'I sound different, I look different, I am different': Protecting and promoting the sense of authenticity of ethnically minoritised medical students

BACKGROUND

Being authentic can improve students' well-being and enhance the medical student-patient communication and patient safety. However, the underrepresentation of ethnically minoritised students in medical education can result in identity suppression, interfering with students' ability to succeed academically and professionally.

METHODS

We conducted interviews with 20 ethnically minoritised medical students, which were analysed thematically, to explore the following: What facilitates and prevents students from being their authentic self during medical school? What learning and teaching strategies can enable students to be or become their authentic self?

FINDINGS

Experiences of discrimination, microaggressions and/or racism were the main barriers to authenticity, leading to fear of being discriminated again if students expressed their true self. Lack of diversity, cultural awareness and staff representation were also fundamental barriers. Being authentic was often perceived as contradictory to being professional and a risk that could damage students' reputation. However, when students could express their true self, they felt happier, safer and developed a stronger sense of belonging.

DISCUSSION

To enhance authenticity, students need to see better staff representation, role models they can relate and aspire to, such as Black professors. Equity/Diversity/Inclusion/Belonging (EDIB) training needs to become embedded throughout the curriculum and be delivered by facilitators with lived experiences. Other strategies to promote students' authenticity included mentoring, better signposting to complaints procedure and well-being resources and implementation of 'zero tolerance' policies. To our knowledge, this is one of the first studies on the concept of authenticity in medical education and the first study focusing on ethnically minoritised students.

Constraints and affordances for UK doctors-in-training to exercise agency: A dialogical analysis

INTRODUCTION

The goal of medical education is to develop clinicians who have sufficient agency (capacity to act) to practise effectively in clinical workplaces and to learn from work throughout their careers. Little research has focused on experiences of organisational structures and the role of these in constraining or affording agency. The aim of this study was to identify priorities for organisational change, by identifying and analysing key moments of agency described by doctors-in-training.

METHODS

This was a secondary qualitative analysis of data from a large national mixed methods research programme, which examined the work and wellbeing of UK doctors-in-training. Using a dialogical approach, we identified 56 key moments of agency within the transcripts of 22 semi-structured interviews with doctors based across the UK in their first year after graduation. By analysing action within the key moments from a sociocultural theoretical perspective, we identified tangible changes that healthcare organisations can make to afford agency.

RESULTS

When talking about team working, participants gave specific descriptions of agency (or lack thereof) and used adversarial metaphors, but when talking about the wider healthcare system, their dialogue was disengaged and they appeared resigned to having no agency to shape the agenda. Organisational changes that could afford greater agency to doctors-in-training were improving induction, smoothing peaks and troughs of responsibility and providing a means of timely feedback on patient care.

CONCLUSIONS

Our findings identified some organisational changes needed for doctors-in-training to practise effectively and learn from work. The findings also highlight a need to improve workplace-based team dynamics and empower trainees to influence policy. By targeting change, healthcare organisations can better support doctors-in-training, which will ultimately benefit patients.

Exploring recent patterns of migration of doctors to the United Kingdom: a mixed-methods study

INTRODUCTION

A shortage of doctors is currently one of the biggest challenges faced by the healthcare workforce in the United Kingdom (UK). While plans are in place to increase the number of medical school places, in the short-term this gap will need to continue to be filled by the international recruitment of doctors. The aim of this study is to identify key factors that explain the patterns of migration of doctors to the UK, in order to aid the development of policies to recruit and retain a sustainable workforce.

METHODS

We analysed General Medical Council (GMC) secondary data on the patterns of migration of internationally trained doctors (2009-2019). Qualitative interviews were conducted with 17 stakeholders by videoconferencing which were audio-recorded, transcribed and thematically analysed using NVivo.

RESULTS

In 2019, 34.5% of UK doctors were trained internationally mainly in India, Pakistan, Italy, Nigeria, Greece, Romania and Egypt. Most new registrations by internationally trained doctors from 2009-2019 did not have a specialty at the time of initial registration (96.2% in 2019). Only a relatively small number of these doctors go on to gain specialist or GP registration (11.6% within 5 years and 27.2% within 10 years of registration). The stakeholder interviews highlighted training opportunities and career progression as the main drivers of migration. The barriers internationally trained doctors face regarding specialty training included differences between UK and destination health systems, systematic bias, bureaucracy and selection processes not being accessible.

CONCLUSION

This study makes a contribution to the literature by identifying recent patterns in the migration of doctors to the UK. The UK's dependence on internationally trained doctors has important global implications as source countries are losing skilled health workers which is undermining their health systems. In keeping with the WHO Global Code on the International Recruitment of Healthcare Personnel, policymakers need to consider how to reduce the UK's reliance on internationally trained doctors, particularly from countries on the safeguard list whilst continuing the drive to increase medical school places. Additional support is required for internationally trained doctors, to ensure that they get on the training programmes they seek, enabling their career progression.

How is transition to medical practice shaped by a novel transitional role? A mixed-methods study

OBJECTIVES

This study considered a novel 'interim' transitional role for new doctors (termed 'FiY1', interim Foundation Year 1), bridging medical school and Foundation Programme (FP). Research questions considered effects on doctors' well-being and perceived preparedness, and influences on their experience of transition. While FiY1 was introduced in response to the COVID-19 pandemic, findings have wider and ongoing relevance.

DESIGN

A sequential mixed-methods study involved two questionnaire phases, followed by semi-structured interviews. In phase 1, questionnaires were distributed to doctors in FiY1 posts, and in phase 2, to all new FP doctors, including those who had not undertaken FiY1.

SETTING AND PARTICIPANTS

Participants were newly qualified doctors from UK medical schools, working in UK hospitals in 2020. 77% (n=668) of all participants across all phases had undertaken FiY1 before starting FP in August. The remainder started FP in August with varying experience beforehand.

OUTCOME MEASURES

Questionnaires measured preparedness for practice, stress, anxiety, depression, burnout, identity, and tolerance of ambiguity. Interviews explored participants' experiences in more depth.

RESULTS

Analysis of questionnaires (phase 1 n=441 FiY1s, phase 2 n=477 FiY1s, 196 non-FiY1s) indicated that FiY1s felt more prepared than non-FiY1 colleagues for starting FP in August (β=2.71, 95% CI=2.21 to 3.22, p<0.0001), which persisted to October (β=1.85, CI=1.28 to 2.41, p<0.0001). Likelihood of feeling prepared increased with FiY1 duration (OR=1.02, CI=1.00 to 1.03, p=0.0097). Despite challenges to well-being during FiY1, no later detriment was apparent. Thematic analysis of interview data (n=22) identified different ways, structural and interpersonal, in which the FiY1 role enhanced doctors' emerging independence supported by systems and colleagues, providing 'supported autonomy'.

CONCLUSIONS

An explicitly transitional role can benefit doctors as they move from medical school to independent practice. We suggest that the features of supported autonomy are those of institutionalised liminality-a structured role 'betwixt and between' education and practice-and this lens may provide a guide to optimising the design of such posts.

A national qualitative investigation of the impact of service change on doctors' training during Covid-19

BACKGROUND

The Covid-19 crisis sparked service reconfigurations in healthcare systems worldwide. With postgraduate medical education sitting within these systems, service reconfigurations substantially impact trainees and their training environment. This study aims to provide an in-depth qualitative understanding of the impact of service reconfiguration on doctors' training during the pandemic, identifying opportunities for the future as well as factors that pose risks to education and training and how these might be mitigated.

METHODS

Qualitative parallel multi-centre case studies examined three Trusts/Health Boards in two countries in the United Kingdom. Data were collected from online focus groups and interviews with trainees and supervisors using semi-structured interview guides (September to December 2020). A socio-cultural model of workplace learning, the expansive-restrictive continuum, informed data gathering, analysis of focus groups and coding.

RESULTS

Sixty-six doctors participated, representing 25 specialties/subspecialties. Thirty-four participants were male, 26 were supervisors, 17 were specialty trainees and 23 were foundation doctors. Four themes described the impact of pandemic-related service reconfigurations on training: (1) Development of skills and job design, (2) Supervision and assessments, (3) Teamwork and communication, and (4) Workload and wellbeing. Service changes were found to both facilitate and hinder education and training, varying across sites, specialties, and trainees' grades. Trainees' jobs were redesigned extensively, and many trainees were redeployed to specialties requiring extra workforce during the pandemic.

CONCLUSIONS

The rapid and unplanned service reconfigurations during the pandemic caused unique challenges and opportunities to doctors' training. This impaired trainees' development in their specialty of interest, but also presented new opportunities such as cross-boundary working and networking.

Drivers and barriers of international migration of doctors to and from the United Kingdom: a scoping review

BACKGROUND

Many high-income countries are heavily dependent on internationally trained doctors to staff their healthcare workforce. Over one-third of doctors practising in the UK received their primary medical qualification abroad. Simultaneously, an average of around 2.1% of doctors leave the UK medical workforce annually to go overseas. The aim of this study was to identify the drivers and barriers of international migration of doctors to and from the UK.

METHODS

A scoping review was conducted. We searched EMBASE, MEDLINE, CINAHL, ERIC and BEI in January 2020 (updated October 2021). Grey literature and citation searching were also carried out. Empirical studies reporting on the drivers and barriers to the international migration of doctors to and from the UK published in the English language from 2009 to present were included. The drivers and barriers were coded in NVivo 12 building on an existing framework.

RESULTS

40 studies were included. 62% were quantitative, 18% were qualitative, 15% were mixed-methods and 5% were literature reviews. Migration into and out of the UK is determined by a variety of macro- (global and national factors), meso- (profession led factors) and micro-level (personal factors). Interestingly, many of the key drivers of migration to the UK were also factors driving migration from the UK, including: poor working conditions, employment opportunities, better training and development opportunities, better quality of life, desire for a life change and financial reasons. The barriers included stricter immigration policies, the registration process and short-term job contracts.

CONCLUSIONS

Our research contributes to the literature by providing a comprehensive up-to-date review of the drivers and barriers of migration to and from the UK. The decision for a doctor to migrate is multi-layered and is a complex balance between push/pull at macro-/meso-/micro-levels. To sustain the UK's supply of overseas doctors, it is vital that migration policies take account of the drivers of migration particularly working conditions and active recruitment while addressing any potential barriers. Immigration policies to address the impact of Brexit and the COVID-19 pandemic on the migration of doctors to and from the UK will be particularly important in the immediate future. Trial registration PROSPERO CRD42020165748.

Can achievement at medical admission tests predict future performance in postgraduate clinical assessments? A UK-based national cohort study

OBJECTIVE

To determine whether scores on two undergraduate admissions tests (BioMedical Admissions Test (BMAT) and University Clinical Aptitude Test (UCAT)) predict performance on the postgraduate Membership of the Royal Colleges of Physicians (MRCP) examination, including the clinical examination Practical Assessment of Clinical Examination Skills (PACES).

DESIGN

National cohort study.

SETTING

Doctors who graduated medical school between 2006 and 2018.

PARTICIPANTS

3045 doctors who had sat BMAT, UCAT and the MRCP.

PRIMARY OUTCOME MEASURES

Passing each section of the MRCP at the first attempt, including the clinical assessment PACES.

RESULTS

Several BMAT and UCAT subtest scores displayed incremental predictive validity for performance on the first two (written) parts of the MRCP. Only aptitude and skills on BMAT (OR 1.34, 1.08 to 1.67, p=0.01) and verbal reasoning on UCAT (OR 1.34, 1.04 to 1.71, p=0.02) incrementally predicted passing PACES at the first attempt.

CONCLUSIONS

Our results imply that the abilities assessed by aptitude and skills and verbal reasoning may be the most important cognitive attributes, of those routinely assessed at selection, for predicting future clinical performance. Selectors may wish to consider placing particular weight on scales assessing these attributes if they wish to select applicants likely to become more competent clinicians. These results are potentially relevant in an international context too, since many admission tests used globally, such as the Medical College Admission Test, assess similar abilities.

Cross-sectional exploration of the impact of the Dr Bawa-Garba case on doctors' professional behaviours and attitudes towards the regulator

OBJECTIVE

This paper examines the impact on doctors' attitudes towards the General Medical Council (GMC) and on professional behaviours (reflective practice and raising concerns) following the Dr Bawa-Garba case.

DESIGN

A cross-sectional survey designed using the theoretical lens of the theory of planned behaviour (TPB) was administered from September 2017 to February 2019. By chance, this coincided with critical events in the Dr Bawa-Garba case.

SETTING

Primary and secondary care settings across a broad geographical spread in England.

PARTICIPANTS

474 doctors.

OUTCOME MEASURES

Attitudes towards the GMC and two professional behaviours in TPB dimensions.

RESULTS

Attitudes towards the GMC became more negative during the period that the Medical Practitioners Tribunal Service and GMC suspended and subsequently erased Dr Bawa-Garba from the medical register. Specifically, confidence that doctors are well regulated by the GMC and that the GMC's disciplinary procedures produce fair outcomes was rated more negatively. After this period, overall attitudes start to recover and soon returned close to baseline; however, confidence in how the GMC regulates doctors and their disciplinary procedures improved but still remained below baseline. There was no change in doctors' attitudes or intention to reflect or raise concerns.

CONCLUSIONS

The lack of change in doctors' attitudes towards the GMC's guidance, the approachability of the regulator, defensive practice and professional behaviours as a response to the Dr Bawa-Garba case demonstrates the resilient and indelible nature of medical professionalism. At the time, professional bodies reported that repairing doctors' trust and confidence would take time and a significant effort to restore. However, this study suggests that attitudes are more fluid. Despite the high-profile nature of this case and concerns articulated by medical bodies regarding its impact on trust, the actual decline in doctors' overall attitudes towards the GMC was relatively short lived and had no measurable impact on professionalism.

Synthetic auxotrophy remains stable after continuous evolution and in coculture with mammalian cells

Understanding the evolutionary stability and possible context dependence of biological containment techniques is critical as engineered microbes are increasingly under consideration for applications beyond biomanufacturing. While synthetic auxotrophy previously prevented Escherichia coli from exhibiting detectable escape from batch cultures, its long-term effectiveness is unknown. Here, we report automated continuous evolution of a synthetic auxotroph while supplying a decreasing concentration of essential biphenylalanine (BipA). After 100 days of evolution, triplicate populations exhibit no observable escape and exhibit normal growth rates at 10-fold lower BipA concentration than the ancestral synthetic auxotroph. Allelic reconstruction reveals the contribution of three genes to increased fitness at low BipA concentrations. Based on its evolutionary stability, we introduce the progenitor strain directly to mammalian cell culture and observe containment of bacteria without detrimental effects on HEK293T cells. Overall, our findings reveal that synthetic auxotrophy is effective on time scales and in contexts that enable diverse applications.

Teaching medical professionalism: a qualitative exploration of persuasive communication as an educational strategy

BACKGROUND

Across the world, local standards provide doctors with a backbone of professional attitudes that must be embodied across their practice. However, educational approaches to develop attitudes are undermined by the lack of a theoretical framework. Our research explored the ways in which the General Medical Council's (GMC) programme of preventative educational workshops (the Duties of a Doctor programme) attempted to influence doctors' professional attitudes and examined how persuasive communication theory can advance understandings of professionalism education.

METHODS

This qualitative study comprised 15 ethnographic observations of the GMC's programme of preventative educational workshops at seven locations across England, as well as qualitative interviews with 55 postgraduate doctors ranging in experience from junior trainees to senior consultants. The sample was purposefully chosen to include various geographic locations, different programme facilitators and doctors, who varied by seniority. Data collection occurred between March to December 2017. Thematic analysis was undertaken inductively, with meaning flowing from the data, and deductively, guided by persuasive communication theory.

RESULTS

The source (educator); the message (content); and the audience (participants) were revealed as key influences on the persuasiveness of the intervention. Educators established a high degree of credibility amongst doctors and worked to build rapport. Their message was persuasive, in that it drew on rational and emotional communicative techniques and made use of both statistical and narrative evidence. Importantly, the workshops were interactive, which allowed doctors to engage with the message and thus increased its persuasiveness.

CONCLUSIONS

This study extends the literature by providing a theoretically-informed understanding of an educational intervention aimed at promoting professionalism, examining it through the lens of persuasive communication. Within the context of interactive programmes that allow doctors to discuss real life examples of professional dilemmas, educators can impact on doctors' professional attitudes by drawing on persuasive communication techniques to enhance their credibility to demonstrate expertise, by building rapport and by making use of rational and emotional appeals.

A theory-based study of doctors' intentions to engage in professional behaviours

BACKGROUND

The Theory of Planned Behaviour (TPB) has been proposed as an appropriate model for creating a theory-driven approach to teaching medical professionalism. However, there is a lack of empirical evidence into its efficacy. This study explores if the TPB can assess UK medical doctors' professional behaviours and explores if there are differences in the TPB's efficacy depending on doctors' primary medical qualification (UK or outside).

METHODS

Three hundred fourteen doctors in England at 21 NHS Trusts completed a questionnaire about reflective practice, using the General Medical Council's confidentiality guidance, and raising a patient safety concern. The majority of participants were male (52%), white (68%), consultants (62%), and UK medical graduates (UKGs) (71%).

RESULTS

The TPB variables of attitudes, subjective norms, and perceived behavioural control were predictive of intention to engage in raising concerns (R² = 35%), reflection (R² = 52%), and use of confidentiality guidance (R² = 45%). Perceived behavioural control was the strongest predictor of intentions to raise a concern (β = 0.44), while attitude was the strongest predictor of intentions to engage in reflective practice (β = 0.61) and using confidentiality guidance (β = 0.38). The TBP constructs predicted intention for raising concerns and reflecting for both UKGs and non-UKGs (Fs ≥ 2.3; ps ≤ .023, βs ≥ 0.12). However, only perceived behaviour control was predictive of intentions to use guidance for both UKGs and non-UKGs (β = 0.24) while attitudes and norms were just predictive for UKGs (βs ≥ 0.26).

CONCLUSIONS

This study demonstrates the efficacy of the TPB for three professional behaviours. The implications for medical educators are to use the variables of the TPB (attitudes, subjective norms, and perceived behavioural control) in the education of professionalism, and for medical education researchers to further our understanding by employing the TPB in more empirical studies of non-clinical behaviours.

Realist evaluation of UK medical education quality assurance

OBJECTIVES

The aim of the study was to explore what components of the General Medical Council's (GMC) Quality Assurance Framework work, for whom, in what circumstances and how?

SETTING

UK undergraduate and postgraduate medical education and training.

PARTICIPANTS

We conducted interviews with a stratified sample of 36 individuals. This included those who had direct experiences, as well as those with external insights, representing local, national and international organisations within and outside medicine.

INTERVENTION

The GMC quality assure education to protect patient and public safety utilising complex intervention components including meeting standards, institutional visits and monitoring performance. However, the context in which these are implemented matters. We undertook an innovative realist evaluation to test an initial programme theory. Data were analysed using framework analysis.

RESULTS

Across components of the intervention, we identified key mechanisms, including transparent reporting to promote quality improvement; dialogical feedback; partnership working facilitating interactions between regulators and providers, and role clarity in conducting proportionate interventions appropriate to risk. The GMC's framework was commended for being comprehensive and enabling a broad understanding of an organisation's performance. Unintended consequences included confusion over roles and boundaries in different contexts which often undermined effectiveness.

CONCLUSIONS

This realist evaluation substantiates the literature and reveals deeper understandings about quality assuring medical education. While standardised approaches are implemented, interventions need to be contextually proportionate. Routine communication is beneficial to verify data, share concerns and check risk; however, ongoing partnership working can foster assurance. The study provides a modified programme theory to explicate how education providers and regulators can work more effectively together to uphold education quality, and ultimately protect public safety. The findings have influenced the GMC's approach to quality assurance which impacts on all medical students and doctors in training.

What are junior doctors for? The work of Foundation doctors in the UK: a mixed methods study

OBJECTIVES

To examine what activities constitute the work of Foundation doctors and understand the factors that determine how that work is constructed.

DESIGN

Cross-sectional mixed methods study. Questionnaire survey of the frequency with which activities specified in curricular documents are performed. Semistructured interviews and focus groups.

SETTING

Postgraduate medical training in the UK.

PARTICIPANTS

Doctors in their first 2 years of postgraduate practice (Foundation Programme). Staff who work with Foundation doctors-supervisors, nurses and employers (clinical; non-clinical).

RESULTS

Survey data from 3697 Foundation doctors identified curricular activities (41/103, 42%) that are carried out routinely (performed at least once or twice per week by >75% of respondents). However, another 30 activities (29%) were carried out rarely (at least once or twice per week by <25% respondents), largely because they are routinely part of nurses', and not doctors', work. Junior doctors indicated their work constituted three roles: 'support' of ward and team, 'independent practitioner' and 'learner'. The support function dominated work, but conflicted with stereotyped expectations of what 'being a doctor' would be. It was, however, valued by the other staff groups. The learner role was felt to be incidental to practice, but was couched in a limited definition of learning that related to new skills, rather than consolidation and practice. Activities and perceived role were shaped by the organisational context, medical hierarchies and through relationships with nurses, which could change unpredictably and cause tension. Training progression did not affect what activities were done, but supported greater autonomy in how they were carried out.

CONCLUSIONS

New doctors must be fit for multiple roles. Strategies for transition should manage graduates' expectations of real-world work, and encourage teams and organisations to better accommodate graduates. These strategies may help ensure that new doctors can adapt to the variable demands of the evolving multiprofessional workforce.

New graduate doctors' preparedness for practice: a multistakeholder, multicentre narrative study

OBJECTIVE

While previous studies have begun to explore newly graduated junior doctors' preparedness for practice, findings are largely based on simplistic survey data or perceptions of newly graduated junior doctors and their clinical supervisors alone. This study explores, in a deeper manner, multiple stakeholders' conceptualisations of what it means to be prepared for practice and their perceptions about newly graduated junior doctors' preparedness (or unpreparedness) using innovative qualitative methods.

DESIGN

A multistakeholder, multicentre qualitative study including narrative interviews and longitudinal audio diaries.

SETTING

Four UK settings: England, Northern Ireland, Scotland and Wales.

PARTICIPANTS

Eight stakeholder groups comprising n=185 participants engaged in 101 narrative interviews (27 group and 84 individual). Twenty-six junior doctors in their first year postgraduation also provided audio diaries over a 3-month period.

RESULTS

We identified 2186 narratives across all participants (506 classified as 'prepared', 663 as 'unprepared', 951 as 'general'). Seven themes were identified; this paper focuses on two themes pertinent to our research questions: (1) explicit conceptualisations of preparedness for practice; and (2) newly graduated junior doctors' preparedness for the General Medical Council's (GMC) outcomes for graduates. Stakeholders' conceptualisations of preparedness for practice included short-term (hitting the ground running) and long-term preparedness, alongside being prepared for practical and emotional aspects. Stakeholders' perceptions of medical graduates' preparedness for practice varied across different GMC outcomes for graduates (eg, Doctor as Scholar and Scientist, as Practitioner, as Professional) and across stakeholders (eg, newly graduated doctors sometimes perceived themselves as prepared but others did not).

CONCLUSION

Our narrative findings highlight the complexities and nuances surrounding new medical graduates' preparedness for practice. We encourage stakeholders to develop a shared understanding (and realistic expectations) of new medical graduates' preparedness. We invite medical school leaders to increase the proportion of time that medical students spend participating meaningfully in multiprofessional teams during workplace learning.

The impact of patient feedback on the medical performance of qualified doctors: a systematic review

BACKGROUND

Patient feedback is considered integral to quality improvement and professional development. However, while popular across the educational continuum, evidence to support its efficacy in facilitating positive behaviour change in a postgraduate setting remains unclear. This review therefore aims to explore the evidence that supports, or refutes, the impact of patient feedback on the medical performance of qualified doctors.

METHODS

Electronic databases PubMed, EMBASE, Medline and PsycINFO were systematically searched for studies assessing the impact of patient feedback on medical performance published in the English language between 2006-2016. Impact was defined as a measured change in behaviour using Barr's (2000) adaptation of Kirkpatrick's four level evaluation model. Papers were quality appraised, thematically analysed and synthesised using a narrative approach.

RESULTS

From 1,269 initial studies, 20 articles were included (qualitative (n=8); observational (n=6); systematic review (n=3); mixed methodology (n=1); randomised control trial (n=1); and longitudinal (n=1) design). One article identified change at an organisational level (Kirkpatrick level 4); six reported a measured change in behaviour (Kirkpatrick level 3b); 12 identified self-reported change or intention to change (Kirkpatrick level 3a), and one identified knowledge or skill acquisition (Kirkpatrick level 2). No study identified a change at the highest level, an improvement in the health and wellbeing of patients. The main factors found to influence the impact of patient feedback were: specificity; perceived credibility; congruence with physician self-perceptions and performance expectations; presence of facilitation and reflection; and inclusion of narrative comments. The quality of feedback facilitation and local professional cultures also appeared integral to positive behaviour change.

CONCLUSION

Patient feedback can have an impact on medical performance. However, actionable change is influenced by several contextual factors and cannot simply be guaranteed. Patient feedback is likely to be more influential if it is specific, collected through credible methods and contains narrative information. Data obtained should be fed back in a way that facilitates reflective discussion and encourages the formulation of actionable behaviour change. A supportive cultural understanding of patient feedback and its intended purpose is also essential for its effective use.

Organisational perspectives on addressing differential attainment in postgraduate medical education: a qualitative study in the UK

OBJECTIVES

To explore how representatives from organisations with responsibility for doctors in training perceive risks to the educational progression of UK medical graduates from black and minority ethnic groups (BME UKGs), and graduates of non-UK medical schools (international medical graduates (IMGs)). To identify the barriers to and facilitators of change.

DESIGN

Qualitative semistructured individual and group interview study.

SETTING

Postgraduate medical education in the UK.

PARTICIPANTS

Individuals with roles in examinations and/or curriculum design from UK medical Royal Colleges. Employees of NHS Employers.

RESULTS

Representatives from 11 medical Royal Colleges (n=29) and NHS Employers (n=2) took part (55% medically qualified, 61% male, 71% white British/Irish, 23% Asian/Asian British, 6% missing ethnicity). Risks were perceived as significant, although more so for IMGs than for BME UKGs. Participants based significance ratings on evidence obtained largely through personal experience. A lack of evidence led to downgrading of significance. Participants were pessimistic about effecting change, two main barriers being sensitivities around race and the isolation of interventions. Participants felt that organisations should acknowledge problems, but felt concerned about being transparent without a solution; and talking about race with trainees was felt to be difficult. Participants mentioned 63 schemes aiming to address differential attainment, but these were typically local or specialty-specific, were not aimed at BME UKGs and were largely unevaluated. Participants felt that national change was needed, but only felt empowered to effect change locally or within their specialty.

CONCLUSIONS

Representatives from organisations responsible for training doctors perceived the risks faced by BME UKGs and IMGs as significant but difficult to change. Strategies to help organisations address these risks include: increased openness to discussing race (including ethnic differences in attainment among UKGs); better sharing of information and resources nationally to empower organisations to effect change locally and within specialties; and evaluation of evidence-based interventions.

"I'd been like freaking out the whole night": exploring emotion regulation based on junior doctors' narratives

The importance of emotions within medical practice is well documented. Research suggests that how clinicians deal with negative emotions can affect clinical decision-making, health service delivery, clinician well-being, attentiveness to patient care and patient satisfaction. Previous research has identified the transition from student to junior doctor (intern) as a particularly challenging time. While many studies have highlighted the presence of emotions during this transition, how junior doctors manage emotions has rarely been considered. We conducted a secondary analysis of narrative data in which 34 junior doctors, within a few months of transitioning into practice, talked about situations for which they felt prepared or unprepared for practice (preparedness narratives) through audio diaries and interviews. We examined these data deductively (using Gross' theory of emotion regulation: ER) and inductively to answer the following research questions: (RQ1) what ER strategies do junior doctors describe in their preparedness narratives? and (RQ2) at what point in the clinical situation are these strategies narrated? We identified 406 personal incident narratives: 243 (60%) contained negative emotion, with 86 (21%) also containing ER. Overall, we identified 137 ER strategies, occurring prior to (n = 29, 21%), during (n = 74, 54%) and after (n = 34, 25%) the situation. Although Gross' theory captured many of the ER strategies used by junior doctors, we identify further ways in which this model can be adapted to fully capture the range of ER strategies participants employed. Further, from our analysis, we believe that raising medical students' awareness of how they can handle stressful situations might help smooth the transition to becoming a doctor and be important for later practice.

'I did try and point out about his dignity': a qualitative narrative study of patients and carers' experiences and expectations of junior doctors

OBJECTIVES

For many years, the voice of patients has been understood as a critical element for the improvement of care quality in healthcare settings. How well medical graduates are prepared for clinical practice is an important question, but one that has rarely been considered from patient and public perspectives. We aimed to fill this gap by exploring patients and carers' experiences and expectations of junior doctors.

DESIGN

This comprises part of a wider study on UK medical graduates' preparedness for practice. A qualitative narrative methodology was used, comprising four individual and six group interviews.

PARTICIPANTS

25 patients and carers from three UK countries.

ANALYSIS

Data were transcribed, anonymised and analysed using framework analysis.

MAIN RESULTS

We identified three themes pertinent to answering our research question: (1) sources of knowledge (sources of information contributing to patients and carers' perceptions of junior doctors' impacting on expectations); (2) desires for student/trainee learning (experiences and expectations of medical training); and (3) future doctors (experiences and expectations of junior doctors). We also highlight metaphorical talk and humour, where relevant, in the quotes presented to give deeper insights into participants' perspectives of the issues. Participants focused on personal and interpersonal aspects of being a doctor, such as respect and communication. There was a strong assertion that medical graduates needed to gain direct experience with a diverse range of patients to encourage individualised care. Participants narrated their experiences of having symptoms ignored and attributed to an existing diagnosis ('diagnostic overshadowing') and problems relating to confidentiality.

CONCLUSIONS

Our findings support the view that patients and carers have clear expectations about junior doctors, and that patient views are important for preparing junior doctors for practice. There is a necessity for greater dialogue between patients, doctors and educators to clarify expectations and confidentiality issues around patient care.

Prevalence of GMC performance assessments in the United Kingdom: a retrospective cohort analysis by country of medical qualification

BACKGROUND

The demographics of doctors working in the UK are changing. The United Kingdom (UK) has voted to leave the European Union (EU) and there is heightened political discourse around the world about the impact of migration on healthcare services. Previous work suggests that foreign trained doctors perform worse than UK graduates in postgraduate medical examinations. We analysed the prevalence by country of primary medical qualification of doctors who were required to take an assessment by the General Medical Council (GMC) because of performance concerns.

METHODS

This was a retrospective cohort analysis of data routinely collected by the GMC. We compared doctors who had a GMC performance assessment between 1996 and 2013 with the medical register in the same period. The outcome measures were numbers experiencing performance assessments by country or region of medical qualification.

RESULTS

The rate of performance assessment varied significantly by place of medical qualification and by year; χ ²(17) = 188, p < 0.0001, pseudo-R² = 15%. Doctors who trained outside of the UK, including those trained in the European Economic Area (EEA), were more likely to have a performance assessment than UK trained doctors, with the exception of South African trained doctors.

CONCLUSIONS

The rate of performance assessment varies significantly by place of medical qualification. This is the first study to explore the risk of performance assessment by individual places of medical qualification. While concern has largely focused on the competence of non-EEA, International Medical Graduates, we discuss implications for how to ensure European trained doctors are fit to practise before their medical licence in the UK is granted. Further research is needed to investigate whether these country effects hold true when controlling for factors like doctors' sex, age, length of time working in the UK, and English language skills. This will allow evidence-based decisions to be made around the regulatory environment the UK should adopt once it leaves the EU. Patients should be reassured that the vast majority of all doctors working in the UK are competent.

The impact of large scale licensing examinations in highly developed countries: a systematic review

BACKGROUND

To investigate the existing evidence base for the validity of large-scale licensing examinations including their impact.

METHODS

Systematic review against a validity framework exploring: Embase (Ovid Medline); Medline (EBSCO); PubMed; Wiley Online; ScienceDirect; and PsychINFO from 2005 to April 2015. All papers were included when they discussed national or large regional (State level) examinations for clinical professionals, linked to examinations in early careers or near the point of graduation, and where success was required to subsequently be able to practice. Using a standardized data extraction form, two independent reviewers extracted study characteristics, with the rest of the team resolving any disagreement. A validity framework was used as developed by the American Educational Research Association, American Psychological Association, and National Council on Measurement in Education to evaluate each paper's evidence to support or refute the validity of national licensing examinations.

RESULTS

24 published articles provided evidence of validity across the five domains of the validity framework. Most papers (n = 22) provided evidence of national licensing examinations relationships to other variables and their consequential validity. Overall there was evidence that those who do well on earlier or on subsequent examinations also do well on national testing. There is a correlation between NLE performance and some patient outcomes and rates of complaints, but no causal evidence has been established.

CONCLUSIONS

The debate around licensure examinations is strong on opinion but weak on validity evidence. This is especially true of the wider claims that licensure examinations improve patient safety and practitioner competence.