Supporting Struggling Trainees with Performance Issues: Lessons from a UK Model.

Approximately 6-9% of trainees will have performance issues of variable degrees with 3-5% of trainees struggling to complete their training and requiring additional targeted time or an extension of training. Some even leave the profession. The environment is complex, often chaotic and overstretched, and, now, made more difficult due to the impact of COVID-19 on medical training. Addressing learning and implementing new behaviours is a challenge and important, as there are still 'never events', and medical errors sadly can include wilful neglect and assault. Such traumatic experiences can be a huge drain of resources for faculty, who often feel underprepared to deal with such occurrences. Failure to address them can lead to bitterness and loss of the medical workforce, rarely suicide, huge remedial costs, and legal challenges to educational institutions and employers. The purpose of this paper is to gain an understanding of why trainees struggle and/or fail and to be able to analyse the causes of poor performance; to know how to pick up these issues early and raise them; and to ultimately deal effectively with performance problems to get a good outcome for the trainees, patients, and institutions.

Empowering trainees through understanding learning theory and changes in medical education.

Background: Empowering trainees to think critically about decision making should result in the National Health Service (NHS) being more efficient and cost effective, thereby reducing the wastage of precious NHS resources on unnecessary investigations, treatment, and consequently putting patients at risk. There is a major shift from acquiring knowledge to critical analysis and synthesis of information for decision making. Trainees must understand how healthcare systems function and consequences of their decisions on budgets and patient care. Equally, faculty need to appreciate that their role is changing from information provider to facilitator of learning through feedback and supervision, role modelling, and innovator of learning approaches. Methods: A survey of 100 postgraduate trainees from the Severn Deanery was conducted on SurveyMonkey in March 2020 and January 2021.  The survey consisted of eight questions focusing on trainee responses to participation in clinical decision-making in the inpatient setting. An additional question on communication with the patient was included in the second iteration. Results: With a response rate of 80, only 35% of trainees had their findings regularly verified by the consultant. One third of trainees reported that decisions were made by the consultant without asking their opinion on investigations or management. It was unusual for trainees to have any interaction with patients on consultant ward rounds and to understand the rationale for the requested investigations. Conclusion: The poor consultant trainee interaction represents a serious lost opportunity for experiential learning with real time feedback. Training programmes should support trainees being given opportunities to nurture analytical, problem-solving skills, dealing with uncertainty among other attributes of patient management. Trainees need to become competent through the art of critical thinking and develop a professional identity. Through this they develop confidence and competence leading to better patient outcomes, and prevention of the depletion of healthcare budgets.

Accelerated transsulfuration metabolically defines a discrete subclass of amyotrophic lateral sclerosis patients.

Amyotrophic lateral sclerosis is a disease characterized by progressive paralysis and death. Most ALS-cases are sporadic (sALS) and patient heterogeneity poses challenges for effective therapies. Applying metabolite profiling on 77-sALS patient-derived-fibroblasts and 43-controls, we found ~25% of sALS cases (termed sALS-1) are characterized by transsulfuration pathway upregulation, where methionine-derived-homocysteine is channeled into cysteine for glutathione synthesis. sALS-1 fibroblasts selectively exhibited a growth defect under oxidative conditions, fully-rescued by N-acetylcysteine (NAC). [U13C]-glucose tracing showed transsulfuration pathway activation with accelerated glucose flux into the Krebs cycle. We established a four-metabolite support vector machine model predicting sALS-1 metabotype with 97.5% accuracy. Both sALS-1 metabotype and growth phenotype were validated in an independent cohort of sALS cases. Importantly, plasma metabolite profiling identified a system-wide cysteine metabolism perturbation as a hallmark of sALS-1. Findings reveal that sALS patients can be stratified into distinct metabotypes with differential sensitivity to metabolic stress, providing novel insights for personalized therapy.

How can medical schools create the general practice workforce? An international perspective.

This article was migrated. The article was marked as recommended. Medical schools are responsible for producing the future medical workforce that is fit for purpose to meet the needs of patients. The burden of care largely falls upon primary care, a specialty which has been under-doctored, under-resourced, culturally not valued, and whose status has been subordinate to secondary care. In addition, the demographic changes of increasing longevity and chronic diseases, have increased the demand for healthcare at a time when governments' finances are stretched more than ever. The poor state of recruitment to the primary care workforce is a global phenomenon as evidenced by similar issues in North America, UK and the Middle East including Turkey. This contradicts the fact that the strength of primary care has a direct effect on the health of the nation. This paper presents an international perspective of why primary care is important, the reasons why new graduates shy away from a career in primary care, and what steps medical schools, residency programmes and governments should undertake to encourage medical students to make primary care a preferred career choice.

Healthcare educational leadership in the twenty-first century.

Education leadership has to intimately lead our future champions of students and nurture them as professional, dynamic, reflective scholars to deal with the complex world of healthcare in a post-truth era. In addition the organization structure needs to develop faculty from clinical and educational supervisors through to program directors and Deans. Leadership theories have taken over from the previous decades of teaching on management. The current dogma is intransigent, and produces silos such as leadership and followership or leaders and managers as class differences which reinforces the obdurate and narrow-minded approach. This contradicts the open society of creating change agents, critical thinkers, and scholars of the conceptual age of post modernity who in a knowledge based economy need to take our world forward. Additionally healthcare is rapidly becoming unaffordable as returns on GDP investment do not give the returns that we as patients and tax payers need. There is the obvious waste of people and funding on constant reorganizations and short-term thinking. This reflects the sort of leaders and organizations we are developing and how decisions are made. This paper through ideas confronts the myths and flaws of current leadership teaching in an education framework. It makes the case for innovative, creative, adroit, adept, experiential learners who can see the bigger picture, avoid harm and be able to cope with complexity and uncertainty, thereby creating a paradigm shift so that future leaders can problem solve, through the ongoing seismic changes that healthcare faces.

HSP90-incorporating chaperome networks as biosensor for disease-related pathways in patient-specific midbrain dopamine neurons.

Environmental and genetic risk factors contribute to Parkinson's Disease (PD) pathogenesis and the associated midbrain dopamine (mDA) neuron loss. Here, we identify early PD pathogenic events by developing methodology that utilizes recent innovations in human pluripotent stem cells (hPSC) and chemical sensors of HSP90-incorporating chaperome networks. We show that events triggered by PD-related genetic or toxic stimuli alter the neuronal proteome, thereby altering the stress-specific chaperome networks, which produce changes detected by chemical sensors. Through this method we identify STAT3 and NF-κB signaling activation as examples of genetic stress, and phospho-tyrosine hydroxylase (TH) activation as an example of toxic stress-induced pathways in PD neurons. Importantly, pharmacological inhibition of the stress chaperome network reversed abnormal phospho-STAT3 signaling and phospho-TH-related dopamine levels and rescued PD neuron viability. The use of chemical sensors of chaperome networks on hPSC-derived lineages may present a general strategy to identify molecular events associated with neurodegenerative diseases.

Quality assurance review of training in oral and maxillofacial surgery by the General Medical Council: areas of good practice, requirements, and recommendations.

The purpose of this paper is to disseminate the outcome of the 2012/13 UK-wide quality assurance review of postgraduate training in oral and maxillofacial surgery (OMFS) by the General Medical Council (GMC), as part of its review of small specialties. OMF surgeons need to be aware of the evidence on which the conclusions are based, and to know about the strengths of the specialty and the areas for future development so that postgraduate training, and ultimately the outcomes for patients, can be improved. This paper, by the authors involved in the review, summarises the salient points and is not a verbatim report.

RNA polymerase V targets transcriptional silencing components to promoters of protein-coding genes.

Transcriptional gene silencing controls transposons and other repetitive elements through RNA-directed DNA methylation (RdDM) and heterochromatin formation. A key component of the Arabidopsis RdDM pathway is ARGONAUTE4 (AGO4), which associates with siRNAs to mediate DNA methylation. Here, we show that AGO4 preferentially targets transposable elements embedded within promoters of protein-coding genes. This pattern of AGO4 binding cannot be simply explained by the sequences of AGO4-bound siRNAs; instead, AGO4 binding to specific gene promoters is also mediated by long non-coding RNAs (lncRNAs) produced by RNA polymerase V. lncRNA-mediated AGO4 binding to gene promoters directs asymmetric DNA methylation to these genomic regions and is involved in regulating the expression of targeted genes. Finally, AGO4 binding overlaps sites of DNA methylation affected by the biotic stress response. Based on these findings, we propose that the targets of AGO4-directed RdDM are regulatory units responsible for controlling gene expression under specific environmental conditions.

Update on chronic diarrhea: a run-through for the clinician.

Chronic diarrhea is a common patient complaint, with an estimated prevalence of 5 %. Diarrhea is defined as >200 g/day of stool with decreased consistency, and chronic diarrhea is defined as lasting more than 4 weeks. The purpose of this review is to guide the clinician's diagnostic evaluation and management of chronic diarrhea, rather than providing a textbook comprehensive review of the subject, focusing on the patient in developed countries and excluding the immune suppressed patient. While the investigation and treatment of chronic diarrhea can be challenging due to its myriad causes, when the clinician employs a practical approach, dividing chronic diarrhea into bloody, fatty, and watery causes, it simplifies and streamlines the work-up and management plan and leads to improved patient outcomes.

The future training of surgeons to manage patients with cleft lip and palate disorders.

The development of the face and the upper lip occurs during the fifth to ninth week of pregnancy. A cleft is a separation or split in either the upper lip or palate and sometimes both. Cleft lip and palate can occur on its own (nonsyndromic) or is sometimes part of a wider series of birth defects (syndromic).

alpha-Adrenoceptor subtypes in isolated corporal tissue from patients undergoing gender re-assignment.

OBJECTIVE: To investigate the pharmacology and functionality of alpha(1)-adrenoceptors in human corpus cavernosum, and to determine the predominant subtype. MATERIALS AND METHODS: Cavernosal tissue specimens were obtained from the penises of 22 men (mean age 37.4 years) removed during gender re-assignment surgery. The men had been maintained on long-term oestrogen therapy before surgery, to aid the development of secondary feminine characteristics (oestrogen treatments were stopped 6 weeks before surgery). Corpus cavernosum strips were mounted in organ baths perfused with Krebs' solution. A control concentration-response curve (CRC) to phenylephrine (a nonselective alpha(1)-agonist) was obtained. Then the tissues were incubated with the alpha(1A) antagonist, WB4101; the alpha(1B) antagonist, chloroethylclonidine; or the alpha(1D) antagonist BMY 7378 (all at 1 microm) and the CRC to phenylephrine was repeated. The concentration producing a half-maximal response (EC(50)) and pK(B) values (logarithm of the dissociation constant, a measure of affinity) were determined. RESULTS: WB4101 produced a parallel rightward shift of the CRC to phenylephrine, with a pK(B) of 7.49. BMY 7378 also produced a parallel rightward shift of the CRC to phenylephrine with a pK(B) of 6.45. Chloroethylclonidine had a similar effect on the phenylephrine CRC, with a pK(B) of 5.90. CONCLUSION: Alpha(1)-adrenoceptors in human cavernosal tissue have a relatively low affinity for BMY 7378 and chloroethylclonidine, but are more sensitive to WB4101. This confirms that the predominant alpha(1)-adrenoceptor subtype in human corpus cavernosum is the alpha(1A) subtype and this might help in developing more selective antagonists and agonists for managing erectile dysfunction and priapism.

The use of health foods, spices and other botanicals in the Sikh community in London.

Attitudes and practice concerning complementary and alternative medicine (CAM) are currently an area of considerable interest. However, little is known about the overall importance of such practices, for example, in immigrant communities such as the Sikh (Punjabi) British. The use of CAM in immigrants belonging to the Sikh religion in London was studied. The primary objective was to analyse the extent to which traditional medicine is used and understood by this population. Traditional Sikh medicine is important to this group of informants and a total of 42 species were recorded and identified tentatively. The most frequently mentioned species were Allium cepa (onion -- gunda), Allium sativum (garlic -- lasan, thon), Capsicum frutescens (cayenne pepper -- lalmirch), Cinnamomum verum (cinnamom--dhal chini), Citrus limon (lemon -- nimbu), Foeniculum vulgare (fennel -- saunf), Elettaria cardamomum (cardamom -- elaichi) and Zingiber officinale (ginger -- adrak). The study also highlights the rapid change this tradition is undergoing in a diaspora situation. In depth studies on the use of CAM among other immigrant communities and among ethnic groups are urgent and may help to manage better the treatment of minor ailments as well as chronic diseases. Specifically, more research on traditional and herbal remedies amongst the numerous ethnic groups in urban Britain and how this impacts on the use of biomedicine (e.g. as it is provided by the NHS) is essential.

Androgen receptor protein expression in prostatic tissues in Black and Caucasian men.

BACKGROUND: CaP has a higher incidence and mortality in Black men. We hypothesized that subpopulation differences in AR expression may contribute to this phenomenon. METHOD: AR immunostaining was compared in epithelium and PES of normal, BPH, and CaP tissues from Black African men and UK Caucasian men. RESULTS: AR expression was similar in normal prostatic epithelium of both groups, but was higher in BPH and CaP epithelium of Black than Caucasian men (P

Sildenafil and nasal obstruction.

OBJECTIVE: Sildenafil (Viagra; Pfizer), a phosphodiesterase inhibitor, promotes penile erection through increased intracellular cyclic guanine monophosphate (a second messenger) in response to nitric oxide (a first messenger) release following sexual stimulation. Nitric oxide is involved in nasal vasodilation, secretion, and mucociliary clearance. The aim of this study was to assess the effect of sildenafil on nasal patency. DESIGN: Pilot study. SETTING: Teaching hospital. METHODS: Nasal patency was assessed by a visual analogue score and by measurement of the peak nasal inspiratory flow (PNIF) in five subjects before and after administration of sildenafil. MAIN OUTCOME MEASURES: Visual analogue score and PNIF. RESULTS: There was a significant increase in the subjective sensation of nasal obstruction (p = .003; -9.6 +/- 2.7, -15.4 to -3.7 [mean +/- SEM, 95% CI) and a significant reduction of PNIF (p < .001; 70.7 +/- 13.2, 43.1 to 98.3). CONCLUSIONS: This pilot study suggests that nasal patency may be reduced following the administration of sildenafil. The role of phosphodiesterase inhibitors in nasal physiology merits further investigation.