"I'm on an island": A qualitative study of underperforming surgical trainee perspectives on remediation.

BACKGROUND: There is a significant gap in the literature regarding trainees' perceptions of remediation. This study aims to explore surgical trainees' experiences and perspectives of remediation. METHODS: This qualitative study used semi-structured interviews with 11 doctors who have experienced formal remediation as a surgical trainee. Reflexive thematic analysis was used for data analysis. RESULTS: In this study, trainees perceived remediation as a harrowing and isolating experience, with long-lasting emotions. There was a perceived lack of clarity regarding explanations of underperformance and subjective goals. Remediation was viewed as a 'performance' and tick-box exercise with superficial plans, with challenging trainee/supervisor dynamics. CONCLUSIONS: These findings about trainees' perspectives on remediation show a need for trainees to be better emotionally supported during remediation and that remediation plans must be improved to address deficits. Integrating the perspectives and experiences of surgical trainees who have undergone remediation should help improve remediation outcomes and patient care.

Impact of COVID-19, gender, race, specialty and seniority on mental health during surgical training: an international study.

BACKGROUND: Superior patient outcomes rely on surgical training being optimized. Accordingly, we conducted an international, prospective, cross-sectional study determining relative impacts of COVID-19, gender, race, specialty and seniority on mental health of surgical trainees. METHOD: Trainees across Australia, New Zealand and UK enrolled in surgical training accredited by the Royal Australasian College of Surgeons or Royal College of Surgeons were included. Outcomes included the short version of the Perceived Stress Scale, Oxford Happiness Questionnaire short scale, Patient Health Questionnaire-2 and the effect on individual stress levels of training experiences affected by COVID-19. Predictors included trainee characteristics and local COVID-19 prevalence. Multivariable linear regression analyses were conducted to assess association between outcomes and predictors. RESULTS: Two hundred and five surgical trainees were included. Increased stress was associated with number of COVID-19 patients treated (P = 0.0127), female gender (P = 0.0293), minority race (P = 0.0012), less seniority (P = 0.001), and greater COVID-19 prevalence (P = 0.0122). Lower happiness was associated with training country (P = 0.0026), minority race (P = 0.0258) and more seniority (P < 0.0001). Greater depression was associated with more seniority (P < 0.0001). Greater COVID-19 prevalence was associated with greater reported loss of training opportunities (P = 0.0038), poor working conditions (P = 0.0079), personal protective equipment availability (P = 0.0008), relocation to areas of little experience (P < 0.0001), difficulties with career progression (P = 0.0172), loss of supervision (P = 0.0211), difficulties with pay (P = 0.0034), and difficulties with leave (P = 0.0002). CONCLUSION: This is the first study to specifically describe the relative impacts of COVID-19 community prevalence, gender, race, surgical specialty and level of seniority on stress, happiness and depression of surgical trainees on an international scale.

Are there differences between SIMG surgeons and locally trained surgeons in Australia and New Zealand, as rated by colleagues and themselves?

BACKGROUND: Representation of specialist international medical graduates (SIMGs) in specific specialties such as surgery can be expected to grow as doctor shortages are predicted in the context of additional care provision for aging populations and limited local supply. Many national medical boards and colleges provide pathways for medical registration and fellowship of SIMGs that may include examinations and short-term training. There is currently very little understanding of how SIMGs are perceived by colleagues and whether their performance is perceived to be comparable to locally trained medical specialists. It is also not known how SIMGs perceive their own capabilities in comparison to local specialists. The aim of this study is to explore the relationships between colleague feedback and self-evaluation in the specialist area of surgery to identify possible methods for enhancing registration and follow-up training within the jurisdiction of Australia and New Zealand. METHODS: Feedback from 1728 colleagues to 96 SIMG surgeons and 406 colleagues to 25 locally trained Fellow surgeons was collected, resulting in 2134 responses to 121 surgeons in total. Additionally, 98 SIMGs and 25 Fellows provided self-evaluation scores (123 in total). Questionnaire and data reliability were calculated before analysis of variance, principal component analysis and network analysis were performed to identify differences between colleague evaluations and self-evaluations by surgeon type. RESULTS: Colleagues rated SIMGs and Fellows in the 'very good' to 'excellent' range. Fellows received a small but statistically significant higher average score than SIMGs, especially in areas dealing with medical skills and expertise. However, SIMGs received higher scores where there was motivation to demonstrate working well with colleagues. Colleagues rated SIMGs using one dimension and Fellows using three, which can be identified as clinical management skills, inter-personal communication skills and self-management skills. On self-evaluation, both SIMGs and Fellows gave themselves a significant lower average score than their colleagues, with SIMGs giving themselves a statistically significant higher score than Fellows. CONCLUSIONS: Colleagues rate SIMGs and Fellows highly. The results of this study indicate that SIMGs tend to self-assess more highly, but according to colleagues do not display the same level of differentiation between clinical management, inter-personal and self-management skills. Further research is required to confirm these provisional findings and possible reasons for lack of differentiation if this exists. Depending on the outcome, possible support mechanisms can be explored that may lead to increased comparable performance with locally trained graduates of Australia and New Zealand in these three dimensions.

A qualitative study of the incentives and barriers that influence preferences for rural placements during surgical training in Australia.

BACKGROUND: Rural exposure of long durations during clinical training is positively associated with rural career uptake and is a central strategy to addressing the geographical maldistribution of Australia's surgical workforce. However, the incentives and barriers to trainees undergoing surgical training preferencing repeated rural placements in Australia are not well understood. This qualitative study explores the incentives and barriers that influence preference for rural placements during surgical training in Australia. METHODS: This qualitative study employed online semi-structured in-depth interviews. Participants were recruited using an online survey, and interviews were conducted between October 2020 and November 2020. Transcripts were transcribed and de-identified, and thematically analysed. RESULTS: Twenty-nine semi-structured interviews were conducted with trainees and 12 Fellows. Twenty-five participants identified as male, and four identified as female. Four main incentives identified were: (1) broad scope of learning opportunities, (2) quality of supervision, (3) positive work environment and (4) lifestyle. Seven barriers identified were: (1) inadequate preparation for placement, (2) limited case mix to support learning outcomes, (3) lack of formally structured learning opportunities, (4) workload and safe hours concerns, (5) lack of peer support, (6) childcare and educational needs and (7) partner career development. CONCLUSION: The strategy of encouraging trainees to undertake rural placements to address the maldistribution of the surgical workforce should include initiatives that support learning outcomes across their training levels. In addition, improving trainees' ability to prepare adequately for placements may also improve the number and duration of rural placements trainees undertake during their training.

Optimising the delivery of remediation programmes for doctors: A realist review.

CONTEXT: Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety. METHOD: We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs). RESULTS: A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection. CONCLUSION: Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.

'You're just a locum': professional identity and temporary workers in the medical profession.

Internationally, there has been substantial growth in temporary working, including in the medical profession where temporary doctors are known as locums. There is little research into the implications of temporary work in health care. In this paper, we draw upon theories concerning the sociology of the medical profession to examine the implications of locum working for the medical profession, healthcare organisations and patient safety. We focus particularly on the role of organisations in professional governance and the positioning of locums as peripheral to or outside the organisation, and the influence of intergroup relationships (in this case between permanent and locum doctors) on professional identity. Qualitative semi-structured interviews were conducted between 2015 and 2017 in England with 79 participants including locum doctors, locum agency staff, and representatives of healthcare organisations who use locums. An abductive approach to analysis combined inductive coding with deductive, theory-driven interpretation. Our findings suggest that locums were perceived to be inferior to permanently employed doctors in terms of quality, competency and safety and were often stigmatised, marginalised and excluded. The treatment of locums may have negative implications for collegiality, professional identity, group relations, team functioning and the way organisations deploy and treat locums may have important consequences for patient safety.

Reviving clinical governance? A qualitative study of the impact of professional regulatory reform on clinical governance in healthcare organisations in England.

BACKGROUND: Until recently, processes of professional regulation and organisational clinical governance in the UK have been largely separate. However, the introduction of medical revalidation in 2012 means that all doctors have to demonstrate periodically to the regulator that they are up to date and fit to practise, and as part of this process doctors must engage with clinical governance activities in the organisations in which they work. OBJECTIVE: To explore how the recent implementation of medical revalidation has affected the arrangements for clinical governance in healthcare organisations in England. DESIGN: Thematic analysis of interviews with 62 senior clinicians and non-clinicians in management or senior administrative roles, from a range of healthcare organisations in England. RESULTS: Revalidation has engendered changes to clinical governance systems, resulting in: increased doctor engagement with clinical governance activities; new or improved systems for access to clinical governance data for doctors and leaders within healthcare organisations; and more leverage - through the Responsible Officer role - to enforce engagement with clinical governance. Organisational context has been an important mediator of the impact of revalidation on clinical governance. CONCLUSION: Revalidation has increased alignment between systems for organisational and professional oversight and accountability, resulting in increased scrutiny of clinical practice. However, it is still a matter of conjecture whether this will in turn lead to improvements in medical performance.

Remediating professionalism lapses in medical students and doctors: A systematic review.

CONTEXT: A remediation intervention aims to facilitate the improvement of an individual whose competence in a particular skill has dropped below the level expected. Little is known regarding the effectiveness of remediation, especially in the area of professionalism. This review sought to identify and assess the effectiveness of interventions to remediate professionalism lapses in medical students and doctors. METHODS: Databases Embase, MEDLINE, Education Resources Information Center and the British Education Index were searched in September 2017 and October 2018. Studies reporting interventions to remediate professionalism lapses in medical students and doctors were included. A standardised data extraction form incorporating a previously described behaviour change technique taxonomy was utilised. A narrative synthesis approach was adopted. Quality was assessed using the Critical Appraisal Skills Programme checklist. RESULTS: A total of 19 studies on remediation interventions reported in 23 articles were identified. Of these, 13 were case studies, five were cohort studies and one was a qualitative study; 37% targeted doctors, 26% medical students, 16% residents and 21% involved mixed populations. Most interventions were multifaceted and addressed professionalism issues concomitantly with clinical skills, but some focused on specific areas (eg sexual boundaries and disruptive behaviours). Most used three or more behaviour change techniques. The included studies were predominantly of low quality as 13 of the 19 were case studies. It was difficult to assess the effectiveness of the interventions as the majority of studies did not carry out any evaluation. CONCLUSIONS: The review identifies a paucity of evidence to guide best practice in the remediation of professionalism lapses in medical students and doctors. The literature tentatively suggests that remediating lapses in professionalism, as part of a wider programme of remediation, can facilitate participants to graduate from a programme of study, and pass medical licensing and mock oral board examinations. However, it is not clear from this literature whether these interventions are successful in remediating lapses in professionalism specifically. Further research is required to improve the design and evaluation of interventions to remediate professionalism lapses.

The 'Reality of Revalidation in Practice' (RRiP) project - Experiences of registrants and preparation of students in nursing and midwifery in the United Kingdom: A descriptive exploratory survey.

BACKGROUND: Renewal of healthcare registration or license to practise is becomingly increasingly common, worldwide. Evidence regarding the experience of nursing and midwifery revalidation in the United Kingdom is limited. Preparation of students for the process has not yet been considered in the literature. OBJECTIVES: To explore registrants' experiences of undertaking or supporting colleagues through revalidation. To consider preparation of pre-registration students for this future professional requirement. DESIGN: A descriptive exploratory study comprising an on-line survey. SETTING: A university in the southwest of England and associated clinical placements. PARTICIPANTS: Nursing and Midwifery Council registrants, comprising 40 university staff and 40 clinicians; 36 pre-registration nursing and midwifery students. METHODS: Participation in an anonymous on-line survey was invited via university databases. Descriptive statistical analysis of quantitative data used a combination of software and manual methods. Qualitative data were manually coded and categorised into themes through inductive reasoning. FINDINGS: Most experiences of revalidation were positive. Reflective discussions resulted in mutual learning, particularly if partners were chosen by the registrant. External scrutiny was welcomed. Some registrants questioned involvement of line managers and alignment with performance review, seeking to avoid a 'tick-box exercise' and conflicts of interest. University staff felt better prepared and more positive than clinicians. Pre-registration curriculum activities preparing students included writing reflections, maintaining portfolios, practice assessment and discussions about the revalidation process. Midwifery students seemed better prepared than nursing peers. Key themes of 'Professional values', 'Preparation', 'Process' and 'Purpose' and a range of positive influences and potential hazards informed development of a conceptual model. CONCLUSIONS: The purpose and process of revalidation is enhanced if confirmation is undertaken by a registered nurse or midwife of the individual's choice. Preparation of students for future revalidation is facilitated by role-modelling of positive attitudes and explicitly linking relevant pre-registration curriculum activities to this process and purpose.

Is Collecting Patient Feedback "a Futile Exercise" in the Context of Recertification?

OBJECTIVE: Patient feedback is considered integral to maintaining excellence, patient safety, and professional development. However, the collection of and reflection on patient feedback may pose unique challenges for psychiatrists. This research uniquely explores the value, relevance, and acceptability of patient feedback in the context of recertification. METHODS: The authors conducted statistical and inductive thematic analyses of psychiatrist responses (n = 1761) to a national census survey of all doctors (n = 26,171) licensed to practice in the UK. Activity theory was also used to develop a theoretical understanding of the issues identified. RESULTS: Psychiatrists rate patient feedback as more useful than some other specialties. However, despite asking a comparable number of patients, psychiatrists receive a significantly lower response rate than most other specialties. Inductive thematic analysis identified six key themes: (1) job role, setting, and environment; (2) reporting issues; (3) administrative barriers; (4) limitations of existing patient feedback tools; (5) attitudes towards patient feedback; and (6) suggested solutions. CONCLUSIONS: The value, relevance, and acceptability of patient feedback are undermined by systemic tensions between division of labor, community understanding, tool complexity, and restrictive rule application. This is not to suggest that patient feedback is "a futile exercise." Rather, existing feedback processes should be refined. In particular, the value and acceptability of patient feedback tools should be explored both from a patient and professional perspective. If issues identified remain unresolved, patient feedback is at risk of becoming a "futile exercise" that is denied the opportunity to enhance patient safety, quality of care, and professional development.

Patient experience and reflective learning (PEARL): a mixed methods protocol for staff insight development in acute and intensive care medicine in the UK.

INTRODUCTION: Patient and staff experiences are strongly influenced by attitudes and behaviours, and provide important insights into care quality. Patient and staff feedback could be used more effectively to enhance behaviours and improve care through systematic integration with techniques for reflective learning. We aim to develop a reflective learning framework and toolkit for healthcare staff to improve patient, family and staff experience. METHODS & ANALYSIS: Local project teams including staff and patients from the acute medical units (AMUs) and intensive care units (ICUs) of three National Health Service trusts will implement two experience surveys derived from existing instruments: a continuous patient and relative survey and an annual staff survey. Survey data will be supplemented by ethnographic interviews and observations in the workplace to evaluate barriers to and facilitators of reflective learning. Using facilitated iterative co-design, local project teams will supplement survey data with their experiences of healthcare to identify events, actions, activities and interventions which promote personal insight and empathy through reflective learning. Outputs will be collated by the central project team to develop a reflective learning framework and toolkit which will be fed back to the local groups for review, refinement and piloting. The development process will be mapped to a conceptual theory of reflective learning which combines psychological and pedagogical theories of learning, alongside theories of behaviour change based on capability, opportunity and motivation influencing behaviour. The output will be a locally-adaptable workplace-based toolkit providing guidance on using reflective learning to incorporate patient and staff experience in routine clinical activities. ETHICS & DISSEMINATION: The PEARL project has received ethics approval from the London Brent Research Ethics Committee (REC Ref 16/LO/224). We propose a national cluster randomised step-wedge trial of the toolkit developed for large-scale evaluation of impact on patient outcomes.

Reflective Practice for Patient Benefit: An Analysis of Doctors' Appraisal Portfolios in Scotland.

INTRODUCTION: Reflective practice has become the cornerstone of continuing professional development for doctors, with the expectation that it helps to develop and sustain the workforce for patient benefit. Annual appraisal is mandatory for all practicing doctors in the United Kingdom as part of medical revalidation. Doctors submit a portfolio of supporting information forming the basis of their appraisal discussion where reflection on the information is mandated and evaluated by a colleague, acting as an appraiser. METHODS: Using an in-depth case study approach, 18 online portfolios in Scotland were examined with a template developed to record the types of supporting information submitted and how far these showed reflection and/or changes to practice. Data from semistructured interviews with the doctors (n = 17) and their appraisers (n = 9) were used to contextualize and broaden our understanding of the portfolios. RESULTS: Portfolios generally showed little written reflection, and most doctors were unenthusiastic about documenting reflective practice. Appraisals provided a forum for verbal reflection, which was often detailed in the appraisal summary. Portfolio examples showed that reflecting on continued professional development, audits, significant events, and colleague multisource feedback were sometimes considered to be useful. Reflecting on patient feedback was seen as less valuable because feedback tended to be uncritical. DISCUSSION: The written reflection element of educational portfolios needs to be carefully considered because it is clear that many doctors do not find it a helpful exercise. Instead, using the portfolio to record topics covered by a reflective discussion with a facilitator would not only prove more amenable to many doctors but would also allay fears of documentary evidence being used in litigation.

Does regulation increase the rate at which doctors leave practice? Analysis of routine hospital data in the English NHS following the introduction of medical revalidation.

BACKGROUND: In 2012, the UK introduced medical revalidation, whereby to retain their licence all doctors are required to show periodically that they are up to date and fit to practise medicine. Early reports suggested that some doctors found the process overly onerous and chose to leave practice. This study investigates the effect of medical revalidation on the rate at which consultants (senior hospital doctors) leave NHS practice, and assesses any differences between the performance of consultants who left or remained in practice before and after the introduction of revalidation. METHODS: We used a retrospective cohort of administrative data from the Hospital Episode Statistics database on all consultants who were working in English NHS hospitals between April 2008 and March 2009 (n = 19,334), followed to March 2015. Proportional hazard models were used to identify the effect of medical revalidation on the time to exit from the NHS workforce, as implied by ceasing NHS clinical activity. The main exposure variable was consultants' time-varying revalidation status, which differentiates between periods when consultants were (a) not subject to revalidation-before the policy was introduced, (b) awaiting a revalidation recommendation and (c) had received a positive recommendation to be revalidated. Difference-in-differences analysis was used to compare the performance of those who left practice with those who remained in practice before and after the introduction of revalidation, as proxied by case-mix-adjusted 30-day mortality rates. RESULTS: After 2012, consultants who had not yet revalidated were at an increased hazard of ceasing NHS clinical practice (HR 2.33, 95% CI 2.12 to 2.57) compared with pre-policy levels. This higher risk remained after a positive recommendation (HR 1.85, 95% CI 1.65 to 2.06) but was statistically significantly reduced (p < 0.001). We found no statistically significant differences in mortality rates between those consultants who ceased practice and those who remained, after adjustment for multiple testing. CONCLUSION: Revalidation appears to have led to greater numbers of doctors ceasing clinical practice, over and above other contemporaneous influences. Those ceasing clinical practice do not appear to have provided lower quality care, as approximated by mortality rates, when compared with those remaining in practice.

Patient and public involvement in the design, administration and evaluation of patient feedback tools, an example in psychiatry: a systematic review and critical interpretative synthesis.

BACKGROUND: Patient feedback is considered integral to healthcare design, delivery and reform. However, while there is a strong policy commitment to evidencing patient and public involvement (PPI) in the design of patient feedback tools, it remains unclear whether this happens in practice. METHODS: A systematic review using thematic analysis and critical interpretative synthesis of peer-reviewed and grey literature published between 2007 and 2017 exploring the presence of PPI in the design, administration and evaluation of patient feedback tools for practising psychiatrists. The research process was carried out in collaboration with a volunteer mental health patient research partner. RESULTS: Fourteen articles (10 peer-reviewed, four grey literature) discussing the development of nine patient feedback tools were included. Six of the nine tools reviewed were designed from a professional perspective only. Tool content and its categorization primarily remained at the professional's discretion. Patient participation rates, presence of missing data and psychometric validation were used to determine validity and patient acceptability. In most instances, patients remained passive recipients with limited opportunity to actively influence change at any stage. No article reviewed reported PPI in all aspects of tool design, administration or evaluation. CONCLUSIONS: The majority of patient feedback tools are designed, administered and evaluated from the professional perspective only. Existing tools appear to assume that: professional and patient agendas are synonymous; psychometric validation is indicative of patient acceptability; and psychiatric patients do not have the capacity or desire to be involved. Future patient feedback tools should be co-produced from the outset to ensure they are valued by all those involved. A reconsideration of the purpose of patient feedback, and what constitutes valid patient feedback, is also required.

Patient and public involvement in medical performance processes: A systematic review.

BACKGROUND: Patient and public involvement (PPI) continues to develop as a central policy agenda in health care. The patient voice is seen as relevant, informative and can drive service improvement. However, critical exploration of PPI's role within monitoring and informing medical performance processes remains limited. OBJECTIVE: To explore and evaluate the contribution of PPI in medical performance processes to understand its extent, purpose and process. SEARCH STRATEGY: The electronic databases PubMed, PsycINFO and Google Scholar were systematically searched for studies published between 2004 and 2018. INCLUSION CRITERIA: Studies involving doctors and patients and all forms of patient input (eg, patient feedback) associated with medical performance were included. DATA EXTRACTION AND SYNTHESIS: Using an inductive approach to analysis and synthesis, a coding framework was developed which was structured around three key themes: issues that shape PPI in medical performance processes; mechanisms for PPI; and the potential impacts of PPI on medical performance processes. MAIN RESULTS: From 4772 studies, 48 articles (from 10 countries) met the inclusion criteria. Findings suggest that the extent of PPI in medical performance processes globally is highly variable and is primarily achieved through providing patient feedback or complaints. The emerging evidence suggests that PPI can encourage improvements in the quality of patient care, enable professional development and promote professionalism. DISCUSSION AND CONCLUSIONS: Developing more innovative methods of PPI beyond patient feedback and complaints may help revolutionize the practice of PPI into a collaborative partnership, facilitating the development of proactive relationships between the medical profession, patients and the public.

The International Landscape of Medical Licensing Examinations: A Typology Derived From a Systematic Review.

BACKGROUND: National licensing examinations (NLEs) are large-scale examinations usually taken by medical doctors close to the point of graduation from medical school. Where NLEs are used, success is usually required to obtain a license for full practice. Approaches to national licensing, and the evidence that supports their use, varies significantly across the globe. This paper aims to develop a typology of NLEs, based on candidacy, to explore the implications of different examination types for workforce planning. METHODS: A systematic review of the published literature and medical licensing body websites, an electronic survey of all medical licensing bodies in highly developed nations, and a survey of medical regulators. RESULTS: The evidence gleaned through this systematic review highlights four approaches to NLEs: where graduating medical students wishing to practice in their national jurisdiction must pass a national licensing exam before they are granted a license to practice; where all prospective doctors, whether from the national jurisdiction or international medical graduates, are required to pass a national licensing exam in order to practice within that jurisdiction; where international medical graduates are required to pass a licensing exam if their qualifications are not acknowledged to be comparable with those students from the national jurisdiction; and where there are no NLEs in operation. This typology facilitates comparison across systems and highlights the implications of different licensing systems for workforce planning. CONCLUSION: The issue of national licensing cannot be viewed in isolation from workforce planning; future research on the efficacy of national licensing systems to drive up standards should be integrated with research on the implications of such systems for the mobility of doctors to cross borders.

Remediating doctors' performance to restore patient safety: a realist review protocol.

INTRODUCTION: Underperformance by doctors poses a risk to patient safety. Remediation is an intervention designed to remedy underperformance and return a doctor to safe practice. Remediation is widely used across healthcare systems globally, and has clear implications for both patient safety and doctor retention. Yet, there is a poor evidence base to inform remediation programmes. In particular, there is a lack of understanding as to why and how a remedial intervention may work to change a doctor's practice. The aim of this research is to identify why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to support patient safety. METHODS AND ANALYSIS: Realist review is an approach to evidence synthesis that seeks to develop programme theories about how an intervention works to produce its effects. The initial search strategy will involve: database and grey literature searching, citation searching and contacting authors. The evidence search will be extended as the review progresses and becomes more focused on the development of specific aspects of the programme theory. The development of the programme theory will involve input from a stakeholder group consisting of professional experts in the remediation process and patient representatives. Evidence synthesis will use a realist logic of analysis to interrogate data in order to develop and refine the initial programme theory into a more definitive realist programme theory of how remediation works. The study will follow and be reported according to Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES). ETHICS AND DISSEMINATION: Ethical approval is not required. Our dissemination strategy will include input from our stakeholder group. Customised outputs will be developed using the knowledge-to-action cycle framework, and will be targeted to: policy-makers; education providers and regulators, the National Health Service, doctors and academics. PROSPERO REGISTRATION NUMBER: CRD42018088779.

Validation of Multisource Feedback in Assessing Medical Performance: A Systematic Review.

INTRODUCTION: Over the past 10 years, a number of systematic reviews have evaluated the validity of multisource feedback (MSF) to assess and quality-assure medical practice. The purpose of this study is to synthesize the results from existing reviews to provide a holistic overview of the validity evidence. METHODS: This review identified eight systematic reviews evaluating the validity of MSF published between January 2006 and October 2016. Using a standardized data extraction form, two independent reviewers extracted study characteristics. A framework of validation developed by the American Psychological Association was used to appraise the validity evidence within each systematic review. RESULTS: In terms of validity evidence, each of the eight reviews demonstrated evidence across at least one domain of the American Psychological Association's validity framework. Evidence of assessment validity within the domains of "internal structure" and "relationship to other variables" has been well established. However, the domains of content validity (ie, ensuring that MSF tools measure what they are intended to measure); consequential validity (ie, evidence of the intended or unintended consequences MSF assessments may have on participants or wider society), and response process validity (ie, the process of standardization and quality control in the delivery and completion of assessments) remain limited. DISCUSSION: Evidence for the validity of MSF has, across a number of domains, been well established. However, the size and quality of the existing evidence remains variable. To determine the extent to which MSF is considered a valid instrument to assess medical performance, future research is required to determine the following: (1) how best to design and deliver MSF assessments that address the identified limitations of existing tools and (2) how to ensure that involvement within MSF supports positive changes in practice. Such research is integral if MSF is to continue to inform medical performance and subsequent improvements in the quality and safety of patient care.

The impact of patient feedback on the medical performance of qualified doctors: a systematic review.

BACKGROUND: Patient feedback is considered integral to quality improvement and professional development. However, while popular across the educational continuum, evidence to support its efficacy in facilitating positive behaviour change in a postgraduate setting remains unclear. This review therefore aims to explore the evidence that supports, or refutes, the impact of patient feedback on the medical performance of qualified doctors. METHODS: Electronic databases PubMed, EMBASE, Medline and PsycINFO were systematically searched for studies assessing the impact of patient feedback on medical performance published in the English language between 2006-2016. Impact was defined as a measured change in behaviour using Barr's (2000) adaptation of Kirkpatrick's four level evaluation model. Papers were quality appraised, thematically analysed and synthesised using a narrative approach. RESULTS: From 1,269 initial studies, 20 articles were included (qualitative (n=8); observational (n=6); systematic review (n=3); mixed methodology (n=1); randomised control trial (n=1); and longitudinal (n=1) design). One article identified change at an organisational level (Kirkpatrick level 4); six reported a measured change in behaviour (Kirkpatrick level 3b); 12 identified self-reported change or intention to change (Kirkpatrick level 3a), and one identified knowledge or skill acquisition (Kirkpatrick level 2). No study identified a change at the highest level, an improvement in the health and wellbeing of patients. The main factors found to influence the impact of patient feedback were: specificity; perceived credibility; congruence with physician self-perceptions and performance expectations; presence of facilitation and reflection; and inclusion of narrative comments. The quality of feedback facilitation and local professional cultures also appeared integral to positive behaviour change. CONCLUSION: Patient feedback can have an impact on medical performance. However, actionable change is influenced by several contextual factors and cannot simply be guaranteed. Patient feedback is likely to be more influential if it is specific, collected through credible methods and contains narrative information. Data obtained should be fed back in a way that facilitates reflective discussion and encourages the formulation of actionable behaviour change. A supportive cultural understanding of patient feedback and its intended purpose is also essential for its effective use.

Policing the profession? Regulatory reform, restratification and the emergence of Responsible Officers as a new locus of power in UK medicine.

Doctors' work and the changing, contested meanings of medical professionalism have long been a focus for sociological research. Much recent attention has focused on those doctors working at the interface between healthcare management and medical practice, with such 'hybrid' doctor-managers providing valuable analytical material for exploring changes in how medical professionalism is understood. In the United Kingdom, significant structural changes to medical regulation, most notably the introduction of revalidation in 2012, have created a new hybrid group, Responsible Officers (ROs), responsible for making periodic recommendations about the on-going fitness to practise medicine of all other doctors in their organisation. Using qualitative data collected in a 2015 survey with 374 respondents, 63% of ROs in the UK, this paper analyses the RO role. Our findings show ROs to be a distinct emergent group of hybrid professionals and as such demonstrate restructuring within UK medicine. Occupying a position where multiple agendas converge, ROs' work expands professional regulation into the organisational sphere in new ways, as well as creating new lines of continuous accountability between the wider profession and the General Medical Council as medical regulator. Our exploration of ROs' approaches to their work offers new insights into the on-going development of medical professionalism, pointing to the emergence of a distinctly regulatory hybrid professionalism shaped by co-existing professional, managerial and regulatory logics, in an era of strengthened governance and complex policy change.