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 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.

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.

Retaining doctors in emergency medicine: an ethnographic study of emergency departments in England.

OBJECTIVES: To gain a deep understanding of factors driving retention in emergency medicine. To understand in detail the day-to-day lived experience of emergency medicine doctors, to identify and explore factors influencing retention, to situate these descriptions within the current educational and health policy contexts and to advance the debate and make policy and practice recommendations. DESIGN: Ethnography and semistructured interviews. SETTING: Two purposively sampled emergency departments in England, with additional interview participants recruited via social media and relevant stakeholder organisations. PARTICIPANTS: 41 interview participants comprising 21 emergency physicians across 2 sites, 10 former emergency physicians and 10 stakeholders, with 132 hours of observation over 11 weeks in one emergency department in England. RESULTS: Three key themes were developed as relevant to the day-to-day lived experience of work in the emergency department, presenting challenges to retention and opportunities for change. First, emergency physicians needed to develop workarounds to mitigate the sensory and material challenges of working in a difficult environment.Second, education influences retention through valuing, fostering competence and entrustment and supporting interdependence. These were primarily observable in the workplace through senior staff prioritising the education of more junior staff.Third, community was important for retention. Linked to education through communities of practice, it was built by brief interpersonal interactions between emergency department workers.Situating these descriptions in current policy contexts identified less than full-time working, portfolio careers and mentorship as retention strategies. Self-rostering and annualisation facilitated these retention strategies. CONCLUSIONS: The emergency department represents a difficult environment with many challenges, yet by focusing on how doctors navigate these difficulties, we can see the way in which retention occurs in everyday practices, and that valuing staff is critical for retention.

Non-technical skills training to enhance patient safety: a systematic review.

CONTEXT: Many quality improvement education programmes have been introduced over the last decade with the purpose of enhancing patient safety. The importance of non-technical skills training is becoming increasingly prominent, but the extent to which educational interventions have been used and the theoretical underpinnings of such interventions remain unclear. These issues were investigated through a systematic review of the literature. METHODS: Any studies involving an educational intervention to improve non-technical skills amongst undergraduate or postgraduate staff in an acute health care environment were considered. A standardised search of online databases was carried out independently by two authors and consensus reached on the inclusion of studies. Data extraction and multimodal quality assessment were completed independently, followed by a content analysis of interventions and the extraction of key themes. RESULTS: A total of 22 studies met the inclusion criteria. Measured outcomes were variable, as was the strength of conclusions. Theoretical underpinning of interventions was not described in any studies. Content analysis revealed reasonable consistency with the emergence of five key themes: error; communication; teamwork and leadership; systems, and situational awareness. Teaching was often multidisciplinary and methods used included simulation and role-play exercises, and observation. CONCLUSIONS: The methodological quality of published studies is reasonable, although the reporting of specific interventions is poor. Although a recognised model to support the design of patient safety education is lacking, a number of theories have been applied to guide educators in future instructional design. Further published work should clearly describe interventions and their theoretical underpinnings, and should aim to further explore which specific aspects of interventions are effective and why. Such research should also try to assess whether such interventions can impact patient outcomes.

A systematic review and thematic analysis of cinema in medical education.

The use of cinema in medical education has the potential to teach students about a variety of subjects, for instance by illustrating a lecture on communication skills with a clip of Sir Lancelot Spratt (Doctor In The House, 1954) demonstrating a paternalistic, doctor-centred approach to medicine or nurturing an ethical discussion around palliative care and dying using the cinematic adaptation of American playwright Margaret Edson's Wit (2001). Much has been written about this teaching method across several medical academic disciplines. It is the aim of this review to assimilate the various experiences in order to gain an insight into current expertise. The results are presented by the following headings under which the articles were examined: the source journal, year of publication, article type, theme, content, target, authors, if a clip or the entire film was used, and if any feedback was documented. This is followed by a chronological account of the development of the literature. Such an approach will allow the reader to gather specific information and contextualise it. This review does not critically appraise the quality of the evidence nor does it determine its validity, rather it is hoped that having read the review educators will know where to locate previous accounts of work that will help them develop more engaging pedagogy.

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.

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.

'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.

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.

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.