Exploring stories of learning and professional development: interactions between GP personal tutors and medical students.

BACKGROUND: The demanding environment at medical school results in some students being prone to a high risk of mental health issues. GMC recommendations include positioning personal tutors for pastoral support and to act as academic role models. Tutors who are clinicians, such as GPs, could help students develop their academic and professional narratives. Our study explores interactions between GP tutors and students and evaluates how personal tutoring can support the ways in which students respond to the medical school culture and its demands. METHOD: Six pairs of GP tutors and medical students had three personal tutor meetings over 9 months. Twelve meetings were recorded. A dialogical narrative analytical approach was used to assess how students' problems and reflective processes were negotiated with tutors. Three themes were formed to consolidate findings. RESULTS: Tutors' affirmations helped students develop an alternative narrative to perfectionism focusing on 'doing well' and self-care. Reflection on students' perceptions of a medical career were prompted by tutors who encouraged students to keep an open-minded and enthusiastic outlook. Active participation from students sometimes required tutors to relinquish hierarchical power and share personal experiences. CONCLUSION: GP tutors can help reframe student narratives of perfectionism and professionalism by expressing their vulnerabilities and working collaboratively. With clear guidance, there is potential for personal tutors working as GPs, to benefit students in the long run both academically and professionally. However, this should go hand in hand with a transformation of medical school culture to prevent sole focus on building student resilience.

What do students actually do on an internal medicine clerkship? A log diary study.

BACKGROUND: There are limited data on the amount of time students spend on teaching and learning while on internal medicine clerkships, and existing data suggest a wide international variation. Community-based teaching of internal medicine is now widespread; but its strengths and weaknesses compared to traditional hospital based teaching are still unclear. AIM: To determine the proportion of time students spend on different activities on an internal medicine clerkship, and to determine whether this differs in general practice and in hospital. In addition we aimed to determine students' views on the educational value and enjoyment of various activities. METHODS: Prospective completion of log diaries recording student activities. Each student was asked to complete the diary for two separate weeks of their internal medicine clerkship: one week of general practice-based teaching and one week of hospital-based teaching. RESULTS: The response rate was 68% (88/130). Students spent approximately 5.5 h per day on teaching and learning activities in both environments, with more time (50 min vs. 30 min, P = 0.007) on unsupervised interaction with patients in hospital than in general practice, and more time (53 min vs. 21 min, P < 0.001) undergoingassessment in general practice than in hospital. Standard deviations were wide, demonstrating the heterogeneous nature of the data. Students perceived supervised interaction with patients and teaching by doctors as the most educational activities in both environments, but found it even more educationally valuable and enjoyable in general practice than in hospital (mean score for educational value: 4.27 in general practice, 3.88 in hospital, P = 0.048; mean score for enjoyment 4.13 in general practice, 3.66 in hospital, P = 0.03). CONCLUSIONS: Students greatly value interactions with patients, perceiving these as both educational and enjoyable. Curriculum planners must continue to place patient-based learning at the centre of undergraduate medical education. The heterogeneity of the data suggests that individual students have very different experiences, despite apparently similar timetables.

Identification and management of stroke risk in older people: a national survey of current practice in primary care.

The current practice of stroke prevention was assessed among UK general practitioners (GPs) using a postal questionnaire. A random sample of 583 GPs (response rate 60%) in practice throughout the UK was examined. Main outcomes were the reported practice in the identification of stroke risk, management of hypertension, and use of other interventions (particularly aspirin treatment) to reduce the risk of stroke. Most respondents (451, 77%) reported that they specifically identified patients at high risk of stroke. However, of these only 301 (67%) used more than one major risk factor to do this and less than one-third used either age or pre-existing cardiovascular disease as an indicator. Thresholds for drug treatment of hypertension increased markedly with patient age with only 68%, 23% and 9% of respondents reporting treating elevated systolic, diastolic and isolated systolic pressures respectively, in accord with the British Hypertension Society (BHS) guidelines for patients aged 70-79 years. Thresholds for blood pressure (BP) treatment in older patients did not differ by region but were higher among respondents who had been in general practice for more than 10 years. The value of aspirin in preventing stroke in patients with pre-existing cardiovascular disease was recognized by almost all (560, 96%) respondents. The results suggest that there is scope for increasing the benefits of stroke prevention in primary care, by focusing on the management of patients at high absolute risk, in whom the greatest treatment benefits are likely to be obtained.

Scoring system to identify men at high risk of stroke: a strategy for general practice.

BACKGROUND: The major risk factors for stroke are well described and there is good evidence that the risks associated with hypertension and cigarette smoking are reversible by appropriate interventions. However, if disease prevention measures are to be efficient, it is important that a system which can identify individuals at high risk of stroke be available for use in general practice. AIM: A study was therefore undertaken to design an effective and practical system for detecting men aged 40 to 59 years at high risk of stroke in primary care. METHOD: Stroke incidence and risk factor data were examined in a cohort of 7735 men aged 40 to 59 years who had taken part in the British regional heart study. Analysis was performed using data from initial entry into the study and then from five and 11.5 years of follow up. Subjects were randomly selected from the age-sex register of one general practice in each of 24 different towns throughout the United Kingdom, representing the full range of cardiovascular mortality rates. RESULTS: A simple scoring system derived from logistic regression using age, systolic blood pressure, current cigarette consumption, and evidence of anginal chest pain was able to detect more than 80% of all strokes occurring within five years in the top fifth of the score distribution. The inclusion of other risk factors for stroke did not increase the score's predictive ability. The combination of smoking and hypertension, while much less sensitive than the scoring system, was a better indicator of risk than any single risk factor, all of whose predictive values were poor. CONCLUSION: Based on readily measured variables, this scoring system could be used in general practice to identify men at high risk of stroke who would benefit from further intervention. Effective identification of high risk individuals requires assessment of the combined effects of multiple risk factors.

Stabilization of chimeric BR96-doxorubicin immunoconjugate.

Chimeric BR96-doxorubicin conjugate (BR96-DOX) is an immunoconjugate designed to specifically target and kill certain tumor cells. The linker between the chimeric BR96 antibody and DOX is an acid-labile hydrazone group which was designed to undergo lysosomal hydrolysis to release DOX in vivo. Stability studies indicated that acid-catalyzed hydrazone hydrolysis was the major degradation route in vitro. Even under optimal conditions of pH and temperature, the stability of BR96-DOX in solution was not acceptable for long-term storage. Lyophilization of BR96-DOX in the presence of added sugars, such as lactose or sucrose, and subsequent storage of the lyophile under refrigeration significantly improved the stability. Therefore lyophilization appears to be a viable approach for achieving long-term stabilization of BR96-DOX.

Chemical and physical stability of chimeric L6, a mouse-human monoclonal antibody.

Chimeric L6 is a mouse-human monoclonal antibody specific for tumor cell-associated antigens. The factors affecting the physical and chemical stability of chimeric L6 were assessed at elevated temperatures (30-60 degrees C) and by multiple freezing and thawing. Three routes of degradation were observed: chemical degradation to smaller molecular weight species, irreversible aggregation, and formation of a reversible dimer. The specific pathway depended on the stress condition applied and the pH, with maximal overall stability to both thermal stress and multiple freezing/thawing observed at about pH 5.5. Other factors including antibody concentration, buffer concentration, NaCl concentration, and agitation had minimal influence on the stability. Commonly used sugars, polyhydric alcohols, and amino acids effectively prevented freeze/thaw-induced aggregation.

Degradation kinetics and mechanism of N6-[(dimethylamino)methylene]mitomycin C in aqueous solutions.

The degradation of N6-[(dimethylamino)methylene]mitomycin C, a semisynthetic analogue of mitomycin C, was studied in aqueous solution. The compound degraded rapidly and followed pseudo-first-order kinetics in both acidic (pH less than 5) and basic pH greater than or equal to 9) media. In the near-neutral pH region, however, biphasic kinetics were observed. At the pH of maximum stability (6.5), 10% activity was lost after approximately 6 h at 22 degrees C. Citrate and phosphate species were catalytic at pH 6.5. Spectrophotometric and HPLC methods were used to elucidate the degradation mechanism at pH 7-9. Under these conditions, equilibrium addition of one water molecule into the amidine side chain occurred, followed by parallel formation of mitomycin C and N6-(formyl)mitomycin C. The latter compound subsequently hydrolyzed to mitomycin C.