The cross-cutting edge: Medical selection and education viewed through the lens of emotional intelligence.

CONTEXT: Evidence suggesting the benefits of compassionate, person-centred care, for both patients and physicians is accruing. Medical selection, for example, aims to choose future health professionals that possess the correct attitudes, beliefs and personal attributes to deliver such care. Moreover, once in training, these desirable personal qualities should be developed and maintained, sometimes in the face of adverse health care service conditions. However, advances in selecting for, and developing, these abilities and attributes in health care have been hindered by a lack of clarity regarding how the relevant skills and traits should be defined, measured, developed and maintained in clinicians. METHODS: In this article, we demonstrate how developments in the emotional intelligence (EI) field can be applied to the challenge of selecting for, and developing, relevant interpersonal care skills in medical students and physicians. The concept of EI itself has been somewhat controversial. However, a more nuanced understanding of EI has evolved in the light of research findings that can be applied to medical selection and education. Specifically, we propose modifications to the existing 'cascading' model of EI. This model identifies, and relates, several key socioemotional skills and traits that could be considered as 'the elementary particles' of EI required to deliver compassionate, person-centred care. CONCLUSIONS: Our model of EI, which is relevant to care delivery, identifies putative targets for both medical selection and training. Selection for medical school and subsequent clinical education should focus on screening out those with low levels of the traits and abilities less amenable to training. Conversely, medical education should be concerned with developing and maintaining the socioemotional skills, attitudes and behaviours critical to the delivery of compassionate, person-centred care. This is especially important for specialties characterised by high levels of emotional labour and possible resultant compassion fatigue.

Debate: Better use of existing services, not more new pathways, is required for psychosis prevention in young people - Commentary on Salazar de Pablo and Arango: 'Prevention of psychosis in adolescents: does CAMHS have a role?'

BACKGROUND: There has been much academic interest in 'the clinical high-risk state for psychosis' (CHR-P) concept. Whilst early intervention in psychosis (EIP) services have offered input to individuals meeting the CHR-P criteria the involvement of CAMHS clinicians in supporting young people with ideational and perceptual disturbance has been more inconsistent and uncertain. METHOD: We bring together our relevant lived experience, empirical evidence and clinical and research expertise to write this commentary. RESULTS: We assert that the CHR-P paradigm needs to be revised. This should reflect the low transition rates to psychosis and the prevalent general, impairing psychopathology in individuals meeting these criteria. Nevertheless, it is clear that both CAMHS and EIP services have potential roles in meeting the needs of young people affected by distressing ideational and perceptual disturbance. CONCLUSIONS: We suggest that new care pathways and services are not required for young people affected by distressing psychosis-like experiences. Rather more effective joint working between CAMHS, EIP, crisis services and other agencies could meet the needs of these young people more comprehensively.

Situational judgement test performance and subsequent misconduct in medical students.

INTRODUCTION: Situational judgement tests (SJTs) have been widely adopted, internationally, into medical selection. It was hoped that such assessments could identify candidates likely to exhibit future professional behaviours. Understanding how performance on such tests may predict the risk of disciplinary action during medical school would provide evidence for the validity of such SJTs within student selection. It would also inform the implementation of such tests within student recruitment. METHODS: This cohort study used data for 6910 medical students from 36 UK medical schools who sat the University Clinical Aptitude Test (UCAT) SJT in 2013. The relationship between SJT scores at application and the risk of subsequent disciplinary action during their studies was modelled. The incremental ability of the SJT scores to predict the risk of disciplinary action, above that already provided by UCAT cognitive test scores and secondary (high) school achievement, was also evaluated in 5535 of the students with information available on this latter metric. RESULTS: Two hundred and ten (3.05%) of the students in the cohort experienced disciplinary action. The risk of disciplinary action reduced with increasing performance on the admissions SJT (odds ratio (OR) 0.80, 95% confidence interval (CI) 0.69 to 0.92, p = 0.002). This effect remained similar after adjusting for cognitive performance and prior academic attainment (OR 0.77, 95% CI 0.65 to 0.92, p = 0.004). The overall estimated effect-size was small (Cohen's d = 0.08) and no evidence of 'threshold' effects were observed for the SJT scores and risk of disciplinary action. CONCLUSIONS: Performance on admissions SJTs can, at least modestly, incrementally predict the risk of subsequent disciplinary action, supporting their use in this context. However, for this SJT and outcome, there did not seem a distinct threshold score above which the risk of disciplinary action disproportionately increased. This should be considered when using the scores within medical selection.

Predicting need for hospital admission in patients with traumatic brain injury or skull fractures identified on CT imaging: a machine learning approach.

BACKGROUND: Patients with mild traumatic brain injury on CT scan are routinely admitted for inpatient observation. Only a small proportion of patients require clinical intervention. We recently developed a decision rule using traditional statistical techniques that found neurologically intact patients with isolated simple skull fractures or single bleeds <5 mm with no preinjury antiplatelet or anticoagulant use may be safely discharged from the emergency department. The decision rule achieved a sensitivity of 99.5% (95% CI 98.1% to 99.9%) and specificity of 7.4% (95% CI 6.0% to 9.1%) to clinical deterioration. We aimed to transparently report a machine learning approach to assess if predictive accuracy could be improved. METHODS: We used data from the same retrospective cohort of 1699 initial Glasgow Coma Scale (GCS) 13-15 patients with injuries identified by CT who presented to three English Major Trauma Centres between 2010 and 2017 as in our original study. We assessed the ability of machine learning to predict the same composite outcome measure of deterioration (indicating need for hospital admission). Predictive models were built using gradient boosted decision trees which consisted of an ensemble of decision trees to optimise model performance. RESULTS: The final algorithm reported a mean positive predictive value of 29%, mean negative predictive value of 94%, mean area under the curve (C-statistic) of 0.75, mean sensitivity of 99% and mean specificity of 7%. As with logistic regression, GCS, severity and number of brain injuries were found to be important predictors of deterioration. CONCLUSION: We found no clear advantages over the traditional prediction methods, although the models were, effectively, developed using a smaller data set, due to the need to divide it into training, calibration and validation sets. Future research should focus on developing models that provide clear advantages over existing classical techniques in predicting outcomes in this population.

Great expectations: views and perceptions of professionalism amongst mental health services staff, patients and carers.

BACKGROUND: Numerous studies have explored the concept of 'professionalism' in medicine, yet little attention has been paid to the concept in a mental health services context. AIMS: This study sought to determine how the lived experience of patients, carers and healthcare professionals in mental health services align with medically defined, generic, professionalism standards. METHOD: Interviews and focus groups were conducted with patients, carers, nurses, occupational therapists, psychiatrists and psychologists. A framework analysis approach was used to analyse the data, based on the 'Improving Selection to the Foundation Programmes' Professional Attributes Framework. RESULTS: Fifty-six individuals participated. Data aligned to all nine attributes of the Professional Attributes Framework, however the expectations within each attribute varied from that originally cited. A tenth attribute was devised during the process of analysis; Working with Carers. This attribute acknowledges the need to liaise with, and support carers in mental health services. Situational examples included both online and offline behaviours and the topic of 'black humour' emerged. CONCLUSIONS: Compared to a conventional medical definition of professionalism, additional themes and differing emphases were observed for mental health and learning disability services. These findings should be used to inform the teaching and evaluation of professionalism, especially for staff pursuing mental health service careers.

Technology Matters: Machine learning approaches to personalised child and adolescent mental health care.

There has been much interest in the potential for machine learning and artificial intelligence to enhance health care. In this article, we discuss the potential applications of the technology to child and adolescent mental health services (CAMHS). We also outline the four key criteria that are likely to be necessary for automated prediction to be translated into clinical benefit. These relate to the choice of task to be automated, the nature of the available data, the methods applied and the context of the system to be implemented.

Unravelling the mental health productivity puzzle: where do we start?

In this editorial we define 'productivity' and 'efficiency' in a mental health service context, outlining the key challenges to measuring these in practice. We attempt to bring clarity of thought to this often debated, but rarely researched area.

Differential attainment in the MRCPsych according to ethnicity and place of qualification between 2013 and 2018: a UK cohort study.

PURPOSE OF THE STUDY: To explore if differential pass rates exist in the clinical component of the UK postgraduate clinical psychiatry exam, the Clinical Assessment of Skills and Competencies (CASC), according to ethnicity and place of qualification (UK vs EEA vs overseas graduates). STUDY DESIGN: Observational study using data from the UK Medical Education Database for 2140 doctors sitting the CASC for the first time between 2013 and 2018. RESULTS: After controlling for age, sex, time of sitting and performance in the written components of the MRCPsych, differences in CASC pass rates persisted between UK graduates self-identifying as Black and Minority Ethnicity (BME) and non-BME (OR for passing 0.36, 95% CI 0.23 to 0.56, p<0.001). Both EEA (OR 0.25, 0.15 to 0.40, p<0.001) and overseas graduates (OR 0.07, 0.05 to 0.11, p<0.001) were less likely to pass the CASC at first attempt, even after controlling for the influence of educational and background variables. These groups, on average, had lower scores on written exams with substantial content relating to procedural skills (eg, critical appraisal) rather than pure recall of factual knowledge. CONCLUSIONS: Substantial differences exist in clinical examination performance between UK BME and non-BME candidates, as well as between UK and non-UK graduates. These differences are not explained by differing levels of clinical knowledge. In the interests of equality, this situation requires further investigation and remediation. Future research should focus on understanding how potential bias may be acting within different stages of recruitment, training and assessment within psychiatry.

Are efforts to recruit to psychiatry closing the stable door after the horse has bolted? Knowledge and attitudes towards a career in psychiatry amongst secondary (high) school students: a UK-based cross-sectional survey.

BACKGROUND: Internationally there is a shortage of psychiatrists, whilst clinical psychology training is generally oversubscribed. School students interested in psychological health may not be aware of the possibility of studying medicine before specialising in psychiatry. This has implications for the mental health workforce. AIMS: To evaluate the knowledge and attitudes relating to a potential career in psychiatry amongst secondary (high) school students. METHOD: A cross-sectional survey evaluated attitudes and knowledge relating to psychiatry and clinical psychology, targeting students from five schools who were studying chemistry, biology and/or psychology at an advanced level. RESULTS: 186 students completed the survey (response rate 41%). Knowledge was generally poor with only 57% of respondents knowing that psychiatrists had medical degrees, and most participants substantially underestimating the salaries of consultant psychiatrists. Attitudinal response patterns were explained by two underlying factors, relating to generally negative attitudes towards psychiatry and positive attitudes towards the effectiveness of psychiatric treatments. Females and those studying psychology reported more positive attitudes towards psychiatry. Those studying chemistry reported more negative attitudes towards the effectiveness of mental health treatment. CONCLUSIONS: Studying psychology predicted positive attitudes towards psychiatry. Such students could be targeted by recruitment campaigns, which emphasise factual information about the specialty.

Innovations in Practice: A randomised controlled feasibility trial of Behavioural Activation as a treatment for young people with depression.

BACKGROUND: Behavioural Activation (BA) treatment effectively reduces symptoms of depression in adults and is more cost-effective than more complex therapies. Two recent systematic reviews of BA for depression in young people highlighted the need for more studies in this area. METHODS: In order to evaluate the acceptability of BA treatment for adolescents with depression and the feasibility of conducting a trial of this intervention in Child and Adolescent Mental Health Services (CAMHS), 22 patients from across three sites were randomised to BA or usual CAMHS care. Existing CAMHS staff were trained to deliver the manualised intervention via a brief course. Following treatment, young people and their parents/carers were asked to complete a feedback survey. Symptoms and functioning were assessed at 3- and 6-month follow-up. The trial was registered with the ISRCTN Registry (ref: ISRCTN52147450; https://www.isrctn.com/). RESULTS: Recruitment targets were achieved through screening large numbers of CAMHS service users. Intervention adherence by the participating adolescents was high (median number of completed BA sessions was seven out of a total of eight). There were tentative suggestions of improvements following treatment; a large change in a positive direction for the BA group, but not for usual care, was observed by visual comparisons of mean scores on measures of depression, self-esteem and functioning. No adverse events were reported. CONCLUSIONS: The findings suggest that BA in this setting is acceptable and warrants evaluation via a fully powered randomised controlled trial.

Situational judgement test validity for selection: A systematic review and meta-analysis.

CONTEXT: Situational judgement tests (SJTs) are widely used to evaluate 'non-academic' abilities in medical applicants. However, there is a lack of understanding of how their predictive validity may vary across contexts. We conducted a systematic review and meta-analysis to synthesise existing evidence relating to the validity of such tools for predicting outcomes relevant to interpersonal workplace performance. METHODS: Searches were conducted in relevant databases to June 2019. Study quality and risk of bias were assessed using the Quality In Prognosis Studies (QUIPS) tool. Results were pooled using random effects meta-analysis and meta-regressions. RESULTS: Initially, 470 articles were identified, 218 title or abstracts were reviewed, and 44 full text articles were assessed with 30 studies meeting the final inclusion criteria and were judged, overall, to be at moderate risk of bias. Of these, 26 reported correlation coefficients relating to validity, with a pooled estimate of 0.32 (95% confidence interval 0.26 to 0.39, P < .0001). Considerable heterogeneity was observed (I2  = 96.5%) with the largest validity coefficients tending to be observed for postgraduate, rather than undergraduate, selection studies (ß = 0.23, 0.11 to 0.36, P < .001). The correction of validity coefficients for attenuation was also independently associated with larger effects (ß = 0.13, 0.03 to 0.23, P = .01). No significant associations with test medium (video vs text format), cross-sectional study design, or period of assessment (one-off vs longer-term) were observed. Where reported, the scores generally demonstrated incremental predictive validity, over and above tests of knowledge and cognitive ability. CONCLUSIONS: The use of SJTs in medical selection is supported by the evidence. The observed trend relating to training stage requires investigation. Further research should focus on developing robust criterion-relevant outcome measures that, ideally, capture interpersonal aspects of typical workplace performance. This will facilitate additional work identifying the optimal place of SJTs within particular selection contexts and further enhancing their effectiveness.

Situational judgement tests for selection: Traditional vs construct-driven approaches.

CONTEXT: Historically, situational judgement tests (SJTs) have been widely used for personnel selection. Their use in medical selection in Europe is growing, with plans for further expansion into North America and Australasia, in an attempt to measure and select on 'non-academic' personal attributes. However, there is a lack of clarity regarding what such tests actually measure and how they should be designed, scored and implemented within the medical and health education selection process. In particular, the theoretical basis from which such tests are developed will determine the scoring options available, influencing their psychometric properties and, ultimately, their validity. METHODS: The aim of this article is to create an awareness of the previous theory and practice that has informed SJT development. We describe the emerging interest in the use of the SJT format to measure specific constructs (eg 'resilience', 'dependability', etc.), drawing on the tradition of 'individual differences' psychology. We compare and contrast this newer 'construct-driven' method with the traditional, pragmatic approach to SJT creation, often employed by organisational psychologists. Making reference to measurement theory, we highlight how the anticipated psychometric properties of traditional vs construct-driven SJTs are likely to differ. CONCLUSIONS: Compared to traditional SJTs, construct-driven SJTs have a strong theoretical basis, are uni- rather than multidimensional, and may behave more like personality self-report instruments. Emerging evidence also suggests that construct-driven SJTs have comparable predictive validity for workplace performance, although they may be more prone to 'faking' effects. It is possible that construct-driven approaches prove more appropriate at early stages of medical selection, where candidates have little or no health care work experience. Conversely, traditional SJTs may be more suitable for specialty recruitment, where a range of hypothetical workplace scenarios can be sampled in assessments.

Evaluating the recruitment process into UK anaesthesia core training: a national data linkage study of doctors' performance at selection and subsequent postgraduate training.

PURPOSE OF THE STUDY: To explore which factors increase the likelihood of being deemed appointable to core anaesthesia training in the UK and whether those factors subsequently predict performance in postgraduate training. STUDY DESIGN: Observational study linking UK medical specialty recruitment data with postgraduate educational performance, as measured by Annual Review of Competence Progression (ARCP) outcomes. Data were available for 2782 trainee doctors recruited to anaesthesia core training from 2012 to 2016 with at least one subsequent ARCP outcome. RESULTS: Both higher interview and shortlisting scores were independent and statistically significant (p≤0.001) predictors of more satisfactory ARCP outcomes, even after controlling for the influence of postgraduate exam failure. It was noted that a number of background variables (eg, age at application) were independently associated with the odds of being deemed appointable at recruitment. Of these, increasing age and experience were also negative predictors of subsequent ARCP rating. These influences became statistically non-significant once ARCP outcomes associated with exam failure were excluded. CONCLUSIONS: The predictors of 'appointability' largely also predict subsequent performance in postgraduate training, as indicated by ARCP ratings. This provides evidence for the validity of the selection process. Our results also suggest that greater weight could be applied to shortlisting scores within the overall process of ranking applicants for posts.

Predictive validity and interrater reliability of the FACE-CARAS toolkit in a CAMHS setting.

BACKGROUND: The FACE-CARAS (Functional Analysis in Care Environments-Child and Adolescent Risk-Assessment Suite) toolkit has been developed to support practitioners in Child and Adolescent Mental Health Services (CAMHS) in performing a structured risk assessment. It covers a number of risk domains including violence, suicide, self-harm, experienced abuse, and exploitation. Interrater and internal reliability has already been established but not predictive validity. AIMS/HYPOTHESIS: Our aim was to establish the predictive validity of the FACE-CARAS in a CAMHS population. METHODS: Records from 123 young people with FACE-CARAS ratings completed by clinicians were examined in a retrospective file review to extract data on a relevant list of adverse outcomes at three and at 6 months following the assessment. Although this was not a prospective longitudinal study, researchers were blind to the clinicians' ratings, allowing valid testing of predictive power. Cases were drawn from across generic and specialist CAMHS teams in approximately equal proportions. Data were analysed using receiver operator characteristic statistics. RESULTS: Areas under the curve values in five of the seven risk areas approached or were greater than 0.8 indicated that the FACE-CARAS profile score was a good potential predictor of risks of self-harm, suicidal behaviours, serious self-neglect, abuse or exploitation by others, and violence to others at both 3 and 6 months. It was weakly "predictive" of accidental self-harm and no better than chance at signalling physical ill health. CONCLUSIONS: Findings support the use of the "profile summary" section of the tool as likely to generate clinically useful risk predictions. We were concerned that clinical use of the scale did not conform to research standards and often left subscales incompletely rated; however, the fact that the tool nonetheless proved a good predictor of most key adversities under scrutiny may add weight to its value in clinical practice. Further work with the FACE-CARAS subscales is recommended.

Men and suicide prevention: a scoping review.

BACKGROUND: Male suicide rates are higher than their female counterparts in almost every country around the world. Several developed countries have attempted to implement suicide prevention programmes, but few have specifically targeted men. AIMS: To identify what is currently known about suicide prevention strategies, programmes, and interventions of relevance to men. METHOD: A scoping review guided by Arksey and O'Malley's five-stage framework. RESULTS: Twenty-two studies were included. Thematic analysis identified three categories: (i) male suicide prevention interventions; (ii) factors or coping strategies that interrupt the suicidal process in men; (iii) men's perspectives on service provision. Interventions included awareness campaigns; training of community "gatekeepers"; psychological support; and educational initiatives targeted to either GPs or depressed or suicidal men. Men emphasised the need to receive support from a trusted and respected individual, preferably in an informal setting. Connecting with others, reframing help-seeking as masculine, and the use of emotional regulation techniques were all identified as factors with potential to interrupt the suicidal process. CONCLUSIONS: This review demonstrates the need for further research examining the perspectives of suicidal middle-aged men and their close family and friends.

Defining professionalism for mental health services: a rapid systematic review.

Background: Efforts have been made to define professionalism across the professions, yet little attention has been paid to the concept in mental health services, where patients' needs differ to that in other healthcare specialties. Aims: To derive a definition of professionalism for mental health services using the existing literature. Method: A rapid, systematic review was conducted to identify empirical and non-empirical records that described professionalism in a mental health service context from 2006 to 2017. Studies were synthesised narratively using thematic analysis. Results: Seventy records were included in the review. Professionalism was described on two levels; at a societal level, a dynamic social contract between professions and society, and; at an individual level, having intrapersonal, interpersonal, and working professionalism. Utilising emerging themes, an operationalised definition of professionalism, suitable for a mental health service context was derived. Conclusions: Within mental health services, emphasis is placed on the interpersonal aspects of practice such as communication skills, maintaining boundaries and humanity. Themes relating to the vulnerability of patients and the challenge of supporting autonomy and choice whilst maintaining safety and acting in a client's best interest are also evident. 'Practical wisdom' and a flexible approach to working are needed to manage these challenging situations.

The psychometrics of psychosis - assessing and rating perceptual and ideational disturbance in adolescents.

BACKGROUND: The early recognition and management of psychosis spectrum disorders is associated with superior outcomes in affected individuals. However, this can be challenging for numerous reasons. This article provides perspectives on the effective evaluation and rating of potentially psychotic phenomena young people. We compare and contrast two widely used instruments that can support this process. FINDINGS: The Comprehensive Assessment for At-Risk Mental States (CAARMS) is used to explore potentially psychotic experiences in young people perceived to be at risk of an emerging or imminent psychosis. There is evidence to support its reliability and, to some extent, the predictive validity of the resultant scores. However, relatively low short-medium transition rates to psychosis in 'positive' cases suggest that its use as a screening instrument should be restricted to groups who show some indication of impending risk (e.g. help-seeking, distress, declining functioning, perceptual disturbance, etc.). In contrast, the Positive and Negative Syndrome Scale (PANSS) is calibrated to rate symptoms in those with an established psychosis, especially those with a diagnosis related to the schizophrenia spectrum. Consequently, the PANSS is useful for evaluating the clinical course and outcomes of psychotic illness. CONCLUSIONS: Although neither instrument is designed specifically for use in those under 18, with care they can be used to effectively support the management of adolescents reporting perceptual and ideational disturbance. However, it is important that any instrument ratings are placed meaningfully in the context of the overall clinical picture and all available information.

Rise of the machines? Machine learning approaches and mental health: opportunities and challenges.

Machine learning methods are being increasingly applied to physical healthcare. In this article we describe some of the potential benefits, challenges and limitations of this approach in a mental health context. We provide a number of examples where machine learning could add value beyond conventional statistical modelling.Declaration of interestNone.

Modelling out-of-area admissions.

Out-of-area (OOA) placements occur when patients cannot be admitted to local facilities, which can be extremely stressful for patients and families. Thus, the Department of Health aims to eliminate the need for OOA admissions. Using data from a UK mental health trust we developed a 'virtual mental health ward' to evaluate the potential impact of referral rates and length of stay (LOS) on OOA rates. The results indicated OOA rates were equally sensitive to LOS and referral rate. This suggests that investment in community services that reduce both LOS and referral rates are required to meaningfully reduce OOA admission rates.Declaration of interestP.A.T. holds an honorary consultant contract with the Tees, Esk and Wear Valleys NHS Foundation Trust.

Unpacking the dark variance of differential attainment on examinations in overseas graduates.

CONTEXT: Differential performance in postgraduate examinations between home medical graduates and those who qualified outside their country of practice is well recognised. This difference is especially marked in the practical component of the UK Membership of the Royal College of General Practitioners (MRCGP) examination. The potential causes of such disparities are not well understood. METHODS: Data were available for 1874 international medical graduates who applied for general practice (GP) specialty training in the UK in 2008-2012. The primary outcome was performance in the Clinical Skills Assessment (CSA) OSCE component of the MRCGP. The main predictors were performance on a situational judgement test (SJT) and clinical problem-solving test (CPST), a test of applied clinical knowledge, used in the selection for GP training. Data relating to demographic characteristics and English language fluency were also available. To better understand the relationship between the predictors, the selection measures and the outcome, a series of univariable and multivariable models were developed and tested, concluding with a structural equation model to explore causality. RESULTS: The CSA rating was more strongly predicted by SJT scores (standardised beta, 0.26) than by performance on the CPST (standardised beta, 0.17). There was a relationship between English language fluency and CSA score that was mainly mediated via SJT performance. CONCLUSIONS: These findings demonstrate that performance on an SJT predicts performance in a high-fidelity clinical simulation (the CSA) in international medical graduates. Although the constructs tested by SJTs are debated, and are likely to vary across settings, culturally appropriate knowledge of interpersonal competence is likely to be evaluated. Improving the confidence of doctors in this area through targeted educational interventions, rather than focusing on increased clinical knowledge, is likely to be more effective at reducing disparities observed in postgraduate examination performance. Thus, there are important implications for the design of specialty selection and licensing assessments globally.