LEARN: A multi-centre, cross-sectional evaluation of Urology teaching in UK medical schools.

OBJECTIVE: To evaluate the status of UK undergraduate urology teaching against the British Association of Urological Surgeons (BAUS) Undergraduate Syllabus for Urology. Secondary objectives included evaluating the type and quantity of teaching provided, the reported performance rate of General Medical Council (GMC)-mandated urological procedures, and the proportion of undergraduates considering urology as a career. MATERIALS AND METHODS: LEARN was a national multicentre cross-sectional study. Year 2 to Year 5 medical students and FY1 doctors were invited to complete a survey between 3rd October and 20th December 2020, retrospectively assessing the urology teaching received to date. Results are reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). RESULTS: 7,063/8,346 (84.6%) responses from all 39 UK medical schools were included; 1,127/7,063 (16.0%) were from Foundation Year (FY) 1 doctors, who reported that the most frequently taught topics in undergraduate training were on urinary tract infection (96.5%), acute kidney injury (95.9%) and haematuria (94.4%). The most infrequently taught topics were male urinary incontinence (59.4%), male infertility (52.4%) and erectile dysfunction (43.8%). Male and female catheterisation on patients as undergraduates was performed by 92.1% and 73.0% of FY1 doctors respectively, and 16.9% had considered a career in urology. Theory based teaching was mainly prevalent in the early years of medical school, with clinical skills teaching, and clinical placements in the later years of medical school. 20.1% of FY1 doctors reported no undergraduate clinical attachment in urology. CONCLUSION: LEARN is the largest ever evaluation of undergraduate urology teaching. In the UK, teaching seemed satisfactory as evaluated by the BAUS undergraduate syllabus. However, many students report having no clinical attachments in Urology and some newly qualified doctors report never having inserted a catheter, which is a GMC mandated requirement. We recommend a greater emphasis on undergraduate clinical exposure to urology and stricter adherence to GMC mandated procedures.

Passing MRCP (UK) PACES: a cross-sectional study examining the performance of doctors by sex and country.

BACKGROUND: There is much discussion about the sex differences that exist in medical education. Research from the United Kingdom (UK) and United States has found female doctors earn less, and are less likely to be senior authors on academic papers, but female doctors are also less likely to be sanctioned, and have been found to perform better academically and clinically. It is also known that international medical graduates tend to perform more poorly academically compared to home-trained graduates in the UK, US, and Canada. It is uncertain whether the magnitude and direction of sex differences in doctors' performance is variable by country. We explored the association between doctors' sex and their performance at a large international high-stakes clinical examination: the Membership of the Royal Colleges of Physicians (UK) Practical Assessment of Clinical Examination Skills (PACES). We examined how sex differences varied by the country in which the doctor received their primary medical qualification, the country in which they took the PACES examination, and by the country in which they are registered to practise. METHODS: Seven thousand six hundred seventy-one doctors attempted PACES between October 2010 and May 2013. We analysed sex differences in first time pass rates, controlling for ethnicity, in three groups: (i) UK medical graduates (N = 3574); (ii) non-UK medical graduates registered with the UK medical regulator, the General Medical Council (GMC), and thus likely to be working in the UK (N = 1067); and (iii) non-UK medical graduates without GMC registration and so legally unable to work or train in the UK (N = 2179). RESULTS: Female doctors were statistically significantly more likely to pass at their first attempt in all three groups, with the greatest sex effect seen in non-UK medical graduates without GMC registration (OR = 1.99; 95% CI = 1.65-2.39; P < 0.0001) and the smallest in the UK graduates (OR = 1.18; 95% CI = 1.03-1.35; P = 0.02). CONCLUSIONS: As found in a previous format of this examination and in other clinical examinations, female doctors outperformed male doctors. Further work is required to explore why sex differences were greater in non-UK graduates, especially those without GMC registration, and to consider how examination performance may relate to performance in practice.

Exploring cultural and linguistic influences on clinical communication skills: a qualitative study of International Medical Graduates.

BACKGROUND: International Medical Graduates (IMGs) are known to perform less well in many postgraduate medical examinations when compared to their UK trained counterparts. This "differential attainment" is observed in both knowledge-based and clinical skills assessments. This study explored the influence of culture and language on IMGs clinical communication skills, in particular, their ability to seek, detect and acknowledge patients' concerns in a high stakes postgraduate clinical skills examination. Hofstede's cultural dimensions framework was used to look at the impact of culture on examination performance. METHODS: This was a qualitative, interpretative study using thematic content analysis of video-recorded doctor-simulated patient consultations of candidates sitting the MRCP(UK) PACES examination, at a single examination centre in November 2012. The research utilised Hofstede's cultural dimension theory, a framework for comparing cultural factors amongst different nations, to help understand the reasons for failure. RESULTS: Five key themes accounted for the majority of communication failures in station 2, "history taking" and station 4, "communication skills and ethics" of the MRCP(UK) PACES examination. Two themes, the ability to detect clues and the ability to address concerns, related directly to the overall construct managing patients' concerns. Three other themes were found to impact the whole consultation. These were building relationships, providing structure and explanation and planning. CONCLUSION: Hofstede's cultural dimensions may help to contextualise some of these observations. In some cultures doctor and patient roles are relatively inflexible: the doctor may convey less information to the patient (higher power distance societies) and give less attention to building rapport (high uncertainty avoidance societies.) This may explain why cues and concerns presented by patients were overlooked in this setting. Understanding cultural differences through Hofstede's cultural dimensions theory can inform the preparation of candidates for high stakes bedside clinical skills examinations and for professional practice.

Sex differences in medico-legal action against doctors: a systematic review and meta-analysis.

BACKGROUND: The relationship between male sex and poor performance in doctors remains unclear, with high profile studies showing conflicting results. Nevertheless, it is an important first step towards understanding the causes of poor performance in doctors. This article aims to establish the robustness of the association between male sex and poor performance in doctors, internationally and over time. METHODS: The electronic databases MEDLINE, EMBASE, and PsycINFO were searched from inception to January 2015. Backward and forward citation searching was performed. Journals that yielded the majority of the eligible articles and journals in the medical education field were electronically searched, along with the conference and poster abstracts from two of the largest international medical education conferences. Studies reporting original data, written in English or French, examining the association between sex and medico-legal action against doctors were included. Two reviewers independently extracted study characteristics and outcome data from the full texts of the studies meeting the eligibility criteria. Study quality was assessed using the Newcastle-Ottawa scale. A random effect meta-analysis model was used to summarize and assess the effect of doctors' sex on medico-legal action. Extracted outcomes included disciplinary action by a medical regulatory board, malpractice experience, referral to a medical regulatory body, complaints received by a healthcare complaints body, criminal cases, and medico-legal matter with a medical defence organisation. RESULTS: Overall, 32 reports examining the association between doctors' sex and medico-legal action were included in the systematic review (n=4,054,551), of which 27 found that male doctors were more likely to have experienced medico-legal action. 19 reports were included in the meta-analysis (n=3,794,486, including 20,666 cases). Results showed male doctors had nearly two and a half times the odds of being subject to medico-legal action than female doctors. Heterogeneity was present in all meta-analyses. CONCLUSION: Male doctors are more likely to have had experienced medico-legal actions compared to female doctors. This finding is robust internationally, across outcomes of varying severity, and over time.

Are the General Medical Council's Tests of Competence fair to long standing doctors? A retrospective cohort study.

BACKGROUND: The General Medical Council's Fitness to Practise investigations may involve a test of competence for doctors with performance concerns. Concern has been raised about the suitability of the test format for doctors who qualified before the introduction of Single Best Answer and Objective Structured Clinical Examination assessments, both of which form the test of competence. This study explored whether the examination formats used in the tests of competence are fair to long standing doctors who have undergone fitness to practise investigation. METHODS: A retrospective cohort design was used to determine an association between year of primary medical qualification and doctors' test of competence performance. Performance of 95 general practitioners under investigation was compared with a group of 376 volunteer doctors. We analysed performance on knowledge test, OSCE overall, and three individual OSCE stations using Spearman's correlation and regression models. RESULTS: Doctors under investigation performed worse on all test outcomes compared to the comparison group. Qualification year correlated positively with performance on all outcomes except for physical examination (e.g. knowledge test r = 0.48, p < 0.001 and OSCE r = 0.37, p < 0.001). Qualification year was associated with test performance in doctors under investigation even when controlling for sex, ethnicity and qualification region. Regression analyses showed that qualification year was associated with knowledge test, OSCE and communication skills performance of doctors under investigation when other variables were controlled for. Among volunteer doctors this was not the case and their performance was more strongly related to where they qualified and their ethnic background. Furthermore, volunteer doctors who qualified before the introduction of Single Best Answer and OSCE assessments, still outperformed their peers under investigation. CONCLUSIONS: Earlier graduates under fitness to practise investigation performed less well on the test of competence than their more recently qualified peers under investigation. The performance of the comparator group tended to stay consistent irrespective of year qualified. Our results suggest that the test format does not disadvantage early qualified doctors. We discuss findings in relation to the GMC's fitness to practise procedures and suggest alternative explanations for the poorer performance of long standing doctors under investigation.

Cross-comparison of MRCGP & MRCP(UK) in a database linkage study of 2,284 candidates taking both examinations: assessment of validity and differential performance by ethnicity.

BACKGROUND: MRCGP and MRCP(UK) are the main entry qualifications for UK doctors entering general [family] practice or hospital [internal] medicine. The performance of MRCP(UK) candidates who subsequently take MRCGP allows validation of each assessment. In the UK, underperformance of ethnic minority doctors taking MRCGP has had a high political profile, with a Judicial Review in the High Court in April 2014 for alleged racial discrimination. Although the legal challenge was dismissed, substantial performance differences between white and BME (Black and Minority Ethnic) doctors undoubtedly exist. Understanding ethnic differences can be helped by comparing the performance of doctors who take both MRCGP and MRCP(UK). METHODS: We identified 2,284 candidates who had taken one or more parts of both assessments, MRCP(UK) typically being taken 3.7 years before MRCGP. We analyzed performance on knowledge-based MCQs (MRCP(UK) Parts 1 and 2 and MRCGP Applied Knowledge Test (AKT)) and clinical examinations (MRCGP Clinical Skills Assessment (CSA) and MRCP(UK) Practical Assessment of Clinical Skills (PACES)). RESULTS: Correlations between MRCGP and MRCP(UK) were high, disattenuated correlations for MRCGP AKT with MRCP(UK) Parts 1 and 2 being 0.748 and 0.698, and for CSA and PACES being 0.636. BME candidates performed less well on all five assessments (P < .001). Correlations disaggregated by ethnicity were complex, MRCGP AKT showing similar correlations with Part1/Part2/PACES in White and BME candidates, but CSA showing stronger correlations with Part1/Part2/PACES in BME candidates than in White candidates. CSA changed its scoring method during the study; multiple regression showed the newer CSA was better predicted by PACES than the previous CSA. CONCLUSIONS: High correlations between MRCGP and MRCP(UK) support the validity of each, suggesting they assess knowledge cognate to both assessments. Detailed analyses by candidate ethnicity show that although White candidates out-perform BME candidates, the differences are largely mirrored across the two examinations. Whilst the reason for the differential performance is unclear, the similarity of the effects in independent knowledge and clinical examinations suggests the differences are unlikely to result from specific features of either assessment and most likely represent true differences in ability.

Doctors who pilot the GMC's Tests of Competence: who volunteers and why?

BACKGROUND: Doctors who are investigated by the General Medical Council for performance concerns may be required to take a Test of Competence (ToC). The tests are piloted on volunteer doctors before they are used in Fitness to Practise (FtP) investigations. OBJECTIVES: To find out who volunteers to take a pilot ToC and why. METHODS: This was a retrospective cohort study. Between February 2011 and October 2012 we asked doctors who volunteered for a test to complete a questionnaire about their reasons for volunteering and recruitment. We analysed the data using descriptive statistics and Pearson's χ(2) test. RESULTS: 301 doctors completed the questionnaire. Doctors who took a ToC voluntarily were mostly women, of white ethnicity, of junior grades, working in general practice and who held a Primary Medical Qualification (PMQ) from the UK. This was a different population to doctors under investigation and all registered doctors in the UK. Most volunteers heard about the General Medical Council's pilot events through email from a colleague and used the experience to gain exam practice for forthcoming postgraduate exams. CONCLUSIONS: The reference groups of volunteers are not representative of doctors under FtP investigation. Our findings will be used to inform future recruitment strategies with the aim to encourage better matching of groups who voluntarily pilot a ToC with those under FtP investigation.

The Academic Backbone: longitudinal continuities in educational achievement from secondary school and medical school to MRCP(UK) and the specialist register in UK medical students and doctors.

BACKGROUND: Selection of medical students in the UK is still largely based on prior academic achievement, although doubts have been expressed as to whether performance in earlier life is predictive of outcomes later in medical school or post-graduate education. This study analyses data from five longitudinal studies of UK medical students and doctors from the early 1970s until the early 2000s. Two of the studies used the AH5, a group test of general intelligence (that is, intellectual aptitude). Sex and ethnic differences were also analyzed in light of the changing demographics of medical students over the past decades. METHODS: Data from five cohort studies were available: the Westminster Study (began clinical studies from 1975 to 1982), the 1980, 1985, and 1990 cohort studies (entered medical school in 1981, 1986, and 1991), and the University College London Medical School (UCLMS) Cohort Study (entered clinical studies in 2005 and 2006). Different studies had different outcome measures, but most had performance on basic medical sciences and clinical examinations at medical school, performance in Membership of the Royal Colleges of Physicians (MRCP(UK)) examinations, and being on the General Medical Council Specialist Register. RESULTS: Correlation matrices and path analyses are presented. There were robust correlations across different years at medical school, and medical school performance also predicted MRCP(UK) performance and being on the GMC Specialist Register. A-levels correlated somewhat less with undergraduate and post-graduate performance, but there was restriction of range in entrants. General Certificate of Secondary Education (GCSE)/O-level results also predicted undergraduate and post-graduate outcomes, but less so than did A-level results, but there may be incremental validity for clinical and post-graduate performance. The AH5 had some significant correlations with outcome, but they were inconsistent. Sex and ethnicity also had predictive effects on measures of educational attainment, undergraduate, and post-graduate performance. Women performed better in assessments but were less likely to be on the Specialist Register. Non-white participants generally underperformed in undergraduate and post-graduate assessments, but were equally likely to be on the Specialist Register. There was a suggestion of smaller ethnicity effects in earlier studies. CONCLUSIONS: The existence of the Academic Backbone concept is strongly supported, with attainment at secondary school predicting performance in undergraduate and post-graduate medical assessments, and the effects spanning many years. The Academic Backbone is conceptualized in terms of the development of more sophisticated underlying structures of knowledge ('cognitive capital' and 'medical capital'). The Academic Backbone provides strong support for using measures of educational attainment, particularly A-levels, in student selection.

Funding of medical education: the need for transparency.

Medical education is vital to the future of healthcare provision. It is also expensive. We should ensure that the funding spent on medical education is spent in the most cost-effective way possible and delivers the best possible returns on our investment. Budgets that have been allocated to medical education should be spent on this and not on research or clinical care. Educational budgets should be transparent - so that their use and misuse are clear. We should develop a culture of lifelong learning and continually make explicit that future healthcare professionals need investment in their education to maintain the quality and safety of healthcare delivery.

Investigating possible ethnicity and sex bias in clinical examiners: an analysis of data from the MRCP(UK) PACES and nPACES examinations.

BACKGROUND: Bias of clinical examiners against some types of candidate, based on characteristics such as sex or ethnicity, would represent a threat to the validity of an examination, since sex or ethnicity are 'construct-irrelevant' characteristics. In this paper we report a novel method for assessing sex and ethnic bias in over 2000 examiners who had taken part in the PACES and nPACES (new PACES) examinations of the MRCP(UK). METHOD: PACES and nPACES are clinical skills examinations that have two examiners at each station who mark candidates independently. Differences between examiners cannot be due to differences in performance of a candidate because that is the same for the two examiners, and hence may result from bias or unreliability on the part of the examiners. By comparing each examiner against a 'basket' of all of their co-examiners, it is possible to identify examiners whose behaviour is anomalous. The method assessed hawkishness-doveishness, sex bias, ethnic bias and, as a control condition to assess the statistical method, 'even-number bias' (i.e. treating candidates with odd and even exam numbers differently). Significance levels were Bonferroni corrected because of the large number of examiners being considered. RESULTS: The results of 26 diets of PACES and six diets of nPACES were examined statistically to assess the extent of hawkishness, as well as sex bias and ethnicity bias in individual examiners. The control (odd-number) condition suggested that about 5% of examiners were significant at an (uncorrected) 5% level, and that the method therefore worked as expected. As in a previous study (BMC Medical Education, 2006, 6:42), some examiners were hawkish or doveish relative to their peers. No examiners showed significant sex bias, and only a single examiner showed evidence consistent with ethnic bias. A re-analysis of the data considering only one examiner per station, as would be the case for many clinical examinations, showed that analysis with a single examiner runs a serious risk of false positive identifications probably due to differences in case-mix and content-specificity. CONCLUSIONS: In examinations where there are two independent examiners at a station, our method can assess the extent of bias against candidates with particular characteristics. The method would be far less sensitive in examinations with only a single examiner per station as examiner variance would be confounded with candidate performance variance. The method however works well when there is more than one examiner at a station and in the case of the current MRCP(UK) clinical examination, nPACES, found possible sex bias in no examiners and possible ethnic bias in only one.

The mediators of minority ethnic underperformance in final medical school examinations.

BACKGROUND: UK-trained medical students and doctors from minority ethnic groups underperform academically. It is unclear why this problem exists, which makes it difficult to know how to address it. AIM: To investigate whether demographic and psychological factors mediate the relationship between ethnicity and final examination scores. SAMPLE: Two consecutive cohorts of Year 5 (final year) UCL Medical School students (n= 703; 51% minority ethnic). A total of 587 (83%) had previously completed a questionnaire in Year 3. METHODS: Participants were administered a questionnaire in 2005 and 2006 that included a short version of the NEO-PI-R, the Study Process Questionnaire, and the General Health Questionnaire (GHQ) as well as socio-demographic measures. Participants were then followed up to final year (2007-2010). White and minority ethnic students' questionnaire responses and final examination grades were compared using univariate tests. The effect of ethnicity on final year grades after taking into account the questionnaire variables was calculated using hierarchical multiple linear regression. RESULTS: Univariate ethnic differences were found on age, personality, learning styles, living at home, first language, parental factors, and prior education. Minority ethnic students had lower final exam scores, were more likely to fail, and less likely to achieve a merit or distinction in finals. Multivariate analyses showed ethnicity predicted final exam scores even after taking into account questionnaire factors. CONCLUSIONS: Ethnic differences in the final year performance of two cohorts of UCL medical students were not due to differences in psychological or demographic factors, which suggests alternative explanations are responsible for the ethnic attainment gap in medicine.

Influences and outcomes of less than full-time working in the medical profession: a systematic review protocol.

INTRODUCTION: An impoverished medical workforce is a global phenomenon, which can impact patient care significantly. Greater flexibility in working patterns is one approach policy-makers adopt to address this issue, and the expansion of less than full-time (LTFT) working forms part of this. Studies suggest that LTFT working has the potential to improve recruitment and retention by aligning with how doctors increasingly want to balance their careers with other commitments and interests. What is less well understood are the influencing factors and outcomes related to LTFT working among doctors. This protocol outlines the methodology for a systematic review that will evaluate existing knowledge on LTFT working in the medical profession. METHODS AND ANALYSIS: The Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines will be followed. Embase, MEDLINE, PsycINFO, Health Management Information Consortium, Web of Science, Cochrane Library, Healthcare Administration, and Applied Social Sciences Index and Abstracts will be searched for studies published up to March 2022. Unpublished literature from EThos and ProQuest Dissertations & Theses Global will also be searched. Bibliographic searching, citation searching and handsearching will be used to retrieve additional papers. Authors will be contacted for data or publications if necessary. Two independent reviewers will undertake study screening, data extraction and quality assessment, with disagreements resolved by consensus or by a third reviewer if necessary. Data synthesis will be by narrative synthesis and meta-analysis if possible. ETHICS AND DISSEMINATION: The proposed study does not require ethical approval; however, it forms part of a larger body of research on the impact of LTFT working on the medical workforce for which ethics approval has been granted by the Research Ethics Committee at University College London. Findings will be published in a peer-reviewed journal and will be presented at national and international conferences. PROSPERO REGISTRATION NUMBER: CRD42022307174.

Changing PACES: developments to the examination in 2009.

As a consequence of change in medical, educational and regulatory practice, MRCP(UK) successfully modified the international PACES examination in 2009. This brief paper explains the rationale for change and summarises the development and implementation process.

Retrospective observational study of ethnicity-gender pay gaps among hospital and community health service doctors in England.

OBJECTIVES: To identify differences in average basic pay between groups of National Health Service (NHS) doctors cross-classified by ethnicity and gender. Analyse the extent to which characteristics (grade, specialty, age, hours, etc.) can explain these differences. DESIGN: Retrospective observational study using repeated cross-section design. SETTING: Hospital and Community Health Service (HCHS) in England. PARTICIPANTS: All HCHS doctors in England employed by the NHS between 2016 and 2020 appearing in the Digital Electronic Staff Record dataset (average N=99 953 per year). MAIN OUTCOME MEASURES: Hours-adjusted full-time equivalent pay gaps; given as raw data and further adjusted for demographic, job, and workplace characteristics (such as grade, specialty, age, whether British nationality, region) using multivariable regression and statistical decomposition techniques. RESULTS: Pay gaps relative to white men vary with the ethnicity-gender combination. Indian men slightly out-earn white men and Bangladeshi women have a 40% pay gap. In most cases, pay gaps can largely be explained by characteristics that can be measured, especially grade, with the extent varying by specific ethnicity-gender group. However, a portion of pay gaps cannot be explained by characteristics that can be measured. CONCLUSIONS: This study presents new evidence on ethnicity-gender pay gaps among NHS doctors in England using high quality administrative and payroll data. The findings indicate all ethnicity-gender groups earn less than white men on average, except for Indian men. In some cases, these differences cannot be explained giving rise to discussions about the role of discrimination.