Girls in scrubs: An ethnographic exploration of the clinical learning environment.

BACKGROUND: Gender bias is an enduring issue in the medical profession despite women being more represented within medical schools and the health care workforce in numerous countries across the world. There have been frequent calls for further exploration of gender-based discriminations within medical education, owing to its lasting impact on student's professional development and career trajectories. This paper presents an ethnographic exploration of the experiences of female medical students and doctors in the clinical learning environment (CLE), aiming to disrupt the cycle of gender inequity in the clinical workplace. METHODS: Our research field involved two teaching wards in a Scottish urban hospital, where 120 h of non-participant observations were conducted over 10 months. Combining purposive and convenience sampling, we conducted 36 individual interviews with key informants, which included medical students, foundation doctors, postgraduate trainees, consultant supervisors, and other health care professionals such as nurses and pharmacists. Data was thematically analysed using Bourdieu's theory of social power reproduction. The research team brought diverse professional backgrounds and perspectives to the exploration of data on gendered encounters. RESULTS: Combining the observational and interview data, five themes were generated, which suggested gender-related differentials in social and cultural capital that the participants acquired in the CLE. Experiences of discriminatory behaviour and stereotypical thought processes impacted the female students' engagement and drive towards learning, implying an adverse influence on habitus. In contrast, the valuable influence of gendered role-models in building confidence and self-efficacy signified a positive transformation of habitus. The research participants displayed considerable internalisation of the gendered processes in the CLE that appeared to be linked to the transient nature of clinical placements. CONCLUSIONS: This research reveals that despite constituting the majority demographic of medical school, female students struggle to gain social and cultural capital. Gendered hierarchies that structure clinical workplaces disadvantage female students and doctors, and the differential experiences transform their habitus. Based on our theoretically informed investigation, we advocate for role-models given their positive impact on students' and doctors' habitus. Additionally, medical educators may consider extended clinical placements that provide opportunities for female students and early-career doctors to secure social and cultural capital through integrating better in health care teams and building meaningful interprofessional relationships.

Placement or displacement: An ethnographic study of space in the clinical learning environment.

PURPOSE: This paper aims to examine the spatial attributes in the hospital ward environment and their impact on medical students' learning and experience of the clinical workplace. MATERIALS AND METHODS: An ethnographic study was conducted in a Scottish teaching hospital, combining observations and interviews over a period of 10 months. Two teaching wards served as the field-sites where approximately 120 h of non-participant observations took place sequentially. In addition, 34 individual interviews were conducted with identified key informants that included medical students, junior doctors, postgraduate trainees, consultant supervisors, ward nurses and hospital pharmacist. A combination of Actor-network Theory (ANT) and Social cognitive theory (SCT) was applied to analyse data pertaining to spatial attributes and their relevance to clinical teaching and learning. RESULTS: Analysis of the observational and interview data led to generation of the following themes: spatial attributes in the clinical workplace can enable or constrain teaching and learning opportunities, inadequate spaces impact students' and junior doctors' sense of value, short clinical rotations influence a sense of ownership of doctors' spaces, and contested nature of space in the clinical environment. Several illustrations of the field-sites help to contextualise the themes and aid in understanding the participants' experiences and perceptions. CONCLUSIONS: Our findings suggest a complex entanglement of space with medical students learning and wellbeing in the clinical workplace. Provision of suitable spaces needs to be a core consideration to realise the full potential of work-based learning in medicine.

Burnout in Israeli medical students: a national survey.

INTRODUCTION: Professional burnout is characterized by loss of enthusiasm for work, cynicism, and a low sense of personal efficacy. Burnout may adversely affect medical professionalism. Burnout is common in clinicians and varying rates have been reported in medical students. No data exist regarding the prevalence of burnout among Israeli medical students. The aims of this study were to assess the rate of burnout in Israeli medical students and to identify students who were particularly susceptible to burnout. METHODS: A cross-sectional questionnaire design was employed, gathering data from medical students in all years of study across three medical schools. Burnout was measured using the Maslach Burnout Inventory Student Survey (MBI-SS), translated into Hebrew. RESULTS: Of the 2160 students in the participating medical schools, 966 (44.7%) completed MBI-SS and demographic questionnaires. The overall burnout rate was 50.6%. Multivariate logistic regression analysis yielded that female gender, age under 25, advanced year of study, studying at a specific medical school and not being a parent are all significantly correlated with higher levels of burnout. CONCLUSIONS: A high rate of burnout was found. The identification of young women who are not parents during advanced years of studies as being at-risk is important, in order to guide the development of burnout prevention interventions.

Micro-feedback skills workshop impacts perceptions and practices of doctoral faculty.

BACKGROUND: Doctoral supervision is a distinct form of supervision with clearly defined responsibilities. One of these is the delivery of effective face-to-face feedback to allow supervisees to improve upon their performances. Unfortunately, doctoral supervisors, especially of health sciences, are often not trained in supervisory skills and therefore practice mostly on a trial and error basis. Lack of understanding of the feedback process leads to incongruence in how supervisors and supervisees perceive feedback. However, standardized training practices like microteaching can allow supervisors to acquire effective feedback practices. In this study we employed a schematic approach of microteaching, that is micro-feedback, in a workshop to develop feedback skills of doctoral supervisors, and assessed the overall effectiveness of this training using the Kirkpatrick evaluation framework. METHODOLOGY: This was a Quasi-experimental study with a repeated measures and a two-group separate sample pre-post test design. A micro-feedback skills workshop was organized to enhance feedback skills of doctoral supervisors using microteaching technique. The first two levels of the Kirkpatrick evaluation model were used to determine the workshop's effectiveness. An informal Objective Structured Teaching Exercise (OSTE) was used to assess feedback skills of the supervisors, both before and after the workshop. A questionnaire was developed to compare pre-and post-workshop perceptions of the supervisors (n = 17) and their corresponding supervisees (n = 34) regarding the ongoing feedback practice. RESULTS: Despite the hectic schedule, most doctoral supervisors (17 of 24, 71%) were willing to undertake faculty development training. Participants indicated a high level of satisfaction with the workshop. A learning gain of 56% was observed on pre-post OSTE scores. Prior to the workshop, perceptions of how supervisees should be given the feedback differed significantly between supervisors and supervisees with an effect size difference of r = 0.30. After the workshop there was a negligible difference in perceptions between supervisors and supervisees (r = .001). Interestingly, supervisors shifted their perceptions more toward those that were originally held by the supervisees. CONCLUSIONS: These findings suggest that well-designed and properly assessed structured programs such as micro-feedback workshops can improve how doctoral supervisors provide feedback to their supervisees and align supervisors' perceptions of that feedback with those of their supervisees.

Taking context seriously: explaining widening access policy enactments in UK medical schools.

CONTEXT: Since the 1970s, the UK medical student body has become increasingly diverse in terms of gender, ethnicity and age, but not in socio-economic background. This variance may be linked to large differences in how individual medical schools interpret and put into practice widening participation (WP) policy. However, attempts to theorise what happens when policy enters practice are neglected in medical education. We aimed to explore the dynamics of policy enactment to give a novel perspective on WP practices across UK medical schools. METHODS: We used a qualitative design employing individual telephone interviews to elicit views and concerns around WP from admissions deans and admissions staff within UK medical schools. We carried out interviews with representatives from 24 of 32 UK medical schools. Data coding and analysis were initially inductive, using framework analysis. After the themes emerged, we applied a deductive framework to group themes into four contextual dimensions of 'situation', 'professional', 'material' and 'external'. RESULTS: Our participants held different positions in relation to the interpreting and translating of WP policy, which were influenced by a number of contextual factors including: geographical locality and positioning of the medical school; the expectations of the university and other key stakeholders, and resources. The latter were subtle and referred to resources for medical selection processes rather than for WP per se. The data hinted that the political goal of WP and medical education's goal of producing the best doctors may conflict. CONCLUSIONS: This is the first study to explicitly explore WP policy enactment in medical education. Our analysis is useful for understanding differences in how WP policy is played out in local contexts, and for planning for future policy enactment and research. The messages identified will resonate internationally with all those engaged in efforts to widen participation in medical education.

Core competencies in teaching and training for doctors in Scotland: a review of the literature and stakeholder survey.

BACKGROUND: The UK General Medical Council requires all registered doctors to be competent in all areas of their work, including teaching and training. AIMS: The current research sought consensus on core competencies for all consultants and GPs involved in teaching and training in Scotland. METHOD: A draft list of 80 competencies was developed from the literature and made available as a survey to all consultants and GPs with teaching roles and all final year speciality trainees working in Scotland. Respondents rated the importance of each competency and provided free text comments. RESULTS: There were 1026 responses. Eighteen competencies were rated as "high priority", and are recommended as a baseline for all doctors involved in teaching and training; 55 were rated as "medium priority", and are recommended in relation to specific teaching and training roles; and 7 were rated as "low priority". Free text responses suggested the topic was controversial and emotive, and emphasised the importance of further work to engage trainers. CONCLUSIONS: The findings appeared to have face validity, and it was felt these could be used as the basis for developing a "Scottish Trainer Framework" for doctors and others involved in teaching and training in Scotland.

The remediation challenge: theoretical and methodological insights from a systematic review.

OBJECTIVES: Remediation is usually offered to medical students and doctors in training who underperform on written or clinical examinations. However, there is uncertainty and conflicting evidence about the effectiveness of remediation. The aim of this systematic review was to synthesise the available evidence to clarify how and why remediation interventions may have worked in order to progress knowledge on this topic. METHODS: The MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Educational Resources Information Centre), Web of Science and Scopus databases were searched for papers published from 1984 to April 2012, using the search terms 'remedial teaching', 'education', 'medical', 'undergraduate'/or 'clinical clerkship'/or 'internship and residency', 'at risk' and 'struggling'. Only studies that included an intervention, then provided retest data, and reported at least one outcome measure of satisfaction, knowledge, skills or effects on patients were eligible for inclusion. Studies of practising doctors were excluded. Data were abstracted independently in duplicate for all items. Coding differences were resolved through discussion. RESULTS: Thirty-one of 2113 studies met the review criteria. Most studies were published after 2000 (n=24, of which 12 were published from 2009 onwards), targeted medical students (n=22) and were designed to improve performance on an immediately subsequent examination (n=22). Control or comparison groups, conceptual frameworks, adequate sample sizes and long-term follow-up measures were rare. In studies that included long-term follow-up, improvements were not sustained. Intervention designs tended to be highly complex, but their design or reporting did not enable the identification of the active components of the remedial process. CONCLUSIONS: Most remediation interventions in medical education focus on improving performance to pass a re-sit of an examination or assessment and provide no insight into what types of extra support work, or how much extra teaching is critical, in terms of developing learning. More recent studies are generally of better quality. Rigorous approaches to developing and evaluating remediation interventions are required.

Using databases in medical education research: AMEE Guide No. 77.

This AMEE Guide offers an introduction to the use of databases in medical education research. It is intended for those who are contemplating conducting research in medical education but are new to the field. The Guide is structured around the process of planning your research so that data collection, management and analysis are appropriate for the research question. Throughout we consider contextual possibilities and constraints to educational research using databases, such as the resources available, and provide concrete examples of medical education research to illustrate many points. The first section of the Guide explains the difference between different types of data and classifying data, and addresses the rationale for research using databases in medical education. We explain the difference between qualitative research and qualitative data, the difference between categorical and quantitative data, and the difference types of data which fall into these categories. The Guide reviews the strengths and weaknesses of qualitative and quantitative research. The next section is structured around how to work with quantitative and qualitative databases and provides guidance on the many practicalities of setting up a database. This includes how to organise your database, including anonymising data and coding, as well as preparing and describing your data so it is ready for analysis. The critical matter of the ethics of using databases in medical educational research, including using routinely collected data versus data collected for research purposes, and issues of confidentiality, is discussed. Core to the Guide is drawing out the similarities and differences in working with different types of data and different types of databases. Future AMEE Guides in the research series will address statistical analysis of data in more detail.

A qualitative study of stakeholder views of a community-based anticipatory care service for patients with COPD.

BACKGROUND: The need to consider anticipatory preventive care for people with chronic obstructive pulmonary disease (COPD) has been highlighted in UK guidelines and policy. AIMS: To explore stakeholder views of the utility and design of a community-based anticipatory care service (CBACS) for COPD. METHODS: This was a qualitative study using focus groups and in-depth interviews in North-East Scotland. Key stakeholders were purposively sampled: GPs (n=7), practice nurses (n=6), community nurses (n=4), district nurses (n=6), physiotherapists (n=6), pharmacists (n=8), COPD Managed Clinical Network members (n=8), NHS managers (n=4), the COPD Early Supported Discharge (ESD) Team (n=7), patients and carers (n=7). Data were analysed using framework analysis. RESULTS: A CBACS for COPD was broadly acceptable to most participants although not all wished direct involvement. Patient education and empowerment, clear roles, effective communication across traditional service boundaries, generic and clinical skills training, ongoing support and a holistic service were seen as crucial. Potential issues included: resources; anticipatory care being in conflict with the 'reactive' ethos of NHS care; and the breadth of clinical knowledge required. CONCLUSION: A CBACS for COPD requires additional resources and professionals will need to adapt to a new model of service delivery for which they may not be ready.

Prevalence of common chronic respiratory diseases in drug misusers: a cohort study.

BACKGROUND: A randomised controlled trial of substance misuse indicated that many patients who use methadone have respiratory symptoms and/or are prescribed respiratory medications. There is little research in this area. AIMS: To determine the prevalence of respiratory disease and prescriptions among drug misusers. METHODS: This historical cohort study of drug misusers and matched controls analysed routinely collected primary care data. The prevalence of common chronic respiratory diseases, class and number of respiratory medications were examined. RESULTS: The cohort of 18,570 patients (9,285 per group) was mostly male (64%, n=11,890) and aged 31-59 years (76%, n=14,060). After adjusting for age, gender, deprivation and smoking status, the results showed that more drug misusers than controls had a diagnosis of asthma or chronic obstructive pulmonary disease (17.1% vs. 10.9%; adjusted odds ratio (OR) 1.61, 95% confidence interval (CI) 1.46 to 1.77, and 2.4% vs. 0.8%; OR 1.86, 95% CI 1.42 to 2.44, respectively) and were prescribed more chronic respiratory medications: short-acting ß(2)-agonists (16.4% vs. 7.9%; OR 2.00, 95% CI 1.80 to 2.22), long-acting ß(2)-agonists (1% vs. 0.4%; OR 1.93, 95% CI 1.29 to 2.89), and inhaled corticosteroids (10.6% vs. 7.6%; OR 1.49, 95% CI 1.33 to 1.67). All differences were statistically significant (p<0.001). CONCLUSIONS: Drug misusers have a significantly higher prevalence of respiratory diseases and respiratory prescriptions than matched controls. Further work is needed to determine the reasons for this.

Asthma and psychological dysfunction.

Despite effective treatment, asthma outcomes remain suboptimal. Anxiety and depression occur more commonly in people with asthma than expected, and are associated with poor asthma outcomes. The direction of the relationship and the mechanisms underlying it are uncertain. Whether screening for and treating co-morbid anxiety and depression can improve asthma outcomes is unclear from the current evidence. Primary care clinicians treating asthma should be aware of the possibility of psychological dysfunction in asthmatics, particularly those with poor control. Further research is required to assess the importance of detecting and treating these conditions in community asthma care.

What happens to patients who have their asthma device switched without their consent?

AIMS: To identify asthma patients who have experienced a non-consented switch (NCS) of their inhaler device and to explore the circumstances and impact of these switches. METHODS: Nineteen asthma patients who had experienced an NCS of their inhaler device were recruited to participate in qualitative, semistructured one-to-one interviews. RESULTS: All 19 participants reported a switch in their asthma inhaler without consultation or approval. There was deterioration in asthma control reported by some participants, many remained unchanged, and two reported better outcomes. Regardless of any change in asthma control, all patients expressed discontent with the NCS. Many felt it had damaged their relationship with their doctor, their confidence in their asthma medication, and their perception of control over their disease. CONCLUSIONS: These qualitative interviews highlight the need to maintain clear and open communication with patients. Switching of patients' inhalers without their consent may diminish the self-control associated with good asthma management, leave the doctor-patient relationship damaged, increase resource utilisation, and waste medication.

Predictive Ability And Stakeholders' Perceptions Of The Selection Tools For Mbbs In Women Medical College: A Mixed Methods Study.

BACKGROUND: The selection criteria for entry into the MBBS programme used by Women Medical College (WMC) includes previous academic achievements, namely Secondary School Certificate (SSC) and Higher Secondary Certificate (HSC), and the Medical and Dental College Admission Test (MDCAT). This study determined the predictive validity of these selection tools and explored the perceptions of stakeholders regarding the selection process and the use of selection tools in WMC. METHODS: This study utilized both quantitative and qualitative methods. Quantitative methods involved a retrospective cohort study design to determine the statistical correlation between the performance of candidates in the selection tools and their subsequent academic achievements at medical college. This consisted of data collected from three cohorts (n=186) of students who graduated in 2014, 2015 and 2016. Qualitative methods of the study explored the perceptions of stakeholders through purposive sampling using face-to-face semi-structured interviews, which were analysed using thematic analysis. RESULTS: The study showed very weak correlations of SSC with performance in the fourth professional examination undertaken by the students and HSC with performance in the first and second professional examinations. MDCAT did not correlate with any professional examination. Qualitative analysis identified three emerging themes; a) lack of standardization, b) fairness of selection criteria, and c) assessment of noncognitive attributes. CONCLUSIONS: The selection tools showed poor predictive ability for the performance of students in the medical college. Standardizing the selection tools and including an assessment of non-cognitive attributes in the selection criteria is suggested.

Can a GP be a generalist and a specialist? Stakeholders views on a respiratory General Practitioner with a special interest service in the UK.

BACKGROUND: Primary care practitioners have a potentially important role in the delivery of specialist care for people with long-term respiratory diseases. Within the UK the development of a General Practitioner with Special Interests (GPwSI) service delivered within Primary Care Trusts (PCTs) involves a process of 'transitional change' which impacts on the professional roles of clinicians who may embrace or resist change. In addition, the perspective of patients on the new roles is important. The objective of the current study is to explore the attitudes and views of stakeholders to the provision of a respiratory GPwSI service within the six PCTs in Leicester, UK. METHODS: Using a qualitative design, GPs, nurses, secondary care doctors, nurse specialists, physiotherapists, a healthcare manager and patients with respiratory disease took part in focus groups and in-depth interviews. RESULTS: The 25 participants expressed diverse opinions about the challenge of integrating specialist services with generalist care and the specific contribution that GPs might make to the care of people with chronic respiratory disease. A range of potential roles for a respiratory GPwSI, working as part of a multi-disciplinary team, were suggested, and a number of practical issues were highlighted. Success of the GPwSI role is deemed to be dependent on having the trust of their primary and secondary care colleagues as well as patients, credibility as a practitioner, and being politically astute thereby enabling them to act as a champion supporting the transition process within the local health service. CONCLUSION: The introduction of a respiratory GPwSI service represents a challenge to traditional roles which, whilst broadly acceptable, raised a number of important issues for the stakeholders in our study. These perspectives need to be taken into account if workforce change is to be successfully negotiated and implemented.

Implementing Health Policy: Lessons from the Scottish Well Men's Policy Initiative.

BACKGROUND: Little is known about how health professionals translate national government health policy directives into action. This paper examines that process using the so-called Well Men's Services (WMS) policy initiative as a 'real world' case study. The WMS were launched by the Scottish Government to address men's health inequalities. Our analysis aimed to develop a deeper understanding of policy implementation as it naturally occurred, used an analytical framework that was developed to reflect the 'rational planning' principles health professionals are commonly encouraged to use for implementation purposes. METHODS AND MATERIALS: A mixed-methods qualitative enquiry using a data archive generated during the WMS policy evaluation was used to critically analyze (post hoc) the perspectives of national policy makers, and local health and social care professionals about the: (a) 'policy problem', (b) interventions intended to address the problem, and (c) anticipated policy outcomes. RESULTS AND CONCLUSIONS: This analysis revealed four key themes: (1) ambiguity regarding the policy problem and means of intervention; (2) behavioral framing of the policy problem and intervention; (3) uncertainty about the policy evidence base and outcomes, and; (4) a focus on intervention as outcome. This study found that mechanistic planning heuristics (as a means of supporting implementation) fails to grapple with the indeterminate nature of population health problems. A new approach to planning and implementing public health interventions is required that recognises the complex and political nature of health problems; the inevitability of imperfect and contested evidence regarding intervention, and, future associated uncertainties.

General practitioners' understanding of severe and difficult asthma: A qualitative study.

AIMS: To explore how severe asthma and difficult asthma are perceived by general practitioners. METHODS: Qualitative grounded theory method was used. 13 GPs were interviewed and the interviews recorded, transcribed and analysed for themes. RESULTS: There were different perceptions of 'severe' asthma and 'difficult' asthma from most GPs. The main difference was that 'severe' asthma was understood in more medical terms where 'difficult' asthma tended to be asthma that was difficult to get under control due to a variety of reasons including social and psychological patient variables. Two GPs refused to use the term 'difficult' asthma, one because of the excessive numbers of terms being used in asthma, and the other because of its pejorative nature. CONCLUSIONS: These different perceptions confirm that there is no one agreed definition for severe asthma nor difficult asthma. However, difficult asthma in most cases had a broader definition, including psychological and social implications and factors, than severe asthma.

Barriers to the provision of smoking cessation assistance: a qualitative study among Romanian family physicians.

BACKGROUND: Smoking cessation is the most effective intervention to prevent and slow down the progression of several respiratory and other diseases and improve patient outcomes. Romania has legislation and a national tobacco control programme in line with the World Health Organization Framework for Tobacco Control. However, few smokers are advised to quit by their family physicians (FPs). AIM: To identify and explore the perceived barriers that prevent Romanian FPs from engaging in smoking cessation with patients. METHODS: A qualitative study was undertaken. A total of 41 FPs were recruited purposively from Bucharest and rural areas within 600 km of the city. Ten FPs took part in a focus group and 31 participated in semistructured interviews. Analysis was descriptive, inductive and themed, according to the barriers experienced. RESULTS: Five main barriers were identified: limited perceived role for FPs; lack of time during consultations; past experience and presence of disincentives; patients' inability to afford medication; and lack of training in smoking cessation skills. Overarching these specific barriers were key themes of a medical and societal hierarchy, which undermined the FP role, stretched resources and constrained care. CONCLUSIONS: Many of the barriers described by the Romanian FPs reflected universally recognised challenges to the provision of smoking cessation advice. The context of a relatively hierarchical health-care system and limitations of time and resources exacerbated many of the problems and created new barriers that will need to be addressed if Romania is to achieve the aims of its National Programme Against Tobacco Consumption.

Community pharmacists' perceptions of barriers to communication with migrants.

OBJECTIVES: Effective communication by pharmacists is essential to ensure patient safety in terms of provision and use of medications by patients. Global migration trends mean community pharmacists increasingly encounter patients with a variety of first languages. The aim of this study was to explore community pharmacists' perceptions of communication barriers during the provision of care to A8 (nationals from central/Eastern European states) migrants. METHODS: A qualitative face-to-face interview study of purposively sampled community pharmacists, North East Scotland. KEY FINDINGS: Participants (n = 14) identified a number of barriers to providing optimal care to A8 migrants including: communication (information gathering and giving); confidentiality when using family/friends as translators; the impact of patient healthcare expectations on communication and the length of the consultation; and frustration with the process of the consultation. CONCLUSIONS: Several barriers were specific to A8 migrants but most seemed pertinent to any group with limited English proficiency and reflect those found in studies of healthcare professionals caring for more traditional UK migrant populations. Further research is needed using objective outcome measures, such as consultation recordings, to measure the impact of these perceived barriers on pharmacist-patient consultations. Language and cultural barriers impact on the quality of pharmacist-patient communication and thus may have patient safety and pharmacist training implications.

Achieving asthma control in practice: understanding the reasons for poor control.

Achieving asthma control remains an elusive goal for the majority of patients worldwide. Ensuring a correct diagnosis of asthma is the first step in assessing poor symptom control; this requires returning to the basics of history taking and physical examination, in conjunction with lung function measurement when appropriate. A number of factors may contribute to sub-optimal asthma control. Concomitant rhinitis, a common co-pathology and contributor to poor control, can often be identified by asking a simple question. Smoking too has been identified as a cause of poor asthma control. Practical barriers such as poor inhaler technique must be addressed. An appreciation of patients' views and concerns about maintenance asthma therapy can help guide discussion to address perceptual barriers to taking maintenance therapy (doubts about personal necessity and concerns about potential adverse effects). Further study into, and a greater consideration of, factors and patient characteristics that could predict individual responses to asthma therapies are needed. Finally, more clinical trials that enrol patient populations reflecting the real world diversity of patients seen in clinical practice, including wide age ranges, presence of comorbidities, current smoking, and differing ethnic origins, will contribute to better individual patient management.