When There is No Guidance From the Guidelines: Renal Transplantation in Recipients With Class III Obesity.

Whilst renal transplantation is the optimal treatment for many patients with end-stage kidney disease, the latest international guidelines are unable to make recommendations for the management of patients with end-stage kidney stage kidney disease and Class III Obesity (BMI ≥40 kg/m2). Data on all adult patients receiving a kidney-only-transplant in the UK between 2015-2021 were analysed from a prospectively collected database and interrogated across a range of parameters. We then analysed in detail the outcomes of patients transplanted at the highest-volume unit. There were 22,845 renal transplants in the study time-period; just 44 (0.2%) were performed in recipients with a BMI ≥40 kg/m2. Most transplant centres did not transplant any patients in this category. In the centre with the highest volume, there were 21 transplants (9 living donor) performed in 20 individuals (13 male, median age 46 years). One-year patient and death-censored graft survival was 95% and 85%. Successful transplantation is possible in patients with BMI ≥40 kg/m2 but carries additional risk. Obesity should not be the sole factor considered when deciding on transplant suitability. Restricting transplantation to a small number of high-volume centres in each country should be considered to optimize outcomes.

Reluctant heroes: New doctors negotiating their identities dialogically on social media.

BACKGROUND: Ensuring that students transition smoothly into the identity of a doctor is a perpetual challenge for medical curricula. Developing professional identity, according to cultural-historical activity theory, requires negotiation of dialectic tensions between individual agency and the structuring influence of institutions. We posed the research question: How do medical interns, other clinicians and institutions dialogically construct their interacting identities? METHODS: Our qualitative methodology was rooted in dialogism, Bakhtin's cultural-historical theory that accounts for how language mediates learning and identity. Reasoning that the COVID pandemic would accentuate and expose pre-existing tensions, we monitored feeds into the Twitter microblogging platform during medical students' accelerated entry to practice; identified relevant posts from graduating students, other clinicians and institutional representatives; and kept an audit trail of chains of dialogue. Sullivan's dialogic methodology and Gee's heuristics guided a reflexive, linguistic analysis. RESULTS: There was a gradient of power and affect. Institutional representatives used metaphors of heroism to celebrate 'their graduates', implicitly according a heroic identity to themselves as well. Interns, meanwhile, identified themselves as incapable, vulnerable and fearful because the institutions from which they had graduated had not taught them to practise. Senior doctors' posts were ambivalent: Some identified with institutions, maintaining hierarchical distance between themselves and interns; others, along with residents, acknowledged interns' distress, expressing empathy, support and encouragement, which constructed an identity of collegial solidarity. CONCLUSIONS: The dialogue exposed hierarchical distance between institutions and the graduates they educated, which constructed mutually contradictory identities. Powerful institutions strengthened their identities by projecting positive affects onto interns who, by contrast, had fragile identities and sometimes strongly negative affects. We speculate that this polarisation may be contributing to the poor morale of doctors in training and propose that, to maintain the vitality of medical education, institutions should seek to reconcile their projected identities with the lived identities of graduates.

Pre-prescribing: Creating a zone of proximal development where medical students can safely fail.

PURPOSE: Prescribing is a common task, often performed by junior clinicians, with potential for significant harm. Despite this, it is common for medical students to qualify having only prescribed in simulated scenarios or assessments. We implemented an alternative: students were given pens with purple ink, which permitted them to write prescriptions for real patients. We set out to understand how this intervention, pre-prescribing, created a zone of proximal development (ZPD) for learners. METHODS: An anonymous, mixed methods, evaluation questionnaire was distributed to all final-year medical students at one university in the United Kingdom. Analysis was guided by Experience Based Learning theory. RESULTS: Two hundred and eighteen students made 386 free-text comments. Most participants reported that pre- helped them become capable doctors (Strongly Agree n = 96, 45%; Agree: n = 110, 50%). Pre-prescribing created a ZPD in which participants could use the tools of practice in authentic contexts under conditions that made it safe to fail. CONCLUSIONS: This research shows how a theoretically informed intervention can create conditions to enhance learning. It encourages educators to identify aspects of routine practice that could be delegated, or co-performed, by learners. With appropriate support, educators can create 'safe-fails' which allow learners to participate safely in authentic, risky, and indeterminate situations they will be expected to navigate as newly qualified clinicians.

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

PURPOSE: The hope that reliably testing clinicians' competencies would improve patient safety is unfulfilled and clinicians' psychosocial safety is deteriorating. Our purpose was to conceptualise 'mutual safety', which could increase benefit as well as reduce harm. METHODS: A cultural-historical analysis of how medical education has positioned the patient as an object of benefit guided implementation research into how mutual safety could be achieved. RESULTS: Educating doctors to abide by moral principles and use rigorous habits of mind and scientific technologies made medicine a profession. Doctors' complex attributes addressed patients' complex diseases and personal circumstances, from which doctors benefited too. The patient safety movement drove reforms, which reorientated medical education from complexity to simplicity: clinicians' competencies should be standardised and measurable, and clinicians whose 'incompetence' caused harm remediated. Applying simple standards to an increasingly complex, and therefore inescapably risky, practice could, however, explain clinicians' declining psychosocial health. We conducted a formative intervention to examine how 'acting wisely' could help clinicians benefit patients amidst complexity. We chose the everyday task of insulin therapy, where benefit and harm are precariously balanced. 247 students, doctors, and pharmacists used a thought tool to plan how best to perform this risky task, given their current clinical capabilities, and in the sometimes-hostile clinical milieus where they practised. Analysis of 1000 commitments to behaviour change and 600 learning points showed that addressing complexity called for a skills-set that defied standardisation. Clinicians gained confidence, intrinsic motivation, satisfaction, capability, and a sense of legitimacy from finding new ways of benefiting patients. CONCLUSION: Medical education needs urgently to acknowledge the complexity of practice and synergise doctors' and patients' safety. We have shown how this is possible.

The pen is mightier than the sword. Reinstating patient care as the object of prescribing education.

Prescribing (writing medication orders) is one of residents' commonest tasks. Superficially, all they have to do is complete a form. Below this apparent simplicity, though, lies the complex task of framing patients' needs and navigating relationships with them and other clinicians. Mistakes, which compromise patient safety, commonly result. There is no evidence that competence-based education is preventing harm. We found a profound contradiction between medical students becoming competent, as defined by passing competence assessments, and becoming capable of safely caring for patients. We reinstated patients as the object of learning by allowing students to 'pre-prescribe' (complete, but not authorise prescriptions). This turned a disabling tension into a driver of curriculum improvement. Students 'knotworked' within interprofessional teams to the benefit of patients as well as themselves. Refocusing undergraduate medical education on patient care showed promise as a way of improving patient safety.

Experience Based Learning (ExBL): Clinical teaching for the twenty-first century.

The problem: Clinical practice commonly presents new doctors with situations that they are incapable of managing safely. This harms patients and stresses the new doctors and other clinicians. Unpreparedness for practice remains a problem despite changes in curricula from apprenticeship to outcome-based designs. This is unsurprising because capability depends on learning from practical experience in supportive learning environments. To assure the care of patients and well-being of residents, the pedagogy of medical students' practice-based education is in urgent need of an overhaul. This Guide: Experience based learning (ExBL) is a 21st century pedagogy of practice-based learning, derived from best current theory and evidence. ExBL specifies capabilities that medical students need to acquire from practical experience. It exemplifies how clinicians' behavior can help students gain experience. It explains how reflection converts real patient learning into capability and identity. It identifies desirable features of learning environments. This Guide advises clinicians, students, placement leads, faculty developers, and other stakeholders how to make new doctors as capable as possible. ExBL is a comprehensive model of medical students' practice-based learning, which complements competency-based education to prepare new doctors to deliver safe, effective, and compassionate care.

How can tomorrow's doctors be more caring? A phenomenological investigation.

CONTEXT: Peabody's maxim 'the secret of the care of the patient is in caring for the patient' inspired generations of doctors to relate humanely to patients. Since then, phrases such as 'managed care' have impersonalised caring. The term 'patient-centred' was introduced to re-personalise caring. Ironically, however, such terms have been defined by professionals' preconceptions rather than patients' experiences. Using patients' experiences of doctors being (un)caring to guide doctors' learning could reinvigorate caring. Interpretive phenomenology provides qualitative research tools with which to do this. METHODS: Ten patients, purposively selected to have broad experiences of primary, secondary and tertiary health care, consented to participate. To stay close to their lived experiences, participants first drew 'Pictor' diagrams to represent relationships between themselves and professionals during remembered experiences of (un)caring. A researcher then used the depictions to structure in-depth, one-to-one explorations of the lived experience of caring. Verbatim transcripts were analysed using template analysis. To remain very close to patients' experiences, the researchers assembled a narrative description of the phenomenon of caring using participants' own words. RESULTS: Caring doctors were genuine. They allowed their own individuality to interact with patients' individuality. This made participants feel recognised as individuals, not just diseases. Caring doctors listened and spoke carefully, encouraged expressions of emotion, were accessible and responsive, and formed relationships. These factors empowered participants to be actively involved in their own care. Little things like smiling, shaking hands, admitting uncertainty, asking a colleague for advice and calling a participant unexpectedly at home showed that doctors were prepared to 'go above and beyond'. This was caring. CONCLUSIONS: These findings provide medical educators with an interpretation of caring that is truly patient-centred. Coupling technical proficiency with human qualities - being genuinely empathic and respectful - within doctor-patient relationships is the essence of caring.

How to navigate entry into the field of clinical education research and scholarship.

Clinical education research (ClinEdR) is a growing field that aims to ensure the way healthcare professionals are taught and learn is evidence-based. There is growing interest in how this evidence is generated in a robust, timely and cost-effective fashion. In this 'How to …' paper, we draw on relevant literature and our own experiences to offer suggestions on how novice researchers can navigate entry into the field of ClinEdR. We summarise key resources for those at the earliest stages of their interest in ClinEdR and scholarship and provide personal experiences of networking, collaborating and balancing research with a clinical or teaching role. This paper will be of interest to those at any stage in their clinical career with little to no experience of ClinEdR, but the enthusiasm to get started.

How do patients experience caring? Scoping review.

OBJECTIVE: Summarise empirical research into patients' experiences of caring in order to promote this as a core condition for the work of health professionals. METHODS: A review team: carried out a scoping review with a phenomenological orientation that did not privilege any profession or context of care; comprehensively searched six databases from inception to the present, including all English language articles that report patients' lived experiences of caring; and identified and contrasted uncaring experiences. RESULTS: 43 articles straddled nursing, medicine, and physiotherapy, and a wide range of care settings. Patients experienced caring when competent professionals displayed positive attitudes, communicated effectively, formed relationships, helped them navigate clinical services, and engaged emotionally. CONCLUSION: This research provides a rich description of caring, which was derived from patients', rather than professionals', experiences. PRACTICE IMPLICATIONS: Whilst publications and basic professional curricula are dominated by the perspectives of single professions, this research describes patients' experiences that can prepare all health professionals to be caring in collaborative, interprofessional practice.