Striking fear into students' hearts: Unforeseen consequences of prescribing education.

PURPOSE: Undergraduate medical education (UGME) has to prepare students to do safety-critical work (notably, to prescribe) immediately after qualifying. Despite hospitals depending on them, medical graduates consistently report feeling unprepared to prescribe and they sometimes harm patients. Research clarifying how to prepare students better could improve healthcare safety. Our aim was to explore how students experienced preparing for one of their commonest prescribing tasks: intravenous fluid therapy (IVFT). METHODS: Complexity assumptions guided the research, which used a qualitative methodology oriented towards hermeneutic phenomenology. The study design was an uncontrolled and unplanned complex intervention: judicial review of the iatrogenic death of five children due to hyponatraemia in our region had resulted in the recommendation that students' education in 'the implementation of important clinical guidelines' relevant to fluid and electrolyte balance should be intensified. An opportunity sample of 40 final-year medical students drew and gave audio-recorded commentaries on rich pictures. We completed two template analyses: one of participants' transcribed commentaries on the pictures and one using a novel heuristic to analyse the pictures themselves. We then reconciled the two analyses into a single template. RESULTS: There were four themes: affects, teaching and learning, contradictions, and the curriculum as a journey. To explore interconnections between themes, we chose the picture best exemplifying each of the four themes and interpreted the curriculum journey depicted in each of them. These interpretations were grounded in each participant's picture, verbal account of the picture, and the aggregate findings of the template analysis. Participants' experiences were influenced by the situated complexity of IVFT. Layered on top of that, contradictions, overlaps, and gaps within the curriculum introduced extraneous complexity. Confusion and apprehension resulted. CONCLUSIONS: After spending five years preparing to prescribe IVFT, participants felt unprepared to do so. We conclude that intensive teaching had not achieved its avowed goal of improving students' preparedness for safe practice. Merton's seminal work on the 'unanticipated consequences of purposive social action' suggests that intensive teaching may even have contributed to their unpreparedness.

Stepping into the shoes of older people: a scoping review of simulating ageing experiences for healthcare professional students.

BACKGROUND: Ageing simulation suits and equipment give healthcare professional (HCP) students the opportunity to experience what it might feel like to be an older person with age-related disability or illness. Ageing simulation experiences, where students complete activities of daily living (ADL) tasks, aim to reproduce the challenges an older person may face. OBJECTIVES: We undertook a scoping literature review to establish, from the evidence base, what is known about simulating ageing experiences for HCP students and its impact on attitudes towards older patients. METHODS: We applied Arksey and O'Malley's scoping literature review framework to achieve relevant articles. Four databases (MEDLINE, Embase, Web of Science and Cumulative Index to Nursing and Allied Health Literature) were searched resulting in 114 citations. After screening and applying our exclusion criteria, 14 articles were selected for inclusion. RESULTS: Fifty percent of studies were mixed-methods, 35% quasi-experimental, 7% quantitative and 7% qualitative. Two types of simulation experience were identified: (i) workshop based and (ii) ageing games. Simulated impairments included vision, hearing and mobility issues. Most common ADLs simulated were managing medications, finances and functional ability. The majority of studies reported a positive impact on knowledge, attitudes and empathy towards older people. CONCLUSIONS: Teaching in Care of Older People is important in HCP undergraduate curricula and should be a positive experience promoting successful ageing while raising awareness of ageism. Ageing suits have a positive impact on students' attitudes and empathic skills towards older people. Future research should include interprofessional education with HCP students learning together throughout undergraduate training.

Towards accountability-centred practices: governance in OSCEs subordinating patient and practitioner clinical experience.

New public management ideals and standards have become increasingly adhered to in health professions education; this is particularly apparent in high-stakes assessment, as a gateway to practice. Using an Institutional Ethnographic approach, we looked at the work involved in running high-stakes Objective Structured Clinical Exams (OSCEs) throughout an academic year including use of observations, interviews and textual analysis. In our results, we describe three types of 'work'-standardising work, defensibility work and accountability work-summarising these in the discussion as an Accountability Circuit, which shows the organising role of texts on people's work processes. We show how this form of governance mandates a shift towards accountability-centred practices, away from practices which are person-centred; this lens on accountability-centring during high-stakes assessments invites critique of the often-unquestioned emphasis of new public management in health professions education.

Is there ever a single best answer (SBA): assessment driving certainty in the uncertain world of GP?

Uncertainty is inherent in all areas of medical practice, not least in primary care, which is defined by its acceptance of uncertainty and complexity. Single best answer (SBA) questions are a ubiquitous assessment tool in undergraduate medical assessments; however clinical practice, particularly in primary care, challenges the supposition that a single best answer exists for all clinical encounters and dilemmas. In this article, we seek to highlight several aspects of the relationship between this assessment format and clinical uncertainty by considering its influence on medical students' views of uncertainty in the contexts of their medical education, personal epistemology, and clinical expectations.

'Visiting uncertainty': an immersive primary care simulation to explore decision-making when there is clinical uncertainty.

Doctors are required to be able to care for patients in a variety of settings, including the patient's home. Patients requiring urgent care in their own homes are at risk of acute deterioration. However, differentiating acute deterioration from self-limiting conditions in the primary care environment can be challenging, even for GPs who are experienced in managing clinical uncertainty and ambiguity. Preparedness for practice of foundation doctors is directly related to opportunities for experiential learning and medical students face many barriers to obtaining experience of acute care in clinical environments. Simulation has been used in healthcare education as an adjunct to experiential learning in clinical environments since the 1950s. At present, the utilisation of immersive simulation in primary care environments for medical students is uncommon even though many foundation doctors will work in primary care. This article describes how faculty at a UK medical school developed an immersive simulated home visit scenario on an 'Acute Care Course' for medical students during their Assistantship. Debriefing discussions between students, faculty, and simulated participants focused on the cognitive, emotional, and ethical impacts of uncertainty and how this influenced clinical decision-making for medical students. Having an authentic simulated scenario in the primary care environment, where clinical uncertainty and ambiguity are ubiquitous, offered students opportunities in experiential learning in how to make clinical decisions, despite clinical uncertainty and ambiguity, when assessing and caring for acutely unwell patients.

Harnessing insights from an activity system - OSCEs past and present expanding future assessments.

Objective Structured Clinical Examinations (OSCEs) are a dominant, yet problematic, assessment tool across health professions education (HPE). OSCEs' standardised approach aligns with regulatory accountability, allowing learners to exchange exam success for the right to practice. We offer a sociohistorical account of OSCEs' development to support an interpretation of present assessment practices. OSCEs create tensions. Preparing for OSCE success diverts students away from the complexity of authentic clinical environments. Students will not qualify and will, therefore, be of no use to patients without getting marks providing evidence of competence. Performing in a formulaic and often non patient-centred way is the price to pay for a qualification. Acknowledging the stultifying effect of standardising human behaviour for OSCEs opens up possibilities to release latent energy for change in medical education. In this imagined future, the overall object of education is refocused on patient care.

'More extraordinary than mundane ' A phenomenological analysis of the experiences of individuals living with CLE and their taking care in the sun.

INTRODUCTION: CLE is a chronic inflammatory autoimmune condition of which photosensitivity is a major symptom. Individuals living with CLE are advised to practice photoprotection. Despite the benefits for disease control, many individuals living with CLE do not practice optimal photoprotection. The aim of this study was to gain a deep insight into the lived experiences of individuals with CLE and their photoprotective practices. METHODS: A qualitative study approach was conducted, using Hermeneutic phenomenology. Individuals living with CLE were recruited and interviewed. Rich pictures were used to enrich the interviews. Interviews were transcribed and analysed using Template Analysis. RESULTS: Analysis revealed four themes: 'Much more than just a photosensitive skin condition', 'The impact of sun on CLE and social dynamics', 'Drifting to the sun: personal transitions and social norms' and 'Taking care in the sun: easier said than done'. DISCUSSION AND CONCLUSION: This study provides a nuanced insight into the lived experiences of individuals with CLE and their photoprotective practices. Taking care in the sun is not a simplistic process. Beyond the biomedical model of illness, the social impact that CLE has on individuals has a dominant influence on their photoprotective behaviours. Such insights could help healthcare professionals tailor photoprotective advice.

In, But Out of Touch: Connecting With Patients During the Virtual Visit.

Covid-19 has rapidly changed physician-patient interaction, from hands-on to hands-off medicine. In this essay, 2 family physicians on different continents reflect on the meaning of touch in clinical practice and how virtual care is transforming this tacit aspect of patient care. Although technology enables physicians to stay in touch with patients verbally, we have lost the ability to physically touch. Traditionally, touch is central to medical practice, physical examination guides diagnosis and informs management. But the silent language of touch fulfills a deeper symbolic function, enabling physicians to acknowledge patient concerns in a tangible way. Touch expresses healing, extending beyond skin-to-skin contact to express humanity, caring, and connection. As we adapt to novel technologies, we wonder how, as family physicians, we will adapt our clinical acumen to extend our ability to connect with patients.

'What you can't tell left from right?' Medical students' experiences in making laterality decisions.

CONTEXT: Wrong-sided procedures represent some of the most catastrophic errors in health care. Although errors in laterality are multifaceted in origin, human error is considered to be an important root cause. Evidence suggests that a significant proportion of the population, including medical students, experience difficulty in left-right discrimination (LRD). Given that not all medical students have equal LRD ability, there have been calls to raise awareness of this issue in medical education. The experiences of medical students with LRD, including those who have difficulty, remain unknown. OBJECTIVES: This study was designed to gain deep insights into the lived experiences of medical students in LRD. METHODS: A qualitative study was conducted using hermeneutic phenomenology. Medical students with a wide range of abilities in LRD were invited to participate and to be interviewed. Interviews were transcribed and analysed using template analysis to generate research themes. Members of the research team were continually reflexive when remaining firmly rooted in the data and in the principles of the hermeneutic process. RESULTS: Analysis yielded four main themes: (i) discriminating right from left: an unconscious or a conscious task? (ii) 'What … you can't tell right from left?': an undesirable skill deficit; (iii) concealment, and (iv) 'But you're going to be a doctor!': impact on professional identity formation. CONCLUSIONS: This study challenges normative expectations that LRD is an effortless task for all. Individuals who are challenged in LRD must engage in a complex conscious process to determine right from left. For the most part, this process is relatively effortless. However, the context of being a medical student can impose extra demands and heightens the risk associated with potential error. Medical education needs to respond by raising the profile of this challenge, with which many of our medical students are confronted, and by extending support to assist them in the interests of safe patient care.

Exploring undergraduate students achievement emotions during ward round simulation: a mixed-method study.

BACKGROUND: Simulation based learning (SBL) has increased in its use to best equip students for clinical practice. Simulations that mirror the complex realities of clinical practice have the potential to induce a range of emotions, without a clear understanding of their impact on learning and the learner. Students' emotional states have important effects on their learning process that can be either positive or negative, and are often difficult to predict. We aimed to determine: (1) To what extent achievement emotions are experienced by medical students during a complex simulation based learning activity, i.e. a ward round simulation (WRS). (2) What their performance scores are and too which extent performance scores do correlate with emotions and 3) how these emotions are perceived to impact learning. METHODS: A mixed methods approach was used in this study. Using an Achievement Emotion Questionnaire, we explored undergraduate medical student's emotions as they participated in a complex ward round-based simulation. Their performance was rated using an observational ward round assessment tool and correlated with emotions scores. Six focus groups were conducted to provide a deeper understanding of their emotional and learning experiences. RESULTS: Students experienced a range of emotions during the simulation, they felt proud, enjoyed the simulation and performed well. Students felt proud because they could show in the complex simulation what they had learned so far. Students reported moderate levels of anxiety and low levels of frustration and shame. We found non-significant correlations between achievement emotions and performance during ward round simulation. CONCLUSIONS: Placing undergraduate students in high complex simulations that they can handle raises positive academic achievement emotions which seem to support students' learning and motivation.

How can tomorrow's doctors be more caring? A phenomenological investigation.

CONTEXT: Peabody's maxim 'the secret of the care of the patient is in caring for the patient' inspired generations of doctors to relate humanely to patients. Since then, phrases such as 'managed care' have impersonalised caring. The term 'patient-centred' was introduced to re-personalise caring. Ironically, however, such terms have been defined by professionals' preconceptions rather than patients' experiences. Using patients' experiences of doctors being (un)caring to guide doctors' learning could reinvigorate caring. Interpretive phenomenology provides qualitative research tools with which to do this. METHODS: Ten patients, purposively selected to have broad experiences of primary, secondary and tertiary health care, consented to participate. To stay close to their lived experiences, participants first drew 'Pictor' diagrams to represent relationships between themselves and professionals during remembered experiences of (un)caring. A researcher then used the depictions to structure in-depth, one-to-one explorations of the lived experience of caring. Verbatim transcripts were analysed using template analysis. To remain very close to patients' experiences, the researchers assembled a narrative description of the phenomenon of caring using participants' own words. RESULTS: Caring doctors were genuine. They allowed their own individuality to interact with patients' individuality. This made participants feel recognised as individuals, not just diseases. Caring doctors listened and spoke carefully, encouraged expressions of emotion, were accessible and responsive, and formed relationships. These factors empowered participants to be actively involved in their own care. Little things like smiling, shaking hands, admitting uncertainty, asking a colleague for advice and calling a participant unexpectedly at home showed that doctors were prepared to 'go above and beyond'. This was caring. CONCLUSIONS: These findings provide medical educators with an interpretation of caring that is truly patient-centred. Coupling technical proficiency with human qualities - being genuinely empathic and respectful - within doctor-patient relationships is the essence of caring.

Improving adherence to multiple medications in older people in primary care: Selecting intervention components to address patient-reported barriers and facilitators.

BACKGROUND: Medication adherence is vital to ensuring optimal patient outcomes, particularly amongst multimorbid older people prescribed multiple medications. Interventions targeting adherence often lack a theoretical underpinning and this may impact on effectiveness. The theoretical domains framework (TDF) of behaviour can aid intervention development by systematically identifying key determinants of medication adherence. OBJECTIVES: This study aimed to (i) identify determinants (barriers, facilitators) of adherence to multiple medications from older people's perspectives; (ii) identify key domains to target for behaviour change; and (iii) map key domains to intervention components [behaviour change techniques (BCTs)] that could be delivered in an intervention by community pharmacists. METHOD: Focus groups were conducted with older people (>65 years) receiving ≥4 medications. Questions explored the 12 domains of the TDF (eg "Knowledge," "Emotion"). Data were analysed using the framework method and content analysis. Identification of key domains and mapping to intervention components (BCTs) followed established methods. RESULTS: Seven focus groups were convened (50 participants). A wide range of determinants were identified as barriers (eg forgetfulness, prioritization of medications) and facilitators (eg social support, personalized routines) of adherence to multiple medications. Eight domains were identified as key targets for behaviour change (eg "Social influences," "Memory, attention and decision processes," "Motivation and goals") and mapped to 11 intervention components (BCTs) to include in an intervention [eg "Social support or encouragement (general)," "Self-monitoring of the behaviour," "Goal-setting (behaviour)"]. CONCLUSION: This study used a theoretical underpinning to identify potential intervention components (BCTs). Future work will incorporate the selected BCTs into an intervention that will undergo feasibility testing in community pharmacies.

Ward round simulation in final year medical students: Does it promote students learning?

INTRODUCTION: Ward round skills are essential for doctors in hospital settings. Literature shows medical students' deficiencies in these skills. Simulation has been used to train these skills. However, exposing learners to simulation at an early stage may be associated with a high cognitive load and limited learning. This study aims to determine how students experience this load and its interplay with performance and which factors promote and impair learning. METHODS: Fifty-six final year medical students participated in a simulated ward round training exercise. Both students' performance and cognitive load were measured to determine if there was any correlation and interviews were carried out to understand which factors support and impair learning. RESULTS: Performance scores revealed deficiencies in ward round skills. Students experienced a cognitive load that weakly correlated with performance. Qualitative findings provided important insights into simulated ward-based learning. It is clear that well-designed clinical scenarios, prioritization tasks, teamwork and feedback support students' learning process whereas distractions impair learning. CONCLUSIONS: WRS proved to be a good teaching method to improve clinical skills at this stage as the cognitive load is not too high to impair learning. Hence, including tasks in the simulation design can enhance the learning process.

Preparation for practice: a novel role for general practice in pre-foundation assistantships.

BACKGROUND: Hospital-based undergraduate assistantships are now widely established in medical school curricula. They are considered to improve graduates' preparedness for practice in their role as a foundation doctor. Foundation doctors play a key team role in ensuring patient safety during complex transitions across the hospital/primary care interface, and their self-reported preparedness for practice still varies considerably. AIMS: We sought to explore what spending one week of the pre-foundation assistantship in General Practice might add. METHODS: We solicited reflective audio diaries from final year students during a one-week pilot attachment delivered during the post-finals, pre-foundation assistantship period, and performed an iterative thematic analysis on the acquired data. RESULTS: From this attachment in General Practice, students described diverse learning, resulting in improved preparedness for (hospital) foundation practice across several domains, impacting positively on how they might approach patients in the future. Self-confidence improved due to affirming outcomes and tutor mentorship. Students deepened their understanding of community healthcare and General Practice; and seeing the 'Patient Journey' across the interface from the patient's perspective helped them contextualise their forthcoming role as foundation doctors in managing it. DISCUSSION: We believe that this novel intervention distinctively contributed to preparedness for practice. It aligns with published recommendations about extending the current assistantship model. We suggest it should be incorporated more widely into pre-foundation assistantship curricula.

The show must go on? Patients, props and pedagogy in the theatre of the OSCE.

According to Shakespeare, all the world's a stage, and all the men and women merely players. The objective structured clinical examination (OSCE), that most ubiquitous form of assessment in health professions education, offers us a particular instance of this maxim. Comprising at first glance a world of psychometric data, detailed checklists and global rating scales, the OSCE sets out to facilitate the assessment of a candidate's competence in a highly standardised and objective fashion. Despite this clear intention, OSCEs also offer a rich vein of (often unacknowledged) social and cultural processes. In this commentary, we draw on Goffman's dramaturgy metaphor and our experiences to undertake a wry examination of some of the least intended consequences of OSCEs. We take a satirical look at both the potential impact on patients and the pedagogical implications of this form of assessment. We now urge you to sit back, settle in and enjoy the show, as we raise the curtain on this one-night-only performance!

Development of an intervention to improve appropriate polypharmacy in older people in primary care using a theory-based method.

BACKGROUND: It is advocated that interventions to improve clinical practice should be developed using a systematic approach and intervention development methods should be reported. However, previous interventions aimed at ensuring that older people receive appropriate polypharmacy have lacked details on their development. This study formed part of a multiphase research project which aimed to develop an intervention to improve appropriate polypharmacy in older people in primary care. METHODS: The target behaviours for the intervention were prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners (GPs) and community pharmacists. Intervention development followed a systematic approach, including previous mapping of behaviour change techniques (BCTs) to key domains from the Theoretical Domains Framework that were perceived by GPs and pharmacists to influence the target behaviours. Draft interventions were developed to operationalise selected BCTs through team discussion. Selection of an intervention for feasibility testing was guided by a subset of the APEASE (Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety, Equity) criteria. RESULTS: Three draft interventions comprising selected BCTs were developed, targeting patients, pharmacists and GPs, respectively. Following assessment of each intervention using a subset of the APEASE criteria (affordability, practicability, acceptability), the GP-targeted intervention was selected for feasibility testing. This intervention will involve a demonstration of the behaviour and will be delivered as an online video. The video demonstrating how GPs can prescribe appropriate polypharmacy during a typical consultation with an older patient will also demonstrate salience of consequences (feedback emphasising the positive outcomes of performing the behaviour). Action plans and prompts/cues will be used as complementary intervention components. The intervention is designed to facilitate the prescribing of appropriate polypharmacy in routine practice. CONCLUSION: A GP-targeted intervention to improve appropriate polypharmacy in older people has been developed using a systematic approach. Intervention content has been specified using an established taxonomy of BCTs and selected to maximise feasibility. The results of a future feasibility study will help to determine if the theory-based intervention requires further refinement before progressing to a larger scale randomised evaluation.

'Sorry, I meant the patient's left side': impact of distraction on left-right discrimination.

CONTEXT: Medical students can have difficulty in distinguishing left from right. Many infamous medical errors have occurred when a procedure has been performed on the wrong side, such as in the removal of the wrong kidney. Clinicians encounter many distractions during their work. There is limited information on how these affect performance. OBJECTIVES: Using a neuropsychological paradigm, we aim to elucidate the impacts of different types of distraction on left-right (LR) discrimination ability. METHODS: Medical students were recruited to a study with four arms: (i) control arm (no distraction); (ii) auditory distraction arm (continuous ambient ward noise); (iii) cognitive distraction arm (interruptions with clinical cognitive tasks), and (iv) auditory and cognitive distraction arm. Participants' LR discrimination ability was measured using the validated Bergen Left-Right Discrimination Test (BLRDT). Multivariate analysis of variance was used to analyse the impacts of the different forms of distraction on participants' performance on the BLRDT. Additional analyses looked at effects of demographics on performance and correlated participants' self-perceived LR discrimination ability and their actual performance. RESULTS: A total of 234 students were recruited. Cognitive distraction had a greater negative impact on BLRDT performance than auditory distraction. Combined auditory and cognitive distraction had a negative impact on performance, but only in the most difficult LR task was this negative impact found to be significantly greater than that of cognitive distraction alone. There was a significant medium-sized correlation between perceived LR discrimination ability and actual overall BLRDT performance. CONCLUSIONS: Distraction has a significant impact on performance and multifaceted approaches are required to reduce LR errors. Educationally, greater emphasis on the linking of theory and clinical application is required to support patient safety and human factor training in medical school curricula. Distraction has the potential to impair an individual's ability to make accurate LR decisions and students should be trained from undergraduate level to be mindful of this.

A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'.

BACKGROUND: The drive for non-medical prescribing has progressed quickly since the late 1990s and involves a range of healthcare professionals including pharmacists. As part of a commissioned research project, this qualitative element of a larger case study focused on the views of patients of pharmacist prescribers. OBJECTIVE: The aim of this study was to explore patients' perspectives of pharmacists as prescribers. METHODS: Three pharmacists working as independent prescribers in the clinical areas of (i) hypertension, (ii) cardiovascular/diabetes management, (iii) anticoagulation were recruited to three case studies of pharmacist prescribing in Northern Ireland. One hundred and five patients were invited to participate in focus groups after they had been prescribed for by the pharmacist. Focus groups took place between November 2010 and March 2011 (ethical/governance approvals granted) were audio taped, transcribed verbatim, read independently by two authors and analysed using constant comparative analysis. RESULTS: Thirty-four patients agreed to participate across seven focus groups. Analysis revealed the emergence of one overarching theme: team approach to patient care. A number of subthemes related to the role of the pharmacist, the role of the doctor and patient benefits. There was an overwhelming lack of awareness of pharmacist prescribing. Patients discussed the importance of a multidisciplinary approach to their care and recognized limitations of the current model of prescribing. CONCLUSION: Patients were positive about pharmacist prescribing and felt that a team approach to their care was the ideal model especially when treating those with more complex conditions. Despite positive attitudes, there was a general lack of awareness of this new mode of practice.