Duration of Endocrine Treatment for DCIS impacts second events: Insights from a large cohort of cases at two academic medical centers.

Ductal carcinoma in situ (DCIS) incidence has risen rapidly with the introduction of screening mammography, yet it is unclear who benefits from both the amount and type of adjuvant treatment (radiation therapy, (RT), endocrine therapy (ET)) versus what constitutes over-treatment. Our goal was to identify the effects of adjuvant RT, or ET+/- RT versus breast conservation surgery (BCS) alone in a large multi-center registry of retrospective DCIS cases (N = 1,916) with median follow up of 8.2 years. We show that patients with DCIS who took less than 2 years of adjuvant ET alone have a similar second event rate as BCS. However, patients who took more than 2 years of ET show a significantly reduced second event rate, similar to those who received either RT or combined ET+RT, which was independent of age, tumor size, grade, or period of diagnosis. This highlights the importance of ET duration for risk reduction.

A realist evaluation of a London general practitioner trainer course.

Clinicians with teaching and training roles should be adequately trained and assessed. However, some debate exists as to what the nature of this training should be. Historically, a postgraduate certificate in education was a pre-requisite to becoming a GP trainer but this is changing with growing concern that such a pre-requisite might act as a deterrent to potential GP trainers. This research examines the impact of a scheme designed to provide an alternative, more practical and focused, pathway to becoming a GP trainer. We interviewed 26 course participants and stakeholders of the London GP Training Course (LGPTC), observed teaching sessions, and analysed course materials. We asked what elements of the course were and weren't effective, for whom, and under what circumstances. Here, we present a summary of our main findings - that GP trainers want to know practically, not theoretically, how to be a trainer; formative assessment boosts trainees' confidence in their own skills and abilities; short, practical GP training courses can help enhance the numbers of GP trainers; important questions remain about the role and value of educational theory in education faculty development.

Is West Really Best? The Discourse of Modernisation in Global Medical School Regulation Policy.

Phenomenon: In 2012, the World Federation for Medical Education (WFME) established a recognition programme to evaluate medical school regulatory agencies across the world, in response to a new U.S. accreditation policy. Given the predominantly Western origins and Eastern impacts of the WFME programme, this article deconstructs tensions in the programme using postcolonial theory. Approach: Critical discourse analysis examines the intersections of language, knowledge, and power relations to highlight what can or cannot be said about a topic. We employed it to delineate the dominant discourse underpinning the WFME recognition programme. We drew on the theoretical devices of Edward Said, whose work is foundational in postcolonial thinking but has not been widely used in medical education scholarship to date. An archive of literature about the WFME recognition programme dating back to 2003, when WFME first released global standards for medical education, was analyzed. Findings: In the globalization of medical school regulation, the discourse of modernization can be conceptualized as a means of holding knowledge and power in the West, and enacting this power on those in the East, playing on fears of marginalization in the event of non-engagement. The discourse allows these practices to be presented in an honorable and heroic way. Insights: By uncovering the representation of the WFME recognition programme as being modern and modernizing, this article explores how such conceptualisations can close off debate and scrutiny, and proposes further examination of this programme through a lens that recognizes the inherent inequities and geopolitical power differentials that it operates within.

UK medical students' mental health during the COVID-19 pandemic: a qualitative interview study.

OBJECTIVES: To understand the impact of COVID-19 on medical students with mental health problems. DESIGN: Qualitative study employing in-depth semistructured interviews with medical students which were analysed using reflexive thematic analysis. SETTING AND PARTICIPANTS: A purposive sample of 20 students originating from 8 geographically spread UK medical schools were selected, representing various mental health issues and demographic characteristics. RESULTS: Three themes were identified: (1) medical schools' response to the pandemic-schools increased awareness-raising of mental health support and increased flexibility in regards to academic requirements; (2) disruption to the medical degree-COVID-19 brought change and uncertainty to medical education and missed learning opportunities reduced students' confidence and (3) psychological consequences of the pandemic-COVID-19 had a negative impact on mental health, most notably raising stress and anxiety but also triggering new or existing conditions. CONCLUSIONS: While there were many negative aspects of the pandemic for medical students experiencing mental ill health, there were also positives. Students felt that the increased focus on mental health support during the pandemic had reduced stigma towards mental health. Given stigma has been identified as a key barrier for help-seeking in medical students, future research should investigate the longer-term impacts of the pandemic and whether medical students are more likely to seek help for mental health difficulties postpandemic.

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.

Biliary cancer brain metastases: a multi-institution case series with case reports.

Background: Biliary cancers are rare, and few reported cases of brain metastases from primary biliary cancers exist, especially describing patients in the United States. This report assesses the proportion and incidence of brain metastases arising from primary biliary cancers [cholangiocarcinoma (CCA) and gallbladder cancer] at Stanford University and the University of California, San Francisco, describes clinical characteristics, and provides a case series. Methods: We queried 3 clinical databases at Stanford and the University of California, San Francisco to retrospectively identify and review the charts of 15 patients with brain metastases from primary biliary cancers occurring between 1990 to 2020. Results: Among patients with brain metastases analyzed at Stanford (3,585), 6 had a primary biliary cancer, representing 0.17% of all brain metastases. Among biliary cancer patients at the University of California, San Francisco (1,055), 9 had brain metastases, representing an incidence in biliary cancer of 0.85%. A total of 15 biliary cancer patients with brain metastases were identified at the two institutions. Thirteen out of 15 patients (86.7%, 95% CI: 59.5-98.3) were female. The median overall survival from primary biliary cancer diagnosis was 214 days (95% CI: 71.69-336.82 days) and subsequent OS from the time of brain metastasis diagnosis was 57 days (95% CI: 13.43-120.64 days). Death within 90 days of brain metastasis diagnosis occurred in 66.67% of patients (95% CI: 38.38-88.17). Conclusions: Brain metastases from primary biliary cancers are rare, with limited survival once diagnosed. This report can aid health care providers in caring for patients with brain metastases from primary biliary cancers.

Does the structure of the medical consultation align with an educational model of clinical communication? A study of physicians' consultations from a postgraduate examination.

OBJECTIVE: This study examined whether the structure of consultations in which physicians were tasked with sharing information corresponded to the chronological stages proposed by an established educational model of clinical communication. METHOD: Seventy six simulated consultations from a postgraduate examination for general medical hospital physicians were transcribed verbatim and converted into diagrams showing consultation structure. All doctor-patient/relative talk was allocated into six phases: Initiating, Gathering information, Summary, Explanation, Planning and Closing, using the 'communication process skills' from the Calgary-Cambridge Guide to the Medical Interview. RESULTS: The majority of consultations included four or five of the expected phases, with most talk (41-92%) in Explanation and Planning. There was no discernible consistency of structure across the consultations or in consultations from the same scenario. Consultations varied in the presence, sequential order, size, location and reappearance of phases. CONCLUSIONS: The structure of consultations in this standardised setting bore little resemblance to the chronological order of phases predicted by an educational model. PRACTICE IMPLICATIONS: Educational guidance and interventions to support patients in preparing for consultations need to take account of doctors' behaviour in practice. Assumptions about the organisation of medical consultations should be queried in the absence of an evidence base.

Decreased enrollment in breast cancer trials by histologic subtype: does invasive lobular carcinoma resist RECIST?

Enrollment in metastatic breast cancer trials usually requires measurable lesions, but patients with invasive lobular carcinoma (ILC) tend to form diffuse disease. We found that the proportion of patients with metastatic ILC enrolled in clinical trials at our institution was significantly lower than that of patients with invasive ductal carcinoma (IDC). Possible links between requiring measurable disease and decreased enrollment of ILC patients require further study to ensure equitable trial access.

Cross-sectional exploration of the impact of the Dr Bawa-Garba case on doctors' professional behaviours and attitudes towards the regulator.

OBJECTIVE: This paper examines the impact on doctors' attitudes towards the General Medical Council (GMC) and on professional behaviours (reflective practice and raising concerns) following the Dr Bawa-Garba case. DESIGN: A cross-sectional survey designed using the theoretical lens of the theory of planned behaviour (TPB) was administered from September 2017 to February 2019. By chance, this coincided with critical events in the Dr Bawa-Garba case. SETTING: Primary and secondary care settings across a broad geographical spread in England. PARTICIPANTS: 474 doctors. OUTCOME MEASURES: Attitudes towards the GMC and two professional behaviours in TPB dimensions. RESULTS: Attitudes towards the GMC became more negative during the period that the Medical Practitioners Tribunal Service and GMC suspended and subsequently erased Dr Bawa-Garba from the medical register. Specifically, confidence that doctors are well regulated by the GMC and that the GMC's disciplinary procedures produce fair outcomes was rated more negatively. After this period, overall attitudes start to recover and soon returned close to baseline; however, confidence in how the GMC regulates doctors and their disciplinary procedures improved but still remained below baseline. There was no change in doctors' attitudes or intention to reflect or raise concerns. CONCLUSIONS: The lack of change in doctors' attitudes towards the GMC's guidance, the approachability of the regulator, defensive practice and professional behaviours as a response to the Dr Bawa-Garba case demonstrates the resilient and indelible nature of medical professionalism. At the time, professional bodies reported that repairing doctors' trust and confidence would take time and a significant effort to restore. However, this study suggests that attitudes are more fluid. Despite the high-profile nature of this case and concerns articulated by medical bodies regarding its impact on trust, the actual decline in doctors' overall attitudes towards the GMC was relatively short lived and had no measurable impact on professionalism.

Changing professional behaviours: mixed methods study utilising psychological theories to evaluate an educational programme for UK medical doctors.

BACKGROUND: The Theory of Planned Behaviour (TPB) has been proposed as a useful framework to investigate professional behaviour, however, was not yet applied to the evaluation of an educational intervention. This study will address this gap by utilising the TPB to evaluate the effectiveness of an education programme delivered by the professional regulator for UK doctors in enhancing three professional behaviours: raising concerns, engaging in reflective practice, and use of regulator confidentiality guidance. METHODS: This is a comprehensive mixed methods study combining qualitative (interviews) and quantitative (quasi-experiment) data. Intervention participants were asked to complete a survey measuring the variables in the TPB (attitudes, subjective norms, perceived behavioural control, and intention) for the three professional behaviours before, immediately post, and 3-months later following the education programme. Ninety-four doctors completed the survey pre/post intervention and 38 at all three times. One hundred and eleven doctors from the same hospital trust who did not take part in the intervention completed the survey at two time points and formed the control group. Forty-two interviews were conducted with intervention participants. RESULTS: The quantitative study revealed that the educational intervention significantly improved attitudes (raising concerns, using confidentiality guidance), subjective norms (raising concerns, reflective practice, using confidentiality guidance), perceived control (raising concerns, using confidentiality guidance), and intentions (using confidentiality guidance) (Group and Time interaction; Fs ≥ 3.996, ps ≤ .047, ηp2 ≥ .020). Non-UK graduate doctors' subjective norms towards raising concerns and confidentiality guidance increased significantly after the intervention (Fs ≤ 6.602, ps ≥ .011, ηp2 = .032 F = 6.602, p = .011, ηp2 = .032), but not UK graduates (p > .05). Interviews revealed that doctors had positive views about professional behaviours but also mentioned numerous barriers to actually engage in more complex, context dependent behaviours. CONCLUSIONS: This study demonstrates that an educational intervention was successful in improving the TPB variables of three professional behaviours. It also revealed that teaching professionalism does not happen in isolation and, therefore, personal and contextual factors are crucial to consider. To change complex professional behaviours, barriers at all levels i.e., personal, organisational and system, should be addressed.

What does the structure of a medical consultation look like? A new method for visualising doctor-patient communication.

OBJECTIVE: This project developed an innovative methodology for visualising consultation structure by categorising doctor-patient talk into the phases proposed by an established educational model of clinical communication. METHOD: Consultation phases were identified from verbatim transcripts using the tasks and process skills of the Calgary-Cambridge Guide to the Medical Interview. Seventy-eight simulated consultations from a 'History-taking' station of a postgraduate examination for physicians were analysed by two independent raters. Transcripts were converted into diagrams comprising up to six phases: Initiating, Gathering information, Summary, Explanation, Planning and Closing. RESULTS: The dominant phases were Gathering information, Planning and Explanation (66 %, 10 % and 12 % of talk respectively). While consultations broadly followed the expected chronological sequence, less than a third (23/78) contained all six phases, with Closing and Summary most frequently absent. Half of consultations (40/78) did not include phases in the predicted order, with intertwined phases commonly observed. CONCLUSIONS: In this standardised setting, doctors created variable consultation structures, typically omitting phases involving consolidation and agreement of plans going forward. PRACTICE IMPLICATIONS: The method enables visualisation and comparison of consultation structure. The findings pose questions about the alignment of practice with educational guidance and the opportunities afforded to patients to actively engage in consultations.

A Large Thyroid Fine Needle Aspiration Biopsy Cohort with Long-Term Population-Based Follow-Up.

Background: Prior studies evaluating thyroid fine needle aspiration biopsies (FNABs) have limited the calculation of risk of malignancy (ROM) to cytologic specimens with corresponding histologic specimens, and clinical follow-up for those patients who do not undergo immediate surgery has been largely disregarded. Moreover, there is marked variability in how researchers have approached thyroid FNAB statistical analyses. This study addresses the urgent need for information from a large cohort of patients with long-term clinical follow-up to more accurately determine the performance of thyroid FNAB and ROM for each diagnostic category. Methods: A retrospective review of the University of California, San Francisco (UCSF), pathology database for thyroid FNABs from January 1, 1997, to December 31, 2004, was performed. Diagnoses were coded using the 2017 The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), and patients were matched to both the UCSF cancer registry and California Cancer Registry. Data were analyzed using the Kaplan-Meier method, and stratified by TBSRTC diagnostic category. Kaplan-Meier curves were used to estimate incidence rates of malignancy, stratified by FNAB category. Cox proportional hazards models were used to determine the instantaneous ROM. Results: Initial FNABs from 2207 patients were included. Median follow-up period after the first thyroid FNAB was 13.9 years (range: 10.5-18.4 years). During follow-up, there were 279 confirmed diagnoses of thyroid malignancy. Estimates derived from Kaplan-Meier curves demonstrated that the risk of having a thyroid malignancy was low for nondiagnostic and benign categories, intermediate for atypia of undetermined significance (AUS), follicular lesion of undetermined significance (FLUS), AUS/FLUS combined, and follicular neoplasm, and high for suspicious and malignant categories. A total of 52/1575 false-negative cases (3.2%) were identified. Excluding papillary microcarcinomas, the false-negative rate was 1.5% (23/1575). No patients with a false-negative diagnosis died of thyroid cancer during the follow-up period. Conclusions: Asymptomatic patients with low-risk clinical and radiologic features and initially benign or unsatisfactory biopsy are unlikely to develop thyroid malignancy and highly unlikely to die of thyroid cancer. FNAB is highly accurate in detecting malignancy. Additional studies evaluating similar large data sets after the adoption of TBSRTC and the integration of molecular testing are needed.

Patient autonomy in the consultation: How signalling structure can facilitate patient-centred care.

OBJECTIVE: To identify types and functions of doctors' verbal signalling behaviours used to share consultation structure with patients. METHOD: Doctors' verbal utterances signalling what would happen in the consultation were identified by two independent raters from transcripts of 78 simulated consultations from a postgraduate examination for physicians. In total, 974 behaviours were categorised as informing, inviting or instructing. Principles adopted from Speech Act Theory and Conversation Analysis were used to examine their function from their literal meaning and use in context. RESULTS: Signalling behaviours to inform were most frequent, particularly 'signposts', with less informative signalling behaviours also found ('posts without signs' and 'signs without posts'). Behaviours to invite involvement offered limited choice. Doctors also instructed the patient in what to do (behaviour) or not to do (emotion). Behaviours signalled more 'micro-level' changes than broader consultation aims. Signalling behaviours carried roles beyond their literal meaning ('hyperfunctions') and were combined ('stacked'), often seen deflecting the conversation away from patient concerns. CONCLUSION: Doctors use a variety of verbal signalling behaviours with multiple functions. As well as sharing information, these behaviours regulate patient agency in the consultation. PRACTICE IMPLICATIONS: Doctors' signalling behaviours may play an important role in facilitating or inhibiting patient autonomy.

Exploring communities of practice in the NHS: A core medical trainee experience.

OBJECTIVES: A community of practice was described by Lave and Wenger as a mutual engagement using a shared repertoire of resources to attain a shared goal. This study explored the extent to which NHS workplaces function as communities of practice for core medical trainees. METHODS: All core medical trainees in one region were invited to a semi-structured interview. A framework was produced using communities of practice themes and a hybrid deductive-inductive method used for data analysis. RESULTS: NHS workplaces function as communities of practice by enabling engagement and by formation of mutual relationships. Joint enterprise was evidenced by multidisciplinary team working. Full participation was limited by service provision and short training rotations. CONCLUSIONS: Trainee attendance in clinic and procedure lists should be facilitated. Trainees should be enabled to 'act up' as registrar. Flexibility is needed in jobs by allowing swaps between trainees and the facilitation of 'taster weeks'.

Blockchain-Authenticated Sharing of Genomic and Clinical Outcomes Data of Patients With Cancer: A Prospective Cohort Study.

BACKGROUND: Efficiently sharing health data produced during standard care could dramatically accelerate progress in cancer treatments, but various barriers make this difficult. Not sharing these data to ensure patient privacy is at the cost of little to no learning from real-world data produced during cancer care. Furthermore, recent research has demonstrated a willingness of patients with cancer to share their treatment experiences to fuel research, despite potential risks to privacy. OBJECTIVE: The objective of this study was to design, pilot, and release a decentralized, scalable, efficient, economical, and secure strategy for the dissemination of deidentified clinical and genomic data with a focus on late-stage cancer. METHODS: We created and piloted a blockchain-authenticated system to enable secure sharing of deidentified patient data derived from standard of care imaging, genomic testing, and electronic health records (EHRs), called the Cancer Gene Trust (CGT). We prospectively consented and collected data for a pilot cohort (N=18), which we uploaded to the CGT. EHR data were extracted from both a hospital cancer registry and a common data model (CDM) format to identify optimal data extraction and dissemination practices. Specifically, we scored and compared the level of completeness between two EHR data extraction formats against the gold standard source documentation for patients with available data (n=17). RESULTS: Although the total completeness scores were greater for the registry reports than those for the CDM, this difference was not statistically significant. We did find that some specific data fields, such as histology site, were better captured using the registry reports, which can be used to improve the continually adapting CDM. In terms of the overall pilot study, we found that CGT enables rapid integration of real-world data of patients with cancer in a more clinically useful time frame. We also developed an open-source Web application to allow users to seamlessly search, browse, explore, and download CGT data. CONCLUSIONS: Our pilot demonstrates the willingness of patients with cancer to participate in data sharing and how blockchain-enabled structures can maintain relationships between individual data elements while preserving patient privacy, empowering findings by third-party researchers and clinicians. We demonstrate the feasibility of CGT as a framework to share health data trapped in silos to further cancer research. Further studies to optimize data representation, stream, and integrity are required.

Teaching medical professionalism: a qualitative exploration of persuasive communication as an educational strategy.

BACKGROUND: Across the world, local standards provide doctors with a backbone of professional attitudes that must be embodied across their practice. However, educational approaches to develop attitudes are undermined by the lack of a theoretical framework. Our research explored the ways in which the General Medical Council's (GMC) programme of preventative educational workshops (the Duties of a Doctor programme) attempted to influence doctors' professional attitudes and examined how persuasive communication theory can advance understandings of professionalism education. METHODS: This qualitative study comprised 15 ethnographic observations of the GMC's programme of preventative educational workshops at seven locations across England, as well as qualitative interviews with 55 postgraduate doctors ranging in experience from junior trainees to senior consultants. The sample was purposefully chosen to include various geographic locations, different programme facilitators and doctors, who varied by seniority. Data collection occurred between March to December 2017. Thematic analysis was undertaken inductively, with meaning flowing from the data, and deductively, guided by persuasive communication theory. RESULTS: The source (educator); the message (content); and the audience (participants) were revealed as key influences on the persuasiveness of the intervention. Educators established a high degree of credibility amongst doctors and worked to build rapport. Their message was persuasive, in that it drew on rational and emotional communicative techniques and made use of both statistical and narrative evidence. Importantly, the workshops were interactive, which allowed doctors to engage with the message and thus increased its persuasiveness. CONCLUSIONS: This study extends the literature by providing a theoretically-informed understanding of an educational intervention aimed at promoting professionalism, examining it through the lens of persuasive communication. Within the context of interactive programmes that allow doctors to discuss real life examples of professional dilemmas, educators can impact on doctors' professional attitudes by drawing on persuasive communication techniques to enhance their credibility to demonstrate expertise, by building rapport and by making use of rational and emotional appeals.