Barriers and facilitators to establishing a clinical academic career in clinical education research in the UK: A focus group study.

In a rapidly changing healthcare environment, we need a robust evidence base to inform effective education and training. This study aimed to examine factors perceived to determine career progression in clinical education research in the UK. Six online focus groups were conducted, with 35 participants from a range of medical, dental, nursing, and allied health professions who identified as aspiring or early career clinical education researchers. Transcripts underwent thematic analysis. Two themes and associated subthemes were constructed to illustrate perceived factors impacting on career development: (1) A cultural challenge from clinical norms. Challenges included differences between the epistemological assumptions of biomedical and clinical research, and the underlying philosophy of education research, which is more closely aligned with the knowledge generation of the social sciences. This led to difficulty communicating the impact of education research to patient care. There were also blurred boundaries between education delivery and research, with the latter lacking a clearly defined group identity. (2) Structures, systems and relationships for career progression. Practical considerations included time and funding (or lack thereof), the opportunity to undertake formal training, networking and role models. This research highlights a number of systemic barriers and facilitators to careers in clinical education research and offers targets of intervention to enable a sustainable academic workforce in clinical education research.

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

INTRODUCTION: The goal of medical education is to develop clinicians who have sufficient agency (capacity to act) to practise effectively in clinical workplaces and to learn from work throughout their careers. Little research has focused on experiences of organisational structures and the role of these in constraining or affording agency. The aim of this study was to identify priorities for organisational change, by identifying and analysing key moments of agency described by doctors-in-training. METHODS: This was a secondary qualitative analysis of data from a large national mixed methods research programme, which examined the work and wellbeing of UK doctors-in-training. Using a dialogical approach, we identified 56 key moments of agency within the transcripts of 22 semi-structured interviews with doctors based across the UK in their first year after graduation. By analysing action within the key moments from a sociocultural theoretical perspective, we identified tangible changes that healthcare organisations can make to afford agency. RESULTS: When talking about team working, participants gave specific descriptions of agency (or lack thereof) and used adversarial metaphors, but when talking about the wider healthcare system, their dialogue was disengaged and they appeared resigned to having no agency to shape the agenda. Organisational changes that could afford greater agency to doctors-in-training were improving induction, smoothing peaks and troughs of responsibility and providing a means of timely feedback on patient care. CONCLUSIONS: Our findings identified some organisational changes needed for doctors-in-training to practise effectively and learn from work. The findings also highlight a need to improve workplace-based team dynamics and empower trainees to influence policy. By targeting change, healthcare organisations can better support doctors-in-training, which will ultimately benefit patients.

Clinical support during COVID-19: An opportunity for service and learning? A cross-sectional survey of UK medical students.

PURPOSE: Medical students providing support to clinical teams during Covid-19 may have been an opportunity for service and learning. We aimed to understand why the reported educational impact has been mixed to inform future placements. METHODS: We conducted a cross-sectional survey of medical students at UK medical schools during the first Covid-19 'lockdown' period in the UK (March-July 2020). Analysis was informed by the conceptual framework of service and learning. RESULTS: 1245 medical students from 37 UK medical schools responded. 57% of respondents provided clinical support across a variety of roles and reported benefits including increased preparedness for foundation year one compared to those who did not (p < 0.0001). However, not every individual's experience was equal. For some, roles complemented the curriculum and provided opportunities for clinical skill development, reflection, and meaningful contribution to the health service. For others, the relevance of their role to their education was limited; these roles typically focused on service provision, with few opportunities to develop. CONCLUSION: The conceptual framework of service and learning can help explain why student experiences have been heterogeneous. We highlight how this conceptual framework can be used to inform clinical placements in the future, in particular the risks, benefits, and structures.[Box: see text].

Real-time patients' perspectives about participating in teaching consultations in primary care: A questionnaire study.

INTRODUCTION: Patients presenting with undifferentiated illnesses provide valuable learning opportunities for medical students. Evidence detailing the factors that affect patient participation in undergraduate medical education is limited. This study examines how patients regard their participation in teaching consultations in primary care. METHODS: We conducted a cross-sectional questionnaire survey in four GP practices. We tested the relationship between variables of interest and willingness to participate, using hierarchical logistic regression. RESULTS: We analysed 525 questionnaires. 88% of respondents were willing to have students take part in their consultation, and 72% were willing to see a student alone before seeing the doctor. Older patients and those with less sensitive clinical problems were more likely to participate. Willingness to participate was also associated with patients' perceptions of certain costs and benefits of participation. Respondents had poor knowledge about medical education, and a sizeable minority perceived a lack of autonomy about the presence of students in their encounters. More than one-third of respondents expressed the presence of a clinician as a precondition for approval of students' performing some active roles. DISCUSSION: The findings have identified potential interventions to enhance patient involvement including patient education, respecting patient autonomy, and ensuring appropriate student supervision.

Development and retention of the dental workforce: findings from a regional workforce survey and symposium in England.

BACKGROUND: To help promote a flexible and sustainable workforce in dentistry, it is necessary to access accurate and timely data about the structure and nature of the evolving dental team. This paper considers the results and learning from a region-wide dental workforce survey conducted in one area of Health Education England and how the team has changed since the last survey a decade earlier. METHODS: A mixed-methods approach comprised two phases. In Phase 1 a customised workforce questionnaire was sent to all dental practices registered with the Care Quality Commission in the North East of England and North Cumbria in March 2016. Findings then informed Phase 2, a regional symposium held in October 2016, where interactive workshops generated qualitative data that elaborated on factors influencing workforce development. RESULTS: Of 431 primary dental care practices identified, 228 questionnaires were returned - a 53% response rate. The largest professional groups were dental nurses (n = 1269, 53% by headcount; 50% of fte) and dentists (34% by headcount; 42% by fte), though there had been increases in numbers of all staff groups over the decade, which was most marked for dental therapists (from 1 per 39 dentists to 1 per 8 dentists). The dental team predominantly fell into 'younger' age groups (< 46 years age), with evidence of a significant increase in the number of dentists reporting part-time working in a practice since the last survey. Around one third of dental practices reported employing dental nurses with additional skills (n = 74, 32.5%) or dental therapists (n = 73, 32%), and nearly half employed a dental hygienist (n = 104, 46%). However, there was considerable variability in whether these staff actually carried out the range of skills within their scope of practice. Factors shaping workforce development were identified as, the national context, loss of expertise, patients' health needs and expectations, surgery premises and financial constraints. CONCLUSIONS: The composition and work patterns of the primary care dental workforce have changed markedly over the last decade, though utilisation of skill-mix continues to be constrained. Consideration of factors determining career progression of dentists and dental care professionals is needed to optimise a sustainable future workforce.

Severity and threshold of peanut reactivity during hospital-based open oral food challenges: An international multicenter survey.

BACKGROUND: Peanut allergy is classically managed by food avoidance. Immunotherapy programs are available at some academic centers for selected patients reacting to small amounts of peanut during food challenge. We aimed to determine and compare reaction thresholds and prevalence of anaphylaxis during peanut oral challenges at multiple specialist allergy centers. METHODS: A retrospective, international survey of anonymized case records from seven specialist pediatric allergy centers from the UK and Ireland, as well as the Australian HealthNuts study. Demographic information, allergy test results, reaction severity and threshold during open oral peanut challenges were collated and analyzed. RESULTS: Of the 1634 children aged 1-18 years old included, 525 (32%) failed their peanut challenge. Twenty-eight percent reacted to 25 mg, while 38% only reacted after consuming 1 g or more of whole peanut. Anaphylaxis (55 [11%]) was 3 times more common in teenagers than younger children and the likelihood increased at all ages as children consuming more peanut at the challenge. Children who developed anaphylaxis to 25-200 mg of whole peanut were significantly older. Previous history of reaction did not predict reaction threshold or severity. CONCLUSIONS: More than a third of the children in this large international cohort tolerated the equivalent of one peanut in an oral challenge. Anaphylaxis, particularly to small amounts of peanut, was more common in older children. Tailored immunotherapy programs might be considered not only for children with low, but also higher reaction thresholds. Whether these programs could prevent heightened sensitivity and anaphylaxis to peanut with age also deserves further study.

Widening interest, widening participation: factors influencing school students' aspirations to study medicine.

BACKGROUND: Under-representation of some socio-economic groups in medicine is rooted in under-representation of those groups in applications to medical school. This study aimed to explore what may deter school-age children from applying to study medicine. METHODS: Workshops were undertaken with school students aged 16-17 years ('Year 12', n = 122 across three workshops) and 13-14 years ('Year 9', n = 295 across three workshops). Workshops used a variety of methods to identify and discuss participants' perceptions of medicine, medical school and the application process. Year 12 workshops focused on applications and medical school, while Year 9 took a broader approach reflecting their relative distance from applying. Subsequent workshops were informed by the findings of earlier ones. RESULTS: The main finding was that potential applicants had limited knowledge about medicine and medical school in several areas. Older students would benefit from accessible information about medical degrees and application processes, access to work experience opportunities and personal contact with medical students and junior doctors, particularly those from a similar background. Younger students demonstrated a lack of awareness of the breadth of medical careers and a limited understanding of what medicine encompasses. Many Year 9 students were attracted by elements of practice which they did not associate with medicine, such as 'talking to people with mental health problems'. An exercise addressing this elicited an increase in their interest in medicine. These issues were identified by participants as being more marked for those without knowledgeable support at home or school. It was apparent that school teachers may not be equipped to fill these knowledge gaps. CONCLUSION: Gaps in knowledge and support may reflect the importance of 'social capital' in facilitating access to medical school. Medical schools could act as hubs to introduce students to resources which are essential for widening participation. Outreach and support to schools may ensure that fundamental knowledge gaps are equitably addressed for all prospective applicants. More generally, a focus on medicine which under-emphasises aspects of medical practice involving communication may deter some students and have longer term impact on recruitment to careers including general practice and psychiatry.

Fifteen-minute consultation: A child with a suspected drug allergy.

Adverse drug reactions are common in children, but true drug allergy is rare. It can be difficult to determine whether signs such as skin rashes are caused by the underlying illness or medications prescribed. Accurate diagnosis is important for patient safety and optimal treatment. We review the presentation of drug allergy and discuss current management options for children.

Development and evaluation of a digistory about autistic spectrum disorder - a pilot study.

BACKGROUND: Digital storytelling ('digistories') offers a way of sharing the personal impact of a condition, if students have limited direct contact. Autistic spectrum disorder (ASD) exemplifies a common condition, where there is need to improve practise in primary care. Hence, we chose this condition to develop and evaluate a digistory. We considered stigmatising attitudes to ASD and wider educational effects. METHODS: In the digistory, a mother of a boy with severe ASD describes her autobiographical experiences, illustrated by customised cartoons. Participants completed, pre-post, a validated attitude questionnaire and word association exercise. Views on educational value were gathered through free text and focus group. RESULTS: Questionnaire scores indicated positive attitudes, with no significant change. In contrast, content analysis of word association responses showed prevalent negative associations. Thematic analysis identified increased empathy of students with the family, enabled by the resource design. The digistory helped students challenge stereotypes associated with the condition and encouraged greater confidence to engage in future clinical encounters. CONCLUSION: The digistory is an accessible and authentic patient analogue that gives additional insight into living with autistic spectrum disorder, with potential benefits for patient-centred learning.

Longitudinal evaluation of a pilot e-portfolio-based supervision programme for final year medical students: views of students, supervisors and new graduates.

BACKGROUND: Little is known about how best to implement portfolio-based learning in medical school. We evaluated the introduction of a formative e-portfolio-based supervision pilot for final year medical students by seeking views of students, supervisors and graduates on use and educational effects. METHODS: Students and supervisors were surveyed by questionnaire, with free text comments invited. Interviews were held with new graduates in their first Foundation Programme placement. RESULTS: Most students used the e-portfolio (54%) and met with their supervisor (62%) 'once or twice' only. Students had more negative views: 22% agreed that the pilot was beneficial, while most supervisors thought that e-portfolio (72%) and supervision (86%) were a 'good idea'. More students reported supervision meetings benefited learning (49%) and professional development (55%) than the e-portfolio did (16%; 28%). Only 47% of students felt 'prepared' for future educational processes, though graduates noted benefits for navigating and understanding e-portfolio building and supervision. Factors limiting engagement reflected 'burden', while supervision meetings and early experience of postgraduate processes offered educational value. CONCLUSION: Final year students have negative attitudes to a formative e-portfolio, though benefits for easing the educational transition are recognised by graduates. Measures to minimize time, repetition and redundancy of processes may encourage use. Engagement is influenced by the supervisor relationship and educational value may be best achieved by supporting supervisors to develop strategies to facilitate, and motivate self-directed learning processes in undergraduates.

The relationship between medical student learning opportunities and preparedness for practice: a questionnaire study.

BACKGROUND: Alongside providing a knowledge base and practical skills, undergraduate medical education must prepare graduates to immediately begin practice as qualified doctors. A significant challenge is to provide safe learning opportunities that will optimise students' preparedness to start work. This study examined UK graduates' preparedness for clinical practice, and their exposure to real-life and simulated immediate care scenarios during final year placements. METHOD: A questionnaire measuring students' perceived preparedness, and their exposure to immediate care scenarios, was distributed to all new Foundation Year 1 doctors (F1s) attending an induction session in one region of the UK. RESULTS: 356 F1s responded to the questionnaire (91% response rate; 89% of cohort) and data from 344 graduates of UK medical schools were analysed. Respondents were generally prepared for practice, but many reported few 'hands-on' experiences of providing immediate care during final year placements (a median of 1-2 experiences).Those who had 1-2 experiences reported no greater preparedness for acute management than those reporting no experience. Several exposures are necessary for a significant increase in perceived preparedness. Real-life experience was a better predictor of preparedness than simulated practice. CONCLUSIONS: Gaps still remain in medical students' acute care experience, with a direct relationship to their perceived preparedness. The format and facilitation of placements may need to be addressed in order to enhance the quality of experience during final year.

Role modelling to support careers in general practice: a realist review protocol.

BACKGROUND: Role models encountered during undergraduate training play an important part in shaping future doctors. They can act as powerful attractants towards, and deterrents away from a career in general practice. Many general practitioner (GP) educators who act as role models are burnt-out and wish to leave the profession which may limit their ability to influence students positively, with consequent detrimental impact on recruitment to the specialty. AIM: A realist review will be undertaken, aiming to explore how, why and for whom role modelling in undergraduate medical education can support medical students towards careers in general practice. DESIGN & SETTING: The realist review will follow Pawson's five steps, including: locating existing theories, searching for evidence, article selection, data extraction, synthesising evidence and drawing conclusions and will explore literature published in English language between 2013 and 2024. METHOD: An initial explanatory framework (initial programme theory, IPT) will be developed guided by a stakeholder panel including medical undergraduates, GPs and patient/public representatives. Searches will be developed and conducted in electronic databases and grey literature. Studies will be included if they explore the relationship between GP role modelling and undergraduate career choice and relevant data will be extracted. CONCLUSION: Findings will refine the initial programme theory, unveiling key contexts, mechanisms and outcomes which influence role modelling in undergraduate GP medical education and support or deter students from careers in general practice. These findings will support recommendations and interventions to facilitate positive outcomes, including improved recruitment to general practice.

GP workforce sustainability to maximise effective and equitable patient care: a realist review of what works, for whom and in what circumstances?

BACKGROUND: UK general practice has been described as being in crisis. A shortage and exodus of GPs is an urgent and challenging problem, attracting significant media attention, widespread public debate, and policy action. AIM: Our review aims to examine which aspects of the healthcare system affect GP workforce sustainability, how, why, and for whom. METHOD: A realist review is an interpretive, theory-driven approach to evidence synthesis, that brings together data from quantitative, qualitative, mixed methods research, and the wider grey literature (e.g., policy documentation). Using this data allows us to examine a diverse range of evidence with a clear focus on understanding factors which support (or hinder) GP workforce sustainability, how these are shaped by contexts, and the mechanisms that underpin them. We identify important individual and system-level contexts that may be amenable to change. RESULTS: We present our emerging findings in the form of a programme theory which explores human connection with patients, colleagues, and across organisations, gaining intellectual enrichment and learning systems comprising socially-situated knowledge. Relational continuity is key across these, supporting GP workforce sustainability. Challenges include standardisation, alienation and professional loneliness, inflexible organisation, and restrictive technologies. CONCLUSION: Our research generates new knowledge about the interdependencies between contexts, mechanisms, and outcomes. The findings can inform strategies and interventions intended to support, facilitate, and assist the GP workforce in delivering equitable and effective patient care. We identify critical gaps in knowledge and prioritise the expectations for scope and nature of future GP work and retention strategies.

General practitioner workforce sustainability to maximise effective and equitable patient care: a realist review protocol.

INTRODUCTION: There are not enough general practitioners (GPs) in the UK National Health Service. This problem is worse in areas of the country where poverty and underinvestment in health and social care mean patients experience poorer health compared with wealthier regions. Encouraging more doctors to choose and continue in a GP career is a government priority. This review will examine which aspects of the healthcare system affect GP workforce sustainability, how, why and for whom. METHODS AND ANALYSIS: A realist review is a theory-driven interpretive approach to evidence synthesis, that brings together qualitative, quantitative, mixed-methods research and grey literature. We will use a realist approach to synthesise data from the available published literature to refine an evidence-based programme theory that will identify the important contextual factors and underlying mechanisms that underpin observed outcomes relating to GP workforce sustainability. Our review will follow Pawson's five iterative stages: (1) finding existing theories, (2) searching for evidence, (3) article selection, (4) data extraction and (5) synthesising evidence and drawing conclusions. We will work closely with key stakeholders and embed patient and public involvement throughout the review process to refine the focus of the review and enhance the impact and relevance of our research. ETHICS AND DISSEMINATION: This review does not require formal ethical approval as it draws on secondary data from published articles and grey literature. Findings will be disseminated through multiple channels, including publication in peer-reviewed journals, at national and international conferences, and other digital scholarly communication tools such as video summaries, X and blog posts. PROSPERO REGISTRATION NUMBER: CRD42023395583.

Dentists' preparedness to provide Level 2 services in the North East of England: a mixed methods study.

Background Dentists capable of delivering Level 2 complexity treatments may benefit patient access to dental care and increase workforce morale. However, little is known about attitudes, capability and training needs relating to Level 2 dental services.Aims To examine attitudes to, and perceived readiness for delivery of Level 2 dental services by NHS dentists in the North East of England and North Cumbria.Method A sequential mixed methods study with an online survey and semi-structured interviews. Participants were general, community, and hospital-based dental practitioners. Descriptive statistics of survey and thematic analysis of qualitative data were undertaken.Results Overall, 56% of 124 respondents had a limited understanding of the Level 2 performer role. A minority felt they were already providing Level 2 care across all speciality areas; 9% (n = 11) had a professional portfolio suitable for Level 2 accreditation. Confidence to undertake Level 2 competencies varied by speciality area, being highest in paediatric dentistry, and lowest in endodontics and orthodontics. Qualitative data identified motivations, and personal, organisational and system factors that were seen as barriers or enablers to upskilling.Conclusion The regional NHS workforce is unprepared to provide Level 2 dental services. Successful introduction will require review of necessary infrastructure and transparency of accreditation and contracting processes.

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

OBJECTIVES: This study considered a novel 'interim' transitional role for new doctors (termed 'FiY1', interim Foundation Year 1), bridging medical school and Foundation Programme (FP). Research questions considered effects on doctors' well-being and perceived preparedness, and influences on their experience of transition. While FiY1 was introduced in response to the COVID-19 pandemic, findings have wider and ongoing relevance. DESIGN: A sequential mixed-methods study involved two questionnaire phases, followed by semi-structured interviews. In phase 1, questionnaires were distributed to doctors in FiY1 posts, and in phase 2, to all new FP doctors, including those who had not undertaken FiY1. SETTING AND PARTICIPANTS: Participants were newly qualified doctors from UK medical schools, working in UK hospitals in 2020. 77% (n=668) of all participants across all phases had undertaken FiY1 before starting FP in August. The remainder started FP in August with varying experience beforehand. OUTCOME MEASURES: Questionnaires measured preparedness for practice, stress, anxiety, depression, burnout, identity, and tolerance of ambiguity. Interviews explored participants' experiences in more depth. RESULTS: Analysis of questionnaires (phase 1 n=441 FiY1s, phase 2 n=477 FiY1s, 196 non-FiY1s) indicated that FiY1s felt more prepared than non-FiY1 colleagues for starting FP in August (ß=2.71, 95% CI=2.21 to 3.22, p<0.0001), which persisted to October (ß=1.85, CI=1.28 to 2.41, p<0.0001). Likelihood of feeling prepared increased with FiY1 duration (OR=1.02, CI=1.00 to 1.03, p=0.0097). Despite challenges to well-being during FiY1, no later detriment was apparent. Thematic analysis of interview data (n=22) identified different ways, structural and interpersonal, in which the FiY1 role enhanced doctors' emerging independence supported by systems and colleagues, providing 'supported autonomy'. CONCLUSIONS: An explicitly transitional role can benefit doctors as they move from medical school to independent practice. We suggest that the features of supported autonomy are those of institutionalised liminality-a structured role 'betwixt and between' education and practice-and this lens may provide a guide to optimising the design of such posts.

Antigenic epitope targets of rhesus macaques self-curing from Schistosoma mansoni infection.

The self-cure of rhesus macaques from a schistosome infection and their subsequent strong immunity to a cercarial challenge should provide novel insights into the way these parasites can be eliminated by immunological attack. High-density arrays comprising overlapping 15-mer peptides from target proteins printed on glass slides can be used to screen sera from host species to determine antibody reactivity at the single epitope level. Careful selection of proteins, based on compositional studies, is crucial to encompass only those exposed on or secreted from the intra-mammalian stages and is intended to focus the analysis solely on targets mediating protection. We report the results of this approach using two pools of sera from hi- and lo-responder macaques undergoing self-cure, to screen arrays comprising tegument, esophageal gland, and gastrodermis proteins. We show that, overall, the target epitopes are the same in both groups, but the intensity of response is twice as strong in the high responders. In addition, apart from Sm25, tegument proteins elicit much weaker responses than those originating in the alimentary tract, as was apparent in IFNγR KO mice. We also highlight the most reactive epitopes in key proteins. Armed with this knowledge, we intend to use multi-epitope constructs in vaccination experiments, which seek to emulate the self-cure process in experimental animals and potentially in humans.

Mapping the epitopes of Schistosoma japonicum esophageal gland proteins for incorporation into vaccine constructs.

BACKGROUND: The development of a schistosome vaccine has proved challenging but we have suggested that characterisation of the self-cure mechanism in rhesus macaques might provide a route to an effective product. The schistosome esophagus is a complex structure where blood processing is initiated by secretions from anterior and posterior glands, achieved by a mixture of ~40 unique proteins. The mechanism of self-cure in macaques involves cessation of feeding, after which worms slowly starve to death. Antibody coats the esophagus lumen and disrupts the secretory processes from the glands, potentially making their secretions ideal vaccine targets. METHODOLOGY/PRINCIPAL FINDINGS: We have designed three peptide arrays comprising overlapping 15-mer peptides encompassing 32 esophageal gland proteins, and screened them for reactivity against 22-week infection serum from macaques versus permissive rabbit and mouse hosts. There was considerable intra- and inter-species variation in response and no obvious unique target was associated with self-cure status, which suggests that self-cure is achieved by antibodies reacting with multiple targets. Some immuno-dominant sequences/regions were evident across species, notably including: MEGs 4.1C, 4.2, and 11 (Array 1); MEG-12 and Aspartyl protease (Array 2); a Tetraspanin 1 loop and MEG-n2 (Array 3). Responses to MEGs 8.1C and 8.2C were largely confined to macaques. As proof of principle, three synthetic genes were designed, comprising several key targets from each array. One of these was expressed as a recombinant protein and used to vaccinate rabbits. Higher antibody titres were obtained to the majority of reactive regions than those elicited after prolonged infection. CONCLUSIONS/SIGNIFICANCE: It is feasible to test simultaneously the additive potential of multiple esophageal proteins to induce protection by combining their most reactive regions in artificial constructs that can be used to vaccinate suitable hosts. The efficacy of the approach to disrupt esophageal function now needs to be tested by a parasite challenge.