Change is never easy: How management theories can help operationalise change in medical education.

CONTEXT: Medical education is neither simple nor stable, and is highly contextualised. Hence, ways of perceiving multiple connections and complexity are fundamental when seeking to describe, understand and address concerns and questions related to change. PROPOSAL: In response to calls in the literature, we introduce three examples of contemporary organisational theory which can be used to understand and operationalise change within medical education. These theories, institutional logics, paradox theory and complexity leadership theory, respectively, are relatively unknown in medical education. However, they provide a way of making sense of the complexity of change creatively. Specifically, they cross-cut different levels of analysis and allow us to 'zoom in' to micro levels, as well as to 'zoom out' and connect what is happening at the individual level (the micro level) to what happens at a wider institutional and even national or international level (the macro level), thereby providing a means of understanding the interactions among individuals, teams, organisations and systems. We highlight the potential value of these theories, provide a brief discussion of the few studies that have used them in medical education, and then briefly critique each theory. CONCLUSIONS: We hope that by drawing the attention of readers to the potential of these management theories, we can unlock some of the complexity of change in medical education, support new ways of thinking and open new avenues for research.

Dyadic explanations during preparatory self-study enhance learning: A randomised controlled study.

OBJECTIVES: The objective of the present study was to investigate to which extent preparatory self-study can be improved by encouraging students to engage in individual self-explanations or dyadic explanations (ie in pairs). Individual self-explanations refer to an act of metacognition in which students, after having processed a certain amount of information, attempt to explain their understanding to themselves of what was just learned. Dyadic explanations refer to the same process, but instead of explaining to oneself, the student explains his/her understanding to another student. METHOD: An experiment was conducted in which 120 medical students studied a video-recorded lecture on the role of protein synthesis inhibition on memory reconsolidation. Participants were randomly allocated to one of four conditions: (1) a control condition in which they listened to the lecture once; (2) a control condition in which they listened to the lecture twice; (3) an experimental condition in which they had to listen to the lecture and provide self-explanations individually; and (4) an experimental condition in which they had to listen to the lecture and provide dyadic explanations. Participants' knowledge regarding the topic was measured three times: at the start and end of the experiment, and one week after the experiment to determine knowledge retention. Data were analysed by means of a 2 × 2 and 4 × 3 repeated-measures ANOVA. RESULTS: The results suggest that participants who engaged in individual self- or dyadic explanations significantly outperformed participants in the two control conditions in terms of learning and retention (F = 5.67, Wilks Λ = 0.94, P = .019, η2  = 0.05). Moreover, the results suggest that dyadic explanations were more effective than individual self-explanations (F = 3.70, Wilks Λ = 0.83, P = .002, η2  = 0.09). CONCLUSIONS: These outcomes suggest that encouraging students to work in pairs or in small teams to prepare for a learning event results in superior preparation and learning.

Redefining scholarship for health professions education: AMEE Guide No. 142.

Scholarship is an integral aspect of academia. It shapes the practice of individuals and the field and is often used to inform career progression decisions and policies. This makes it high stakes. Yet it is complex, and ambiguous. Definitions vary and the term does not necessarily translate well across contexts. In this AMEE guide, our aim is to establish a contemporary definition of scholarship which is appropriate to health professions education (HPE). Our specific objectives are to provide guidance to support colleagues in their career development as professional educators and to challenge biases and assumptions about scholarship which may still exist in educational systems and structures. Ultimately, we hope that this work will advance the stature/standing of scholarship in the field. We provide a general definition of scholarship and how this relates to the scholarship of teaching (and learning) (SoT[L]) and scholarly teaching. Drawing on Boyer's seminal work, we describe different types of scholarship and reflect on how these apply to HPE, before moving on to describe different types of engagement with scholarship in HPE, including scope of contribution and influence. Using cases and examples, we illustrate differences in scholarly engagement across stages of a career, contexts, and ways of engaging. We provide guidance on how to assess 'quality' of scholarship. We offer practical advice for health professions' educators seeking academic advancement. We advocate that institutional leaders consider their systems and structures, so that these align with faculty work patterns, and judge teaching and professional practice appropriately. We conclude by offering a new definition of scholarship in HPE.

Thinking of selection and widening access as complex and wicked problems.

OBJECTIVES: 'Wicked problems' are complex in nature, have innumerable causes associated with multiple social environments and actors with unpredictable behaviour and outcomes, and are difficult to define or even resolve. This paper considers why and how the frameworks of complexity theory and wicked problems can help medical educators consider selection and widening access (WA) to medicine through fresh eyes to guide future policy and practice. We illustrate how 'wickedity' can frame the key issues in this area, and then address steps that education stakeholders might take to respond to and act on these issues. METHODS: We used the 10 properties of a wicked problem to frame common issues in the broad field of selection and WA in medicine. We drew heavily on literature from different disciplines, particularly education, and, through debate and reflection, agreed on the applicability of the theory for illuminating and potentially addressing outstanding issues in selection and WA. RESULTS: Framing medical school selection using the 10 properties of wicked problems is a means of shifting thinking from erroneous 'simple' solutions to thinking more contextually and receptively. The wicked problem framework positions selection as a multi-causal, complex, dynamic, social problem and foregrounds stakeholders' views and context as being highly relevant in medical school selection. CONCLUSIONS: The wicked problem lens shifts thinking and action from seeking one elusive, objective truth to recognising the complexity of medical school selection, managing uncertainty, questioning and considering 'issues' associated with medical school selection more productively. Although there are criticisms of this framework, labelling medical selection as 'wicked' provides original insights and genuine reframing of the challenges of this important, and high profile, aspect of medical education. Doing so, in turn, opens the door to different responses than would be the case if selection and WA were simple and readily tamed.

Geographical mobility of UK trainee doctors, from family home to first job: a national cohort study.

BACKGROUND: The UK faces geographical variation in the recruitment of doctors. Understanding where medical graduates choose to go for training is important because doctors are more likely to consider practicing in areas where they completed postgraduate training. The wider literature also suggests that there is a relationship between origin and background, and where doctors wish to train/work. Thus, the purpose of this paper is to investigate the geographical mobility of UK medical graduates from different socio-economic groups in terms of where they wish to spend their first years of postgraduate training. METHODS: This was an observational study of Foundation Programme (FP) doctors who graduated from 33 UK medical schools between 2012 and 2014. Data was accessed via the UK medical education database (UKMED: https://www.ukmed.ac.uk/ ). Chi-square tests were used to examine the relationships between doctor's sociodemographic characteristics and the dependent variable, average driving time from parental home to foundation school/region. Generalised Linear Mixed Models (GLMM) were used to estimate the effects of those factors in combination against the outcome measure. RESULTS: The majority of doctors prefer to train at foundation schools that are reasonably close to the family home. Those who attended state-funded schools, from non-white ethnic groups and/or from lower socio-economic groups were significantly more likely to choose foundation schools nearer their parental home. Doctors from disadvantaged backgrounds (as determined by entitlement to free school meals, OR = 1.29, p = 0.003 and no parental degree, OR = 1.34, p < 0.001) were associated with higher odds of selecting a foundation schools that were closer to parental home. CONCLUSION: The data suggests that recruiting medical students from lower socioeconomic groups and those who originate from under-recruiting areas may be at least part of the solution to filling training posts in these areas. This has obvious implications for the widening access agenda, and equitable distribution of health services.

What do UK medical students value most in their careers? A discrete choice experiment.

CONTEXT: Many individual- and job-related factors are known to influence medical careers decision making. Previous research has extensively studied medical trainees' (residents') and students' views of the factors that are important. However, how trainees and students trade off these factors at times of important careers-related decision making is under-researched. Information about trade-offs is crucial to the development of effective policies to enhance the recruitment and retention of junior doctors. OBJECTIVES: Our aim was to investigate the strength of UK medical students' preferences for the characteristics of training posts in terms of monetary value. METHODS: We distributed a paper questionnaire that included a discrete choice experiment (DCE) to final-year medical students in six diverse medical schools across the UK. The main outcome measure was the monetary value of training post characteristics, based on willingness to forgo and willingness to accept extra income for a change in each job characteristic calculated from regression coefficients. RESULTS: A total of 810 medical students answered the questionnaire. The presence of good working conditions was by far the most influential characteristic of a training position. Medical students consider that, as newly graduated doctors, they will require compensation of an additional 43.68% above average earnings to move from a post with excellent working conditions to one with poor working conditions. Female students value excellent working conditions more highly than male students, whereas older medical students value them less highly than younger students. CONCLUSIONS: Students on the point of completing medical school and starting postgraduate training value good working conditions significantly more than they value desirable geographical location, unit reputation, familiarity with the unit or opportunities for partners or spouses. This intelligence can be used to address the crisis in workforce staffing that has developed in the UK and opens up fruitful areas for future research across contexts and in terms of examining stated preferences versus actual career-related behaviour.

Taking context seriously: explaining widening access policy enactments in UK medical schools.

CONTEXT: Since the 1970s, the UK medical student body has become increasingly diverse in terms of gender, ethnicity and age, but not in socio-economic background. This variance may be linked to large differences in how individual medical schools interpret and put into practice widening participation (WP) policy. However, attempts to theorise what happens when policy enters practice are neglected in medical education. We aimed to explore the dynamics of policy enactment to give a novel perspective on WP practices across UK medical schools. METHODS: We used a qualitative design employing individual telephone interviews to elicit views and concerns around WP from admissions deans and admissions staff within UK medical schools. We carried out interviews with representatives from 24 of 32 UK medical schools. Data coding and analysis were initially inductive, using framework analysis. After the themes emerged, we applied a deductive framework to group themes into four contextual dimensions of 'situation', 'professional', 'material' and 'external'. RESULTS: Our participants held different positions in relation to the interpreting and translating of WP policy, which were influenced by a number of contextual factors including: geographical locality and positioning of the medical school; the expectations of the university and other key stakeholders, and resources. The latter were subtle and referred to resources for medical selection processes rather than for WP per se. The data hinted that the political goal of WP and medical education's goal of producing the best doctors may conflict. CONCLUSIONS: This is the first study to explicitly explore WP policy enactment in medical education. Our analysis is useful for understanding differences in how WP policy is played out in local contexts, and for planning for future policy enactment and research. The messages identified will resonate internationally with all those engaged in efforts to widen participation in medical education.

Exploring stakeholders' views of medical education research priorities: a national survey.

CONTEXT: Setting research priorities is important when exploring complex issues with limited resources. Only two countries (Canada and New Zealand) have previously conducted priority-setting exercises for medical education research (MER). This study aimed to identify the views of multiple stakeholders on MER priorities in Scotland. METHODS: This study utilised a two-stage design to explore the views of stakeholders across the medical education continuum using online questionnaires. In Stage 1, key informants outlined their top three MER priorities and justified their choices. In Stage 2, participants rated 21 topics generated in Stage 1 according to importance and identified or justified their top priorities. A combination of qualitative (i.e. framework analysis) and quantitative (e.g. exploratory factor analysis) data analyses were employed. RESULTS: Views were gathered from over 1300 stakeholders. A total of 21 subthemes (or priority areas) identified in Stage 1 were explored further in Stage 2. The 21 items loaded onto five factors: the culture of learning together in the workplace; enhancing and valuing the role of educators; curriculum integration and innovation; bridging the gap between assessment and feedback, and building a resilient workforce. Within Stage 2, the top priority subthemes were: balancing conflicts between service and training; providing useful feedback; promoting resiliency and well-being; creating an effective workplace learning culture; selecting and recruiting doctors to reflect need, and ensuring that curricula prepare trainees for practice. Participant characteristics were related to the perceived importance of the factors. Finally, five themes explaining why participants prioritised items were identified: patient safety; quality of care; investing for the future; policy and political agendas, and evidence-based education. CONCLUSIONS: This study indicates that, across the spectrum of stakeholders and geography, certain MER priorities are consistently identified. These priority areas are in harmony with a range of current drivers in UK medical education. They provide a platform of evidence on which to base decisions about MER programmes in Scotland and beyond.

A survey of factors influencing career preference in new-entrant and exiting medical students from four UK medical schools.

BACKGROUND: Workforce planning is a central issue for service provision and has consequences for medical education. Much work has been examined the career intentions, career preferences and career destinations of UK medical graduates but there is little published about medical students career intentions. How soon do medical students formulate careers intentions? How much do these intentions and preferences change during medical school? If they do change, what are the determining factors? Our aim was to compare medical students' career preferences upon entry into and exit from undergraduate medical degree programmes. METHODS: This was a cross-sectional questionnaire survey. Two cohorts [2009-10, 2010-11] of first and final year medical students at the four Scottish graduating medical schools took part in career preference questionnaire surveys. Questions were asked about demographic factors, career preferences and influencing factors. RESULTS: The response rate was 80.9% [2682/3285]. Significant differences were found across the four schools, most obviously in terms of student origin [Scotland, rest of UK or overseas], age group, and specialty preferences in Year 1 and Year 5. Year 1 and Year 5 students' specialty preferences also differed within each school and, while there were some common patterns, each medical school had a different profile of students' career preferences on exit. When the analysis was adjusted for demographic and job-related preferences, specialty preferences differed by gender, and wish for work-life balance and intellectual satisfaction. CONCLUSIONS: This is the first multi-centre study exploring students' career preferences and preference influences upon entry into and exit from undergraduate medical degree programmes. We found various factors influenced career preference, confirming prior findings. What this study adds is that, while acknowledging student intake differs by medical school, medical school itself seems to influence career preference. Comparisons across medical school populations must therefore control for differences in input [the students] as well as context and process [the medical school] when looking at output [e.g., performance]. A robust, longitudinal study is required to explore how medical students' career preferences change as they progress through medical school and training to understand the influence of the learning environment on training choice and outcomes.

Medical educators' social acts of explaining passing underperformance in students: a qualitative study.

Passing underperformance in students is ubiquitous across health and social care educators and is intimately related to the subsequent welfare of patients: underperforming students may become underperforming practitioners. This paper aims to examine how medical educators construct passing underperformance through an analysis of their social act of explaining such behaviours in peer-group settings. Ten focus groups were conducted with 70 medical educators across two UK schools with different curricular/assessment styles (England, Scotland). A qualitative content analysis of how educators explained their behaviours of passing underperformance was undertaken using the psychological concepts of proximality and distalness according to: (1) Malle's F.Ex. coding framework for behavioural explanations, and (2) participants' use of pronouns. 149 explanations of passing underperformance were identified: 72 for participants' own behaviour, 77 for others' behaviour. When explaining their own behaviour, participants used the proximal pronoun I 37% (n = 27) of the time and the distancing pronouns we/you 51% (n = 37) of the time. More Causal History of Reasons (38%; n = 27) and Enabling Factors (29%; n = 21) than Reasons (33%; n = 24) were cited. A similar pattern was found for explaining others' behaviour. Thus, medical educators used linguistic form, explanation mode and informational content within peer-group discussions to distance themselves from intentionality for their action of passing underperformance and highlighted desirable characteristics of themselves and medical educators in general. Faculty development programmes should develop assessors' awareness of how implicit factors within their talk can legitimise a culture of passing underperformance and explore the steps for cultural change.

Simulated patient visits with immediate feedback to improve the supply of over-the-counter medicines: a feasibility study.

BACKGROUND: The supply of over-the-counter (OTC) medicines from community pharmacies should be safe and effective, but there is evidence that appropriate practice is not always achieved. The primary objective of this study was to assess the acceptability of simulated patient (SP) visits combined with feedback, delivered by either SPs or pharmacy educators (PEs), as a method for improving the supply of OTC medicines in community pharmacies. METHODS: This feasibility study used a randomized controlled trial design where participating pharmacies were randomized into two groups (SP or PE, feedback). SP visits were audiotaped and questionnaire data collected from participants post-intervention. Each pharmacy received three covert visits from SPs. Feedback was provided immediately after the first and second visits. Data were collected on information gathering and advice provision. The visits were assessed for minimum standards of practice and appropriateness of outcome. RESULTS: Twenty-two pharmacists and 34 medicine counter assistants (MCAs) from 20 community pharmacies in Grampian, Scotland, participated. Sixty SP visits were completed (three per pharmacy) and were well received, particularly by the pharmacists. Similar results were shown across both study groups in terms of information gathering and information/advice provision during consultations. Few SP consultations achieved the minimum standard of practice although most resulted in an appropriate outcome. CONCLUSIONS: SP visits with feedback were acceptable to pharmacists as a method of improving the quality of consultations for OTC medicines, irrespective of the person giving feedback (SP or PE). The process by which pharmacists and their staff derived their recommendations, in terms of information gathering, could be improved. A large-scale study is needed to assess the effectiveness and cost-effectiveness of SP visits with feedback.

The use of simulated patients in medical education: AMEE Guide No 42.

Medical training has traditionally depended on patient contact. However, changes in healthcare delivery coupled with concerns about lack of objectivity or standardization of clinical examinations lead to the introduction of the 'simulated patient' (SP). SPs are now used widely for teaching and assessment purposes. SPs are usually, but not necessarily, lay people who are trained to portray a patient with a specific condition in a realistic way, sometimes in a standardized way (where they give a consistent presentation which does not vary from student to student). SPs can be used for teaching and assessment of consultation and clinical/physical examination skills, in simulated teaching environments or in situ. All SPs play roles but SPs have also been used successfully to give feedback and evaluate student performance. Clearly, given this potential level of involvement in medical training, it is critical to recruit, train and use SPs appropriately. We have provided a detailed overview on how to do so, for both teaching and assessment purposes. The contents include: how to monitor and assess SP performance, both in terms of validity and reliability, and in terms of the impact on the SP; and an overview of the methods, staff costs and routine expenses required for recruiting, administrating and training an SP bank, and finally, we provide some intercultural comparisons, a 'snapshot' of the use of SPs in medical education across Europe and Asia, and briefly discuss some of the areas of SP use which require further research.

An intercalated BSc degree is associated with higher marks in subsequent medical school examinations.

BACKGROUND: To compare medical students on a modern MBChB programme who did an optional intercalated degree with their peers who did not intercalate; in particular, to monitor performance in subsequent undergraduate degree exams. METHODS: This was a retrospective, observational study of anonymised databases of medical student assessment outcomes. Data were accessed for graduates, University of Aberdeen Medical School, Scotland, UK, from the years 2003 to 2007 (n = 861). The main outcome measure was marks for summative degree assessments taken after intercalating. RESULTS: Of 861 medical students, 154 (17.9%) students did an intercalated degree. After adjustment for cohort, maturity, gender and baseline (3rd year) performance in matching exam type, having done an IC degree was significantly associated with attaining high (18-20) common assessment scale (CAS) marks in three of the six degree assessments occurring after the IC students rejoined the course: the 4th year written exam (p < 0.001), 4th year OSCE (p = 0.001) and the 5th year Elective project (p = 0.010). CONCLUSION: Intercalating was associated with improved performance in Years 4 and 5 of the MBChB. This improved performance will further contribute to higher academic ranking for Foundation Year posts. Long-term follow-up is required to identify if doing an optional intercalated degree as part of a modern medical degree is associated with following a career in academic medicine.

A Narrative Synthesis of Qualitative Studies Conducted to Assess Patient Safety Culture in Hospital Settings.

This review aimed to identify methodological aspects of qualitative studies conducted to assess patient safety culture (PSC) in hospital settings. Searches of Google Scholar (Google LLC, Menlo Park, California, USA), MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA), EMBASE (Elsevier, Amsterdam, Netherlands), PsycINFO (American Psychological Association, Washington, District of Columbia, USA) and Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA) databases were used to identify qualitative articles published between 2000 and 2017 that focused on PSC. A total of 22 studies were included in this review and analysis of methodological approaches showed that most researchers adopted purposive sampling, individual interviews, inductive content and thematic analysis. PSC was affected by factors related to staffing, communication, non-human resources, organisation and patient-related factors. Most studies lacked theoretical frameworks. However, many commonalities were found across studies. Therefore, it is recommended that future studies adopt a mixed methods approach to gain a better understanding of PSC.

Cohort study on predicting grades: is performance on early MBChB assessments predictive of later undergraduate grades?

OBJECTIVE: Timely intervention, based on early identification of poor performance, is likely to help weaker medical students improve their performance. We wished to identify if poor performance in degree assessments early in the medical degree predicts later undergraduate grades. If it does, this information could be used to signpost strategically placed supportive interventions for our students. METHODS: We carried out a retrospective, observational study of anonymised databases of student assessment outcomes at the University of Aberdeen Medical School. Data were accessed for students who graduated in the years 2003-07 (n = 861). The main outcome measure was marks for summative degree assessments from the end of Year 2 to the end of Year 5. RESULTS: After adjustment for cohort, maturity, gender, funding source, intercalation and graduate status, poor performance (fail and borderline pass) in the Year 2 first semester written examination Principles of Medicine II was found to be a significant predictor of poor performance in all subsequent written examinations (all P < 0.001). Poor performance in the Year 3 objective structured clinical examination (OSCE) was a significant predictor of poor performance in Year 4 and 5 OSCEs. Relationships between essay-based summative assessments were not significantly predictive. Male gender appeared to significantly predict poor performance. DISCUSSION: Examinations taken as early as mid-Year 2 can be used to identify medical students who would benefit from intervention and support. Strategic delivery of appropriate intervention at this time may enable poorer students to perform better in subsequent examinations. We can then monitor the impact of remedial support on subsequent performance.

Is it me or is it them? Factors that influence the passing of underperforming students.

CONTEXT: Research has found that clinical assessments do not always accurately reflect medical student performance. Barriers to failing underperformance in students have been identified in other vocational settings. Is 'failure to fail' an issue for medical educators in the UK, and, if so, what are its determinants? METHODS: We carried out a qualitative focus group study exploring the views of medical educators (general practitioners, hospital doctors and non-clinical tutors) from two different UK medical schools. To make sense of a potential multitude of factors impacting on failure to fail, we selected the integrative model of behavioural prediction to underpin our data collection and analysis. RESULTS: Ten focus groups were carried out with 70 participants. Using both theory and data-driven framework analysis, we identified six main themes relevant to the integrative model of behavioural prediction. These are: tutor attitudes towards an individual student; tutor attitudes towards failing a student; normative beliefs and motivation to comply; efficacy beliefs (self-efficacy); skills and knowledge, and environmental constraints. DISCUSSION: Many different factors impact on medical educators' failure to report underperformance in students. There are conflicts between these factors and the need to report competence accurately (i.e. duty to protect the public). Although some of the barriers identified are similar to those found in previous studies, using a theory-based approach added value in that it facilitated a richer exploration of failure to fail. Insights offered in this study will be used to plan a questionnaire study and subsequent intervention to support medical educators in accurately reporting underperformance in students.

Relationship between sociodemographic factors and selection into UK postgraduate medical training programmes: a national cohort study.

INTRODUCTION: Knowledge about allocation of doctors into postgraduate training programmes is essential in terms of workforce planning, transparency and equity issues. However, this is a rarely examined topic. To address this gap in the literature, the current study examines the relationships between applicants' sociodemographic characteristics and outcomes on the UK Foundation Training selection process. METHODS: A longitudinal, cohort study of trainees who applied for the first stage of UK postgraduate medical training in 2013-2014. We used UK Medical Education Database (UKMED) to access linked data from different sources, including medical school admissions, assessments and postgraduate training. Multivariable ordinal regression analyses were used to predict the odds of applicants being allocated to their preferred foundation schools. RESULTS: Applicants allocated to their first-choice foundation school scored on average a quarter of an SD above the average of all applicants in the sample. After adjusting for Foundation Training application score, no statistically significant effects were observed for gender, socioeconomic status (as determined by income support) or whether applicants entered medical school as graduates or not. Ethnicity and place of medical qualification were strong predictors of allocation to preferred foundation school. Applicants who graduated from medical schools in Wales, Scotland and Northern Ireland were 1.17 times, 3.33 times and 12.64 times (respectively), the odds of applicants who graduated from a medical school in England to be allocated to a foundation school of their choice. CONCLUSIONS: The data provide supportive evidence for the fairness of the allocation process but highlight some interesting findings relating to 'push-pull' factors in medical careers decision-making. These findings should be considered when designing postgraduate training policy.

The relationship between school type and academic performance at medical school: a national, multi-cohort study.

OBJECTIVES: Differential attainment in school examinations is one of the barriers to increasing student diversity in medicine. However, studies on the predictive validity of prior academic achievement and educational performance at medical school are contradictory, possibly due to single-site studies or studies which focus only on early years' performance. To address these gaps, we examined the relationship between sociodemographic factors, including school type and average educational performance throughout medical school across a large number of diverse medical programmes. METHODS: This retrospective study analysed data from students who graduated from 33 UK medical schools between 2012 and 2013. We included candidates' demographics, pre-entry grades (adjusted Universities and Colleges Admissions Service tariff scores) preadmission test scores (UK Clinical Aptitude Test (UKCAT) and Graduate Medical School Admissions Test (GAMSAT)) and used the UK Foundation Programme's educational performance measure (EPM) decile as an outcome measure. Logistic regression was used to assess the independent relationship between students' background characteristics and EPM ranking. RESULTS: Students from independent schools had significantly higher mean UKCAT scores (2535.1, SD=209.6) than students from state-funded schools (2506.1, SD=224.0, p<0.001). Similarly, students from independent schools came into medical school with significantly higher mean GAMSAT scores (63.9, SD=6.9) than students from state-funded schools (60.8, SD=7.1, p<0.001). However, students from state-funded schools were almost twice as likely (OR=2.01, 95% CI 1.49 to 2.73) to finish in the highest rank of the EPM ranking than those who attended independent schools. CONCLUSIONS: This is the first large-scale study to examine directly the relationship between school type and overall performance at medical school. Our findings provide modest supportive evidence that, when students from independent and state schools enter with similar pre-entry grades, once in medical school, students from state-funded schools are likely to outperform students from independent schools. This evidence contributes to discussions around contextualising medical admission.

A pragmatic, three-arm randomised controlled trial of spiritual healing for asthma in primary care.

BACKGROUND: Well-designed trials are required to assess if complementary and alternative medicine (CAM) is effective. AIM: This study assessed the effectiveness of spiritual healing for asthma. DESIGN OF STUDY: Randomised, placebo-controlled trial. SETTING: Aberdeen, Scotland. METHOD: This was a single-blind, three-armed randomised, controlled trial of spiritual healing for asthma, comparing the effectiveness of five sessions of spiritual healing with placebo (delivered by an actor), and with a control group receiving normal care only. The primary outcome measure was the Juniper Asthma Quality of Life Questionnaire (AQLQ). Secondary outcomes were forced expiratory flow in one second (FEV1), peak expiratory flow (PEF), HADS (Hospital Anxiety Depression Scale), SF-36 and MYMOP (Measure Yourself Medical Outcome Profile). Baseline and follow-up data were collected. RESULTS: Eighty-eight adult patients receiving pharmacological treatment for asthma participated. AQLQ scores improved significantly from baseline and the end of treatment in all groups (spiritual healing P = 0.008; 'sham' healing P = 0.001 and control P = 0.01) but there was no significant difference between groups (P = 0.57). These improvements were maintained at follow-up 1 for two of the groups (spiritual healing P = 0.016; sham healing P = 0.001 and control P = 0.09) but none of the groups showed an improvement at follow-up 2 (spiritual healing P = 0.161; sham healing P = 0.016 and control P = 0.11). Similar proportions of patients in each group showed a clinically important improvement in AQLQ score. Analysis of AQLQ scores at end of treatment and both follow-up periods indicated no significance between group differences. No consistent changes were seen in secondary outcome measures, possibly due to the small sample size. CONCLUSION: Spiritual healing does not appear to have any specific affect on patient asthma related quality of life.