A Modified Medical Education Research Study Quality Instrument (MMERSQI) developed by Delphi consensus.

BACKGROUND: The Medical Education Research Study Quality Instrument (MERSQI) is widely used to appraise the methodological quality of medical education studies. However, the MERSQI lacks some criteria which could facilitate better quality assessment. The objective of this study is to achieve consensus among experts on: (1) the MERSQI scoring system and the relative importance of each domain (2) modifications of the MERSQI. METHOD: A modified Delphi technique was used to achieve consensus among experts in the field of medical education. The initial item pool contained all items from MERSQI and items added in our previous published work. Each Delphi round comprised a questionnaire and, after the first iteration, an analysis and feedback report. We modified the quality instruments' domains, items and sub-items and re-scored items/domains based on the Delphi panel feedback. RESULTS: A total of 12 experts agreed to participate and were sent the first and second-round questionnaires. First round: 12 returned of which 11 contained analysable responses; second-round: 10 returned analysable responses. We started with seven domains with an initial item pool of 12 items and 38 sub-items. No change in the number of domains or items resulted from the Delphi process; however, the number of sub-items increased from 38 to 43 across the two Delphi rounds. In Delphi-2: eight respondents gave 'study design' the highest weighting while 'setting' was given the lowest weighting by all respondents. There was no change in the domains' average weighting score and ranks between rounds. CONCLUSIONS: The final criteria list and the new domain weighting score of the Modified MERSQI (MMERSQI) was satisfactory to all respondents. We suggest that the MMERSQI, in building on the success of the MERSQI, may help further establish a reference standard of quality measures for many medical education studies.

Association of Thyroid Dysfunction With Cognitive Function: An Individual Participant Data Analysis.

Importance: In clinical guidelines, overt and subclinical thyroid dysfunction are mentioned as causal and treatable factors for cognitive decline. However, the scientific literature on these associations shows inconsistent findings. Objective: To assess cross-sectional and longitudinal associations of baseline thyroid dysfunction with cognitive function and dementia. Design, Setting, and Participants: This multicohort individual participant data analysis assessed 114 267 person-years (median, 1.7-11.3 years) of follow-up for cognitive function and 525 222 person-years (median, 3.8-15.3 years) for dementia between 1989 and 2017. Analyses on cognitive function included 21 cohorts comprising 38 144 participants. Analyses on dementia included eight cohorts with a total of 2033 cases with dementia and 44 573 controls. Data analysis was performed from December 2016 to January 2021. Exposures: Thyroid function was classified as overt hyperthyroidism, subclinical hyperthyroidism, euthyroidism, subclinical hypothyroidism, and overt hypothyroidism based on uniform thyrotropin cutoff values and study-specific free thyroxine values. Main Outcomes and Measures: The primary outcome was global cognitive function, mostly measured using the Mini-Mental State Examination. Executive function, memory, and dementia were secondary outcomes. Analyses were first performed at study level using multivariable linear regression and multivariable Cox regression, respectively. The studies were combined with restricted maximum likelihood meta-analysis. To overcome the use of different scales, results were transformed to standardized mean differences. For incident dementia, hazard ratios were calculated. Results: Among 74 565 total participants, 66 567 (89.3%) participants had normal thyroid function, 577 (0.8%) had overt hyperthyroidism, 2557 (3.4%) had subclinical hyperthyroidism, 4167 (5.6%) had subclinical hypothyroidism, and 697 (0.9%) had overt hypothyroidism. The study-specific median age at baseline varied from 57 to 93 years; 42 847 (57.5%) participants were women. Thyroid dysfunction was not associated with global cognitive function; the largest differences were observed between overt hypothyroidism and euthyroidism-cross-sectionally (-0.06 standardized mean difference in score; 95% CI, -0.20 to 0.08; P = .40) and longitudinally (0.11 standardized mean difference higher decline per year; 95% CI, -0.01 to 0.23; P = .09). No consistent associations were observed between thyroid dysfunction and executive function, memory, or risk of dementia. Conclusions and Relevance: In this individual participant data analysis of more than 74 000 adults, subclinical hypothyroidism and hyperthyroidism were not associated with cognitive function, cognitive decline, or incident dementia. No rigorous conclusions can be drawn regarding the role of overt thyroid dysfunction in risk of dementia. These findings do not support the practice of screening for subclinical thyroid dysfunction in the context of cognitive decline in older adults as recommended in current guidelines.

Effectiveness of technology-enhanced simulation in teaching digital rectal examination: a systematic review narrative synthesis.

Background: Digital rectal examination (DRE) is a challenging examination to learn. Objective: To synthesise evidence regarding the effectiveness of technology-enhanced simulation (TES) for acquiring DRE skills. Study selection: EMBASE, Medline, CINAHL, Cochrane, Web of Knowledge (Science and Social Science), Scopus and IEEE Xplore were searched; the last search was performed on 3 April 2019. Included were original research studies evaluating TES to teach DRE. Data were abstracted on methodological quality, participants, instructional design and outcomes; a descriptive synthesis was performed. Quality was assessed using a modified Medical Education Research Study Quality Instrument. The study design domain was modified by scoring the papers based on (1) evaluation of risk of bias for randomised controlled trials, (2) description of participants and (3) assessment of robustness and degree of simulation fidelity of the assessments used to evaluate learning. Findings: 863 articles were screened; 12 were eligible, enrolling 1507 prequalified medical/clinical students and 20 qualified doctors. For skill acquisition, role player was statistically significantly superior to a static manikin (2 studies). For knowledge acquisition, manikin use was significantly superior to role player (1 study); 2 studies showed no difference. For confidence, manikin use was significantly superior to no manikin (4 studies). For comfort, manikin use was significantly superior to no manikin (2 studies). For anxiety, role player was significantly superior to manikin (1 study).Median overall quality score (QS) was 48% (27-62). Highest median QS was 73% (33-80) for data analysis; lowest median QS was 20% (7-40) for the validity of instrument. Six papers scored over 50% of the maximum score for overall quality. Conclusions: TES training is associated with improved DRE skills and should be used more widely.

Comparing physician associates and foundation year two doctors-in-training undertaking emergency medicine consultations in England: a mixed-methods study of processes and outcomes.

OBJECTIVES: To compare the contribution of physician associates to the processes and outcomes of emergency medicine consultations with that of foundation year two doctors-in-training. DESIGN: Mixed-methods study: retrospective chart review using 4 months' anonymised clinical record data of all patients seen by physician associates or foundation year two doctors-in-training in 2016; review of a subsample of 40 records for clinical adequacy; semi-structured interviews with staff and patients; observations of physician associates. SETTING: Three emergency departments in England. PARTICIPANTS: The records of 8816 patients attended by 6 physician associates and 40 foundation year two doctors-in-training; of these n=3197 had the primary outcome recorded (n=1129 physician associates, n=2068 doctor); 14 clinicians and managers and 6 patients or relatives for interview; 5 physician associates for observation. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was unplanned re-attendance at the same emergency department within 7 days. SECONDARY OUTCOMES: consultation processes, clinical adequacy of care, and staff and patient experience. RESULTS: Re-attendances within 7 days (n=194 (6.1%)) showed no difference between physician associates and foundation year two doctors-in-training (OR 0.87, 95% CI 0.61 to 1.24, p=0.437). If seen by a physician associate, patients were more likely receive an X-ray investigation (OR 2.10, 95% CI 1.72 to 4.24), p<0.001), after adjustment for patient characteristics, triage severity of condition and statistically significant clinician intraclass correlation. Clinical reviewers found almost all patients' charts clinically adequate. Physician associates were evaluated as assessing patients in a similar way to foundation year two doctors-in-training and providing continuity in the team. Patients were positive about the care they had received from a physician associate, but had poor understanding of the role. CONCLUSIONS: Physician associates in emergency departments in England treated patients with a range of conditions safely, and at a similar level to foundation year two doctors-in-training, providing clinical operational efficiencies.

Contribution of physician assistants/associates to secondary care: a systematic review.

OBJECTIVE: To appraise and synthesise research on the impact of physician assistants/associates (PA) in secondary care, specifically acute internal medicine, care of the elderly, emergency medicine, trauma and orthopaedics, and mental health. DESIGN: Systematic review. SETTING: Electronic databases (Medline, Embase, ASSIA, CINAHL, SCOPUS, PsycINFO, Social Policy and Practice, EconLit and Cochrane), reference lists and related articles. INCLUDED ARTICLES: Peer-reviewed articles of any study design, published in English, 1995-2017. INTERVENTIONS: Blinded parallel processes were used to screen abstracts and full text, data extractions and quality assessments against published guidelines. A narrative synthesis was undertaken. OUTCOME MEASURES: Impact on: patients' experiences and outcomes, service organisation, working practices, other professional groups and costs. RESULTS: 5472 references were identified and 161 read in full; 16 were included-emergency medicine (7), trauma and orthopaedics (6), acute internal medicine (2), mental health (1) and care of the elderly (0). All studies were observational, with variable methodological quality. In emergency medicine and in trauma and orthopaedics, when PAs are added to teams, reduced waiting and process times, lower charges, equivalent readmission rate and good acceptability to staff and patients are reported. Analgesia prescribing, operative complications and mortality outcomes were variable. In internal medicine outcomes of care provided by PAs and doctors were equivalent. CONCLUSIONS: PAs have been deployed to increase the capacity of a team, enabling gains in waiting time, throughput, continuity and medical cover. When PAs were compared with medical staff, reassuringly there was little or no negative effect on health outcomes or cost. The difficulty of attributing cause and effect in complex systems where work is organised in teams is highlighted. Further rigorous evaluation is required to address the complexity of the PA role, reporting on more than one setting, and including comparison between PAs and roles for which they are substituting. PROSPERO REGISTRATION NUMBER: CRD42016032895.

Gaining an advantage by sitting an OSCE after your peers: A retrospective study.

Purpose: To investigate if final year medical students undertaking an OSCE station at a later stage during examination diet were advantaged over their peers who undertook the same station at an earlier stage, and whether any such effect varies by the student's relative academic standing. Methods: OSCE data from six consecutive final year cohorts totaling 1505 students was analyzed. Mixed effects logistic regression was used to model factors associated with the probability of passing each individual station (random effects for students and circuits; and fixed effects to assess the association with day of examination, time of day, gender and year). Results: Weaker students were more likely to pass if they took their OSCE later in the examination period. The odds of passing a station increased daily by 20%. Overall, the mean number of stations passed by each student increased over the 5 days. Conclusions: Students undertaking the same OSCE stations later in examination period statistically had higher chances of passing compared to their peers, and the weaker students appear to be particularly advantaged. These findings have major implications for OSCE design, to ensure students are not advantaged by examination timing, and weaker students are not "passing in error".

Physician associates working in secondary care teams in England: Interprofessional implications from a national survey.

Physician associates (PAs) are a new type of healthcare professional to the United Kingdom; however, they are well established in the United States (where they are known as physician assistants). PAs are viewed as one potential solution to the current medical workforce doctor shortage. This study investigated the deployment of PAs within secondary care teams in England, through the use of a cross-sectional electronic, self-report survey. The findings from 14 questions are presented. Sixty-three PAs working in a range of specialties responded. A variety of work settings were reported, most frequently inpatient wards, with work generally taking place during weekdays. Both direct and non-direct patient care activities were reported, with the type of work undertaken varying at times, depending on the presence or absence of other healthcare professionals. PAs reported working within a variety of secondary care team staffing permutations, with the majority of these being interprofessional. Line management was largely provided by consultants; however day-to-day supervision varied, often relating to different work settings. A wide variation in ongoing supervision was also reported. Further research is required to understand the nature of PAs' contribution to collaborative care within secondary care teams in England.

Physician associates in England's hospitals: a survey of medical directors exploring current usage and factors affecting recruitment.

In the UK secondary care setting, the case for physician associates is based on the cover and stability they might offer to medical teams. We assessed the extent of their adoption and deployment - that is, their current usage and the factors supporting or inhibiting their inclusion in medical teams - using an electronic, self-report survey of medical directors of acute and mental health NHS trusts in England. Physician associates - employed in small numbers, in a range of specialties, in 20 of the responding trusts - were reported to have been employed to fill gaps in medical staffing and support medical specialty trainees. Inhibiting factors were commonly a shortage of physician associates to recruit and lack of authority to prescribe, as well as a lack of evidence and colleague resistance. Our data suggest there is an appetite for employment of physician associates while practical and attitudinal barriers are yet to be fully overcome.

The case for the physician assistant.

The NHS is facing a crisis from the combination of EWTD, MMC, the ageing population and rising expectations; thus its tradition of high quality care is under pressure. Physician assistants (PAs) are a new profession to the UK, educated to nationally set standards and, working as dependent practitioners, provide care in the medical model. PAs are currently employed by over 20 hospital Trusts as well as in primary care. They offer greater continuity than locum doctors and at considerably lower cost. PAs maintain generic competence and can therefore be utilised as required across different clinical areas. The stability of PAs in the workforce will be an additional resource for junior doctors on brief rotations. For the full benefits of PAs to be realised, and for the safety of the public, statutory registration and prescribing rights are required. Active support from the NHS is now needed to develop the workforce required.

Examination performance of graduate entry medical students compared with mainstream students.

OBJECTIVES: To assess whether medical students on graduate entry/fast- track programmes perform as well as students on standard courses. DESIGN: Retrospective cohort study. SETTING: University of Birmingham Medical School. PARTICIPANTS: Medical students on graduate entry/fast-track course and standard (5-year) course ('mainstream'). MAIN OUTCOME MEASURES: Examination marks from all assessments taken simultaneously by graduate entry course (GEC) and mainstream course students once the cohorts have combined: i.e. for the final three years of the programme. Honours awards for 2007 and 2008 graduates. RESULTS: In total 19,263 examination results were analysed from 1547 students. Of these 161 were GEC students and 1386 were mainstream medical students. On average mainstream students, male students, overseas students and students of South Asian ethnicity obtained lower examination marks than graduate entry students, female students, home or EU students and students of non-South Asian ethnicity, respectively. Graduate entry students were significantly more likely to achieve honours degrees than mainstream students. CONCLUSION: On average the academic performance of Graduate Entry medical students at the University of Birmingham is better than mainstream medical students.

The medical care practitioner: developing a physician assistant equivalent for the United Kingdom.

A range of demographic, social and other factors are creating a crisis in the provision of clinical care in the United Kingdom for which the physician assistant (PA) model developed in the United States appears to offer a partial solution. Local and national moves are underway to develop a similar cadre of registered health care professionals in England, with the current title of medical care practitioners (MCPs). A competence and curriculum framework document produced by a national steering group has formed the basis for a recent consultation process. A limited evaluation of US-trained PAs working in the West Midlands region of England in both primary care and acute secondary care suggests that PA activity is similar to that of doctors working in primary care and to primary care doctors working in the accident and emergency setting. The planned introduction of MCPs in England appears to offer, first, an effective strategy for increasing medical capacity, without jeopardising quality in frontline clinical services; and, second, the prospect of increased flexibility and stability in the medical workforce. The deployment of MCPs may offer advantages over increasing the number of doctors or taking nurses out of nursing roles. The introduction of MCPs may also enhance service effectiveness and efficiency.