Girls in scrubs: An ethnographic exploration of the clinical learning environment.

BACKGROUND: Gender bias is an enduring issue in the medical profession despite women being more represented within medical schools and the health care workforce in numerous countries across the world. There have been frequent calls for further exploration of gender-based discriminations within medical education, owing to its lasting impact on student's professional development and career trajectories. This paper presents an ethnographic exploration of the experiences of female medical students and doctors in the clinical learning environment (CLE), aiming to disrupt the cycle of gender inequity in the clinical workplace. METHODS: Our research field involved two teaching wards in a Scottish urban hospital, where 120 h of non-participant observations were conducted over 10 months. Combining purposive and convenience sampling, we conducted 36 individual interviews with key informants, which included medical students, foundation doctors, postgraduate trainees, consultant supervisors, and other health care professionals such as nurses and pharmacists. Data was thematically analysed using Bourdieu's theory of social power reproduction. The research team brought diverse professional backgrounds and perspectives to the exploration of data on gendered encounters. RESULTS: Combining the observational and interview data, five themes were generated, which suggested gender-related differentials in social and cultural capital that the participants acquired in the CLE. Experiences of discriminatory behaviour and stereotypical thought processes impacted the female students' engagement and drive towards learning, implying an adverse influence on habitus. In contrast, the valuable influence of gendered role-models in building confidence and self-efficacy signified a positive transformation of habitus. The research participants displayed considerable internalisation of the gendered processes in the CLE that appeared to be linked to the transient nature of clinical placements. CONCLUSIONS: This research reveals that despite constituting the majority demographic of medical school, female students struggle to gain social and cultural capital. Gendered hierarchies that structure clinical workplaces disadvantage female students and doctors, and the differential experiences transform their habitus. Based on our theoretically informed investigation, we advocate for role-models given their positive impact on students' and doctors' habitus. Additionally, medical educators may consider extended clinical placements that provide opportunities for female students and early-career doctors to secure social and cultural capital through integrating better in health care teams and building meaningful interprofessional relationships.

Enabling and inhibiting doctors transitions: introducing the social identity resource and belonginess model (SIRB).

The transition into postgraduate medical training is complex, requiring an integration into the workplace, adjustment to new identities, and understanding of the social and organisational structure of healthcare. Studies suggest that social resources, including a sense of belonging, inclusivity from social groups, and having strong social identities can facilitate positive transitions. However, little is known about the role these resources play in junior doctors' transitions into the healthcare community. This study aimed to explore the implications of having access to social resources for junior doctors. This study undertook secondary analysis from a longitudinal qualitative study which followed 19 junior doctors (residents within two years of qualification) for nine months. Data were thematically analysed using an abductive approach, with the social identity resource and belongingness (SIRB) model as a conceptual lens to explore how social networks of support act as identity resources (IRs) for junior doctors as they experience transitions. The doctors narrated that having accessible IRs in the form of supportive workplace relationships enabled an integration and a sense of belonging into healthcare practice, supported the construction of new professional identities, and strengthened career intentions. Those with inaccessible IRs (i.e. poor workplace relationships) expressed a lack of belonging, and casted doubt on their identity as a doctor and their career intentions. Our study indicates that SIRB model would be beneficial for medical educators, supervisors, and managers to help them understand the importance and implications of having IRs within the workplace environment and the consequences of their accessibility for healthcare staff experiencing transitions.

Knowing me, knowing you: evaluation of the impact of trainer involvement at an enhanced induction programme for International Medical Graduates (IMGs).

Addressing differential attainment between International Medical Graduates (IMGs) and their peers who hold UK Primary Medical Qualifications remains one of the most significant challenges facing postgraduate General Practice (GP) training. Enhanced Induction programme, such as the Scottish Trainee Enhanced Programme (STEP), is one tool designed to try and facilitate transition into training and reduce this inequity. The STEP course is attended by both the trainee and their educational supervisor, and aims to lay the foundations of a successful and supportive supervisory relationship. Previous work has evaluated this programme from the perspective of the trainee. Through the use semi-structured interviews, we evaluated the impact and the benefits of the programme from the perspective of the educational supervisors, building on the literature on interventions to support inequity in medical education.

The Glasgow experience: a model for GP out-of-hours teaching for year 3 medical students.

We present a model for delivering out-of-hours (OOH) teaching to year 3 medical students at Glasgow University. Clinical placement time in general practice for students is under unprecedented pressure, and scope to further increase placement capacity in daytime general practice is challenging. The OOH primary care setting is underutilized in Glasgow. We undertook a four-week pilot study based in two OOH centres in Glasgow. Third year medical students could sign up to attend a three-hour teaching session at an OOH site with a dedicated GP tutor. The logistical arrangements and evaluation of this pilot project are presented. Student, GP tutor, OOH staff and administration staff logistics are considered and learning opportunities for students in this setting are discussed. The pilot study received positive feedback from all stakeholders. Our project provides a model for further teaching in this environment to help mitigate placement shortage and provide additional valuable general practice clinical experience for students. The capacity for teaching in the OOH setting could be easily upscaled by either increasing the duration of the placement or utilising more out-of-hours sites for teaching.

Operationalising generalism in medical education: a narrative review of international policy and mission documents.

INTRODUCTION: Despite moves across medical education to increase learning of generalist principles, a lack of clarity about what generalism means and how we should train doctors as 'generalists', has remained. This study explores how international, undergraduate and postgraduate, policy and educational mission documents characterise the practice and learning of generalism and how this can inform physician training. METHODS: A narrative literature review was conducted based on policy and mission documents identified through grey literature searches and a wider systematic review looking at empirical texts. Texts published between 1999 and present and related to 'generalism' were eligible for inclusion. Texts were coded and codes were reviewed and grouped into key themes. RESULTS: Thirty-four documents were included. Definitions vary: some described generalism as a basic skill, whilst others emphasised expertise. Factors which support learning generalism include: favourable financial outcomes; ageing populations; coordination of multidisciplinary care; demand for doctors with transferable skills; and patient expectations. Barriers to learning about generalism include: preference for specialisation; structure of undergraduate teaching and assessment; and the hidden curriculum. Solutions may include re-imagining generalists and specialists as being on a continuum as well as increasing exposure throughout medical education. DISCUSSION: Whilst generalism is consistently positioned as valuable, less clarity exists about how best to operationalise this in medical education. Fundamental ideological and structural changes within teaching curricula and assessment, are necessary to improve generalist learning and to promote sustainable practice. Medical education needs careful, considered planning to ensure workforce expertise is meeting population needs.

Every doctor an educator?

INTRODUCTION: The education of the future health care workforce is fundamental to ensuring safe, effective, and inclusive patient care. Despite this there has been chronic underinvestment in health care education and, even though there is an increased need for educators, the true number of medical educators has been in relative decline for over a decade. PURPOSE: In this paper, we focus on the role of doctors as medical educators. We reflect on the culture in which medical education and training are delivered, the challenges faced, and their origins and sustaining factors. We propose a re-framing of this culture by applying Maslow's principles of the hierarchy of needs to medical educators, not only as individuals but as a specialist group and to the system in which this group works, to instigate actionable change and promote self-actualization for medical educators. DISCUSSION: Promoting and supporting the work of doctors who are educators is critically important. Despite financial investment in some practice areas, overall funding for and the number of medical educators continues to decline. Continuing Professional Development (CPD) schemes such as those offered by specialised medical education associations are welcomed, but without time, funding and a supportive culture from key stakeholders, medical educators cannot thrive and reach their potential. CONCLUSION: We need to revolutionise the culture in which medical education is practised, where medical educators are valued and commensurately rewarded as a diverse group of specialists who have an essential role in training the health care workforce to support the delivery of excellent, inclusive health care for patients. By reimagining the challenges faced as a hierarchy we show that until the fundamental needs of value, funding and time are realised, it will remain challenging to instigate the essential change that is needed.

Placement or displacement: An ethnographic study of space in the clinical learning environment.

PURPOSE: This paper aims to examine the spatial attributes in the hospital ward environment and their impact on medical students' learning and experience of the clinical workplace. MATERIALS AND METHODS: An ethnographic study was conducted in a Scottish teaching hospital, combining observations and interviews over a period of 10 months. Two teaching wards served as the field-sites where approximately 120 h of non-participant observations took place sequentially. In addition, 34 individual interviews were conducted with identified key informants that included medical students, junior doctors, postgraduate trainees, consultant supervisors, ward nurses and hospital pharmacist. A combination of Actor-network Theory (ANT) and Social cognitive theory (SCT) was applied to analyse data pertaining to spatial attributes and their relevance to clinical teaching and learning. RESULTS: Analysis of the observational and interview data led to generation of the following themes: spatial attributes in the clinical workplace can enable or constrain teaching and learning opportunities, inadequate spaces impact students' and junior doctors' sense of value, short clinical rotations influence a sense of ownership of doctors' spaces, and contested nature of space in the clinical environment. Several illustrations of the field-sites help to contextualise the themes and aid in understanding the participants' experiences and perceptions. CONCLUSIONS: Our findings suggest a complex entanglement of space with medical students learning and wellbeing in the clinical workplace. Provision of suitable spaces needs to be a core consideration to realise the full potential of work-based learning in medicine.

Students' and tutors' experiences of remote 'student-patient' consultations.

BACKGROUND: Remote consulting has become part of the medical student clinical experience in primary care, but little research exists regarding the impact on learning. AIM: To describe the experiences of General Practitioner (GP) educators and medical students in using student-led remote consultations as an educational tool. METHOD: A qualitative, explorative study conducted at four UK medical schools. GP educators and medical students were purposively sampled and interviewed. RESULTS: Nine themes arose: practical application, autonomy, heuristics, safety, triage of undifferentiated patients, clinical reasoning, patient inclusion in student education, student-patient interaction, and student-doctor interaction. DISCUSSION: Remote consulting has become part of the clinical placement experience. This has been found to expose students to a wider variety of clinical presentations. Verbal communication, history-taking, triage, and clinical reasoning skills were practised through remote consulting, but examination skills development was lacking. Students found building rapport more challenging, although this was mitigated by having more time with patients. Greater clinical risk was perceived in remote consulting, which had potential to negatively impact students' psychological safety. Frequent debriefs could ameliorate this risk and positively impact student-doctor relationships. Student autonomy and independence increased due to greater participation and responsibility. Pre-selection of patients could be helpful but had potential to expose students to lower complexity patients.[Box: see text].

Developing a career as a GP educationalist: contemporary challenges and workforce solutions.

GP educationalists are crucial in training the future medical workforce and in developing and advancing the field of primary care medical education, yet opportunities in the UK are patchy and varied. In this article, a group of GP educationalists summarise the challenges facing the sustainability of this particular group of clinical academics and outline opportunities available at each career stage, from medical students through to senior GP educationalists. Recommendations to support the growth of this workforce include the development of a nationally recognised framework for GP educationalist careers, collaboration with professional and educational bodies and taking steps to level out opportunities in order to reduce existing inequity.

Heard, valued, supported? Doctors' wellbeing during transitions triggered by COVID-19.

INTRODUCTION: Supporting doctors' wellbeing is crucial for medical education to help minimise negative long-term impacts on medical workforce retention and ultimately patient care. There is limited study of how doctors' transitions experiences impact wellbeing, particularly socially and culturally. Multiple Multidimensional Transitions (MMT) theory views transitions as dynamic, incorporating multiple contexts and multiple domains. Using MMT as our lens, we report a qualitative analysis of how transitions experienced by doctors during the pandemic impacted on social and cultural aspects of wellbeing. METHODS: Longitudinal narrative inquiry was employed, using interviews and audio-diaries. Data were collected over 6 months in three phases: (i) interviews with doctors from across the career spectrum (n = 98); (ii) longitudinal audio-diaries for 2-4 months (n = 71); (iii) second interviews (n = 83). Data were analysed abductively, narrowing focus to factors important to social and cultural wellbeing. RESULTS: Doctors described experiencing multiple interacting transitions triggered by the pandemic in multiple contexts (workplace, role, homelife and education). Patterns identifiable across the dataset allowed us to explore social and cultural wellbeing crosscutting beyond individual experience. Three critical factors contributed to social and cultural wellbeing both positively and negatively: being heard (e.g., by colleagues asking how they are); being valued (e.g., removal of rest spaces by organisations showing lack of value); and being supported (e.g., through regular briefing by education bodies). CONCLUSIONS: This study is the first to longitudinally explore the multiple-multidimensional transitions experienced by doctors during the COVID-19 pandemic. Our data analysis helped us move beyond existing perceptions around wellbeing and articulate multiple factors that contribute to social and cultural wellbeing. It is vital that medical educators consider the learning from these experiences to help pinpoint what aspects of support might be beneficial to trainee doctors and their trainers. This study forms the basis for developing evidenced-based interventions that ensure doctors are heard, valued and supported.

Reflections on the integration of virtual GP tutorials to the medical undergraduate curriculum at Glasgow.

Virtual tutorials were introduced into the Year 3 medical undergraduate curriculum at Glasgow in 2020/21. This model of teaching proved highly successful from tutor and student perspective. A hybrid teaching model, comprising virtual tutorial teaching alongside placement time will be implemented this year. Virtual (videoed) GP patient cases are selected for tutorials each week, linked to other curriculum content in Year 3. Pedagogically, this aligns pathological and clinical learning for our students and enables some consistency of taught GP content. Concomitant clinical placement time complements this learning with actual patient cases. Communication and consultation techniques considered in the virtual tutorials with facilitated tutor discussion are practised on GP placement days, encapsulating the essence of experiential learning. Challenging or unusual patient cases can be selected for teaching from the virtual case repertoire. This provides uniform exposure to clinically important aspects of general practice, and simultaneously enables an increased diversity of patient cases for our students. Logistical advantages of virtual tutorial delivery include its appeal to a different demographic of GP tutor, enabling us to diversify and expand our teaching team. Remote tutorial delivery offers a futureproof adjunct to the traditional practice-based GP teaching models.

'I wouldn't know what to do with the breasts': the impact of patient gender on medical student confidence and comfort in clinical skills.

BACKGROUND: Previous research has found a relationship between students' gender and attitudes surrounding peer physical examination, but relationship between patient gender and confidence/comfort is less clear. We explored whether patient gender affects medical students' levels of confidence and comfort in clinical examination skills. METHODS: An electronic survey and focus groups were conducted with medical students from one UK institution. Students reported levels of confidence/comfort when carrying out clinical examinations on men/women. An inductive thematic analysis was performed. RESULTS: Of a total of 1500 students provided with the opportunity to participate, ninety (6%) responded. For cardiovascular and respiratory examinations, confidence/comfort were higher when examining male-presenting patients. The opposite was true for mental state examinations. Barriers to confidence/comfort included perceiving males as a norm, difficulty navigating breasts, tutors' internalised gendered attitudes and a wider sociocultural issue. Facilitators of confidence/comfort included students relating to patients, embodying a professional role, gender blindness, and authentic clinical environments. Fewer than 20% (n = 18) of students felt they had enough opportunity to practice clinical skills on women, versus 90% (n = 82) on men. CONCLUSION: Our study identified an area where students' confidence and comfort in clinical examinations could be enhanced within medical education. Changes were implemented in the institution under study's vocational skills teaching, which is rooted in general practice. Information on gender and clinical skills was provided within course handbooks, time was scheduled to discuss gender and clinical skills in small group settings, and equitable gender representation was ensured in clinical assessment.

Delivering medical education for future healthcare needs: a community-focused challenge.

Medical schools are required to train the workforce needed to care for the population they serve. In the UK, we are expected to produce more graduates choosing to be general practitioners and to equip all graduates with the ability to care for an ageing population with increasingly complex care needs. These doctors need to be effective members of multi-professional teams, possessing generalist skills including an understanding of uncertainty and risk. Curricula where a significant proportion of clinical learning is based in general practice are best placed to address this pedagogic need. The authors evaluate the sociocultural factors which impede the expansion of undergraduate medical education in general practice. These include historic cultural divides between secondary and primary care, medical school leadership, funding, contractual arrangements and capacity in general practice to deliver increasing education of medical students alongside other established and emerging health professions. The piece concludes with two recommendations: undergraduate student teaching should be incorporated into contract negotiations and there must be urgent UK-wide investment in appropriate placement tariff for students. Furthemore, there is an imperative to pilot and evaluate novel collaborative approaches to the education of undergraduate medical and other health professions students.

Promoting general practice in medical schools. Where are we now?

In November 2016, the Medical Schools Council and Health Education England published a joint report chaired by Professor Val Wass: 'By choice - not by chance' to raise the profile of general practice as a positive career choice for medical students. We sought to evaluate the impact of the report by firstly, asking the views of Heads of GP teaching at UK medical schools whether and how the report has supported them in raising the profile of general practice and secondly, describing the initiatives developed by medical schools in a national survey. There was a perception reported by heads of GP teaching that the report has been highly influential in facilitating the promotion of general practice as a career to medical students. We describe multiple specific initiatives developed in response to the report's recommendations. The national survey confirmed that whilst there is significant variation across medical schools in their response to the specific recommendations in the report, definite progress is being made. A number of areas that need particular consideration have been highlighted and we would recommend that future surveys are completed at appropriate time intervals to review further progress.

The MRCGP Clinical Skills Assessment: an integrative review of evidence.

Background Successful completion of all three components of the Membership of the Royal College of General Practitioners UK (MRCGP) is required for a doctor to practise independently as a general practitioner (GP). One component, the Clinical Skills Assessment (CSA), is a high fidelity, high stakes examination designed to provide an objective external assessment of clinical skills. Aim The aim of this integrative review was to identify, critically appraise and synthesise published empirical evidence on the CSA to identify areas for further inquiry or future collaboration. Design and setting An integrative review of empirical literature focused on the MRCGP CSA. Method A search strategy was developed to conduct an integrative review of empirical published literature. The quality of studies was assessed using the Mixed Methods Appraisal Tool (MMAT). Results 11 of the 31 records reviewed were included. Studies were heterogeneous looking at the use of simulated patients, child actors and mock CSAs. Variables contributing to performance on the CSA, with a particular emphasis on the International Medical Graduate, were identified. Conclusion A small pool of published evidence regarding the CSA exists, focused on factors influencing CSA performance. Future research could explore the effectiveness of interventions to improve performance on the CSA and use robust measures to consider candidates' experience of the CSA.

'They say': medical students' perceptions of General Practice, experiences informing these perceptions, and their impact on career intention-a qualitative study among medical students in England.

OBJECTIVES: The number of UK graduates choosing General Practice training remains significantly lower than the current numbers required to meet the demands of the service. This work aims to explore medical students' perceptions of General Practice, experiences which lead to the development of these perceptions, and the ultimate impact of these on career intention. DESIGN: This mixed-methods, qualitative study used focus groups, semistructured interviews, longitudinal audio diary data and debrief interviews to explore and capture the experiences and perceptions of students in their first and penultimate years of university. SETTING: Three English medical schools. PARTICIPANTS: Twenty students were recruited to focus groups from first and fourth/fifth year of study. All students in these years of study were invited to attend. Six students were recruited into the longitudinal diary study to further explore their experiences. RESULTS: This work identified that external factors, internal driving force and the 'they say' phenomenon were all influential on the development of perceptions and ultimately career intention. External factors may be split into human or non-human influences, for example, aspirational/inspirational seniors, family, peers (human), placements and 'the push' of GP promotion (non-human). Driving force refers to internal factors, to which the student compares their experiences in an ongoing process of reflection, to understand if they feel General Practice is a career they wish to pursue. The 'they say' phenomenon refers to a passive and pervasive perception, without a known source, whereby usually negative perceptions circulate around the undergraduate community. CONCLUSION: Future strategies to recruit graduates to General Practice need to consider factors at an undergraduate level. Positive placement experiences should be maximised, while avoiding overtly 'pushing' GP onto students.

Performance of ethnic minority versus White doctors in the MRCGP assessment 2016-2021: a cross-sectional study.

BACKGROUND: Differential attainment has previously been suggested as being due to subjective bias because of racial discrimination in clinical skills assessments. AIM: To investigate differential attainment in all UK general practice licensing tests comparing ethnic minority with White doctors. DESIGN AND SETTING: Observational study of doctors in GP specialty training in the UK. METHOD: Data were analysed from doctors' selection in 2016 to the end of GP training, linking selection, licensing, and demographic data to develop multivariable logistic regression models. Predictors of pass rates were identified for each assessment. RESULTS: A total of 3429 doctors entering GP specialty training in 2016 were included, with doctors of different sex (female 63.81% versus male 36.19%), ethnic group (White British 53.95%, minority ethnic 43.04%, and mixed 3.01%), country of primary medical qualification (UK 76.76% versus non-UK 23.24%), and declared disability (disability declared 11.98% versus not declared 88.02%). Multi-Specialty Recruitment Assessment (MSRA) scores were highly predictive for GP training end-point assessments, including the Applied Knowledge Test (AKT), Clinical Skills Assessment (CSA), Recorded Consultation Assessment (RCA), and Workplace-Based Assessment (WPBA) and Annual Review of Competency Progression (ARCP). Ethnic minority doctors did significantly better compared with White British doctors in the AKT (odds ratio [OR] 2.05, 95% confidence interval [CI] = 1.03 to 4.10, P = 0.042). There were no significant differences on other assessments: CSA (OR 0.72, 95% CI = 0.43 to 1.20, P = 0.201), RCA (OR 0.48, 95% CI = 0.18 to 1.32, P = 0.156), or WPBA-ARCP (OR 0.70, 95% CI = 0.49 to 1.01, P = 0.057). CONCLUSION: Ethnic background did not reduce the chance of passing GP licensing tests once sex, place of primary medical qualification, declared disability, and MSRA scores were accounted for.

Barriers and attitudes influencing non-engagement in a peer feedback model to inform evidence for GP appraisal.

BACKGROUND: The UK general practitioner (GP) appraisal system is deemed to be an inadequate source of performance evidence to inform a future medical revalidation process. A long-running voluntary model of external peer review in the west of Scotland provides feedback by trained peers on the standard of GP colleagues' core appraisal activities and may 'add value' in strengthening the robustness of the current system in support of revalidation. A significant minority of GPs has participated in the peer feedback model, but a clear majority has yet to engage with it. We aimed to explore the views of non-participants to identify barriers to engagement and attitudes to external peer review as a means to inform the current appraisal system. METHODS: We conducted semi-structured interviews with a sample of west of Scotland GPs who had yet to participate in the peer review model. A thematic analysis of the interview transcriptions was conducted using a constant comparative approach. RESULTS: 13 GPs were interviewed of whom nine were males. Four core themes were identified in relation to the perceived and experienced 'value' placed on the topics discussed and their relevance to routine clinical practice and professional appraisal: 1. Value of the appraisal improvement activity. 2. Value of external peer review. 3. Value of the external peer review model and host organisation and 4. Attitudes to external peer review. CONCLUSIONS: GPs in this study questioned the 'value' of participation in the external peer review model and the national appraisal system over the standard of internal feedback received from immediate work colleagues. There was a limited understanding of the concept, context and purpose of external peer review and some distrust of the host educational provider. Future engagement with the model by these GPs is likely to be influenced by policy to improve the standard of appraisal and contractual related activities, rather than a self-directed recognition of learning needs.

Cultural diversity and inclusion in UK medical schools.

BACKGROUND: Racially minoritised groups across the globe continue to experience differential outcomes in both health and education. Medical schools can play an instrumental role in addressing both these disparities, by creating inclusive student communities and ensuring that tomorrow's doctors can care for our increasingly diverse populations. OBJECTIVES: This collaborative, qualitative study led by three United Kingdom (UK) institutions aimed to explore the perspectives of Heads of Primary Care Teaching (HOTs) on cultural diversity and inclusion across UK medical schools. METHODS: In December 2020, five focus groups were conducted remotely with 23 HOTs, or a nominated deputy. We explored participants' opinions regarding opportunities and barriers to cultural diversity and inclusion in medical education, ways to overcome these challenges and shared examples of best practice. Data were transcribed verbatim and thematically analysed by three researchers. RESULTS: Investigators identified six themes from the data: lack of faculty diversity, tokenistic faculty training, institutional mindset, diversifying the formal and hidden curricula, intersectionality and student voice. CONCLUSION: Medical schools worldwide face similar challenges, uncertainties and opportunities when integrating diversity and inclusion throughout the learning environment. Although the importance of the topic is increasingly acknowledged, current efforts are viewed as being passive and tokenistic, hindered by challenges at multiple levels. Partnership with students and collaboration within and between institutions nationally and internationally will enable us to move forwards with both local and global positive, sustainable change.