Heard, valued, supported? Doctors' wellbeing during transitions triggered by COVID-19.

INTRODUCTION: Supporting doctors' wellbeing is crucial for medical education to help minimise negative long-term impacts on medical workforce retention and ultimately patient care. There is limited study of how doctors' transitions experiences impact wellbeing, particularly socially and culturally. Multiple Multidimensional Transitions (MMT) theory views transitions as dynamic, incorporating multiple contexts and multiple domains. Using MMT as our lens, we report a qualitative analysis of how transitions experienced by doctors during the pandemic impacted on social and cultural aspects of wellbeing. METHODS: Longitudinal narrative inquiry was employed, using interviews and audio-diaries. Data were collected over 6 months in three phases: (i) interviews with doctors from across the career spectrum (n = 98); (ii) longitudinal audio-diaries for 2-4 months (n = 71); (iii) second interviews (n = 83). Data were analysed abductively, narrowing focus to factors important to social and cultural wellbeing. RESULTS: Doctors described experiencing multiple interacting transitions triggered by the pandemic in multiple contexts (workplace, role, homelife and education). Patterns identifiable across the dataset allowed us to explore social and cultural wellbeing crosscutting beyond individual experience. Three critical factors contributed to social and cultural wellbeing both positively and negatively: being heard (e.g., by colleagues asking how they are); being valued (e.g., removal of rest spaces by organisations showing lack of value); and being supported (e.g., through regular briefing by education bodies). CONCLUSIONS: This study is the first to longitudinally explore the multiple-multidimensional transitions experienced by doctors during the COVID-19 pandemic. Our data analysis helped us move beyond existing perceptions around wellbeing and articulate multiple factors that contribute to social and cultural wellbeing. It is vital that medical educators consider the learning from these experiences to help pinpoint what aspects of support might be beneficial to trainee doctors and their trainers. This study forms the basis for developing evidenced-based interventions that ensure doctors are heard, valued and supported.

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.

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.

A new approach for measuring the work and quality of histopathology reporting.

AIMS: Cancer datasets drive report quality, but require more work to inform compliant reports. The aim of this study was to correlate the number of words with measures of quality, to examine the impact of the drive for improved quality on the workload of histopathology reporting over time. METHODS AND RESULTS: We examined the first 10 reports of colon, breast, renal, lung and ovarian carcinoma, melanoma resection, nodal lymphoma appendicitis and seborrhoeic keratosis (SK) issued in 1991, 2001 and 2011. Correlations were analysed using Pearson's partial correlation coefficients. Word count increased significantly over time for most specimen types examined. Word count almost always correlated with units of information, indicating that the word count was a good measure of the amount of information contained within the reports; this correlation was preserved following correction for the effect of time. A good correlation with compliance with cancer datasets was also observed, but was weakened or lost following correction for the increase in word count and units of information that occurred between time points. CONCLUSIONS: These data indicate that word count could potentially be used as a measure of information content if its integrity and usefulness are continuously validated. Further prospective studies are required to assess and validate this approach.

Associations between medical school and career preferences in Year 1 medical students in Scotland.

OBJECTIVES: Little is known about the relationship between the career preferences of medical students and the medical schools at which they are enrolled. Our aim was to explore this relationship early in students' medical training. METHODS: Year 1 (2009-2010) medical students at the five Scottish medical schools were invited to take part in a career preference questionnaire survey. Questions were asked about demographic factors, career preferences and influencing factors. RESULTS: The response rate was 87.9% (883/1005). No significant differences were found among medical schools with regard to first-choice specialty. Surgery (22.5%), medicine (19.0%), general practice (17.6%) and paediatrics (16.1%) were the top career choices. Work-life balance, perceived aptitude and skills, intellectual satisfaction, and amount of patient contact were rated as the most important job-related factors by most respondents. Few differences were found among schools in terms of the impact of job-related factors on future career preferences. Students for whom the work-life balance was extremely important (odds ratio [OR]=0.6) were less likely to prefer surgery. Students for whom the work-life balance (OR=2.2) and continuity of care (OR=2.1) were extremely important were more likely to prefer general practice. CONCLUSIONS: Students' early career preferences were similar across the five medical schools. These preferences result from the interplay among demographic factors and the perceived characteristics of the various specialties. Maintaining a satisfactory work-life balance is very important to tomorrow's doctors, and the data hint that this may be breaking down some of the traditional gender differences in specialty choice. Longitudinal work is required to explore whether students' career preferences change as they progress through medical school and training.

Supporting doctors' well-being and resilience during COVID-19: A framework for rapid and rigorous intervention development.

This paper aims to outline the development of a theoretically informed and evidence-based intervention strategy to underpin interventions to support the well-being of doctors during COVID-19 and beyond; delineate new ways of working were employed to ensure a rapid and rigorous process of intervention development and present the resulting novel framework for intervention development. The research comprised four workstreams: literature review (WS1), qualitative study (WS2), intervention development and implementation (WS3) and evaluation (WS4). Due to time constraints, we employed a parallel design for WS1-3 with the findings of WS1-2 informing WS3 on a continual basis. WS3 was underpinned by the Behaviour Change Wheel. We recruited expert panels to assist with intervention development. We reflected on decisions taken to facilitate the rapid yet rigorous process of intervention development. The empirical output was a theoretically informed and evidence-based intervention strategy to underpin interventions to support doctors' well-being during COVID-19 and beyond. The methodological output was a novel framework that facilitates rapid and rigorous development of interventions. The intervention strategy provides a foundation for development and evaluation of tailored interventions to support doctors' well-being. The novel framework provides guidance for the development of interventions where the situation demands a rapid yet rigorous development process.

Non-technical skills in histopathology: definition and discussion.

Health care is a high-risk industry, with most documented adverse incidents being associated with 'human factors' including cognitive and social skills termed 'non-technical skills'. Non-technical skills complement the diagnostic and specialist skills and professional attributes required by medical practitioners, including histopathologists, and can enhance the quality of practice and delivery of health-care services and thus contribute to patient safety. This review aims to introduce histopathologists to non-technical skills and how these pertain to everyday histopathological practice. Drawing from other domains in medicine, specifically anaesthesia and surgery, a variety of non-technical skills are identified and described in the context of histopathology to illustrate the role each plays, often collectively, in daily practice. The generic non-technical skills are defined as situation awareness, decision-making, communication, teamwork, leadership, managing stress and coping with fatigue. Example scenarios from histopathology are presented and the contributions to outcomes made by non-technical skills are explained. Consideration of these specific non-technical skills as a component in histopathology training may benefit practitioners as well as assuring patient safety.

The relationships between Epstein-Barr virus latent membrane protein 1 and regulatory T cells in Hodgkin's lymphoma.

OBJECTIVE: Epstein-Barr virus (EBV) encoded latent membrane protein 1 (LMP1) is expressed by the malignant cells of about 30% of cases of Hodgkin's lymphoma (HL) and is therefore a potential target for immune attack. Given the predominantly immunosuppressive nature of HL infiltrating lymphocytes (HLILs) and the ability of LMP1 to stimulate regulatory T (Treg) responses in healthy donors, we hypothesized that LMP1 was important in the generation of Treg responses in HL. METHODS: We compared T helper (Th) 1, Th2, and Treg responses to LMP1 by peripheral blood mononuclear cells (PBMCs) and HLILs from EBV-positive and -negative HL patients. The number of Treg cells in patients' PBMCs and HLILs was determined by flow cytometry ex vivo. Proliferation ((3)H-thymidine incorporation) and cytokine (interleukin [IL]-10, IL-4 and gamma-interferon) secretion by LMP1-stimulated PBMCs and HLILs was also measured. RESULTS: Ex vivo EBV-positive HL patients had increased numbers of IL-10-secreting/cytotoxic T-lymphocyte-associated antigen-4-expressing cells compared with EBV-negative HL patients. PBMC/HLIL responses to LMP1 from most patients were characterized by IL-10 secretion, although isolated HL patients mounted Th1-like responses. Several responses to LMP1 peptides were made by HLILs, which were otherwise unresponsive to control stimuli. CONCLUSIONS: These results suggest that LMP1 epitopes can induce HLIL Treg cells. However, there was no clear evidence of a greater bias toward regulation in EBV-positive HL cases over EBV-negative cases, and thus there are likely to be other mechanisms of Treg cell induction in EBV-negative HL patients. Manipulating the balance of T-helper response to LMP1 might be exploited in immunotherapy of these lymphomas.

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.

Analysis of selection tools for appointment of specialty trainees in histopathology in Scotland.

This study explores possible benefits of structured selection methods in the employment of specialty trainees in histopathology in Scotland. It examines methods used in 2007 demonstrating novel approaches and discusses the positive reaction of consultants involved in the process.

CD4(+) T-cell responses to Epstein-Barr virus (EBV) latent membrane protein 1 in infectious mononucleosis and EBV-associated non-Hodgkin lymphoma: Th1 in active disease but Tr1 in remission.

Primary infection with Epstein-Barr virus (EBV) in childhood is usually asymptomatic, whereas infection in adolescence may result in infectious mononucleosis (IM) often followed by a fatigue syndrome. EBV latent membrane protein 1 (LMP1) is expressed in latency and in many EBV-associated tumours, including non-Hodgkin lymphoma (NHL). Given the regulatory nature of the CD4(+) T-cell response against LMP1 previously reported in healthy donors, we investigated whether patients with active EBV-driven disease can nevertheless mount effector [T-helper cell, type 1 (Th1)] anti-LMP1 responses. We therefore performed a longitudinal study of the nature of CD4(+) T-cell responses to LMP1 in four patients with IM, and five patients with NHL. In both groups, responses changed with time. During symptomatic infection or active tumour growth, responses were dominated by a Th1 effector phenotype, but switched to a regulatory interleukin-10 response upon recovery. In addition, the fine specificities of the T cells driving these responses evolved. This study showed the dynamic nature of CD4(+) T-cell responses to LMP1, and demonstrated that, although patients can mount Th1 effector responses, recovery from IM and NHL is associated with regulatory responses.

Histochemical identification of cortical areas in the auditory region of the human brain.

Despite numerous studies stretching over the last 100 years there is still no general agreement on the number of auditory areas in the human cortex or even how to define them by histological methods. Full definition of these areas will require a combination of functional and histological methods but, by using six complementary histological methods, of which most have been used in the monkey, we provide a clearer description of these areas. The primary auditory area was located on the posteromedial two-thirds of the first transverse temporal (Heschl's) gyrus and was distinguished by a dense band of cytochrome oxidase activity in layer IV and the base of layer III, as well as a relatively thick, pale layer V and VI. Layers V and VI together made up 40% of the cortical thickness. Acetylcholinesterase (AChE)-containing pyramidal cells were sparsely distributed within the primary auditory area. The anterolateral third of Heschl's gyrus did not have a clear band of high cytochrome oxidase activity but contained a moderately high density of AChE-containing pyramidal cells and thus appeared to be part of the auditory belt. Within Heschl's sulcus there was a third area, which had a band of high cytochrome oxidase activity and bands of high parvalbumin immunoreactivity and AChE activity in layer IV. This area appeared to be part of the auditory core. Thus the use of staining methods for cytochrome oxidase, AChE and parvalbumin provided additional information which allowed a clearer definition of auditory areas than Nissl or myelin staining alone. Our results suggest that there are two core areas surrounded by at least six belt areas in the human auditory region.

Immunosuppressive regulatory T cells are abundant in the reactive lymphocytes of Hodgkin lymphoma.

Although immunosuppression has long been recognized in Hodgkin lymphoma (HL), the underlying basis for the lack of an effective immune response against the tumor remains unclear. The aim was to test our hypothesis that regulatory T cells dominate involved lymph nodes. The approach was to assay CD4+ T-cell function in HL-infiltrating lymphocytes (HLILs) and paired peripheral blood mononuclear cells (PBMCs) of 24 patients. Strikingly, unlike PBMCs, HLILs were anergic to stimulation with mitogen, primary, or recall antigens, mounting no proliferative responses and only rare T-helper 1 (Th1) or Th2 cytokine responses. Mixing paired HLILs and PBMCs showed the anergic effect was dominant and suppressed PBMC responses. Furthermore, flow cytometry demonstrated that HLILs contained large populations of both interleukin-10 (IL-10)-secreting T-regulatory 1 (Tr1) and CD4+CD25+ regulatory T cells. We found evidence for 3 mechanisms of action implicated in the suppressive functions of regulatory T cells: the inhibition of PBMCs by HLILs was ameliorated by neutralizing IL-10, by preventing cell-to-cell contact, and by blocking anti-cytotoxic T lymphocyte-associated antigen 4 (anti-CTLA-4). Thus, HLILs are highly enriched for regulatory T cells, which induce a profoundly immunosuppressive environment and so provide an explanation for the ineffective immune clearance of Hodgkin-Reed Sternberg cells.