"User involvement is a sine qua non, almost, in medical education": learning with rather than just about health and social care service users.

Despite the General Medical Council emphasising the value of service users to medical students' education, there is scant literature about service user involvement in medical education. Although some research has outlined the effectiveness of service users as teachers, none has explored social issues surrounding how medical students learn 'with' rather than just 'about' service users. Incorporating insights from contemporary socio-cultural learning theory, this study examines the views and experiences of 47 stakeholders (comprising 19 service users, 13 medical students and 15 medical educators) concerning service user involvement in medical education. Eight audiotaped focus group discussions were convened and the audiotapes were transcribed. The transcripts and audiotapes were independently analysed by multiple researchers using Framework analysis. Seven content- and five process-orientated themes emerged from the analysis. Content-related themes included the costs and benefits of service user involvement in medical education and process-related themes included the use and function of humour and metaphor. In this paper, we focus primarily on the content-related themes. We discuss these findings in light of the existing service user involvement literature and contemporary socio-cultural learning theory and provide implications for further research and educational practice. We encourage educators to involve service users in medical education but only in a considered way.

Does increasing the grades of the knee osteoarthritis line drawing atlas alter its clinimetric properties?

OBJECTIVES: To (a) develop further logically derived line drawing atlases (LDAs) for grading radiographic knee osteoarthritis (OA); and (b) determine which is superior using metrological criteria. METHODS: A series of LDAs (-3 to +3, -4 to +4, and -5 to +5) were produced by (a) incorporating additional grades for osteophyte and joint space width (JSW) above the 0-3 pilot LDA, over an equivalent range of disease; and (b) adding negative grades for JSW. 121 sets of bilateral knee radiographs (standing, anteroposterior plus flexed skyline), plus serial views of 68 tibiofemoral joints (TFJs) and 36 patellofemoral joints were scored twice by one observer for each LDA. Minimum JSW of 50 radiograph sets was directly measured and awarded a categorical grade dependent upon the boundaries of each LDA grade. Time taken to grade 30 randomly selected knee radiograph sets was measured. RESULTS: Intraobserver reproducibility was similar for all LDAs, (weighted kappa: JSW = 0.85-0.87; osteophyte = 0.77-0.79), with no deterioration with increasing grades. Criterion validity favoured the -5 to +5 LDA, which was also quickest to use. All atlases showed similar responsiveness (standardised response mean: medial TFJ JSW = 0.78-0.83; medial femoral osteophyte = 0.61-0.73), with most sites compromised by small sample size, little change in score, and high variation between subjects. CONCLUSIONS: A set of LDAs was created illustrating the full range of normality/abnormality likely to be encountered in a community study of knee pain or OA. Despite superior validity and equivalent reproducibility, improved responsiveness of the -5 to +5 LDA was not confirmed.

Review of teenage health: time for a new direction.

Teenagers represent a large proportion of the population and have the potential for considerable morbidity because of high smoking rates and unwanted teenage pregnancy. The government intends to reduce the incidence of this important morbidity, but there is no coherent strategy for attaining these improvements. Research in this area is limited in the United Kingdom, but research from elsewhere has clarified teenagers' attitudes. There have also been some intervention studies resulting in improvements in specific aspects of teenage health. A worrying theme which emerges from this research is of a new inverse care law. Teenagers with low self-esteem and less hope for their own future are more likely to lead lifestyles which put them at risk and are less likely to ask for advice in relation to their health or lifestyle. Thus, it may be more difficult to alter behaviour in these patients; overall population based improvements may be difficult to achieve. Teenagers' own concerns appear to be at variance with the goals dictated by government and health professionals. It is suggested that the only method of meeting the needs of teenagers and at the same time aiming to reduce morbidity in this age group is to foster an atmosphere of patient centredness in dealings with adolescent patients and for further ther research in this important health gain area.

Prospective evaluation of a risk scoring system for cervical neoplasia in primary care.

BACKGROUND: Against a background of concern over the costs of the cervical screening programme in the United Kingdom, increased precision in targeting groups at high risk of having an abnormal cervical smear offers a means of increasing efficiency. Previous papers have described the development of a risk scoring system and its feasibility and reliability in primary care. AIM: A study was carried out to assess the validity of the scoring system by testing its predictive ability on a prospective data set. METHOD: Consecutive attenders for cervical smear tests at seven practices and three clinics were recruited for the study. The women completed a questionnaire from which their risk scores could be calculated. The scores were compared with cytology and histology results. Various performance statistics were obtained. RESULTS: In terms of cervical intraepithelial neoplasia (CIN) 2 or 3, there was an 11 fold increased risk among the low risk group (scores of four or five) compared with the very low risk group (scores of three or less). The system enabled the identification of 75% (95% confidence interval 62% to 84%) of cases of CIN 2 or 3 among the 21% of the 3629 women with known histology who had a score of four or five. CONCLUSION: Given the ease with which risk status can be ascertained (a risk score could not be calculated for only 23 of 3661 women) and the magnitude of difference in risk, the risk scoring system appears to have potential for assisting the targeting of screening resources. Studies of risk perception and behaviour, and ultimately a randomized controlled trial, are required to assess the effectiveness and cost effectiveness of risk targeting.

Feasibility, reliability and women's views of a risk scoring system for cervical neoplasia in primary care.

BACKGROUND: A risk assessment scale for cervical neoplasia has been developed which gives a risk score based on four factors: level of education, current smoking status, number of years of oral contraceptive use and number of sexual partners ever. AIM: A pilot study was undertaken to determine the feasibility and acceptability of a self-report data form, used to assess risk of cervical neoplasia, and the test-retest reliability of women's responses to the questions. METHOD: A sample of women attending one general practice were asked to complete a self-report data form which included some highly personal questions, and a questionnaire assessing their level of difficulty and discomfort completing the form. Women were sent a second self-report data form four weeks later in order to assess test-retest reliability. RESULTS: There was a high level of cooperation with the study (94% initial participation rate), little evidence of discomfort with the questions posed, and high test-retest reliability. CONCLUSION: The results of this pilot study have positive implications for a large prospective study evaluating the predictive power of the risk scale in relation to the result of the cervical smear test.

Risk targeting in cervical screening: a new look at an old problem.

In the face of continuing debate about the level of effectiveness of the United Kingdom cervical cytology screening programme in preventing cervical cancer, more precise targeting of high risk groups might offer a means of enhancing its efficiency. Broad risk targeting is already practised by screening only sexually active women aged 20 to 65 years. This paper describes a risk scoring system constructed from the available literature and designed to be used by primary care health professionals and patients. The system involves four independent risk factors: educational level, current smoking habit, years of oral contraceptive use and number of sexual partners. Since the objective is simply to identify women at relatively high risk, inclusion of a factor neither requires nor implies causality. The next steps are to study the feasibility of putting the scale to practical use and to investigate its predictive value in a prospective evaluation.

PIP: This paper proposes an individual risk scoring system to target cervical screening beyond the broad targeting already used in Britain, that is, screening only sexually active women aged 20-65 years. It may be practical to introduce risk-related screening schedules, with intervals graduated by risk status. 5 large well-controlled studies were selected from the literature to construct a risk-scoring system. From these studies several significant risk factors emerged: 5-7 or more years of oral contraceptive use, current smoking, number of sexual partners, pregnancy outside of marriage, and age at first intercourse. In all 5 studies current smoking and number of sexual partners were identified as risk factors. The 3 North American studies found educational level to be an independent risk factor. Also the woman's age and the time interval since her last smear were significant. 4 independent risk factors were chosen as best describing risk of cervical intraepithelial neoplasia or cervical cancer: woman's educational level, current smoking, 5 or more years of oral contraceptive use, and lifetime number of sexual partners. These risk factors are not intended to imply causality or a formal statistical meta-analysis. This risk scoring tool is being tested in a pilot study for feasibility.