Optimising planned medical education strategies to develop learners' person-centredness: A realist review.

CONTEXT: Person-centeredness is a stated aim for medical education; however, studies suggest this is not being achieved. There is a gap in our understanding of how, why and in what circumstances medical education interventions that aim to develop person-centredness are successful. METHODS: A realist review was conducted with a search of Medline, Embase, HMIC and ERIC databases and the grey literature using the terms 'medical education' and 'person-centred' and related synonyms. Studies that involved a planned educational intervention in medical education with data on outcomes related to person-centredness were included. The analysis focused on how and why different educational strategies interact with biomedical learner perspectives to trigger mechanisms that may or may not lead to a change in perspective towards person-centredness. RESULTS: Sixty-one papers representing fifty-three interventions were included in the final synthesis. Nine context-intervention-mechanism-outcome configuration (CIMOc) statements generated from the data synthesis make up our refined programme theory. Where educational interventions focused on communication skills learning or experiences without person-centred theory, learners experienced dissonance with their biomedical perspective which they resolved by minimising the importance of the learning, resulting in perspective endurance. Where educational interventions applied person-centred theory to meaningful experiences and included support for sense making, learners understood the relevance of person-centeredness and felt able to process their responses to learning, resulting in perspective transformation towards person-centredness. CONCLUSION: Our findings offer explanations as to why communication skills-based interventions may be insufficient to develop learners' person-centredness. Integrating experiential person-centred learning with theory on why person-centredness matters to clinical practice and enabling learners to make sense of their responses to learning, may support perspective transformation towards person-centredness. Our findings offer programme and policymakers testable theory to inform the development of medical education strategies that aim to support person-centredness.

Improving medical students' confidence in end-of-life consultations.

BACKGROUND: End-of-life discussions are associated with improved quality of care for patients. In the UK, the General Medical Council outlines a requirement for medical graduates to involve patients and their families in discussions on their care at the end-of-life. However medical students feel ill-equipped to conduct these discussions. METHODS: In 2018, Sheffield Medical School introduced a small group role-play session on end-of-life discussions for all final year medical students. Scenarios were devised to improve confidence in the following learning domains: communicating prognosis with patients and family; ascertaining patient's goals, values and preferred place of death; discussing escalation of treatment, discussing do not attempt resuscitation orders, care in the dying phase of illness and pre-emptive prescribing. Evaluation was conducted over 16 weeks with a before and after questionnaire. Students rated their confidence in the above learning domains on a Likert-style scale and explained their ratings in free-text boxes. RESULTS: There was a 76% response rate to the questionnaire and analysis showed statistically significant improvements in confidence across all learning domains following the session. Qualitative analysis of free-text responses showed that prior to the sessions, students expressed low confidence due to lack of experience and fear of upsetting patients. After the session students felt they had gained skills but expressed persistent anxiety and a desire for further practice. CONCLUSIONS: Our innovation suggests that the opportunity to experience End-of-life discussions through role-play can significantly improve students' confidence in conducting these conversations. However, repeated sessions are likely necessary for students to feel prepared upon graduation.

Developing Medical Students' Broad Clinical Diagnostic Reasoning Through GP-Facilitated Teaching in Hospital Placements.

PURPOSE: Graduating medical students need broad clinical diagnostic reasoning skills that integrate learning across clinical specialties to deal with undifferentiated patient problems. The opportunity to acquire these skills may be limited during clinical placements on increasingly specialized hospital wards. We developed an intervention of regular general practitioner (GP) facilitated teaching in hospital placements to enable students to develop broad clinical diagnostic reasoning. The intervention was piloted, refined and delivered to a whole cohort of medical students at the start of their third year. This paper examines whether students perceived opportunities to improve their broad diagnostic clinical reasoning through our intervention. METHODS: GP-facilitated teaching sessions were delivered weekly in hospital placements to small groups of 6-8 students for 90 mins over 6 weeks. Students practiced clinical reasoning with real patient cases that they encountered on their placements. Evaluation of learning outcomes was conducted through a student questionnaire using Likert scales with free-text boxes for additional explanation. Focus groups were conducted to gain a more in-depth understanding of student perspectives. RESULTS: As high as 87% of students agreed that their broad clinical diagnostic reasoning ability had improved. Thematic analysis of the qualitative data revealed four factors supporting this improvement: practicing the hypothetico-deductive method, using real patient cases, composing student groups from different speciality placements and the breadth of the facilitators' knowledge. Students additionally reported enhanced person-centredness in terms of understanding the patient's perspective and journey. Students perceived that the added value of general practitioner facilitators lay in their broad knowledge base and knowledge of patient needs in the community. CONCLUSION: Our results suggest that medical students can develop broad clinical diagnostic reasoning skills in hospital settings through regular GP-facilitated teaching. Our approach has the advantage of working within the established curricular format of hospital placements and being deliverable at scale to whole student cohorts.

Using professional interpreters in undergraduate medical consultation skills teaching.

The ability to work with interpreters is a core skill for UK medical graduates. At the University of Sheffield Medical School, this teaching was identified as a gap in the curriculum. Teaching was developed to use professional interpreters in role-play, based on evidence that professional interpreters improve health outcomes for patients with limited English proficiency. Other principles guiding the development of the teaching were an experiential learning format, integration to the core consultation skills curriculum, and sustainable delivery. The session was aligned with existing consultation skills teaching to retain the small-group experiential format and general practitioner (GP) tutor. Core curricular time was found through conversion of an existing consultation skills session. Language pairs of professional interpreters worked with each small group, with one playing patient and the other playing interpreter. These professional interpreters attended training in the scenarios so that they could learn to act as patient and family interpreter. GP tutors attended training sessions to help them facilitate the session. This enhanced the sustainability of the session by providing a cohort of tutors able to pass on their expertise to new staff through the existing shadowing process. Tutors felt that the involvement of professional interpreters improved student engagement. Student evaluation of the teaching suggests that the learning objectives were achieved. Faculty evaluation by GP tutors suggests that they perceived the teaching to be worthwhile and that the training they received had helped improve their own clinical practice in consulting through interpreters. We offer the following recommendations to others who may be interested in developing teaching on interpreted consultations within their core curriculum: 1) consider recruiting professional interpreters as a teaching resource; 2) align the teaching to existing consultation skills sessions to aid integration; and 3) invest in faculty development for successful and sustainable delivery.

Comparative evaluation of two commercially available desensitizing agents for the treatment of dentinal hypersensitivity.

AIMS: A randomized clinical trail was designed to compare the efficacy of two commercially available desensitizing agents (fluoride varnish containing 6% sodium fluoride and 6% calcium fluoride and a gel containing 6% potassium nitrate and 0.11% fluoride ions) in the treatment of dentinal hypersensitivity. SETTINGS AND DESIGN: Randomized clinical trial. MATERIALS AND METHODS: Twenty-one patients were selected. Subjects were evaluated using three different stimuli, i.e., tactile test, air blast test and cold water test. They were then randomly divided into two groups. Patients in group I were treated with fluoride varnish and group II patients were treated with gel containing 6% potassium nitrate and 0.11% fluoride ions. The patients were examined at baseline, immediately after application of the agent, at 1 week, 1 month and 3 months interval. STATISTICAL ANALYSIS: Statistical analysis was done using unpaired "t" test, paired "t" test and Chi-square test with Yate's correction. RESULTS: The results were analyzed; it was seen that patients treated in group I showed significantly better results compared to group II patients at 1 month and 3 months interval. Teeth which required repeat dose and those which did not require repeat dose were comparable in number. CONCLUSIONS: Both the agents showed significant reduction in sensitivity at all time intervals compared to baseline. A comparatively significant reduction in sensitivity score was seen in patients treated with fluoride varnish and it appeared to be more effective in providing long-term relief against all the three test stimuli. Teeth with initial high sensitivity score required repeat doses, which was comparable for both the groups.