Influences and outcomes of less than full-time working in the medical profession: a systematic review protocol.

INTRODUCTION: An impoverished medical workforce is a global phenomenon, which can impact patient care significantly. Greater flexibility in working patterns is one approach policy-makers adopt to address this issue, and the expansion of less than full-time (LTFT) working forms part of this. Studies suggest that LTFT working has the potential to improve recruitment and retention by aligning with how doctors increasingly want to balance their careers with other commitments and interests. What is less well understood are the influencing factors and outcomes related to LTFT working among doctors. This protocol outlines the methodology for a systematic review that will evaluate existing knowledge on LTFT working in the medical profession. METHODS AND ANALYSIS: The Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines will be followed. Embase, MEDLINE, PsycINFO, Health Management Information Consortium, Web of Science, Cochrane Library, Healthcare Administration, and Applied Social Sciences Index and Abstracts will be searched for studies published up to March 2022. Unpublished literature from EThos and ProQuest Dissertations & Theses Global will also be searched. Bibliographic searching, citation searching and handsearching will be used to retrieve additional papers. Authors will be contacted for data or publications if necessary. Two independent reviewers will undertake study screening, data extraction and quality assessment, with disagreements resolved by consensus or by a third reviewer if necessary. Data synthesis will be by narrative synthesis and meta-analysis if possible. ETHICS AND DISSEMINATION: The proposed study does not require ethical approval; however, it forms part of a larger body of research on the impact of LTFT working on the medical workforce for which ethics approval has been granted by the Research Ethics Committee at University College London. Findings will be published in a peer-reviewed journal and will be presented at national and international conferences. PROSPERO REGISTRATION NUMBER: CRD42022307174.

LEARN: A multi-centre, cross-sectional evaluation of Urology teaching in UK medical schools.

OBJECTIVE: To evaluate the status of UK undergraduate urology teaching against the British Association of Urological Surgeons (BAUS) Undergraduate Syllabus for Urology. Secondary objectives included evaluating the type and quantity of teaching provided, the reported performance rate of General Medical Council (GMC)-mandated urological procedures, and the proportion of undergraduates considering urology as a career. MATERIALS AND METHODS: LEARN was a national multicentre cross-sectional study. Year 2 to Year 5 medical students and FY1 doctors were invited to complete a survey between 3rd October and 20th December 2020, retrospectively assessing the urology teaching received to date. Results are reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). RESULTS: 7,063/8,346 (84.6%) responses from all 39 UK medical schools were included; 1,127/7,063 (16.0%) were from Foundation Year (FY) 1 doctors, who reported that the most frequently taught topics in undergraduate training were on urinary tract infection (96.5%), acute kidney injury (95.9%) and haematuria (94.4%). The most infrequently taught topics were male urinary incontinence (59.4%), male infertility (52.4%) and erectile dysfunction (43.8%). Male and female catheterisation on patients as undergraduates was performed by 92.1% and 73.0% of FY1 doctors respectively, and 16.9% had considered a career in urology. Theory based teaching was mainly prevalent in the early years of medical school, with clinical skills teaching, and clinical placements in the later years of medical school. 20.1% of FY1 doctors reported no undergraduate clinical attachment in urology. CONCLUSION: LEARN is the largest ever evaluation of undergraduate urology teaching. In the UK, teaching seemed satisfactory as evaluated by the BAUS undergraduate syllabus. However, many students report having no clinical attachments in Urology and some newly qualified doctors report never having inserted a catheter, which is a GMC mandated requirement. We recommend a greater emphasis on undergraduate clinical exposure to urology and stricter adherence to GMC mandated procedures.

Retrospective observational study of ethnicity-gender pay gaps among hospital and community health service doctors in England.

OBJECTIVES: To identify differences in average basic pay between groups of National Health Service (NHS) doctors cross-classified by ethnicity and gender. Analyse the extent to which characteristics (grade, specialty, age, hours, etc.) can explain these differences. DESIGN: Retrospective observational study using repeated cross-section design. SETTING: Hospital and Community Health Service (HCHS) in England. PARTICIPANTS: All HCHS doctors in England employed by the NHS between 2016 and 2020 appearing in the Digital Electronic Staff Record dataset (average N=99 953 per year). MAIN OUTCOME MEASURES: Hours-adjusted full-time equivalent pay gaps; given as raw data and further adjusted for demographic, job, and workplace characteristics (such as grade, specialty, age, whether British nationality, region) using multivariable regression and statistical decomposition techniques. RESULTS: Pay gaps relative to white men vary with the ethnicity-gender combination. Indian men slightly out-earn white men and Bangladeshi women have a 40% pay gap. In most cases, pay gaps can largely be explained by characteristics that can be measured, especially grade, with the extent varying by specific ethnicity-gender group. However, a portion of pay gaps cannot be explained by characteristics that can be measured. CONCLUSIONS: This study presents new evidence on ethnicity-gender pay gaps among NHS doctors in England using high quality administrative and payroll data. The findings indicate all ethnicity-gender groups earn less than white men on average, except for Indian men. In some cases, these differences cannot be explained giving rise to discussions about the role of discrimination.

The transition to consultant: Identifying gaps in higher specialist training.

BACKGROUND: New consultants consistently feel better prepared for the clinical rather than non-clinical aspects of their role. However, deficiencies in generic competencies have been linked to burnout and patient complaints. This study explored how higher specialty training prepares doctors for the transition to consultant in genitourinary medicine. RESULTS: New consultants felt less prepared for non-clinical aspects of their role. Prior practical experience was the greatest influencing factor in levels of preparedness, with increased responsibility and leadership driving deeper learning. Observation of others helped individuals develop a professional identity but also learn about the wider processes within their service. The learning environment positively influenced preparedness but highlighted a need for dedicated time to learn non-clinical aspects. CONCLUSION: To ensure future trainees feel prepared for the non-clinical aspects of the consultant role, practical experience of non-clinical areas with high levels of leadership and responsibility within a supportive learning environment is essential.

Sex differences in fitness to practise test scores: a cohort study of GPs.

BACKGROUND: Tests of competence are written and clinical assessments taken by doctors under investigation by the General Medical Council (GMC) who have significant performance concerns. Male doctors on average perform more poorly in clinical assessments than female doctors, and are more likely to be sanctioned. It is unclear why. AIM: To examine sex differences in the tests of competence assessment scores of GPs under investigation by the GMC, compared with GPs not under investigation, and whether scores mediate any relationship between sex and sanction likelihood. DESIGN AND SETTING: Retrospective cohort study of GPs' administrative tests of competence data. METHOD: Analysis of variance was undertaken to compare written and clinical tests of competence performance by sex and GP group (under investigation versus volunteers). Path analysis was conducted to explore the relationship between sex, written and clinical tests of competence performance, and investigation outcome. RESULTS: On the written test, female GPs under investigation outperformed male GPs under investigation (Cohen's d = 0.28, P = 0.01); there was no sex difference in the volunteer group (Cohen's d = 0.02, P = 0.93). On the clinical assessment, female GPs outperformed male GPs in both groups (Cohen's d = 0.61, P<0.0001). A higher clinical score predicted remaining on the UK medical register without a warning or sanction, with no independent effect of sex controlling for assessment performance. CONCLUSION: Female GPs outperform male GPs on clinical assessments, even among GPs with generally very poor performance. Male GPs under investigation may have particularly poor knowledge. Further research is required to understand potential sex differences in doctors who take tests of competence and how these impact on sex differences in investigation outcomes.

Passing MRCP (UK) PACES: a cross-sectional study examining the performance of doctors by sex and country.

BACKGROUND: There is much discussion about the sex differences that exist in medical education. Research from the United Kingdom (UK) and United States has found female doctors earn less, and are less likely to be senior authors on academic papers, but female doctors are also less likely to be sanctioned, and have been found to perform better academically and clinically. It is also known that international medical graduates tend to perform more poorly academically compared to home-trained graduates in the UK, US, and Canada. It is uncertain whether the magnitude and direction of sex differences in doctors' performance is variable by country. We explored the association between doctors' sex and their performance at a large international high-stakes clinical examination: the Membership of the Royal Colleges of Physicians (UK) Practical Assessment of Clinical Examination Skills (PACES). We examined how sex differences varied by the country in which the doctor received their primary medical qualification, the country in which they took the PACES examination, and by the country in which they are registered to practise. METHODS: Seven thousand six hundred seventy-one doctors attempted PACES between October 2010 and May 2013. We analysed sex differences in first time pass rates, controlling for ethnicity, in three groups: (i) UK medical graduates (N = 3574); (ii) non-UK medical graduates registered with the UK medical regulator, the General Medical Council (GMC), and thus likely to be working in the UK (N = 1067); and (iii) non-UK medical graduates without GMC registration and so legally unable to work or train in the UK (N = 2179). RESULTS: Female doctors were statistically significantly more likely to pass at their first attempt in all three groups, with the greatest sex effect seen in non-UK medical graduates without GMC registration (OR = 1.99; 95% CI = 1.65-2.39; P < 0.0001) and the smallest in the UK graduates (OR = 1.18; 95% CI = 1.03-1.35; P = 0.02). CONCLUSIONS: As found in a previous format of this examination and in other clinical examinations, female doctors outperformed male doctors. Further work is required to explore why sex differences were greater in non-UK graduates, especially those without GMC registration, and to consider how examination performance may relate to performance in practice.

The value of the physical examination in clinical practice: an international survey.

A structured online survey was used to establish the views of 2,684 practising clinicians of all ages in multiple countries about the value of the physical examination in the contemporary practice of internal medicine. 70% felt that physical examination was 'almost always valuable' in acute general medical referrals. 66% of trainees felt that they were never observed by a consultant when undertaking physical examination and 31% that consultants never demonstrated their use of the physical examination to them. Auscultation for pulmonary wheezes and crackles were the two signs most likely to be rated as frequently used and useful, with the character of the jugular venous waveform most likely to be rated as -infrequently used and not useful. Physicians in contemporary hospital general medical practice continue to value the contribution of the physical examination to assessment of outpatients and inpatients, but, in the opinion of trainees, teaching and demonstration could be improved.

Exploring cultural and linguistic influences on clinical communication skills: a qualitative study of International Medical Graduates.

BACKGROUND: International Medical Graduates (IMGs) are known to perform less well in many postgraduate medical examinations when compared to their UK trained counterparts. This "differential attainment" is observed in both knowledge-based and clinical skills assessments. This study explored the influence of culture and language on IMGs clinical communication skills, in particular, their ability to seek, detect and acknowledge patients' concerns in a high stakes postgraduate clinical skills examination. Hofstede's cultural dimensions framework was used to look at the impact of culture on examination performance. METHODS: This was a qualitative, interpretative study using thematic content analysis of video-recorded doctor-simulated patient consultations of candidates sitting the MRCP(UK) PACES examination, at a single examination centre in November 2012. The research utilised Hofstede's cultural dimension theory, a framework for comparing cultural factors amongst different nations, to help understand the reasons for failure. RESULTS: Five key themes accounted for the majority of communication failures in station 2, "history taking" and station 4, "communication skills and ethics" of the MRCP(UK) PACES examination. Two themes, the ability to detect clues and the ability to address concerns, related directly to the overall construct managing patients' concerns. Three other themes were found to impact the whole consultation. These were building relationships, providing structure and explanation and planning. CONCLUSION: Hofstede's cultural dimensions may help to contextualise some of these observations. In some cultures doctor and patient roles are relatively inflexible: the doctor may convey less information to the patient (higher power distance societies) and give less attention to building rapport (high uncertainty avoidance societies.) This may explain why cues and concerns presented by patients were overlooked in this setting. Understanding cultural differences through Hofstede's cultural dimensions theory can inform the preparation of candidates for high stakes bedside clinical skills examinations and for professional practice.