Supervision, scheduling, satisfaction and shared working: how experiences of junior doctors relate to excess mortality within the NHS.

BACKGROUND: We sought to explore associations between trainee doctor perception and excess patient mortality. METHODS: Data from two publicly available databases reflecting mortality and components of trainee satisfaction within 81 NHS healthcare institutions between the years 2012 and 2019 were analysed. Pearson's correlation coefficients were calculated. RESULTS: All domains of trainee perception were correlated with excess mortality. Clinical supervision out of hours (R=-0.44; p<0.0001), teamwork (R=-0.36; p<0.0001) and clinical supervision at any time (R=-0.35; p<0.0001) were most strongly correlated. Most associations remained consistent year on year. CONCLUSION: Trainee doctor perceptions of clinical supervision, rota design and teamwork within the NHS are consistently correlated with excess patient mortality. Further exploration of these associations could identify opportunities for interventions to reduce excess patient mortality. Given the clinical significance of our findings, organisations should consider rapid implementation of evidence-based interventions where they exist.

Hospital Mortality and Trainee Experiences: How General Medical Council Survey Findings Correlate With Summary Hospital-Level Mortality Indicator.

OBJECTIVES: This study aimed to investigate whether components of junior doctor satisfaction are associated with patient mortality within the United Kingdom. METHODS: We conducted a cross-sectional study of publicly available data (the General Medical Council [GMC] National Survey and the Summary Hospital-level Mortality Indicator [SHMI]) pertaining to subjective physician trainee satisfaction and patient mortality within 80 United Kingdom-based healthcare institutions. The direction and strength of correlation between components of the GMC National Survey and relative patient mortality as described by the SHMI were calculated. Additional outcomes included mean GMC survey scores for reported domains and mean SHMI by healthcare institution. RESULTS: SHMI for included healthcare institutions ranged from 0.69 to 1.21 (mean [SD], 1.01 [0.1]). Mean GMC domain scores ranged between 44.61 and 88.62 (mean [SD], 71.16 [10.84]). Statistically significant correlations were observed for clinical supervision, clinical supervision out of hours, rota design, overall satisfaction, and teamwork. After application of Bonferroni correction, statistically significant correlations remained for both clinical supervision and clinical supervision out of hours. CONCLUSIONS: There is a significant association between components of subjective trainee satisfaction and patient mortality within the United Kingdom. Further investigation to examine these relationships, perhaps to target intervention, may prevent avoidable patient harm.

Shielding during medical training: an exploration of effects, consequences and best practices.

Background: Shielding during the COVID-19 pandemic impacted postgraduate medical training, likely affecting between 7% and 14% of trainees. We examine the burden of shielding on this cohort and provide strategies for future working practices. Methods: Seventeen postgraduate doctors in training took part in non-incentivised, virtual focus groups or interviews. Focus group content underwent thematic analysis. Results were validated in subsequent focused interviews. Results: Shielding trainees reported guilt, limited support and occasionally stigmatisation. Rotational changes and returning to work were also difficult and led to contractual challenges. Departmental support, IT provision and proactivity were key to successful shielding. Early discussion with training bodies was deemed essential to plan objective onward progression. Conclusion: As we enter an era of endemic COVID-19, adjusted working practices will continue. Embedding successful working practices for shielding at national and local levels will minimise the long-term impact on postgraduate medical training.

Medical students' pattern of self-directed learning prior to and during the coronavirus disease 2019 pandemic period and its implications for Free Open Access Meducation within the United Kingdom

PURPOSE: Self-directed learning (SDL) has been increasingly emphasized within medical education. However, little is known about the SDL resources medical students use. This study aimed to identify patterns in medical students' SDL behaviors, their SDL resource choices, factors motivating these choices, and the potential impact of the coronavirus disease 2019 (COVID-19) pandemic on these variables. Methods: An online cross-sectional survey comprising multiple-choice, ranked, and free-text response questions were disseminated to medical students across all 41 UK medical schools between April and July 2020. Independent study hours and sources of study materials prior to and during the COVID-19 pandemic were compared. Motivational factors guiding resource choices and awareness of Free Open Access Meducation were also investigated. Results: The target sample was 75 students per medical school across a total of 41 medical schools within the United Kingdom (3,075 total students), and 1,564 responses were analyzed. University-provided information comprised the most commonly used component of independent study time, but a minority of total independent study time. Independent study time increased as a result of the COVID-19 pandemic (P<0.001). All sub-cohorts except males reported a significant increase in the use of resources such as free websites and question banks (P<0.05) and paid websites (P<0.05) as a result of the pandemic. Accessibility was the most influential factor guiding resource choice (Friedman's µrank=3.97, P<0.001). Conclusion: The use of learning resources independent of university provision is increasing. Educators must ensure equitable access to such materials while supporting students in making informed choices regarding their independent study behaviors.

The GMC national training survey: Does it have an impact?

The General Medical Council (GMC) national trainee survey (NTS) monitors junior doctor training experience annually, which is then used by organisations such as Health Education England to inform quality management. Its validity as an assessment of the learning environment to drive improvement is frequently questioned; currently there are no published evidence-based studies to demonstrate its impact. To explore the effects of the GMC survey, we carried out a retrospective cohort study using publicly available GMC NTS survey data. We compared 2018 and 2019 scores in paediatrics in London across all 18 survey indicators, to identify any relationship between these 2 consecutive years of data. Our findings demonstrate that results of the GMC NTS in 1 year are associated with a change in the NTS the following year, with both an improvement in below average departments and deterioration in above average units. These findings suggest that annual GMC NTS results may have an impact on the quality of learning environments as measured in subsequent surveys - therefore they act as both a measure and a potential modifier of outcome.

Paediatric Free Open Access Meducation (FOAM): behaviours, trends and implications.

INTRODUCTION: Free Open Access Meducation (FOAM) describes online resources assisting learning in medicine. Little is known about users or their behaviours. METHODS: Using Google Analytics for a popular FOAM site (www.paedatricfoam.com), we explored user demographics and patterns of behaviour. We analysed these further with descriptive and statistical tests using SPSS (version 26). Data are presented as mean (SD). RESULTS: There were 181.44 (75.16) mean daily users accessing the site throughout a 4-month period during 2018/2019. 68.9% of users were female; 44% were 25-34 years; 57.3% used a mobile device. The mean session duration was 73.55 (9.41) seconds, with more time spent per session and a greater number of pages per session observed in users accessing the site from a desktop or tablet as opposed to a mobile phone. 84.3% of mobile users left the site after viewing a single page. Referral source was also associated with device used (p<0.001). Age was not related to user behaviours (p>0.05). DISCUSSION: FOAM is a rapidly developing form of medical education, with large user numbers seen for a site just 2 years old. The site is being used by many beyond its intended readership. Rather than accessing multiple pages from a desktop, users have varied online behaviours, with the majority viewing a single page on a mobile phone, referred by social media or Google. CONCLUSIONS: Google Analytics can powerfully display usage of medical websites but has important limitations if statistical exploration is required. FOAM users are a heterogenous group, and thus content should be designed with this in mind. Further research must be prioritised focussing on the scope, curriculum coverage, accuracy of information and the effectiveness of FOAM as an educational resource.

Virtual patients designed for training against medical error: Exploring the impact of decision-making on learner motivation.

OBJECTIVES: Medical error is a significant cause of patient harms in clinical practice, but education and training are recognised as having a key role in minimising their incidence. The use of virtual patient (VP) activities targeting training in medical error allows learners to practice patient management in a safe environment. The inclusion of branched decision-making elements in the activities has the potential to drive additional generative cognitive processing and improved learning outcomes, but the increased cognitive load on learning risks negatively affecting learner motivation. The aim of this study is to better understand the impact that the inclusion of decision-making and inducing errors within the VP activities has on learner motivation. METHODS: Using a repeated study design, over a period of six weeks we provided undergraduate medical students at six institutions in three countries with a series of six VPs written around errors in paediatric practice. Participants were divided into two groups and received either linearly structured VPs or ones that incorporated branched decision-making elements. Having completed all the VPs, each participant was asked to complete a survey designed to assess their motivation and learning strategies. RESULTS: Our analysis showed that in general, there was no significant difference in learner motivation between those receiving the linear VPs and those who received branched decision-making VPs. The same results were generally reflected across all six institutions. CONCLUSIONS: The findings demonstrated that the inclusion of decision-making elements did not make a significant difference to undergraduate medical students' motivation, perceived self-efficacy or adopted learning strategies. The length of the intervention was sufficient for learners to overcome any increased cognitive load associated with branched decision-making elements being included in VPs. Further work is required to establish any immediate impact within periods shorter than the length of our study or upon achieved learning outcomes.

Vocal Cord Palsy in Children With Cancer: A 10-Year Analysis of UK Pediatric Intensive Care Admissions.

Vocal cord palsy (VCP) is a rare but potentially life-threatening complication in children with cancer. This study reviews UK Intensive Care admissions for children with cancer and VCP using data obtained from the Pediatric Intensive Care Audit Network (PICANet) database. 26 children with cancer and VCP were admitted to intensive care from 2002 to 2012. The majority of admissions (23/26) required respiratory intervention (17 invasive ventilation, 8 noninvasive ventilation, and 5 tracheostomy). VCP should be considered early in children with cancer who present with signs of upper airway obstruction, especially in those receiving vinca-alkaloids as VCP is likely to be reversible.

Medical Student and Tutor Perceptions of Video Versus Text in an Interactive Online Virtual Patient for Problem-Based Learning: A Pilot Study.

BACKGROUND: The impact of the use of video resources in primarily paper-based problem-based learning (PBL) settings has been widely explored. Although it can provide many benefits, the use of video can also hamper the critical thinking of learners in contexts where learners are developing clinical reasoning. However, the use of video has not been explored in the context of interactive virtual patients for PBL. OBJECTIVE: A pilot study was conducted to explore how undergraduate medical students interpreted and evaluated information from video- and text-based materials presented in the context of a branched interactive online virtual patient designed for PBL. The goal was to inform the development and use of virtual patients for PBL and to inform future research in this area. METHODS: An existing virtual patient for PBL was adapted for use in video and provided as an intervention to students in the transition year of the undergraduate medicine course at St George's, University of London. Survey instruments were used to capture student and PBL tutor experiences and perceptions of the intervention, and a formative review meeting was run with PBL tutors. Descriptive statistics were generated for the structured responses and a thematic analysis was used to identify emergent themes in the unstructured responses. RESULTS: Analysis of student responses (n=119) and tutor comments (n=18) yielded 8 distinct themes relating to the perceived educational efficacy of information presented in video and text formats in a PBL context. Although some students found some characteristics of the videos beneficial, when asked to express a preference for video or text the majority of those that responded to the question (65%, 65/100) expressed a preference for text. Student responses indicated that the use of video slowed the pace of PBL and impeded students' ability to review and critically appraise the presented information. CONCLUSIONS: Our findings suggest that text was perceived to be a better source of information than video in virtual patients for PBL. More specifically, the use of video was perceived as beneficial for providing details, visual information, and context where text was unable to do so. However, learner acceptance of text was higher in the context of PBL, particularly when targeting clinical reasoning skills. This pilot study has provided the foundation for further research into the effectiveness of different virtual patient designs for PBL.

Exploring the efficacy of replacing linear paper-based patient cases in problem-based learning with dynamic Web-based virtual patients: randomized controlled trial.

BACKGROUND: Problem-based learning (PBL) is well established in medical education and beyond, and continues to be developed and explored. Challenges include how to connect the somewhat abstract nature of classroom-based PBL with clinical practice and how to maintain learner engagement in the process of PBL over time. OBJECTIVE: A study was conducted to investigate the efficacy of decision-PBL (D-PBL), a variant form of PBL that replaces linear PBL cases with virtual patients. These Web-based interactive cases provided learners with a series of patient management pathways. Learners were encouraged to consider and discuss courses of action, take their chosen management pathway, and experience the consequences of their decisions. A Web-based application was essential to allow scenarios to respond dynamically to learners' decisions, to deliver the scenarios to multiple PBL classrooms in the same timeframe, and to record centrally the paths taken by the PBL groups. METHODS: A randomized controlled trial in crossover design was run involving all learners (N=81) in the second year of the graduate entry stream for the undergraduate medicine program at St George's University of London. Learners were randomized to study groups; half engaged in a D-PBL activity whereas the other half had a traditional linear PBL activity on the same subject material. Groups alternated D-PBL and linear PBL over the semester. The measure was mean cohort performance on specific face-to-face exam questions at the end of the semester. RESULTS: D-PBL groups performed better than linear PBL groups on questions related to D-PBL with the difference being statistically significant for all questions. Differences between the exam performances of the 2 groups were not statistically significant for the questions not related to D-PBL. The effect sizes for D-PBL-related questions were large and positive (>0.6) except for 1 question that showed a medium positive effect size. The effect sizes for questions not related to D-PBL were all small (≤0.3) with a mix of positive and negative values. CONCLUSIONS: The efficacy of D-PBL was indicated by improved exam performance for learners who had D-PBL compared to those who had linear PBL. This suggests that the use of D-PBL leads to better midterm learning outcomes than linear PBL, at least for learners with prior experience with linear PBL. On the basis of tutor and student feedback, St George's University of London and the University of Nicosia, Cyprus have replaced paper PBL cases for midstage undergraduate teaching with D-PBL virtual patients, and 6 more institutions in the ePBLnet partnership will be implementing D-PBL in Autumn 2015.

Introducing physician assistants into an intensive care unit: process, problems, impact and recommendations.

The National Health Service (NHS) is facing substantial staffing challenges arising from reduced working hours, fewer trainees and more protected training of those trainees. Although increasing consultant-delivered care helps to meet these challenges, there remains a need to remodel the workforce. One component of the solution is physician assistants (PAs), who are professionals trained in patient assessment and care, working under the supervision of trained doctors. In October 2010, three PAs began working in the paediatric intensive care unit (PICU) at St George's Hospital, Tooting, which is a large tertiary hospital. This study used surveys and semi-structured interviews to explore the process and end results of this development. Initially, there was a large discrepancy between expectations and the capabilities of the PAs. Shortly after starting, there was friction arising from PAs being untrained in PICU activities, and the facts that they would take training opportunities from other staff and that their remuneration was disproportionate to their usefulness. At five months, all those interviewed stressed the positive impact of PAs on patient care and the running of the unit. Staff had found that the PAs had integrated well and there was little evidence of earlier frictions. When surveyed at 10 months, PAs were undertaking most PICU procedures, albeit with some supervision. The study shows that PAs can be a valuable addition to the medical workforce, but that predictable problems can mar their introduction. Solutions are suggested for other units intending to follow this model.

Intensive care admissions for children with imported malaria in the United kingdom.

This study describes 977 children with imported malaria in England and Wales between 2004 and 2008, focusing on 29 (3.0%) patients admitted to intensive care, of whom 10 had cerebral malaria, 4 required inotropes, and 1 had concurrent septicemia. The remaining 14 were admitted for monitoring only. None died, but 1 child developed cerebellar infarction.

Evaluating venepuncture practice on a general children's ward.

AIM: To assess the training for, practice of, and effects of venepuncture in children on a general children's ward. To identify approaches that might reduce the adverse physical and psychological effects related to venepuncture. METHODS: Questionnaire survey of 51 parents, 39 children and 72 junior doctors following venepuncture in the children. Telephone survey of 25 paediatric senior house officers on venous access training. RESULTS: Parents and children assessed venepuncture as extremely distressing. Parents' assessments of the mean number of venepuncture attempts were markedly higher than those of the doctors surveyed. When carrying out venepuncture, doctors used therapeutic measures much less frequently than expected. Only seven of the 25 departments surveyed offered any training in venepuncture. CONCLUSION: Venepuncture is consistently one of the most distressing aspects of hospital admission for children. Much could be done to alleviate this, but trainir patchy and interventions shown to reduce distress are not uniformly used.

Improving assessment with virtual patients.

Assessments should accurately predict future performance in a wide variety of settings yet be feasible to conduct. In medical education a robust and comprehensive system of assessment is essential to protect the public from inadequate professionals. The parameters for devising such an assessment are well-defined, and good practice for writing examinations well-established. However even excellent written assessments are limited in their predictive validity, and limited in sampling, face and construct validity. The increasing availability and power of computing has led to growing interest in computer simulations for use in examinations, creating assessment virtual patients (AVPs). They can potentially test knowledge and data interpretation, incorporate images, sound or video and test decision making. Such AVPs could represent the most comprehensive, integrated assessment possible that is both objective and feasible. This article focuses on AVP design, distinguishing between linear and branched models, choice and consequence driven designs. It reviews the use of AVPs in the context of assessment theory. It presents different AVP designs discussing their benefits and problems. AVPs can become valuable components in high stakes medical exams, particularly in later years of courses. However this requires application of established assessment principles to AVP design.

The replacement of 'paper' cases by interactive online virtual patients in problem-based learning.

St George's University of London (SGUL) has a Problem-Based Learning (PBL) curriculum for its undergraduate medicine course, using traditional paper-based patient cases. To counter the limitation that paper cases are linear and do not allow students to explore the consequences of decisions, interactive online virtual patients (VPs) were developed which allowed students to consider options as the cases unfold, and allow students to explore the consequences of their actions. A PBL module was converted to VPs, and delivered to 72 students in 10 tutorial groups, with 5 groups each week receiving VPs with options and consequences, and 5 groups receiving online VPs but without options. A comprehensive evaluation was carried out, using questionnaires, and interviews.Both tutors and students believed that the ability to explore options and consequences created a more engaging experience and encouraged students to explore their learning. They regretted the loss of paper and neither group could see any value in putting cases online without the options. SGUL is now adapting its transitional year between the early campus years and the clinical attachment years. This will include the integration of all technology-based resources with face-to-face learning and create a more adaptive, personalised, competency-based style of learning.

Training staff to create simple interactive virtual patients: the impact on a medical and healthcare institution.

BACKGROUND: Virtual patients (VPs) are excellent teaching tools for developing clinical decision-making skills and improving clinical competency, but are believed to be very expensive and time consuming to make. AIM: The aim of this study was to establish whether it was possible to design a workshop for VP creation, which would enable teaching staff to create interactive, immersive VPs quickly, and with limited technical support. METHODS: The Centre for Medical and Healthcare Education at St George's University of London's (SGUL) medical school developed an ergonomic and generic 'model' for VP creation, simple enough for clinicians and educators to use, yet flexible enough to simulate real decisions through non-linear pathways. One-day workshops were set up to support the development of VPs by medical and healthcare educators. RESULTS: VP creation workshops have been successfully trialled, attracting a large number of clinicians and educators from a range of medicine and healthcare courses. Feedback from participants was very positive. Educators, organised into small groups, were unable to complete VPs within the workshop, but many groups completed a VP after the workshop. Interest was highest in mental health. DISCUSSION: The workshops catalysed a change in the awareness of the value of VPs, with staff directly integrating VPs into the curriculum.