Medical student experiences of equality, diversity, and inclusion: content analysis of student feedback using Bronfenbrenner's ecological systems theory

BACKGROUND

Issues relating to equality, diversity, and inclusion (EDI) significantly impact on medical student achievement and wellbeing. Interventions have been introduced at curricular and organisational levels, yet progress in addressing these issues remains limited. Timely evaluation is needed to assess effectiveness of interventions, and to explore issues and interactions in learning environments impacting on student experience. We introduced an anonymous question concerning students' experiences of EDI into routine online student feedback questionnaires, to scope the nature of ongoing issues and develop greater understanding of students' experiences in our programme environment. Ecological systems theory, which conceptualizes learning as a function of complex social interactions, determined by characteristics of individual learners and their environment, provides a framework for understanding.

METHODS

Free-text responses regarding experiences of EDI gathered over 20 months from all programme years (n = 760) were pooled for analysis, providing a holistic overview of experiences in the learning environment. A counting exercise identified broad categories reported by students. Content analysis of the qualitative dataset was undertaken. Bronfenbrenner's ecological systems theory was applied as a framework to demonstrate interdependencies between respondents' experiences and environments, and associated impacts.

RESULTS

Three hundred and seventy-six responses were received relating to wide-ranging EDI issues, most frequently gender or ethnicity. Responses mapped onto all areas of the ecological systems model, with frequent links between subsystems, indicating considerable complexity and interdependencies. Interpersonal interactions and associated impacts like exclusion were frequently discussed. Differential experiences of EDI-related issues in medical school compared to clinical settings were reported. Impacts of institutional leadership and wider societal norms were considered by respondents. Respondents discussed their need for awareness of EDI with reference to future professional practice.

CONCLUSIONS

Implementation of a regular free-text evaluation question allowed data-gathering across cohorts and throughout several stages of the curriculum, illuminating student experience. Connections established demonstrated intersectionality, and how environment and other factors interact, impacting on student experiences. Students experience EDI-related issues on multiple levels within the educational environment, with consequent impacts on learning. Any successful approach towards tackling issues and promoting equity of opportunity for all requires multi-level actions and widespread culture change. Students can offer fresh and distinct perspectives regarding change needed, to complement and diversify perspectives provided by staff and organisational leadership. Student voice should be enabled to shape change.

Effects of Resistance Training on Academic Outcomes in School-Aged Youth: A Systematic Review and Meta-Analysis

BACKGROUND

The primary aim of our systematic review and meta-analysis was to investigate the effect of resistance training on academic outcomes in school-aged youth.

METHODS

We conducted a systematic search of six electronic databases (CINAHL Complete, PsycINFO, SCOPUS, Ovid MEDLINE, SPORTDiscus and EMBASE) with no date restrictions. Studies were eligible if they: (a) included school-aged youth (5-18 years), and (b) examined the effect of resistance training on academic outcomes (i.e., cognitive function, academic achievement, and/or on-task behaviour in the classroom). Risk of bias was assessed using the appropriate Cochrane Risk of Bias Tools, funnel plots and Egger's regression asymmetry tests. A structural equation modelling approach was used to conduct the meta-analysis.

RESULTS

Fifty-three studies were included in our systematic review. Participation in resistance training (ten studies with 53 effect sizes) had a small positive effect on the overall cognitive, academic and on-task behaviours in school-aged youth (standardized mean difference (SMD) 0.19, 95% confidence interval (CI) 0.05-0.32). Resistance training was more effective (SMD 0.26, 95% CI 0.10-0.42) than concurrent training, i.e., the combination of resistance training and aerobic training (SMD 0.11, 95% CI - 0.05-0.28). An additional 43 studies (including 211 effect sizes) examined the association between muscular fitness and cognition or academic achievement, also yielding a positive relationship (SMD 0.13, 95% CI 0.10-0.16).

CONCLUSION

This review provides preliminary evidence that resistance training may improve cognitive function, academic performance, and on-task behaviours in school-aged youth.

PROSPERO REGISTRATION

CRD42020175695.

Twelve tips to foster healthcare student recognition and reporting of unprofessional behaviour or concerns

Medical trainees and students are required to report concerns where they identify concerning practice or behaviours. While leadership attributes and skills are increasingly expected curricular outcomes, students still struggle to report concerns due to a variety of factors. Changing societal awareness and expectations continue to shine light on poor professionalism and unethical behaviours whose reach extends to medical training and education and that need to be systematically reported and addressed. To prepare graduates for these challenges in professional practice and for exercising skills of reporting concerns, education and training environments must ensure that speaking up is ingrained in the organisational ethos. Supported by evidence from the literature and our experience of revising and enhancing approaches, this paper outlines tips for developing and embedding an infrastructure that facilitates robust concerns reporting and management. Further, we consider mechanisms that support students to develop tendencies and skills for reporting concerns.

E-cigarette use by people who smoke or have recently quit, New South Wales, 2016-2020

OBJECTIVE

To examine e-cigarette use by adults who smoke or have recently quit, and demographic characteristics associated with their use; to assess reasons for using e-cigarettes.

DESIGN

The Cancer Institute NSW Tobacco Tracking Survey (CITTS) is an ongoing, serial, cross-sectional telephone survey study (40 interviews each week). This report is based on interviews during 4 January 2016 - 31 December 2020.

SETTING, PARTICIPANTS

Randomly selected New South Wales adults who are current smokers (smoked cigarettes, pipes, or other tobacco products daily, weekly, or less often) or recent quitters (smoked tobacco products in the past twelve months but who no longer smoked).

MAIN OUTCOMES

E-cigarette use by age group; reasons for using e-cigarettes.

RESULTS

CITTS callers rang 1 494 233 randomly selected numbers; in 203 203 answered calls (13.6%), 11 125 people were eligible for the survey (5.5% of answered calls), of whom 10 004 completed the survey interview, including the question about whether they used e-cigarettes (89.9%). Overall e-cigarette use increased from 6.6% of respondents in 2016 to 13.0% in 2020 (adjusted odds ratio, 1.86; 95% confidence interval [CI], 1.47-2.36). The proportion of respondents aged 18-24 years who reported e-cigarette use increased from 18.4% (95% CI, 12.9-23.9%) in 2018 to 27.2% (95% CI, 20.5-33.9%) in 2020, a larger proportion than for any other age group. The leading reasons offered for e-cigarette use were "to help me quit smoking" (33%; 95% CI, 30-37%) and "to cut down on the number of cigarettes I smoke" (25%; 95% CI, 22-28%).

CONCLUSION

The increase between 2016 and 2020 in the proportions of young adults who smoke or have recently quit who use e-cigarettes undermines claims that these products are designed for older smokers who have struggled to quit using other methods.

Impact of Increased Patient-Clinician Virtual Visits During the COVID-19 Pandemic on Medical Student Enthusiasm for Future General Practice Careers

BACKGROUND

The COVID-19 pandemic restricted the availability of face-to-face primary care visits. This rapidly increased the proportion of primary care patient-clinician visits conducted virtually and asynchronously (remote consultations via video, telephone, and web-based text/email), altering the educational environment for medical students. Our study explored the impact of the increased proportion of primary care visits conducted virtually and asynchronously, on medical students' self-reported interest in pursuing a career in general (family) practice.

METHODS

We conducted a cross-sectional survey study of medical students at six universities within England and Wales to explore the impact of the increased proportion of primary care visits conducted virtually and asynchronously on medical students' interest in pursuing a career in general practice.

RESULTS

One hundred fifty-four medical students were recruited between December 2020 and May 2021; 79 (51%) of the participants reported being less interested in pursuing a career in general practice as a result of the increased proportion of virtual and asynchronous primary care visits during the COVID-19 pandemic. This increased to 104 (68%) of the participants reporting being less interested should primary care visits continue to be delivered virtually or asynchronously by default. Analysis of open-ended survey questions identified a poorer educational experience, concerns regarding the impact on patient care, an isolated working environment and technological challenges as key negative themes.

CONCLUSIONS

Sociable, supportive working and learning environments and offering equitable care are important motivators for the future workforce. There is a need to develop robust training and assessment in patient-clinician virtual visits and asynchronous communication and to integrate this into curricula.

Physical activity, burnout and quality of life in medical students: A systematic review

BACKGROUND

Medical students are at risk of burnout and reduced quality of life (QoL). The risk of burnout doubles from third to sixth year of medical school, and medical students have an 8%-11% lower QoL than nonmedical students. It is imperative to prevent this, as burnout and reduced QoL is independently associated with errors in practice. This systematic review aims to examine whether physical activity/exercise is associated with burnout and/or QoL in medical students.

METHODS

Articles were identified through database searches of Embase, Medline, PsycINFO, Scopus and Web of Science. Studies were included if both physical activity/exercise and burnout or QoL were measured and limited to those focussing on medical students. Risk of bias was assessed using accredited cohort and cross-sectional checklists. A narrative synthesis was conducted due to heterogeneity in the dataset.

FINDINGS

Eighteen studies were included, comprising 11,500 medical students across 13 countries. Physical activity was negatively associated with burnout and positively associated with QoL. Furthermore, the findings were suggestive of a dose-response effect of physical activity on both burnout and QoL; higher intensities and frequencies precipitated greater improvements in outcomes.

CONCLUSIONS

This multinational review demonstrates that physical activity is associated with reduced burnout and improved QoL in medical students. It also identifies a paucity of research into the optimal intensity, frequency, volume and mode of physical activity. Further research, building on this review, is likely to inform the long overdue development of evidence-based, well-being curricula. This could involve incorporating physical activity into medical education which may improve well-being and better prepare students for the demands of medical practice.

Joint associations of social health and movement behaviours with mortality and cardiovascular disease: an analysis of 497,544 UK biobank participants

Background

Poor physical activity and excessive sedentary behaviour are well-established risk factors for morbidity and mortality. In the presence of emerging social problems, including loneliness and social isolation, these risks may be even greater. We aimed to investigate the joint effects of social health and movement behaviours on mortality and cardiovascular disease (CVD).

Methods

497,544 UK Biobank participants were followed for an average of 11 years. Loneliness and social isolation were measured via self-report. Physical activity was categorised around current World Health Organisation (WHO) guidelines as low (< 600 metabolic equivalent of task [MET]-mins/week), moderate (600 < 1200) and high (≥ 1200). Sedentary behaviour was classified as low (≤ 3.5 h/day), moderate (3.5 ≤ 5) and high (> 5.5). We derived 24 social health–movement behaviour combinations, accordingly. Mortality and hospitalisations were ascertained to May 2020 for all-cause and CVD mortality, and non-fatal cardiovascular events.

Results

Social isolation amplified the risk of both all-cause and CVD death across all physical activity and sedentary levels (hazard ratio, 95% confidence interval [HR, 95% CIs] for all-cause mortality; 1.58 [1.49 to 1.68] for low active-isolated vs. 1.26 [1.22 to 1.30] for low active-not isolated). Loneliness was only found to amplify the risk of death from cardiovascular disease among the high active and low sedentary participants. Loneliness and social isolation did not add to the risk of non-fatal cardiovascular events across most activity levels.

Conclusion

The detrimental associations of poor physical activity and sedentary behaviour with mortality were consistently amplified by social isolation. Our study supports the need to target the socially isolated as a priority group in preventive public health strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01372-3.

O3-2 Evaluation of implementation and impact of a national mass media campaign to promote active lifestyles in Portugal: ‘Follow the Whistle: Physical Activity is Calling You'

Background

Portugal has one of the highest rates of physical inactivity in Europe. To raise the profile of physical activity (PA) among adults, the Portuguese National Physical Activity Promotion Program of the Directorate-General of Health developed and implemented a national mass media campaign in 2019 named ?Follow the Whistle?. The campaign was based on social marketing principles and behavior change theory, namely the COM-B model, and was developed through formative research. We aim to describe the implementation process and short-term impact evaluation data.

Methods

‘Follow the Whistle' was launched in June 2019 and continued for 4 weeks (TV, Radio, Online and Cinema, newspapers, outdoors). Pre (n = 878, 57%women) and post (n = 1319, 58%women) independent adult population samples were used to assess campaign impact. Participants were recruited through the mailing list of a Portuguese mutual insurance company, a network from across Portugal. The online questionnaire comprised socio-demographic factors, campaign awareness and recall, and psychosocial and behavioral measures linked to the four targets of the COM-B model, including items to assess perceived capability for physical activity(C), perceived opportunity for practice/ ease of integration of PA in daily living(O), motivation for PA practice(M) and behavior(B) assessed with IPAQ and the Activity Choice Index.

Results

Pre-and post-campaign samples were broadly demographically similar. Campaign recall increased significantly from 1% to 24% in prompted tagline recall (1/3 at post-campaign correctly recalled specific campaign images). All the targeted COM-B indicators changed in the expected direction, suggesting increases in perceived capability to engage in PA, perceived daily opportunities for being physically active, and in motivation (considering PA as fun, important, and compatible with other important things in life) (all p > 0.05). Results from PA behavior measures revealed increases only for vigorous activities (p > 0.001).

Conclusions

The GAPPA recommends the creation of active societies starting with best-practice community-wide communications campaigns. Although one focus of the ?Follow-the whistle? (i.e. promotion of active transport and incidental everyday forms of physical activity) was not entirely achieved (i.e. changes only in vigorous activities), the initial campaign objectives of increases in awareness, and influencing intermediate outcomes were achieved. Further campaign waves are planned for future years.

Barriers to initiating and maintaining participation in parkrun

Interventions that increase population physical activity are required to promote health and wellbeing. parkrun delivers community-based, 5 km events worldwide yet 43% who register never participate in a parkrun event. This research had two objectives; i) explore the demographics of people who register for parkrun in United Kingdom, Australia, Ireland, and don’t initiate or maintain participation ii) understand the barriers to participating in parkrun amongst these people. Mandatory data at parkrun registration provided demographic characteristics of parkrun registrants. A bespoke online survey distributed across the three countries captured the reasons for not participating or only participating once. Of 680,255 parkrun registrants between 2017 and 19, 293,542 (43%) did not participate in any parkrun events and 147,148 (22%) only participated in one parkrun event. Females, 16–34 years and physically inactive were more likely to not participate or not return to parkrun. Inconvenient start time was the most frequently reported barrier to participating, with females more likely than males to report the psychological barrier of feeling too unfit to participate. Co-creating strategies with and for people living with a chronic disease, women, young adults, and physically inactive people, could increase physical activity participation within parkrun.

Effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management for people with type 2 diabetes. A randomized controlled trial

OBJECTIVE

Determine the effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management behaviors for Australian adults with type 2 diabetes.

METHODS

Using intention to treat analysis and generalized estimating equations, this randomized controlled trial of 395 adults determined change in HbA1c at 3 and 6 months between the intervention and control group. Secondary outcomes included change in nutrition, physical activity, blood lipid profile, body mass index, quality of life, self-efficacy, medication taking and program acceptability.

RESULTS

No significant difference was observed between the intervention or control group for HbA1c at 3 months (P = 0.23) or 6 months (P = 0.22). Significant improvements were seen in consumption of vegetables at 3 months (P < 0.001) and 6 months (P = 0.04); fruit at 3 months (P = 0.046) and discretionary sweet foods at 3 months (P = 0.02). No other significant effects seen. The intervention demonstrated high rates of acceptability (94.0%) and minimal withdrawal (1.5%).

CONCLUSIONS

DTEXT was an acceptable text message intervention that improved some nutritional behaviors in people with type 2 diabetes, but did not significantly improve HbA1c or other outcomes. Further research is required to optimize DTEXT.

PRACTICE IMPLICATIONS

DTEXT provides an acceptable, feasible form of self-management support that may complement existing diabetes care.

Active Kids: evaluation protocol for a universal voucher program to increase children's participation in organised physical activity and sport

OBJECTIVE

Background: Regular participation in physical activity during childhood and adolescence is important for good health. There is strong evidence of the physical and psychosocial benefits associated with recreational physical activity in these age groups, specifically in the context of organised sport. Most children in New South Wales (NSW), Australia, do not meet the recommended guidelines for physical activity, with financial cost commonly cited as a barrier to the initiation and maintenance of sport. The Active Kids program is a major policy initiative introduced in 2018 that aimed to overcome this barrier by implementing a statewide sport voucher scheme, allowing all NSW school-enrolled children (1.2 million) initial access to a $100 annual contribution towards organised sport and physical activity, with concurrent evaluation over the initial 4-year phase of the program.

STUDY TYPE

This paper presents the protocol for evaluation of the Active Kids program, including an assessment of program impact on children's organised sport participation and recreational physical activity level, and analysis of the correlates of participation at individual, state and national levels.

METHODS

A quasi-experimental and mixed-method evaluation will be used to examine the patterns of organised sport and recreational physical activity behaviour and the correlates associated with sports participation, voucher uptake and program reach. Sociodemographic information will be collected for each child who registers for a voucher. The effects of this program on children's health-enhancing physical activity, engagement with the sport sector, self-efficacy and social influences on participation will be monitored through a cohort study. Acceptability, engagement and experience of the voucher program will be assessed from both user and provider perspectives. Additionally, effects of the program on families' annual sport-related expenditure will be assessed.

RESULTS AND CONCLUSION

It is anticipated that the implementation of the NSW Government's Active Kids program will increase participation in recreational physical activity among NSW children. The results of this evaluation will contribute to the evidence base and policy directions for sport voucher programs in Australia and internationally.

Qualitative exploration of medical student experiences during the Covid-19 pandemic: implications for medical education

BACKGROUND

During the Covid-19 pandemic medical students were offered paid roles as medical student healthcare assistants. Anecdotal reports suggested that students found this experience rich for learning. Previous studies have explored alternative models of student service, however this defined medical student support role is novel.

METHODS

Individual semi-structured interviews were recorded with 20 medical students at a UK medical school exploring their experiences of placement learning and experiences of working as healthcare assistants. Responses were analysed qualitatively using a framework approach. The framework was developed into a model describing key findings and their relationships.

RESULTS

Interviews yielded data that broadly covered aspects of (1) Medical students' experiences of clinical placement learning (2) Medical students' experiences of working as medical student healthcare assistants (3) Learning resulting from working as a healthcare assistant (4) Hierarchies and professional barriers in the clinical environment (5) Influences on professional identity. Participants described barriers and facilitators of clinical learning and how assuming a healthcare assistant role impacted on learning and socialisation within the multidisciplinary team. Students became increasingly socialised within the healthcare team, contributing directly to patient care; the resulting social capital opened new opportunities for learning, team working and enhanced students' interprofessional identity. Students described the impact of these experiences on their aspirations for their future practice.

CONCLUSIONS

Changes to work patterns in healthcare and delivery models of medical education have eroded opportunities for students to contribute to healthcare delivery and be embedded within a team. This is impacting negatively on student learning and socialisation and we suggest that medical curricula have much to learn from nursing and allied health professional training. Longitudinal embedment with a multidisciplinary team, where students have a defined role and work directly with patients may not only add value to clinical service, but also overcome current barriers to effective placement learning and interprofessional identity formation for medical students.

Comparisons of leisure-time physical activity participation by adults with and without a disability: results of an Australian cross-sectional national survey

Objectives

The objective of this study was to describe and compare the amount and type of leisure-time physical activity, and motivations and barriers to participation among adults with and without a disability.

Methods

Analysis of deidentified data from an Australian cross-sectional national telephone-based survey (October 2015 to June 2018) of sport and physical recreation participation over the previous 12 months, and barriers and motivations to participation. Descriptive statistics (incorporating weighted proportions), χ² tests and regression analyses were conducted to describe aspects of participation and compare those with and without self-reported disability.

Results

Of the 54 343 adults surveyed, 15% reported a disability. Adults with a disability were half as likely to meet physical activity guidelines through sport and/or physical recreation than adults without a disability (OR 0.53, 95% CI 0.51 to 0.57). A greater proportion of adults with a disability participated in physical recreation only (40% vs 31%; χ²=187; p<0.001), whereas a greater proportion of adults without a disability participated in sport only (20% vs 12%; χ²=188; p<0.001). Adults with a disability were more motivated than adults without a disability to try a new activity for physical health or fitness benefits (55% vs 46%; χ²=36; p<0.001). The most reported barrier to participation for adults with a disability not currently participating in sport and/or physical recreation was poor health or injury (62%), whereas for adults without a disability it was lack of time/too many other commitments (43%).

Conclusion

Adults with a disability are less physically active and report different physical activity profiles and barriers to being active than adults without a disability. Urgent action is required to address this discrepancy.

"Follow the Whistle: Physical Activity Is Calling You": Evaluation of Implementation and Impact of a Portuguese Nationwide Mass Media Campaign to Promote Physical Activity

To raise perceived capability (C), opportunity (O) and motivation (M) for physical activity (PA) behaviour (B) among adults, the Portuguese Directorate-General of Health developed a mass media campaign named "Follow the Whistle", based on behaviour change theory and social marketing principles. Comprehensive formative and process evaluation suggests this media-led campaign used best-practice principles. The campaign adopted a population-wide approach, had clear behavioural goals, and clear multi-strategy implementation. We assessed campaign awareness and initial impact using pre (n = 878, 57% women) and post-campaign (n = 1319, 58% women) independent adult population samples via an online questionnaire, comprising socio-demographic factors, campaign awareness and recall, and psychosocial and behavioural measures linked to the COM-B model. PA was assessed with IPAQ and the Activity Choice Index. The post-campaign recall was typical of levels following national campaigns (24%). Post-campaign measures were higher for key theory-based targets (all p < 0.05), namely self-efficacy, perceived opportunities to be more active and intrinsic motivation. The impact on social norms and self-efficacy was moderated by campaign awareness. Concerning PA, effects were found for vigorous activity (p < 0.01), but not for incidental activity. Overall the campaign impacted key theory-based intermediate outcomes, but did not influence incidental activity, which highlights the need for sustained and repeated campaign efforts.

GP retention in the UK: a worsening crisis. Findings from a cross-sectional survey

OBJECTIVE

To investigate how recent national policy-led workforce interventions are affecting intentions to remain working as a general practitioner (GP).

DESIGN

Online questionnaire survey with qualitative and quantitative questions.

SETTING AND PARTICIPANTS

All GPs (1697) in Wessex region, an area in England for which previous GP career intention data from 2014 is available.

RESULTS

929 (54.7%) participated. 59.4% reported that morale had reduced over the past two years, and 48.5% said they had brought forward their plans to leave general practice. Intention to leave/retire in the next 2 years increased from 13% in the 2014 survey to 18% in October/November 2017 (p=0.02), while intention to continue working for at least the next 5 years dropped from 63.9% to 48.5% (p<0.0001). Age, length of service and lower job satisfaction were associated with intention to leave. Work intensity and amount were the most common reasons given for intention to leave sooner than previously planned; 51.0% participants reported working more hours than 2 years previously, predominantly due to increased workload.GPs suggested increased funding, more GPs, better education of the public and expanding non-clinical and support staff as interventions to improve GP retention.National initiatives that aligned with these priorities, such as funding to expand practice nursing were viewed positively, but low numbers of GPs had seen evidence of their roll-out. Conversely, national initiatives that did not align, such as video consulting, were viewed negatively.

CONCLUSION

While recent initiatives may be having an impact on targeted areas, most GPs are experiencing little effect. This may be contributing to further lowering of morale and bringing forward intentions to leave. More urgent action appears to be needed to stem the growing workforce crisis.

Language matters. Addressing the use of language in the care of people with diabetes: position statement of the English Advisory Group

The language used by healthcare professionals can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it day-to-day. At its best, good use of language, both verbal and written, can lower anxiety, build confidence, educate and help to improve self-care. Conversely, poor communication can be stigmatizing, hurtful and undermining of self-care and can have a detrimental effect on clinical outcomes. The language used in the care of those with diabetes has the power to reinforce negative stereotypes, but it also has the power to promote positive ones. The use of language is controversial and has many perspectives. The development of this position statement aimed to take account of these as well as the current evidence base. A working group, representing people with diabetes and key organizations with an interest in the care of people with diabetes, was established to review the use of language. The work of this group has culminated in this position statement for England. It follows the contribution of Australia and the USA to this important international debate. The group has set out practical examples of language that will encourage positive interactions with those living with diabetes and subsequently promote positive outcomes. These examples are based on a review of the evidence and are supported by a simple set of principles.

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.

The preclinical toxicology of salmeterol hydroxynaphthoate

An extensive toxicology programme on salmeterol hydroxynaphthoate (SereventTM), a marketed long-acting β2-adrenoceptor agonist, has been carried out. The studies evaluated both the local (respiratory tract) and systemic tolerance to single and repeated dosing, effects on all stages of reproduction, as well as the genotoxic and oncogenic potential. High acute doses were well tolerated and caused no specific target organ toxicity. In repeat dose studies, animals tolerated salmeterol very well both locally and systemically. No significant effects on the respiratory tract of dogs were seen and only minor laryngeal changes, typical of those occurring with many inhaled medicines, were noted in rats. The high systemic concentrations achieved resulted in a number of changes that are considered to be the result of excessive and prolonged β 2-adrenoceptor stimulation. These included tachycardia, skeletal muscle hypertrophy and minor haematological and blood biochemical changes in general toxicity studies, foetal effects in rabbit organogenesis studies and increased incidences of smooth muscle tumours of the mesovarium in the rat and of the uterus in the mouse oncogenicity studies. Salmeterol showed no evidence of any genotoxic potential. Results of the extensive toxicology programme provide good assurance of the safety for the inhaled use of salmeterol in patients; this has ben confirmed by many years of clinical experience during its development and marketing.