Why do students struggle in their first year of medical school? A qualitative study of student voices.

BACKGROUND: Struggling at medical school incorporates academic failure, course disruption and early course exit. Struggling is usually multi-factorial involving academic, personal, financial and health factors. Struggling students may fail to engage with available support. First year students are particularly susceptible as they transition to university and a professional career. METHODS: The study aim was to explore medical students' own voices on struggling and assess how they match up to existing literature. During one academic year, all first year medical students at the University of Birmingham (UK) who opted to leave or were required to withdraw (n = 52) were asked to participate in an individual exit interview. Fifteen students responded and fourteen (27%) agreed to be interviewed. Interviews were face to face (n = 10), telephone (n = 3) and via email (n = 1). Interviews were unstructured and led by a general open question. Framework analysis identified key data themes. RESULTS: Students described year one of medical school as a critical transition. They simultaneously needed to adapt to being a university student, a medical student and a doctor. A six-group typology of students emerged, each of which struggled with one or more of these adaptations. The groups were: wrong degree choice, mental health problems, acute crisis, at capacity, slow starter and family rock. Some students experienced an isolated problem from within this typology. Most had a multi-factorial story of struggling. Mental health problems and acute crises were the most common issues. Early professional identity formation was a key hurdle. Help-seeking behaviours were varied. CONCLUSIONS: This study explores the narratives of medical students who struggled from an early stage and presents a data-driven typology of their issues. It advances existing qualitative understanding of this topic, which to date is predominantly derived from educator perceptions and not specific to early course issues. Although our results broadly cohere with existing knowledge, we also present novel findings which may reflect our focus on first year students. Issues around early professional identity formation may reflect the increasing emphasis on professionalism in medical school curricula. Listening to these narratives could help university staff to identify students at risk of struggling for targeted support.

Work-life balance in medical students: self-care in a culture of self-sacrifice.

BACKGROUND: Work-life balance is a key contributor to doctors' wellbeing and consequently is a central factor in their career decisions. General Medical Council guidance outlines the importance of work-life balance as part of compassionate self-care. Learning self-care should begin as an undergraduate, when academic and clinical workload can contribute to stress, anxiety and burnout. METHODS: Sequential mixed methods study of medical students in Years 3-5 at the University of Birmingham, UK. Students (n = 145) defined work-life balance in free-text answers and self-assessed their current work-life balance via questionnaires. Following this, a sub-sample of students (n = 44) participated in exploratory individual mini-interviews. RESULTS: Work-life balance emerged as a broad and multifactorial concept. Questionnaire respondents most frequently referenced enjoyment, meeting work requirements and time management in their definitions. Interview participants highlighted additional influencing factors such as peer groups, study skills, family and professional culture. Students expect a significant shift towards work after graduating and expressed concerns about the stresses of delivering patient care. 42% (n = 60) of students felt they had received support with their work-life balance during their training, mostly from family and friends. Most students had not received support or advice on their work-life balance from University or hospital staff. CONCLUSION: Self-care and work-life balance are essential for medical students and doctors to cope with lifelong learning and deliver effective care. Medical school staff should be pro-active in supporting students to develop these skills, particularly during critical transition periods. Early interventions targeting study skills and time management may be beneficial. Further research should include students in Years 1-2 and compare different institutions.

Hypophosphatasia mimicking hypoxic-ischaemic encephalopathy: early recognition and management.

BACKGROUND: Hypophosphatasia (HPP) is a rare inherited disorder affecting bone and teeth development. Perinatal HPP is the most severe form and associated with a high mortality. Features include respiratory distress, skeletal abnormalities and low alkaline phosphatase (ALP) activity. CASE: A baby boy developed respiratory distress, hypotonia and seizures within an hour of birth. Blood gas showed mixed acidosis and abnormal base deficit. Hypoxic-ischaemic encephalopathy (HIE) was suspected and managed with therapeutic hypothermia. Subsequent investigations identified low ALP activity and abnormal bone mineralisation, leading to a diagnosis of HPP. On day 5 of life, enzyme replacement therapy (ERT) was commenced, its first use via direct NHS England funding since UK licensing in 2017. CONCLUSIONS: Early hypotonia is an atypical presentation for perinatal HPP. Combined with acidosis and encephalopathy, it can clinically mimic HIE. Early recognition of biochemical and radiological features of HPP is essential for rapid diagnosis and timely initiation of life-saving ERT.

A systematic review of supervisory relationships in general practitioner training.

OBJECTIVES: The educational alliance is argued to be at the heart of supervision in medical education. This review aims to map the research field and develop a conceptualisation of the nature of such educational alliances within postgraduate supervision for general practitioners. METHODS: An integrative review of the international literature on supervision from 2011 to 2018 was undertaken, and papers assessed for relevance and quality. Data analysis incorporated framework analysis techniques. Bordin's working alliance-based model of supervision was used as a springboard for synthesis, as well as allowing for the emergence of new ideas, theories and concepts from the literature. RESULTS: A total of 49 full texts were included for analysis. There was evidence of the importance of trust, agreement and bond in accordance with Bordin's model. The results also highlighted the importance of greater clarity on supervisory goals, and the tasks to support these goals, to effectively address competing priorities and roles within supervision. Non-hierarchical relationships were advocated, although supervisors must remain impartial in their assessment and monitoring roles. The influence of the wider practice community and situated learning through legitimate peripheral participation are documented. A model of General practice (GP) supervision is proposed that integrates the findings. CONCLUSIONS: GP supervision requires a greater emphasis than is suggested by the working alliance model, both on the clarity of expectations and the appreciation of the multiple roles and competing priorities of both trainee and supervisor. Furthermore, as GP supervision develops within the rising workload of contemporary general practice, the role of the wider community of practice may become more prominent. We have adapted the working alliance model for postgraduate General practice (GP) supervision, emphasising the explicit sharing of expectations relating to goals, tasks and roles to facilitate negotiation and agreement.

Does medical students' gender affect their clinical learning of gynaecological examination? A retrospective cohort study.

INTRODUCTION: Medical graduates should be competent in gynaecological examination as well as associated skills including speculum use and swabbing. Male and female medical students may have different opportunities to practise these skills in clinical environments, potentially impacting on confidence and competence. This study explores this further via reviewing students' learning experience in genitourinary medicine (GUM) and obstetrics and gynaecology (O&G) clinics. METHODS: Cross-sectional study of 759 year 4 and year 5 University of Birmingham medical students via an online questionnaire. This explored degree of participation, impact of gender and self-reported confidence. RESULTS: Overall response rate was 31% (233/759). Students of either gender who observed an examination being performed by a clinician were more likely to perform the same examination. Female students reported more opportunities to practise gynaecological examination and associated skills. Female students were more likely to be granted consent to perform speculum examinations, vaginal swabbing and vaginal bimanual examinations. Sixty-five per cent of male students felt that their gender affected their learning experience with female patients. Despite this, there was no significant difference in self-reported confidence level in performing gynaecological examinations between genders at the end of placement. CONCLUSION: The majority of male students perceived that their gender impacted their clinical experience in O&G and GUM. Self-reported confidence levels were unaffected, which could reflect varying approaches to competence between genders. The link between observing examinations and subsequent opportunities to practise is key. This could demonstrate students developing rapport and trust with patients, and clinicians' roles as gatekeepers.