Not ready in the ways that count- a qualitative exploration of junior doctor's perceived preparedness for practice using Legitimation Code Theory.

Despite demonstrating the required competencies to graduate, many newly qualified doctors find the transition to internship difficult. There is a concern over whether their preparation is aligned with the expectations of the role. This study aimed to gain a better understanding of the competencies needed for legitimate practice as junior doctors and explores their perceived preparedness for practice. A qualitative, descriptive study using focus groups was undertaken with first year internship doctors. Thirty-two junior doctors in their first year of internship took part in five focus groups. The data were analysed using a reflective thematic analysis approach with a subsequent analysis using the Legitimation Code Theory (LCT) specialisation dimension coding framework to aid interpretation. Personal attributes including adaptability, organisation and proactivity form the basis of achievement in internship. While graduates felt ready in some ways, it was not in the ways that counted. Participants felt well prepared in terms of their clinical knowledge and skills, but legitimacy came from being able to take responsibility, communicate effectively and apply knowledge confidently and efficiently to all aspects of patient care, something that they did not feel ready to do. Using LCT has revealed a shift in the basis of achievement between medical school, where individual academic performance is rewarded, and internship, where personal and social competencies are legitimised. There is a clash between what graduates feel well prepared for and the expectations and demands of the internship role, resulting in a difficult and stressful transition from student to doctor.

Longitudinal exploration of students' identity formation during the transition from pre-clinical to clinical training using research poetry.

BACKGROUND: Transitions are critical periods that can lead to growth and, or, distress. Transitions are a sociocultural process, yet most approaches to transitions in practice and research do not explore the social or developmental aspects of entering a new training phase. Wenger reminds us that identity development is crucial when newcomers navigate change. In this paper, we use Wenger's modes of identification: engagement, imagination and alignment to explore students' identity development (as a student and professional) during the transition from pre-clinical to clinical training. METHODS: We enrolled nine 2nd-year medical students who generated 61 entries comprising audio diary (or typed) reflections over 9 months (starting 3 months before clinical clerkships began) and interviewed them twice. We used research poems (transcripts reframed as poetry) to help construct a meaningful, emotive elicitation of our longitudinal data and analysed data using sensitising concepts from Wenger's modes of identification. RESULTS: Students described their transition as a journey filled with positive and negative emotions and uncertainty about their current and future careers. Students navigated the transition using three mechanisms: (1) becoming more engaged through taking charge, (2) shaping their image of self through engagement and finding role models and (3) learning to flexibly adapt to clerkship norms by managing expectations and adopting a journey mindset. CONCLUSIONS: We successfully narrated students' identity formation during their transition to clinical training. We learned that students became more engaged over time by learning to take charge. They shaped their image of self by engaging in team activities and reflecting on role models. They learnt to adapt flexibly to clerkship norms by managing expectations and adopting a journey mindset. We suggest that institutions provide a safe opportunity for medical students to reflect, allowing students' transition periods to be lived, reflected on and supported.

Temporal trends of sex differences for COVID-19 infection, hospitalisation, severe disease, intensive care unit (ICU) admission and death: a meta-analysis of 229 studies covering over 10M patients.

Background: This review aims to investigate the association of sex with the risk of multiple COVID-19 health outcomes, ranging from infection to death. Methods: Pubmed and Embase were searched through September 2020. We considered studies reporting sex and coronavirus disease 2019 (COVID-19) outcomes. Qualitative and quantitative data were extracted using standardised electronic data extraction forms with the assessment of Newcastle Ottawa Scale for risk of bias. Pooled trends in infection, hospitalization, severity, intensive care unit (ICU) admission and death rate were calculated separately for men and women and subsequently random-effects meta-analyses on relative risks (RR) for sex was performed. Results: Of 10,160 titles, 229 studies comprising 10,417,452 patients were included in the analyses. Methodological quality of the included studies was high (6.9 out of 9). Men had a higher risk for infection with COVID-19 than women (RR = 1.14, 95%CI: 1.07 to 1.21). When infected, they also had a higher risk for hospitalization (RR = 1.33, 95%CI: 1.27 to 1.41), higher risk for severe COVID-19 (RR = 1.22, 95%CI: 1.17 to 1.27), higher need for Intensive Care (RR = 1.41, 95%CI: 1.28 to 1.55), and higher risk of death (RR = 1.35, 95%CI: 1.28 to 1.43). Within the period studied, the RR for infection and severity increased for men compared to women, while the RR for mortality decreased for men compared to women. Conclusions: Meta-analyses on 229 studies comprising over 10 million patients showed that men have a higher risk for COVID-19 infection, hospitalization, disease severity, ICU admission and death. The relative risks of infection, disease severity and death for men versus women showed temporal trends with lower relative risks for infection and severity of disease and higher relative risk for death at the beginning of the pandemic compared to the end of our inclusion period. PROSPERO registration: CRD42020180085 (20/04/2020).

Medical Students' Socialization Tactics When Entering a New Clinical Clerkship: A Mixed Methods Study of Proactivity.

PURPOSE: Socialization into clinical clerkships is difficult in part due to ambiguity around students' new roles and expected behaviors. Being proactive reduces ambiguity and is essential to socialization. Proactive behavior can be taught and goes beyond having a proactive personality. Among students entering new undergraduate clinical clerkships, this study aimed to investigate (1) reported proactive behaviors and their association with social integration and (2) enabling and inhibiting factors for proactive behavior. METHOD: This study was conducted at the 5-year MBBS program at Western Sydney University during academic year 2019-2020. Using a convergent mixed methods approach, survey and interview data from third-, fourth-, and fifth-year students were collected. Surveys explored 5 proactive behaviors: feedback seeking, information seeking, task negotiation, positive framing, and relationship building. Interviews elicited descriptions of how students described their proactivity and what influenced students to be proactive when entering a new clerkship. Data were integrated using the following the thread and mixed methods matrix techniques. RESULTS: Students exhibited all 5 proactive behaviors. Survey data showed positive framing and task negotiation had the highest and lowest scores, respectively. Only positive framing correlated significantly with social integration scores (r = 0.27; P < .01), but this contrasted to interviews, in which students described how other proactive behaviors also led to social integration. Proactive behavior scores decreased across academic years. Integrated data showed 3 linked antecedents to whether students exhibited proactive behavior: feeling capable of being proactive, individual intention to be proactive, and the immediate environment and system-level factors. CONCLUSIONS: Students who framed the experience positively were more likely to report increased social integration. Initiating task negotiation was challenging for most students. The authors propose a conceptual model for proactivity and social integration to support socialization and learning during clinical transitions for future research and interventional design.

An exploration of burnout and resilience among emergency physicians at three teaching hospitals in the English-speaking Caribbean: A cross-sectional survey.

Background: Burnout is common among doctors working in emergency departments. It has significant consequences and is multifactorial. Self-care and resilience tendencies may contribute to being burnt out, or not. This study explores burnout and resilience amongst physicians working in Caribbean emergency departments. Methods: Data were collected from 111 participants using the Maslach Burnout Inventory (MBI) and the Resilience Scale-14 (RS14) as measures of burnout and resilience, respectively. Questions collected data on participant demographics and characteristics related to self-care. The associations between demographic characteristics and total burnout and resilience scales were explored. Findings: Among participants, 88.6% had medium to high range emotional exhaustion, 82.8% exhibited medium to high range depersonalization, and 19.6% had low to medium range personal accomplishment. Participants in Barbados had higher emotional exhaustion and depersonalization scores (p=0.009), and those in a postgraduate programme had higher depersonalization scores (p=0.047). The mean RS-14 score was 81.1 out of a maximum of 98.0 with a standard deviation of 13.1 and a range of 26 to 98. Depression correlated with high emotional exhaustion scores (p=0.004) and low resilience scores (p<0.0001). Emotional exhaustion scores increased among participants using alcohol daily (p=0.01), using recreational drugs (p=0.021) and sleeping aids (p=0.028). Interpretation: High burnout, despite high resilience, is present in this sample of physicians working in emergency departments of teaching hospitals in the Caribbean. Although resilience scores were high, those with lower resilience tendencies had poorer self-care habits. Funding: No external funding.

Qualitative ego networks in health professions education: Capturing the self in relation to others.

INTRODUCTION: Our very sense of self emerges through interactions with others. As part of this State of the Science series on Self, Society, and Situation, we introduce a qualitative ego network research approach. This research approach offers insights into the self's (the ego's) interpretation of and relation to named others in the social network in question. PURPOSE: Visual mapping of participants' social networks is gaining traction, yet this research approach has received no focused attention in the health professions education (HPE) literature. A qualitative ego network approach is a compelling research approach because it uniquely maps participants' perceptions of the complex social world they are embedded in. Although many methodologies can explore participants' social world, ego networks can enhance expression of tacit knowledge of one's social environment and encourage reflection. This approach, combined with other qualitative data, can also reveal hidden relational data that the researcher may not observe or consider. To demonstrate its value as a visual methodology, we will showcase two examples of qualitative ego network studies. We then balance the paper with some critical reflections of this research approach. CONCLUSIONS: A qualitative ego network approach holds potential for deepening understanding of the self in relation to society and situation in future HPE research. We look forward to intentional, impactful and invigorated research using a qualitative ego network approach as we tackle unknowns about how self and society in specific HPE situations interact.

Advancing the science of health professions education through a shared understanding of terminology: a content analysis of terms for "faculty".

INTRODUCTION: Health professions educators risk misunderstandings where terms and concepts are not clearly defined, hampering the field's progress. This risk is especially pronounced with ambiguity in describing roles. This study explores the variety of terms used by researchers and educators to describe "faculty", with the aim to facilitate definitional clarity, and create a shared terminology and approach to describing this term. METHODS: The authors analyzed journal article abstracts to identify the specific words and phrases used to describe individuals or groups of people referred to as faculty. To identify abstracts, PubMed articles indexed with the Medical Subject Heading "faculty" published between 2007 and 2017 were retrieved. Authors iteratively extracted data and used content analysis to identify patterns and themes. RESULTS: A total of 5,436 citations were retrieved, of which 3,354 were deemed eligible. Based on a sample of 594 abstracts (17.7%), we found 279 unique terms. The most commonly used terms accounted for approximately one-third of the sample and included faculty or faculty member/s (n = 252; 26.4%); teacher/s (n = 59; 6.2%) and medical educator/s (n = 26; 2.7%) were also well represented. Content analysis highlighted that the different descriptors authors used referred to four role types: healthcare (e.g., doctor, physician), education (e.g., educator, teacher), academia (e.g., professor), and/or relationship to the learner (e.g., mentor). DISCUSSION: Faculty are described using a wide variety of terms, which can be linked to four role descriptions. The authors propose a template for researchers and educators who want to refer to faculty in their papers. This is important to advance the field and increase readers' assessment of transferability.

Demographic risk factors for COVID-19 infection, severity, ICU admission and death: a meta-analysis of 59 studies.

OBJECTIVE: We aimed to describe the associations of age and sex with the risk of COVID-19 in different severity stages ranging from infection to death. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed and Embase through 4 May 2020. STUDY SELECTION: We considered cohort and case-control studies that evaluated differences in age and sex on the risk of COVID-19 infection, disease severity, intensive care unit (ICU) admission and death. DATA EXTRACTION AND SYNTHESIS: We screened and included studies using standardised electronic data extraction forms and we pooled data from published studies and data acquired by contacting authors using random effects meta-analysis. We assessed the risk of bias using the Newcastle-Ottawa Scale. RESULTS: We screened 11.550 titles and included 59 studies comprising 36.470 patients in the analyses. The methodological quality of the included papers was high (8.2 out of 9). Men had a higher risk for infection with COVID-19 than women (relative risk (RR) 1.08, 95% CI 1.03 to 1.12). When infected, they also had a higher risk for severe COVID-19 disease (RR 1.18, 95% CI 1.10 to 1.27), a higher need for intensive care (RR 1.38, 95% CI 1.09 to 1.74) and a higher risk of death (RR 1.50, 95% CI 1.18 to 1.91). The analyses also showed that patients aged 70 years and above have a higher infection risk (RR 1.65, 95% CI 1.50 to 1.81), a higher risk for severe COVID-19 disease (RR 2.05, 95% CI 1.27 to 3.32), a higher need for intensive care (RR 2.70, 95% CI 1.59 to 4.60) and a higher risk of death once infected (RR 3.61, 95% CI 2.70 to 4.84) compared with patients younger than 70 years. CONCLUSIONS: Meta-analyses on 59 studies comprising 36.470 patients showed that men and patients aged 70 and above have a higher risk for COVID-19 infection, severe disease, ICU admission and death. PROSPERO REGISTRATION NUMBER: CRD42020180085.

Appraising the use of smartphones and apps when conducting qualitative medical education research: AMEE Guide No. 130.

Smartphone use is rampant in everyday life and is increasing in: patient management, teaching and learning of medicine and health research. There is untapped potential to use smartphones as research tools in MER for a range of research approaches. Qualitative research is increasingly common in medical education research (MER). Smartphone use as a research tool has not been well explored in MER and this Guide will be useful to researchers considering integrating smartphones specifically in qualitative MER. First, we discuss the potential for smartphones in qualitative MER. Then, we discuss the opportunities and drawbacks for using smartphones in qualitative MER. We then provide three principles to consider when conducting smartphone MER: communication, ethics and reflection. Next we share ten lessons that emerged from the literature and our experiences. We end by looking to the future of smartphones in qualitative MER and hope this Guide provides evidence-based information to optimise smartphone use in qualitative MER. This Guide is important as there is an urgent need to redefine ethical boundaries to account for blurred lines between personal and professional use of smartphones.

Students' social networks are diverse, dynamic and deliberate when transitioning to clinical training.

CONTEXT: Transitions in medical education are dynamic, emotional and complex yet, unavoidable. Relationships matter, especially in times of transition. Using qualitative, social network research methods, we explored social relationships and social support as medical students transitioned from pre-clinical to clinical training. METHODS: Eight medical students completed a social network map during a semi-structured interview within two weeks of beginning their clinical clerkships (T0 ) and then again four months later (T1 ). They indicated meaningful interactions that influenced their transition from pre-clinical to clinical training and discussed how these relationshipsimpacted their transition. We conducted mixed-methods analysis on this data. RESULTS: At T0 , eight participants described the influence of 128 people in their social support networks; this marginally increased to 134 at T1 . People from within and beyond the clinical space made up participants' social networks. As new relationships were created (eg with peers and doctors), old relationships were kept (eg with doctors and family) or dissolved over time (eg with near-peers and nurses). Participants deliberately created, kept or dissolved relationships over time dependent on whether they provided emotional support (eg they could trust them) or instrumental support (eg they provided academic guidance). CONCLUSIONS: This is the first social networks analysis paper to explore social networks in transitioning students in medicine. We found that undergraduate medical students' social support networks were diverse, dynamic and deliberate as they transitioned to clerkships. Participants created and kept relationships with those they trusted and who provided emotional or instrumental support and dissolved relationships that did not provide these functions.

Beyond the struggles: a scoping review on the transition to undergraduate clinical training.

CONTEXT: The transition to clinical training within medical school is often seen as a struggle and students remain in distress despite numerous efforts to minimise threats. Efforts to change this may be misdirected if they are based on narrow conceptualisations of transitions. The authors conducted a scoping review to explore existing conceptual perspectives regarding the transition within medical school from pre-clinical training to clinical training to suggest a research agenda and practical implications. METHODS: Between October 2017 and February 2018 the authors searched PubMed, MEDLINE, ERIC, PsycINFO, Web of Science and CINAHL for English language literature with no date limits and retrieved 1582 articles; 46 were included in this review. Two reviewers independently screened articles and extracted data. Data were then charted, analysed and discussed with the research team. RESULTS: The transition to clinical training was often described negatively as 'difficult', 'a problem' and 'a struggle'. Our analysis found that researchers in medical education conducted studies on the transition to clinical training from three conceptual perspectives: educational; social, and developmental. Most research approached the transition to clinical training as a problem to be addressed from an educational perspective through transition to clerkship courses and curriculum innovations. Some research was conducted from a social perspective, focusing on building relationships. Regarding development, authors found a few articles highlighting opportunities for personal and professional development by nurturing transferrable learning strategies and reflection. CONCLUSIONS: This review provides an empirical base on which future research can be built to better understand and support medical students' ability to navigate change. Finding new perspectives to approach the transition to clinical training could allow researchers to look beyond preparing students for struggles.

The Barbados Insulin Matters (BIM) study: Barriers to insulin therapy among a population-based sample of people with type 2 diabetes in the Caribbean island of Barbados.

AIM: The purpose of this study was to document in people with type 2 diabetes (T2DM) in Barbados, attitudes and beliefs that may result in psychological insulin resistance. METHODS: A representative, population-based, sample of 175 eligible people with T2DM 25 years of age and over was surveyed by telephone. The 20-item insulin treatment appraisal scale (ITAS) was administered (score range 20 to 100 for positive to negative perceptions). RESULTS: 117 people participated (67% response rate, 32% male, mean age 66 years, 90% Black, 22% on insulin). Of non-responders, 52 were not contactable and 6 were difficult to communicate with. Negative perceptions about insulin use included - meant a worsening of diabetes (68%), would worry family (63%), feared self-injection (58%), meant a failure in self-management (57%), injections were painful (54%), would be seen as being sicker (46%), increased hypoglycaemia risk (38%), required effort (34%), causes weight gain (27%), causes a deterioration in health (14%), and would have to give up enjoyable activities (10%). Positive perceptions were - helps good glycaemic control (78%), would prevent complications (61%) and improves health (58%). Mean total ITAS score (61.6, SD = 7.7) was lower for those on insulin compared to those not on insulin (53.7 vs. 63.8, p < 0.0001). Sex, age and diabetes diagnosis duration were not significant predictors of ITAS score. CONCLUSIONS: Multiple factors related to patient beliefs and attitudes need to be considered and addressed when initiating insulin in order to minimise psychological insulin resistance and delay. Patients using insulin had less negative perceptions than those not on insulin.

Barbados Insulin Matters (BIM) study: Perceptions on insulin initiation by primary care doctors in the Caribbean island of Barbados.

AIMS: With regards to insulin initiation in Barbados we explored primary care doctor (PCD) perception, healthcare system factors and predictors of PCD reluctance to initiate insulin. METHODS: PCDs completed a questionnaire based on the theory of planned behaviour (TPB) and a reluctance to initiate insulin scale. Using linear regression, we explored the association between TPB domains and the reluctance to initiate insulin scale. RESULTS: Of 161 PCDs, 70% responded (75 private and 37 public sector). The majority felt initiating insulin was uncomplicated (68%) and there was benefit if used before complications developed (68%), but would not use it until absolutely necessary (58%). More private than public sector PCDs (p<0.05) thought that the healthcare system allowed enough flexibility of time for education (68 vs 38%) and initiating insulin was easy (63 vs 35%), but less thought system changes would help initiating insulin (42 vs 70%). Reasons for reluctance to initiate insulin included patient nonadherence (83%) and reluctance (63%). Only the attitudes and belief domain of the TPB was associated with the reluctance to initiate insulin scale (p<0.001). CONCLUSIONS: Interventions focusing on PCD attitudes and beliefs and restructuring services inclusive of the use of diabetes specialist nurses are required.

Student perceptions of clerkship handbooks.

BACKGROUND: When students transition into new clerkships, it can be useful to provide them with information to assist them in their adjustment to the new social environment. Handbooks could support students by providing information, particularly during clerkship orientation. The authors explored aspects of existing handbooks that students found useful, and sought additional desirable content. METHODS: During seven semi-structured focus group discussions, 48 final-year medical students discussed their perceptions of six handbooks at the end of their training. Focus group discussions continued until data saturation. Transcripts were thematically analysed. RESULTS: Students appreciated handbooks that were concise, and valued reviewing handbooks with faculty members who could highlight important content. Most students valued and desired content related to assessment, and specifically used handbooks when preparing for examinations. Most students appreciated handbooks that provided study guidance such as a syllabus. Students also appreciated logistical aspects such as a timetable and information on clerkship cultural norms. Students disliked handbooks with vague descriptions of faculty member expectations and students' roles. CONCLUSIONS: Students liked, disliked and desired many aspects of clerkship handbooks. The findings of our study could be used when designing handbooks to enhance their perceived value to students. Further research is needed on the impact of handbooks on learning and increasing students' engagement with handbook content. There are many aspects of handbook content and delivery that could be used to improve students' perceptions regarding handbooks. Handbooks could support students by providing information.

Exploring the transition of undergraduate medical students into a clinical clerkship using organizational socialization theory.

BACKGROUND: Transitions in medical education are emotionally and socially dynamic; this may affect learning. Students transitioning from preclinical to clinical training may experience negative consequences. Less is understood about students' experiences during transitions within clinical training and influential factors. METHODS: The authors used organizational socialization theory to explore a transition within the clinical years. Final-year medical students experienced a nine-week internal medicine clerkship; willing students participated. Students (n = 101; 97 %) completed a questionnaire with open-ended questions at the beginning and end of the clerkship and participated in six consecutive focus groups, until data saturation occurred (n = 37). Data were thematically analyzed. RESULTS: Socialization was challenging. Many students experienced difficulty developing relationships with team members. Students with a positive attitude experienced a smoother transition. Many students were uncertain of their roles, concerned about the workload and desired guidance to meet clerkship demands. This transition resulted in varied outcomes from enjoyment, increased confidence and student development through to disinterest. CONCLUSION: Transitions within clinical training are complex. Faculty should focus on adequate socialization in a new clerkship as this may facilitate a smoother transition. This may necessitate orientations, staff training, and formal student support. Further research is needed on the impact of these recommendations on learning and well-being.

This thing called life.

Academic pursuits are inseparable from the medium within which they take place - life. The lives of medical trainees can present many challenges that are independent of academic demands. Poor psychological health has been found to develop in medical trainees. Can medical educators minimize this decline in well-being? Positive education - learning skills for traditional academia and to foster happiness - has been shown to improve students' well-being. This piece considers the application of 'positive education' to medical training. By using this approach, we may optimize the lives of our trainees, potentially enhance learning and improve their academic and personal outcomes.

How we implemented a classroom-based educational intervention for ward-based diabetes care.

BACKGROUND: Junior doctors require training to adequately manage the increasing numbers of adult, hospitalized patients with diabetes whom they encounter. AIMS: Junior doctors experiencing the intervention acquire knowledge and skills that improve their management of inpatients with diabetes. METHODS: We designed and administered, a one-hour, classroom-based, educational intervention to 242 juniors doctors. This resulted in a 49% reduction in insulin prescription errors and an increase in their confidence in the delivery of care. A number of key steps were taken to develop the intervention. First, aims, objectives, methods and assessment were carefully aligned with learning objectives at the appropriate level of Bloom's Taxonomy. Clarity was enhanced through the structuring of the introduction, body and conclusion. Clinically authentic active learning methods were used to increase engagement and provide an opportunity for junior doctors to reflect and make connections with their own clinical practice. Additionally, refinement was integrated into the process of administration. RESULTS: Qualitative analysis from 205 trainees (85%) revealed that trainees liked a number of design features, their ability to be interactive, and immediacy behaviors of facilitators. CONCLUSION: Classroom-based training can impact clinically delivered care. Achieving this goal requires well-thought-out content design and evaluation.