Graduates' preparedness for the changing doctor-patient relationship: A qualitative study.

BACKGROUND: A positive doctor-patient relationship is a crucial part of high-quality patient care. There is a general perception that it has been changing in recent years; however, there is a lack of evidence for this. Adapting to the changing doctor-patient relationship has been identified as an important skill doctors of the future must possess. This study explores (1) multiple stakeholder perspectives on how the doctor-patient relationship is changing and (2) in what ways medical graduates are prepared for working in this changing doctor-patient relationship. METHODS: We conducted a national qualitative study involving semi-structured interviews with multiple stakeholders across the United Kingdom. Interviews lasting 45-60 minutes were conducted with 67 stakeholders including doctors in the first 2 years of practice (ECD's), patient representatives, supervisors, deans, medical educators and other health care professionals. The interviews were audiorecorded, transcribed, analysed, coded in NVivo and analysed thematically using a Thematic Framework Analysis approach. RESULTS: The main ways the doctor-patient relationship was perceived to be changing related to increased shared decision making and patients having increasing access to information. Communication, patient-centred care and fostering empowerment, were the skills identified as being crucial for preparedness to work in the changing doctor-patient relationship. Graduates were reported to be typically well-prepared for the preconditions (communication and delivering patient-centred care) of patient empowerment, but that more work is needed to achieve true patient empowerment. CONCLUSION: This study offers a conceptual advance by identifying how the doctor-patient relationship is changing particularly around the 'patient-as-knowledge-source' dimension. On the whole ECD's are well-prepared for working in the changing doctor-patient relationship with the exception of patient empowerment skills. Further research is now needed to provide an in-depth understanding of patient empowerment that is shared among key stakeholders (particularly the patient perspective) and to underpin the design of educational interventions appropriate to career stage.

Constraints and affordances for UK doctors-in-training to exercise agency: A dialogical analysis.

INTRODUCTION: The goal of medical education is to develop clinicians who have sufficient agency (capacity to act) to practise effectively in clinical workplaces and to learn from work throughout their careers. Little research has focused on experiences of organisational structures and the role of these in constraining or affording agency. The aim of this study was to identify priorities for organisational change, by identifying and analysing key moments of agency described by doctors-in-training. METHODS: This was a secondary qualitative analysis of data from a large national mixed methods research programme, which examined the work and wellbeing of UK doctors-in-training. Using a dialogical approach, we identified 56 key moments of agency within the transcripts of 22 semi-structured interviews with doctors based across the UK in their first year after graduation. By analysing action within the key moments from a sociocultural theoretical perspective, we identified tangible changes that healthcare organisations can make to afford agency. RESULTS: When talking about team working, participants gave specific descriptions of agency (or lack thereof) and used adversarial metaphors, but when talking about the wider healthcare system, their dialogue was disengaged and they appeared resigned to having no agency to shape the agenda. Organisational changes that could afford greater agency to doctors-in-training were improving induction, smoothing peaks and troughs of responsibility and providing a means of timely feedback on patient care. CONCLUSIONS: Our findings identified some organisational changes needed for doctors-in-training to practise effectively and learn from work. The findings also highlight a need to improve workplace-based team dynamics and empower trainees to influence policy. By targeting change, healthcare organisations can better support doctors-in-training, which will ultimately benefit patients.

Optimising the delivery of remediation programmes for doctors: A realist review.

CONTEXT: Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety. METHOD: We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs). RESULTS: A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection. CONCLUSION: Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.

Remediating professionalism lapses in medical students and doctors: A systematic review.

CONTEXT: A remediation intervention aims to facilitate the improvement of an individual whose competence in a particular skill has dropped below the level expected. Little is known regarding the effectiveness of remediation, especially in the area of professionalism. This review sought to identify and assess the effectiveness of interventions to remediate professionalism lapses in medical students and doctors. METHODS: Databases Embase, MEDLINE, Education Resources Information Center and the British Education Index were searched in September 2017 and October 2018. Studies reporting interventions to remediate professionalism lapses in medical students and doctors were included. A standardised data extraction form incorporating a previously described behaviour change technique taxonomy was utilised. A narrative synthesis approach was adopted. Quality was assessed using the Critical Appraisal Skills Programme checklist. RESULTS: A total of 19 studies on remediation interventions reported in 23 articles were identified. Of these, 13 were case studies, five were cohort studies and one was a qualitative study; 37% targeted doctors, 26% medical students, 16% residents and 21% involved mixed populations. Most interventions were multifaceted and addressed professionalism issues concomitantly with clinical skills, but some focused on specific areas (eg sexual boundaries and disruptive behaviours). Most used three or more behaviour change techniques. The included studies were predominantly of low quality as 13 of the 19 were case studies. It was difficult to assess the effectiveness of the interventions as the majority of studies did not carry out any evaluation. CONCLUSIONS: The review identifies a paucity of evidence to guide best practice in the remediation of professionalism lapses in medical students and doctors. The literature tentatively suggests that remediating lapses in professionalism, as part of a wider programme of remediation, can facilitate participants to graduate from a programme of study, and pass medical licensing and mock oral board examinations. However, it is not clear from this literature whether these interventions are successful in remediating lapses in professionalism specifically. Further research is required to improve the design and evaluation of interventions to remediate professionalism lapses.

Tacrolimus restores the high- and low-pressure baroreflex control of renal sympathetic nerve activity in cisplatin-induced renal injury rats.

NEW FINDINGS: What is the central question of this study? Does immunosuppression restore the baroreflex control of renal sympathetic nerve activity (RSNA) in an animal model of kidney injury? What is the main finding and its importance? Tacrolimus, a calcineurin inhibitor, restored the high- and low-pressure baroreflex control of RSNA following cisplatin-induced renal injury. ABSTRACT: Cisplatin administration causes depression of renal haemodynamic and excretory function and is associated with renal sympatho-excitation and loss of baroreflex regulation of renal sympathetic nerve activity (RSNA). This study investigated whether administration of the immunosuppressant tacrolimus in this cisplatin-mediated renal injury model could restore, or the acute intra-renal infusion of tumour necrosis factor α (TNF-α) could blunt, the high- or low-pressure baroreflex control of RSNA. Groups of control and cisplatin-treated (5 mg kg-1 , i.p. on day 0) rats received either saline or tacrolimus (0.25 mg kg-1  day-1 , i.p.) for 7 days prior to study. Rats were anaesthetised and prepared for measurement of mean arterial pressure (MAP), heart rate (HR) and RSNA. Baroreflex gain curves were generated and the degree of renal sympatho-inhibition determined (area under the curve (AUC) reported as %RSNA min) during acute volume expansion. Intrarenal TNF-α infusion (0.3 µg kg-1  h-1 ) in control rats decreased baroreflex gain by 32% (P < 0.05) compared to intra-renal saline infusion. In the cisplatin group (MAP: 98 ± 14 mmHg; HR: 391 ± 24beats min-1 ), the baroreflex gain for RSNA was 39% (P < 0.05) lower than that for the control group (MAP: 91 ± 7 mmHg; HR: 382 ± 29 beats min-1 ). In cisplatin-treated rats given daily tacrolimus (MAP: 84 ± 12 mmHg; HR: 357 ± 30 beats min-1 ), the baroreflex gain and renal sympatho-inhibition (AUC, 2440 ± 1071 vs. 635 ± 498% min) were restored to normal values. These findings provide evidence for the view that cisplatin administration initiates an injury involving inflammation which may contribute to the deranged baroreflex regulation of RSNA. This phenomenon appears mediated in part via the renal innervation.

Optimising feedback for early career professionals: a scoping review and new framework.

CONTEXT: Meta-analyses have shown that feedback can be a powerful intervention to increase learning and performance but there is significant variability in impact. New trials are adding little to the question of whether feedback interventions are effective, so the focus now is how to optimise the effect. Early career professionals (ECPs) in busy work environments are a particularly important target group. This literature review aimed to synthesise information to support the optimal design of feedback interventions for ECPs. METHODS: We undertook a scoping literature review, using search terms such as 'feedback' and 'effectiveness' in MEDLINE, MEDLINE-In-Process, PsycINFO, CINAHL, Education Research Complete, Education Resources Information Center, the Cochrane Database of Systematic Reviews, the Social Sciences Citation Index and Applied Social Sciences Index and Abstracts, to identify empirical studies describing feedback interventions in busy workplaces published in English since 1990. We applied inclusion criteria to identify studies for the mapping stage and extracted key data to inform the next stage. We then selected a subset of papers for the framework development stage, which were subjected to a thematic synthesis by three authors, leading to a new feedback framework and a modified version of feedback intervention theory specifically for ECPs. RESULTS: A total of 80 studies were included in the mapping stage, with roughly equal studies from hospital settings and school classrooms, and 17 papers were included in the framework development stage. The feedback framework comprised three main categories (audit, feedback and goal setting) and 22 subcategories. The review highlighted the limited empirical research focusing solely on feedback for ECPs, which was surprising given the particular nuances in feedback for ECPs identified through this study. CONCLUSIONS: We offer the feedback framework to optimise the design of future feedback interventions for early career professionals and encourage future feedback research to move away from generic models and tailor work to specific target audiences.

Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review.

Background: Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods: The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results: By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions: This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.

Towards an understanding of how appraisal of doctors produces its effects: a realist review.

CONTEXT: Revalidation was launched in the UK to provide assurances to the public that doctors are up to date and fit to practice. Appraisal is a fundamental component of revalidation. Approximately 150 000 doctors are appraised annually, costing an estimated £97 million over 10 years. There is little understanding of the theory of how and why appraisal is supposed to produce its effects. A realist review of the literature was utilised to explore these issues, as they generate context-mechanism-outcome (CMO) configurations, resulting in the creation of theories of how and why appraisal of doctors produces its effects. METHODS: A programme theory of appraisal was created by convening stakeholders in appraisal and searching a database of research on appraisal of doctors. Supplementary searches provided literature on theories identified in the programme theory. Relevant sections of texts relating to the programme theory were extracted from included articles, coded in NVivo and synthesised using realist logic of analysis. A classification tool categorised the included articles' contributions to programme theory. RESULTS: One hundred and twenty-five articles were included. Three mechanisms were identified: dissonance, denial and self-affirmation. The dissonance mechanism is most likely to cause outcomes of reflection and insight. Important contexts for the dissonance mechanism include the appraiser being highly skilled, the appraisee's working environment being supportive and the appraisee having the right attitude. The denial mechanism is more likely to be enacted if the opposite of these contexts occurs and could lead to game-playing behaviour. A skilled appraiser was also important in triggering the self-affirmation mechanism, resulting in reflection and insight. The contexts, mechanisms and outcomes identified were, however, limited by a lack of evidence that could enable further refining of the CMO configurations. CONCLUSION: This review makes a significant contribution to our understanding of appraisal by identifying different ways that appraisal of doctors produces its effects. Further research will focus on testing the CMO configurations.

Comparative toxicity of imidacloprid and thiacloprid to different species of soil invertebrates.

Neonicotinoid insecticides have come under increasing scrutiny for their impact on non-target organisms, especially pollinators. The current scientific literature is mainly focused on the impact of these insecticides on pollinators and some aquatic insects, leaving a knowledge gap concerning soil invertebrates. This study aimed at filling this gap, by determining the toxicity of imidacloprid and thiacloprid to five species of soil invertebrates: earthworms (Eisenia andrei), enchytraeids (Enchytraeus crypticus), Collembola (Folsomia candida), oribatid mites (Oppia nitens) and isopods (Porcellio scaber). Tests focused on survival and reproduction or growth, after 3-5 weeks exposure in natural LUFA 2.2 standard soil. Imidacloprid was more toxic than thiacloprid for all species tested. F. candida and E. andrei were the most sensitive species, with LC50s of 0.20-0.62 and 0.77 mg/kg dry soil for imidacloprid and 2.7-3.9 and 7.1 mg/kg dry soil for thiacloprid. EC50s for effects on the reproduction of F. candida and E. andrei were 0.097-0.30 and 0.39 mg/kg dry soil for imidacloprid and 1.7-2.4 and 0.44 mg/kg dry soil for thiacloprid. The least sensitive species were O. nitens and P. scaber. Enchytraeids were a factor of 5-40 less sensitive than the taxonomically related earthworm, depending on the endpoint considered. Although not all the species showed high sensitivity to the neonicotinoids tested, these results raise awareness about the effects these insecticides can have on non-target soil invertebrates.

Qualified doctor and medical students' use of resources for accessing information: what is used and why?

BACKGROUND: Learning to access information using resources such as books and search engines is an important and fast changing challenge for doctors and medical students. Many resources exist to support evidence-based clinical decision-making, but a wide range of factors influences their use. OBJECTIVE: To explore qualified doctor and medical students' use of resources for accessing information and to determine what is used and why. METHODS: A stratified sample of 46 participants was recruited in Devon, UK. Participants kept a self-report diary of resources used over a week. The diaries were then used to stimulate recall within a semi-structured interview. Diary data were collated into tables of resource use. Qualitative data from the interviews were transcribed verbatim and thematically analysed. RESULTS: Many resources were used by participants but typically for a short duration of time. Categories of reasons for accessing resources were 'to check', 'to learn' and 'to demonstrate'. The two main factors influencing choice of information resource were 'ease of access' and 'quality of information'. Students accessed more information, for a longer duration. DISCUSSION & CONCLUSION: Resources must be quick to use, easy to access and tailored to the different purposes that they serve for qualified doctors and medical students.

How prepared are newly qualified allied health professionals for practice in the UK? A systematic review.

OBJECTIVES: It is important that allied health professionals (AHPs) are prepared for clinical practice from the very start of their working lives to provide quality care for patients, for their personal well-being and for retention of the workforce. The aim of this study was to understand how well newly qualified AHPs were prepared for practice in the UK. DESIGN: Systematic review. DATA SOURCES: Embase, MEDLINE, CINAHL, ERIC and BEI were searched from 2012 to 2024. Grey literature searching and citation chasing were also conducted. ELIGIBILITY CRITERIA: We included primary studies reporting the preparedness for practice of UK graduates across 15 professions; all study types; participants included graduates who were up to 2 years postgraduation, their supervisors, trainers, practice educators and employers; and all outcome measures. DATA EXTRACTION AND SYNTHESIS: A standardised data extraction form was used. Studies were quality assessed using the Quality Appraisal for Diverse Studies tool. 10% of articles were independently double-screened, extracted and quality assessed; 90% was completed by one researcher. RESULTS: 14 reports were included (9 qualitative, 3 mixed-method and 2 quantitative). Six papers focused on radiographers, three on a mixture of professions, two on paramedics, and one each on physiotherapists, clinical psychologists and orthotists. An important finding of the review is the paucity and low-medium quality of research on the topic. The narrative synthesis tentatively suggests that graduates are adequately prepared for practice with different professions having different strengths and weaknesses. Common areas of underpreparedness across the professions were responsibility and decision-making, leadership and research. Graduates were generally well prepared in terms of their knowledge base. CONCLUSION: High-quality in-depth research is urgently needed across AHPs to elucidate the specific roles, their nuances and the areas of underpreparedness. Further work is also needed to understand the transition into early clinical practice, ongoing learning opportunities through work, and the supervision and support structures in place. PROSPERO REGISTRATION NUMBER: CRD42022382065.

A systematic review of educational interventions to change behaviour of prescribers in hospital settings, with a particular emphasis on new prescribers.

AIMS: Prescribing is a complex task and a high risk area of clinical practice. Poor prescribing occurs across staff grades and settings but new prescribers are attributed much of the blame. New prescribers may not be confident or even competent to prescribe and probably have different support and development needs than their more experienced colleagues. Unfortunately, little is known about what interventions are effective in this group. Previous systematic reviews have not distinguished between different grades of staff, have been narrow in scope and are now out of date. Therefore, to inform the design of educational interventions to change prescribing behaviour, particularly that of new prescibers, we conducted a systematic review of existing hospital-based interventions. METHODS: Embase, Medline, SIGLE, Cinahl and PsychINFO were searched for relevant studies published 1994-2010. Studies describing interventions to change the behaviour of prescribers in hospital settings were included, with an emphasis on new prescibers. The bibliographies of included papers were also searched for relevant studies. Interventions and effectiveness were classified using existing frameworks and the quality of studies was assessed using a validated instrument. RESULTS: Sixty-four studies were included in the review. Only 13% of interventions specifically targeted new prescribers. Most interventions (72%) were deemed effective in changing behaviour but no particular type stood out as most effective. CONCLUSION: Very few studies have tailored educational interventions to meet needs of new prescribers, or distinguished between new and experienced prescribers. Educational development and research will be required to improve this important aspect of early clinical practice.

Trust in the health-care provider-patient relationship: a systematic mapping review of the evidence base.

PURPOSE: Trust is important for patients and may be used as an indicator and potential 'marker' for how patients evaluate the quality of health care. The review aimed to classify the current evidence base on trust in the patient-provider relationship in order to identify strengths and weaknesses and to point towards areas for future research. DATA SOURCES: Nine electronic databases were searched from 2004 onwards using text and subject heading keywords relating to 'trust' and 'health care' and 'relationships'. STUDY SELECTION: Abstracts were identified for empirical studies carried out in health-care settings that explicitly examined trust or reported trust-related findings as a secondary outcome. Data extraction Two review authors assessed the relevance of abstracts and extracted data relating to year published, country of study, clinical speciality, STUDY DESIGN: and participants. RESULTS OF DATA SYNTHESIS: Five hundred and ninety-six abstracts were included. Most reported on patients' trust in providers; were carried out in the USA; collected data in family care or oncology/palliative care settings; used questionnaires and interviews and elicited patients' perspectives. Only one study explicitly set out to examine providers' trust in patients and <5% of included studies reported on providers' trust in patients. CONCLUSION: Providers' trust in patients remains a neglected area on the trust research agenda. Empirical studies examining the factors that influence providers' trust in patients and how this might affect the quality of care and patient health-related behaviours are urgently needed to readdress this imbalance. Further exploration of this area using observational methods is recommended.

How is transition to medical practice shaped by a novel transitional role? A mixed-methods study.

OBJECTIVES: This study considered a novel 'interim' transitional role for new doctors (termed 'FiY1', interim Foundation Year 1), bridging medical school and Foundation Programme (FP). Research questions considered effects on doctors' well-being and perceived preparedness, and influences on their experience of transition. While FiY1 was introduced in response to the COVID-19 pandemic, findings have wider and ongoing relevance. DESIGN: A sequential mixed-methods study involved two questionnaire phases, followed by semi-structured interviews. In phase 1, questionnaires were distributed to doctors in FiY1 posts, and in phase 2, to all new FP doctors, including those who had not undertaken FiY1. SETTING AND PARTICIPANTS: Participants were newly qualified doctors from UK medical schools, working in UK hospitals in 2020. 77% (n=668) of all participants across all phases had undertaken FiY1 before starting FP in August. The remainder started FP in August with varying experience beforehand. OUTCOME MEASURES: Questionnaires measured preparedness for practice, stress, anxiety, depression, burnout, identity, and tolerance of ambiguity. Interviews explored participants' experiences in more depth. RESULTS: Analysis of questionnaires (phase 1 n=441 FiY1s, phase 2 n=477 FiY1s, 196 non-FiY1s) indicated that FiY1s felt more prepared than non-FiY1 colleagues for starting FP in August (ß=2.71, 95% CI=2.21 to 3.22, p<0.0001), which persisted to October (ß=1.85, CI=1.28 to 2.41, p<0.0001). Likelihood of feeling prepared increased with FiY1 duration (OR=1.02, CI=1.00 to 1.03, p=0.0097). Despite challenges to well-being during FiY1, no later detriment was apparent. Thematic analysis of interview data (n=22) identified different ways, structural and interpersonal, in which the FiY1 role enhanced doctors' emerging independence supported by systems and colleagues, providing 'supported autonomy'. CONCLUSIONS: An explicitly transitional role can benefit doctors as they move from medical school to independent practice. We suggest that the features of supported autonomy are those of institutionalised liminality-a structured role 'betwixt and between' education and practice-and this lens may provide a guide to optimising the design of such posts.

How to define clinical education research terminology: A glossary.

Clinical education research (ClinEdR) utilises diverse terminology, which can lead to confusion. A common language is essential for enhancing impact. An expert panel drawn from various workstreams within the National Institute for Health and Care Research (NIHR) Incubator for Clinical Education Research was tasked with reviewing an initial list of terms for the development of a glossary of terms in the field of ClinEdR. The glossary was populated with terms, definitions and foundational papers by the authors and peer-reviewed for accuracy. The glossary of terms developed for ClinEdR should enable researchers to use a common language, promoting consistency and improving communication. We anticipate this will be useful for ClinEdR students and early career researchers. The glossary could be integrated into educational research methods courses in ClinEdR, and through critical and reflective use, enhance the quality and subsequent impact of ClinEdR.

Does undergraduate curriculum design make a difference to readiness to practice as a junior doctor?

BACKGROUND: Undergraduate medicine curricula can be designed to enable smoother transition to work as a junior doctor. Evaluations should improve curriculum design. AIM: To compare a graduate cohort from one medical school with a cohort from other medical schools in the same Foundation Year 1 (FY1) programme in terms of retrospective perceptions of readiness for practice. METHOD: A Likert-scale questionnaire measured self-perception of readiness to practice, including general capabilities and specific clinical skills. RESULTS: Response rate was 74% (n = 146). The Peninsula Medical School cohort reported readiness for practice at a significantly higher level than the comparison cohort in 14 out of 58 items (24%), particularly for 'coping with uncertainty'. In only one item (2%) does the comparison cohort report at a significantly higher level. CONCLUSIONS: Significant differences between cohorts may be explained by undergraduate curriculum design, where the opportunity for early, structured work-based, experiential learning as students, with patient contact at the core of the experience, may promote smoother transition to work as a junior doctor. Evaluation informs continuous quality improvement of the curriculum.

Exploring the Map of Medicine's potential in undergraduate medical education.

BACKGROUND: Map of Medicine is a web-based knowledge resource depicting evidence-based pathways of patient care. Recent publications suggest a possible role for the Map of Medicine as a training tool in postgraduate education. AIM: The aim of this study was to explore the potential of the Map of Medicine to enhance undergraduate medical education. METHODS: A mixed-method study including a survey of UK medical schools, and the embedding of the resource at one medical school and the evaluation of its impact. RESULTS: The survey found that only 1 of 23 medical schools was using the Map of Medicine in its undergraduate curriculum. The Peninsula Medical School students' reaction to the resource was extremely positive. Students liked the Map of Medicine's navigability and help in accessing reliable information. Use of the resource by students grew steadily throughout the period of the study and peaked at 595 sessions a month. There was evidence that usage was directly linked to curricular events, particularly problem-based learning tutorials and medical knowledge assessments. CONCLUSION: There is clear potential for the Map of Medicine in undergraduate medical education and a short-active period of resource promotion led to its embedding within routine learning practice.

The Map of Medicine: a review of evidence for its impact on healthcare.

OBJECTIVES: Map of Medicine is an evidence-based online clinical knowledge resource. Procured at significant cost by healthcare providers in the UK, Sweden and Denmark, it is important to establish the beneficial impact that investment has had on healthcare practise and, ultimately, on patient outcomes. The objective of this study is to review the evidence for the impact of the Map of Medicine on clinical practice. METHODS: A systematic review of peer-reviewed and grey literature was conducted. Nine healthcare databases, Google Scholar and Google were searched for articles containing the terms 'map of medicine'. RESULTS: The search identified 133 articles. Eleven of the articles identified met the inclusion criteria. The main finding of the study is the paucity of evidence available on the impact of the Map of Medicine and the variable quality of that which does exist. There are some encouraging early indications for the Map of Medicine as a tool within service redesign, leading to an increase in appropriate referrals to secondary care, decreased patient waiting times and considerable cost savings. CONCLUSION: Further research with study designs that can generate high quality evidence for the impact of Map of Medicine is essential in order to support policy decisions.

The transition from medical student to junior doctor: today's experiences of Tomorrow's Doctors.

CONTEXT Medical education in the UK has recently undergone radical reform. Tomorrow's Doctors has prescribed undergraduate curriculum change and the Foundation Programme has overhauled postgraduate education. OBJECTIVES This study explored the experiences of junior doctors during their first year of clinical practice. In particular, the study sought to gain an understanding of how junior doctors experienced the transition from the role of student to that of practising doctor and how well their medical school education had prepared them for this. METHODS The study used qualitative methods comprising of semi-structured interviews and audio diary recordings with newly qualified doctors based at the Peninsula Foundation School in the UK. Purposive sampling was used and 31 of 186 newly qualified doctors self-selected from five hospital sites. All 31 participants were interviewed once and 17 were interviewed twice during the year. Ten of the participants also kept audio diaries. Interview and audio diary data were transcribed verbatim and thematically analysed with the aid of a qualitative data analysis software package. RESULTS The findings show that, despite recent curriculum reforms, most participants still found the transition stressful. Dealing with their newly gained responsibility, managing uncertainty, working in multi-professional teams, experiencing the sudden death of patients and feeling unsupported were important themes. However, the stress of transition was reduced by the level of clinical experience gained in the undergraduate years. CONCLUSIONS Medical schools need to ensure that students are provided with early exposure to clinical environments which allow for continuing 'meaningful' contact with patients and increasing opportunities to 'act up' to the role of junior doctor, even as students. Patient safety guidelines present a major challenge to achieving this, although with adequate supervision the two aims are not mutually exclusive. Further support and supervision should be made available to junior doctors in situations where they are dealing with the death of a patient and on surgical placements.