Improving transitions between clinical placements.

BACKGROUND: Students regularly transition between clinical learning environments as they rotate through their clinical placements. These transitions are stressful for learners, as they must navigate unfamiliar policies, people and physical spaces. It is important to reduce cognitive overload at the start of each placement through appropriate inductions. Our governance processes found there was significant variation between induction processes at our affiliated teaching-hospital sites: our aim was to optimise and standardise these. APPROACH: We opted for induction websites for each of our affiliated hospital sites, as these could be dynamically updated and quality assured. Our websites were informed by a conceptual framework of the clinical learning environment and the theory of sociomateriality. We co-produced them with students and other stakeholders through iterative evaluation and improvement cycles. EVALUATION: To elicit end-user analysis, we conducted three focus groups with 19 students. We used the technology acceptance model to inform our topic guide and coding categories. Students reported that the websites were useful, easy to use, and fulfilled a significant unmet need. IMPLICATIONS: Induction websites can be optimised through the involvement of a range of stakeholders and the application of theory. They can be pushed to students before each new placement and used to scaffold in-person inductions. Further research is needed to explore the wider impacts of improved site inductions on participation and engagement with clinical learning opportunities and on student satisfaction and experience.

Factors underpinning an improved menopausal experience in the workplace for doctors: a UK-based qualitative study.

OBJECTIVES: A recent British Medical Association survey revealed that very few National Health Service (NHS) doctors felt comfortable discussing symptoms with their managers, and many feel unable to make changes to their working lives to accommodate their menopause. An improved menopausal experience (IME) in the workplace has been associated with increased job satisfaction, increased economic participation and reduced absenteeism. Currently, existing literature fails to explore menopausal doctors' experiences and none factors in non-menopausal colleagues' perspectives. This qualitative study aims to determine the factors underpinning an IME for UK doctors. DESIGN: Qualitative study using semistructured interviews and thematic analysis. PARTICIPANTS: Menopausal doctors (n=21) and non-menopausal (n=20) doctors including men. SETTING: General practices and hospitals in the UK. RESULTS: Four overarching themes underpinning an IME were identified: menopausal knowledge and awareness, openness to discussion, organisational culture, and supported personal autonomy. The levels of knowledge held by menopausal participants themselves, their colleagues and their superiors were identified as crucial in determining menopausal experiences. Likewise, the ability to openly discuss menopause was also identified as an important factor. The NHS culture, gender dynamics and an adopted superhero mentality-where doctors feel compelled to prioritise work over personal well-being-further impacted under the umbrella of Organisational culture. Personal autonomy at work was considered important in improving menopausal experiences at work for doctors. The superhero mentality, lack of organisational support and a lack of open discussion were identified as novel themes not found in current literature, particularly in the healthcare context. CONCLUSIONS: This study highlights that doctors' factors underpinning an IME in the workplace are comparable to other sectors. The potential benefits of an IME for doctors in the NHS are considerable. NHS leaders can address these challenges by using pre-existing training materials and resources for their employees if menopausal doctors are to feel supported and retained.

Partners in academic endeavour: Characterising student engagement across internationally excellent medical schools.

There is increasing interest in how student engagement can be enhanced in medical schools: not just engagement with learning but with broader academic practices such as curriculum development, research, organisational leadership, and community involvement. To foster evidence-based practice, it is important to understand how institutions from diverse sociocultural contexts achieve excellence in student engagement.We analysed 11 successful applications for an international award in student engagement and interviewed nine key informants from five medical schools across four continents, characterising how and why student engagement was fostered at these institutions.Document analysis revealed considerable consensus on the core practices of student engagement, as well as innovative and creative practices often in response to local strengths and challenges. The interviews uncovered the importance of an authentic partnership culture between students and faculty which sustained mutually beneficial enhancements across multiple domains. Faculty promoted, welcomed, and acted on student inputs, and students reported greater willingness to participate if they could see the benefits. These combined to create self-perpetuating virtuous cycles of academic endeavour. Successful strategies included having participatory values actively reinforced by senior leadership, engagement activities that are driven by both students and staff, and focusing on strategies with reciprocal benefits for all stakeholders.

"Concrete ways we can make a difference": A multi-centre, multi-professional evaluation of sustainability in quality improvement education.

Quality improvement (QI) projects are a mandatory part of postgraduate medical training in the UK and graduating medical students must be competent in QI theory. We evaluated an educational toolkit that links concepts of sustainable healthcare with established quality improvement methodologies (the SusQI approach, available at www.susqi.org). The SusQI approach was implemented across a range of undergraduate and postgraduate nursing and medical education contexts. Educational strategies included guided online learning, live interactive webinars, small group activities and scaffolded project work. The evaluation strategy was informed by theories of academic motivation, educational value within communities of practice and behaviour change. A simultaneous nested design was tested using a mixed methods survey with input from learners and teachers. 177 survey responses were analysed to quantify and compare self-rated impacts of teaching across different audiences. Qualitative data were inductively coded into themes that were categorised according to above theoretical frameworks. Participants felt that this was 'time well spent' and many described transformative impacts that guided their daily professional practice beyond learning about QI. We suggest that meaningful space is found within both undergraduate and postgraduate healthcare curricula for SusQI, as a way of engaging and motivating learners to contribute to the creation of a sustainable healthcare system.

"More than just a medical student": a mixed methods exploration of a structured volunteering programme for undergraduate medical students.

BACKGROUND: As a result of the COVID-19 pandemic Imperial College School of Medicine developed a structured volunteering programme involving 398 medical students, across eight teaching hospitals. This case study aims to explore the relationship between the processes, context, participant experiences and impacts of the programme so that lessons can be learned for future emergencies and service-learning programmes. METHODS: Using an illuminative approach to evaluation we invited all volunteers and supervisors to complete a mixed-methods survey. This explored differences in experience across demographics and contextual factors, correlations between aspects of induction, supervision and overall experience, and reviewed the impacts of the programme. Quantitative responses were statistically analysed and qualitative reflections were thematically coded to triangulate and explain quantitative findings. Follow up interviews were carried out to check back findings and co-create conclusions. RESULTS: We received responses from 61 students and 17 supervisors. Student participants described predominantly altruistic motivations and transformational changes to their professional identity driven by feeling included, having responsibility, and engaging in authentic workplace-based learning afforded by freedom from the assessed curriculum. They reported new perspectives on their future professional role within the multidisciplinary team and the value of workplace-based learning. They reported increases in wellbeing and self-esteem related to feeling included and valued, and positively contributing to service provision at a time of need. Significantly higher overall satisfaction was associated with a personalised induction, active supervision, earlier stage of training, and male gender. Gender-related differences were not explained through our data but have been reported elsewhere and warrant further study. The duration, intensity and type of role that volunteers performed was similar across demographics and did not appear to modulate their overall experience. CONCLUSIONS: Whilst acknowledging the uniqueness of emergency volunteering and the survey response rate of 15% of volunteers, we suggest the features of a successful service-learning programme include: a learner-centred induction, regular contact with engaged and appreciative supervisors, and roles where students feel valued. Programmes in similar settings may find that service learning is most impactful earlier in medical students' training and that students with altruistic motivations and meaningful work may flourish without formal outcomes and assessments.

Twelve tips for surgeons to maximise medical student learning in the operating theatre.

Theatre-based learning is an essential component of undergraduate surgical education and offers a wide range of learning opportunities. However, studies have demonstrated that medical students have not always benefited from this holistic learning environment due to many reasons, including intimidation, hierarchies within the surgical environment and fear of making mistakes. The lead surgical educator's approach is an important influence on the experience and learning of their medical students. These twelve tips are aimed at surgical educators with undergraduate teaching responsibilities. This guidance is based upon evidence from literature and established theories of teaching and learning, supplemented by qualitative interviews with surgeons and medical students. The resulting tips were checked and refined by surgical teaching fellows. These learner-centred tips provide guidance on thorough induction, managing mutual expectations and approaches that optimise teaching and learning in the operating theatre. They are designed to support surgical educators in improving their students' engagement and learning experiences in this setting.

An outbreak of appreciation: A discursive analysis of tweets of gratitude expressed to the National Health Service at the outset of the COVID-19 pandemic.

BACKGROUND: The early stages of the coronavirus disease 2019 pandemic prompted unprecedented displays of gratitude to healthcare workers. In the United Kingdom, gratitude was a hotly debated topic in public discourse, catalysing compelling displays of civic togetherness but also attracting criticism for being an unhelpful distraction that authorized unrealistic expectations of healthcare workers. Expressions of thanks tend to be neglected as drivers of transformation, and yet, they are important indicators of qualities to which people attach significance. OBJECTIVE: This study aimed to use discursive analysis to explore how the National Health Service (NHS) was constructed in attention-attracting tweets that expressed and/or discussed gratitude to the NHS. METHODS: Having determined that Twitter was the most active site for traffic relating to gratitude and the NHS, we established a corpus of 834 most-liked tweets, purposively sampled from Twitter searches on a day-by-day basis over the period of the first lockdown in the United Kingdom (22 March-28 May 2020). We developed a typology for tweets engaging with gratitude as well as analysing what the NHS was thanked for. RESULTS: Our analysis, informed by a discursive psychology approach, found that the meanings attributed to gratitude were highly mobile and there were distinct patterns of activity. The NHS was predominantly-and sometimes idealistically-thanked for working, effort, saving and caring. Displays of gratitude were seen as incommensurable with failures of responsibility. The clap-for-carers campaign was a potent driver of affect, especially in the early parts of the lockdown. CONCLUSIONS: The social value of gratitude is implicated in the re-evaluation of the risks and rewards of healthcare and social care work in the wake of the pandemic. We caution against cynicism about gratitude overshadowing the well-being effects that expressing and receiving gratitude can engender, particularly given concerns over the detrimental effects of the pandemic on mental health. PUBLIC CONTRIBUTION: This study involves the analysis of data provided by the public and published on social media.

Sustainability in Quality Improvement (SusQI): challenges and strategies for translating undergraduate learning into clinical practice.

BACKGROUND: The healthcare sector is a major contributor to climate change and there are international calls to mitigate environmental degradation through more sustainable forms of clinical care. The UK healthcare sector has committed to net zero carbon by 2040 and sustainable healthcare is a nationally mandated outcome for all UK graduating doctors who must demonstrate their ability to address social, economic, and environmental challenges. Bristol Medical School piloted successful Sustainability in Quality Improvement (SusQI) workshop, but identified challenges translating classroom learning into clinical practice. This paper aims to identify and address those challenges. METHODS: We conducted five focus groups that identified and iteratively explored barriers and facilitators to practice among medical students, comparing a range of experiences to generate a conceptual model. We then combined our findings with behaviour change theory to generate educational recommendations. RESULTS: Students that applied their learning to the clinical workplace were internally motivated and self-determined but needed time and opportunity to complete projects. Other students were cautious of disrupting established hierarchies and practices or frustrated by institutional inertia. These barriers impacted on their confidence in suggesting or achieving change. A minority saw sustainable healthcare as beyond their professional role. CONCLUSIONS: We present a series of theoretically informed recommendations. These include wider curricular engagement with concepts of sustainable clinical practice; supportive workplace enablement strategies such as workplace champions and co-creation of improvement goals; and time and headspace for students to engage through structured opportunities for credit-bearing project work.

Perspectives of Clinical Teaching Fellows on preparedness for practice: a mixed-methods exploration of what needs to change.

Supporting medical students in their transition to newly qualified doctor is an important educational priority. Clinical Teaching Fellows (CTFs), as both recent graduates and trained educators, are uniquely positioned to suggest curricular enhancements to support preparedness for practice. Our mixed-methods approach involved CTFs across eight UK teaching hospitals. We conducted five activity-oriented focus groups to explore what CTFs felt needed to change to increase preparedness for practice. We analysed these focus groups to create a dataset of their suggestions followed by a survey. The survey invited CTFs to rate and rank these suggestions in relation to their own self-rated preparedness for practice, with qualitative insights into their choices. We explored commonalities and differences between high and low confidence participants, with findings qualitatively illuminated. 24 CTFs attended focus groups from which we identified 28 curriculum items and 10 curriculum agendas. We collected 23 complete survey responses. All confidence groups rated communicating with colleagues and managing working life as unmet needs, whereas core clinical competencies such as history and examination were well met. Participants with low confidence identified more complex clinical competencies including clinical decision making, task prioritisation and end-of-life care as unmet needs, with decision making and prioritisation being the most important. Confident graduates rated higher professional competencies such as quality improvement, career planning and education as unmet needs but of low importance. Graded transition of responsibility was the highest ranked curriculum agenda. Qualitative insights included suggestions for how learning in clinical environments could be enhanced. Our findings suggest that transitioning from student to newly qualified doctor could be supported by graded entrustment and enhanced shadowing opportunities. Other recommendations include prioritising more complex clinical competencies, identifying wellbeing as part of preparedness for practice, equipping students to communicate with colleagues and aligning higher professional competencies with learners' needs.

Sustainability in quality improvement (SusQI): a case-study in undergraduate medical education.

BACKGROUND: There is a pressing need for more sustainable healthcare. UK medical graduates are required to apply social, economic, and environmental principles of sustainability to their practice. The Centre for Sustainable Healthcare has developed a sustainability in quality improvement (SusQI) framework and educator's toolkit to address these challenges. We aimed to develop and evaluate SusQI teaching using this toolkit at Bristol Medical School. METHODS: We facilitated a SusQI workshop for all third-year Bristol Medical School students. We used mixed methods including questionnaires, exit interviews and follow-up focus groups to evaluate the outcomes and processes of learning. RESULTS: Students reported: improvements in knowledge, confidence, and attitudes in both sustainable healthcare and quality improvement; increased self-rated likelihood to engage in SusQI projects; and willingness to change practices to reduce environmental impact in their healthcare roles. Factors for successful teaching included: interactivity; collaboration and participation; and real-life, relevant and tangible examples of projects delivered by credible role models. CONCLUSIONS: Students reported that SusQI education supported by the toolkit was effective at building knowledge and skills, and reframed their thinking on sustainability in quality improvement. Combining the two topics provided enhanced motivation for and engagement in both. Further research is needed on the clinical impacts of SusQI learning.

Success and limiting factors in health service innovation: a theory-generating mixed methods evaluation of UK projects.

OBJECTIVES: To explore and explain success and limiting factors in UK health service innovation. DESIGN: Mixed methods evaluation of a series of health service innovations involving a survey and interviews, with theory-generating analysis. SETTING: The research explored innovations supported by one of the UK's Academic Health Science Networks which provides small grants, awards and structural support to health service innovators including clinical academics, health and social care professionals and third-sector organisations. PARTICIPANTS: All recipients of funding or support 2014-2018 were invited to participate. We analysed survey responses relating to 56 innovation projects. RESULTS: Responses were used to conceptualise success along two axes: value creation for the intended beneficiaries and expansion beyond its original pilot. An analysis of variance between categories of success indicated that participation, motivation and evaluation were critical to value generation; organisational, educational and administrative support were critical to expansion; and leadership and collaborative expertise were critical to both value creation and expansion. Additional limiting factors derived from qualitative responses included difficulties navigating the boundaries and intersections between organisations, professions, sectors and cultures; a lack of support for innovation beyond the start-up phase; a lack of protected time; and staff burn-out and turnover. CONCLUSIONS: A nested hierarchy of innovation needs has been derived via an analysis of these factors, providing targeted suggestions to enhance the success of future innovations.

Whole consultation simulation in undergraduate surgical education: a breast clinic case study.

BACKGROUND: Safe and effective clinical outcomes (SECO) clinics enable medical students to integrate clinical knowledge and skills within simulated environments. This realistic format may better prepare students for clinical practice. We aimed to evaluate how simulated surgical clinics based on the SECO framework aligned with students' educational priorities in comparison with didactic tutorials. METHODS: We delivered two breast surgery SECO-based simulated clinics to Year 3 students during their surgical attachments at a London teaching hospital. All students attended a didactic breast surgery tutorial the previous week. Pre- and post-session surveys and post-session debriefs were used to explore learning gain, processes, preferences and impacts on motivation to learn. Data were analysed using inductive thematic analysis to categorise student views into themes. RESULTS: Seventeen students enrolled in the simulated clinics and debriefs. Students expressed that passing examinations was a key extrinsic motivating factor, although the SECO-based format appeared to shift their motivation for learning towards aspiring to be clinically competent. Self-reported confidence in clinical skills such as history taking and examination improved significantly. Active learning methods were valued. Students expressed a preference for simulated clinics to complement, but not replace, tutorial-based learning. CONCLUSION: The SECO-based simulated clinic promoted a shift towards intrinsic motivation for learning by allowing students to recognise the importance of preparing for clinical practice in addition to passing examinations. Integration of surgical simulated clinics into the undergraduate curriculum could facilitate acquisition of clinical skills through active learning, a method highly valued by students.

Video-assisted reflection: improving OSCE feedback.

BACKGROUND: Objective Structured Clinical Examinations (OSCEs) are commonly used to provide feedback to students on their performance in formative examinations. However, students are often unable to act independently on the feedback they receive. This study explored how the use of video-assisted reflection in OSCEs can enhance students' ability to reflect and engage in sustainable feedback. METHODS: Twenty-one students undertaking a mock-final OSCE consented to have one of their examination stations filmed. Participants completed a series of reflective forms immediately after the OSCE, after verbal feedback from an examiner and finally, after watching the video of their own performance. Students were asked to predict their overall grade as well as list areas for improvement. Pearson r correlations examined the relationship between the examiners' grades and the candidates' self-predicted grades. Wilcoxon signed-rank tests were used to compare the length of reflections at each stage. Semi-structured interviews were conducted to explore students' beliefs on self-efficacy and how the video-assisted reflection altered their ability to act on feedback. RESULTS: The students' ability to self-assess and gauge their own performance improved significantly after undertaking the video-assisted reflection (p < 0.01). Furthermore, video-assisted reflection significantly increased the length of the student's reflections. In interviews, participants described multiple ways in which the video-assisted reflection improved their confidence and ability to act on feedback, highlighting a clear enhancement in self-efficacy. DISCUSSION: Video-assisted reflection of recorded OSCE stations represents an effective approach to increase student self-efficacy and subsequently improve engagement in sustainable feedback practice.

The role of humanities in the medical curriculum: medical students' perspectives.

BACKGROUND: The humanities have long been shown to play an important role in the medical school curriculum. However, few studies have looked into the opinions of medical students on the usefulness and necessity of the humanities as well as their extracurricular involvement with them. The aim of this study was to: a) understand medical students' attitude towards the humanities in medical education and b) assess their understanding of the necessary qualities of doctors and how interaction with the humanities affects the development of such attributes. METHODS: A mixed methods survey was designed to elicit demographics, engagement, interest and perspective on curricular positioning, and to explore how students ranked the qualities of a doctor. It was distributed to medical students of all year groups in the 6-year bachelor of medicine, bachelor of surgery (MBBS) course at Imperial College London. RESULTS: One hundred nine fully completed questionnaires were received. No significant difference was found in engagement or interest in the humanities between genders. Students felt strongly that humanities subjects shouldn't be assessed (71:18) though some felt it was necessary for engagement, while no consensus was reached on whether these subjects should be elective or not (38:31). The majority of students wanted more medical humanities to be incorporated into the traditional medical course with a preference of incorporation into the first 3 years. Junior medical students were more likely to rank empathy as a highly desirable attribute than senior students. Students provided qualitative insights into curricular positioning, assessment and value. CONCLUSIONS: This study provides the perspective of medical students on how and whether the humanities should be positioned in medical education. It may be helpful to medical schools that are committed to student involvement in curriculum design.

AMEE Consensus Statement: Planetary health and education for sustainable healthcare.

The purpose of this Consensus Statement is to provide a global, collaborative, representative and inclusive vision for educating an interprofessional healthcare workforce that can deliver sustainable healthcare and promote planetary health. It is intended to inform national and global accreditation standards, planning and action at the institutional level as well as highlight the role of individuals in transforming health professions education. Many countries have agreed to 'rapid, far-reaching and unprecedented changes' to reduce greenhouse gas emissions by 45% within 10 years and achieve carbon neutrality by 2050, including in healthcare. Currently, however, health professions graduates are not prepared for their roles in achieving these changes. Thus, to reduce emissions and meet the 2030 Sustainable Development Goals (SDGs), health professions education must equip undergraduates, and those already qualified, with the knowledge, skills, values, competence and confidence they need to sustainably promote the health, human rights and well-being of current and future generations, while protecting the health of the planet.The current imperative for action on environmental issues such as climate change requires health professionals to mobilize politically as they have before, becoming strong advocates for major environmental, social and economic change. A truly ethical relationship with people and the planet that we inhabit so precariously, and to guarantee a future for the generations which follow, demands nothing less of all health professionals.This Consensus Statement outlines the changes required in health professions education, approaches to achieve these changes and a timeline for action linked to the internationally agreed SDGs. It represents the collective vision of health professionals, educators and students from various health professions, geographic locations and cultures. 'Consensus' implies broad agreement amongst all individuals engaged in discussion on a specific issue, which in this instance, is agreement by all signatories of this Statement developed under the auspices of the Association for Medical Education in Europe (AMEE).To ensure a shared understanding and to accurately convey information, we outline key terms in a glossary which accompanies this Consensus Statement (Supplementary Appendix 1). We acknowledge, however, that terms evolve and that different terms resonate variably depending on factors such as setting and audience. We define education for sustainable healthcare as the process of equipping current and future health professionals with the knowledge, values, confidence and capacity to provide environmentally sustainable services through health professions education. We define a health professional as a person who has gained a professional qualification for work in the health system, whether in healthcare delivery, public health or a management or supporting role and education as 'the system comprising structures, curricula, faculty and activities contributing to a learning process'. This Statement is relevant to the full continuum of training - from undergraduate to postgraduate and continuing professional development.

Outpatient learning perspectives at a UK hospital.

BACKGROUND: Undergraduate students spend much of their training in the clinical workplace, increasingly in hospital outpatient settings; however, they report that this does not always yield the educational value that they expect. This study investigates ways in which outpatient learning can be enhanced from the perspectives of students and teachers, exploring which approaches may be most appropriate in different circumstances. METHODS: We conducted 14 semi-structured interviews with medical students from one UK medical school and consultants (specialists) at a single teaching hospital. We explored their experiences and perceptions of clinical teaching and learning in this outpatient setting. Transcripts were analysed through a consensual qualitative research approach. An evaluation of established frameworks for outpatient teaching was conducted and strategies were matched to stakeholder needs. FINDINGS: A total of 24 core ideas were identified, which were categorised into: individual factors (student, doctor and patient), interpersonal factors, team factors and organisational factors. Teaching strategies that address stakeholder needs included: student-led clinics, case-based discussions, one-minute preceptor, the SNAPPS tool (summarize, narrow differential, analyse, probe preceptor, plan and select issues for self-learning), advanced organisers and supplementing. DISCUSSION: There is a complex interplay between personal, interpersonal, team and organisational factors that contribute to the effectiveness of the outpatient setting as a learning environment. Strategies at the personal and interpersonal levels are unlikely to be successful or sustained without organisational resourcing and support. Further research is needed to implement and evaluate these suggested strategies.

Factors impacting on retention, success and equitable participation in clinical academic careers: a scoping review and meta-thematic synthesis.

OBJECTIVES: To examine and synthesise current evidence on the factors that affect recruitment, retention, participation and progression within the clinical academic pathway, focusing on equitable participation across protected characteristics including gender, ethnicity and sexual orientation. DESIGN: Scoping review and meta-thematic synthesis. DATA SOURCES: Web of Science, Google Scholar. ARTICLE SELECTION: We conducted a scoping review of English language articles on factors affecting recruitment, retention, progression and equitable participation in clinical academic careers published in North America, Australasia and Western Europe between January 2005 and April 2019. The most recent and relevant 39 articles were selected for meta-thematic synthesis using detailed inclusion/exclusion criteria. DATA EXTRACTION: The articles were purposively sampled to cover protected characteristics and career stages and coded for factors related to equitable participation. 17 articles were fully coded. No new themes arose after nine papers. Themes and higher level categories were derived through an iterative consensual process. RESULTS: 13 discrete themes of factors impacting on equitable participation were identified including societal attitudes and expectations; national and organisational policies, priorities and resourcing; academic and clinical workplace cultures; supportive, discriminatory and compensatory interpersonal behaviours and personal factors related to social capital, finances, competing priorities, confidence and ambition, and orientation to clinical, academic and leadership roles. CONCLUSIONS: The broad and often interconnected nature of these factors suggests that interventions will need to address structural and cultural factors as well as individual needs. In addition to standard good practice on equality and diversity, we suggest that organisations provide equitable support towards early publication success and targeted mentoring; address financial and role insecurity; address the clinical workplace culture; mitigate clinical-academic-personal role conflicts and overload; ensure that promotional structures and processes encourage diverse applicants and promote family-friendly, coherent and transparent national career pathways.

A qualitative analysis of junior doctors' journeys to preparedness in acute care.

BACKGROUND: New doctors are expected to assess and manage acutely deteriorating patients from their first days in the hospital. However, current evidence suggests that medical graduates are not prepared for this. We aimed to explore junior doctors' first experiences with unwell patients and how they developed preparedness over time. METHODS: We conducted seven semi-structured interviews with doctors in their first postgraduate year. The interview transcripts underwent inductive thematic analysis using consensual qualitative research approaches. Themes identified were categorised into early experiences of unpreparedness, first experiences of genuine preparedness, and making sense of how they became prepared. Reflection on how participants progressed between the two was facilitated through a sorting and ranking exercise. RESULTS: Most participants initially felt unprepared when responding to acutely unwell patients. They described feeling overwhelmed, apprehensive and challenged. Two main challenges involved knowing when to escalate, and feeling expected to perform beyond their level of competency. A lack of acute care exposure at medical school was a common thread. All participants felt prepared to respond to unwell patients three to six months after starting work. Hands-on experience, reflection, simulation and multidisciplinary team-working were consistently ranked as the most useful learning experiences. CONCLUSION: Starting work as a doctor is a challenging time and preparedness to manage an acutely deteriorating patient is a common area of concern. As preparedness in acute care ranks poorly compared to other outcomes, we see this as an important area for improvement. Our findings suggest that undergraduates may lack sufficient opportunities for scaffolded decision making in acute care, and that increasing the intensity of clinical shadowing may improve preparedness and should inform future educational interventions.

Intra- and interprofessional practices through fresh eyes: a qualitative analysis of medical students' early workplace experiences.

BACKGROUND: Professional identities are influenced by experiences in the clinical workplace including socialisation processes that may be hidden from academic faculty and potentially divergent from formal curricula. With the current educational emphasis on complexity, preparedness for practice, patient safety and team-working it is necessary to evaluate and respond to what students are learning about collaborative practices during their clinical placements. METHODS: 394 second year medical students at a London medical school were invited to submit a short formative essay as part of their coursework describing, evaluating and reflecting on their experiences of how healthcare professionals work together. Their experiences were derived from having spent two days each week for 25 weeks in clinical contexts across primary and secondary care. We consented 311 participants and used a Consensual Qualitative Research approach to analyse these essays, creating a 'students-eye view' of intra- and interprofessional practices in the workplace. RESULTS: We identified four overarching themes in students' essays:Theme 1: analyses of contextual factors driving team tensions including staff shortages, shifting teams, and infrastructural issues;Theme 2: observations of hierarchical and paternalistic attitudes and behaviours;Theme 3: respect for team members' ability to manage and mitigate tensions and attitudes; andTheme 4: take-forward learning including enthusiasm for quality improvement and system change. CONCLUSIONS: Students are being socialised into a complex, hierarchical, pressurised clinical workplace and experience wide variations in professional behaviours and practices. They articulate a need to find constructive ways forward in the interests of staff wellbeing and patient care. We present educational recommendations including providing safe reflective spaces, using students' lived experience as raw material for systems thinking and quality improvement, and closing the feedback loop with placement sites on behalf of students.

Brief intervention for obesity in primary care: how does student learning translate to the clinical context?

This article was migrated. The article was marked as recommended. There is an international call for more sustainable approaches to healthcare and for graduating doctors to develop the competencies to address the behavioural, psychological and social determinants of health. Obesity is a global challenge, and the case for preventative health is evident. There is growing evidence to support brief interventions for obesity in primary care. The feasibility and acceptability of teaching within classroom contexts have been demonstrated, however there are known barriers to adopting these approaches with patients. It is unclear how well classroom learning translates to the clinical context. 329 final year medical students from Aristotle University of Thessaloniki attended training that had been developed through action research processes at King's College London and adapted to the local context. Students conducted brief interventions with 3,177 overweight or obese patients across 136 primary healthcare facilities over three rotations. Their reflective learning essays were coded for content and thematically analysed to illuminate their experiences. Emergent themes include students' insights into the drivers behind the obesity epidemic and psychosocial barriers to change; transformative experiences using patient-centred approaches to communication and behaviour change; progression in skills and attitudes to broaching obesity in clinical contexts; and insights into the factors that drive patient engagement. Their experiences indicate that facilitative approaches are acceptable to patients, and result in commitment to change where relevant to the patient's agenda.