IGF-1R inhibitor, in combination with TKIs (Figure 5A-B). Inhibition of IGF-1R activation also led to decreased KDM5A expression and restoration of H3K4 methylation, suggesting a direct link between the IGF-1R signaling pathway and KDM5A function (Figure 7A, 7C, and 7I). The Reproducibility Project: Cancer Biology is a collaboration between the Center for Open Science and Science Exchange and the results of the replications will be published in eLife.

DOI:http://dx.doi.org/10.7554/eLife.09462.001

Detection of genes encoding multidrug resistance and biofilm virulence factor in uterine pathogenic bacteria in postpartum dairy cows

Reckless use of antibiotics and/or development of biofilm are the rationale for the development of multidrug resistance (MDR) of pathogenic bacteria. The objective of the present study was to detect MDR genes in Trueperella pyogenes and to detect biofilm virulence factor (VF) genes in Escherichia coli isolated from the uterus of postpartum dairy cows. Uterine secretions from different parity postpartum Holstein cows (n = 40) were collected using cytobrush technique after a sterile procedure from cows with varying degree of uterine inflammatory conditions. The cytobrush was stored in a specimen collector, placed in a cooler with ice, and transported to the laboratory within 2 hours. The pathogens were isolated and were identified initially by their colony morphology and biochemical characteristics. To further identify and classify the single species, and to determine the presence of MDR and VF genes, the genes fragments were amplified using the respective primers by either singleplex or multiplex polymerase chain reaction protocol, and amplicons were detected by electrophoresis method. T pyogenes was isolated in 17 of 40 (42.5%) cows in the study population as recognized by the 16S rRNA gene. Of the positive T pyogenes samples, 8 of 17 (42.1%) were positive for integron type 1 (intI I), and none were positive for integron type 2 (intI II). Of those 8 positive for intI I, six of eight (66.7%) were positive for amplicons aadA5 and aadA24-ORF1 at 1048 and 1608 bp, respectively, associated with specific drug resistance. Presence of addA5 indicated resistance to sulfadiazine, bacitracin, florfenicol, and ceftiofur. Presence of addA24-ORF1 indicated resistant to sulfadiazine, bacitracin, penicillin, clindamycin, and erythromycin. E coli was isolated in 18 of 40 (45.0%) cows in the study population. The genes for VF, Agn43a, and Agn43 b, associated with biofilm production, were found in 6 of 18 (33.3%) of the positive isolates. Both T pyogenes MDR gene and E coli biofilm VF existed in more severe form of uterine diseases than subclinical endometritis. In conclusion, 35% of T pyogenes isolates found were positive for a gene cassette associated with antibiotic resistance, and 33% of the E coli isolates contained genes for the VF associated with biofilm production.

Retaining the general practitioner workforce in England: what matters to GPs? A cross-sectional study

Background

The general practice (GP) workforce in England is in crisis, reflected in increasing rates of early retirement and intentions to reduce hours of working. This study aimed to investigate underlying factors and how these might be mitigated.

Methods

GPs in central England were invited to participate in an on-line survey exploring career plans and views and experiences of work-related pressures. Quantitative data were analysed using logistic regression analysis and principal components analysis. Qualitative data were analysed using a thematic framework approach.

Results

Of 1,192 GPs who participated, 978 (82.0 %) stated that they intend to leave general practice, take a career break and/or reduce clinical hours of work within the next five years. This included 488 (41.9 %) who intend to leave practice, and almost a quarter (279; 23.2 %) intending to take a career break. Only 67 (5.6 %) planned to increase their hours of clinical work.

For participants planning to leave practice, the issues that most influenced intentions were volume and intensity of workload, time spent on “unimportant tasks”, introduction of seven-day working and lack of job satisfaction.

Four hundred fifty five participants responded to open questions (39128 words in total). The main themes were the cumulative impact of work-related pressures, the changing and growing nature of the workload, and the consequent stress.

Reducing workload intensity, workload volume, administrative activities, with increased time for patient care, no out-of-hour commitments, more flexible working conditions and greater clinical autonomy were identified as the most important requirements to address the workforce crisis. In addition, incentive payments, increased pay and protected time for education and training were also rated as important.

Conclusions

New models of professionalism and organisational arrangements may be needed to address the issues described here. Without urgent action, the GP workforce crisis in England seems set to worsen.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0363-1) contains supplementary material, which is available to authorized users.

Registered report: BET bromodomain inhibition as a therapeutic strategy to target c-Myc

The Reproducibility Project: Cancer Biology seeks to address growing concerns about reproducibility in scientific research by replicating selected results from a substantial number of high-profile papers in the field of cancer biology published between 2010 and 2012. This Registered report describes the proposed replication plan of key experiments from 'BET bromodomain inhibition as a therapeutic strategy to target c-Myc' by Delmore and colleagues, published in Cell in 2011 (Delmore et al., 2011). The key experiments that will be replicated are those reported in Figures 3B and 7C-E. Delmore and colleagues demonstrated that treatment with JQ1, a small molecular inhibitor targeting BET bromodomains, resulted in the transcriptional down-regulation of the c-Myc oncogene in vitro (Figure 3B; Delmore et al., 2011). To assess the therapeutic efficacy of JQ1 in vivo, mice bearing multiple myeloma (MM) lesions were treated with JQ1 before evaluation for tumor burden and overall survival. JQ1 treatment significantly reduced disease burden and increased survival time (Figure 7C-E; Delmore et al., 2011). The Reproducibility Project: Cancer Biology is a collaboration between the Center for Open Science and Science Exchange and the results of the replications will be published in eLife.

New ways of working in mental health services: a qualitative, comparative case study assessing and informing the emergence of new peer worker roles in mental health services in England

Background

A variety of peer worker roles are being introduced into the mental health workforce in England, in a range of organisational contexts and service delivery settings. The evidence base demonstrating the effectiveness of peer worker-based interventions is inconclusive and largely from outside England. An emerging qualitative literature points to a range of benefits, as well as challenges to introducing the peer worker role.

Aims

In this study we aimed to test the international evidence base, and what is known generally about role adoption in public services, in a range of mental health services in England. We also aimed to develop organisational learning supporting the introduction of peer worker roles, identifying learning that was generic across mental health services and that which was specific to organisational contexts or service delivery settings.

Team

The research was undertaken by a team that comprised researchers from a range of academic and clinical disciplines, service user researchers, a peer worker, and managers and service providers in the NHS and voluntary sector. Service user researchers undertook the majority of the data collection and analysis. We adopted a coproduction approach to research, integrating the range of perspectives in the team to shape the research process and interpret our findings.

Study design

The study employed a qualitative, comparative case study design. We developed a framework, based on existing evidence and the experiential insight of the team, which conceptualised the challenges and facilitators of introducing peer worker roles into mental health services. The framework was used to inform data collection and to enable comparisons between different organisational contexts, service delivery settings and the perspectives of different stakeholders.

Settings

The study took place in 10 contrasting cases comprising mental health NHS trusts, voluntary sector service providers and partnerships between the NHS and voluntary sector or social care providers. Peer workers were employed in a variety of roles, paid and unpaid, in psychiatric inpatient settings, community mental health services and black and minority ethnic (BME)-specific services.

Participants

Participants were 89 people involved in services employing peer workers, recruited purposively in approximately equal proportion from the following stakeholder groups: service users; peer workers; (non-peer) coworkers; line managers; strategic managers; and commissioners.

Data collection

All participants completed an interview that comprised structured and open-ended questions. Structured questions addressed a number of domains identified in the existing evidence as barriers to, or facilitators of, peer worker role adoption. Open-ended questions elicited detailed data about participants’ views and experiences of peer worker roles.

Data analysis

Structured data were analysed using basic statistics to explore patterns in implementation across cases. Detailed data were analysed using a framework approach to produce a set of analytical categories. Patterns emerging in the structured analysis informed an in-depth interrogation of the detailed data set, using NVivo 9 qualitative software (QSR International Pty Ltd, Victoria, Australia) to compare data between organisational contexts, service delivery settings and stakeholder groups. Preliminary findings were refined through discussion with a range of stakeholders at feedback workshops.

Findings

Many of the facilitators of peer worker role adoption identified in the existing evidence base were also evident in mental health services in England, although there were issues around pay, leadership, shared understanding of the role, training and management where good practice was uneven. A number of examples of good practice were evident in the voluntary sector, where peer worker roles had been established for longer and organisations were more flexible. In the NHS there were a range of challenges around introducing peer worker roles into existing structures and cultures of practice. Peer workers were able to engage people with services by building relationships based on shared lived experience – the language they used was particularly important in BME-specific services – but barriers to engagement could be created where roles were overformalised.

Conclusions

Key barriers to, and facilitators of, peer worker role adoption were identified, including valuing the differential knowledge and practice that peer workers brought to the role (especially around maintaining personally, rather than professionally defined boundaries); maintaining peer identity in a role of work; changing organisational structures to support peer workers to remain well in their work; and challenging organisational cultures to empower peer workers to use their lived experience. Recommendations for future research include developing a theoretical framework articulating the change mechanisms underpinning ‘what peer workers do’, piloting and formally evaluating the effectiveness and cost-effectiveness of peer worker interventions, and mixed-method research to better understand the impact of working as a peer worker.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Introducing peer worker roles into UK mental health service teams: a qualitative analysis of the organisational benefits and challenges

Background

The provision of peer support as a component of mental health care, including the employment of Peer Workers (consumer-providers) by mental health service organisations, is increasingly common internationally. Peer support is strongly advocated as a strategy in a number of UK health and social care policies. Approaches to employing Peer Workers are proliferating. There is evidence to suggest that Peer Worker-based interventions reduce psychiatric inpatient admission and increase service user (consumer) empowerment. In this paper we seek to address a gap in the empirical literature in understanding the organisational challenges and benefits of introducing Peer Worker roles into mental health service teams.

Methods

We report the secondary analysis of qualitative interview data from service users, Peer Workers, non-peer staff and managers of three innovative interventions in a study about mental health self-care. Relevant data was extracted from interviews with 41 participants and subjected to analysis using Grounded Theory techniques. Organisational research literature on role adoption framed the analysis.

Results

Peer Workers were highly valued by mental health teams and service users. Non-peer team members and managers worked hard to introduce Peer Workers into teams. Our cases were projects in development and there was learning from the evolutionary process: in the absence of formal recruitment processes for Peer Workers, differences in expectations of the Peer Worker role can emerge at the selection stage; flexible working arrangements for Peer Workers can have the unintended effect of perpetuating hierarchies within teams; the maintenance of protective practice boundaries through supervision and training can militate against the emergence of a distinctive body of peer practice; lack of consensus around what constitutes peer practice can result in feelings for Peer Workers of inequality, disempowerment, uncertainty about identity and of being under-supported.

Conclusions

This research is indicative of potential benefits for mental health service teams of introducing Peer Worker roles. Analysis also suggests that if the emergence of a distinctive body of peer practice is not adequately considered and supported, as integral to the development of new Peer Worker roles, there is a risk that the potential impact of any emerging role will be constrained and diluted.

[Changes in weight and diabetes compensation (HbA1c) in patients with diabetes mellitus type 2 after adding exenatide (Byetta) to the current treatment in 28 diabetology departments in the Czech Republic - BIBYII study (observations lasting 24 months)]

BIBYII STUDY OBJECTIVE: To obtain experience with longterm (24 months) exenatide treatment (Byetta) in patients with diabetes mellitus type 2 from a common clinical practice of diabetology departments in the Czech Republic. TYPE OF OBSERVATION: Observational study conducted by a randomly selected group of outpatient medical practitioners from 28 diabetology departments in the Czech Republic. OBSERVED AND ASSESSED POPULATION: From the original population of 465 patients, who underwent a minimum of three months Byetta treatment, 169 patients (36.6%) remained during the second prolonged observation after 18 months, and 76 patients completed 24 months of uninterrupted Byetta treatment. The following basic information about the patients was collected: year of birth, sex, age when diabetes mellitus (DM) manifested, height, maximum weight before diabetes and when DM manifested. The study recorded the following values in three- month intervals: weight, waistline, glycated haemoglobin (HbA1c), and DM treatment. The population of the prolonged observation comprised 50.3% women and 49.7 % men, and the average age at the time of DM2 manifestation was 48.0 (20- 73 years).

RESULTS

At the beginning of Byetta treatment, the average maximum BMI in the subpopulation observed for 24 months was 38.44; after 3, 6, 9, 12 and 24 months the following levels were measured, respectively: 36.79, 36.22, 35.91, 35.57 and 35.58. The original HbA1c level of 7.44% at the beginning of Byetta treatment decreased after 3, 6, 9, 12 and 24 months to 6.33, 5.98, 5.83, 5.86 and 5.93%.

CONCLUSION

Adding Byetta to the currently applied treatment of obese patients with diabetes mellitus type 2 over a period of 24 months has led to an improvement in HbA1c level by 1.51%, and BMI level was reduced by 2.37 after two years of Byetta treatment.

[Changes in weight and diabetes compensation (HbA(1c)) in patients with diabetes mellitus type 2 after adding exenatide (Byetta) to the current treatment in 28 diabetology departments in the Czech Republic - BIBY-I study (observations lasting 3 to 12 months)]

BIBY STUDY OBJECTIVE: To obtain experience with exenatide treatment (Byetta) in patients with diabetes mellitus type 2 in a common clinical practice ofdiabetology departments. TYPE OF OBSERVATION: Observational study conducted by a randomly selected group of outpatient medical practitioners from 28 diabetology departments in the Czech Republic. OBSERVED AND ASSESSED POPULATION: 465 patients underwent at least three months of Byetta treatment; 347 persons (74.6% ofthe research population) stayed forthe extended observation of 6-12 months. Apart from the basic identification data (year of birth, sex, age when diabetes mellitus manifested, height, maximum patient weight before diabetes and when diabetes mellitus manifested), the following information was recorded in three-month intervals: weight, waistline, glycated haemoglobin (HbA(1c)), and diabetes mellitus treatment The population included 50.3% women and 49.7% men, and the average age at the time of diabetes manifestation was 48 (20-73 years). The period between the diabetes manifestation and the start of exenatide treatment was 8.3 years on average.

RESULTS

The average maximum BMI value before the detection of diabetes was 39.05 (+/- 6.73); at the time of the diabetes manifestation 37.88 (+/- 6.40); and at the start of Byetta treatment 39.01 (+/- 6.22). The BMI after three, six, and 12 months of treatment was as follows: 37.86 (+/- 6.12), 37.18 (+/- 6.0), and 36.60 (+/- 6.21); it decreased by > or = 0.5 in 83.3% patients who were under observation for 12 months. HbA(1c) value decreased in the first three months from 7.39% (+/- 1.57) to 6.41% (+/- 1.34), p < 0.0001. In the period of three-six months, the value decreased to 6.22% (+/- 1.34), and after 12 months, HbA(1c) was at 6.04 (+/- 1.20). An improvement in HbA(1c) value of 0.5-2.0% occurred after the first year in 49% of our research population. The waistline was measured on a regular basis in only 267 patients (58.9%). The average initial value of 120.7 cm was reduced within three months of the treatment to 118.3 cm, and within six and 12 months to 117.3 and 112.6 cm respectively.

CONCLUSION

Adding Byetta to the currently applied treatment of obese patients with diabetes mellitus type 2 led, in 66.8% of the population, to a statistically significant reduction in HbA(1c) levels in the first three-six months of the treatment; after 12 months of treatment, 25% of the population was still showing an improvement in HbA(1c) of > 2.0%. Of observed patients, 74.4% significantly reduced their BMI (by > 0.5) during the first three months; 39.6% of patients reduced their BMI in the period of three-six months.

The recognition and internalization of apoptotic cells and Gram negative bacteria share the BAI1-ELMO1 pathway in the gastrointestinal tract (49.4)

Clearance of apoptotic cells, debris and pathogens by phagocytes is essential role for the homeostasis of host responses. It has been shown previously that the BAI1-ELMO1-Dock180 pathway stimulates Rac1 activity which has a pivotal role in enabling phagocytosis. ELMO1 was first identified as a protein required for the phagocytosis of apoptotic cells bound by BAI1. Recently we found that BAI1 recognizes LPS on Gram-negative bacteria and helps in bacterial attachment. The objective of these studies was to determine if the BAI1-ELMO1 pathway contributes to the internalization of targets relevant to the digestive tract. Both BAI1 and ELMO1 were expressed by macrophages in the murine small intestine. Inhibition of BAI1 function by siRNA decreased the binding of cellular and microbial targets to macrophages from culture or freshly isolated from the gut. Inhibition of ELMO1 reduced internalization of both apoptotic epithelial cells and Salmonella in association with decreased Rac1 activity. This loss of ELMO1 function had no effect on binding suggesting these events are downstream of the surface interaction mediated by BAI1. Interestingly, inhibition of ELMO1/Rac function impaired the pro-inflammatory response to infection. These results suggest a novel role for the BAI1-ELMO1 pathway in Rac1 activation and the scavenging of apoptotic cells and bacteria by macrophages in the digestive tract.