Perceived impact of equality and equity in medical education by junior doctors in the UK.

This exploratory study was undertaken to provide an insight into issues of equality and equity that UK junior doctors perceive in relation to being able to achieve a work-life balance within educational and clinical practice. A survey with 443 junior doctors was conducted between May 2018 and September 2019. Thematic analysis of open question responses alongside correlative analyses were used to highlight issues in equity and equality faced by junior doctors. The survey revealed 77% were junior doctors in Health Education England (HEE) posts. 59% were noti n personal relationships, 60% had no children, 38% perceived the national recruitment process as helpful and 70% perceived HEE did not impact on their training. 72% had no personal barriers and 77% felt the role eas not a barrier. 1% identified no barriers. The research raised important implications for redress of equality and equity issues for all within inclusive postgraduate training in the UK.

BEST of Surgical Training: the pan-London Core Surgical Training induction programme: "There's no I in team, but there is a me."

BACKGROUND: In the UK, Core Surgical Training (CST) marks the start of a surgical career, but previous experience and skills vary widely. Whilst Individual hospital Trusts offer local inductions, these are generally of a generic, administrative nature rather than advising trainees on how best to harness training opportunities. We designed a regional induction programme, 'Building Excellence in Surgical Training' (BEST) to address this, develop essential technical and non-technical skills, and engender support networks. METHODS: All incoming London Core Surgical Trainees (annual cohort size 90) were invited to participate, during the week prior to commencement of training. Trainees undertook 3 modules (portfolio, surgical skills and human factors-based simulation) and a research paper presentation day. We collected qualitative and quantitative data through a structured evaluation form, pre and post course Likert-scale scores and self-assessment utilising the non-technical skills for surgeons (NOTSS) framework. RESULTS: 972 CSTs have completed BEST over the past 12 years. In 2019, significant improvements were seen in: confidence for starting CST, 45% (n = 22/49)-83% (n = 33/40,p = 0.00045); feeling the core programme cared about them, 55% (n = 27/49)-98% (n = 41/42, p =< 0.00001); getting to know peers 16% (n = 8/49)-88% (n = 35/40, p =< 0.00001); understanding human factors 82% (n = 40/49)-95% (n = 36/38, p = 0.00427); gaining confidence of trainers, 49% (n = 23/47)-86% (n = 31/36, p = 0.00114), and ability to speak out over patient safety concerns, 78% (n = 38/49)-97% (n = 37/38,p = 0.00019). NOTSS assessments showed significant improvement across all 4 criteria (n = 142, p =< 0.00001). CONCLUSION: BEST equips trainees with the fundamental skills and confidence to safely embark on surgical training and provides tools to navigate the challenges training presents. The ethos of collaboration and support will aid the development of more resilient and empowered surgeons, vital in this era.

Workplace factors associated with mental health of healthcare workers during the COVID-19 pandemic: an international cross-sectional study.

BACKGROUND: The association of workplace factors on mental health of healthcare workers (HCWs) during the COVID-19 pandemic needs to be urgently established. This will enable governments and policy-makers to make evidence-based decisions. This international study reports the association between workplace factors and the mental health of HCWs during the pandemic. METHODS: An international, cross-sectional study was conducted in 41 countries. The primary outcome was depressive symptoms, derived from the validated Patient Health Questionnaire-2 (PHQ-2). Multivariable logistic regression identified factors associated with mental health outcomes. Inter-country differences were also evaluated. RESULTS: A total of 2527 responses were received, from 41 countries, including China (n = 1213; 48.0%), UK (n = 891; 35.3%), and USA (n = 252; 10.0%). Of all participants, 1343 (57.1%) were aged 26 to 40 years, and 2021 (80.0%) were female; 874 (34.6%) were doctors, and 1367 (54.1%) were nurses. Factors associated with an increased likelihood of depressive symptoms were: working in the UK (OR = 3.63; CI = [2.90-4.54]; p < 0.001) and USA (OR = 4.10; CI = [3.03-5.54]), p < 0.001); being female (OR = 1.74; CI = [1.42-2.13]; p < 0.001); being a nurse (OR = 1.64; CI = [1.34-2.01]; p < 0.001); and caring for a COVID-19 positive patient who subsequently died (OR = 1.20; CI = [1.01-1.43]; p = 0.040). Workplace factors associated with depressive symptoms were: redeployment to Intensive Care Unit (ICU) (OR = 1.67; CI = [1.14-2.46]; p = 0.009); redeployment with perceived unsatisfactory training (OR = 1.67; CI = [1.32-2.11]; p < 0.001); not being issued with appropriate personal protective equipment (PPE) (OR = 2.49; CI = [2.03-3.04]; p < 0.001); perceived poor workplace support within area/specialty (OR = 2.49; CI = [2.03-3.04]; p < 0.001); and perceived poor mental health support (OR = 1.63; CI = [1.38-1.92]; p < 0.001). CONCLUSION: This is the first international study, demonstrating that workplace factors, including PPE availability, staff training pre-redeployment, and provision of mental health support, are significantly associated with mental health during COVID-19. Governments, policy-makers and other stakeholders need to ensure provision of these to safeguard HCWs' mental health, for future waves and other pandemics.

Grit and burnout in UK doctors: a cross-sectional study across specialties and stages of training.

PURPOSE OF THE STUDY: Grit is characterised by the ability to persevere during difficulties and maintain a sustained effort over an extended period of time. Throughout their careers, doctors will experience many periods of stress and difficulty. This may result in burnout, defined by the presence of exhaustion and disengagement from work. This study aims to characterise the relationship between grit and burnout in doctors and to establish whether there are differences between specialties and levels of training. STUDY DESIGN: A multicentre cross-sectional survey by questionnaire was used. Participants were recruited from training days and an online medical forum. The survey consisted of the Short Grit Scale and the Oldenburg Burnout Inventory, which examine levels of grit and burnout, respectively. RESULTS: 548 responses were collected. We found a weak negative correlation between grit and burnout in UK doctors (r=-0.243, p<0.001). Hospital consultants had significantly higher grit scores than trainees. The highest level of burnout was found among general practitioners (GPs). When GPs were analysed separately, the correlation between grit and resilience was not seen. CONCLUSIONS: An understanding of an individual's level of grit may be used to identify doctors at a greater risk of burnout. As a high level of grit is associated with less burnout, interventions to improve grit through resilience training should be examined. Further research is needed to understand how grit levels change during a doctor's career and why GPs experience higher levels of burnout.

DiffErential attainment and Factors AssoCiated with Training applications and Outcomes (DE FACTO) study: Trauma & Orthopaedic surgery in the UK.

Aims: The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O). Methods: Data collected by the UK Medical Education Database (UKMED) between 1 January 2014 and 31 December 2019 were used in this retrospective longitudinal cohort study comprising 1,960 CSTs eligible for ST3. The primary outcome measures were whether CSTs applied for a T&O ST3 post and if they were subsequently offered a post. A directed acyclic graph was used for detecting confounders and adjusting logistic regression models to calculate odds ratios (ORs), which assessed the association between the primary outcomes and relevant exposures of interest, including: age, sex, ethnicity, parental socioeconomic status (SES), domiciliary status, category of medical school, Situational Judgement Test (SJT) scores at medical school, and success in postgraduate examinations. This study followed STROBE guidelines. Results: Compared to the overall cohort of CSTs, females were significantly less likely to apply to T&O (OR 0.37, 95% CI 0.30 to 0.46; n = 155/720 female vs n = 535/1,240 male; p < 0.001). CSTs who were not UK-domiciled prior to university were nearly twice as likely to apply to T&O (OR 1.99, 95% CI 1.39 to 2.85; n = 50/205 vs not UK-domiciled vs n = 585/1,580 UK-domiciled; p < 0.001). Age, ethnicity, SES, and medical school category were not associated with applying to T&O. Applicants who identified as 'black and minority ethnic' (BME) were significantly less likely to be offered a T&O ST3 post (OR 0.70, 95% CI 0.51 to 0.97; n = 165/265 BME vs n = 265/385 white; p = 0.034). Differences in age, sex, SES, medical school category, and SJT scores were not significantly associated with being offered a T&O ST3 post. Conclusion: There is an evident disparity in sex between T&O applicants and an ethnic disparity between those who receive offers on their first attempt. Further high-quality, prospective research in the post-COVID-19 pandemic period is needed to improve equality, diversity, and inclusion in T&O training.

A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction.

INTRODUCTION: Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes. METHODS: We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital. RESULTS: We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway. CONCLUSION: In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

Developing Bespoke High Volume Low Complexity (HVLC) Theatre Lists With a Focus on Training to Address the Impact of COVID-19: A Pilot Study.

Introduction The COVID-19 pandemic has had an unprecedented impact on both healthcare delivery and surgical training. There have been significant efforts to manage the growing elective waiting list backlog whilst addressing the training deficit. We outline a successful pilot high volume low complexity (HVLC) program held at the Croydon Elective Centre between 2021-2022 which aimed to amalgamate training and elective recovery. Methods Two pilot HVLC training lists were carried out in June 2021 and March 2022. Three parallel theatre lists on each date were supervised by a single consultant floor trainer. All lists followed a standard pre-defined HVLC protocol. Trainees and trainers were invited to participate and encouraged to utilize these lists to sign off relevant work-based assessments. HVLC cases included hernia repairs and simple lesion excisions. Patient, theatre staff, and trainee experiences were collated via questionnaires. Results A total of one consultant supervisor, six trainers, and eight trainees participated in the pilot with a total of 34 elective procedures performed on 29 patients. The mean patient age was 52.4 years with 8 out of 29 patients being female. Of these patients 41.4% were American Society of Anaesthesiologists (ASA) Classification one, 51.72% were ASA two and 6.9% were ASA three. No patients to date were readmitted to the hospital post-operatively or presented with post-operative complications. One hundred percent of trainees felt satisfied with the training and would recommend it to a colleague. Conclusion The training deficit that developed during the first COVID-19 pandemic wave has been compounded by the second and third waves, and trainees are concerned that further waves are anticipated. Returning to operating is vital and our approach has been shown to improve training, whilst maintaining patient safety and accelerating elective waiting list recovery.

Variation in Experiences and Attainment in Surgery Between Ethnicities of UK Medical Students and Doctors (ATTAIN): Protocol for a Cross-Sectional Study.

BACKGROUND: The unequal distribution of academic and professional outcomes between different minority groups is a pervasive issue in many fields, including surgery. The implications of differential attainment remain significant, not only for the individuals affected but also for the wider health care system. An inclusive health care system is crucial in meeting the needs of an increasingly diverse patient population, thereby leading to better outcomes. One barrier to diversifying the workforce is the differential attainment in educational outcomes between Black and Minority Ethnic (BME) and White medical students and doctors in the United Kingdom. BME trainees are known to have lower performance rates in medical examinations, including undergraduate and postgraduate exams, Annual Review of Competence Progression, as well as training and consultant job applications. Studies have shown that BME candidates have a higher likelihood of failing both parts of the Membership of the Royal Colleges of Surgeons exams and are 10% less likely to be considered suitable for core surgical training. Several contributing factors have been identified; however, there has been limited evidence investigating surgical training experiences and their relationship to differential attainment. To understand the nature of differential attainment in surgery and to develop effective strategies to address it, it is essential to examine the underlying causes and contributing factors. The Variation in Experiences and Attainment in Surgery Between Ethnicities of UK Medical Students and Doctors (ATTAIN) study aims to describe and compare the factors and outcomes of attainment between different ethnicities of doctors and medical students. OBJECTIVE: The primary aim will be to compare the effect of experiences and perceptions of surgical education of students and doctors of different ethnicities. METHODS: This protocol describes a nationwide cross-sectional study of medical students and nonconsultant grade doctors in the United Kingdom. Participants will complete a web-based questionnaire collecting data on experiences and perceptions of surgical placements as well as self-reported academic attainment data. A comprehensive data collection strategy will be used to collect a representative sample of the population. A set of surrogate markers relevant to surgical training will be used to establish a primary outcome to determine variations in attainment. Regression analyses will be used to identify potential causes for the variation in attainment. RESULTS: Data collected between February 2022 and September 2022 yielded 1603 respondents. Data analysis is yet to be competed. The protocol was approved by the University College London Research Ethics Committee on September 16, 2021 (ethics approval reference 19071/004). The findings will be disseminated through peer-reviewed publications and conference presentations. CONCLUSIONS: Drawing upon the conclusions of this study, we aim to make recommendations on educational policy reforms. Additionally, the creation of a large, comprehensive data set can be used for further research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40545.

Gender diversity in UK surgical specialties: a national observational study.

OBJECTIVES: To compare gender diversity between UK surgical specialties, assess trends over time, and estimate when gender parity might be achieved. DESIGN: Observational study. SETTING: National Health Service, UK. PARTICIPANTS: NHS Hospital & Community Health Service workforce statistics for 2011 to 2020 MAIN OUTCOME MEASURES: Logistic regression was used to compare female representation in 2020 between surgical specialties, and to examine for any significant trends between 2011 and 2020. The method of least squares was used to estimate when female representation of specialty registrars would reach 50% ('gender parity') for specialties with <40% female representation. RESULTS: In 2020, female consultant and specialty registrar representation was significantly different between surgical specialties (both p<0.001). Female representation for each specialty were as follows (from highest to lowest): Specialty Registrars-Ophthalmology 49.7%, Otolaryngology 48.2%, Paediatric Surgery 45.5%, Plastic Surgery 42.2%, General Surgery 39.8%, Urology 31.6%, Vascular Surgery 25.0%, Neurosurgery 24.7%, Cardiothoracic Surgery 21.3%, and Trauma and Orthopaedics 20.6%; Consultants-Ophthalmology 32.4%, Paediatric Surgery 31.7%, Plastic Surgery 20.9%, General Surgery 17.5%, Otolaryngology 17%, Vascular Surgery 13.7%, Urology 11.7%, Cardiothoracic Surgery 10.8%, Neurosurgery 8.2%, and Trauma and Orthopaedics 7.3%. There was a significant positive trend in female representation of specialty registrars between 2011 and 2020 for all specialties except for Paediatric Surgery (representation consistently >45%) and Vascular Surgery (representation consistently <30%). General Surgery was estimated to achieve gender parity of their specialty registrars by 2028, Urology by 2033, Neurosurgery by 2064, Trauma and Orthopaedics by 2070, and Cardiothoracic Surgery by 2082. CONCLUSIONS: Despite improvements over the last decade, gender disparity persists in the UK surgical workforce and there are significant differences between surgical specialties. Further work is necessary to establish the reasons for these observed differences with a specific focus on Vascular Surgery, Cardiothoracic Surgery, Neurosurgery, and Trauma and Orthopaedics.

Variation in the clinical commissioning of surgery for three common hand conditions in England.

The surgical referral policies for patients with trigger finger, ganglion removal and Dupuytren's disease were collected for all Clinical Commissioning Groups in England. The aim was to assess whether there was variation in the policies across England, resulting in inequality in patients' access to surgery. Data were collected between October 2018 and January 2019 and compared with national guidelines. Analysis of the results showed that for all three conditions, surgical commissioning policies varied depending on the locality. The results also show that despite the existence of national guidelines, they are not implemented. This has the potential to lead to variation in surgical referral and access to services for patients in different localities in England.Level of evidence: III.

Impact of copper compression stockings on venous insufficiency and lipodermatosclerosis: A randomised controlled trial.

OBJECTIVE: Compression stockings are the primary treatment for lipodermatosclerosis secondary to chronic venous disease, but do not improve the skin condition. The aim of this study was to investigate the impact of copper on lipodermatosclerosis. METHODS: A double-blind randomised controlled pilot study was performed including patients with bilateral lipodermatosclerosis. One compression stocking of a pair was impregnated with copper. Symptom score and surface area of lipodermatosclerosis were assessed at baseline, after 2, 4 and 8 weeks. RESULTS: Sixteen patients were included. There was no significant difference in mean symptom scores; however, there was a significant reduction of the surface area in the study group 42,637 to 35,739 mm2 versus 41,487 to 43,210 mm2 in the control group (p = 0.04). CONCLUSION: This study demonstrates the beneficial effect of copper on lipodermatosclerosis secondary to chronic venous disease with reduction in surface area but no benefit on symptoms. Trials identification number: NCT03283800.

Improving safety for medical students and patients during medical electives-a novel simulation-based course.

INTRODUCTION: The medical elective is a common component of undergraduate medical education in the UK and Ireland. These are often undertaken in varied hospitals and countries across the world, most of which are not related to their parent institutions, in order to explore specialties and regions of interest. However experiences are varied, with goals not always established beforehand, or indeed reached, when present. METHODS: Using a novel 20-item, self-administered questionnaire distributed via social media to 436 medical students and doctors in the UK and Republic of Ireland, we sought to delineate common elective experiences and establish what procedures and clinical scenarios medical students commonly undertake and manage during their medical electives, in order to ascertain their confidence level with each of these tasks at the time of their medical electives. We also looked to determine if there are any adverse effects or events related to these situations. Following this, we developed a simulation-based course to address knowledge and skill gaps identified in the above fields. This course was delivered to two groups of medical students from St George's University London and King's College London medical schools by the same faculty over two separate afternoons. RESULTS: We found that a significant proportion of medical students feel pressured to perform skills, which are beyond their competence level during their elective placements, putting both patient and student safety at risk. Our simulation course was successful in significantly improving key technical and non-technical skills, which would be useful for students during their medical electives.

S-TEAMS: A Truly Multiprofessional Course Focusing on Nontechnical Skills to Improve Patient Safety in the Operating Theater.

BACKGROUND: Possessing adequate nontechnical skills (NTS) in operating theaters is of increasing interest to health care professionals, yet these are rarely formally taught. Teams make human errors despite technical expertise and knowledge, compromising patient safety. We designed a 1-day, multiprofessional, multidisciplinary course to teach, practice, and apply these skills through simulation. METHODS: The course, "S-TEAMS," comprised a morning of lectures, case studies, and interactive teamworking exercises. The afternoon divided the group into multiprofessional teams to rotate around simulated scenarios. During the scenarios, teams were encouraged to focus on NTS, including communication strategies, situational awareness, and prompts such as checklists. A thorough debrief with experienced clinician observers followed. Data was collected through self-assessments, immediate and 6-month feedback to assess whether skills continued to be used and their effect on safety. FINDINGS: In total, 68 health care professionals have completed the course thus far. All participants felt the course had a clear structure and that learning objectives were explicit. Overall, 95% felt the scenarios had good or excellent relevance to clinical practice. Self-assessments revealed a 55% increase in confidence for "speaking up" in difficult situations. Long-term data revealed 97% of the participants continued to use the skills, with 88% feeling the course had prevented them from making errors. Moreover, 94% felt the course had directly improved patient safety. CONCLUSIONS: There is a real demand and enthusiasm for developing NTS within the modern theater team. The simple and easily reproducible format of S-TEAMS is sustainable and inclusive, and crucially, the skills taught continue to be used in long term to improve patient safety and teamworking.

Personality differences among junior postgraduate trainees in the United Kingdom.

IMPORTANCE: An early understanding of the personality profiles of junior trainees may be valuable for supporting the professional and educational development of tomorrow's doctors. OBJECTIVE: This study aims to describe the personality profile of junior trainees and to explore whether the personality profiles differed according to the level of training, specialty choice, or gender. DESIGN: The Mental Muscle Diagram Indicator was distributed electronically. SETTING: South West London, Health Education England South London. PARTICIPANTS: A total of 157 junior trainees completed the personality questionnaire. Specifically, there were core surgical (n = 40), core medical (n = 24), and foundation trainees (n = 93). RESULTS: The preferential profile across all groups was Extroversion (E), Sensing (S), Feeling (F), and Perception (P). More foundation doctors favored an extrovert and sensing personality when compared with core trainees (72% vs 60.4% and 77.4% vs 57.5%, respectively). More core surgical trainees appeared to prefer Extroversion when compared with their medical counterparts (66.7% vs 54.2%). More core medical trainees favored an intuitive behavior when compared with their surgical colleagues (50% vs 35%). Significantly, more female trainees (83.3%) displayed an extrovert personality than male trainees (66.7%) did. CONCLUSIONS: According to the Mental Muscle Diagram Indicator analysis, this work shows that the more junior the trainees are in their career, the more they tend to enjoy human interaction and to favor acting before thinking. The most junior trainees tend to be slightly more interested in dealing with facts rather than ideas and favor a flexible approach of life. The reducing ratio of Extroversion and Sensing in the core trainees when compared with foundation doctors may suggest that clinical experience has an effect on personality. As trainees begin to progress, they may tend to reflect more on their practice and to start thinking about more long term. These results suggest that a greater understanding of their personality preferences and how they might change with experience may help trainees to develop a greater personal and professional insight.

Temporal artery biopsy size does not matter.

This study aimed to clarify whether positive temporal artery biopsies had a greater sample length than negative biopsies in temporal arteritis. It has been suggested that biopsy length should be at least 1 cm to improve diagnostic accuracy. A retrospective review of 149 patients who had 151 temporal artery biopsies was conducted. Twenty biopsies were positive (13.3%), 124 negative (82.1%) and seven samples were insufficient (4.6%). There was no clinically significant difference in the mean biopsy size between positive (0.7 cm) and negative samples (0.65 cm) (t-test: p = .43 NS). Ninety-four patients fulfilled all three ACR criteria prior to biopsy (62.3%) and four patients (2.6%) changed ACR score from 2 to 3 after biopsy. Treatment should not be delayed in anticipation of the biopsy or withheld in the case of a negative biopsy if the patient's symptoms improve.