Neurologists' lived experiences of communicating the diagnosis of a motor neurodegenerative condition: an interpretative phenomenological analysis.

BACKGROUND: Receiving the diagnosis of a motor neurodegenerative condition (MNDC) can be a life-changing experience. Although several studies of individuals' experiences have indicated dissatisfaction with aspects of how an MNDC diagnosis was communicated, few studies have addressed doctors' experiences of breaking bad news for these conditions, especially from a qualitative perspective. This study explored UK neurologists' lived experience of delivering an MNDC diagnosis. METHODS: Interpretative phenomenological analysis was used as the overarching method. Eight consultant neurologists working with patients with MNDCs took part in individual, semi-structured interviews. RESULTS: Two themes were constructed from the data: 'Meeting patients' emotional and information needs at diagnosis: a balancing act between disease, patient and organization-related factors', and 'Empathy makes the job harder: the emotional impact and uncovered vulnerabilities associated with breaking bad news'. Breaking the news of an MNDC diagnosis was challenging for participants, both in terms of achieving a patient-centred approach and in terms of dealing with their own emotions during the process. CONCLUSIONS: Based on the study's findings an attempt to explain sub-optimal diagnostic experiences documented in patient studies was made and how organizational changes can support neurologists with this demanding clinical task was discussed.

Exploring the validity of the body image scale with survivors of breast cancer: A cognitive interview approach.

OBJECTIVE: The aim of this study is to explore the construct validity of the Body Image Scale for Cancer Questionnaire (BIS) using cognitive interviews. METHODS: Twelve breast cancer survivors participated in a cognitive interview while completing the BIS. Each participant was asked to think-out-loud while answering items, and an interviewer asked probing questions relating to the participants' comprehension, example retrieval, certainty of answer and other decision-making factors. Interviews were audio recorded and transcribed, and the data were analysed deductively and inductively. RESULTS: The participants' interpretations of the questions varied significantly. Several participants perceived the phrasing of some questions to be leading. The participants were able to provide examples of how their physical, physiological and body function affected their body image. The participants expressed positive attitudes towards, and gratitude for their body, which was not captured by the questionnaire. At times, the participants felt uncertain in how to respond appropriately to specific items, and the participants found some items challenging to answer. Finally, the BIS included sensitive questions that elicited emotional reactions and discomfort for some participants. CONCLUSION: The findings of this study provide insight into, and suggestions for potential questionnaire revisions that may enhance the validity and relevance of the BIS for use with breast cancer survivors.

Staff compassion in acute mental health wards: a grounded theory investigation.

BACKGROUND: Staff working on acute inpatient mental health wards face unique challenges in terms of short admissions, acuity, complexity and exposure to violence, suicide and self-harm. They experience high levels of stress and burnout, which can impact compassion. AIM: To qualitatively explore staff's understanding and conceptualisation of the development, loss and restoration of compassion within acute inpatient environments. METHOD: Eleven participants from a variety of professional backgrounds currently working on acute wards were interviewed. Using constructivist grounded theory, data were synthesised into theoretical categories and sub-categories. RESULTS: A conceptual model of the facilitators and inhibitors of compassionate care was developed, based on five categories that emerged from the data: A compassionate stance; the challenges of acute wards; feeling under threat; restoring compassion; and a compassionate organisation. CONCLUSIONS: Findings outline the process whereby staff compassion can be challenged or depleted, leading to a negative appraisal of the patient. Colleague support, knowing and understanding patients, and accessing a reflective space all supported the restoration of compassion. Staff reported lack of organisational compassion influenced their ability to maintain a compassionate stance. The importance of appropriate training and support structures is discussed, alongside recommendations to support the development of compassionate acute mental health care.

Healthcare professionals' involvement in breaking bad news to newly diagnosed patients with motor neurodegenerative conditions: a qualitative study.

PURPOSE: Research on breaking bad news (BBN) in healthcare has mostly focused on the doctor-patient interaction during a single consultation. However, it has been increasingly recognised that BBN is a wider process that also involves other healthcare professionals. This qualitative study explored non-medical1 healthcare professionals' involvement in BBN to newly diagnosed patients with motor neurodegenerative conditions in the UK. MATERIALS AND METHODS: 19 healthcare professionals working with people with motor neurone disease, multiple sclerosis, Parkinson's disease or Huntington's disease took part in individual, semi-structured interviews which were analysed using thematic analysis. RESULTS: Four themes were constructed: dealing with the diagnostic aftermath, unpacking the diagnosis, breaking bad news as a balancing act and empowering patients to regain control over their health and lives. Participants reported being broadly involved in BBN by supporting patients with negative diagnostic experiences, re-iterating diagnostic information and helping patients understand the impact of their condition. The challenges of effectively breaking bad news and how these difficult conversations could help empower patients were also emphasised. CONCLUSIONS: BBN was a critical and challenging aspect of healthcare professionals' clinical work with newly diagnosed patients with motor neurodegenerative conditions. Besides providing information, BBN was perceived as a way to educate patients, encourage them to make decisions and prepare for the future.Implications for rehabilitationBreaking bad news is a potentially under-recognised but significant aspect in the neurorehabilitation of neurodegenerative conditions.Listening to patients' stories about a long and occasionally unsatisfactory diagnostic journey and allowing them to express their frustration can be critical in regaining patients' trust and building a relationship with them.Newly diagnosed patients have not always received adequate information about their condition at diagnosis or they might have not understood or retained that information. It is, therefore, essential that patients' understanding of their condition is assessed, misconceptions are cleared and appropriate information about the nature and impact of the diagnosis is provided.Irrespective of the length of experience, breaking bad news was perceived as a multi-faceted, challenging, stressful and emotionally demanding task.Formal support and specialised training on breaking the bad news that addresses the incurable, unpredictable and progressive nature of motor neurodegenerative conditions could help professionals with this challenging task.

Eocene animal trace fossils in 1.7-billion-year-old metaquartzites.

The Paleoproterozoic (1.7 Ga [billion years ago]) metasedimentary rocks of the Mount Barren Group in southwestern Australia contain burrows indistinguishable from ichnogenera Thalassinoides, Ophiomorpha, Teichichnus, and Taenidium, known from firmgrounds and softgrounds. The metamorphic fabric in the host rock is largely retained, and because the most resilient rocks in the sequence, the metaquartzites, are too hard for animal burrowing, the trace fossils have been interpreted as predating the last metamorphic event in the region. Since this event is dated at 1.2 Ga, this would bestow advanced animals an anomalously early age. We have studied the field relationships, petrographic fabric, and geochronology of the rocks and demonstrate that the burrowing took place during an Eocene transgression over a weathered regolith. At this time, the metaquartzites of the inundated surface had been weathered to friable sandstones or loose sands (arenized), allowing for animal burrowing. Subsequent to this event, there was a resilicification of the quartzites, filling the pore space with syntaxial quartz cement forming silcretes. Where the sand grains had not been dislocated during weathering, the metamorphic fabric was seemingly restored, and the rocks again assumed the appearance of hard metaquartzites impenetrable to animal burrowing.

Participatory Development Process of Two Human Dimension Intervention Programs to Foster Physical Fitness and Psychological Health and Well-Being in Wildland Firefighting.

Intervention programs designed, delivered, and evaluated by and within organizations are a critical component in the promotion of employee health and well-being and in the prevention of occupational injury. Critical for transference of findings across complex occupational settings is a clearly articulated development process, a reliance on and evaluation of underlying theoretical foundations, and the inclusion of relevant outcomes emerging out of participatory action processes. To date, there have been no documented efforts outlining the development, implementation, or evaluation of human dimension intervention programs targeting wildland firefighters. The purpose of this paper is to outline the development of two collaborative and participatory intervention programs, targeting wildland firefighters' physical and psychological health and well-being. Two human dimension intervention programs were developed in a collaborative, iterative and participatory process following the Context-Content-Process-Outcomes Framework. First, a physical fitness training intervention program was designed to maintain wildland firefighter's physical fitness levels and attenuate risk of injury. Second, a psychosocial education intervention program was developed to mitigate the impact of psychosocial risk factors, foster work engagement, and decrease job stress. The current study provides evidence for the capacity of researchers and organizations to collaboratively develop practical programs primed for implementation and delivery.

Neurologists' current practice and perspectives on communicating the diagnosis of a motor neurodegenerative condition: a UK survey.

BACKGROUND: The communication of a life-changing diagnosis can be a difficult task for doctors with potential long-term effects on patient outcomes. Although several studies have addressed the experiences of individuals with motor neurodegenerative diseases in receiving this diagnosis, a significant research gap exists regarding professionals' perspectives, especially in the UK. This study aimed to assess UK neurologists' current practice and perspectives on delivering the diagnosis of a motor neurodegenerative disease, explore different aspects of the process and detail the potential challenges professionals might face. METHODS: We conducted an anonymised online survey with 44 questions, grouped into four sections; basic demographic information, current practice, the experience of breaking bad news and education and training needs. RESULTS: Forty-nine professionals completed the survey. Overall, participants seemed to meet the setting-related standards of good practice; however, they also acknowledged the difficulty of this aspect of their clinical work, with about half of participants (46.5%) reporting moderate levels of stress while breaking bad news. Patients' relatives were not always included in diagnostic consultations and participants were more reluctant to promote a sense of optimism to patients with poorer prognosis. Although professionals reported spending a mean of around 30-40 min for the communication of these diagnoses, a significant proportion of participants (21-39%) reported significantly shorter consultation times, highlighting organisational issues related to lack of capacity. Finally, the majority of participants (75.5%) reported not following any specific guidelines or protocols but indicated their interest in receiving further training in breaking bad news (78.5%). CONCLUSIONS: This was the first UK survey to address neurologists' practice and experiences in communicating these diagnoses. Although meeting basic standards of good practice was reported by most professionals, we identified several areas of improvement. These included spending enough time to deliver the diagnosis appropriately, including patients' relatives as a standard, promoting a sense of hope and responding to professionals' training needs regarding breaking bad news.

Giving and receiving a diagnosis of a progressive neurological condition: A scoping review of doctors' and patients' perspectives.

OBJECTIVE: Delivering a life changing diagnosis can be a distressing experience for patients and a challenging task for professionals. Diagnosis delivery can be especially difficult for individuals with neurodegenerative diseases such as motor neurone disease (MND), multiple sclerosis (MS) and Parkinson's disease (PD). This review aims to scope the literature on doctors' and patients' perspectives on diagnosis delivery for these conditions in order to enhance our understanding in this area and identify potential research gaps. METHODS: A scoping review methodology was used, and data were summarised using content analysis. RESULTS: 47 studies fulfilled the inclusion criteria. Studies showed that although patients were generally satisfied with diagnosis delivery, a considerable proportion was still dissatisfied with aspects of the consultation, especially the information and time provided and the doctor's approach. Only six studies addressed doctors' perspectives, which focused more on doctors' practice. CONCLUSION: There was a significant research gap in professionals' perspectives. The review also found that although basic standards of good practice were being met, a significant proportion of patients were dissatisfied with diagnosis communication. PRACTICE IMPLICATIONS: Professionals delivering such diagnoses need to assess and respond to patients' information needs, provide time for questions and maintain an empathic attitude.

An exploration of medical student attitudes towards disclosure of mental illness.

Background: Medical students are reluctant to access mental health services, despite having high rates of anxiety and depression. This reluctance persists through residency and into practice. Physicians and trainees who are unwell deliver lower quality patient care, behave less professionally, communicate less effectively and are at an increased risk for burnout and suicide. Little is known about whether students would disclose a mental health diagnosis on a state board medical license application.Objectives: The objectives of this study were to determine whether University of New Mexico School of Medicine (UNM SOM) students would be willing to disclose a mental health diagnosis on a medical licensing application if prompted to do so, and, if not, to identify the reasons for their unwillingness to do so.Design: We electronically invited all UNM SOM students enrolled in the Classes of 2019, 2020, 2021, and 2022 to participate in a confidential RedCap survey about mental health diagnoses and treatment. Four e-mail invitations and reminders were sent to students over a one-month period.Results: Response rate was 50.1%. Thirty-six percent of all respondents considered themselves to have had a mental health condition prior to medical school, and 47% of all respondents perceived a decline in mental health during medical school. The majority of respondents who perceived they had a mental health diagnosis (51%) stated they would not disclose this information on a New Mexico Medical Board (NMMB) license application. Fear of stigmatization, fear of repercussions, and a belief that such disclosure was irrelevant were the top reasons for non-disclosure.Conclusion: Students who perceive themselves to have mental health diagnoses are unlikely to disclose their mental health status on state medical board licensing applications when asked to do so. Addressing barriers to disclosure of mental health diagnoses is necessary for building a healthier physician workforce.

Musculoskeletal Preparticipation Physical Evaluation-Does it Lead to Decreased Musculoskeletal Morbidity?

A preparticipation physical evaluation (PPE) is a requirement that many athletes must complete before participating in organized sports. Currently, the traditional musculoskeletal (MSK) portion of the PPE lacks robust evidence to support its ability to accurately predict those at greater risk for MSK injury. Functional movement testing has garnered attention for potential use in the PPE having shown some promise for greater sensitivity at identifying those at greater risk for MSK injury. Despite the widespread use of MSK PPE screening to identify athletes at greater risk for MSK injury, there is no significant evidence demonstrating that subsequent interventions result in decreased MSK injury.

Experiences of clinical psychologists working in palliative care: A qualitative study.

BACKGROUND: Compassion fatigue refers to the emotional and physical exhaustion felt by professionals in caring roles, whereas compassion satisfaction encompasses the positive aspects of helping others. Levels of compassion satisfaction and fatigue have been found to be inconsistent in palliative care professionals, which could have serious implications for patients, professionals and organisations. OBJECTIVES: This study explored the experiences of clinical psychologists working in palliative care, all worked with adults with cancer, to gain an understanding of the impact this work has on their self and how they manage this. METHODS: A qualitative approach was taken, using semi-structured interviews and interpretative phenomenological analysis. RESULTS: Three superordinate themes were identified: commitment, existential impact on the self and the oracle. The participants' experiences were characterised by the relationship between themselves and their patients, the influence of working in palliative services on their world view and the impact of organisational changes. Differences between working as a clinical psychologist in palliative care versus non-palliative settings were considered. CONCLUSIONS: Professionals working in palliative care should be supported to reflect on their experiences of compassion and resilience, and services should provide resources that facilitate staff to practice positive self-care to maintain their well-being.

Critical Evaluation of the Methodologic Quality of the Top 50 Cited Articles Relating to Knee Dislocation and Multiligamentous Knee Injury.

BACKGROUND: Many studies have evaluated the management of knee dislocations (KDs) and multiligamentous knee injuries (MLKIs). However, no study to date has analyzed the quality of the most cited articles in this literature. HYPOTHESIS: There is a positive correlation between the number of article citations in the KD and MLKI literature and their methodologic quality. STUDY DESIGN: Systematic review. METHODS: The Web of Science online database was searched to identify the top 50 cited articles in KD and MLKI care. Demographic data were recorded for each study. The Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies (MINORS) were used to analyze the methodological quality of each article. Spearman correlation coefficients (r s) were then calculated. RESULTS: The articles identified were published between 1958 and 2015 in a wide variety of peer-reviewed journals (n = 16). The majority of study level of evidence (LOE) was of low quality (level 5, 16%; level 4, 54%; level 3, 16%; level 2, 14%). There were no studies of level 1 evidence. The mean MCMS and MINORS scores were 29.0 (SD, 19.1; range, 3-72) and 6.1 (SD, 3.7; range, 0-14), respectively. No significant correlation was identified between the number of citations and the publication year, LOE, MCMS, or MINORS (r s = 0.123 [P = .396]; r s = 0.125 [P = .389]; r s = 0.182 [P = .204]; and r s = 0.175 [P = .224], respectively). Positive correlations were observed between improved MCMS and MINORS scores and more recent year of publication (r s = 0.43 [P = .002]; r s = 0.32 [P = .022]) as well as improved study LOE (r s = 0.65 [P < .001]; r s = 0.67 [P < .001]). CONCLUSION: The top 50 cited articles on KD and MLKI care consisted of low LOE and methodological quality, with no existing level 1 articles. There was no significant correlation between the number of citations and publication year, LOE, or study methodological quality. Positive correlations were observed between later publication date and improved methodological quality.

Clinical communication and the 'triangle of care' in mental health and deafness: Sign language interpreters' perspectives.

Objective To explore the processes by which therapeutic alliance develops in mental health consultations with Sign Language interpreters. Method Semi-structured interviews with 7 qualified interpreters were transcribed and analysed with interpretative phenomenological analysis. Results Two key themes were generated: (1) Nurturing the triangle of care, where the therapeutic process relied on collaboration, continuity, and trust; and (2) Shared vision and knowledge, in which participants felt misunderstood and unsupported; there was a lack of deaf awareness and clinicians appeared to feel deskilled. Conclusions Interpreters should be viewed as valued members of clinical teams and have access to clinical supervision so that they can be supported in interpreting emotional distressing content. Clinicians can aim to be collaborative with interpreters and improve their knowledge of mental health issues that are relevant to deaf people. Practice Implications An aide-memoire of the role and practicalities of working with SL interpreters should be developed and disseminated to relevant services to support collaborative working with clinicians. A core competence in SL interpreter training is reflexivity. This should be embedded in educational curricula and facilitated through clinical supervision. Funding by commissioning services should be subject to services being deaf aware and interpreters being mental health aware.

Photoelectrocatalytic H2 evolution from integrated photocatalysts adsorbed on NiO.

A new approach to increasing the faradaic efficiency of dye-sensitised photocathodes for H2 evolution from water, using integrated photocatalysts, furnished with ester groups on the peripheral ligands, [Ru(decb)2(bpt)PdCl(H2O)](PF6)2 (1) and [Ru(decb)2(2,5-bpp)PtI(CH3CN)](PF6)2 (2), (decb = 4,4'-diethylcarboxy-2,2'-bipyridine, bpp = 2,2':5',2''-terpyridine, bpt = 3,5-bis(2-pyridyl)-1,2,4-triazole) is described. Overall, 1|NiO is superior to previously reported photocathodes, producing photocurrent densities of 30-35 µA cm-2 at an applied bias of -0.2 V vs. Ag/AgCl over 1 hour of continuous white light irradiation, resulting in the generation of 0.41 µmol h-1 cm-2 of H2 with faradaic efficiencies of up to 90%. Furthermore, surface analysis of the photocathodes before and after photoelectrocatalysis revealed that the ruthenium bipyridyl chromophore and Pd catalytic centre (1) were photochemically stable, highlighting the benefits of the approach towards robust, hybrid solar-to-fuel devices.

'I have a feeling I can't speak to anybody': A thematic analysis of communication perspectives in people with Huntington's disease.

OBJECTIVES: This study explored the perspectives of people affected by Huntington's disease (HD) on their own communicative abilities. METHODS: Qualitative semi-structured interviews were carried out with eight people with early HD. The data were analysed through thematic analysis. RESULTS: Four themes were constructed from the data, characterised by the following core topics: How HD directs and mediates communication; Regaining control to improve communication; Emotional outflows into communication and the struggle for separation; Sheltering as a way to boost confidence in communication. DISCUSSION: Separating patients' identity as individuals from that of a person with a disease can help increase communicative control. Consistent with the general theory and model of self-regulation, patients should be allowed a wider range of choices to regain control over communication. Achieving better emotion regulation is of paramount importance for communication, and factors such as medication regimes, relationships and existing coping strategies should be strengthened. Consistent with previous research, feelings of safety and the idea of a safe place ('sheltering') represent an effective coping mechanism. Practical implications include the refinement of communication and relationships among clinicians, caregivers, and patients with HD by considering a wider range of medical, psychological and socio-environmental factors.

New Perspectives on Emotional Processing in People with Symptomatic Huntington's Disease: Impaired Emotion Regulation and Recognition of Emotional Body Language†.

OBJECTIVE: Emotion regulation and emotional body language (EBL) recognition represent two fundamental components of emotional processing that have recently seen a considerable surge in research interest, in part due to the role they play in optimizing mental health. This appears to be particularly true for clinical conditions that can profoundly affect emotional functioning. Among these is Huntington's disease (HD), a neurodegenerative disorder that is associated with several psychological difficulties and cognitive impairments, including well-established deficits in facial emotion recognition. However, although the theoretical case for impairments is strong, the current evidence in HD on other components such as emotion regulation and EBL recognition is sparse. METHOD: In this study, it was hypothesized that emotion regulation and recognition of EBL are impaired in people with symptomatic HD, and that these impairments significantly and positively correlate with each other. A between-subjects design was adopted to compare 13 people with symptomatic HD with 12 non-affected controls matched for age and education. RESULTS: The results showed that emotion regulation and EBL recognition were significantly impaired in individuals with HD. Moreover, a significant positive correlation was observed between facial and EBL recognition impairments, whereas EBL performance was negatively related to the disease stage. However, emotion regulation and recognition performances were not significantly correlated. CONCLUSIONS: This investigation represents the first evidence of a deficit of emotion regulation and EBL recognition in individuals with HD. The clinical implications of these findings are explored, and indications for future research are proposed.

A new scale measuring adaptive perceived control for people with Parkinson's: Initial construction and further validation.

INTRODUCTION: Perceived control is an important concept in understanding adjustment to chronic conditions such as Parkinson's. While generic measures have been used to measure the construct in Parkinson's, no Parkinson's-specific scale currently exists. This study outlines the initial development and further validation of a free-to-use scale, the Parkinson's UK Scale of Perceived Control (PUKSoPC). METHOD: Focus groups were used to create items for the new scale. Potential items were then subject to screening for readability and coherence by people affected by the condition. This left 49 items that were then completed, along with other measures, by 231 people with Parkinson's. Exploratory factor analysis then created a 15-item scale with five distinct subscales. This initial structure was then further tested using confirmatory factor analysis with 2032 people with Parkinson's. Structural equation modelling confirmed the acceptability of the total scale and subscale structures. RESULTS: The final scale is concluded to be a psychometrically robust measure of perceived control. It has good face validity, evidence of convergent and criterion (concurrent and divergent) validity, good test-retest reliability and is internally coherent, with a demonstrably solid factor structure. While further testing would be useful to assess the scale's predictive ability, it is currently considered robust enough for more widespread use. CONCLUSION: The PUKSoPC is an appropriate scale to provide a more comprehensive measure of perceived control. It is preferable to single item, non-validated measures and can provide evidence of perceptions of control across a number of domains important in the measurement of the construct.

Exploring emotion regulation and emotion recognition in people with presymptomatic Huntington's disease: The role of emotional awareness.

Interest in the role of both emotion regulation and recognition in our understanding of mental health has been steadily increasing, especially in people with chronic illness who also have psychological difficulties. One illness which belongs to this category is Huntington's disease. Huntington's disease (HD) is a chronic neurodegenerative disorder that can cause a number of cognitive and psychological difficulties, including emotion recognition deficits, even before the onset of the symptoms required to make a formal diagnosis. Despite the lack of definite evidence, recent studies have suggested that deficits of emotion regulation and recognition may be expected to play a pivotal role in the early cognitive manifestations of HD. In this study, we hypothesised that the ability to regulate emotions can be impaired in people with presymptomatic HD, and that such impairment may be associated with a deficit of emotion recognition. To test this, an online survey was carried out with 117 English and Italian-speaking people with presymptomatic HD, compared to 217 controls matched for age and education. The results suggest that, in presymptomatic participants, emotion regulation and emotion recognition are generally not significantly impaired, and no significant relationships between performances on the two constructs were observed. However, a specific impairment in emotional awareness (a subscale on the Difficulties in Emotion Regulation Scale, DERS) was observed, which appears to be enhanced by the co-occurrence of depressive symptoms, even at a subclinical level. Consequently, it is suggested that difficulties in emotional awareness may represent a precursor of more general emotion recognition impairments, which only become apparent as the disease reaches a more symptomatic level. Clinical implications of the findings are discussed and directions for future research are proposed.

Do doctors' attachment styles and emotional intelligence influence patients' emotional expressions in primary care consultations? An exploratory study using multilevel analysis.

OBJECTIVE: To investigate whether and how doctors' attachment styles and emotional intelligence (EI) might influence patients' emotional expressions in general practice consultations. METHODS: Video recordings of 26 junior doctors consulting with 173 patients were coded using the Verona Coding Definition of Emotional Sequences (VR-CoDES). Doctors' attachment style was scored across two dimensions, avoidance and anxiety, using the Experiences in Close Relationships: Short Form questionnaire. EI was assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test. Multilevel Poisson regressions modelled the probability of patients' expressing emotional distress, considering doctors' attachment styles and EI and demographic and contextual factors. RESULTS: Both attachment styles and EI were significantly associated with frequency of patients' cues, with patient- and doctor-level explanatory variables accounting for 42% of the variance in patients' cues. The relative contribution of attachment styles and EI varied depending on whether patients' presenting complaints were physical or psychosocial in nature. CONCLUSION: Doctors' attachment styles and levels of EI are associated with patients' emotional expressions in primary care consultations. Further research is needed to investigate how these two variables interact and influence provider responses and patient outcomes. PRACTICE IMPLICATIONS: Understanding how doctors' psychological characteristics influence PPC may help to optimise undergraduate and postgraduate medical education.

Exploring the geochemical distribution of organic carbon in early land plants: a novel approach.

Terrestrialization depended on the evolution of biosynthetic pathways for biopolymers including lignin, cutin and suberin, which were concentrated in specific tissues, layers or organs such as the xylem, cuticle and roots on the submillimetre scale. However, it is often difficult, or even impossible especially for individual cells, to resolve the biomolecular composition of the different components of fossil plants on such a scale using the well-established coupled techniques of gas chromatography/mass spectrometry and liquid chromatography/mass spectrometry. Here, we report the application of techniques for surface analysis to investigate the composition of Rhynia gwynne-vaughanii X-ray photoelectron spectroscopy of two different spots (both 300 µm × 600 µm) confirmed the presence of carbon. Time-of-flight secondary ion mass spectrometry (ToF-SIMS) revealed 'chemical maps' (imaging mode with 300 nm resolution) of aliphatic and aromatic carbon in the intact fossil that correlate with the vascular structures observed in high-resolution optical images. This study shows that imaging ToF-SIMS has value for determining the location of the molecular components of fossil embryophytes while retaining structural information that will help elucidate how terrestrialization shaped the early evolution of land plant cell wall biochemistry.This article is part of a discussion meeting issue 'The Rhynie cherts: our earliest terrestrial ecosystem revisited'.