Communicating the diagnosis of a hematological neoplastic disease to patients' minor children: a multicenter prospective study.

BACKGROUND: When a hematological malignancy is diagnosed, the whole family carries the burden of the disease; parents often try to protect minor children from suffering by avoiding communication about their disease. Since 2009, patients with minors at the Adult Hematology Division at San Gerardo Hospital (Monza) can take part in the "Emanuela Project": children can visit parents and talk with psychologists and hematologists, who explain the disease through simple metaphors. MATERIALS AND METHODS: The EMY STUDY aimed to evaluate the impact of illness-related communication on children's behavior, comparing Monza's experience with other Hematology Units, where the communication is delegated to parents or psychological support. Questionnaires exploring the children's main behaviors (school performance, appetite, sleeping patterns, attachment to family figures, and family dialogue) were administered to both sick (SP) and healthy (HP) parents. From 2017 to 2021, 32 patients were enrolled, 20 from Monza and 12 from other hospitals; 84 questionnaires were globally collected. RESULTS: In Monza's group, no major changes in children's behavior were observed and an open dialogue about the disease was often possible. Disease communication is considered crucial and perceived as a responsibility of parents together with a professional figure, mainly the hematologist. Patients were satisfied with "Emanuela Project," reporting positive effects on doctor-patient relationship. Difficulties in separation were significantly higher at other hospitals (P = .019) than in Monza. While at other centers communication is considered parents' responsibility, Monza's patients emphasize the role of professional figures (P = .007). Differently from other hospitals, the role of the hematologist is crucial to Monza's patients (P = .001). CONCLUSION: Disease communication to patients' offspring is a crucial moment in the process of care, and the hematologist can play a major role in this difficult task, with potential positive effects both on children's well-being and on doctor-patient relationship.

Prescribing and Acceptance of Medications for Opioid Use Disorder in VA Primary Care: Veteran and Provider Perspectives.

BACKGROUND: Medications to treat opioid use disorder (MOUD) such as buprenorphine/naloxone can effectively treat OUD and reduce opioid-related mortality, but they remain underutilized, especially in non-substance use disorder settings such as primary care (PC). OBJECTIVE: To uncover the factors that can facilitate successful prescribing of MOUD and uptake/acceptance of MOUD by patients in PC settings in the Veterans Health Administration. DESIGN: Semi-structured qualitative telephone interviews with 77 providers (e.g., primary care providers, hospitalists, nurses, addiction psychiatrists) and 22 Veteran patients with experience taking MOUD. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach. KEY RESULTS: Providers and patients shared their general perceptions and experiences with MOUD, including high satisfaction with buprenorphine/naloxone with few side effects and caveats, although some patients reported drawbacks to methadone. Both providers and patients supported the idea of prescribing MOUD in PC settings to prioritize patient comfort and convenience. Providers described individual-level barriers (e.g., time, stigma, perceptions of difficulty level), structural-level barriers (e.g., pharmacy not having medications ready, space for inductions), and organizational-level barriers (e.g., inadequate staff support, lack of nursing protocols) to PC providers prescribing MOUD. Facilitators centered on education and knowledge enhancement, workflow and practice support, patient engagement and patient-provider communication, and leadership and organizational support. The most common barrier faced by patients to starting MOUD was apprehensions about pain, while facilitators focused on personal motivation, encouragement from others, education about MOUD, and optimally timed provider communication strategies. CONCLUSIONS: These findings can help improve provider-, clinic-, and system-level supports for MOUD prescribing across multiple settings, as well as foster communication strategies that can increase patient acceptance of MOUD. They also point to how interprofessional collaboration across service lines and leadership support can facilitate MOUD prescribing among non-addiction providers.

Challenges experienced by those with polycystic ovary syndrome in healthcare interactions: a qualitative evidence synthesis.

Studies report interaction difficulties between patients with polycystic ovary syndrome (PCOS) and healthcare professionals (HCP). This systematic review and qualitative evidence synthesis aimed to collate and synthesize the existing peer-reviewed literature investigating challenges for people with PCOS when interacting with HCP. Medline, PsycInfo, EMBASE, All EBM and CINAHL were searched from 1990 to September 2022. Study risk of bias (RoB) was performed and all textual data relevant to challenging interactions between patients with PCOS and HCP were extracted and analysed using thematic synthesis. Of the 6353 studies identified, 28 were included. Two were appraised as high, four as moderate and 22 as low RoB. Four analytic themes were derived illustrating that interactions were challenging when: (i) medical information (PCOS, its management) was not shared in the best way; (ii) information provision and deliberation opportunities were insufficient to achieve outcomes that mattered to patients; (iii) interactions prompted but did not support patient activation; and (iv) health system-level barriers (e.g. policies and guidelines) were present or made worse by HCP behaviour. Future research should examine methods for the implementation and evaluation of established frameworks for sharing medical information and supporting patient agency in the context of PCOS care.

Factors affecting delays in seeking treatment among malaria patients during the pre-certification phase in China.

BACKGROUND: Delays in malaria treatment can not only lead to severe and even life-threatening complications, but also foster transmission, putting more people at risk of infection. This study aimed to investigate the factors influencing treatment delays among malaria patients and their health-seeking behaviour. METHODS: The medical records of 494 patients diagnosed with malaria from 6 different malaria-endemic provinces in China were analysed. A bivariate and multivariable regression model was used to investigate the association between delays in seeking treatment and various factors. A Sankey diagram was used to visualize the trajectories of malaria patients seeking medical care. Total treatment delays were categorized as patient delays and doctor delays. RESULTS: The incidence of total delays in seeking malaria treatment was 81.6%, of which 28.4% were delayed by patients alone and 34.8% by doctors alone. The median time from the onset of symptoms to the initial healthcare consultation was 1 day. The median time from the initial healthcare consultation to the conclusive diagnosis was 2 day. After being subjected to multiple logistic regression analysis, living in central China was less likely to experience patient delays (OR = 0.43, 95% CI 0.24-0.78). The factors significantly associated with the lower likelihood of doctor delays included: age between 30 to 49 (OR = 0.43, 95% CI 0.23-0.81), being single/divorce/separated (OR = 0.48, 95% CI 0.24-0.95), first visiting a county-level health institution (OR = 0.25, 95% CI 0.14-0.45), first visiting a prefectural health institution (OR = 0.06, 95% CI 0.03-0.12) and first visiting a provincial health institution (OR = 0.05, 95%CI 0.02-0.12). Conversely, individuals with mixed infections (OR = 2.04, 95% CI 1.02-4.08) and those experiencing periodic symptoms (OR = 1.71, 95% CI 1.00-2.92) might face increased doctor delays. Furthermore, higher financial burden and complications were found to be associated with patient delays. Doctor delays, in addition to incurring these two consequences, were associated with longer hospital stays. CONCLUSION: There was a substantial delay in access to health care for malaria patients before China was certified malaria free. Region, marital status, periodic symptoms and the level of health institutions were factors contributing to delays in treatment-seeking among malaria patients.

UK Prescribing Safety Assessment (PSA): The development, implementation and outcomes of a national online prescribing assessment.

AIMS: The United Kingdom (UK) Prescribing Safety Assessment (PSA) is a 2-h online assessment of basic competence to prescribe and supervise the use of medicines. It has been undertaken by students and doctors in UK medical and foundation schools for the past decade. This study describes the academic characteristics and performance of the assessment; longitudinal performance of candidates and schools; stakeholder feedback; and surrogate markers of prescribing safety in UK healthcare practice. METHODS: We reviewed the performance data generated by over 70 000 medical students and 3700 foundation doctors who have participated in the PSA since its inception in 2013. These data were supplemented by Likert scale and free text feedback from candidates and a variety of stakeholder groups. Further data on medication incidents, collected by national reporting systems and the regulatory body, are reported, with permission. RESULTS: We demonstrate the feasibility, high quality and reliability of an online prescribing assessment, uniquely providing a measure of prescribing competence against a national standard. Over 90% of candidates pass the PSA on their first attempt, while a minority are identified for further training and assessment. The pass rate shows some variation between different institutions and between undergraduate and foundation cohorts. Most responders to a national survey agreed that the PSA is a useful instrument for assessing prescribing competence, and an independent review has recommended adding the PSA to the Medical Licensing Assessment. Surrogate markers suggest there has been improvement in prescribing safety in practice, temporally associated with the introduction of the PSA but other factors could be influential too. CONCLUSIONS: The PSA is a practical and cost-effective way of delivering a reliable national assessment of prescribing competence that has educational impact and is supported by the majority of stakeholders. There is a need to develop national systems to identify and report prescribing errors and the harm they cause, enabling the impact of educational interventions to be measured.

Impact of body mass index and examination type on utilization of screening programs: A big data study.

OBJECTIVE: To investigate the relationship between Body Mass Index (BMI) and adherence to recommended screening tests, addressing gaps in previous literature by utilizing a large cohort, while considering longitudinal changes in weight and the type of screening. METHODS: Data from Clalit Health Services in Israel were retrospectively analyzed, including participants aged 50 and above from 2002 to 2021. BMI measurements and various screening test records were examined. Generalized Estimating Equations were employed for analysis, adjusting for potential confounding variables, including age, gender, geographic location, and socioeconomic status. RESULTS: The study included 634,879 participants with 4,630,030 BMI measurements and 56,453,659 test records. Participants were categorized into BMI cohorts at the time of the test, with overweight and obese individuals showing lower odds of undergoing intimate examination-based screening tests (mammography, PAPS, and skin examination), as opposed to higher odds of several non-intimate tests (e.g., diabetes and eye disorder screenings). DISCUSSION: Our findings suggest that individuals with overweight and obesity are less likely to undergo screenings involving intimate physical examinations, potentially due to weight stigma and discomfort. This avoidance behavior may contribute to increased morbidity rates in these populations. Interventions addressing weight stigma, improving access to care, and enhancing patient engagement are warranted.

Experiences of families post treatment for childhood brain tumours during medical clinic consultations regarding health-related quality of life, unmet needs and communication barriers: A qualitative exploration.

BACKGROUND: Many studies highlight poor health-related quality of life (HRQoL) in children treated for brain tumours and their parents. However, little is known about the extent to which their informational, healthcare and communication needs regarding HRQoL are met during medical outpatient consultations. AIM: To explore the experiences of families regarding communication with physicians about HRQoL issues during consultations after treatment for childhood brain tumours. METHODS: Interviews were conducted with 18 families of children and adolescents aged 8-17 years after completion of brain tumour treatment. Participants had completed treatment within the last 5 years and were receiving regular outpatient follow-up care. Thematic analysis was undertaken using the Framework Method. RESULTS: Five main themes were identified: (i) unmet emotional and mental health needs; (ii) double protection; (iii) unmet information needs; (iv) communication barriers within consultations; and (v) finding a new normal. CONCLUSION: There was a need to improve communication between clinicians and these families, improve information provision, and overcome barriers to conversing with children within these outpatient consultations. Children and their parents should be supported to voice their current needs and concerns regarding their HRQoL. These findings will inform further development of the UK version of the 'KLIK' patient- and parent-reported outcome (PROM) portal.

An Anthroposophic Medical Treatment in the Land of Salt and Gold.

In this narrative, a general practitioner and psychotherapist trained in anthroposophic medicine presents the narrative and treatment of a 60-year-old woman who experienced the horrors of the "Dark Sabbath" attack in southern Israel on October 7, 2023. The patient's story is narrated by the physician, who shares his multi-disciplinary and multi-modal anthroposophic medicine approach to address the patient's acute stress disorder-related symptoms and concerns.

Cross-Cultural Patient Counseling and Communication in the Integrative Medicine Setting: Respecting the Patient's Health Belief Model of Care.

PURPOSE OF REVIEW: Communicating effectively with patients having a traditional, alternative or complementary medicine-related health-belief model is challenging in today's cross-cultural society. This narrative review explores the integrative medicine setting of care, focusing on insights from the integrative oncology daily practice, while addressing the relevance to the mental health setting. The way in which healthcare providers can enhance cultural-sensitive communication with patients and informal caregivers; recognize and respect health-beliefs to bridge cultural gaps; and generate an open, non-judgmental and mindful dialogue are discussed. RECENT FINDINGS: Identifying cross-cultural barriers to healthcare provider-patient communication is important in order to address the potential for conflict between conventional and "alternative" health beliefs; difficulties in creating a shared-decision making process; disagreement on therapeutic goals and treatment plan; and finally, the potential for non-compliance or non-adherence to the conventional oncology treatment. Acquiring intercultural competencies is needed at all stages of medical education, and should be implemented in medical and nursing curricula, as well as during specialization and sub-specialization. As with patient-centered paradigms of care, integrative medicine entails a dual patient-centered and sensitive-cultural approach, based on a comprehensive bio-psycho-social-spiritual model of care.

Doctor trustworthiness influences pain and its neural correlates in virtual medical interactions.

Trust is an important component of the doctor-patient relationship and is associated with improved patient satisfaction and health outcomes. Previously, we reported that patient feelings of trust and similarity toward their clinician predicted reductions in evoked pain in response to painful heat stimulations. In the present study, we investigated the brain mechanisms underlying this effect. We used face stimuli previously developed using a data-driven computational modeling approach that differ in perceived trustworthiness and superimposed them on bodies dressed in doctors' attire. During functional magnetic resonance imaging, participants (n = 42) underwent a series of virtual medical interactions with these doctors during which they received painful heat stimulation as an analogue of a painful diagnostic procedure. Participants reported increased pain when receiving painful heat stimulations from low-trust doctors, which was accompanied by increased activity in pain-related brain regions and a multivariate pain-predictive neuromarker. Findings suggest that patient trust in their doctor may have tangible impacts on pain and point to a potential brain basis for trust-related reductions in pain through the modulation of brain circuitry associated with the sensory-discriminative and affective-motivational dimensions of pain.

Timing of prognostic discussions in people with advanced cancer: a systematic review.

PURPOSE: Many people with cancer (patients) want to know their prognosis (a quantitative estimate of their life expectancy) but this is often not discussed or poorly communicated. The optimal timing of prognostic discussions with people with advanced cancer is highly personalised and complex. We aimed to find, organise, and summarise research regarding the timing of discussions of prognosis with people with advanced cancer. METHODS: We conducted a systematic review of publications from databases, clinical practice guidelines, and grey literature from inception to 2023. We also searched the reference lists of systematic reviews, editorials, and clinical trial registries. Eligibility criteria included publications regarding adults with advanced cancer that reported a timepoint when a discussion of prognosis occurred or should occur. RESULTS: We included 63 of 798 identified references; most of which were cross-sectional cohort studies with a range of 4-9105 participants. Doctors and patients agreed on several timepoints including at diagnosis of advanced cancer, when the patient asked, upon disease progression, when there were no further anti-cancer treatments, and when recommending palliative care. Most of these timepoints aligned with published guidelines and expert recommendations. Other recommended timepoints depended on the doctor's clinical judgement, such as when the patient 'needed to know' or when the patient 'seemed ready'. CONCLUSIONS: Prognostic discussions with people with advanced cancer need to be individualised, and there are several key timepoints when doctors should attempt to initiate these conversations. These recommended timepoints can inform clinical trial design and communication training for doctors to help improve prognostic understanding.

Qualitative evaluation of motives for acceptance or refusal of early palliative care in patients included in early-phase clinical trials in a French comprehensive cancer center: the PALPHA study.

PURPOSE: The integration of palliative care (PC) into oncological management is recommended well before the end of life. It improves quality of life and symptom control and reduces the aggressiveness of end-of-life care. However, its appropriate timing is still debated. Entry into an early-phase clinical trial (ECT) represents hopes for the patient when standard treatments have failed. It is an opportune moment to integrate PC to preserve the patient's general health status. The objective of this study was to evaluate the motives for acceptance or refusal of early PC management in patients included in an ECT. METHODS: Patients eligible to enter an ECT were identified and concomitant PC was proposed. All patients received exploratory interviews conducted by a researcher. Their contents were analyzed in a double-blind thematic analysis with a self-determination model. RESULTS: Motives for acceptance (PC acceptors: n = 27) were both intrinsic (e.g., pain relief, psychological support, anticipation of the future) and extrinsic (e.g., trust in the medical profession, for a relative, to support the advance of research). Motives for refusal (PC refusers: n = 3) were solely intrinsic (e.g., PC associated with death, negative representation of psychological support, no need for additional care, claim of independence). CONCLUSIONS: The motives of acceptors and refusers are not internalized in the same way and call for different autonomy needs. Acceptors and refusers are influenced by opposite representations of PC and a different perception of mixed management.

Shared decision-making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting: a qualitative study of Clinicians' perspectives (STREAMS-C).

BACKGROUND: Shared decision-making (SDM) is increasingly expected in healthcare systems prioritising patient autonomy. Treatment escalation plans (TEPs) outline contingency for medical intervention in the event of patient deterioration. This study aimed to understand clinicians' perspectives on SDM in TEP for older patients in the acute medical setting. METHODS: This was a qualitative study following a constructivist approach. Semistructured interviews with vignettes were conducted with 26 consultant and registrar doctors working in emergency medicine, general internal medicine, intensive care medicine and palliative care medicine. Reflexive thematic analysis was performed. RESULTS: There were three themes: 'An unequal partnership', 'Options without equipoise' and 'Decisions with shared understanding'. Clinicians' expertise in synthesising complex, uncertain clinical information was contrasted with perceived patient unfamiliarity with future health planning and medical intervention. There was a strong sense of morality underpinning decision-making and little equipoise about appropriate TEP decisions. Communication around the TEP was important, and clinicians sought control over the high-stakes decision whilst avoiding conflict and achieving shared understanding. CONCLUSIONS: Clinicians take responsibility for securing a 'good' TEP decision for older patients in the acute medical setting. They synthesise clinical data with implicit ethical reasoning according to their professional predictions of qualitative and quantitative success following medical intervention. SDM is seldom considered a priority for this context. Nonetheless, avoidance of conflict, preserving the clinical relationship and shared understanding with the patient and family are important.

Establishing trust with children.

Trust forms the bedrock of the doctor-patient relationship. While establishing trust is a foundational skill for healthcare providers who care for children, there is no systematic approach to teaching this skill set, nor is there formal training during medical school or residency. Traditionally, these skills have been taught by example, in an unstructured and ad hoc manner, with trainees picking it up along the way by observing and modeling their instructors. Here, we define and examine the elements of establishing trust and describe a methodology for establishing trust and managing a child's emotional state during medical encounters.

Primary health care coverage in Portugal: the promise of a general practitioner for all.

BACKGROUND: Primary care is an essential pillar of health systems. Many countries have implemented different policies to improve access to primary care. However, persistent challenges remain. This paper offers a critical analysis of the evolution of primary care coverage in Portugal, focusing on the number of patients without an assigned general practitioner (GP). METHODS: We collected and analyzed publicly available data from 2009 to 2023 to decompose primary care coverage in three components: the number of patients enrolled in primary care units (demand-side effect), the number of GPs measured in full-time equivalent (supply-side effect), and the average number of patients on each GP's list (patient-to-GP ratio, capturing a productivity effect). We provide national and local level estimates for these three components. RESULTS: Between 2009 and 2023, there was an overall decline in the number of patients enrolled in primary health care units. Concurrently, there was also a net decrease of GPs measured in full-time equivalent. Additionally, there was a progressive reduction in the average number of patients on each GP's list. The rise in the number of patients without an assigned GP is attributed not only to a reduction in the number of physicians, but also to a decrease in the patient load per doctor. CONCLUSIONS: Hiring additional GPs may not suffice to enhance coverage. Achieving higher coverage may imply revisiting patient load per doctor or considering alternative care models. Understanding the challenges related to GP coverage is critical for improving the efficiency of primary care.

Dealing with the doctor shortage: a qualitative study exploring French general practitioners' lived experiences, difficulties, and adaptive behaviours.

CONTEXT: The shortage of general practitioners (GPs) is a growing concern in Europe, especially in France. This problem is likely to continue until the end of the 2020s. OBJECTIVES: To study the GPs' perceptions of access to care in medically underserved areas (i.e. with low physician density), its consequences on their working conditions, and how they cope with the resulting difficulties. METHODS: Semi-structured individual interviews were conducted between May and August 2021 of 29 GPs practising in areas of southeastern France with a low physician density or at risk of a doctor shortage. Purposive sampling was used to include profiles of diverse physicians and diverse rural and urban areas. The interviews, conducted with an interview guide, were transcribed and analysed thematically. RESULTS: The participants described a serious degradation of access to care in their areas. These issues also concerned urban areas, where they were, according to the participants, underrecognized. The participants' workloads were rising, at a rate often perceived as unsustainable: many participants, including the youngest group, reported they were exhausted. Their principal source of dissatisfaction was their impression that they could not do their work correctly. Participants reported that these difficulties required them to improvise and adapt without any official or formal method to keep their practice manageable. CONCLUSION: These GPs were worried about the future of their profession and their patients. They expected strong measures by public policymakers and officials, but paradoxically seemed to have little interest in the solutions these officials are promoting.

Measuring continuity in primary care: how it is done and why it matters.

Continuity of care (COC) is a foundational element of primary care and is associated with improved patient satisfaction and health outcomes and decreased total cost of care. The patient-physician relationship is highly valued by both parties and is often the reason providers choose to specialize in primary care. In some settings, such as outpatient residency clinics, however, patients may only see their primary care provider (PCP) 50% or less of the time. Considering the many benefits of COC for patients and providers, there is a clear need for us in primary care to understand how to compare different COC measures across studies and how to choose the best COC measure when conducting quality improvement efforts. However, at least 32 different measures have been used to evaluate COC. The manifold variations for measuring COC arise from data source restrictions, purpose (research or clinical use), perspective (patient or provider), and patient visit frequency/type. Key factors distinguishing common COC formulas are data source (e.g. claims data or electronic medical records), and whether a PCP is identifiable. There is no "right" formula, so understanding the nuances of COC measurement is essential for primary care research and clinical quality improvement. While the full complexity of COC cannot be captured by formulas and indices, they provide an important measure of how consistently patients are interacting with the same provider.

Factors Associated with Corticosteroid Adherence in Sarcoidosis.

PURPOSE: We measured corticosteroid medication adherence (CMA) in sarcoidosis patients and analyzed if demographic and clinical factors, beliefs about medications, corticosteroid side-effects, psychosocial status, and the doctor-patient relationship were associated with corticosteroid adherence. METHODS: Sarcoidosis patients receiving corticosteroids were eligible to participate. CMA was measured using the Medication Adherence Response Scale-10 (MARS-10), a validated patient reported outcome measure (PRO). Data collection included patient demographics and clinical variables to assess their sarcoidosis phenotype. The patients were administered additional PROs concerning their psychosocial status, beliefs about medication use, corticosteroid side-effects and the strength of their doctor-patient relationship. RESULTS: 132 patients were enrolled. Their mean prednisone dose was 9.9 ± 7.5 mg/day. 75% (99/132) were adherent with corticosteroids (MARS-10 ≥ 6) and 25% (33/132) were nonadherent (MARS-10 < 6). All demographic features, education level, and annual family income were not associated with CMA. Most clinical variables including spirometry, use of additional sarcoidosis drugs, number of organs involved with sarcoidosis were not associated with CMA. Almost all PROs including a better attitude toward medication use, less psychological issues, less corticosteroid side-effects, and a stronger doctor-patient relationship were associated with better CMA. A multi-logistic regression found that patient-doctor communication and the patient's intrinsic beliefs about the use of medications remained associated with CMA. CONCLUSION: We found no significant relationship between demographic or socioeconomic factors and CMA. Few clinical factors were associated with CMA. In a univariate analysis, CMA was associated with physician-doctor communication, beliefs about medication use, psychological/emotional issues, and corticosteroid side-effects. Only the first two of these factors remained associated with CMA in a multi-logistic analysis. These data suggest that CMA is heavily influenced by sarcoidosis patient beliefs about medications, and less so by patient demographics.

Aesthetic doctors' perception and attitudes toward tolerance in botulinum toxin.

BACKGROUND: Botulinum toxin is a crucial therapeutic tool with broad indications in both cosmetic and medical fields. However, the expanding cosmetic use and increased dosages of botulinum toxin have raised concerns about resistance, making it essential to study the awareness and management practices among healthcare professionals. METHODS: A survey was conducted among clinical physicians using botulinum toxin. The study investigated their experiences, awareness, and management practices related to toxin resistance. Real-time mobile app-based surveys were administered to clinicians attending the 45th International Academic Conference of the Korean Academy of Laser and Dermatology (KALDAT) on December 3, 2023. RESULTS: Among 3140 participants, 673 clinical physicians completed the survey. Of these, 363 clinicians (53.9%) reported experiencing botulinum toxin resistance. Regarding the resistance rate, 59.4% indicated less than 1%, 36% reported approximately 1%-25%, and 95.4% reported less than 25%. Efforts to prevent resistance included maintaining intervals of over 3 months (54.8%), using products with lower resistance potential (47.0%), employing minimal effective doses (28.2%), and minimizing re-administration (14.9%). CONCLUSION: In the South Korean aesthetic medicine community, a majority of clinical physician's report encountering botulinum toxin resistance. Given the potential loss of various benefits associated with resistance, there is a need to establish appropriate guidelines based on mechanistic studies and current status assessments. Educating clinicians on applicable guidelines is crucial.

Not ready in the ways that count- a qualitative exploration of junior doctor's perceived preparedness for practice using Legitimation Code Theory.

Despite demonstrating the required competencies to graduate, many newly qualified doctors find the transition to internship difficult. There is a concern over whether their preparation is aligned with the expectations of the role. This study aimed to gain a better understanding of the competencies needed for legitimate practice as junior doctors and explores their perceived preparedness for practice. A qualitative, descriptive study using focus groups was undertaken with first year internship doctors. Thirty-two junior doctors in their first year of internship took part in five focus groups. The data were analysed using a reflective thematic analysis approach with a subsequent analysis using the Legitimation Code Theory (LCT) specialisation dimension coding framework to aid interpretation. Personal attributes including adaptability, organisation and proactivity form the basis of achievement in internship. While graduates felt ready in some ways, it was not in the ways that counted. Participants felt well prepared in terms of their clinical knowledge and skills, but legitimacy came from being able to take responsibility, communicate effectively and apply knowledge confidently and efficiently to all aspects of patient care, something that they did not feel ready to do. Using LCT has revealed a shift in the basis of achievement between medical school, where individual academic performance is rewarded, and internship, where personal and social competencies are legitimised. There is a clash between what graduates feel well prepared for and the expectations and demands of the internship role, resulting in a difficult and stressful transition from student to doctor.