Preparing clinicians for practice: effectiveness and design of on-call simulation.

BACKGROUND: Final year medical students and postgraduate doctors regularly contend with feelings of under-preparedness when transitioning into new areas of clinical practice. This lack of confidence is most evident in the context of on-call work which frequently requires sound clinical prioritisation, rigorous decision making and the management of acutely unwell patients, often with reduced senior support and staffing. This has prompted the emergence of on-call simulation which seeks to enhance participant confidence in performing on-call tasks and facilitate the development of key clinical and non-technical skills. This narrative review examined the use of on-call simulation in medical student and newly qualified doctor cohorts, its effectiveness in achieving its stated outcomes and to identify novel areas for the development of existing models. METHOD: A search strategy was developed in conjunction with a specialist medical librarian. OVID Medline and Embase searches identified articles related to the use and design of on-call simulation in medical education with no restrictions placed upon date or language of publication. Key findings from articles were summarised to develop comprehensive themes for discussion. RESULTS: Twenty Three unique publications were reviewed which unanimously reported that on-call simulation had a positive effect on self-reported participant confidence in performing on-call roles. Furthermore the value on-call simulation when used as an induction activity was also evident. However, there was limited evidence around improved patient and performance outcomes following simulation. It also remains resource intensive as an educational tool and there is a distinct absence of interprofessional education in current models. CONCLUSIONS: We concluded that on-call simulation must adopt an interprofessional educational approach, incorporating other clinical roles. Further studies are needed to characterise the impact on patient outcomes. It remains highly useful as a confidence-boosting induction activity, particularly in specialities where clinical exposure is limited. Virtual and tabletop simulation formats, could potentially address the resource burden of manikin-based models, particularly with ever growing demands on medical educators and the expansion of training posts.

Combatting climate change using education and training in pharmacology and therapeutics.

The climate crisis has implications for the physical and mental health of people worldwide, while, paradoxically, healthcare itself contributes significant greenhouse gas emissions. Healthcare professionals need to be prepared to both mitigate the impacts of climate change and also manage the health effects of the climate crisis. Widespread adoption of sustainable healthcare models is required, with sustainability-driven improvements in clinical pharmacology intrinsically linked to this. Recognizing that education and training are essential steps to equip medical professionals with the knowledge to face the unprecedented challenges that the climate crisis presents, here, with reference to pharmacology and therapeutics, we discuss how the theme of Education for Sustainable Healthcare (ESH) can be integrated into undergraduate and postgraduate teaching programmes and how barriers to successful implementation can be tackled. We support the use of the Principles of Sustainable Clinical Practice as a framework to guide educational interventions and draw upon examples of our own practice at Brighton and Sussex Medical School where ESH has become a core component of medical education in our undergraduate curriculum.

A Clinical Pharmacology and Therapeutics Teacher's Guide to Race-Based Medicine, Inclusivity, and Diversity.

The relationship between race and biology is complex. In contemporary medical science, race is a social construct that is measured via self-identification of study participants. But even though race has no biological essence, it is often used as variable in medical guidelines (e.g., treatment recommendations specific for Black people with hypertension). Such recommendations are based on clinical trials in which there was a significant correlation between self-identified race and actual, but often unmeasured, health-related factors such as (pharmaco)genetics, diet, sun exposure, etc. Many teachers are insufficiently aware of this complexity. In their classes, they (unintentionally) portray self-reported race as having a biological essence. This may cause students to see people of shared race as biologically or genetically homogeneous, and believe that race-based recommendations are true for all individuals (rather than reflecting the average of a heterogeneous group). This medicalizes race and reinforces already existing healthcare disparities. Moreover, students may fail to learn that the relation between race and health is easily biased by factors such as socioeconomic status, racism, ancestry, and environment and that this limits the generalizability of race-based recommendations. We observed that the clinical case vignettes that we use in our teaching contain many stereotypes and biases, and do not generally reflect the diversity of actual patients. This guide, written by clinical pharmacology and therapeutics teachers, aims to help our colleagues and teachers in other health professions to reflect on and improve our teaching on race-based medical guidelines and to make our clinical case vignettes more inclusive and diverse.

COVID-19 pandemic interim Foundation Year 1 post and confidence in core skills and competencies: a longitudinal survey.

OBJECTIVES: The interim Foundation Year 1 (FiY1) post was created in response to the COVID-19 pandemic to help bolster the workforce and manage increased clinical pressures. This study aimed to assess the impact of the FiY1 post on medical graduates' self-reported confidence in common tasks, core skills, competencies and procedures prior to starting FY1, as a measure of increasing preparedness for practice. SETTING: A longitudinal survey was performed at a tertiary teaching hospital in the South East of England. FiY1 posts ran from June to July 2020. PARTICIPANTS: Questionnaires were sent to 122 medical graduates from a single medical school (recipients included FiY1s and non-FiY1s) and to 69 FiY1s at a single Teaching Hospital NHS Trust, irrespective of medical school attended. Initial and follow-up questionnaires had 86 and 62 respondents, respectively. Of these, 39 graduates were matched; 26 were FiY1s and 13 non-FiY1s. The 39 matched results were analysed. PRIMARY OUTCOME MEASURES: Confidence levels in common FY1 tasks, core procedures and competencies were gathered before and after the FiY1 post through online questionnaires. Change in confidence comparing FiY1s and non-FiY1s was measured and analysed using linear regression. RESULTS: On a 5-point scale, the FiY1 post increased overall confidence in starting FY1 by 0.62 (95% CI 0.072 to 1.167, p=0.028). The FiY1 post increased confidence in performing venepuncture by 0.32 (95% CI 0.011 to 0.920, p=0.045), performing intravenous cannulation by 0.48 (95% CI 0.030 to 1.294, p=0.041) and recognising, assessing and initiating the management of the acutely ill patient by 0.32 (95% CI 0.030 to 1.301, p=0.041). CONCLUSIONS: The COVID-19 pandemic FiY1 post improved confidence in core skills and competencies. These findings may help guide future educational interventions in conjunction with further larger scale studies, ultimately aiding to bridge the transition gap between being a medical student and a doctor.

The education and training of medical students in electronic prescribing.

Education and training in prescribing for medical student often relies on the use of paper drug charts. With the pending elimination of paper prescribing in UK hospitals we look to address how educators can introduce eprescribing into medical undergraduate teaching of prescribing skills.

Diagnosis of spontaneous secondary tension pneumothorax following apparent recovery from coronavirus disease 2019 pneumonitis: a case report.

BACKGROUND: Coronavirus disease 2019 has been associated with a plethora of different manifestations of systems affected (including pulmonary, gastrointestinal, and thrombotic disease) and time to presentation of complications. Pneumothorax has been established as a complication in the literature. However, tension pneumothorax remains a rare presentation with higher mortality. We report a case of secondary tension pneumothorax in a patient following apparent recovery from coronavirus disease 2019 pneumonitis. CASE PRESENTATION: Eight days after resolution of coronavirus disease 2019 pneumonitis symptoms, a 51-year-old Caucasian man with no pre-existing pulmonary disease was brought into the emergency department following 48 hours of progressive shortness of breath. Further clinical assessment revealed reduced breath sounds in the right lung, blood pressure was 116/95 mmHg, and jugular venous pressure was not elevated. Chest x-ray showed right-sided tension pneumothorax with mediastinal shift. Insertion of a chest drain led to rapid resolution of symptoms, and the patient was discharged following full re-expansion of the lung. CONCLUSIONS: The period of recovery from coronavirus disease 2019 is variable. Clinicians should consider tension pneumothorax as a possible complication of coronavirus disease 2019 pneumonitis in patients presenting with type 1 respiratory failure, even after resolution of pneumonitis symptoms and a considerable time period following initial contraction of coronavirus disease 2019.

White-coat hypertension/effect is associated with higher arterial stiffness and stroke events.

OBJECTIVES: The risk profile of white-coat hypertension/effect (WCH/E) remains unclear. This study aimed to investigate the relationship between WCH/E, markers of cardiovascular risk and cerebrovascular events. METHODS: This is a sub-group analysis of The Arterial Stiffness In lacunar Stroke and Transient ischemic attack (ASIST) study, which recruited 96 patients aged at least 40 years old with a diagnosis of transient ischemic attack or lacunar stroke in the preceding 14 days. Thirty-two patients with target blood pressure (clinic blood pressure <140/90 mmHg and daytime ambulatory blood pressure <135/85 mmHg) and 30 patients with WCH/E (clinic blood pressure ≥140/90 mmHg and daytime ambulatory blood pressure <135/85 mmHg) were included in the analysis. RESULTS: Patients with WCH/E were older and had a higher BMI. Central SBP (145 ±â€Š13 vs. 118 ±â€Š8 mmHg, P < 0.001) and DBP (82 ±â€Š8 vs. 76 ±â€Š7 mmHg, P = 0.004) were higher in those with WCH/E. They also had higher arterial stiffness measured by carotid-femoral pulse wave velocity (11.9 ±â€Š3.0 vs. 9.6 ±â€Š2.3 m/s, P = 0.002) and cardio-ankle vascular index (10.3 ±â€Š1.3 vs. 9.4 ±â€Š1.7, P = 0.027). Regression analysis showed an independent relationship between WCH/E and both measures of arterial stiffness. Lacunar strokes were more prevalent in those with WCH/E (47 vs. 22%, P = 0.039) and individuals in this group were more likely to have had a lacunar stroke than a transient ischemic attack (odds ratio 9.6, 95% CI 1.5-62.6, P = 0.02). CONCLUSION: In this cohort of patients with lacunar stroke and transient ischemic attack, WCH/E was associated with elevated markers of cardiovascular risk and a higher prevalence of lacunar stroke. These results suggest that WCH/E is associated with adverse cardiovascular risk.

Medication Without Harm: Developing Optimal Medication Error Reporting Systems.

Medication errors are amongst the most frequently occurring healthcare-related incidents and have the potential to lead to life-threatening harm to patients. An incident reporting system is a traditional approach to the improvement of patient safety and entails the retrieval of information from incident reports. This not only provides a better understanding of causes and contributing factors but also enables the collection of data on the severity of incidents, system deficiencies and the role of human factors in safety incidents. Medication error reporting systems are often developed as a part of larger incident reporting systems that deal with other types of incidents. Although a rise in the prevalence of medication errors has led to an increased demand for medication error reporting, little is known about the characteristics and limitations of medication error reporting systems. The authors broach the subject of medication error reporting systems and propose a more robust and standardized approach.

Stability testing of the Pfizer-BioNTech BNT162b2 COVID-19 vaccine: a translational study in UK vaccination centres.

OBJECTIVE: The roll-out of the Pfizer-BioNTech BNT162b2 COVID-19 vaccine has brought many logistical challenges, such as the absence of comprehensive stability data leading to strict handling instructions during dilution and administration. Accidental mishandling therefore presents challenging clinical dilemmas, which often led vaccine providers to err on the side of caution and discard mishandled vials rather than risk administering ineffective vaccine. This study aims to answer key questions about the vaccine's stability to allow for a more informed decision-making process should a non-conformity occur. METHODS: Residual vaccine in freshly used, but appropriately stored vials collected from vaccination centres in Brighton, UK, were tested after exposure to various handling conditions and analysed by dynamic light scattering to determine the size of the lipid-mRNA nanoparticles, and gel electrophoresis to visualise the mRNA integrity and separation from the lipid formulation. RESULTS: Knocking or dropping vaccine samples from small heights resulted in lowest levels of instability, indicating low risk of compromising clinical efficacy. However, repeated drawing and injecting through 23 G needles at high speed and, more significantly, shaking and vortexing led to progressive increase in the size and polydispersity index of the lipid-mRNA nanoparticles, coupled with or caused by up to ~50% release of mRNA from the lipid formulation. This is thought to impact the vaccine's efficacy due to lack of free mRNA protection and cellular internalisation. CONCLUSIONS: These results reiterate the importance of adhering to the manufacturer's instructions on handling, especially with regard to shaking and exposing the vaccine to excessive vibration.

Climate change in healthcare: Exploring the potential role of inhaler prescribing.

Climate change has been described as the biggest global health threat of the 21st century. As a result, governments around the world are committing to legislative change in order to reduce greenhouse gas emissions (GHGEs). The healthcare sector makes a significant contribution to GHGEs and in line with national legislation in the UK, the NHS has recently committed to achieving net zero emissions by 2050. The management of asthma and COPD largely depends on the prescribing of medications that are delivered through inhalers. In the UK, the use of pressurized metered dose inhalers (pMDIs), which rely on hydrofluorocarbon (HFC) propellants accounts for 3.5% of the NHS's total carbon footprint. In contrast, dry powder inhalers (DPIs) have a much lower carbon footprint due to the absence of a HFC propellant. Here we review evidence of the impact of inhaler choices across four domains: environmental impact, clinical effectiveness, cost effectiveness and patient preferences. We find that as well as a lower global-warming potential, DPIs have additional benefits over pMDIs in other domains and should be considered first line where clinically appropriate.

Current status of white coat hypertension: where are we?

White coat hypertension (WCH) is characterised by an elevated clinic blood pressure (BP) with normal ambulatory or home BP. It is well recognised in clinical practice and occurs in approximately one-third of untreated patients with elevated clinic BP. Current evidence suggests that WCH is associated with cardiovascular risk factors, including the development of sustained hypertension and the presence of target organ damage. However, its effects on cardiovascular outcomes remain a matter of debate. There is also insufficient evidence from randomised controlled trials to determine whether WCH warrants treatment. This narrative review aims to provide an update on the current understanding of WCH. It focuses on the clinical characteristics and potential implications of WCH, its relationship to cardiovascular risk and the evidence regarding treatment. Gaps in existing research are also highlighted.

The role of undergraduate teaching, learning and a national prescribing safety assessment in preparation for practical prescribing: UK medical students' perspective.

AIMS: To investigate medical students' perspectives on the influence of their undergraduate course and the UK prescribing safety assessment (PSA) on the acquisition of practical prescribing skills. METHODS: An online questionnaire comprising multiple choice and open-ended questions was available to UK medical students in years 3, 4 and 5. Descriptive statistics and thematic analysis were completed. RESULTS: In total, 1023 medical students from 25 UK medical schools responded: 22% (3rd year), 37% (4th year) and 41% (final year). A minority of medical students believed that their medical course prepared them sufficiently for practical prescribing (36.4%, n = 372, 95% confidence interval [CI] = 32-41%), 52.6%, of students thought that practical prescribing should be introduced into the curriculum earlier (n = 538, CI = 48-57%), and 73.7% reported that a more consistent approach to the teaching and learning of practical prescribing might be beneficial (n = 754, CI = 71-77%). An awareness of the national PSA was high (86.5%, n = 885), particularly amongst final year students (98.3%, n = 413, CI = 97-100%); 67.4% of all students (n = 690, CI = 64-71%) and 72.1% (n = 303) of final year students perceived that the PSA will improve or had improved their practical prescribing skills. CONCLUSIONS: The majority of medical students perceive that their undergraduate course does not adequately prepare them for practical prescribing. Many believe that there is some merit in introducing practical prescribing teaching earlier in the curriculum and medical schools adopting a more consistent approach. Among medical students, the PSA is thought to have a positive influence on prescribing skills learning. These data might be useful in developing a programme of study dedicated to practical prescribing.

Safe and effective prescribing with dyslexia.

BACKGROUND: The term 'dyslexia' refers to a condition that impacts upon reading and writing abilities whilst not altering intelligence. Individuals with dyslexia may have difficulties with the speed and accuracy and their reading and writing, amongst other issues. Dyslexia is not automatically considered a disability but is a protected characteristic under the UK Equality Act (2010), and therefore employers and educational institutions are required to provide 'reasonable adjustments' in order to allow individuals to reach their full potential. There is a lack of research on this issue, but what little there is suggests that doctors feel as though any support they received ended when they graduated from medical school. MAIN BODY: A core distinction between medical school and medical practice is the requirement to prescribe medicines as registered medical practitioners. Junior doctors have to master this complex and potentially hazardous skill "on the job", with a perceived lack of support. Here, we open up a debate about the potential impact of dyslexia on prescribing, and the need to find supports that may be effective in enabling doctors with dyslexia prescribe medicines safely and effectively - and thus reach their full potential as medical practitioners and promote patient safety. CONCLUSION: We argue that medical schools and hospitals could immediately provide dyslexia awareness training in both undergraduate and postgraduate settings. We discuss electronic prescribing systems, and conclude that research is required to identify effective supports for junior doctors with dyslexia.

UK physician associate primary care placements: staff and student experiences and perceptions.

OBJECTIVES: To provide an insight into the experiences and perceptions of physician associate students and primary care staff involved in primary care educational placements in the United Kingdom. METHODS: A qualitative study was conducted. Data were collected from focus groups and semi-structured interviews with eight first year physician associate students and six primary care staff in two general practice surgeries in East Sussex, United Kingdom. Recruitment was via purposeful sampling. Thematic Analysis was used to identify themes. RESULTS: Three themes were identified: perceptions of the physician associate role, interprofessional working, and the physician associate course structure and placements. Staff demonstrated a lack of familiarity with the physician associate programme and there was a risk of unrealistic expectations. Overall, staff and students were positive about their experiences. However, students expressed anxiety over a large amount of learning in a short timeframe, the perceptions of others, and the reluctance of staff to train them in phlebotomy skills. In addition, students were unsure about their career aspirations for the future. CONCLUSIONS: Participants were positive about their experiences however students expressed a number of anxieties, with a scope to improve interprofessional education. Practice staff demonstrated an overall lack of knowledge of the curriculum and physician associates in general leading to a risk of unrealistic expectations. Further studies on these themes with a larger sample size across relevant training institutions in the United Kingdom is required to explore this further.

Preparing medical students for clinical practice: easing the transition.

The transition from medical student to junior doctor is a challenge; the UK General Medical Council has issued guidance emphasizing the importance of adequate preparation of medical students for clinical practice. This study aimed to determine whether a junior doctor-led simulation-based course is an effective way of preparing final year medical students for practice as a junior doctor.We piloted a new 'preparation for practice' course for final year medical students prior to beginning as Foundation Year 1 (first year of practice) doctors. The course ran over three days and consisted of four simulated stations: ward round, prescribing, handover, and lessons learnt. Quantitative and qualitative feedback was obtained.A total of 120 students attended (40 on each day) and feedback was collected from 95 of them. Using a scale of 1 (lowest) to 5 (highest), feedback was positive, with 99% and 96% rating 4 or 5 for the overall quality of the program and the relevance of the program content, respectively. A score of 5 was awarded by 67% of students for the ward round station; 58% for the handover station; 71% for the prescribing station, and 35% for the lessons learnt station. Following the prescribing station, students reported increased confidence in their prescribing.Preparation for practice courses and simulation are an effective and enjoyable way of easing the transition from medical student to junior doctor. Together with 'on-the-job' shadowing time, such programs can be used to improve students' confidence, competence, and ultimately patient safety and quality of care.

Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: a multicountry observational study from the Africa Liver Cancer Consortium.

BACKGROUND: Hepatocellular carcinoma is a leading cause of cancer-related death in Africa, but there is still no comprehensive description of the current status of its epidemiology in Africa. We therefore initiated an African hepatocellular carcinoma consortium aiming to describe the clinical presentation, management, and outcomes of patients with hepatocellular carcinoma in Africa. METHODS: We did a multicentre, multicountry, retrospective observational cohort study, inviting investigators from the African Network for Gastrointestinal and Liver Diseases to participate in the consortium to develop hepatocellular carcinoma research databases and biospecimen repositories. Participating institutions were from Cameroon, Egypt, Ethiopia, Ghana, Ivory Coast, Nigeria, Sudan, Tanzania, and Uganda. Clinical information-demographic characteristics, cause of disease, liver-related blood tests, tumour characteristics, treatments, last follow-up date, and survival status-for patients diagnosed with hepatocellular carcinoma between Aug 1, 2006, and April 1, 2016, were extracted from medical records by participating investigators. Because patients from Egypt showed differences in characteristics compared with patients from the other countries, we divided patients into two groups for analysis; Egypt versus other African countries. We undertook a multifactorial analysis using the Cox proportional hazards model to identify factors affecting survival (assessed from the time of diagnosis to last known follow-up or death). FINDINGS: We obtained information for 2566 patients at 21 tertiary referral centres (two in Egypt, nine in Nigeria, four in Ghana, and one each in the Ivory Coast, Cameroon, Sudan, Ethiopia, Tanzania, and Uganda). 1251 patients were from Egypt and 1315 were from the other African countries (491 from Ghana, 363 from Nigeria, 277 from Ivory Coast, 59 from Cameroon, 51 from Sudan, 33 from Ethiopia, 21 from Tanzania, and 20 from Uganda). The median age at which hepatocellular carcinoma was diagnosed significantly later in Egypt than the other African countries (58 years [IQR 53-63] vs 46 years [36-58]; p<0·0001). Hepatitis C virus was the leading cause of hepatocellular carcinoma in Egypt (1054 [84%] of 1251 patients), and hepatitis B virus was the leading cause in the other African countries (597 [55%] of 1082 patients). Substantially fewer patients received treatment specifically for hepatocellular carcinoma in the other African countries than in Egypt (43 [3%] of 1315 vs 956 [76%] of 1251; p<0·0001). Among patients with survival information (605 [48%] of 1251 in Egypt and 583 [44%] of 1315 in other African countries), median survival was shorter in the other African countries than in Egypt (2·5 months [95% CI 2·0-3·1] vs 10·9 months [9·6-12·0]; p<0·0001). Factors independently associated with poor survival were: being from an African countries other than Egypt (hazard ratio [HR] 1·59 [95% CI 1·13-2·20]; p=0·01), hepatic encephalopathy (2·81 [1·72-4·42]; p=0·0004), diameter of the largest tumour (1·07 per cm increase [1·04-1·11]; p<0·0001), log α-fetoprotein (1·10 per unit increase [1·02-1·20]; p=0·0188), Eastern Cooperative Oncology Group performance status 3-4 (2·92 [2·13-3·93]; p<0·0001) and no treatment (1·79 [1·44-2·22]; p<0·0001). INTERPRETATION: Characteristics of hepatocellular carcinoma differ between Egypt and other African countries. The proportion of patients receiving specific treatment in other African countries was low and their outcomes were extremely poor. Urgent efforts are needed to develop health policy strategies to decrease the burden of hepatocellular carcinoma in Africa. FUNDING: None.

Safe prescribing training provision for junior doctors: is this optimal?

BACKGROUND: The aim of this study was to determine the training provisions in practical safe prescribing for foundation doctors in NHS hospitals located in the South Thames region. METHODS: A web-based questionnaire was distributed by e-mail to all 1762 foundation doctors in the South Thames Foundation School (STFS) region. In addition, a separate questionnaire was distributed to prescribing training Leads at 15 NHS Hospital Trusts. Quantitative data were analysed using descriptive statistics and thematic analysis was performed on qualitative data. RESULTS: Trainers: 10 Prescribing Leads (67 %) responded. Of the 9 NHS Trusts that offered safe prescribing training in their induction programme, 5 included a practical prescribing session. By the end of the foundation year, 6 NHS Trusts had provided at least one dedicated practical prescribing session for F1s compared with 2 NHS Trusts for F2s. Trainees: A total of 124 foundation trainees (7.2 %) responded (69 F1s and 55 F2s). 87 % of F1s received dedicated training in safe prescribing at their Trust induction (n = 60) in comparison to 49 % of F2s (n = 27). 80 % of F1s (n = 55) had a practical prescribing session during induction versus 27 % of F2s (n = 15). The difference was significant, X (2) (1, N = 124) = 34.23, p <0.0001. Emerging themes from qualitative data included, recognition of medical education as a continuum, importance of working relationships with pharmacists and neglect of F2s. CONCLUSIONS: There appears to be a lack of emphasis on the training of F2 doctors in practical safe prescribing compared with F1 doctors. There should be standardisation of safe prescribing training provisions, particularly in the induction period and for F2 doctors.