Training, experience, and perceptions of chest tube insertion by higher speciality trainees: implications for training, patient safety, and service delivery.

BACKGROUND: Seldinger Chest Tube Insertion (CTI) is a high acuity low occurrence procedure and remains a core capability for UK physician higher speciality trainee's (HST). A multitude of factors have emerged which may affect the opportunity of generalists to perform CTI. In view of which, this paper sought to establish the current experiences, attitudes, training, and knowledge of medical HST performing Seldinger CTI in acute care hospitals in the Peninsula deanery. METHODS: A Scoping review was performed to establish the UK medical HST experience of adult seldinger CTI. Synonymous terms for CTI training were searched across Cochrane, ERIC, Pubmed and British education index databases. Following which, a regional survey was constructed and completed by HST and pleural consultants from five hospitals within the Peninsula deanery between April-July 2022. Data collected included participants demographics, attitudes, training, experience, and clinical knowledge. Outcomes were collated and comparisons made across groups using SPSS. A p-value of < 0.05 was defined as significant. RESULTS: The scoping review returned six papers. Salient findings included low self-reported procedural confidence levels, poor interventional selection for patient cases, inadequate site selection for CTI and 1 paper reported only 25% of respondents able to achieve 5-10 CTI annually. However, all papers were limited by including grades other than HST in their responses. The regional survey was completed by 87 HST (12 respiratory, 63 non-respiratory medical HST and 12 intensivists/anaesthetists HST). An additional seven questionnaires were completed by pleural consultants. Respiratory HSTs performed significantly more Seldinger CTI than general and ICM/anaesthetic registrars (p < 0.05). The percentage of HST able to achieve a self-imposed annual CTI number were 81.8, 12.9 and 41.7% respectively. Self-reported transthoracic ultrasound competence was 100, 8 and 58% respectively (p < 0.001). The approach to clinical management significantly differed with national guidance with pleural consultants showing an agreement of 89%, respiratory HST 75%, general HST 52% and ICM/anaesthetic HST 54% (p = 0.002). CONCLUSION: Compared to respiratory trainees, non-respiratory trainees perform lower numbers of Seldinger CTI, with lower confidence levels, limited knowledge, and a reduced perceived relevance of the skill set. This represents a significant training and service challenge, with notable patient safety implications.

Optimising the delivery of remediation programmes for doctors: A realist review.

CONTEXT: Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety. METHOD: We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs). RESULTS: A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection. CONCLUSION: Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.

'You're just a locum': professional identity and temporary workers in the medical profession.

Internationally, there has been substantial growth in temporary working, including in the medical profession where temporary doctors are known as locums. There is little research into the implications of temporary work in health care. In this paper, we draw upon theories concerning the sociology of the medical profession to examine the implications of locum working for the medical profession, healthcare organisations and patient safety. We focus particularly on the role of organisations in professional governance and the positioning of locums as peripheral to or outside the organisation, and the influence of intergroup relationships (in this case between permanent and locum doctors) on professional identity. Qualitative semi-structured interviews were conducted between 2015 and 2017 in England with 79 participants including locum doctors, locum agency staff, and representatives of healthcare organisations who use locums. An abductive approach to analysis combined inductive coding with deductive, theory-driven interpretation. Our findings suggest that locums were perceived to be inferior to permanently employed doctors in terms of quality, competency and safety and were often stigmatised, marginalised and excluded. The treatment of locums may have negative implications for collegiality, professional identity, group relations, team functioning and the way organisations deploy and treat locums may have important consequences for patient safety.

Reviving clinical governance? A qualitative study of the impact of professional regulatory reform on clinical governance in healthcare organisations in England.

BACKGROUND: Until recently, processes of professional regulation and organisational clinical governance in the UK have been largely separate. However, the introduction of medical revalidation in 2012 means that all doctors have to demonstrate periodically to the regulator that they are up to date and fit to practise, and as part of this process doctors must engage with clinical governance activities in the organisations in which they work. OBJECTIVE: To explore how the recent implementation of medical revalidation has affected the arrangements for clinical governance in healthcare organisations in England. DESIGN: Thematic analysis of interviews with 62 senior clinicians and non-clinicians in management or senior administrative roles, from a range of healthcare organisations in England. RESULTS: Revalidation has engendered changes to clinical governance systems, resulting in: increased doctor engagement with clinical governance activities; new or improved systems for access to clinical governance data for doctors and leaders within healthcare organisations; and more leverage - through the Responsible Officer role - to enforce engagement with clinical governance. Organisational context has been an important mediator of the impact of revalidation on clinical governance. CONCLUSION: Revalidation has increased alignment between systems for organisational and professional oversight and accountability, resulting in increased scrutiny of clinical practice. However, it is still a matter of conjecture whether this will in turn lead to improvements in medical performance.

Remediating professionalism lapses in medical students and doctors: A systematic review.

CONTEXT: A remediation intervention aims to facilitate the improvement of an individual whose competence in a particular skill has dropped below the level expected. Little is known regarding the effectiveness of remediation, especially in the area of professionalism. This review sought to identify and assess the effectiveness of interventions to remediate professionalism lapses in medical students and doctors. METHODS: Databases Embase, MEDLINE, Education Resources Information Center and the British Education Index were searched in September 2017 and October 2018. Studies reporting interventions to remediate professionalism lapses in medical students and doctors were included. A standardised data extraction form incorporating a previously described behaviour change technique taxonomy was utilised. A narrative synthesis approach was adopted. Quality was assessed using the Critical Appraisal Skills Programme checklist. RESULTS: A total of 19 studies on remediation interventions reported in 23 articles were identified. Of these, 13 were case studies, five were cohort studies and one was a qualitative study; 37% targeted doctors, 26% medical students, 16% residents and 21% involved mixed populations. Most interventions were multifaceted and addressed professionalism issues concomitantly with clinical skills, but some focused on specific areas (eg sexual boundaries and disruptive behaviours). Most used three or more behaviour change techniques. The included studies were predominantly of low quality as 13 of the 19 were case studies. It was difficult to assess the effectiveness of the interventions as the majority of studies did not carry out any evaluation. CONCLUSIONS: The review identifies a paucity of evidence to guide best practice in the remediation of professionalism lapses in medical students and doctors. The literature tentatively suggests that remediating lapses in professionalism, as part of a wider programme of remediation, can facilitate participants to graduate from a programme of study, and pass medical licensing and mock oral board examinations. However, it is not clear from this literature whether these interventions are successful in remediating lapses in professionalism specifically. Further research is required to improve the design and evaluation of interventions to remediate professionalism lapses.

Sociodemographic and educational characteristics of doctors applying for psychiatry training in the UK: secondary analysis of data from the UK Medical Education Database project.

Aims and methodWorkforce shortages in psychiatry are common worldwide. The international literature provides insights into factors influencing decisions to train in psychiatry but is predominately survey based. This national cohort study aimed to identify the characteristics of doctors who were most likely to apply to psychiatry training programmes. The sample comprised doctors who entered UK medical schools in 2007/8 and who made first-time specialty training applications in 2015. The association between application to psychiatry and doctors' sociodemographic and educational characteristics was examined using multivariable logistic regression. RESULTS: Those most likely to apply were White, privately educated older doctors with below average performance at medical school.Clinical implicationsTo reduce workforce shortages, psychiatry must make itself more attractive to all doctors, especially those from underrepresented groups such as state-educated Black and minority ethnic individuals. Otherwise, national policies to widen participation in the study of medicine by such groups may exacerbate the current recruitment crisis.Declaration of interestNone.

Reforming regulatory relationships: The impact of medical revalidation on doctors, employers, and the General Medical Council in the United Kingdom.

In 2012, medical regulation in the United Kingdom was fundamentally changed by the introduction of revalidation - a process by which all licensed doctors are required to regularly demonstrate that they are up to date and fit to practice in their chosen field and are able to provide a good level of care. This paper examines the implications of revalidation on the structure, governance, and performance management of the medical profession, as well as how it has changed the relationships between the regulator, employer organizations, and the profession. We conducted semi-structured interviews with clinical and non-clinical staff from a range of healthcare organizations. Our research suggests that organizations have become intermediaries in the relationship between the General Medical Council and doctors, enacting regulatory processes on its behalf and extending regulatory surveillance and oversight at local level. Doctors' autonomy has been reduced as they have become more accountable to and reliant on the organizations that employ them.

The International Landscape of Medical Licensing Examinations: A Typology Derived From a Systematic Review.

BACKGROUND: National licensing examinations (NLEs) are large-scale examinations usually taken by medical doctors close to the point of graduation from medical school. Where NLEs are used, success is usually required to obtain a license for full practice. Approaches to national licensing, and the evidence that supports their use, varies significantly across the globe. This paper aims to develop a typology of NLEs, based on candidacy, to explore the implications of different examination types for workforce planning. METHODS: A systematic review of the published literature and medical licensing body websites, an electronic survey of all medical licensing bodies in highly developed nations, and a survey of medical regulators. RESULTS: The evidence gleaned through this systematic review highlights four approaches to NLEs: where graduating medical students wishing to practice in their national jurisdiction must pass a national licensing exam before they are granted a license to practice; where all prospective doctors, whether from the national jurisdiction or international medical graduates, are required to pass a national licensing exam in order to practice within that jurisdiction; where international medical graduates are required to pass a licensing exam if their qualifications are not acknowledged to be comparable with those students from the national jurisdiction; and where there are no NLEs in operation. This typology facilitates comparison across systems and highlights the implications of different licensing systems for workforce planning. CONCLUSION: The issue of national licensing cannot be viewed in isolation from workforce planning; future research on the efficacy of national licensing systems to drive up standards should be integrated with research on the implications of such systems for the mobility of doctors to cross borders.

Remediating doctors' performance to restore patient safety: a realist review protocol.

INTRODUCTION: Underperformance by doctors poses a risk to patient safety. Remediation is an intervention designed to remedy underperformance and return a doctor to safe practice. Remediation is widely used across healthcare systems globally, and has clear implications for both patient safety and doctor retention. Yet, there is a poor evidence base to inform remediation programmes. In particular, there is a lack of understanding as to why and how a remedial intervention may work to change a doctor's practice. The aim of this research is to identify why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to support patient safety. METHODS AND ANALYSIS: Realist review is an approach to evidence synthesis that seeks to develop programme theories about how an intervention works to produce its effects. The initial search strategy will involve: database and grey literature searching, citation searching and contacting authors. The evidence search will be extended as the review progresses and becomes more focused on the development of specific aspects of the programme theory. The development of the programme theory will involve input from a stakeholder group consisting of professional experts in the remediation process and patient representatives. Evidence synthesis will use a realist logic of analysis to interrogate data in order to develop and refine the initial programme theory into a more definitive realist programme theory of how remediation works. The study will follow and be reported according to Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES). ETHICS AND DISSEMINATION: Ethical approval is not required. Our dissemination strategy will include input from our stakeholder group. Customised outputs will be developed using the knowledge-to-action cycle framework, and will be targeted to: policy-makers; education providers and regulators, the National Health Service, doctors and academics. PROSPERO REGISTRATION NUMBER: CRD42018088779.

UK Policy on Doctor Remediation: Trajectories and Challenges.

Around the world, policy-makers, academics, and health service professionals have become increasingly aware of the importance of remediation, the process by which poor performance is "remedied," as part of the changing landscape of medical regulation. It is, therefore, an opportune time to critique the UK experience with remediation policy. This article frames, for the first time, the UK remediation policy as developing from a central policy aim that was articulated in the 1990s: to accelerate the identification of underperformance and, subsequently, remedy any problems identified as soon as possible. In pursuit of this aim, three policy trajectories have emerged: professionalizing and standardizing remediation provision; linking remediation with other forms of regulation, namely relicensure (known in the UK as medical revalidation); and fostering obligations for doctors to report themselves and others for remediation needs. The operationalization of policy along these trajectories, and the challenges that have arisen, has relevance for anyone seeking to understand or indeed improve remediation practices within any health care system. It is argued here that the UK serves as an example of the more general challenges posed by seeking to integrate remediation policy within broader frameworks of medical governance, in particular systems of relicensure, and the need to develop a solid evidence base for remediation practices.

The impact of large scale licensing examinations in highly developed countries: a systematic review.

BACKGROUND: To investigate the existing evidence base for the validity of large-scale licensing examinations including their impact. METHODS: Systematic review against a validity framework exploring: Embase (Ovid Medline); Medline (EBSCO); PubMed; Wiley Online; ScienceDirect; and PsychINFO from 2005 to April 2015. All papers were included when they discussed national or large regional (State level) examinations for clinical professionals, linked to examinations in early careers or near the point of graduation, and where success was required to subsequently be able to practice. Using a standardized data extraction form, two independent reviewers extracted study characteristics, with the rest of the team resolving any disagreement. A validity framework was used as developed by the American Educational Research Association, American Psychological Association, and National Council on Measurement in Education to evaluate each paper's evidence to support or refute the validity of national licensing examinations. RESULTS: 24 published articles provided evidence of validity across the five domains of the validity framework. Most papers (n = 22) provided evidence of national licensing examinations relationships to other variables and their consequential validity. Overall there was evidence that those who do well on earlier or on subsequent examinations also do well on national testing. There is a correlation between NLE performance and some patient outcomes and rates of complaints, but no causal evidence has been established. CONCLUSIONS: The debate around licensure examinations is strong on opinion but weak on validity evidence. This is especially true of the wider claims that licensure examinations improve patient safety and practitioner competence.