Sociodemographic and educational characteristics of doctors applying for psychiatry training in the UK: secondary analysis of data from the UK Medical Education Database project.

Aims and methodWorkforce shortages in psychiatry are common worldwide. The international literature provides insights into factors influencing decisions to train in psychiatry but is predominately survey based. This national cohort study aimed to identify the characteristics of doctors who were most likely to apply to psychiatry training programmes. The sample comprised doctors who entered UK medical schools in 2007/8 and who made first-time specialty training applications in 2015. The association between application to psychiatry and doctors' sociodemographic and educational characteristics was examined using multivariable logistic regression. RESULTS: Those most likely to apply were White, privately educated older doctors with below average performance at medical school.Clinical implicationsTo reduce workforce shortages, psychiatry must make itself more attractive to all doctors, especially those from underrepresented groups such as state-educated Black and minority ethnic individuals. Otherwise, national policies to widen participation in the study of medicine by such groups may exacerbate the current recruitment crisis.Declaration of interestNone.

Factors associated with junior doctors' decisions to apply for general practice training programmes in the UK: secondary analysis of data from the UKMED project.

BACKGROUND: The UK, like many high-income countries, is experiencing a worsening shortfall of general practitioners (GPs) alongside an increasing demand for their services. At the same time, factors influencing junior doctors' decisions to apply for GP training are only partially understood and research in this area has been hampered by the difficulties in connecting the datasets that map the journey from student to qualified GP. The UK Medical Education Database (UKMED) has been established to ameliorate this problem by linking institutional data across the spectrum of medical education from school to specialty training. Our study aimed to use UKMED to investigate which demographic and educational factors are associated with junior doctors' decisions to apply for GP training. METHODS: Study data, provided by the UKMED Development Group and accessed remotely, contained longitudinal educational and sociodemographic information on all doctors who entered UK medical schools in the 2007/2008 academic year and who made first-time specialty training applications in 2015. We used multivariable logistic regression models to investigate two binary outcomes, namely (1) application to GP training, possibly alongside applications to other specialties, and (2) application solely to GP training. RESULTS: Of 7634 doctors in the sample, 43% applied to GP training possibly alongside other specialities and 26% applied solely to GP training. The odds of applying to GP training were associated with particular demographic factors (being female, non-white or secondary educated in the UK increased the odds of application) and educational factors (non-graduate entry, intercalation and above-median academic performance during medical school all decreased the odds of application). After adjusting for these factors, both the medical school and the foundation school attended were independently associated with the odds of applying to GP training. CONCLUSIONS: Our findings suggest that the supply and demand imbalance in UK primary care might be improved by (1) efforts to attract greater numbers of female, non-white and UK secondary-educated students into medical schools, and (2) targeting resources at medical and foundation schools that deliver doctors likely to fill significant gaps in the workforce. Further research is required to better understand inter-school differences and to develop strategies to improve recruitment of GP trainees.

Test-retest stability of patient experience items derived from the national GP patient survey.

PURPOSE: The validity and reliability of various items on the GP Patient Survey (GPPS) survey have been reported, however stability of patient responses over time has not been tested. The purpose of this study was to determine the test-retest reliability of the core items from the GPPS. METHODS: Patients who had recently consulted participating GPs in five general practices across the South West England were sent a postal questionnaire comprising of 54 items concerning their experience of their consultation and the care they received from the GP practice. Patients returning the questionnaire within 3 weeks of mail-out were sent a second identical (retest) questionnaire. Stability of responses was assessed by raw agreement rates and Cohen's kappa (for categorical response items) and intraclass correlation coefficients and means (for ordinal response items). RESULTS: 348 of 597 Patients returned a retest questionnaire (58.3 % response rate). In comparison to the test phase, patients responding to the retest phase were older and more likely to have white British ethnicity. Raw agreement rates for the 33 categorical items ranged from 66 to 100 % (mean 88 %) while the kappa coefficients ranged from 0.00 to 1.00 (mean 0.53). Intraclass correlation coefficients for the 21 ordinal items averaged 0.67 (range 0.44-0.77). CONCLUSIONS: Formal testing of items from the national GP patient survey examining patient experience in primary care highlighted their acceptable temporal stability several weeks following a GP consultation.

Interpreting multisource feedback: online study of consensus and variation among GP appraisers.

BACKGROUND: GPs collect multisource feedback (MSF) about their professional practice and discuss it at appraisal. Appraisers use such information to identify concerns about a doctor's performance, and to guide the doctor's professional development plan (PDP). AIM: To investigate whether GP appraisers detect variation in doctors' MSF results, and the degree of consensus in appraisers' interpretations of this information. DESIGN AND SETTING: Online study of GP appraisers in north-east England. METHOD: GP appraisers were invited to review eight anonymised doctors' MSF reports, which represented different patterns of scores on the UK General Medical Council's Patient and Colleague Questionnaires. Participants provided a structured assessment of each doctor's report, and recommended actions for their PDP. Appraiser ratings of each report were summarised descriptively. An 'agreement score' was calculated for each appraiser to determine whether their assessments were more lenient than those of other participants. RESULTS: At least one report was assessed by 101/146 appraisers (69%). The pattern of appraisers' ratings suggested that they could detect variation in GPs' MSF results, and recommend reasonable actions for the doctors' PDP. Increasing appraiser age was associated with more favourable interpretations of MSF results. CONCLUSION: Although preliminary, the finding of broad consensus among GP appraisers in their assessment of MSF reports should be reassuring for GPs, appraisers, and employing organisations. However, if older appraisers are more lenient than younger appraisers in their interpretation of MSF and in the actions they suggest to their appraisees as a result, organisations need to consider what steps could be taken to address such differences.

Rising to the challenge: acute stress appraisals and selection centre performance in applicants to postgraduate specialty training in anaesthesia.

The ability to work under pressure is a vital non-technical skill for doctors working in acute medical specialties. Individuals who evaluate potentially stressful situations as challenging rather than threatening may perform better under pressure and be more resilient to stress and burnout. Training programme recruitment processes provide an important opportunity to examine applicants' reactions to acute stress. In the context of multi-station selection centres for recruitment to anaesthesia training programmes, we investigated the factors influencing candidates' pre-station challenge/threat evaluations and the extent to which their evaluations predicted subsequent station performance. Candidates evaluated the perceived stress of upcoming stations using a measure of challenge/threat evaluation-the cognitive appraisal ratio (CAR)-and consented to release their demographic details and station scores. Using regression analyses we determined which candidate and station factors predicted variation in the CAR and whether, after accounting for these factors, the CAR predicted candidate performance in the station. The CAR was affected by the nature of the station and candidate gender, but not age, ethnicity, country of training or clinical experience. Candidates perceived stations involving work related tasks as more threatening. After controlling for candidates' demographic and professional profiles, the CAR significantly predicted station performance: 'challenge' evaluations were associated with better performance, though the effect was weak. Our selection centre model can help recruit prospective anaesthetists who are able to rise to the challenge of performing in stressful situations but results do not support the direct use of challenge/threat data for recruitment decisions.

Understanding high and low patient experience scores in primary care: analysis of patients' survey data for general practices and individual doctors.

OBJECTIVES: To determine the extent to which practice level scores mask variation in individual performance between doctors within a practice. DESIGN: Analysis of postal survey of patients' experience of face-to-face consultations with individual general practitioners in a stratified quota sample of primary care practices. SETTING: Twenty five English general practices, selected to include a range of practice scores on doctor-patient communication items in the English national GP Patient Survey. PARTICIPANTS: 7721 of 15,172 patients (response rate 50.9%) who consulted with 105 general practitioners in 25 practices between October 2011 and June 2013. MAIN OUTCOME MEASURE: Score on doctor-patient communication items from post-consultation surveys of patients for each participating general practitioner. The amount of variance in each of six outcomes that was attributable to the practices, to the doctors, and to the patients and other residual sources of variation was calculated using hierarchical linear models. RESULTS: After control for differences in patients' age, sex, ethnicity, and health status, the proportion of variance in communication scores that was due to differences between doctors (6.4%) was considerably more than that due to practices (1.8%). The findings also suggest that higher performing practices usually contain only higher performing doctors. However, lower performing practices may contain doctors with a wide range of communication scores. CONCLUSIONS: Aggregating patients' ratings of doctors' communication skills at practice level can mask considerable variation in the performance of individual doctors, particularly in lower performing practices. Practice level surveys may be better used to "screen" for concerns about performance that require an individual level survey. Higher scoring practices are unlikely to include lower scoring doctors. However, lower scoring practices require further investigation at the level of the individual doctor to distinguish higher and lower scoring general practitioners.

Why do GPs exclude patients from participating in research? An exploration of adherence to and divergence from trial criteria.

BACKGROUND: The role of GPs in recruiting or excluding participants critically underpins the feasibility, external validity and generalizability of primary care research. A better understanding of this role is needed. AIM: To investigate why GPs excluded potentially eligible participants from a large scale randomized controlled trial (RCT), to determine the proportion of patients excluded on account of trial eligibility compared with other reasons, and to explore the impact of such exclusions on the management and generalizability of RCTs. DESIGN AND SETTING: Secondary analysis of data from the CoBalT study, a multi-centre general-practice-based RCT investigating cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression. METHOD: GPs were asked to screen patient lists generated from computerized record searches for trial eligibility and to provide narrative reasons for excluding patients. These reasons were coded independently by two researchers, with a third researcher resolving discrepancies. RESULTS: Thirty-one percent (4750/15,379) of patients were excluded at the GP screening stage, including 663 on patient lists that remained unscreened. Of the 4087 actively excluded patients, 67% were excluded on account of trial exclusion criteria, 20% for other criteria (half of which were comorbid conditions) and 13% without reason. CONCLUSION: Clear, comprehensive criteria, particularly with regards to comorbidities, are required for GPs to confidently screen patients for potential participation in research. Future studies should promote inclusivity and encourage GPs to adopt a liberal approach when screening patient lists. This would enhance the validity and generalizability of primary care research and encourage greater patient autonomy.

Factors affecting patients' trust and confidence in GPs: evidence from the English national GP patient survey.

OBJECTIVES: Patients' trust in general practitioners (GPs) is fundamental to effective clinical encounters. Associations between patients' trust and their perceptions of communication within the consultation have been identified, but the influence of patients' demographic characteristics on these associations is unknown. We aimed to investigate the relative contribution of the patient's age, gender and ethnicity in any association between patients' ratings of interpersonal aspects of the consultation and their confidence and trust in the doctor. DESIGN: Secondary analysis of English national GP patient survey data (2009). SETTING: Primary Care, England, UK. PARTICIPANTS: Data from year 3 of the GP patient survey: 5 660 217 questionnaires sent to patients aged 18 and over, registered with a GP in England for at least 6 months; overall response rate was 42% after adjustment for sampling design. OUTCOME MEASURES: We used binary logistic regression analysis to investigate patients' reported confidence and trust in the GP, analysing ratings of 7 interpersonal aspects of the consultation, controlling for patients' sociodemographic characteristics. Further modelling examined moderating effects of age, gender and ethnicity on the relative importance of these 7 predictors. RESULTS: Among 1.5 million respondents (adjusted response rate 42%), the sense of 'being taken seriously' had the strongest association with confidence and trust. The relative importance of the 7 interpersonal aspects of care was similar for men and women. Non-white patients accorded higher priority to being given enough time than did white patients. Involvement in decisions regarding their care was more strongly associated with reports of confidence and trust for older patients than for younger patients. CONCLUSIONS: Associations between patients' ratings of interpersonal aspects of care and their confidence and trust in their GP are influenced by patients' demographic characteristics. Taking account of these findings could inform patient-centred service design and delivery and potentially enhance patients' confidence and trust in their doctor.

Accessing primary care: a simulated patient study.

BACKGROUND: Simulated patient, or so-called 'mystery-shopper', studies are a controversial, but potentially useful, approach to take when conducting health services research. AIM: To investigate the construct validity of survey questions relating to access to primary care included in the English GP Patient Survey. DESIGN AND SETTING: Observational study in 41 general practices in rural, urban, and inner-city settings in the UK. METHOD: Between May 2010 and March 2011, researchers telephoned practices at monthly intervals, simulating patients requesting routine, but prompt, appointments. Seven measures of access and appointment availability, measured from the mystery-shopper contacts, were related to seven measures of practice performance from the GP Patient Survey. RESULTS: Practices with lower access scores in the GP Patient Survey had poorer access and appointment availability for five out of seven items measured directly, when compared with practices that had higher scores. Scores on items from the national survey that related to appointment availability were significantly associated with direct measures of appointment availability. Patient-satisfaction levels and the likelihood that patients would recommend their practice were related to the availability of appointments. Patients' reports of ease of telephone access in the national survey were unrelated to three out of four measures of practice call handling, but were related to the time taken to resolve an appointment request, suggesting responders' possible confusion in answering this question. CONCLUSION: Items relating to the accessibility of care in a the English GP patient survey have construct validity. Patients' satisfaction with their practice is not related to practice call handling, but is related to appointment availability.

Self-other agreement in multisource feedback: the influence of doctor and rater group characteristics.

INTRODUCTION: Multisource feedback (MSF) ratings provided by patients and colleagues are often poorly correlated with doctors' self-assessments. Doctors' reactions to feedback depend on its agreement with their own perceptions, but factors influencing self-other agreement in doctors' MSF ratings have received little attention. We aimed to identify the characteristics of doctors and their rater groups that affect self-other agreement in MSF ratings. METHODS: We invited 2454 doctors to obtain patient and colleague feedback using the UK General Medical Council's MSF questionnaires and to self-assess on core items from both patient (PQ) and colleague (CQ) questionnaires. Correlations and differences between doctor, patient and colleague mean feedback scores were examined. Regression analyses identified the characteristics of doctors and their rater groups that influenced self-other score agreement. RESULTS: 1065 (43%) doctors returned at least one questionnaire, of whom 773 (73%) provided self and patient PQ scores and 1026 (96%) provided self and colleague CQ scores. Most doctors rated themselves less favourably than they were rated by either their patients or their colleagues. This tendency to underrate performance in comparison to external feedback was influenced by the doctor's place of training, clinical specialty, ethnicity and the profile of his/her patient and colleague rater samples but, in contrast to studies undertaken in nonmedical settings, was unaffected by age or gender. DISCUSSION: Self-other agreement in MSF ratings is influenced by characteristics of both raters and ratees. Managers, appraisers, and others responsible for interpreting and reviewing feedback results with the doctor need to be aware of these influences.

Multisource feedback in evaluating the performance of doctors: the example of the UK General Medical Council patient and colleague questionnaires.

PURPOSE: Internationally, there is increasing interest in monitoring and evaluating doctors' professional practice. Multisource feedback (MSF) offers one way of collecting information about doctors' performance. The authors investigated the psychometric properties of two questionnaires developed for this purpose and explored the biases that may exist within data collected via such instruments. METHOD: A cross-sectional study was conducted in 11 UK health care organizations during 2008-2011. Patients (n = 30,333) and colleagues (n = 17,012) rated the professional performance of 1,065 practicing doctors, using the General Medical Council Patient Questionnaire (PQ) and Colleague Questionnaire (CQ). The psychometric properties of the questionnaires were assessed, and regression modeling was used to explore factors that influenced patient and colleague responses on the core questionnaire items. RESULTS: Although the questionnaires demonstrated satisfactory internal consistency, test-retest reliability, and convergent validity, patient and colleague ratings were highly skewed toward favorable impressions of doctor performance. At least 34 PQs and 15 CQs were required to achieve acceptable reliability (G > 0.70). Item ratings were influenced by characteristics of the patient and colleague respondents and the context in which their feedback was provided. CONCLUSIONS: The PQ and CQ are acceptable for the provision of formative feedback on a doctor's professional practice within an appraisal process. However, biases identified in the questionnaire data suggest that caution is required when interpreting and acting on this type of information. MSF derived from these questionnaires should not be used in isolation to inform decisions about a doctor's fitness to practice medicine.