Retention of doctors in emergency medicine: a scoping review of the academic literature.

INTRODUCTION: Workforce issues prevail across healthcare; in emergency medicine (EM), previous work improved retention, but the staffing problem changed rather than improved. More experienced doctors provide higher quality and more cost-effective care, and turnover of these physicians is expensive. Research focusing on staff retention is an urgent priority. METHODS: This study is a scoping review of the academic literature relating to the retention of doctors in EM and describes current evidence about sustainable careers (focusing on factors influencing retention), as well as interventions to improve retention. The established and rigorous JBI scoping review methodology was followed. The data sources searched were MEDLINE, Embase, Cochrane, HMIC and PsycINFO, with papers published up to April 2020 included. Broad eligibility criteria were used to identify papers about retention or related terms, including turnover, sustainability, exodus, intention to quit and attrition, whose population included emergency physicians within the setting of the ED. Papers which solely measured the rate of one of these concepts were excluded. RESULTS: Eighteen papers met the inclusion criteria. Multiple factors were identified as linked with retention, including perceptions about teamwork, excessive workloads, working conditions, errors, teaching and education, portfolio careers, physical and emotional strain, stress, burnout, debt, income, work-life balance and antisocial working patterns. Definitions of key terms were used inconsistently. No factors clearly dominated; studies of correlation between factors were common. There were minimal research reporting interventions. CONCLUSION: Many factors have been linked to retention of doctors in EM, but the research lacks an appreciation of the complexity inherent in career decision-making. A broad approach, addressing multiple factors rather than focusing on single factors, may prove more informative.

Systematic literature search, review and dissemination methodology for the COVID-19 pandemic.

Purpose of the study: SARS-CoV-2 has caused healthcare systems globally to reorganise. A pandemic paradox emerged; while clinicians were desperate for information on a new disease, they had less time to find and evaluate the vast volume of publications at times of significant strain on healthcare systems.A multidisciplinary team undertook a weekly literature search capturing all COVID-19 publications. We also monitored free open access medical education (FOAMed) sources for emerging themes. Title and abstract screening pooled the most relevant papers for emergency medicine. Three summary types were created, a 'Top 5 Flash Update', a journal club and a rapid response to emerging FOAMed themes. From these summaries, three modes of dissemination were used: short written summaries, blogs and podcasts. These were amplified through social media. Study design: A retrospective review was conducted assessing the impact of this knowledge dissemination strategy for the period of March to September 2020. Results: In total, 64 687 papers were identified and screened. Of the papers included in the 'Top 5', 28.3% were on epidemiology, 23.6% treatment, 16.7% diagnostics, 12% prognosis, 8.7% pathophysiology with the remaining 10.7% consisting of PPE, public health, well-being and 'other'. We published 37 blogs, 17 podcasts and 18 Top 5 Flash Updates. The blogs were read 138 343 times, the Top 5 Flash Updates 68 610 times and the podcasts had 72 501 listens. Conclusion: A combination of traditional academic and novel social media approaches can address the pandemic paradox clinicians are facing.

'Where have all the doctors gone?' A protocol for an ethnographic study of the retention problem in emergency medicine in the UK.

INTRODUCTION: 'Emergency medicine (EM) in the UK has a medical staffing crisis.' Inadequate staffing, in EM and across healthcare, is a problem that affects the quality of patient care globally. Retention of doctors in EM is a particularly acute problem in the UK's National Health Service. Sustainable careers in healthcare are gaining increasing attention at a national and international policy level, but research to understand the factors that facilitate retention is lacking.This study aims to develop understanding of what drives retention of doctors in EM by focusing on those who remain in these careers, where previous research has targeted those who have left. By addressing the problem of retention in a different way, using innovative methods in this context, we aim to develop a deeper and more nuanced understanding of sustainable careers in EM. METHODS AND ANALYSIS: This is an ethnographic study combining participant observation in two emergency departments, interviews with doctors from these departments, from organisations with influence or interest at a policy level and with doctors who have left EM. The analyses will integrate detailed workplace observation alongside key academic and policy documents using reflexive thematic analysis. ETHICS AND DISSEMINATION: Approvals have been obtained from Lancaster University via the Faculty of Health and Medicine Research Ethics Committee (FHMREC18058) and the Health Research Authority (IRAS number 256306). The findings will inform understanding of sustainable careers in EM that may be transferable to other settings, professions, and locations that share key characteristics with EM such as paediatrics, emergency nursing and general practice. Findings will be disseminated through a series of academic publications and presentations, through local and specialty research engagement, and through targeted policy statements.

Retention of doctors in emergency medicine: a scoping review protocol.

OBJECTIVE: The primary question of the review is: What is known about retention of doctors in emergency medicine? INTRODUCTION: There is a staffing crisis in emergency medicine and retention problems across healthcare. The evidence is disparate and includes healthcare research, management studies and policy documents from government and other agencies. Therefore there is a need to map the evidence on retention of emergency medicine doctors. This review is part of a wider study of the retention of doctors in emergency medicine situated in the UK. INCLUSION CRITERIA: We will identify papers relating to emergency medicine doctors at all levels, using the different terms used internationally for these practitioners. We will exclude papers relating to other healthcare professions. We aim to include papers relating to retention; to identify these our search will include terms such as turnover and exodus. The setting is focused on the emergency department; studies focusing on working in other settings, for example, a minor injuries unit, will be excluded. Studies from any country will be included; however, we are limited to those published in English. METHODS: We will search medical literature databases including MEDLINE, Embase, HMIC, PsycINFO, the Cochrane Database of Systematic Reviews, and the British Medical Journal collection. We will supplement this by searching business and management journals including Business Source Complete, ProQuest Business Database and Emerald Business and Management Journals. A structured iterative search of the gray literature will be conducted. Retrieved papers will be screened for inclusion by two reviewers. Data will be extracted and presented in tabular form and a narrative summary that align with the review's objective.

Trainee and supervisor experience of the Academic Foundation Programme.

BACKGROUND: The Academic Foundation Programme (AFP) is often the initial step along the Integrated Academic Training pathway in the UK. It is relatively new and research as to its effectiveness is limited. Our objective was to evaluate the AFP in terms of its impact on academic career aspirations and to explore trainees' expectations and experience of the programme and investigate the enablers and barriers to success. METHOD: Seven supervisors of Academic Foundation trainees were interviewed over a 5-month period in 2014. AFP trainees' views were sought by way of an online questionnaire that covered six areas: demographics, expectations, academic time, experience, research and achievements. RESULTS: Thirty-four trainees completed online questionnaires. The majority of trainees (94%) did not proceed directly along the Integrated Academic Training pathway to complete Academic Clinical Fellowships, but those who applied to do so were often successful (nine applicants, six successful). Free-text comments revealed an expectation of a more course-like structure to the programme, this is in contrast to the authentic experience of clinical academia, along with its associated challenges, that some of the supervisors reported. The importance of planning and preparation for success was a recurring theme from the supervisor interviews. CONCLUSIONS: The programme is achieving some success in encouraging academic careers. There are several areas that can be improved. Improving the availability of information and guidance for supervisors and facilitating Academic Foundation Doctors to network are both feasible changes that could lead to improvement.

Systematic review of interventions to encourage careers in academic medicine.

AIMS: Academic medicine is a career route that historically struggles to recruit and retain suitable doctors. The aim of this paper is to review the evidence for interventions to encourage careers in academic medicine by way of a descriptive systematic review. METHODS: Key databases were searched in February 2017. Studies that evaluated interventions to encourage careers in academic medicine and that used a pre-post analysis or included a comparison group were included. Interventions reporting only learner satisfaction were excluded. The review was specific to medical students and graduates. RESULTS: Twenty-four studies were identified for inclusion within the review. The included studies identified interventions across five domains: postgraduate funding, postgraduate training, mentoring, undergraduate interventions, and institutional change. The papers varied in terms of strength of conclusion and method of analysis with broad, structured, well-funded programs having the most palpable results. CONCLUSIONS: The five domains identified offer a framework that can be used by institutions who wish to develop similar programs. It also offers a body of research on which an evidence base can be built.

Physicians' Practice of Dispensing Medicines: A Qualitative Study.

OBJECTIVES: The physical act of giving medication to patients to administer away from a health care setting, dispensing, is normally performed by pharmacists. Dispensing of medication by physicians is a neglected patient safety issue, and having observed considerable variation in practice, the lead author sought to explore this issue further. A literature review yielded zero articles pertaining to this, so an exploratory study was commenced. The qualitative arm, relating to junior physicians' experience of, and training in, dispensing, is reported here. METHODS: Focus groups were conducted to explore the beliefs, ideas, and experiences of physicians-in-training pertaining to dispensing of medication. These were recorded and transcribed. The transcriptions were thematically analyzed using the grounded theory. RESULTS: The emergency department was the most common site of dispensing. No formal training in dispensing had been received. Informal training was variable in content and utility. The physicians felt that dispensing was part of their role. CONCLUSIONS: Despite being expected to dispense, and the patient safety issues involved in giving drugs to patients to use at home, physicians do not feel that they have been trained to undertake this task. These findings from 1 hospital raise questions about the wider quality and safety of this practice.

A solid grounding: prescribing skills training.

BACKGROUND: Prescribing is an error-prone process for all doctors, from those who are newly qualified through to those at consultant level. Newly qualified doctors write the majority of in-patient prescriptions and therefore represent an opportunity for safety improvement. Attention to prescribing as a patient-safety issue and potential educational interventions to help improve the situation have been published, but offer little to inform educators why and how any interventions may succeed. In order to identify areas of good practice, and to provide evidence of areas requiring further investigation and innovation, we aimed to ascertain the full range of prescribing practices for final-year medical students and newly qualified doctors across a large geopolitical region of the UK. METHODS: A questionnaire methodology was used. One questionnaire was sent to those responsible for final-year education, and a further, different questionnaire was sent to those responsible for the training of newly qualified doctors, asking about prescribing education in their locality. Questionnaires were sent to 15 hospitals in total. Prescribing is an error-prone process for all doctors RESULTS: Twelve hospitals contributed to final-year medical student data: a response rate of 80 per cent. A variety of methods, including student assistantship, pharmacist-led skills sessions and practical assessment, were offered to varying degrees. Free-text responses identified opportunities for different prescribing education and support. All 15 hospitals provided data on doctors' education, with interventions including e-learning, assessment and support from ward-based pharmacists. DISCUSSION: Current education focuses on the technical and knowledge-based paradigm of prescribing. Human factors and the impact of electronic prescribing should play a part in future developments in prescribing education.

Measuring ward round quality in urology.

BACKGROUND: Ward rounds are the traditional process by which clinical information is interpreted and management plans made in the inpatient setting and the only time during which patient-doctor interaction can reliably occur. Efforts to improve quality and safety have started looking at the ward round but this has mainly been in the acute medical setting. OBJECTIVE: To begin the quality improvement process for Urological ward rounds. METHODS: Twenty indicators thought to relate to quality were recorded for every weekday ward round by the Urology team for one month. RESULTS: Twenty ward rounds, 93 patient encounters, were reviewed. A consultant was present for 37% of the patient encounters. 84% of observation charts were reviewed; drug charts 28% and antibiotics 70%. Plans were communicated to the doctors, patient and nursing staff. All notes were typed directly onto the electronic system, 20% of notes were checked by the lead clinician. Mean time per patient was 6 minutes. CONCLUSIONS: By starting a discussion about ward rounds we aim to align the process with the broader values of the organisation. Ward rounds can be the cornerstone of delivering safe, clean and personal care and measuring this process is vital to understanding efforts to improve them.

Devising a consensus definition and framework for non-technical skills in healthcare to support educational design: A modified Delphi study.

BACKGROUND: Non-technical skills are a subset of human factors that focus on the individual and promote safety through teamwork and awareness. There is no widely adopted competency- or outcome-based framework for non-technical skills training in healthcare. The authors set out to devise such a framework using a modified Delphi approach. METHODS: An exhaustive list of published and team suggested items was presented to the expert panel for ranking and to propose a definition. In the second round, a focused list was presented, as well as the proposed definition elements. The finalised framework was sent to the panel for review. RESULTS: Sixteen experts participated. The final framework consists of 16 competencies for all and eight specific competencies for team leaders. The consensus definition describes non-technical skills as "a set of social (communication and team work) and cognitive (analytical and personal behaviour) skills that support high quality, safe, effective and efficient inter-professional care within the complex healthcare system". CONCLUSIONS: The authors have produced a new competency framework, through the works of an International expert panel, which is not discipline specific that can be used by curriculum developers, educational innovators and clinical teachers to support developments in the field.

Limitations of poster presentations reporting educational innovations at a major international medical education conference.

BACKGROUND: In most areas of medical research, the label of 'quality' is associated with well-accepted standards. Whilst its interpretation in the field of medical education is contentious, there is agreement on the key elements required when reporting novel teaching strategies. We set out to assess if these features had been fulfilled by poster presentations at a major international medical education conference. METHODS: Such posters were analysed in four key areas: reporting of theoretical underpinning, explanation of instructional design methods, descriptions of the resources needed for introduction, and the offering of materials to support dissemination. RESULTS: Three hundred and twelve posters were reviewed with 170 suitable for analysis. Forty-one percent described their methods of instruction or innovation design. Thirty-three percent gave details of equipment, and 29% of studies described resources that may be required for delivering such an intervention. Further resources to support dissemination of their innovation were offered by 36%. Twenty-three percent described the theoretical underpinning or conceptual frameworks upon which their work was based. CONCLUSIONS: These findings suggest that posters presenting educational innovation are currently limited in what they offer to educators. Presenters should seek to enhance their reporting of these crucial aspects by employing existing published guidance, and organising committees may wish to consider explicitly requesting such information at the time of initial submission.

Encouraging new doctors to do medical education research.

BACKGROUND: An academic foundation programme in medical education may allow junior medical trainees to gain experience in teaching and medical education research. After 2 years, three trainees will have completed the programme, and three more will be halfway through it. The authors explore problems encountered and how trainees maximised their experience, helping to inform future planning. SUMMARY OF WORK: Semi-structured group discussions covering trainees' experiences were conducted in the summer of 2011. All six trainees in the programme participated. SUMMARY OF RESULTS: Both site-specific and general issues were raised, most of which were dealt with in a pragmatic fashion. The trainees' goals and subsequent achievements varied. Important factors for trainees and those supervising them, and the organisation of the programme, are discussed. CONCLUSIONS: Our experience is that an academic foundation programme in medical education can be successful. This requires collaboration between trainees and supervisors. TAKE-HOME MESSAGE: The role of the academic supervisor in medical education research is key, but those involved in the practicalities of helping trainees maintain their protected research time is just as important.