Medical Students Raising Concerns.

ABSTRACT: After a number of high-profile incidents and national reports, it has become clear that all health professionals and all medical students must be able to raise concerns about a colleague's behavior if this behavior puts patients, colleagues, or themselves at risk.Detailed evidence from medical students about their confidence to raise concerns is limited, together with examples of barriers, which impair their ability to do so. We describe a questionnaire survey of medical students in a single-center, examining self-reported confidence about raising concerns in a number of possible scenarios. Thematic analysis was applied to comments about barriers identified.Although 80% of respondents felt confident to report a patient safety issue, students were less confident around issues of probity, attitude, and conduct. This needs to be addressed to create clear mechanisms to raise concerns, as well as support for students during the process.

Improving the management of musculoskeletal conditions: can an alternative approach to referral management underpinned by quality improvement and behavioural change theories offer a solution and a better patient experience? A mixed-methods study.

OBJECTIVES: To assess whether a quality improvement-based approach to referral management can result in better musculoskeletal care within general practice. DESIGN: Prospective cohort study using mixed methodology including random-effects meta-analysis and interrupted time series. SETTING AND PARTICIPANTS: 36 general practices in East London. INTERVENTION: Informed by the results of a Cochrane review on educational interventions to improve general practitioners' (GPs) musculoskeletal care, we developed a multifaceted intervention, underpinned by quality improvement and behavioural change theories. It combined locally agreed clinical pathways, feedback on referral rates, clinical audit and peer review. MAIN OUTCOME MEASURES: Referral letter content, pathway adherence, referral rates, inter-practice variability and patient experience were evaluated before and after the intervention. RESULTS: Referral letter content on suspected diagnosis and prior management improved from a pooled preintervention proportion of 59% (95% CI 53% to 65%) and 67% (95% CI 61% to 73%), respectively, to 77% (95% CI 70% to 84%) and 81% (95% CI 74% to 88%). Pathway adherence improved from a pooled preintervention percentage of 42% (95% CI 35% to 48%) to 66% (95% CI 57% to 76%). The effect was greater across all quality outcomes for practices with baseline performance below or equal to the pooled baseline performance. There were reductions in the variability and rates of orthopaedic referrals at 6, 12 and 18 months (referral rate relative effect 32% (95% CI 14% to 48%), 30% (95% CI 7% to 53%) and 30% (95% CI 0% to 59%), respectively). Patient rating of how well GPs explained the musculoskeletal condition improved by 29% (95% CI 14% to 43%) and patient perception on the usefulness of the GP appointment improved by 24% (95% CI 9% to 38%). CONCLUSIONS: A quality improvement-based approach to referral management which values GPs' professionalism can result in improvements across a range of outcomes including referral quality, patient experience, referral rates and variability.

Professional interventions for general practitioners on the management of musculoskeletal conditions.

BACKGROUND: Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs. OBJECTIVES: To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care.  SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013. SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls. DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions. MAIN RESULTS: Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low. AUTHORS' CONCLUSIONS: There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.

Patient safety and communication: a new assessment for doctors trained in countries where language differs from that of the host country: results of a pilot using a domain-based assessment.

OBJECTIVE: Global migration of healthcare workers places responsibility on employers to comply with legal employment rights whilst ensuring patient safety remains the central goal. We describe the pilot of a communication assessment designed for doctors who trained and communicated with patients and colleagues in a different language from that of the host country. It is unique in assessing clinical communication without assessing knowledge. METHODS: A 14-station OSCE was developed using a domain-based marking scheme, covering professional communication and English language skills (speaking, listening, reading and writing) in routine, acute and emotionally challenging contexts, with patients, carers and healthcare teams. Candidates (n=43), non-UK trained volunteers applying to the UK Foundation Programme, were provided with relevant station information prior to the exam. RESULTS: The criteria for passing the test included achieving the pass score and passing 10 or more of the 14 stations. Of the 43 candidates, nine failed on the station criteria. Two failed the pass score and also the station criteria. The Cronbach's alpha coefficient was 0.866. CONCLUSION: This pilot tested 'proof of concept' of a new domain-based communication assessment for non-UK trained doctors. PRACTICE IMPLICATIONS: The test would enable employers and regulators to verify communication competence and safety in clinical contexts, independent of clinical knowledge, for doctors who trained in a language different from that of the host country.

Peer feedback as an aid to learning--what do we want? Feedback. When do we want it? Now!

BACKGROUND: With 360° appraisals integral to professional life, learning how to give constructive feedback is an essential generic skill. AIM: To use a formative objective structured clinical examination (OSCE) for skills acquisition and development in giving feedback, whilst facilitating awareness of the importance of communication skills in clinical practice. METHODS: Medical and nursing students took part in a formative OSCE. Using actors as simulated patients, a three-station OSCE circuit was repeated three times so that students could rotate through the roles as 'candidate', 'examiner' and 'observer'. As 'candidates', they received immediate feedback on their consultation from the 'examiner'/'observer'. The events were evaluated using a questionnaire and focus groups. RESULTS: Students immensely valued this learning event for considering expectations for a performance (91-100%). Concerns around giving peers feedback were acknowledged, and they were divided on preference for feedback from peers or tutors (48% versus 52%). But training in providing feedback and criteria for assessment were considered helpful, as was instruction by faculty to give corrective feedback to peers. CONCLUSIONS: Peer observation and professional accountability for giving constructive feedback enhanced awareness of their skills education and training needs. It also opened the dialogue for identifying opportunities for peer assessment and feedback to support work-based education and skills development.

Provision of continued professional development for non-medical prescribers within a South of England Strategic Health Authority: a report on a training needs analysis.

AIMS: This paper reports on a Training Needs Analysis for Non-Medical Prescribers commissioned by a south of England Strategic Health Authority. BACKGROUND: The aim of the TNA was to inform future policy, educational provision and practice development and provide nurse managers with significant information on the perceived Continuing Professional Development (CPD) needs of the non-medical prescribers. METHODS: Data were collected from a sample of 270 non-medical prescribers using an in-depth questionnaire, and telephone interviews with a purposive sample of 11 key stakeholders. RESULTS: The findings report: * The qualifications that non-medical prescribers possess. * The level of confidence described by the non-medical prescribers in their role. * What non-medical prescribers identify as their present and future CPD requirements in relation to prescribing. * What education and training provision non-medical prescribers have attended in relation to their prescribing role since qualifying. CONCLUSIONS: The findings suggest, first that short courses that were specific to the non-medical prescribers role were considered to be the most popular and useful. However, courses needed to be advertised well in advance. Second, training gaps were identified. IMPLICATIONS FOR NURSING MANAGEMENT: Pharmacology and prescribing are rapidly changing and require regular CPD in order to keep up to date with the latest developments. Non-medical prescribing is a comparatively new innovation to the NHS, therefore those who are not medically qualified need mentorship from experienced prescribers, as well as the encouragement from nurse managers to be confident prescribers themselves and enhance patient care.

Characterisation of epitopes of pan-IgG/anti-G3m(u) and anti-Fc monoclonal antibodies.

The characterisation of monoclonal antibodies (MAbs) and their epitopes is important prior to their application as molecular probes. In this study, Western blotting using IgG1 Fc and pFc' fragments was employed to screen seven MAbs before pepscan analysis to determine their reactivity to potentially linear epitopes. MAbs PNF69C, PNF110A, X1A11 and MAbs WC2, G7C, JD312, 1A1 detected epitopes within the C(H)3 and C(H)2 domains, respectively. However, only four MAbs showed pepscan profiles that highlighted likely target residues. In particular, MAbs PNF69C and PNF110A that have previously been characterised with pan-IgG and anti-G3m(u) specificity, detected the peptide motif 338-KAKGQPR-344 which was located within the N-terminal region of the C(H)3 domain. Furthermore the majority of residues were present in all four IgG subclasses. Consequently the peptide identified was consistent with the pan-IgG nature of these antibodies. By using PCImdad, a molecular display programme, this sequence was visualised as surface accessible, located in the C(H)2/C(H)3 inter-domain region and proximal to the residue arginine(435). It is speculated that this residue may be important for phenotypic expression of G3m(u) and specificity of these reagents. Pepscan analysis of MAbs G7C and JD312 (both pan-IgG) highlighted the core peptide sequence 290-KPREE-294, which was present in the C(H)2 domain and was common to all four IgG subclasses. PCImdad also showed this region to be highly accessible and was consistent with previous bioinformatic and autoimmune analysis of IgG. Overall these MAbs may serve as useful anti-IgG or anti-G3m(u) reagents and probes of immunoglobulin structure.