Are there differences between SIMG surgeons and locally trained surgeons in Australia and New Zealand, as rated by colleagues and themselves?

BACKGROUND: Representation of specialist international medical graduates (SIMGs) in specific specialties such as surgery can be expected to grow as doctor shortages are predicted in the context of additional care provision for aging populations and limited local supply. Many national medical boards and colleges provide pathways for medical registration and fellowship of SIMGs that may include examinations and short-term training. There is currently very little understanding of how SIMGs are perceived by colleagues and whether their performance is perceived to be comparable to locally trained medical specialists. It is also not known how SIMGs perceive their own capabilities in comparison to local specialists. The aim of this study is to explore the relationships between colleague feedback and self-evaluation in the specialist area of surgery to identify possible methods for enhancing registration and follow-up training within the jurisdiction of Australia and New Zealand. METHODS: Feedback from 1728 colleagues to 96 SIMG surgeons and 406 colleagues to 25 locally trained Fellow surgeons was collected, resulting in 2134 responses to 121 surgeons in total. Additionally, 98 SIMGs and 25 Fellows provided self-evaluation scores (123 in total). Questionnaire and data reliability were calculated before analysis of variance, principal component analysis and network analysis were performed to identify differences between colleague evaluations and self-evaluations by surgeon type. RESULTS: Colleagues rated SIMGs and Fellows in the 'very good' to 'excellent' range. Fellows received a small but statistically significant higher average score than SIMGs, especially in areas dealing with medical skills and expertise. However, SIMGs received higher scores where there was motivation to demonstrate working well with colleagues. Colleagues rated SIMGs using one dimension and Fellows using three, which can be identified as clinical management skills, inter-personal communication skills and self-management skills. On self-evaluation, both SIMGs and Fellows gave themselves a significant lower average score than their colleagues, with SIMGs giving themselves a statistically significant higher score than Fellows. CONCLUSIONS: Colleagues rate SIMGs and Fellows highly. The results of this study indicate that SIMGs tend to self-assess more highly, but according to colleagues do not display the same level of differentiation between clinical management, inter-personal and self-management skills. Further research is required to confirm these provisional findings and possible reasons for lack of differentiation if this exists. Depending on the outcome, possible support mechanisms can be explored that may lead to increased comparable performance with locally trained graduates of Australia and New Zealand in these three dimensions.

Optimising the delivery of remediation programmes for doctors: A realist review.

CONTEXT: Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety. METHOD: We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs). RESULTS: A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection. CONCLUSION: Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.

'You're just a locum': professional identity and temporary workers in the medical profession.

Internationally, there has been substantial growth in temporary working, including in the medical profession where temporary doctors are known as locums. There is little research into the implications of temporary work in health care. In this paper, we draw upon theories concerning the sociology of the medical profession to examine the implications of locum working for the medical profession, healthcare organisations and patient safety. We focus particularly on the role of organisations in professional governance and the positioning of locums as peripheral to or outside the organisation, and the influence of intergroup relationships (in this case between permanent and locum doctors) on professional identity. Qualitative semi-structured interviews were conducted between 2015 and 2017 in England with 79 participants including locum doctors, locum agency staff, and representatives of healthcare organisations who use locums. An abductive approach to analysis combined inductive coding with deductive, theory-driven interpretation. Our findings suggest that locums were perceived to be inferior to permanently employed doctors in terms of quality, competency and safety and were often stigmatised, marginalised and excluded. The treatment of locums may have negative implications for collegiality, professional identity, group relations, team functioning and the way organisations deploy and treat locums may have important consequences for patient safety.

Remediating professionalism lapses in medical students and doctors: A systematic review.

CONTEXT: A remediation intervention aims to facilitate the improvement of an individual whose competence in a particular skill has dropped below the level expected. Little is known regarding the effectiveness of remediation, especially in the area of professionalism. This review sought to identify and assess the effectiveness of interventions to remediate professionalism lapses in medical students and doctors. METHODS: Databases Embase, MEDLINE, Education Resources Information Center and the British Education Index were searched in September 2017 and October 2018. Studies reporting interventions to remediate professionalism lapses in medical students and doctors were included. A standardised data extraction form incorporating a previously described behaviour change technique taxonomy was utilised. A narrative synthesis approach was adopted. Quality was assessed using the Critical Appraisal Skills Programme checklist. RESULTS: A total of 19 studies on remediation interventions reported in 23 articles were identified. Of these, 13 were case studies, five were cohort studies and one was a qualitative study; 37% targeted doctors, 26% medical students, 16% residents and 21% involved mixed populations. Most interventions were multifaceted and addressed professionalism issues concomitantly with clinical skills, but some focused on specific areas (eg sexual boundaries and disruptive behaviours). Most used three or more behaviour change techniques. The included studies were predominantly of low quality as 13 of the 19 were case studies. It was difficult to assess the effectiveness of the interventions as the majority of studies did not carry out any evaluation. CONCLUSIONS: The review identifies a paucity of evidence to guide best practice in the remediation of professionalism lapses in medical students and doctors. The literature tentatively suggests that remediating lapses in professionalism, as part of a wider programme of remediation, can facilitate participants to graduate from a programme of study, and pass medical licensing and mock oral board examinations. However, it is not clear from this literature whether these interventions are successful in remediating lapses in professionalism specifically. Further research is required to improve the design and evaluation of interventions to remediate professionalism lapses.

Does regulation increase the rate at which doctors leave practice? Analysis of routine hospital data in the English NHS following the introduction of medical revalidation.

BACKGROUND: In 2012, the UK introduced medical revalidation, whereby to retain their licence all doctors are required to show periodically that they are up to date and fit to practise medicine. Early reports suggested that some doctors found the process overly onerous and chose to leave practice. This study investigates the effect of medical revalidation on the rate at which consultants (senior hospital doctors) leave NHS practice, and assesses any differences between the performance of consultants who left or remained in practice before and after the introduction of revalidation. METHODS: We used a retrospective cohort of administrative data from the Hospital Episode Statistics database on all consultants who were working in English NHS hospitals between April 2008 and March 2009 (n = 19,334), followed to March 2015. Proportional hazard models were used to identify the effect of medical revalidation on the time to exit from the NHS workforce, as implied by ceasing NHS clinical activity. The main exposure variable was consultants' time-varying revalidation status, which differentiates between periods when consultants were (a) not subject to revalidation-before the policy was introduced, (b) awaiting a revalidation recommendation and (c) had received a positive recommendation to be revalidated. Difference-in-differences analysis was used to compare the performance of those who left practice with those who remained in practice before and after the introduction of revalidation, as proxied by case-mix-adjusted 30-day mortality rates. RESULTS: After 2012, consultants who had not yet revalidated were at an increased hazard of ceasing NHS clinical practice (HR 2.33, 95% CI 2.12 to 2.57) compared with pre-policy levels. This higher risk remained after a positive recommendation (HR 1.85, 95% CI 1.65 to 2.06) but was statistically significantly reduced (p < 0.001). We found no statistically significant differences in mortality rates between those consultants who ceased practice and those who remained, after adjustment for multiple testing. CONCLUSION: Revalidation appears to have led to greater numbers of doctors ceasing clinical practice, over and above other contemporaneous influences. Those ceasing clinical practice do not appear to have provided lower quality care, as approximated by mortality rates, when compared with those remaining in practice.

Patient and public involvement in medical performance processes: A systematic review.

BACKGROUND: Patient and public involvement (PPI) continues to develop as a central policy agenda in health care. The patient voice is seen as relevant, informative and can drive service improvement. However, critical exploration of PPI's role within monitoring and informing medical performance processes remains limited. OBJECTIVE: To explore and evaluate the contribution of PPI in medical performance processes to understand its extent, purpose and process. SEARCH STRATEGY: The electronic databases PubMed, PsycINFO and Google Scholar were systematically searched for studies published between 2004 and 2018. INCLUSION CRITERIA: Studies involving doctors and patients and all forms of patient input (eg, patient feedback) associated with medical performance were included. DATA EXTRACTION AND SYNTHESIS: Using an inductive approach to analysis and synthesis, a coding framework was developed which was structured around three key themes: issues that shape PPI in medical performance processes; mechanisms for PPI; and the potential impacts of PPI on medical performance processes. MAIN RESULTS: From 4772 studies, 48 articles (from 10 countries) met the inclusion criteria. Findings suggest that the extent of PPI in medical performance processes globally is highly variable and is primarily achieved through providing patient feedback or complaints. The emerging evidence suggests that PPI can encourage improvements in the quality of patient care, enable professional development and promote professionalism. DISCUSSION AND CONCLUSIONS: Developing more innovative methods of PPI beyond patient feedback and complaints may help revolutionize the practice of PPI into a collaborative partnership, facilitating the development of proactive relationships between the medical profession, patients and the public.

Is Collecting Patient Feedback "a Futile Exercise" in the Context of Recertification?

OBJECTIVE: Patient feedback is considered integral to maintaining excellence, patient safety, and professional development. However, the collection of and reflection on patient feedback may pose unique challenges for psychiatrists. This research uniquely explores the value, relevance, and acceptability of patient feedback in the context of recertification. METHODS: The authors conducted statistical and inductive thematic analyses of psychiatrist responses (n = 1761) to a national census survey of all doctors (n = 26,171) licensed to practice in the UK. Activity theory was also used to develop a theoretical understanding of the issues identified. RESULTS: Psychiatrists rate patient feedback as more useful than some other specialties. However, despite asking a comparable number of patients, psychiatrists receive a significantly lower response rate than most other specialties. Inductive thematic analysis identified six key themes: (1) job role, setting, and environment; (2) reporting issues; (3) administrative barriers; (4) limitations of existing patient feedback tools; (5) attitudes towards patient feedback; and (6) suggested solutions. CONCLUSIONS: The value, relevance, and acceptability of patient feedback are undermined by systemic tensions between division of labor, community understanding, tool complexity, and restrictive rule application. This is not to suggest that patient feedback is "a futile exercise." Rather, existing feedback processes should be refined. In particular, the value and acceptability of patient feedback tools should be explored both from a patient and professional perspective. If issues identified remain unresolved, patient feedback is at risk of becoming a "futile exercise" that is denied the opportunity to enhance patient safety, quality of care, and professional development.

Responding effectively to adult mental health patient feedback in an online environment: A coproduced framework.

BACKGROUND: Responding to online patient feedback is considered integral to patient safety and quality improvement. However, guidance on how to respond effectively is limited, with limited attention paid to patient perceptions and reactions. OBJECTIVES: To identify factors considered potentially helpful in enhancing response quality; coproduce a best-practice response framework; and quality-appraise existing responses. DESIGN: A four-stage mixed methodology: (i) systematic search of stories published on Care Opinion about adult mental health services in the South West of England; (ii) collaborative thematic analysis of responses to identify factors potentially helpful in enhancing response quality; (iii) validation of identified factors by a patient-carer group (n = 12) leading to the coproduction of a best-practice response framework; and (iv) quality appraisal of existing responses. RESULTS: A total of 245 stories were identified, with 183 (74.7%) receiving a response. Twenty-four (9.8%) had been heard but not yet responded to. 1.6% (n = 4/245) may lead to a change. Nineteen factors were considered influential in response quality. These centred around seven subject areas: (i) introductions; (ii) explanations; (iii) speed of response; (iv) thanks and apologies; (v) response content; (vi) signposting; and (vii) response sign-off that were developed into a conceptual framework (the Plymouth, Listen, Learn and Respond framework). Quality appraisal of existing responses highlighted areas for further improvement demonstrating the framework's utility. CONCLUSION: This study advances existing understanding by providing previously unavailable guidance. It has clear practical and theoretical implications for those looking to improve health-care services, patient safety and quality of care. Further validation of the conceptual framework is encouraged.

The impact of patient feedback on the medical performance of qualified doctors: a systematic review.

BACKGROUND: Patient feedback is considered integral to quality improvement and professional development. However, while popular across the educational continuum, evidence to support its efficacy in facilitating positive behaviour change in a postgraduate setting remains unclear. This review therefore aims to explore the evidence that supports, or refutes, the impact of patient feedback on the medical performance of qualified doctors. METHODS: Electronic databases PubMed, EMBASE, Medline and PsycINFO were systematically searched for studies assessing the impact of patient feedback on medical performance published in the English language between 2006-2016. Impact was defined as a measured change in behaviour using Barr's (2000) adaptation of Kirkpatrick's four level evaluation model. Papers were quality appraised, thematically analysed and synthesised using a narrative approach. RESULTS: From 1,269 initial studies, 20 articles were included (qualitative (n=8); observational (n=6); systematic review (n=3); mixed methodology (n=1); randomised control trial (n=1); and longitudinal (n=1) design). One article identified change at an organisational level (Kirkpatrick level 4); six reported a measured change in behaviour (Kirkpatrick level 3b); 12 identified self-reported change or intention to change (Kirkpatrick level 3a), and one identified knowledge or skill acquisition (Kirkpatrick level 2). No study identified a change at the highest level, an improvement in the health and wellbeing of patients. The main factors found to influence the impact of patient feedback were: specificity; perceived credibility; congruence with physician self-perceptions and performance expectations; presence of facilitation and reflection; and inclusion of narrative comments. The quality of feedback facilitation and local professional cultures also appeared integral to positive behaviour change. CONCLUSION: Patient feedback can have an impact on medical performance. However, actionable change is influenced by several contextual factors and cannot simply be guaranteed. Patient feedback is likely to be more influential if it is specific, collected through credible methods and contains narrative information. Data obtained should be fed back in a way that facilitates reflective discussion and encourages the formulation of actionable behaviour change. A supportive cultural understanding of patient feedback and its intended purpose is also essential for its effective use.

Towards an understanding of how appraisal of doctors produces its effects: a realist review.

CONTEXT: Revalidation was launched in the UK to provide assurances to the public that doctors are up to date and fit to practice. Appraisal is a fundamental component of revalidation. Approximately 150 000 doctors are appraised annually, costing an estimated £97 million over 10 years. There is little understanding of the theory of how and why appraisal is supposed to produce its effects. A realist review of the literature was utilised to explore these issues, as they generate context-mechanism-outcome (CMO) configurations, resulting in the creation of theories of how and why appraisal of doctors produces its effects. METHODS: A programme theory of appraisal was created by convening stakeholders in appraisal and searching a database of research on appraisal of doctors. Supplementary searches provided literature on theories identified in the programme theory. Relevant sections of texts relating to the programme theory were extracted from included articles, coded in NVivo and synthesised using realist logic of analysis. A classification tool categorised the included articles' contributions to programme theory. RESULTS: One hundred and twenty-five articles were included. Three mechanisms were identified: dissonance, denial and self-affirmation. The dissonance mechanism is most likely to cause outcomes of reflection and insight. Important contexts for the dissonance mechanism include the appraiser being highly skilled, the appraisee's working environment being supportive and the appraisee having the right attitude. The denial mechanism is more likely to be enacted if the opposite of these contexts occurs and could lead to game-playing behaviour. A skilled appraiser was also important in triggering the self-affirmation mechanism, resulting in reflection and insight. The contexts, mechanisms and outcomes identified were, however, limited by a lack of evidence that could enable further refining of the CMO configurations. CONCLUSION: This review makes a significant contribution to our understanding of appraisal by identifying different ways that appraisal of doctors produces its effects. Further research will focus on testing the CMO configurations.

The implementation of medical revalidation: an assessment using normalisation process theory.

BACKGROUND: Medical revalidation is the process by which all licensed doctors are legally required to demonstrate that they are up to date and fit to practise in order to maintain their licence. Revalidation was introduced in the United Kingdom (UK) in 2012, constituting significant change in the regulation of doctors. The governing body, the General Medical Council (GMC), envisages that revalidation will improve patient care and safety. This potential however is, in part, dependent upon how successfully revalidation is embedded into routine practice. The aim of this study was to use Normalisation Process Theory (NPT) to explore issues contributing to or impeding the implementation of revalidation in practice. METHODS: We conducted seventy-one interviews with sixty UK policymakers and senior leaders at different points during the development and implementation of revalidation: in 2011 (n = 31), 2013 (n = 26) and 2015 (n = 14). We selected interviewees using purposeful sampling. NPT was used as a framework to enable systematic analysis across the interview sets. RESULTS: Initial lack of consensus over revalidation's purpose, and scepticism about its value, decreased over time as participants recognised the benefits it brought to their practice (coherence category of NPT). Though acceptance increased across time, revalidation was not seen as a legitimate part of their role by all doctors. Key individuals, notably the Responsible Officer (RO), were vital for the successful implementation of revalidation in organisations (cognitive participation category). The ease with which revalidation could be integrated into working practices varied greatly depending on the type of role a doctor held and the organisation they work for and the provision of resources was a significant variable in this (collective action category). Formal evaluation of revalidation in organisations was lacking but informal evaluation was taking place. Revalidation had not yet reached the stage where feedback was being used for improvement (reflexive monitoring category). CONCLUSIONS: Requiring all organisations to use the same revalidation model made revalidation easy to integrate into existing work for some but problematic for others. In order for revalidation to be fully embedded and successful, impeding factors, such as a lack of resources, need to be addressed.

The impact of large scale licensing examinations in highly developed countries: a systematic review.

BACKGROUND: To investigate the existing evidence base for the validity of large-scale licensing examinations including their impact. METHODS: Systematic review against a validity framework exploring: Embase (Ovid Medline); Medline (EBSCO); PubMed; Wiley Online; ScienceDirect; and PsychINFO from 2005 to April 2015. All papers were included when they discussed national or large regional (State level) examinations for clinical professionals, linked to examinations in early careers or near the point of graduation, and where success was required to subsequently be able to practice. Using a standardized data extraction form, two independent reviewers extracted study characteristics, with the rest of the team resolving any disagreement. A validity framework was used as developed by the American Educational Research Association, American Psychological Association, and National Council on Measurement in Education to evaluate each paper's evidence to support or refute the validity of national licensing examinations. RESULTS: 24 published articles provided evidence of validity across the five domains of the validity framework. Most papers (n = 22) provided evidence of national licensing examinations relationships to other variables and their consequential validity. Overall there was evidence that those who do well on earlier or on subsequent examinations also do well on national testing. There is a correlation between NLE performance and some patient outcomes and rates of complaints, but no causal evidence has been established. CONCLUSIONS: The debate around licensure examinations is strong on opinion but weak on validity evidence. This is especially true of the wider claims that licensure examinations improve patient safety and practitioner competence.

"I'm on an island": A qualitative study of underperforming surgical trainee perspectives on remediation.

BACKGROUND: There is a significant gap in the literature regarding trainees' perceptions of remediation. This study aims to explore surgical trainees' experiences and perspectives of remediation. METHODS: This qualitative study used semi-structured interviews with 11 doctors who have experienced formal remediation as a surgical trainee. Reflexive thematic analysis was used for data analysis. RESULTS: In this study, trainees perceived remediation as a harrowing and isolating experience, with long-lasting emotions. There was a perceived lack of clarity regarding explanations of underperformance and subjective goals. Remediation was viewed as a 'performance' and tick-box exercise with superficial plans, with challenging trainee/supervisor dynamics. CONCLUSIONS: These findings about trainees' perspectives on remediation show a need for trainees to be better emotionally supported during remediation and that remediation plans must be improved to address deficits. Integrating the perspectives and experiences of surgical trainees who have undergone remediation should help improve remediation outcomes and patient care.

Developing a multisource feedback tool for postgraduate medical educational supervisors.

PURPOSE: Supervisors play a key role in the development of postgraduate medical trainees both in the oversight of their day-to-day clinical practice but also in the support of their learning experiences. In the UK, there has been a clear distinction made between these two activities. In this article, we report on the development of a web-based multisource feedback (MSF) tool for educational supervisors in the London Deanery, an organisation responsible for 20% of the UK's doctors and dentists in training. METHODS: A narrative review of the literature generated a question framework for a series of focus groups. Data were analysed using an interpretative thematic approach and the resulting instrument piloted online. Instrument performance was analysed using a variety of tools including factor analysis, generalisability theory and analysis of performance in the first year of implementation. RESULTS: Two factors were initially identified. Three questions performed inadequately and were subsequently discarded. Educational supervisors scored well, generally rating themselves lower than they were by their trainees. The instrument was launched in July 2010, requiring five respondents to generate a summated report, with further validity evidence collated over the first year if implementation. CONCLUSIONS: Arising out of a robust development process, the London Deanery MSF instrument for educational supervisors is a tool that demonstrates considerable evidence of validity and can provide supervisors with useful evidence of their effectiveness.

Workplace-based assessments in psychiatry: evaluation of a whole assessment system.

OBJECTIVE: Work Place-Based Assessments (WPBAs) were introduced into psychiatry along with the new curriculum in 2005. The Royal College of Psychiatrists decided to pilot several WPBAs to ascertain their suitability. METHOD: Eight types of assessments (Case-Based Discussion, Assessment of Clinical Expertise, Mini-Assessed Clinical Encounter, Mini-Peer Assessment Tool, Direct Observations of Procedural Skills, Patient Satisfaction Questionnaires, Case Conference, and Journal Club Presentation) were piloted, either singly or in combination, on 16 sites, with 600 psychiatric trainees. RESULTS: Consultant psychiatrists carried out most of the assessments. Case-Based Discussion was the most popular, and high levels of correlation were obtained across several assessment tools. CONCLUSION: There is evidence that with suitable training of assessors and trainees, WPBAs can be introduced and are feasible in assessing some competencies.

A qualitative study of the incentives and barriers that influence preferences for rural placements during surgical training in Australia.

BACKGROUND: Rural exposure of long durations during clinical training is positively associated with rural career uptake and is a central strategy to addressing the geographical maldistribution of Australia's surgical workforce. However, the incentives and barriers to trainees undergoing surgical training preferencing repeated rural placements in Australia are not well understood. This qualitative study explores the incentives and barriers that influence preference for rural placements during surgical training in Australia. METHODS: This qualitative study employed online semi-structured in-depth interviews. Participants were recruited using an online survey, and interviews were conducted between October 2020 and November 2020. Transcripts were transcribed and de-identified, and thematically analysed. RESULTS: Twenty-nine semi-structured interviews were conducted with trainees and 12 Fellows. Twenty-five participants identified as male, and four identified as female. Four main incentives identified were: (1) broad scope of learning opportunities, (2) quality of supervision, (3) positive work environment and (4) lifestyle. Seven barriers identified were: (1) inadequate preparation for placement, (2) limited case mix to support learning outcomes, (3) lack of formally structured learning opportunities, (4) workload and safe hours concerns, (5) lack of peer support, (6) childcare and educational needs and (7) partner career development. CONCLUSION: The strategy of encouraging trainees to undertake rural placements to address the maldistribution of the surgical workforce should include initiatives that support learning outcomes across their training levels. In addition, improving trainees' ability to prepare adequately for placements may also improve the number and duration of rural placements trainees undertake during their training.

Impact of COVID-19, gender, race, specialty and seniority on mental health during surgical training: an international study.

BACKGROUND: Superior patient outcomes rely on surgical training being optimized. Accordingly, we conducted an international, prospective, cross-sectional study determining relative impacts of COVID-19, gender, race, specialty and seniority on mental health of surgical trainees. METHOD: Trainees across Australia, New Zealand and UK enrolled in surgical training accredited by the Royal Australasian College of Surgeons or Royal College of Surgeons were included. Outcomes included the short version of the Perceived Stress Scale, Oxford Happiness Questionnaire short scale, Patient Health Questionnaire-2 and the effect on individual stress levels of training experiences affected by COVID-19. Predictors included trainee characteristics and local COVID-19 prevalence. Multivariable linear regression analyses were conducted to assess association between outcomes and predictors. RESULTS: Two hundred and five surgical trainees were included. Increased stress was associated with number of COVID-19 patients treated (P = 0.0127), female gender (P = 0.0293), minority race (P = 0.0012), less seniority (P = 0.001), and greater COVID-19 prevalence (P = 0.0122). Lower happiness was associated with training country (P = 0.0026), minority race (P = 0.0258) and more seniority (P < 0.0001). Greater depression was associated with more seniority (P < 0.0001). Greater COVID-19 prevalence was associated with greater reported loss of training opportunities (P = 0.0038), poor working conditions (P = 0.0079), personal protective equipment availability (P = 0.0008), relocation to areas of little experience (P < 0.0001), difficulties with career progression (P = 0.0172), loss of supervision (P = 0.0211), difficulties with pay (P = 0.0034), and difficulties with leave (P = 0.0002). CONCLUSION: This is the first study to specifically describe the relative impacts of COVID-19 community prevalence, gender, race, surgical specialty and level of seniority on stress, happiness and depression of surgical trainees on an international scale.

Factors that might undermine the validity of patient and multi-source feedback.

CONTEXT: Multi-source feedback (MSF) and patient feedback (PF) are used increasingly around the world to assess and quality-assure clinical practice. However, concerns about the evidence for their utility pertain to their ability to identify poor performance, the impact of allowing assessees to select their own assessors and the many confounders that may undermine validity. METHODS: This study was conducted in conjunction with the National Clinical Assessment Service (NCAS) in the UK and used established MSF and PF instruments to assess doctors in potential difficulty. Multi-source feedback assessors were nominated by both the practitioner (Pnom) and the referring body (RBnom). Demographics were collected to elucidate any differences found. Ratings generated by MSF and PF were compared with one another and with findings of a previous study that provided a normative cohort. RESULTS: Using MSF, NCAS-assessed doctors scored significantly lower than the reference cohort. Nineteen (28%) NCAS-assessed doctors achieved scores that were less than satisfactory. This rose to 50% when only RBnom assessors were used. Overall, ratings awarded by RBnom assessors were significantly lower than those awarded by Pnom assessors. Collected demographics did not help to explain the difference. Only one NCAS-assessed doctor scored below average according to PF. Doctors in the NCAS-assessed group did not score significantly lower than the reference cohort in PF. Doctor assessment scores awarded by patients were significantly higher than those awarded by colleagues. CONCLUSIONS: Although colleagues appear to report poor performance using MSF, patients fail to report concurrent findings. This challenges the validity of PF as it is currently constructed. Scores in MSF differ significantly depending on whether they are practitioner- or third party-nominated. Previously recognised confounding factors do not help to explain this difference.

State of the science in health professional education: effective feedback.

BACKGROUND: Effective feedback may be defined as feedback in which information about previous performance is used to promote positive and desirable development. This can be challenging as educators must acknowledge the psychosocial needs of the recipient while ensuring that feedback is both honest and accurate. Current feedback models remain reductionist in their approach. They are embedded in the hierarchical, diagnostic endeavours of the health professions. Even when it acknowledges the importance of two-way interactions, feedback often remains an educator-driven, one-way process. LESSONS FROM THE LITERATURE: An understanding of the various types of feedback and an ability to actively seek an appropriate approach may support feedback effectiveness. Facilitative rather than directive feedback enhances learning for high achievers. High-achieving recipients undertaking complex tasks may benefit from delayed feedback. It is hypothesised that such learners are supported by reducing interruptions during the task. If we accept that medical students and doctors are high achievers, we can draw on some guiding principles from a complex and rarely conclusive literature. Feedback should focus on the task rather than the individual and should be specific. It should be directly linked to personal goals. Self-assessment as a means to identify personal learning requirements has no theoretical basis. Motivated recipients benefit from challenging facilitated feedback from external sources. A NEW MODEL: To achieve truly effective feedback, the health professions must nurture recipient reflection-in-action. This builds on self-monitoring informed by external feedback. An integrated approach must be developed to support a feedback culture. Early training and experience such as peer feedback may over time support the required cultural change. Opportunities to provide feedback must not be missed, including those to impart potentially powerful feedback from high-stakes assessments. Feedback must be conceptualised as a supported sequential process rather than a series of unrelated events. Only this sustained approach will maximise any effect.

The transition from medical student to junior doctor: today's experiences of Tomorrow's Doctors.

CONTEXT Medical education in the UK has recently undergone radical reform. Tomorrow's Doctors has prescribed undergraduate curriculum change and the Foundation Programme has overhauled postgraduate education. OBJECTIVES This study explored the experiences of junior doctors during their first year of clinical practice. In particular, the study sought to gain an understanding of how junior doctors experienced the transition from the role of student to that of practising doctor and how well their medical school education had prepared them for this. METHODS The study used qualitative methods comprising of semi-structured interviews and audio diary recordings with newly qualified doctors based at the Peninsula Foundation School in the UK. Purposive sampling was used and 31 of 186 newly qualified doctors self-selected from five hospital sites. All 31 participants were interviewed once and 17 were interviewed twice during the year. Ten of the participants also kept audio diaries. Interview and audio diary data were transcribed verbatim and thematically analysed with the aid of a qualitative data analysis software package. RESULTS The findings show that, despite recent curriculum reforms, most participants still found the transition stressful. Dealing with their newly gained responsibility, managing uncertainty, working in multi-professional teams, experiencing the sudden death of patients and feeling unsupported were important themes. However, the stress of transition was reduced by the level of clinical experience gained in the undergraduate years. CONCLUSIONS Medical schools need to ensure that students are provided with early exposure to clinical environments which allow for continuing 'meaningful' contact with patients and increasing opportunities to 'act up' to the role of junior doctor, even as students. Patient safety guidelines present a major challenge to achieving this, although with adequate supervision the two aims are not mutually exclusive. Further support and supervision should be made available to junior doctors in situations where they are dealing with the death of a patient and on surgical placements.