"Important but risky": attitudes of global thought leaders towards cost and value research in health professions education.

Studies of cost and value can inform educational decision making, yet our understanding of the barriers to such research is incomplete. To address this gap, our aim was to explore the attitudes of global thought leaders in HPE towards cost and value research. This was a qualitative virtual interview study underpinned by social constructionism. In telephone or videoconference interviews in 2018-2019, we asked global healthcare professional thought leaders their views regarding HPE cost and value research, outstanding research questions in this area and why addressing these questions was important. Analysis was inductive and thematic, and incorporated review and comments from the original interviewees (member checking). We interviewed 11 thought leaders, nine of whom gave later feedback on our data interpretation (member checking). We identified four themes: Cost research is really important but potentially risky (quantifying and reporting costs provides evidence for decision-making but could lead to increased accountability and loss of autonomy); I don't have the knowledge and skills (lack of economic literacy); it's not what I went into education research to do (professional identity); and it's difficult to generate generalizable findings (the importance of context). This study contributes to a wider conversation in the literature about cost and value research by bringing in the views of global HPE thought leaders. Our findings provide insight to inform how best to engage and empower educators and researchers in the processes of asking and answering meaningful, acceptable and relevant cost and value questions in HPE.

"You can't always get what you want ": economic thinking, constrained optimization and health professions education.

Every choice we make in health professions education has a cost, whether it be financial or otherwise; by choosing one action (e.g., integrating more simulation, studying more for a summative examination) we lose the opportunity to take an alternative action (e.g., freeing up time for other teaching, leisure time). Economics significantly shapes the way we behave and think as educators and learners and so there is increasing interest in using economic ways of thinking and approaches to examine and understand how choices are made, the influence of constraints and boundaries in educational decision making, and how costs are felt. Thus, in this article, we provide a brief historical overview of modern economics, to illustrate how the core concepts of economics-scarcity (and desirability), rationality, and optimization-developed over time. We explain the important concept of bounded rationality, which explains how individual, meso-factors and contextual factors influence decision making. We then consider the opportunities that these concepts afford for health professions education and research. We conclude by proposing that embracing economic thinking opens up new questions and new ways of approaching old questions which can add knowledge about how choice is enacted in contemporary health professions education.

Trigger point dry needling, manual therapy and exercise versus manual therapy and exercise for the management of Achilles tendinopathy: a feasibility study.

OBJECTIVES: The effects of trigger point dry needling (TDN) on myofascial trigger points (MTP) in Achilles tendinopathy (AT) are unknown. We conducted a study to test the feasibility of a large randomized controlled trial (RCT) to compare the effects of TDN to MT and exercise in a patient population with AT. METHODS: Twenty-two subjects were randomly assigned to a control (MT+Ex) or experimental group (TDN+MT+Ex) and completed eight treatment sessions over 4 weeks with follow up at 3 months. TDN was performed to MTPs in the gastrocnemius, soleus or tibialis posterior each session. The same MT and exercise program was conducted in both groups. RESULTS: Two of three criteria for feasibility were met. The attrition rate at 4-week and 3-month follow-up was 18.1% and 68%, respectively. Significant differences (p < .05) reported for within group analysis for FAAM, NPRS, pain pressure threshold and strength in both groups at 4 weeks and 3 months. The GROC was significant for MT + Ex at 3 months. No between group differences were found.  The MCID for the FAAM, GROC was surpassed in both groups at 4 weeks and 3 months and NPRS for the MT + Ex group at 4 weeks. DISCUSSION: A large RCT to investigate the effects of TDN on MTP in AT is not feasible without modifications due to low recruitment and high attrition rate. Modifications to study design should give consideration for closed or national health-care system for access to large patient populations and reduced financial burden to subjects. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03261504F.

Identifying and exploring factors influencing career choice, recruitment and retention of anaesthesia trainees in the UK.

BACKGROUND: Many acute hospital specialties are experiencing low recruitment and high attrition of trainees. Understanding what is important to current trainees is critical in terms of identifying and addressing factors which adversely affect recruitment and retention. OBJECTIVES: To identify and explore factors involved in anaesthetic trainees' career decision making. METHODS: This was a mixed methods study using a questionnaire survey (assessing how influential 18 different factors were when choosing anaesthetics, using a five-point Likert scale), supplemented by semi-structured interviews, carried out in August-December 2014, in Scotland, UK. RESULTS: 42/68 (62%) completed responses were received, representing over half of all core (58%) and Acute Care Common Stem (65%) trainees across Scotland. Overall, questionnaire data indicated that the following were most important in career decision making: perceived job satisfaction among those already in the specialty, structured training, the nature of the work (practical, varied, immediate outcomes). Thirteen interviews were carried out. These highlighted that prior positive exposure and experience with anaesthetists encouraged trainees into the specialty. Enthusiastic, supportive colleagues and structured training (including clear milestones, regular teaching and feedback) were considered to enhance the quality of training. Sustainable working conditions, flexibility within programme and out-of-programme opportunities were valued. Respondents reported concerns about the impact of increasing service delivery demands on training quality. CONCLUSIONS: Many of the elements important to today's anaesthetics trainees are related to positive learning and working environments. This fits with research findings from other professional groups. These findings can inform the development of programmes which cultivate trainee commitment to, and enthusiasm for, anaesthetics.

Do personality traits assessed on medical school admission predict exit performance? A UK-wide longitudinal cohort study.

Traditional methods of assessing personality traits in medical school selection have been heavily criticised. To address this at the point of selection, "non-cognitive" tests were included in the UK Clinical Aptitude Test, the most widely-used aptitude test in UK medical education (UKCAT: http://www.ukcat.ac.uk/ ). We examined the predictive validity of these non-cognitive traits with performance during and on exit from medical school. We sampled all students graduating in 2013 from the 30 UKCAT consortium medical schools. Analysis included: candidate demographics, UKCAT non-cognitive scores, medical school performance data-the Educational Performance Measure (EPM) and national exit situational judgement test (SJT) outcomes. We examined the relationships between these variables and SJT and EPM scores. Multilevel modelling was used to assess the relationships adjusting for confounders. The 3343 students who had taken the UKCAT non-cognitive tests and had both EPM and SJT data were entered into the analysis. There were four types of non-cognitive test: (1) libertariancommunitarian, (2) NACE-narcissism, aloofness, confidence and empathy, (3) MEARS-self-esteem, optimism, control, self-discipline, emotional-nondefensiveness (END) and faking, (4) an abridged version of 1 and 2 combined. Multilevel regression showed that, after correcting for demographic factors, END predicted SJT and EPM decile. Aloofness and empathy in NACE were predictive of SJT score. This is the first large-scale study examining the relationship between performance on non-cognitive selection tests and medical school exit assessments. The predictive validity of these tests was limited, and the relationships revealed do not fit neatly with theoretical expectations. This study does not support their use in selection.

"It's making contacts": notions of social capital and implications for widening access to medical education.

In the UK widening access (WA) activities and policies aim to increase the representation from lower socio-economic groups into Higher Education. Whilst linked to a political rhetoric of inclusive education such initiatives have however failed to significantly increase the number of such students entering medicine. This is compounded by a discourse that portrays WA applicants and students as lacking the essential skills or attributes to be successful in medical education. Much of the research in this area to date has been weak and it is critical to better understand how WA applicants and students negotiate medical admissions and education to inform change. To address this gap we amalgamated a larger dataset from three qualitative studies of student experiences of WA to medicine (48 participants in total). Inductively analysing the findings using social capital as a theoretical lens we created and clustered codes into categories, informed by the concepts of "weak ties" and "bridging and linking capital", terms used by previous workers in this field, to better understand student journeys in medical education. Successful applicants from lower socio-economic groups recognise and mobilise weak ties to create linking capital. However once in medical school these students seem less aware of the need for, or how to create, capital effectively. We argue WA activities should support increasing the social capital of under-represented applicants and students, and future selection policy needs to take into account the varying social capital of students, so as to not overtly disadvantage some social groups.

Does the UKCAT predict performance on exit from medical school? A national cohort study.

OBJECTIVES: Most UK medical programmes use aptitude tests during student selection, but large-scale studies of predictive validity are rare. This study assesses the UK Clinical Aptitude Test (UKCAT: http://www.ukcat.ac.uk), and 4 of its subscales, along with individual and contextual socioeconomic background factors, as predictors of performance during, and on exit from, medical school. METHODS: This was an observational study of 6294 medical students from 30 UK medical programmes who took the UKCAT from 2006 to 2008, for whom selection data from the UK Foundation Programme (UKFPO), the next stage of UK medical education training, were available in 2013. We included candidate demographics, UKCAT (cognitive domains; total scores), UKFPO Educational Performance Measure (EPM) and national exit situational judgement test (SJT). Multilevel modelling was used to assess relationships between variables, adjusting for confounders. RESULTS: The UKCAT-as a total score and in terms of the subtest scores-has significant predictive validity for performance on the UKFPO EPM and SJT. UKFPO performance was also affected positively by female gender, maturity, white ethnicity and coming from a higher social class area at the time of application to medical school An inverse pattern was seen for a contextual measure of school, with those attending fee-paying schools performing significantly more weakly on the EPM decile, the EPM total and the total UKFPO score, but not the SJT, than those attending other types of school. CONCLUSIONS: This large-scale study, the first to link 2 national databases-UKCAT and UKFPO, has shown that UKCAT is a predictor of medical school outcome. The data provide modest supportive evidence for the UKCAT's role in student selection. The conflicting relationships of socioeconomic contextual measures (area and school) with outcome adds to wider debates about the limitations of these measures, and indicates the need for further research.

Risk stratification of patients with low back pain seen in physical therapy practice.

DESIGN: A secondary analysis of a retrospective cohort was conducted using data obtained from a commercial outcomes database. OBJECTIVE: To identify predictive characteristics related to patients with lumbar impairments who have a high risk of a bad prognosis (lowest functional recovery compared to visit utilization) as well as those who are at low risk of a bad prognosis (highest functional recovery compared to visit utilization). BACKGROUND: Lumbar impairments are highly prevalent and routinely cause people to seek medical care, including physiotherapy. Most prognostic studies focus solely on good outcomes but do not factor in the intensity of care needed to achieve the outcome. Understanding care intensity needed per outcome achieved could help assign appropriate care quantities. METHODS: Data from 6379 patients with lumbar impairments were analyzed to determine predictive characteristics that identify patients who either have a low or high risk of a bad prognosis to physiotherapy care. Multinomial regression was used to identify significant patient characteristics predictive of treatment response. RESULTS: Statistically significant predictors for high risk categorization included older age, longer duration of symptoms, surgical history, current use of medications, lower levels of disability at baseline, and insurance categorization. Statistically significant predictors of low risk categorization included younger age, male gender, shorter duration of symptoms, no surgical history, higher levels of disability at baseline, and insurance status. CONCLUSION: Selected variables were associated with both poor and good recovery. Further research on prognosis, efficacy of physiotherapy care, and cost appear warranted for patients with lumbar impairments.

Shared decision-making in back pain consultations: an illusion or reality?

PURPOSE: Amid a political agenda for patient-centred healthcare, shared decision-making is reported to substantially improve patient experience, adherence to treatment and health outcomes. However, observational studies have shown that shared decision-making is rarely implemented in practice. The purpose of this study was to measure the prevalence of shared decision-making in clinical encounters involving physiotherapists and patients with back pain. METHOD: Eighty outpatient encounters (comprising 40 h of data) were observed audio-recorded, transcribed verbatim and analysed using the 12-item OPTION scale. The higher the score, the greater is the shared decision-making competency of the clinicians. RESULTS: The mean OPTION score was 24.0% (range 10.4-43.8%). CONCLUSION: Shared decision-making was under-developed in the observed back pain consultations. Clinicians' strong desire to treat acted as a barrier to shared decision-making and further work should focus on when and how it can be implemented.

A mixed-methods study identifying and exploring medical students' views of the UKCAT.

BACKGROUND: The United Kingdom Clinical Aptitude Test (UKCAT) is used by 23 UK medical schools. Research to date has focused on validity and utility but it is also critical to examine selection processes from the applicant's perspective. METHODS: This was a mixed-methods study using a paper-based survey and focus groups with first year medical students in Scotland in 2009-2010. Questionnaire data were analysed using SPSS, focus group data using framework analysis. RESULTS: The survey return rate was 88% (883/1005). More than 99% of respondents had sat the UKCAT. Only 20% of respondents agreed the UKCAT was useful in the selection procedure. Nineteen students then took part in three focus groups held in three medical schools. These identified four themes related to views of the UKCAT: lack of face validity, concerns about fairness and cost, and the use of data by medical schools and influence of preparation. CONCLUSION: The UKCAT was viewed unfavourably by first year medical students completing it pre-admission. These negative views seem due to concern as to the use of UKCAT data, and the fairness of the test. More evidence as to validity and fairness of the UKCAT and how it is used in practice is required.

"There is a chain of Chinese whispers ...": empirical data support the call to formally teach handover to prequalification doctors.

BACKGROUND: Changing patterns of work in the hospital setting mean different teams look after the same group of patients over the course of any given day. Shift handovers, or hand/sign-off, can give rise to miscommunication of critical information, a patient safety issue. How can we best prepare new doctors for handover? METHODS: This was a qualitative, focus-group study, exploring the views of doctors (Foundation Year, Senior House Officers, Registrars and Consultants) and night nurse practitioners, in Aberdeen, UK. RESULTS: Five focus groups were carried out with 21 participants. Using framework analysis, five main themes relevant to the task of effectively handing over, and how to best teach handover, emerged. These were: definition of handover; experience of handover as a junior doctor; perceptions of junior doctors' handover skills and attitudes; systems factors, and their interaction with individual factors; and the "what" and the "how" of teaching handover. CONCLUSIONS: New doctors feel unprepared for handover and are seen as poor at handing over. Certain skills are required for effective handover, but professional attitudes are also critical. The skills identified reflect those suggested in policy documents based on expert panel views. Poor systems are a barrier to effective learning and practice. Our empirical approach adds to existing knowledge by highlighting that handover is not solely a skills-based task; there are complex interactions between individual and systems factors; and junior doctors should be prepared for handover prequalification. These data can be used to plan optimal handover teaching for medical students.

The effects of manual therapy and exercise directed at the cervical spine on pain and pressure pain sensitivity in patients with myofascial temporomandibular disorders.

No studies have investigated the effects of the treatments directed at the cervical spine in patients with temporomandibular disorders (TMD). Our aim was to investigate the effects of joint mobilization and exercise directed at the cervical spine on pain intensity and pressure pain sensitivity in the muscles of mastication in patients with TMD. Nineteen patients (14 females), aged 19-57 years, with myofascial TMD were included. All patients received a total of 10 treatment session over a 5-week period (twice per week). Treatment included manual therapy techniques and exercise directed at the cervical spine. Outcome measures included bilateral pressure pain threshold (PPT) levels over the masseter and temporalis muscles, active pain-free mouth opening (mm) and pain (Visual Analogue Scale) and were all assessed pre-intervention, 48 h after the last treatment (post-intervention) and at 12-week follow-up period. Mixed-model anovas were used to examine the effects of the intervention on each outcome measure. Within-group effect sizes were calculated in order to assess clinical effect. The 2 x 3 mixed model anova revealed significant effect for time (F = 77.8; P < 0.001) but not for side (F = 0.2; P = 0.7) for changes in PPT over the masseter muscle and over the temporalis muscle (time: F = 66.8; P < 0.001; side: F = 0.07; P = 0.8). Post hoc revealed significant differences between pre-intervention and both post-intervention and follow-up periods (P < 0.001) but not between post-intervention and follow-up period (P = 0.9) for both muscles. Within-group effect sizes were large (d > 1.0) for both follow-up periods in both muscles. The anova found a significant effect for time (F = 78.6; P < 0.001) for changes in pain intensity and active pain-free mouth opening (F = 17.1; P < 0.001). Significant differences were found between pre-intervention and both post-intervention and follow-up periods (P < 0.001) but not between the post-intervention and follow-up period (P > 0.7). Within-group effect sizes were large (d > 0.8) for both post-intervention and follow-up periods. The application of treatment directed at the cervical spine may be beneficial in decreasing pain intensity, increasing PPTs over the masticatory muscles and an increasing pain-free mouth opening in patients with myofascial TMD.

Predictor variables for identifying patients with chronic tension-type headache who are likely to achieve short-term success with muscle trigger point therapy.

To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with tension-type headache pain who are likely to benefit from muscle trigger point (TrP) therapy. The purpose of this study was to develop a preliminary clinical prediction rule (CPR) to identify chronic tension-type headache (CTTH) patients who are likely to experience a successful response from TrP therapy. Consecutive patients with CTTH underwent a standardized examination and then received six sessions of TrP therapy over 3 weeks (two sessions per week). They were classified as having experienced a successful outcome at short-term (1 week after discharge) and 1-month follow-up based on a 50% reduction on at least one headache parameter (intensity, frequency or duration) and self-report perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for identifying treatment success. Data from 35 patients were included, of which 19 (55%) experienced a successful outcome. A CPR with four variables for short-term (headache duration < 8.5 h/day, headache frequency < 5.5 days/week, bodily pain < 47 and vitality < 47.5) and a CPR with two variables for 1-month (headache frequency < 5.5 days/week and bodily pain < 47) follow-up were identified. At short-term follow-up, if three of four variables [positive likelihood ratio (LR) 3.4] were present, the chance of experiencing a successful outcome improved from 54% to 80%, and if all the variables (positive LR 5.9) were present, the probability of success was 87.4%. At 1-month follow-up, if one of two variables (positive LR 2.2) was present, the probability of success increased from 54% to 72%, and if both variables (positive LR 4.6) were present, the probability of success was 84.4%. The present CPR provides the potential to identify CTTH patients who are likely to experience short-term and 1-month follow-up success with a muscle TrP therapy approach. Future studies are necessary to validate the CPR.