Scoping review of smoking cessation interventions in pregnant women attending primary care.

BACKGROUND: Smoking during pregnancy has many adverse effects for infant and mother. Despite this, many pregnant women continue smoking. Primary care is a suitable area to provide smoking cessation interventions. AIM: To investigate available literature regarding effectiveness of smoking cessation interventions for pregnant women in primary care, the factors contributing to this effectiveness and to provide suggestions for future research. DESIGN & SETTING: Systematic scoping literature review. METHOD: The methodology followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. Five electronic databases were searched. Inclusion criteria included original research studies and studies published in English. Data were extracted using a modified Johanna Briggs Institute data charting tool. RESULTS: The initial search yielded 878 articles. Following article screening, twelve studies were included. Five studies found a statistically significant increase in smoking cessation rates or reduction in tobacco consumed in the intervention group. The remaining studies showed no significant difference between the groups. However, ten studies showed the control group received usual antenatal care involving smoking cessation promotion. An increase in smoking cessation rates was seen in intervention and control groups, demonstrating the effectiveness of these interventions. Interventions included education, counselling, self-help and financial incentives. They were delivered by general practitioners, midwives, counsellors and pregnancy advisors. CONCLUSION: Primary care is suitable to offer smoking cessation interventions to pregnant women, as it is often the first point of care and more easily accessible than secondary care. Future research is needed to determine the most effective types of interventions.

In vivo expansion of gene-targeted hepatocytes through transient inhibition of an essential gene.

Homology Directed Repair (HDR)-based genome editing is an approach that could permanently correct a broad range of genetic diseases. However, its utility is limited by inefficient and imprecise DNA repair mechanisms in terminally differentiated tissues. Here, we tested "Repair Drive", a novel method for improving targeted gene insertion in the liver by selectively expanding correctly repaired hepatocytes in vivo. Our system consists of transient conditioning of the liver by knocking down an essential gene, and delivery of an untargetable version of the essential gene in cis with a therapeutic transgene. We show that Repair Drive dramatically increases the percentage of correctly targeted hepatocytes, up to 25%. This resulted in a five-fold increased expression of a therapeutic transgene. Repair Drive was well-tolerated and did not induce toxicity or tumorigenesis in long term follow up. This approach will broaden the range of liver diseases that can be treated with somatic genome editing.

Paracetamol toxicity in classic homocystinuria: Effect of N-acetylcysteine on total homocysteine.

Classical homocystinuria (HCU) is caused by cystathionine ß-synthase deficiency leading to impaired homocysteine transsulfuration and accumulation of homocysteine and methionine. Patients present with a wide spectrum of manifestations including ocular, skeletal, neuropsychiatric, and vascular manifestations. We report a 48-year-old female with pyridoxine-unresponsive HCU treated with betaine, cyanocobalamin, and folate. Her diet was non-restricted due to intolerance of low-methionine diet. She was admitted to hospital following a fall, with multiple fractures and subsequently developed acute liver failure with encephalopathy. Shock, sepsis, and liver ischaemia/thrombosis were excluded. In the context of glutathione depletion expected in HCU, hepatic dysfunction was presumed to be due to iatrogenic paracetamol toxicity, despite paracetamol intake at conventional therapeutic dose, with role of hypermethioninemia as a contributing factor being uncertain. Betaine was discontinued on hospital admission. N-Acetylcysteine (NAC) infusion was initiated. Plasma total homocysteine (tHcy) was 3.4 µmol/L 9 days following initiation of NAC treatment with a markedly elevated plasma methionine of 1278 µmol/L. tHcy concentration returned to pre-admission baseline after NAC was discontinued. Recovery following this episode was slow with a prolonged cholestatic phase and gradual improvement in jaundice and coagulopathy. We recommend that paracetamol should be administered cautiously in HCU patients due to underlying glutathione depletion and risk of toxicity even at therapeutic doses. NAC is clearly effective in lowering tHcy in classical HCU in the short-term however further research is required to assess clinical efficacy and use as a potential therapy in classical HCU.

Placement Architectures in Practice: An Exploration of Student Learning during Non-Traditional Work-Integrated Learning in Rural Communities.

BACKGROUND: Work-integrated learning (WIL) in rural communities provides students with important learning opportunities while also providing a service to those communities. To optimise the potential benefits of work-integrated learning for health students and rural communities it is important to explore the practices and outcomes of these experiences. METHODS: This study used a qualitative research design underpinned by the theoretical framework of Theory of Practice Architectures to examine the way students learn during these placements. Purposive sampling was used to identify students for participation in the study. Seven students from the disciplines of paramedicine, physiotherapy, and speech pathology participated in semi-structured interviews. Data were analysed using inductive thematic analysis. RESULTS: The learning described by the students was examined, followed by a critical interrogation of the data to assess how these learnings and associated practices were made possible given the site-specific practice architectures. The findings of the research are represented by three themes: learning affordances related to placement design, learning through relationships between people and professions, and learning through rural embeddedness. CONCLUSION: Being embedded in rural communities gave the students access to several arrangements that fostered learning, particularly through the sayings, relatings and doings that the students engaged with. This research demonstrates the transformative potential of rural WIL opportunities for learning and future rural practice.

ANGPTL7, a therapeutic target for increased intraocular pressure and glaucoma.

Glaucoma is a leading cause of blindness. Current glaucoma medications work by lowering intraocular pressure (IOP), a risk factor for glaucoma, but most treatments do not directly target the pathological changes leading to increased IOP, which can manifest as medication resistance as disease progresses. To identify physiological modulators of IOP, we performed genome- and exome-wide association analysis in >129,000 individuals with IOP measurements and extended these findings to an analysis of glaucoma risk. We report the identification and functional characterization of rare coding variants (including loss-of-function variants) in ANGPTL7 associated with reduction in IOP and glaucoma protection. We validated the human genetics findings in mice by establishing that Angptl7 knockout mice have lower (~2 mmHg) basal IOP compared to wild-type, with a trend towards lower IOP also in heterozygotes. Conversely, increasing murine Angptl7 levels via injection into mouse eyes increases the IOP. We also show that acute Angptl7 silencing in adult mice lowers the IOP (~2-4 mmHg), reproducing the observations in knockout mice. Collectively, our data suggest that ANGPTL7 is important for IOP homeostasis and is amenable to therapeutic modulation to help maintain a healthy IOP that can prevent onset or slow the progression of glaucoma.

Role of a "Magic" Methyl: 2'-Deoxy-2'-α-F-2'-ß-C-methyl Pyrimidine Nucleotides Modulate RNA Interference Activity through Synergy with 5'-Phosphate Mimics and Mitigation of Off-Target Effects.

Although 2'-deoxy-2'-α-F-2'-ß-C-methyl (2'-F/Me) uridine nucleoside derivatives are a successful class of antiviral drugs, this modification had not been studied in oligonucleotides. Herein, we demonstrate the facile synthesis of 2'-F/Me-modified pyrimidine phosphoramidites and their subsequent incorporation into oligonucleotides. Despite the C3'-endo preorganization of the parent nucleoside, a single incorporation into RNA or DNA resulted in significant thermal destabilization of a duplex due to unfavorable enthalpy, likely resulting from steric effects. When located at the terminus of an oligonucleotide, the 2'-F/Me modification imparted more resistance to degradation than the corresponding 2'-fluoro nucleotides. Small interfering RNAs (siRNAs) modified at certain positions with 2'-F/Me had similar or better silencing activity than the parent siRNAs when delivered via a lipid nanoparticle formulation or as a triantennary N-acetylgalactosamine conjugate in cells and in mice. Modification in the seed region of the antisense strand at position 6 or 7 resulted in an activity equivalent to the parent in mice. Additionally, placement of the antisense strand at position 7 mitigated seed-based off-target effects in cell-based assays. When the 2'-F/Me modification was combined with 5'-vinyl phosphonate, both E and Z isomers had silencing activity comparable to the parent. In combination with other 2'-modifications such as 2'-O-methyl, the Z isomer is detrimental to silencing activity. Presumably, the equivalence of 5'-vinyl phosphonate isomers in the context of 2'-F/Me is driven by the steric and conformational features of the C-methyl-containing sugar ring. These data indicate that 2'-F/Me nucleotides are promising tools for nucleic acid-based therapeutic applications to increase potency, duration, and safety.

From bench to bedside: Improving the clinical safety of GalNAc-siRNA conjugates using seed-pairing destabilization.

Preclinical mechanistic studies have pointed towards RNA interference-mediated off-target effects as a major driver of hepatotoxicity for GalNAc-siRNA conjugates. Here, we demonstrate that a single glycol nucleic acid or 2'-5'-RNA modification can substantially reduce small interfering RNA (siRNA) seed-mediated binding to off-target transcripts while maintaining on-target activity. In siRNAs with established hepatotoxicity driven by off-target effects, these novel designs with seed-pairing destabilization, termed enhanced stabilization chemistry plus (ESC+), demonstrated a substantially improved therapeutic window in rats. In contrast, siRNAs thermally destabilized to a similar extent by the incorporation of multiple DNA nucleotides in the seed region showed little to no improvement in rat safety suggesting that factors in addition to global thermodynamics play a role in off-target mitigation. We utilized the ESC+ strategy to improve the safety of ALN-HBV, which exhibited dose-dependent, transient and asymptomatic alanine aminotransferase elevations in healthy volunteers. The redesigned ALN-HBV02 (VIR-2218) showed improved specificity with comparable on-target activity and the program was reintroduced into clinical development.

Identifying features of quality in rural placements for health students: scoping review.

OBJECTIVES: To explore and synthesise the evidence relating to features of quality in rural health student placements. DESIGN: Scoping review. DATA SOURCES: MEDLINE, CINAHL, Embase, ProQuest, Informit, Scopus, ERIC and several grey literature data sources (1 January 2005 to 13 October 2020). STUDY SELECTION: The review included peer-reviewed and grey literature from Organisation for Economic Co-operation and Development listed countries that focused on quality of health student placements in regional, rural and remote areas. DATA EXTRACTION: Data were extracted regarding the methodological and design characteristics of each data source, and the features suggested to contribute to student placement quality under five categories based on a work-integrated learning framework. RESULTS: Of 2866 resulting papers, 101 were included for data charting and content analysis. The literature was dominated by medicine and nursing student placement research. No literature explicitly defined quality in rural health student placements, although proxy indicators for quality such as satisfaction, positive experiences, overall effectiveness and perceived value were identified. Content analysis resulted in four overarching domains pertaining to features of rural health student placement quality: (1) learning and teaching in a rural context, (2) rural student placement characteristics, (3) key relationships and (4) required infrastructure. CONCLUSION: The findings suggest that quality in rural health student placements hinges on contextually specific features. Further research is required to explore these findings and ways in which these features can be measured during rural health student placements.

Knowledge, attitudes, and self-reported practices (KAP) towards hand hygiene in medical students versus the public.

BACKGROUND: The COVID-19 pandemic and its associated morbidity, mortality, and economic disruption has reignited interest in simple protective and preventive measures. AIMS: The aim of this study was to assess the knowledge, attitudes, and practices (KAP) of hand hygiene in a sample of medical students in Ireland and members of the public to evaluate these within the context of the COVID-19 pandemic. We also explored any differences between the two groups. METHODS: A 35-question survey was formulated and circulated to potential participants comprising Irish medical students and members of the public. The data was analysed using Microsoft Excel with P-values being calculated using chi-squared goodness-of-fit analysis. RESULTS: There were 356 responses to the survey, categorised into medical students and general public populations. Incomplete surveys were removed leaving 303 responses. There was no statistical difference between the groups for attitudes and self-reported practices towards hand hygiene. Statistical differences were found between the two groups in terms of knowledge. CONCLUSIONS: The study showed that medical students and the public had a good knowledge base and positive attitude in regards to hand hygiene. Both groups displayed consensus that the practices are essential, especially within the current pandemic context. However, larger studies, involving multiple universities and a larger portion of the public, may be useful to ascertain whether there is a true difference in the KAP between healthcare students and the general public.

OSCE rater cognition - an international multi-centre qualitative study.

INTRODUCTION: This study aimed to explore the decision-making processes of raters during objective structured clinical examinations (OSCEs), in particular to explore the tacit assumptions and beliefs of raters as well as rater idiosyncrasies. METHODS: Thinking aloud protocol interviews were used to gather data on the thoughts of examiners during their decision-making, while watching trigger OSCE videos and rating candidates. A purposeful recruiting strategy was taken, with a view to interviewing both examiners with many years of experience (greater than six years) and those with less experience examining at final medical examination level. RESULTS: Thirty-one interviews were conducted in three centres in three different countries. Three themes were identified during data analysis, entitled 'OSCEs are inauthentic', 'looking for glimpses of truth' and 'evolution with experience'. CONCLUSION: Raters perceive that the shortcomings of OSCEs can have unwanted effects on student behaviour. Some examiners, more likely the more experienced group, may deviate from an organisations directions due to perceived shortcomings of the assessment. No method of assessment is without flaw, and it is important to be aware of the limitations and shortcomings of assessment methods on student performance and examiner perception. Further study of assessor and student perception of OSCE performance would be helpful.

Symbiotic relationships through longitudinal integrated clerkships in general practice.

BACKGROUND: Longitudinal integrated clerkships (LICs) are an innovation in medical education that are often successfully implemented in general practice contexts. The aim of this study was to explore the experiences and perspectives of general practitioner (GP)-tutors on the impact of LICs on their practices, patients and the wider community. METHODS: GPs affiliated with the University of Limerick School of Medicine- LIC were invited to participate in in-depth interviews. Semi-structured interviews were conducted in person and over the phone and were based on a topic guide. The guide and approach to analysis were informed by symbiosis in medical education as a conceptual lens. Data were recorded, transcribed and analysed using an inductive thematic approach. RESULTS: Twenty-two GPs participated. Two main themes were identified from interviews: 'roles and relationships' and 'patient-centred physicians'. Five subthemes were identified which were: 'GP-role model', 'community of learning', and 'mentorship', 'student doctors' and 'serving the community'. CONCLUSION: LICs have the potential to develop more patient-centred future doctors, who have a greater understanding of how medicine is practised in the community. The LIC model appears to have a positive impact on all stakeholders but their success hinges on having adequate support for GPs and resourcing for the practices.

Development and sustainment of professional relationships within longitudinal integrated clerkships in general practice (LICs): a narrative review.

BACKGROUND: Longitudinal integrated clerkships (LICs) are a relatively new model of clinical medical education, whereby students participate in patient care over time and develop relationships with those patients', their clinicians, and other health care staff involved in the care of those patients. It has been called 'relationship-based education' but, to date, no review has investigated the development and impact of these central relationships within this curricula model. AIMS: The aim of this study is to review the literature pertaining to relationships in LICs, specifically to understand how they come about and how they affect learning. METHODS: The search strategy systematically explored PubMed, ERIC (EBSCO) and Academic Search Complete, using key words and MESH terms. Original research published in peer-reviewed journals between January 2007 and August 2020 that were written in the English language were included in the review. RESULTS: After applying set inclusion and exclusion criteria, 43 studies were included in this review. A qualitative thematic analysis was undertaken, and results were synthesised narratively. Four distinct categories were identified: defining relationships in LICs, developing relationships in LICs, relationship maintenance and multi-stakeholder impact. CONCLUSIONS: The longitudinal integrated clerkship model of clinical education facilitates the development of meaningful triangular relationships between student, clinical teacher and patient, which are the central drivers of successful learning within the context of an LIC. These relationships are nested in a set of important supporting relationships involving other supervisors, the medical school and university, the practice clinical and administrative team and peers.

Mapping health, social and health system issues and applying a social accountability inventory to a problem based learning medical curriculum.

Social accountability is a powerful concept. It is applied to medical education to encourage future doctors to take action to address health inequalities and overlooked health needs of disadvantaged populations. Problem-based learning (PBL) provides an ideal setting to teach medical students about these topics. The objective of this study is to explore how well the components of social accountability are covered in a pre-clinical PBL medical curriculum and to determine the usefulness of an adapted validated social accountability framework. We identified Irish health needs and social issues through a literature review. The retrieved documents were aligned to four values (relevance, equity, cost-effectiveness and quality) from a validated social accountability inventory, to generate a map of social accountability values present in the Irish health system and population. We then used the adapted validated social accountability inventory to evaluate the content of the PBL medical curriculum at an Irish medical school. We identified 45 documents, which upon analysis lead to the identification of health and social issues related to social accountability. 66 pre-clinical PBL cases included demographic, health and psychosocial issues similar to the local population. Analysing along the four social accountability values, the PBL cases demonstrated room for improvement in the equity and relevance domains. Topics for expansion are Traveller health, LGBTI health, alcohol use, climate change and more. Medical educators can use the paper as an example of how to apply this methodology to evaluate PBL cases. Adapting and applying a validated framework is a useful pedagogical exercise to understand established societal values related to social accountability to inform a medical curriculum. We identified opportunities to improve the PBL cases to depict emerging global and social issues.

Reducing postoperative opioid pill prescribing via a quality improvement approach.

BACKGROUND: The opioid epidemic has been fueled by prescribing unnecessary quantities of opioid pills for postoperative use. While evidence mounts that postoperative opioids can be reduced or eliminated, implementing such changes within various institutions can be met with many barriers to adoption. OBJECTIVE: To address excess opioid prescribing within our institutions, we applied a plan-do-study-act (PDSA)-like quality improvement strategy to assess local opioid prescribing and use, modify our institutional protocols, and assess the impacts of the change. The opioid epidemic has been fueled by prescribing unnecessary quantities of opioid pills for postoperative use. While evidence mounts that postoperative opioids can be reduced or eliminated, implementing such changes within various institutions can be met with many barriers to adoption. We describe our approach, findings, and lessons learned from our quality improvement approach. METHODS: We prospectively recorded home pain pill usage after robotic-assisted laparoscopic prostatectomy (RALP) and robotic-assisted partial nephrectomy (RAPN) at two academic institutions from July 2016 to July 2019. Patients prospectively recorded their home pain pill use on a take-home log. Other factors, including numeric pain rating scale on the day of discharge, were extracted from patient records. We analyzed our data and modified opioid prescription protocols to meet the reported use data of 80% of patients. We continued collecting data after the protocol change. We also used our prospectively collected data to assess the accuracy of a retrospective phone survey designed to measure postdischarge opioid use. Our primary outcomes were the proportion of patients taking zero opioid pills postdischarge, median pills taken after discharge and the number of excess pills prescribed but not taken. We compared these outcomes before and after protocol change. RESULTS: A total of 266 patients (193 RALP, 73 RAPN) were included. Reducing the standard number of prescribed pills did not increase the percentage of patients taking zero pills postdischarge in either group (RALP: 47% vs. 41%; RAPN 48% vs. 34%). The patients in either group reporting postoperative Day 1 pain score of 0 or 1 were much more likely to use zero postdischarge opioid pills. Our reduction in prescribing protocol resulted in an estimated reduction in excess pills from 1555 excess pills in the prior protocol to just 155 excess pills in the new protocol. CONCLUSION: Our PDSA-like approach led to an acceptable protocol revision resulting in significant reductions in excess pills released into the community. Reducing the quantity of opioids prescribed postoperatively does not increase the percentage of patients taking zero pills postdischarge. To eliminate opioid use may require no-opioid pathways. Our approach can be used in implementing zero opioid discharge plans and can be applied to opioid reduction interventions at other institutions where barriers to reduced prescribing exist.

'Re-placing' professional practice.

While preparation for professional practice is conceived as placeless, it is enacted in place. Consequently, many professionals find themselves working in conditions significantly different than those they were educated in and for. This is especially relevant for new professionals arriving in rural settings after preparation in urban programs, where metrocentric models of orientation to practice are implicitly privileged. The consequent dis-join between practice and place often results in new professionals feeling 'out of place' and questioning their professional competence. It also results in settings outside the metrocentric norm being viewed as less desirable practice contexts. Negative desirability hinders professional recruitment, while feeling out of place and incompetent hinders professional retention; both are longstanding issues in rural communities. Recent developments in professional education and practice standards emphasise adaptability to practise in specific contexts. However, 'context,' a primary focus to date for rural preparation is presented as a largely static backdrop that needs to be accommodated to engage in the 'real practice' one was trained for. Drawing on the spatial turn in social theory, we argue that place both shapes and is shaped by professionals and their practices and as such, must be engaged with deeply and dynamically. This conceptualisation of the relationship between place and practice has critical implications for professional preparation. As interdisciplinary practitioners and researchers working in diverse contexts, we examine 'place' from a social constructivist perspective as a focal point for professional preparation.

Co-designing community-focused rural placements for collaborative practice.

AIMS AND CONTEXT: As a University Department of Rural Health, we have identified recurrent areas of service need among vulnerable rural populations, specifically the need for allied health. Concurrently, we have also identified missed opportunities for deliberate collaborative practice in rural clinical placements. This paper provides a commentary on our work in progress as we work to leverage available opportunities to provide both service from and education for health profession students on rural clinical placements. APPROACH: We developed a transdisciplinary placement model, informed by practice theory, which encompasses pre-placement preparation, student support, host sites and clinicians, and a structured evaluation strategy. This model aims to facilitate service provision alongside of student learning about community and collaborative practice. In particular, the co-design of the model is expected to facilitate student's sense of social accountability and reduce stigma in working with vulnerable population groups. CONCLUSION: This paper highlights the need for greater alignment between rural health education and practice, describes a placement model that is working towards this and showcases how this has been enacted in a remote community in New South Wales. More cross-sector discussion and evaluation is needed to determine the implications of adopting this model more widely if service and learning opportunities are to be equally achieved, and to determine the ways in which training and service provision can be aligned with community need, as recommended in the recent Rural Health Commissioner Report.

Medical school clinical placements - the optimal method for assessing the clinical educational environment from a graduate entry perspective.

BACKGROUND: Educational environment is a strong determinant of student satisfaction and achievement. The learning environments of medical students on clinical placements are busy workplaces, composed of many variables. There is no universally accepted method of evaluating the clinical learning environment, nor is there consensus on what concepts or aspects should be measured. The aims of this study were to compare the Dundee ready educational environment measure (DREEM - the current de facto standard) and the more recently developed Manchester clinical placement index (MCPI) for the assessment of the clinical learning environment in a graduate entry medical student cohort by correlating the scores of each and analysing free text comments. This study also explored student perceptionof how the clinical educational environment is assessed. METHODS: An online, anonymous survey comprising of both the DREEM and MCPI instruments was delivered to students on clinical placement in a graduate entry medical school. Additional questions explored students' perceptions of instruments for giving feedback. Numeric variables (DREEM score, MCPI score, ratings) were tested for normality and summarised. Pearson's correlation coefficient was used to measure the strength of the association between total DREEM score and total MCPI scores. Thematic analysis was used to analyse the free text comments. RESULTS: The overall response rate to the questionnaire was 67% (n = 180), with a completed response rate for the MCPI of 60% (n = 161) and for the DREEM of 58% (n = 154). There was a strong, positive correlation between total DREEM and MCPI scores (r = 0.71, p < 0.001). On a scale of 0 to 7, the mean rating for how worthwhile students found completing the DREEM was 3.27 (SD 1.41) and for the MCPI was 3.49 (SD 1.57). 'Finding balance' and 'learning at work' were among the themes to emerge from analysis of free text comments. CONCLUSIONS: The present study confirms that DREEM and MCPI total scores are strongly correlated. Graduate entry students tended to favour this method of evaluation over the DREEM with the MCPI prompting rich description of the clinical learning environment. Further study is warranted to determine if this finding is transferable to all clinical medical student cohorts.

Undergraduate medical students' empathy: current perspectives.

Empathy is important to patient care. It enhances patients' satisfaction, comfort, self-efficacy, and trust which in turn may facilitate better diagnosis, shared decision making, and therapy adherence. Empathetic doctors experience greater job satisfaction and psychological well-being. Understanding the development of empathy of tomorrow's health care professionals is important. However, clinical empathy is poorly defined and difficult to measure, while ways to enhance it remain unclear. This review examines empathy among undergraduate medical students, focusing upon three main questions: How is empathy measured? This section discusses the problems of assessing empathy and outlines the utility of the Jefferson Scale of Empathy - Student Version and Davis's Interpersonal Reactivity Index. Both have been used widely to assess medical students' empathy. Does empathy change during undergraduate medical education? The trajectory of empathy during undergraduate medical education has been and continues to be debated. Potential reasons for contrasting results of studies are outlined. What factors may influence the development of empathy? Although the influence of sex is widely recognized, the impact of culture, psychological well-being, and aspects of undergraduate curricula are less well understood. This review identifies three interrelated issues for future research into undergraduate medical students' empathy. First, the need for greater clarity of definition, recognizing that empathy is multidimensional. Second, the need to develop meaningful ways of measuring empathy which include its component dimensions and which are relevant to patients' experiences. Medical education research has generally relied upon single, self-report instruments, which have utility across large populations but are limited. Finally, there is a need for greater methodological rigor in investigating the possible determinants of clinical empathy in medical education. Greater specificity of context and the incorporation of work from other disciplines may facilitate this.

Empathy among undergraduate medical students: A multi-centre cross-sectional comparison of students beginning and approaching the end of their course.

BACKGROUND: Although a core element in patient care the trajectory of empathy during undergraduate medical education remains unclear. Empathy is generally regarded as comprising an affective capacity: the ability to be sensitive to and concerned for, another and a cognitive capacity: the ability to understand and appreciate the other person's perspective. The authors investigated whether final year undergraduate students recorded lower levels of empathy than their first year counterparts, and whether male and female students differed in this respect. METHODS: Between September 2013 and June 2014 an online questionnaire survey was administered to 15 UK, and 2 international medical schools. Participating schools provided both 5-6 year standard courses and 4 year accelerated graduate entry courses. The survey incorporated the Jefferson Scale of Empathy-Student Version (JSE-S) and Davis's Interpersonal Reactivity Index (IRI), both widely used to measure medical student empathy. Participation was voluntary. Chi squared tests were used to test for differences in biographical characteristics of student groups. Multiple linear regression analyses, in which predictor variables were year of course (first/final); sex; type of course and broad socio-economic group were used to compare empathy scores. RESULTS: Five medical schools (4 in the UK, 1 in New Zealand) achieved average response rates of 55 % (n = 652) among students starting their course and 48 % (n = 487) among final year students. These schools formed the High Response Rate Group. The remaining 12 medical schools recorded lower response rates of 24.0 % and 15.2 % among first and final year students respectively. These schools formed the Lower Response Rate Group. For both male and female students in both groups of schools no significant differences in any empathy scores were found between students starting and approaching the end of their course. Gender was found to significantly predict empathy scores, with females scoring higher than males. CONCLUSIONS: Participant male and female medical students approaching the end of their undergraduate education, did not record lower levels of empathy, compared to those at the beginning of their course. Questions remain concerning the trajectory of empathy after qualification and how best to support it through the pressures of starting out in medical practice.

Leadership and management in the undergraduate medical curriculum: a qualitative study of students' attitudes and opinions at one UK medical school.

OBJECTIVE: To explore undergraduate medical students' attitudes towards and opinions about leadership and management education. DESIGN: Between 2009 and 2012 we conducted a qualitative study comprising five focus group discussions, each devoted to one of the five domains in the Medical Leadership Competency Framework, (Personal Qualities, Working with Others, Managing Services, Improving Services and Setting Direction). Each discussion examined what should be learnt, when should learning occur, what methods should be used, how should learning be assessed, what are the barriers to such education. PARTICIPANTS: 28 students from all three clinical years (4-6) of whom 10 were women. RESULTS: 2 inter-related themes emerged: understanding the broad perspective of patients and other stakeholders involved in healthcare provision and the need to make leadership and management education relevant in the clinical context. Topics suggested by students included structure of the National Health Service (NHS), team working skills, decision-making and negotiating skills. Patient safety was seen as particularly important. Students preferred experiential learning, with placements seen as providing teaching opportunities. Structured observation, reflection, critical appraisal and analysis of mistakes at all levels were mentioned as existing opportunities for integrating leadership and management education. Students' views about assessment and timing of such education were mixed. Student feedback figured prominently as a method of delivery and a means of assessment, while attitudes of medical professionals, students and of society in general were seen as barriers. CONCLUSIONS: Medical students may be more open to leadership and management education than thought hitherto. These findings offer insights into how students view possible developments in leadership and management education and stress the importance of developing broad perspectives and clinical relevance in this context.