Australian doctors are more engaged than UK doctors: why is this the case?

BACKGROUND: Despite reports highlighting the need for greater medical engagement and the benefits of being widely understood, very little information is available on the status of medical engagement in Australia, and how this compares to the UK. Answering this question will no doubt assist training bodies, curriculum designers and policy makers better understand relevant issues. METHODS: The medical engagement questionnaire (MES) was emailed to all medical staff working at 159 UK National Health Service Trusts and 18 health service organisations in Australia. The questionnaire consists of 30 predetermined items seeking responses using a 5-point Likert scale. RESULTS: Overall, doctors in the Australian dataset are slightly more engaged, or more positive, than their UK colleagues. Good interpersonal relationships was the only variable that UK doctors scored more positively than their Australian counterparts. At the lower end of the responses, that is the least engaged, we found this even more apparent. Where doctors in Australia are less disengaged, that is still more positive than the UK colleagues. CONCLUSION: While the profiles of medical engagement vary at the sites and also across the MES and subscales, the data illustrate that overall doctors in Australia feel valued and empowered, and they have purpose and direction and work in a collaborate culture. At the most disengaged end of the scale, Australian doctors are markedly less disengaged than their UK counterparts. There may be numerous factors that influence and change how engaged doctors are in both countries. The most prominent of these are appear to be working conditions and lifestyle, driven by funding and other economics issues. This research is likely to be of great interest to regulators and training bodies in both countries.

Enhanced Nanostructure Dynamics on Au(111) with Adsorbed Sulfur due to Au-S Complex Formation.

Chemisorbed species can enhance the fluxional dynamics of nanostructured metal surfaces which has implications for applications such as catalysis. Scanning tunneling microscopy studies at room temperature reveal that the presence of adsorbed sulfur (S) greatly enhances the decay rate of 2D Au islands in the vicinity of extended step edges on Au(111). This enhancement is already significant at S coverages, θS , of a few hundredths of a monolayer (ML), and is most pronounced for 0.1-0.3 ML where the decay rate is increased by a factor of around 30. For θS close to saturation at about 0.6 ML, sulfur induces pitting and reconstruction of the entire surface, and Au islands are stabilized. Enhanced coarsening at lower θS is attributed to the formation and diffusion across terraces of Au-S complexes, particularly AuS2 and Au4 S4 , with some lesser contribution from Au3 S4 . This picture is supported by density functional theory analysis of complex formation energies and diffusion barriers.

Structure of chalcogen overlayers on Au(111): Density functional theory and lattice-gas modeling.

Ordering of different chalcogens, S, Se, and Te, on Au(111) exhibit broad similarities but also some distinct features, which must reflect subtle differences in relative values of the long-range pair and many-body lateral interactions between adatoms. We develop lattice-gas (LG) models within a cluster expansion framework, which includes about 50 interaction parameters. These LG models are developed based on density functional theory (DFT) analysis of the energetics of key adlayer configurations in combination with the Monte Carlo (MC) simulation of the LG models to identify statistically relevant adlayer motifs, i.e., model development is based entirely on theoretical considerations. The MC simulation guides additional DFT analysis and iterative model refinement. Given their complexity, development of optimal models is also aided by strategies from supervised machine learning. The model for S successfully captures ordering motifs over a broader range of coverage than achieved by previous models, and models for Se and Te capture the features of ordering, which are distinct from those for S. More specifically, the modeling for all three chalcogens successfully explains the linear adatom rows (also subtle differences between them) observed at low coverages of ∼0.1 monolayer. The model for S also leads to a new possible explanation for the experimentally observed phase with a (5 × 5)-type low energy electron diffraction (LEED) pattern at 0.28 ML and to predictions for LEED patterns that would be observed with Se and Te at this coverage.

Identification of an AgS2 Complex on Ag(110).

Adsorbed sulfur has been investigated on the Ag(110) surface at two different coverages, 0.02 and 0.25 monolayers. At the lower coverage, only sulfur adatoms are present. At the higher coverage, there are additional bright features which we identify as linear, independent AgS2 complexes. This identification is based upon density functional theory (DFT) and its comparison with experimental observations including bias dependence and separation between complexes. DFT also predicts the absence of AgS2 complexes at low coverage, and the development of AgS2 complexes around a coverage of 0.25 monolayers of sulfur, as is experimentally observed. To our knowledge, this is the first example of an isolated linear sulfur-metal-sulfur complex.

Sulfur adsorption on coinage metal(100) surfaces: propensity for metal-sulfur complex formation relative to (111) surfaces.

Experimental data from low-temperature Scanning Tunneling Microscopy (LTSTM) studies on coinage metal surfaces with very low coverages of S is providing new insights into metal-S interactions. A previous LTSTM study for Cu(100), and a new analysis reported here for Ag(100), both indicate no metal-sulfur complex formation, but an Au4S5 complex was observed previously on Au(100). In marked contrast, various complexes have been proposed and/or observed on Ag(111) and Cu(111), but not on Au(111). Also, exposure to trace amounts of S appears to enhance mass transport far more dramatically on (111) than on (100) surfaces for Cu and Ag, a feature tied to the propensity for complex formation. Motivated by these observations, we present a comprehensive assessment at the level of DFT to assess the existence and stability of complexes on (100) surfaces, and compare results with previous analyses for (111) surfaces. Consistent with experiment, our DFT analysis finds no stable complexes on Ag(100) and Cu(100), but several exist for Au(100). In addition, we systematically relate stability for adsorbed and gas-phase species within the framework of Hess's law. We thereby provide key insight into the various energetic contributions to stability which in turn elucidates the difference in behavior between (100) and (111) surfaces.

Reshaping, Intermixing, and Coarsening for Metallic Nanocrystals: Nonequilibrium Statistical Mechanical and Coarse-Grained Modeling.

Self-assembly of supported 2D or 3D nanocrystals (NCs) by vacuum deposition and of 3D NCs by solution-phase synthesis (with possible subsequent transfer to a support) produces intrinsically nonequilibrium systems. Individual NCs can have far-from-equilibrium shapes and composition profiles. The free energy of NC ensembles is lowered by coarsening which can involve Ostwald ripening or Smoluchowski ripening (NC diffusion and coalescence). Preservation of individual NC structure and inhibition of coarsening are key, e.g., for avoiding catalyst degradation. This review focuses on postsynthesis evolution of metallic NCs. Atomistic-level modeling typically utilizes stochastic lattice-gas models to access appropriate time and length scales. However, predictive modeling requires incorporation of realistic rates for relaxation mechanisms, e.g., periphery diffusion and intermixing, in numerous local environments (rather than the use of generic prescriptions). Alternative coarse-grained modeling must also incorporate appropriate mechanisms and kinetics. At the level of individual NCs, we present analyses of reshaping, including sintering and pinch-off, and of compositional evolution in a vacuum environment. We also discuss modeling of coarsening including diffusion and decay of individual NCs and unconventional coarsening processes. We describe high-level modeling integrated with scanning tunneling microscopy (STM) studies for supported 2D epitaxial nanoclusters and developments in modeling for 3D NCs motivated by in situ transmission electron microscopy (TEM) studies.

Characteristics of sulfur atoms adsorbed on Ag(100), Ag(110), and Ag(111) as probed with scanning tunneling microscopy: experiment and theory.

In this paper, we report that S atoms on Ag(100) and Ag(110) exhibit a distinctive range of appearances in scanning tunneling microscopy (STM) images, depending on the sample bias voltage, VS. Progressing from negative to positive VS, the atomic shape can be described as a round protrusion surrounded by a dark halo (sombrero) in which the central protrusion shrinks, leaving only a round depression. This progression resembles that reported previously for S atoms on Cu(100). We test whether DFT can reproduce these shapes and the transition between them, using a modified version of the Lang-Tersoff-Hamann method to simulate STM images. The sombrero shape is easily reproduced, but the sombrero-depression transition appears only for relatively low tunneling current and correspondingly realistic tip-sample separation, dT, of 0.5-0.8 nm. Achieving these conditions in the calculations requires sufficiently large separation (vacuum) between slabs, together with high energy cutoff, to ensure appropriate exponential decay of electron density into vacuum. From DFT, we also predict that an analogous transition is not expected for S atoms on Ag(111) surfaces. The results are explained in terms of the through-surface conductance, which defines the background level in STM, and through-adsorbate conductance, which defines the apparent height at the point directly above the adsorbate. With increasing VS, for Ag(100) and Ag(110), we show that through-surface conductance increases much more rapidly than through-adsorbate conductance, so the apparent adsorbate height drops below background. In contrast, for Ag(111) the two contributions increase at more comparable rates, so the adsorbate level always remains above background and no transition is seen.

The Relationships Between Use of Quality-of-Care Feedback Reports on Chronic Diseases and Medical Engagement in General Practice.

BACKGROUND: There is a limited knowledge on how medical engagement influences quality of care provided in primary care. The extent of the use of feedback reports from a national quality-of-care database can be considered as a measure of process quality. This study explores relationships between the use of feedback reports and medical engagement among general practitioners, general practitioner demographics, clinic characteristics, and services. METHODS: A cross-sectional combined questionnaire and register study in a sample of 352 single-handed general practitioners in 2013. Logistic regression analysis was used to explore associations between the use of feedback reports for diabetes and chronic obstructive pulmonary disease and medical engagement. RESULTS: For both diabetes and chronic obstructive pulmonary disease, a higher degree of medical engagement was associated with an increased use of feedback reports. Furthermore, we identified positive associations between using feedback reports and general practitioner services (spirometry, influenza vaccinations, performing annual reviews for patients with chronic diseases) and a negative association between usage of quality-of-care feedback reports and the number of consultations per patient. CONCLUSION: Using feedback reports for chronic diseases in general practice was positively associated with medical engagement and also with the provision of services in general practice.

Implications of bond disorder in a S=1 kagome lattice.

Strong hydrogen bonds such as F···H···F offer new strategies to fabricate molecular architectures exhibiting novel structures and properties. Along these lines and, to potentially realize hydrogen-bond mediated superexchange interactions in a frustrated material, we synthesized [H2F]2[Ni3F6(Fpy)12][SbF6]2 (Fpy = 3-fluoropyridine). It was found that positionally-disordered H2F+ ions link neutral NiF2(Fpy)4 moieties into a kagome lattice with perfect 3-fold rotational symmetry. Detailed magnetic investigations combined with density-functional theory (DFT) revealed weak antiferromagnetic interactions (J ~ 0.4 K) and a large positive-D of 8.3 K with ms = 0 lying below ms = ±1. The observed weak magnetic coupling is attributed to bond-disorder of the H2F+ ions which leads to disrupted Ni-F···H-F-H···F-Ni exchange pathways. Despite this result, we argue that networks such as this may be a way forward in designing tunable materials with varying degrees of frustration.

Sulfur Atoms Adsorbed on Cu(100) at Low Coverage: Characterization and Stability against Complexation.

Using scanning tunneling microscopy, we characterize the size and bias-dependent shape of sulfur atoms on Cu(100) at low coverage (below 0.1 monolayers) and low temperature (quenched from 300 to 5 K). Sulfur atoms populate the Cu(100) terraces more heavily than steps at low coverage, but as coverage approaches 0.1 monolayers, close-packed step edges become fully populated, with sulfur atoms occupying sites on top of the step. Density functional theory (DFT) corroborates the preferential population of terraces at low coverage as well as the step adsorption site. In experiment, small regions with p(2 × 2)-like atomic arrangements emerge on the terraces as sulfur coverage approaches 0.1 monolayer. Using DFT, a lattice gas model has been developed, and Monte Carlo simulations based on this model have been compared with the observed terrace configurations. A model containing eight pairwise interaction energies, all repulsive, gives qualitative agreement. Experiment shows that atomic adsorbed sulfur is the only species on Cu(100) up to a coverage of 0.09 monolayers. There are no Cu-S complexes. In contrast, prior work has shown that a Cu2S3 complex forms on Cu(111) under comparable conditions. On the basis of DFT, this difference can be attributed mainly to stronger adsorption of sulfur on Cu(100) as compared with Cu(111).

Are we nearly there yet? A study of the English National Health Service as professional bureaucracies.

Purpose The purpose of this paper is to explore issues of medical engagement in the management and leadership of health services in the English National Health Service (NHS). The literature suggests that this is an important component of high performing health systems, although the NHS has traditionally struggled to engage doctors and has been characterised as a professional bureaucracy. This study explored the ways in which health care organisations structure and operate medical leadership processes to assess the degree to which professional bureaucracies still exist in the English NHS. Design/methodology/approach Drawing on the qualitative component of a research into medical leadership in nine case study sites, this paper reports on findings from over 150 interviews with doctors, general managers and nurses. In doing so, the authors focus specifically on the operation of medical leadership in nine different NHS hospitals. Findings Concerted attention has been focussed on medical leadership and this has led to significant changes to organisational structures and the recruitment and training processes of doctors for leadership roles. There is a cadre of doctors that are substantially more engaged in the leadership of their organisations than previous research has found. Yet, this engagement has tended to only involve a small section of the overall medical workforce in practice, raising questions about the nature of medical engagement more broadly. Originality/value There are only a limited number of studies that have sought to explore issues of medical leadership on this scale in the English context. This represents the first significant study of this kind in over a decade.

Creating safer health systems: Lessons from other sectors and an account of an application in the Safer Clinical Systems programme.

Despite well meaning initiatives over decades, the percentage of inpatients suffering adverse events remains constant in most advanced health systems. The notion of incident reporting as used in other safety critical industries has proved far less effective in healthcare. This article describes a new patient safety paradigm in the search for improved patient safety in healthcare. Underpinned by a holistic use of human factors the Safer Clinical Systems programme involves a proactive, risk-based approach seeking to eliminate or control risk before it is converted to patient harm. The tools and techniques applied by healthcare professional in real-life settings are described along with the outcomes of a significant reduction in risk and improvement in safety culture as measured by the Safety Culture Index. The challenges of applying the approach are discussed but it is argued that important progress could be made if a critical mass of healthcare staff were helped to acquire skills in human factors.

Leadership and management in UK medical school curricula.

Purpose Although medical leadership and management (MLM) is increasingly being recognised as important to improving healthcare outcomes, little is understood about current training of medical students in MLM skills and behaviours in the UK. The paper aims to discuss these issues. Design/methodology/approach This qualitative study used validated structured interviews with expert faculty members from medical schools across the UK to ascertain MLM framework integration, teaching methods employed, evaluation methods and barriers to improvement. Findings Data were collected from 25 of the 33 UK medical schools (76 per cent response rate), with 23/25 reporting that MLM content is included in their curriculum. More medical schools assessed MLM competencies on admission than at any other time of the curriculum. Only 12 schools had evaluated MLM teaching at the time of data collection. The majority of medical schools reported barriers, including overfilled curricula and reluctance of staff to teach. Whilst 88 per cent of schools planned to increase MLM content over the next two years, there was a lack of consensus on proposed teaching content and methods. Research limitations/implications There is widespread inclusion of MLM in UK medical schools' curricula, despite the existence of barriers. This study identified substantial heterogeneity in MLM teaching and assessment methods which does not meet students' desired modes of delivery. Examples of national undergraduate MLM teaching exist worldwide, and lessons can be taken from these. Originality/value This is the first national evaluation of MLM in undergraduate medical school curricula in the UK, highlighting continuing challenges with executing MLM content despite numerous frameworks and international examples of successful execution.

Medical engagement and organizational characteristics in general practice.

BACKGROUND: Medical engagement is a mutual concept of the active and positive contribution of doctors to maintaining and enhancing the performance of their health care organization, which itself recognizes this commitment in supporting and encouraging high quality care. A Medical Engagement Scale (MES) was developed by Applied Research Ltd (2008) on the basis of emerging evidence that medical engagement is critical for implementing radical improvements. OBJECTIVES: To study the importance of medical engagement in general practice and to analyse patterns of association with individual and organizational characteristics. DESIGN AND SETTING: A cross-sectional study using a sampled survey questionnaire and the official register from the Danish General Practitioners' Organization comprising all registered Danish GPs. METHOD: The Danish version of the MES Questionnaire was distributed and the survey results were analysed in conjunction with the GP register data. RESULTS: Statistically adjusted analyses revealed that the GPs' medical engagement varied substantially. GPs working in collaboration with colleagues were more engaged than GPs from single-handed practices, older GPs were less engaged than younger GPs and female GPs had higher medical engagement than their male colleagues. Furthermore, GPs participating in vocational training of junior doctors were more engaged than GPs not participating in vocational training. CONCLUSION: Medical engagement in general practice varies a great deal and this is determined by a complex interaction between both individual and organizational characteristics. Working in collaboration, having staff and being engaged in vocational training of junior doctors are all associated with enhanced levels of medical engagement among GPs.

Do we need medical leadership or medical engagement?

PURPOSE: The purpose of this paper is to address issues of medical leadership within health systems and to clarify the associated conceptual issues, for example, leadership versus management and medical versus clinical leadership. However, its principle contribution is to raise the issue of the purpose or outcome of medical leadership, and, in this respect, it argues that it is to promote medical engagement. DESIGN/METHODOLOGY/APPROACH: The approach is to provide evidence, both from the literature and empirically, to suggest that enhanced medical engagement leads to improved organisational performance and, in doing so, to review the associated concepts. FINDINGS: Building on current evidence from the UK and Australia, the authors strengthen previous findings that effective medical leadership underpins the effective organisational performance. RESEARCH LIMITATIONS/IMPLICATIONS: There is a current imbalance between the size of the databases on medical engagement between the UK (very large) and Australia (small but developing). PRACTICAL IMPLICATIONS: The authors aim to equip medical leaders with the appropriate skill set to promote and enhance greater medical engagement. The focus of leaders in organisations should be in creating a culture that fosters and supports medical engagement. SOCIAL IMPLICATIONS: This paper provides empowerment of medical professionals to have greater influence in the running of the organisation in which they deliver care. ORIGINALITY/VALUE: The paper contains, for the first time, linked performance data from the Care Quality Commission in the UK and from Australia with the new set of medical engagement findings.

Medical engagement and improving quality of care.

This paper argues that establishment of a positive culture that promotes and enhances levels of medical engagement should be a key objective of medical leadership. Two particular and critical arguments underlie this proposition a) that levels of medical engagement, as measured by the Medical Engagement Scale, is strongly associated with organisational performance, including quality of care; and b) that any aspiration to achieve an organisational culture known as 'clinically led' cannot be achieved without high levels of medical engagement. Medical engagement as a concept is discussed, as well as the need for robust and reliable assessment. Approaches to support organisations enhance levels of engagement are presented as part of the goal to improve overall care quality.

Managing competing organizational priorities in clinical handover across organizational boundaries.

OBJECTIVES: Handover across care boundaries poses additional challenges due to the different professional, organizational and cultural backgrounds of the participants involved. This paper provides a qualitative account of how practitioners in emergency care attempt to align their different individual and organizational priorities and backgrounds when handing over patients across care boundaries (ambulance service to emergency department (ED), and ED to acute medicine). METHODS: A total of 270 clinical handovers were observed in three emergency care pathways involving five participating NHS organizations (two ambulance services and three hospitals). Half-day process mapping sessions were conducted for each pathway. Semi-structured interviews were carried out with 39 participants and analysed thematically. RESULTS: The management of patient flow and the fulfilment of time-related performance targets can create conflicting priorities for practitioners during handover. Practitioners involved in handover manage such competing organizational priorities through additional coordination effort and dynamic trade-offs. Practitioners perceive greater collaboration across departments and organizations, and mutual awareness of each other's goals and constraints as possible ways towards more sustainable improvement. CONCLUSION: Sustainable improvement in handover across boundaries in emergency care might require commitment by leaders from all parts of the local health economy to work as partners to establish a culture of integrated, patient-centred care.

Defining the structure of undergraduate medical leadership and management teaching and assessment in the UK.

Medical leadership and management (MLM) skills are essential in preventing failings of healthcare; it is unknown how these attitudes can be developed during undergraduate medical education. This paper aims to quantify interest in MLM and recommends preferred methods of teaching and assessment at UK medical schools. Two questionnaires were developed, one sent to all UK medical school faculties, to assess executed and planned curriculum changes, and the other sent to medical students nationally to assess their preferences for teaching and assessment. Forty-eight percent of UK medical schools and 260 individual student responses were recorded. Student responses represented 60% of UK medical schools. 65% of schools valued or highly valued the importance of teaching MLM topics, compared with 93.2% of students. Students' favoured teaching methods were seminars or lectures (89.4%) and audit and quality improvement (QI) projects (77.8%). Medical schools preferred portfolio entries (55%) and presentations (35%) as assessment methods, whilst simulation exercises (76%) and audit reports (61%) were preferred by students. Preferred methods encompass experiential learning or simulation and a greater emphasis should be placed on encouraging student audit and QI projects. The curriculum changes necessary could be achieved via further integration into future editions of Tomorrow's Doctors.

Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history.

BACKGROUND: Inadequate handover in emergency care is a threat to patient safety. Handover across care boundaries poses particular problems due to different professional, organisational and cultural backgrounds. While there have been many suggestions for standardisation of handover content, relatively little is known about the verbal behaviours that shape handover conversations. This paper explores both what is communicated (content) and how this is communicated (verbal behaviours) during different types of handover conversations across care boundaries in emergency care. METHODS: Three types of interorganisational (ambulance service to emergency department (ED) in 'resuscitation' and 'majors' areas) and interdepartmental handover conversations (referrals to acute medicine) were audio recorded in three National Health Service EDs. Handover conversations were segmented into utterances. Frequency counts for content and language forms were derived for each type of handover using Discourse Analysis. Verbal behaviours were identified using Conversation Analysis. RESULTS: 203 handover conversations were analysed. Handover conversations involving ambulance services were predominantly descriptive (60%-65% of utterances), unidirectional and focused on patient presentation (75%-80%). Referrals entailed more collaborative talk focused on the decision to admit and immediate care needs. Across all types of handover, only 1.5%-5% of handover conversation content related to the patient's social and psychological needs. CONCLUSIONS: Handover may entail both descriptive talk aimed at information transfer and collaborative talk aimed at joint decision-making. Standardisation of handover needs to accommodate collaborative aspects and should incorporate communication of information relevant to the patient's social and psychological needs to establish appropriate care arrangements at the earliest opportunity.

Organizational coherence in health care organizations: conceptual guidance to facilitate quality improvement and organizational change.

OBJECTIVE: We sought to improve our understanding of how health care quality improvement (QI) methods and innovations could be efficiently and effectively translated between settings to reduce persistent gaps in health care quality both within and across countries. We aimed to examine whether we could identify a core set of organizational cultural attributes, independent of context and setting, which might be associated with success in implementing and sustaining QI systems in health care organizations. METHODS: We convened an international group of investigators to explore the issues of organizational culture and QI in different health care contexts and settings. This group met in person 3 times and held a series of conference calls to discuss emerging ideas over 2 years. Investigators also conducted pilot studies in their home countries to examine the applicability of our conceptual model. RESULTS AND CONCLUSIONS: We suggest that organizational coherence may be a critical element of QI efforts in health care organizations and propose that there are 3 key components of organizational coherence: (1) people, (2) processes, and (3) perspectives. Our work suggests that the concept of organizational coherence embraces both culture and context and can thus help guide both researchers and practitioners in efforts to enhance health care QI efforts, regardless of organizational type, location, or context.