Reframing pain: the power of individual and societal factors to enhance pain treatment.

The effectiveness of analgesics can be increased if synergistic behavioural, psychological, and pharmacological interventions are provided within a supportive environment.

Educational impact of COVID-19 on foundation doctors and the decision to take a break from structured approved training programmes in the United Kingdom.

INTRODUCTION: The COVID-19 pandemic impacted the Foundation Programme for doctors in the United Kingdom. Foundation doctors were working under increased pressure and significant changes were made to their training. AIMS: The aim of this study is to explore the educational impact the COVID-19 pandemic had on foundation doctors and to understand how this resulted in doctors choosing to take time away from structured training programmes within the United Kingdom to make up for lost educational opportunities. METHODS: In this phenomenological research, semi-structured interviews were carried out with post-foundation doctors who had completed their training during the pandemic. The data collected from these interviews were coded to carry out a thematic analysis. RESULTS: All 12 participants reported that their formalised teaching had been cancelled, and due to the pandemic, many doctors felt that service provision was prioritised over their postgraduate education. Some doctors had positive experiences of informal teaching; however, many felt they missed out on educational opportunities. Doctors acknowledged that this was a contributing factor when deciding to take time out of training. This also resulted in doctors seeking educational opportunities outside of training. DISCUSSION: The pandemic created many educational challenges for foundation doctors; this has contributed to doctors deciding to take time away from training. In some cases, due to a focus on service provision and their 'lost education', doctors are using time away from training to address their own specific educational needs. The impact of this 'lost education' requires further research and needs to be considered when doctors do apply to speciality training.

The interprofessional education of medical students and physician associate students during the COVID-19 pandemic.

Background: Due to the potential for improved team working and patient care, interprofessional education (IPE) is increasingly recognized as a core competency within the education of health-care professionals. Methods: In response to cancellation of the physician associate (PA) acute medicine clinical placement at our institution following COVID-19, a technology-focused, case-based IPE course between medical and PA students was implemented. The course consisted of 6 weekly seminars involving an average of 16 PA students, two medical students, and two supervising general practitioners. Course evaluation was mixed methods, comprising pre/postcourse questionnaires, weekly feedback forms, and postcourse e-mail interviews. Results: The course improved the confidence and perceived knowledge base of all participating students across every clinical topic covered, while promoting interprofessional collaboration and understanding. Discussion: To our knowledge, this represents one of the first IPE courses implemented between medical and PA students alone and has highlighted the need for further IPE courses between both professions. We show that successful IPE is feasible during a global pandemic, and that initiatives relying on technology alone are successful. Weekly written feedback was overwhelmingly positive, and based on the success of this course, faculty have planned further IPE opportunities between both professions.

Ibuprofen, other NSAIDs and COVID-19: a narrative review.

At the start of the coronavirus disease 2019 (COVID-19) pandemic (March 2020), there was speculation that non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, used to manage some of the symptoms of COVID-19, could increase the susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and negatively impact clinical outcomes. In the absence of any robust mechanistic and clinical evidence, this speculation led to confusion about the safety of ibuprofen, contributing to the so-called 'infodemic' surrounding COVID-19. A wealth of evidence has been generated in subsequent years, and this narrative review aims to consider the body of in vitro and in vivo research, observational studies, systematic reviews and meta-analyses on the use of NSAIDs, including ibuprofen, in COVID-19. Overall, the direction of evidence supports that NSAIDs do not increase susceptibility to infection, nor worsen disease outcomes in patients with COVID-19. Neither do they impact the immune response to COVID-19 vaccines. There is no basis to limit the use of NSAIDs, and doing so may deprive patients of effective self-care measures to control symptoms.

Can stoic training develop medical student empathy and resilience? A mixed-methods study.

BACKGROUND: Empathic erosion and burnout represent crises within medicine. Psychological training has been used to promote empathy and personal resilience, yet some training useful within adjacent fields remain unexplored, e.g., Stoic training. Given recent research within psychology suggesting that Stoic training increases emotional wellbeing, exploring this type of training within health professions education is important. We therefore asked: What impact would a Stoicism informed online training package have on third year medical students' resilience and empathy? METHODS: 24 third year medical students took part in 12 days of online training (SeRenE), based on Stoic philosophy, and co-developed with psychotherapists. A mixed-methods study was conducted to evaluate impact. Pre- and post-SeRenE students completed the Stoic Attitudes and Behaviours Scale (SABS), Brief Resilience Scale (BRS) and Jefferson Scale of Empathy (JSE). All students completed semi-structured interviews following training and 2 months post-SeRenE. Thematic analysis was employed to analyse qualitative data, whilst within subjects t-tests and correlational analyses were conducted on quantitative data. RESULTS: Quantitatively, stoic ideation, resilience and empathy increased post-training, with correlational analyses suggesting resilience and empathy increase in tandem. Qualitatively, four themes were identified: 1. Negative visualisation aids emotional and practical preparedness; 2. Stoic mindfulness encourages students to think about how they think and feel; 3. Stoic reflection develops the empathic imagination; and 4. Evaluating the accessibility of SeRenE. CONCLUSIONS: Our data lend support to the ability of Stoic-based psychological training to positively influence resilience and empathy. Although, quantitatively, results were mixed, qualitative data offers rich insight. The practice of negative visualisation, promoted by SeRenE, encourages student self-efficacy and planning, domains of resilience associated with academic success. Further, this study demonstrates a connection between Stoic practice and empathy, which manifests through development of the empathic imagination and a sense of empathic bravery.

Ibuprofen, Flurbiprofen, Etoricoxib or Paracetamol Do Not Influence ACE2 Expression and Activity In Vitro or in Mice and Do Not Exacerbate In-Vitro SARS-CoV-2 Infection.

SARS-CoV-2 uses the human cell surface protein angiotensin converting enzyme 2 (ACE2) as the receptor by which it gains access into lung and other tissue. Early in the pandemic, there was speculation that a number of commonly used medications-including ibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs)-have the potential to upregulate ACE2, thereby possibly facilitating viral entry and increasing the severity of COVID-19. We investigated the influence of the NSAIDS with a range of cyclooxygenase (COX)1 and COX2 selectivity (ibuprofen, flurbiprofen, etoricoxib) and paracetamol on the level of ACE2 mRNA/protein expression and activity as well as their influence on SARS-CoV-2 infection levels in a Caco-2 cell model. We also analysed the ACE2 mRNA/protein levels and activity in lung, heart and aorta in ibuprofen treated mice. The drugs had no effect on ACE2 mRNA/protein expression and activity in the Caco-2 cell model. There was no up-regulation of ACE2 mRNA/protein expression and activity in lung, heart and aorta tissue in ibuprofen-treated mice in comparison to untreated mice. Viral load was significantly reduced by both flurbiprofen and ibuprofen at high concentrations. Ibuprofen, flurbiprofen, etoricoxib and paracetamol demonstrated no effects on ACE2 expression or activity in vitro or in vivo. Higher concentrations of ibuprofen and flurbiprofen reduced SARS-CoV-2 replication in vitro.

Empathy in Medical Education: Its Nature and Nurture - a Qualitative Study of the Views of Students and Tutors.

Context: Medical education is committed to teaching patient centred communication and empathy. However, quantitative research suggests empathy scores tend to decline as students progress through medical school. In qualitative terms, there is a need to better understand how students and tutors view the practice and teaching of clinical empathy and the phenomenon of empathic erosion. Methods: Working within a constructivist paradigm, researchers thematically analysed the individual interview data from a purposive sample of 13 senior students and 9 tutors. Results: The four major themes were as follows: (1) 'the nature of empathy', including the concept of the innate empathy that students already possess at the beginning of medical school; (2) 'beyond the formal curriculum' and the central importance of role modelling; (3) 'the formal curriculum and the tick-box influence of assessments'; and (4) the 'durability of empathy', including ethical erosion and resilience. A garden model of empathy development is proposed - beginning with the innate seeds of empathy that students bring to medical school, the flowering of empathy is a fragile process, subject to both enablers and barriers in the formal, informal, and hidden curricula. Conclusion: This study provides insights into empathic erosion in medical school, including the problems of negative role modelling and the limitations of an assessment system that rewards 'tick-box' representations of empathy, rather than true acts of compassion. It also identifies factors that should enable the flowering of empathy, such as new pedagogical approaches to resilience and a role for the arts and humanities.

Love and breakup letter methodology: A new research technique for medical education.

In everyday life, feelings are important to us, influencing our decision-making and motivating our actions. This is equally true within medicine and medical education, where feelings influence key aspects such as clinical decision-making, empathy, resilience, professional identity, reflection, team dynamics, career choices and questions of prejudice and bias. Feelings are therefore legitimate targets in medical education research, but asking research participants to talk openly about feelings can be challenging for participants and researchers alike. Within the disciple of User Experience (UX)-a relatively new research discipline used in the world of technology-researchers also seek to understand their customer's feelings, which are central to aspects of brand loyalty and choice of software platforms. UX researchers have developed innovative ways to explore feelings, in particular through the use of Love and Breakup Methodology (LBM)-participants are asked to write love and breakup letters to the product or app under study, and the letters are then used to guide the focus group discussion that follows. Methods: In this article, we describe the theoretical underpinnings of LBM, including ontological considerations. We also consider how LBM can be successfully used in medical education research and outline how we have adapted it in our own research studies and programme evaluations. Conclusions: Love and breakup letters are creative ways of understanding participants' positive and negative emotions about the matter under study. LBM has been utilised extensively by UX researchers in technology, but has been little used in medical education. It has rich potential to enhance research approaches to aspects of medicine that are influenced by feelings, including empathy and resilience, team working and many other aspects of professional practice. Although principally a focus group research tool, it can be adapted to other approaches, including questionnaire surveys and individual interviews.

Holding a mirror up to nature: the role of medical humanities in postgraduate primary care training.

The humanities are academic disciplines that study aspects of human society, experience and culture. Typically, the humanities, including philosophy, literature, art, music, history and language have been used to interpret and record our understanding of the world. In recent decades, the humanities have seen somewhat of a renaissance within medicine, particularly within undergraduate medical education. This leading article explores the value of utilising medical humanities, such as art, poetry and theatre, within postgraduate primary care training. Using examples of approaches already interwoven into the fabric of undergraduate medical education, such as simulated patient consultations and anatomical body painting, the tangible benefits of applying humanities disciplines within general practice training are discussed. The humanities have much to offer from the value of utilising an artistic lens to examine the body, the creation of socially cohesive working environments and supporting the development of empathy within trainees. This article recommends the provision of both increased informal and formal engagement with the medical humanities within postgraduate primary care training, providing practical tips for GP educators looking to integrate the humanities within pre-existing tutorials.

Teaching Professionalism to Medical Students Using Dissection-Based Anatomy Education: a Practical Guide.

Professionalism is a core competency for all healthcare professionals and is a subject of great interest within the academic community due to its vital importance in delivering the highest quality patient care. Despite this, professionalism remains difficult to define, teach and assess. The potential use of anatomy education in teaching professionalism has been increasingly highlighted within the literature, but still remains an underutilised tool in medical education. Therefore, this practical guide offers evidence-based practical points for successfully incorporating professionalism within a dissection-based anatomy course delivered to undergraduate medical students.

How medical school alters empathy: Student love and break up letters to empathy for patients.

INTRODUCTION: Medical education is committed to promoting empathic communication. Despite this, much research indicates that empathy actually decreases as students progress through medical school. In qualitative terms, relatively little is known about this changing student relationship with the concept of empathy for patients and how teaching affects it. This study explores that knowledge gap. METHODS: Adopting a constructivist paradigm, we utilised a research approach new to medical education: Love and Breakup Letter Methodology. A purposive sample of 20 medical students were asked to write love and break up letters to 'empathy for patients'. The letters were prompts for the focus group discussions that followed. Forty letters and three focus group discussions were thematically analysed. RESULTS: The three major themes were: art and artifice; empathic burden; and empathy as a virtue. Students were uncomfortable with the common practice of faking empathic statements, a problem exacerbated by the need to 'tick the empathy box' during examinations. Students evolved their own empathic style, progressing from rote empathic statements towards phrases which suited their individual communication practice. They also learned non-verbal empathy from positive clinician role-modelling. Students reported considerable empathic burden. Significant barriers to empathy were reported within the hidden curriculum, including negative role-modelling that socialises students into having less compassion for difficult patients. Students strongly associated empathy with virtue. CONCLUSIONS: Medical education should address the problem of inauthentic empathy, including faking empathic s in assessments. Educators should remember the value of non-verbal compassionate communication. The problems of empathic burden, negative role modelling and of finding empathy difficult for challenging patients may account for some of the empathy decline reported in quantitative research. Framing empathy as a virtue may help students utilise empathy more readily when faced with patients they perceive as challenging and may promote a more authentic empathic practice.

Physician Associate students and primary care paradigmatic trajectories: perceptions, positioning and the process of pursuit.

As the role of the Physician Associate (PA) establishes within the UK, there is increasing interest in the recruitment of PAs to primary care. Yet, currently 72% of all UK PAs work in secondary care. Recruitment to primary care is wanting, for reasons that remain unclear. This work sought to investigate student PA experiences in primary care and their attitudes to primary care as a career choice. A multi-site, qualitative study involving one-to-one semi-structured interviews with 19 student PAs was conducted. Data were thematically analysed, in line with an interpretivist approach and informed by communities of practice and paradigmatic trajectory theory - 'visible career paths provided by a community'. Factors were identified enabling student PA engagement with primary care paradigmatic trajectories including engaging students with a degree of responsibility in service provision. Barriers to engagement included ignorance regarding the PA role, and reverence of medical students as a 'gold standard'. A conceptual model is proposed detailing the student process of engagement with primary care trajectories, encapsulating how this process influences emerging career identity. This model could be used to optimise student PA engagement in learning about, and coming to identify with, primary care careers.

'I'm sorry to hear that'-Empathy and Empathic Dissonance: the Perspectives of PA Students.

CONTEXT: Our understanding of clinical empathy could be enhanced through qualitative research-research currently under-represented in the field. Physician associates within the UK undergo an intensive 2-year postgraduate medical education. As a new group of health professionals, they represent a fresh pair of eyes through which to examine clinical empathy, its nature and teaching. METHODS: Working with a constructivist paradigm, utilising grounded theory methodology, researchers studied 19 purposively sampled physician associate students in two UK medical schools. One-to-one semi-structured interviews were transcribed verbatim. Data were analysed using a grounded theory approach. RESULTS: The global themes were the pathways to empathy, empathy modifiers and empathic dissonance a novel term to describe the discomfort students experience when pressurised into making empathic statements they don't sincerely feel. Students preferred using non-verbal over verbal expressions of empathy. A conceptual model is proposed. The more substantial empathic pathway, affective empathy, involves input from the heart. An alternative empathy, more constrained, comes from the head: cognitive empathy was considered a solution to time pressure and emotional burden. Formal teaching establishes empathic dissonance, a problem which stems from over-reliance on the empathic statement as the means to deliver clinical empathy. CONCLUSIONS: This study furthers our understanding of the construct and teaching of empathy. It identifies empathic barriers, especially time pressure. It proposes a novel concept-empathic dissonance-a concept that challenges medical educationalists to reframe future empathy teaching.

Forging a new identity: a qualitative study exploring the experiences of UK-based physician associate students.

OBJECTIVE: To explore student physician associates' (PAs) experiences of clinical training to ascertain the process of their occupational identity formation. SETTING: The role of the PA is relatively new within the UK. There has been a rapid expansion in training places driven by National Health Service (NHS) workforce shortages, with the Department of Health recently announcing plans for the General Medical Council to statutorily regulate PAs. Given such recent changes and the relative newness of their role, PAs are currently establishing their occupational identity. Within adjacent fields, robust identity development improves well-being and career success. Thus, there are implications for recruitment, retention and workplace performance. This qualitative study analyses the views of student PAs to ascertain the process of PA occupational identity formation through the use of one-to-one semistructured interviews. A constructivist grounded theory approach to data analysis was taken. Research was informed by communities of practice and socialisation theory. PARTICIPANTS: A theoretical sample of 19 PA students from two UK medical schools offering postgraduate PA studies courses. RESULTS: A conceptual model detailing student PA identity formation is proposed. Factors facilitating identity formation include clinical exposure and continuity. Barriers to identity formation include ignorance and negativity regarding the PA role. Difficulties navigating identity formation and lacking support resulted in identity dissonance. CONCLUSIONS: Although similarities exist between PA and medical student identity formation, unique challenges exist for student PAs. These include navigating a new role and poor access to PA role models. Given this, PA students are turning to medicine for their identity. Educators must provide support for student PA identity development in line with this work's recommendations. Such support is likely to improve the job satisfaction and retention of PAs within the UK NHS.