XTRA Study Protocol: eXploring medical sTudents caReer reAdiness - A cross sectional study in the UK

Background and objectives: Professional and career enhancing opportunities are essential for developing skills required for a successful career in medicine. Research to date has mainly focused on the extent to which medical schools prepare students for clinical work as junior doctors. However, there remains a need to ascertain how students prepare for their career and what facilitates or hinders learning regarding careers in medicine. The purpose of the XTRA study is to examine career readiness of medical students at UK universities and the support they receive during their studies regarding career planning. Methods: The eXploring medical sTudents caReer reAdiness (XTRA) study is a national cross sectional study of all medical students enrolled at a UK medical school. Data collection will occur via a secure online survey designed as a training need analysis based on the principles of Supers theory (Super, 1953) of career development. A snowball sampling strategy will be used to recruit participants via social media and networks. Results will be analysed using quantitative analysis and thematic analysis to identify themes in qualitative responses. The primary outcome is to understand the perspective of current medical students on how well prepared they are about entering their careers in healthcare. Conclusions: We anticipate that findings from this study will help identify career readiness of medical students to facilitate the development of career development programmes and resources to ensure medical students are well equipped for their future careers. Keywords: medical education; medical school; medical students; careers; hidden curriculum; extracurriculars; career readiness.

The Introduction of An Intravenous Fluid Bundle to Improve the Prescribing of Intravenous Fluids Within a District General Hospital (Preprint)

BACKGROUND Intravenous (IV) fluids are some of the most commonly prescribed day-to-day drugs. Evidence suggests that such prescriptions are rarely ever done correctly despite the presence of clear guidelines (NICE CG174). This is believed to be due to lack of knowledge and experience, which often breeds confusion and places patients at increased risk of harm. It also incurs avoidable costs to hospitals. OBJECTIVE This quality improvement project (QIP) aims to ensure that IV fluid prescriptions are: safe, appropriate and adhere to evidence-based NICE guidance. The project’s aims will be achieved through implementing multiple interventions that are categorised under: educational, changing prescribing habits and raising awareness. METHODS Review and improve the prescribing process of “IV fluid prescribing” via three simultaneous approaches. Teaching sessions were delivered to all junior doctors in order to improve knowledge and awareness of appropriate IV fluid prescribing and promote familiarity with the current NICE IV fluid guidelines. This included a ‘feature session’ at our local hospital Grand Round. A point-of-care aide-memoire containing a summary of the information needed for correct prescription was designed and printed. This complimented the teaching sessions and supported good clinical practice. Using serial Plan-Do-Study-Act (PDSA) cycles, a novel “IV fluid bundle” was developed, fine-tuned and trialled on five wards, (three surgical, two medical). The aim of the bundle was to ensure that patients were clinically reviewed in order to assess their volaemic status in order that appropriate IV fluids could then be selected and prescribed safely. The impact of these interventions was assessed on the trial wards via a weekly point prevalence audit of the IV fluid bundles for the duration of the trial. Parameters looked at were: incidence of deranged U&E’s, incidence of AKI and the number of days between the latest U&E’s and the patient’s IV fluid prescription. RESULTS These interventions were assessed on trial wards via a weekly point prevalence audit of the new IV fluid prescription chart (bundle; IFB) for the duration of the trial. Parameters monitored were: incidence of deranged U&E’s, incidence of acute kidney injury (AKI) and the number of days between the latest U&E’s and the patient’s IV fluid prescription. Of all of the patients on the IV fluid bundle, 100% had a documented weight, review of both fluid status and balance. The incidence of deranged U&E’s decreased from 48% to 35%. Incidence of AKI decreased from 24% to 10%. The average number of days between the latest U&E’s and a fluid prescription decreased from 2.2 days to 0.6 day. CONCLUSIONS Prescribing IV fluids is a complex task that requires significant improvement both locally and nationally. With 85% uptake of the IFB, we were able to significantly improve all measured outcomes. Through carefully structured interventions geared towards tackling the confounding issues identified from previous audits and process mapping we have shown that prescribing IV fluids can be made safer.

Telemedicine in neonatal care-Saving lives with technology!

Madam, neonatal mortality in Pakistan i.e. death of babies within first twenty eight days of life is 49 per 1000 live births. Moreover, Pakistan contributes to 7% of global neonatal deaths. (1) Cause of mortality may be infection, intra-partum complications, prematurity or congenital birth defects but there is one thing common in all; majority of them occur in rural population due to lack of access to health care facilities. (2) With recent advances, role of tele-medicine has proved to be a milestone in field of medicine especially in underdeveloped and rural areas. According to World Health Organization (WHO), Telemedicine is defined as affordable use of Information and Communication Technology (ICT) for provision of health facilities and care. (3) A study done in Karachi in early 2020 by Ashfaq A et al showed average knowledge of telemedicine among clinicians and junior doctors, but we are still hopeful that since after the global pandemic of COVID-19, not just this knowledge has improved but also perceptions regarding telemedicine should have changed (4). In another study done in china by Makkar A. et al, they demonstrated the role of tele-medicine in not just tele-rounds of NICU but also successful e-examinations of Retinopathy of prematurity, tele-echocardiography, tele-NPR guidance to healthcare providers and family support. Moreover, home based care can be efficiently provided to preterm low birth weight babies including establishment of enteral feeding. (5) With a global shortage of physicians worldwide, lack of neonatologists is a major reason of neonatal referrals from rural areas and tele-medicine can give promising results in this regard. It can not only prevent unnecessary ambulation of tiny patients but also improve survival and quality care. Though under umbrella of private NGOs, tele-medicine is being started for satellite centers in few regions of country but obviously it doesn’t cover majority of population. It is high time to realize importance of Tele-medicine in periphery care setups. Though provision of equipment, installments of high quality ICT and infrastructure might seem a barrier in establishment of Tele-medicine but it can bring revolutionary improvement in neonatal care. It cannot just help reducing over burdening to tertiary care hospitals but also in avoiding hazards and cost of patient transfer.

Referral writing: Consensus building on a tool for writing structured referrals

Competency in referral writing skill is needed by doctors for which they are never trained. Although there is a lot of work done about improvement of consultation letters still priority is not given. There must be a course for teaching and learning medical referral writing skills to students along with the assessment. Currently there is such tool to assess the way communication letter are written. An 18-point assessment scale has been developed through Delphi technique to increase the quality of referral letters. The objective of the present study was to design a structured Performa for writing referrals, validated by 7 participants using Delphi. Results were finalised after the acceptance of structured referral by selected participants through Delphi. The response rate was 70%. The validity and interrater reliability were calculated using SPSS25. The Cronbach’s alpha was 0.7 and Kappa was 0.3. Both were statistically significant. The designed Performa for writing referrals, with its inter-rater reliability calculated, is best for writing effective and structured referrals. The study further recommending training junior doctors in making proper referrals. MeSH Words: Referral and consultation, improving quality and referral, Checklists and referrals and consultation.

Do consultants do what they say they do? Observational study of the extent to which clinicians involve their patients in the decision-making process

ObjectivesTo assess whether consultants do what they say they do in reaching decisions with their patients.DesignCross-sectional analysis of hospital outpatient encounters, comparing consultants’ self-reported usual decision-making style to their actual observed decision-making behaviour in video-recorded encounters.SettingLarge secondary care teaching hospital in the Netherlands.Participants41 consultants from 18 disciplines and 781 patients.Primary and secondary outcome measureWith the Control Preference Scale, the self-reported usual decision-making style was assessed (paternalistic, informative or shared decision making). Two independent raters assessed decision-making behaviour for each decision using the Observing Patient Involvement (OPTION)5 instrument ranging from 0 (no shared decision making (SDM)) to 100 (optimal SDM).ResultsConsultants reported their usual decision-making style as informative (n=11), shared (n=16) and paternalistic (n=14). Overall, patient involvement was low, with mean (SD) OPTION5 scores of 16.8 (17.1). In an unadjusted multilevel analysis, the reported usual decision-making style was not related to the OPTION5 score (p>0.156). After adjusting for patient, consultant and consultation characteristics, higher OPTION5 scores were only significantly related to the category of decisions (treatment vs the other categories) and to longer consultation duration (p<0.001).ConclusionsThe limited patient involvement that we observed was not associated with the consultants’ self-reported usual decision-making style. Consultants appear to be unconsciously incompetent in shared decision making. This can hinder the transfer of this crucial communication skill to students and junior doctors.

Opinion of the junior doctors on the existing morale, support and autonomy at their workplace and the factors positively influencing them

Background: Junior doctors form the majority of the workforce in patient care. Their job is perilous, highly critical, tedious and exhausting and it is imperative that they stay motivated while at work. Improving the morale of physicians has the potential to increase efficiency, ensure patient safety and improve patient outcomes. We aimed to identify the existing status and explore the factors affecting junior doctors’ morale, their sense of feeling supported and their levels of autonomy in 2 large teaching hospitals in Bangladesh. Methods: This cross-sectional observational study was done across 2 large tertiary hospitals- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders(BIRDEM) General Hospital and Dhaka Shishu Hospital, over 4 months period from September- December 2020. The study was carried out on 120 junior doctors by an online questionnaire, distributed through emails and Facebook messenger, asking junior doctors to rate their morale, sense of feeling supported and autonomy and rank the top factors that positively affected them. Results: Data were finally collected from 117 junior doctors after 3 incomplete data were discarded. Most of the junior doctors felt ‘neither good nor bad’ in the domains of existing ‘morale’ (44.4%), ‘feeling supported’ (46.5%) and ‘autonomy’ (48.7%). Additionally, ‘good’ morale was seen in 39.3%, while around 34% rated their support system as ‘good’ and around 24% reported a ‘good’ autonomy. The most important factor positively affecting morale was recognition and reward for good performance (70.1%), factor influencing support was an easy access to senior clinicians (70.4%) and that defining autonomy was constant senior supervision of the everyday work (61.1%). Conclusion: The study aims to identify the existing level of morale, support and autonomy of the junior doctors at their workplace and explore the factors positively affecting them. It is concluded from this study that the junior doctors rated their existing morale, support and autonomy as ‘average’. According to the opinions of the doctors, this study also concludes that, to improve their morale, there is a need to recognize and reward their good work and provide positive feedback. Doctors identified an easy access to senior clinicians with a problem was the primary factor influencing support. Finally, junior doctors wanted constant senior supervision of their everyday work in the wards to improve output. BIRDEM Med J 2022; 12(1): 30-35

The current state of the surgical care team in the United Kingdom: Shall we ‘do a time out’?

The reduction of junior doctors’ working hours over the last two decades paved the way to non-medical practitioners providing care traditionally discharged by surgeons and other medics. These registered practitioners play a vital role in the care of patients in surgery and work within multi-disciplinary teams comprising surgical care practitioners, advanced clinical practitioners in surgery, and physician associates, with significant experience in nursing or allied health care professional practice. Health Education England and the Royal Colleges of Surgeons have invested considerably in developing the relevant educational frameworks to support and quality assure the training of non-medical practitioners. Notwithstanding, to ascertain whether advanced and extended practice have been developed appropriately, a wide critical stance is needed. This article aims to begin to analyse the status quo of the extended surgical team and of the associated pitfalls and challenges, making conservative comparisons between the roles with the international scene. The objective is to help students, trainees and all involved in surgical care to adopt an informed and critical viewpoint about the extended surgical team in the United Kingdom, in the hope that this can lead to improvement and forward planning in workforce design for the benefit of patients and their communities.

Medical students’ and junior doctors’ leadership and teamwork skills improved after involvement with Simulation via Instant Messaging-Birmingham Advance (SIMBA)

BackgroundLeadership and teamwork skills are essential components of medical education. Simulation via Instant Messaging-Birmingham Advance (SIMBA) is an innovative simulation-based learning tool mainly delivered by medical students and junior doctors. This study aimed to investigate the effect of SIMBA on leadership and teamwork skills of medical students and junior doctors during COVID-19.MethodsAll medical students and junior doctors involved in the delivery of SIMBA were invited to complete the Leadership Trait Questionnaire (LTQ) and Teamwork Skills Questionnaire (TSQ) assessing their views pre-SIMBA and post-SIMBA involvement. The changes in scores were analysed using the Wilcoxon signed-rank test. Open-ended questions were reviewed in an inductive thematic analysis.ResultsA total of 33 SIMBA team members completed both questionnaires. There was improvement in all traits measured in the LTQ and TSQ, significant in 9/14 LTQ traits, and all 6 TSQ traits (p<0.05). ‘Decision making’ had the highest improvement (p<0.0001). Response to open-ended questions reported positive effects on personal development, medical professionalism, communication skills and medical/clinical knowledge.ConclusionsSIMBA is an effective model to inculcate leadership and teamwork skills among medical students and junior doctors. Prospective studies are underway to assess long-term impact.