Role modelling to support careers in general practice: a realist review protocol.

BACKGROUND: Role models encountered during undergraduate training play an important part in shaping future doctors. They can act as powerful attractants towards, and deterrents away from a career in general practice. Many general practitioner (GP) educators who act as role models are burnt-out and wish to leave the profession which may limit their ability to influence students positively, with consequent detrimental impact on recruitment to the specialty. AIM: A realist review will be undertaken, aiming to explore how, why and for whom role modelling in undergraduate medical education can support medical students towards careers in general practice. DESIGN & SETTING: The realist review will follow Pawson's five steps, including: locating existing theories, searching for evidence, article selection, data extraction, synthesising evidence and drawing conclusions and will explore literature published in English language between 2013 and 2024. METHOD: An initial explanatory framework (initial programme theory, IPT) will be developed guided by a stakeholder panel including medical undergraduates, GPs and patient/public representatives. Searches will be developed and conducted in electronic databases and grey literature. Studies will be included if they explore the relationship between GP role modelling and undergraduate career choice and relevant data will be extracted. CONCLUSION: Findings will refine the initial programme theory, unveiling key contexts, mechanisms and outcomes which influence role modelling in undergraduate GP medical education and support or deter students from careers in general practice. These findings will support recommendations and interventions to facilitate positive outcomes, including improved recruitment to general practice.

An innovative and authentic way of learning how to consult remotely in response to the COVID-19 pandemic.

Medical students preparing to undertake general practice (GP) placements need to be equipped with the unique skills required to successfully utilise and adapt to current and emerging remote consultation modalities used in primary care and integrate this into their day-to-day clinical practice. Medical educators needed to flexibly and quickly cater learning to the evolving landscape.A three-hour teaching session was devised to be delivered to 50 students online via Microsoft Teams™ and facilitated by five general practice tutors in groups of 10, prior to students' GP placements. In pre-assigned pairs, students undertook two role-play scenarios for the main remote modalities of telephone and video-consultations. E-consultations were explored via discussion of simulated encounters. The authentic technology pertinent to each modality was used; this included a training version of NHS Scotland's Near Me IT platform for video-consultations, the students' own mobile phones for telephone consultations and simulated PDFs generated using the e-consultation facility. Teaching was evaluated via a student focus group pre and post placement.Student feedback was positive. The session prepared them for their placement and increased their confidence. They suggested this teaching be incorporated earlier in the medical school curriculum. They appreciated learning with the same IT platforms used on placement. Some students had no prior experience of remote consultations and subsequently were expected to undertake independent remote consultations almost immediately upon arrival.Careful design of challenging scenarios mirroring common GP presentations via remote modalities can increase student preparedness and confidence prior to GP placements during the COVID-19 pandemic.

Unknown unknowns: can bringing patients' lived experience of long term conditions into curriculum design help our future doctors offer more holistic, socially accountable care?

Understanding the holistic impact of long-term conditions (LTCs) on a patient, due to their high prevalence, morbidity, mortality and cost, is an important part of the primary care undergraduate medicine curriculum. Increasingly, we set learning outcomes for our students anticipating what the patient would want them to know. But are our expectations congruent with what patients would want them to know? In this leading article, we propose that patient involvement in curriculum design remains inadequate. We base our argument on (1) an existing strong theoretical premise that increasing patient incorporation enhances the delivery of medical education, (2) recommendations from major health organisations, our regulator and leading healthcare educationalists and (3) a growing body of evidence that what is important to physicians may not reflect what is important to patients. We advocate that patient involvement in curriculum design will result in a better understanding of how LTCs affect their physical, psychological and social health and of their journey through health care and community support services. This learning is essential, but unfortunately often overlooked, if we are to ensure that students in their future roles plan patient care using an empathic, holistic, patient-centred and socially accountable approach.

Changing the culture of assessment: the dominance of the summative assessment paradigm.

BACKGROUND: Despite growing evidence of the benefits of including assessment for learning strategies within programmes of assessment, practical implementation of these approaches is often problematical. Organisational culture change is often hindered by personal and collective beliefs which encourage adherence to the existing organisational paradigm. We aimed to explore how these beliefs influenced proposals to redesign a summative assessment culture in order to improve students' use of assessment-related feedback. METHODS: Using the principles of participatory design, a mixed group comprising medical students, clinical teachers and senior faculty members was challenged to develop radical solutions to improve the use of post-assessment feedback. Follow-up interviews were conducted with individual members of the group to explore their personal beliefs about the proposed redesign. Data were analysed using a socio-cultural lens. RESULTS: Proposed changes were dominated by a shared belief in the primacy of the summative assessment paradigm, which prevented radical redesign solutions from being accepted by group members. Participants' prior assessment experiences strongly influenced proposals for change. As participants had largely only experienced a summative assessment culture, they found it difficult to conceptualise radical change in the assessment culture. Although all group members participated, students were less successful at persuading the group to adopt their ideas. Faculty members and clinical teachers often used indirect techniques to close down discussions. The strength of individual beliefs became more apparent in the follow-up interviews. CONCLUSIONS: Naïve epistemologies and prior personal experiences were influential in the assessment redesign but were usually not expressed explicitly in a group setting, perhaps because of cultural conventions of politeness. In order to successfully implement a change in assessment culture, firmly-held intuitive beliefs about summative assessment will need to be clearly understood as a first step.

Factors influencing students' receptivity to formative feedback emerging from different assessment cultures.

INTRODUCTION: Feedback after assessment is essential to support the development of optimal performance, but often fails to reach its potential. Although different assessment cultures have been proposed, the impact of these cultures on students' receptivity to feedback is unclear. This study aimed to explore factors which aid or hinder receptivity to feedback. METHODS: Using a constructivist grounded theory approach, the authors conducted six focus groups in three medical schools, in three separate countries, with different institutional approaches to assessment, ranging from a traditional summative assessment structure to a fully implemented programmatic assessment system. The authors analyzed data iteratively, then identified and clarified key themes. RESULTS: Helpful and counterproductive elements were identified within each school's assessment system. Four principal themes emerged. Receptivity to feedback was enhanced by assessment cultures which promoted students' agency, by the provision of authentic and relevant assessment, and by appropriate scaffolding to aid the interpretation of feedback. Provision of grades and comparative ranking provided a helpful external reference but appeared to hinder the promotion of excellence. CONCLUSIONS: This study has identified important factors emerging from different assessment cultures which, if addressed by programme designers, could enhance the learning potential of feedback following assessments. Students should be enabled to have greater control over assessment and feedback processes, which should be as authentic as possible. Effective long-term mentoring facilitates this process. The trend of curriculum change towards constructivism should now be mirrored in the assessment processes in order to enhance receptivity to feedback.

Limits of 'patient-centredness': valuing contextually specific communication patterns.

CONTEXT: Globally, doctor-patient communication is becoming synonymous with high-quality health care in the 21st century. However, what is meant by 'good communication' and whether there is consensus internationally remain unclear. OBJECTIVES: Here, we characterise understandings of 'good communication' in future doctors from medical schools in three contextually contrasting continents. Given locally specific socio-cultural influences, we hypothesised that there would be a lack of global consensus on what constitutes 'good communication'. METHODS: A standardised two-phase methodology was applied in turn to each of three medical schools in the UK, Egypt and India (n = 107 subjects), respectively, in which students were asked: 'What is good communication?' Phase I involved exploratory focus groups to define preliminary themes (mean number of participants per site: 17). Phase II involved thematic confirmation and expansion in one-to-one semi-structured interviews (mean number of participants per site: 18; mean hours of dialogue captured per site: 55). Findings were triangulated and analysed using grounded theory. RESULTS: The overarching theme that emerged from medical students was that 'good communication' requires adherence to certain 'rules of communication'. A shared rule that doctors must communicate effectively despite perceived disempowerment emerged across all sites. However, contradictory culturally specific rules about communication were identified in relation to three major domains: family; gender, and emotional expression. Egyptian students perceived emotional aspects of Western doctors' communication strikingly negatively, viewing these doctors as problematically cold and unresponsive. CONCLUSIONS: Contradictory perceptions of 'good communication' in future doctors are found cross-continentally and may contribute to prevalent cultural misunderstandings in medicine. The lack of global consensus on what defines good communication challenges prescriptively taught Western 'patient-centredness' and questions assumptions about international transferability. Health care professionals must be educated openly about flexible, context-specific communication patterns so that they can avoid cultural incompetence and tailor behaviours in ways that optimise therapeutic outcomes wherever they work around the globe.

Prevalence, Nature, Severity and Risk Factors for Prescribing Errors in Hospital Inpatients: Prospective Study in 20 UK Hospitals.

INTRODUCTION: It has been suggested that doctors in their first year of post-graduate training make a disproportionate number of prescribing errors. OBJECTIVE: This study aimed to compare the prevalence of prescribing errors made by first-year post-graduate doctors with that of errors by senior doctors and non-medical prescribers and to investigate the predictors of potentially serious prescribing errors. METHODS: Pharmacists in 20 hospitals over 7 prospectively selected days collected data on the number of medication orders checked, the grade of prescriber and details of any prescribing errors. Logistic regression models (adjusted for clustering by hospital) identified factors predicting the likelihood of prescribing erroneously and the severity of prescribing errors. RESULTS: Pharmacists reviewed 26,019 patients and 124,260 medication orders; 11,235 prescribing errors were detected in 10,986 orders. The mean error rate was 8.8 % (95 % confidence interval [CI] 8.6-9.1) errors per 100 medication orders. Rates of errors for all doctors in training were significantly higher than rates for medical consultants. Doctors who were 1 year (odds ratio [OR] 2.13; 95 % CI 1.80-2.52) or 2 years in training (OR 2.23; 95 % CI 1.89-2.65) were more than twice as likely to prescribe erroneously. Prescribing errors were 70 % (OR 1.70; 95 % CI 1.61-1.80) more likely to occur at the time of hospital admission than when medication orders were issued during the hospital stay. No significant differences in severity of error were observed between grades of prescriber. Potentially serious errors were more likely to be associated with prescriptions for parenteral administration, especially for cardiovascular or endocrine disorders. CONCLUSION: The problem of prescribing errors in hospitals is substantial and not solely a problem of the most junior medical prescribers, particularly for those errors most likely to cause significant patient harm. Interventions are needed to target these high-risk errors by all grades of staff and hence improve patient safety.

Barriers to the uptake and use of feedback in the context of summative assessment.

Despite calls for feedback to be incorporated in all assessments, a dichotomy exists between formative and summative assessments. When feedback is provided in a summative context, it is not always used effectively by learners. In this study we explored the reasons for this. We conducted individual interviews with 17 students who had recently received web based feedback following a summative assessment. Constant comparative analysis was conducted for recurring themes. The summative assessment culture, with a focus on avoiding failure, was a dominant and negative influence on the use of feedback. Strong emotions were prevalent throughout the period of assessment and feedback, which reinforced the focus on the need to pass, rather than excel. These affective factors were heightened by interactions with others. The influence of prior learning experiences affected expectations about achievement and the need to use feedback. The summative assessment and subsequent feedback appeared disconnected from future clinical workplace learning. Socio-cultural influences and barriers to feedback need to be understood before attempting to provide feedback after all assessments. A move away from the summative assessment culture may be needed in order to maximise the learning potential of assessments.

How we give personalised audio feedback after summative OSCEs.

BACKGROUND: Students often receive little feedback after summative objective structured clinical examinations (OSCEs) to enable them to improve their performance. Electronic audio feedback has shown promise in other educational areas. AIM: We investigated the feasibility of electronic audio feedback in OSCEs. METHODS: An electronic OSCE system was designed, comprising (1) an application for iPads allowing examiners to mark in the key consultation skill domains, provide "tick-box" feedback identifying strengths and difficulties, and record voice feedback; (2) a feedback website giving students the opportunity to view/listen in multiple ways to the feedback. Acceptability of the audio feedback was investigated, using focus groups with students and questionnaires with both examiners and students. RESULTS: 87 (95%) students accessed the examiners' audio comments; 83 (90%) found the comments useful and 63 (68%) reported changing the way they perform a skill as a result of the audio feedback. They valued its highly personalised, relevant nature and found it much more useful than written feedback. Eighty-nine per cent of examiners gave audio feedback to all students on their stations. Although many found the method easy, lack of time was a factor. CONCLUSIONS: Electronic audio feedback provides timely, personalised feedback to students after a summative OSCE provided enough time is allocated to the process.

Sustainability in clinical skills teaching.

BACKGROUND: The deleterious effects of climate change mean that environmental sustainability is increasingly becoming a moral and economic necessity. Consequently, clinicians will increasingly be called upon to manage the effects of health care on climate change, and they must therefore do as much as is practically possible to limit the negative effects of their practice on the environment. As medical educators we have the opportunity not only to reduce the environmental impact of our own clinical practice, but also that of those who we teach, through innovation. Such novelty can be explored during student-selected components (SSCs). Clinicians will increasingly be called upon to manage effects of health care on climate change CONTEXT: The project, entitled 'Can we introduce sustainability to clinical skills teaching?' was led by two third-year medical students during their SSC periods. New ways to make existing skills more sustainable were explored by surveying existing practice in the workplace, analysing selected skills in a lab-based setting and through discussions with sustainability champions. INNOVATION: Cannulation and intravenous (IV) antibiotic preparation were chosen by the students as prototype skills. These skills were observed by the students in the workplace and adapted by them to appease the 'triple bottom line' of sustainability: environmental, social and economic factors were addressed. The revised skills were taught by the students to their peers in a sustainably conscious fashion. IMPLICATIONS: Provided that such innovations in sustainable skills teaching are deemed appropriate by clinical skills directors, such methods could be adopted across medical schools and expanded to cover a wider range of skills.

Web-based feedback after summative assessment: how do students engage?

CONTEXT: There is little research into how to deliver summative assessment student feedback effectively. The main aims of this study were to clarify how students engage with feedback in this context and to explore the roles of learning-related characteristics and previous and current performance. METHODS: A website was developed to deliver feedback about the objective structural clinical examination (OSCE) in various formats: station by station or on skills across stations. In total, 138 students (in the third year out of five) completed a questionnaire about goal orientation, motivation, self-efficacy, control of learning beliefs and attitudes to feedback. Individual website usage was analysed over an 8-week period. Latent class analyses were used to identify profiles of students, based on their use of different aspects of the feedback website. Differences in learning-related student characteristics between profiles were assessed using analyses of variance (anovas). Individual website usage was related to OSCE performance. RESULTS: In total, 132 students (95.7%) viewed the website. The number of pages viewed ranged from two to 377 (median 102). Fifty per cent of students engaged comprehensively with the feedback, 27% used it in a minimal manner, whereas a further 23% used it in a more selective way. Students who were comprehensive users of the website scored higher on the value of feedback scale, whereas students who were minimal users scored higher on extrinsic motivation. Higher performing students viewed significantly more web pages showing comparisons with peers than weaker students did. Students who just passed the assessment made least use of the feedback. CONCLUSIONS: Higher performing students appeared to use the feedback more for positive affirmation than for diagnostic information. Those arguably most in need engaged least. We need to construct feedback after summative assessment in a way that will more effectively engage those students who need the most help.

Bad apples spoil the barrel: Addressing unprofessional behaviour.

Given the changes in society we are experiencing, the increasing focus on patient-centred care and acknowledgement that medical education including professionalism issues needs to continue not only in the residency programmes but also throughout the doctors career, is not surprising. Although most of the literature on professionalism pertains to learning and teaching professionalism issues, addressing unprofessional behaviour and related patient safety issues forms an alternative or perhaps complementary approach. This article describes the possibility of selecting applicants for a medical school based on personality characteristics, the attention to professional lapses in contemporary undergraduate training, as well as the magnitude, aetiology, surveillance and methods of dealing with reports of unprofessional behaviour in postgraduate education and CME.

Professionalism beyond medical school: an educational continuum?

Given the changes in society we are experiencing, the increasing focus on patient centred care and acknowledgment that medical education needs to continue not only in the residency programmes but throughout the doctors career, is not surprising. This article describes the attention currently paid to professionalism in the residency programmes, differences in perception of professionalism between patients, faculty, students and residents, differences in professionalism issues in the different educational phases, as well as their consequences for training and assessment regarding professionalism. Continuous medical education in professionalism is thereafter briefly discussed.

Approaches to professional behaviour assessment: tools in the professionalism toolbox.

There is general agreement that professionalism and professional behaviour should be (formatively and summatively) assessed, but consensus on how this should be done is still lacking. After discussing some of the remaining issues and questions regarding professionalism assessment, this article discusses the importance of qualitative comments to the assessment of professional behaviour, focuses on the currently most frequently used tools, as well as stresses the need for triangulation (combining) of these tools.

Teaching and learning professional behavior in practice.

This paper is the fourth article in a series on Professionalism and provides an overview of current methods used for teaching and learning about professionalism. The questions "whether" and "how" professionalism can be placed in the formal medical school curricula are addressed, and the informal learning related to professionalism reviewed.

Professionalism: evolution of the concept.

The concept of professionalism has undergone major changes over the millennia in general and the last century specifically. This article, the first in a series of articles in this Journal on professionalism, attempts to provide the reader with a historical overview of the evolution of the concept of professionalism over time. As a result of these changes, medical school curricula, and contemporary specialist training programs are increasingly becoming competence based, with professionalism becoming an integral part of a resident's training and assessment program.

The concepts of professionalism and professional behaviour: conflicts in both definition and learning outcomes.

This article is the second in a series on professionalism in the European Journal of Internal Medicine. The current article will first focus on these different views and definitions that are currently adopted by the various researchers, and subsequently discuss the consequences for the training and assessment of professionalism and professional behaviour in medical education.

General considerations regarding assessment of professional behaviour.

Core medical knowledge has been assessed for over fifty years and technical and communication skills for at least twenty. The assessment of professionalism however has failed to achieve recognition within this time frame. The interest in the assessment of professionalism and professional behaviour thus is a fairly recent development. This article will firstly clarify how professional behaviour assessment relates to other assessment methods using the framework proposed by Miller6. Thereafter a brief overview will be provided of the current "tool box" of methods available to assess professionalism. Data on the validity, reliability, feasibility, acceptability and educational utility of these "tools" as derived from published evidence will be reviewed. Subsequently a general overview of the way forward in the assessment of professionalism and professional behaviour will be given.

Training and learning professionalism in the medical school curriculum: current considerations.

Recommendations in the literature concerning measures to address the challenges to professionalism have converged on the establishment of an education community, on a structured curriculum dealing with professionalism, on developing programs for role modelling and mentoring, and on attention to the assessment of professional conduct. The interventions in the field of medical education appear central among these efforts, since it is during medical school that the template for professional conduct in medicine is primarily learned. This article attempts to provide a more in-depth discussion of the goals, purposes and current factors influencing teaching and learning professional behaviour in the medical school curriculum and the residency programs.