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1.  Newly qualified doctors' views about whether their medical school had trained them well: questionnaire surveys 
Background
A survey of newly qualified doctors in the UK in 2000/2001 found that 42% of them felt unprepared for their first year of employment in clinical posts. We report on how UK qualifiers' preparedness has changed since then, and on the impact of course changes upon preparedness.
Methods
Postal questionnaires were sent to all doctors who qualified from UK medical schools, in their first year of clinical work, in 2003 (n = 4257) and 2005 (n = 4784); and findings were compared with those in 2000/2001 (n = 5330). The response rates were 67% in 2000/2001, 65% in 2003, and 43% in 2005. The outcome measure was the percentage of doctors agreeing with the statement "My experience at medical school has prepared me well for the jobs I have undertaken so far".
Results
In the 2000/2001 survey 36.3% strongly agreed or agreed with the statement, as did 50.3% in the 2003 survey and 58.5% in 2005 (chi-squared test for linear trend: χ2 = 259.5; df = 1; p < 0.001). Substantial variation in preparedness between doctors from different medical schools, reported in the first survey, was still present in 2003 and 2005. Between 1998 and 2006 all UK medical schools updated their courses. Within each cohort a significantly higher percentage of the respondents from schools with updated courses felt well prepared.
Conclusion
UK medical schools are now training doctors who feel better prepared for work than in the past. Some of the improvement may be attributable to curricular change.
doi:10.1186/1472-6920-7-38
PMCID: PMC2203980  PMID: 17945007
2.  "Seeing a doctor is just like having a date": a qualitative study on doctor shopping among overactive bladder patients in Hong Kong 
BMC Family Practice  2014;15:27.
Background
Although having a regular primary care provider is noted to be beneficial to health, doctor shopping has been documented as a common treatment seeking behavior among chronically ill patients in different countries. However, little research has been conducted into the reasons behind doctor shopping behavior among patients with overactive bladder, and even less into how this behavior relates to these patients’ illness and social experiences, perceptions, and cultural practices. Therefore, this study examines overactive bladder patients to investigate the reasons behind doctor shopping behavior.
Methods
My study takes a qualitative approach, conducting 30 semi-structured individual interviews, with 30 overactive bladder patients in Hong Kong.
Results
My study found six primary themes that influenced doctor shopping behavior: lack of perceived need, convenience, work-provided medical insurance, unpleasant experiences with doctors, searching for a match doctor, and switching between biomedicine and traditional Chinese medicine. Besides the perceptual factors, participants’ social environment, illness experiences, personal cultural preference, and cultural beliefs also intertwined to generate their doctor shopping behavior. Due to the low perceived need for a regular personal primary care physician, environmental factors such as time, locational convenience, and work-provided medical insurance became decisive in doctor shopping behavior. Patients’ unpleasant illness experiences, stemming from a lack of understanding among many primary care doctors about overactive bladder, contributed to participants’ sense of mismatch with these doctors, which induced them to shop for another doctor.
Conclusions
Overactive bladder is a chronic bladder condition with very limited treatment outcome. Although patients with overactive bladder often require specialty urology treatment, it is usually beneficial for the patients to receive continuous, coordinated, comprehensive, and patient-centered support from their primary care providers. Primary care doctors’ understanding on patients with overactive bladder with empathetic attitudes is important to reduce the motivations of doctor shopping behavior among these patients.
doi:10.1186/1471-2296-15-27
PMCID: PMC3936809  PMID: 24502367
Hong Kong; Doctor shopping; Perceptions; Social environment; Illness and treatment experiences; Personal cultural preference; Cultural beliefs; Overactive bladder patients
3.  Views of Foundation Doctors (Year 2) on Distress Likely with Genital Examination in Children 
The Ulster Medical Journal  2011;80(3):141-143.
Little is known about the attitude of newly qualified doctors towards intimate examination of children. During the 2 course of a training day in child protection, an exercise was undertaken to ask Foundation doctors (FY2) what impact they thought genitalia examination had on children. These responses have been compared with the only systematic examination of the response of children and their parents to such examinations that has been published.
The doctors in question believe such examinations to be more distressing than children or their parents appear to perceive. It is likely that such perceptions may inhibit newly qualified in efforts to acquire such skills that may not have been acquired as medical students. This may be an area of continuing difficulty for the future because of the changes in access to relevant learning experiences for medical students.
PMCID: PMC3605525  PMID: 23526175
intimate examination; children; training; perception
4.  Well prepared for work? Junior doctors' self-assessment after medical education 
BMC Medical Education  2011;11:99.
Background
Apart from objective exam results, the overall feeling of preparedness is important for a successful transition process from being a student to becoming a qualified doctor. This study examines the association between self-assessed deficits in medical skills and knowledge and the feeling of preparedness of junior doctors in order to determine which aspects of medical education need to be addressed in more detail in order to improve the quality of this transition phase and in order to increase patient safety.
Methods
A cohort of 637 doctors with up to two years of clinical work experience was included in this analysis and was asked about the overall feeling of preparedness and self-assessed deficits with regard to clinical knowledge and skills. Three logistic regression models were used to identify medical skills which predict the feeling of preparedness.
Results
All in all, about 60% of the participating doctors felt poorly prepared for post-graduate training. Self-assessed deficits in ECG interpretation (aOR: 4.39; 95% CI: 2.012-9.578), treatment and therapy planning (aOR: 3.42; 95% CI: 1.366-8.555), and intubation (aOR: 2.10; 95% CI: 1.092-4.049) were found to be independently associated with the overall feeling of preparedness in the final regression model.
Conclusions
Many junior doctors in Germany felt inadequately prepared for being a doctor. With regard to the contents of medical curricula, our results show that more emphasis on ECG-interpretation, treatment and therapy planning and intubation is required to improve the feeling of preparedness of medical graduates.
doi:10.1186/1472-6920-11-99
PMCID: PMC3267657  PMID: 22114989
5.  Medical student teaching in the UK: how well are newly qualified doctors prepared for their role caring for patients with cancer in hospital? 
British Journal of Cancer  2007;97(4):472-478.
A number of studies have identified problems with undergraduate oncology teaching. We have investigated how well prepared newly qualified doctors (first foundation year, or FY1 doctors) are for treating patients with cancer. Twenty-five FY1 doctors and 15 senior doctors participated in interviews. We turned the emergent themes into a questionnaire for all 5143 UK FY1 doctors in 2005. The response rate was 43% (2062 responses). Sixty-one percent of FY1 doctors had received oncology teaching at medical school, but 31% recalled seeing fewer than 10 patients with cancer. Forty percent of FY1 doctors felt prepared for looking after patients with cancer. Sixty-five percent felt prepared for diagnosing cancer, 15% felt they knew enough about chemotherapy and radiotherapy, and 11% felt prepared for dealing with oncological emergencies. Respondents believed medical students should learn about symptom control (71%) and communication skills (41%). Respondents who had received oncology teaching were more likely to feel prepared for looking after patients with cancer (OR 1.52; 95% CI 1.14–2.04). Preparedness also correlated with exposure to patients with cancer (OR 1.48; 95% CI 1.22–1.79). We have found worryingly low levels of exposure of medical students to patients with cancer. First foundation year doctors lack knowledge about cancer care and symptom control. Oncologists should maintain involvement in undergraduate teaching, and encourage greater involvement of patients in this teaching.
doi:10.1038/sj.bjc.6603888
PMCID: PMC2360340  PMID: 17667931
undergraduate; medical education; oncology; communication skills; palliative care
6.  Doctor-patient interaction in Finnish primary health care as perceived by first year medical students 
Background
In Finland, public health care is the responsibility of primary health care centres, which render a wide range of community level preventive, curative and rehabilitative medical care. Since 1990's, medical studies have involved early familiarization of medical students with general practice from the beginning of the studies, as this pre-clinical familiarisation helps medical students understand patients as human beings, recognise the importance of the doctor-patient relationship and identify practicing general practitioners (GPs) as role models for their professional development. Focused on doctor-patient relationship, we analysed the reports of 2002 first year medical students in the University of Kuopio. The students observed GPs' work during their 2-day visit to primary health care centres.
Methods
We analysed systematically the texts of 127 written reports of 2002, which represents 95.5% of the 133 first year pre-clinical medical students reports. The reports of 2003 (N = 118) and 2004 (N = 130) were used as reference material.
Results
Majority of the students reported GPs as positive role models. Some students reported GPs' poor attitudes, which they, however, regarded as a learning opportunity. Students generally observed a great variety of responsibilities in general practice, and expressed admiration for the skills and abilities required. They appreciated the GPs' interest in patients concerns. GPs' communication styles were found to vary considerably. Students reported some factors disturbing the consultation session, such as the GP staring at the computer screen and other team members entering the room. Working with marginalized groups, the chronically and terminally ill, and dying patients was seen as an area for development in the busy Finnish primary health care centres.
Conclusion
During the analysis, we discovered that medical students' perceptions in this study are in line with the previous findings about the importance of role model (good or bad) in making good doctors. Therefore, medical students' pre-clinical primary health care centre visits may influence their attitudes towards primary health care work and the doctor-patient relationship. We welcome more European studies on the role of early pre-clinical general practice exposure on medical students' primary care specialty choice.
doi:10.1186/1472-6920-5-34
PMCID: PMC1242232  PMID: 16162300
7.  How do medical doctors use a web-based oncology protocol system? A comparison of Australian doctors at different levels of medical training using logfile analysis and an online survey 
Background
Electronic decision support is commonplace in medical practice. However, its adoption at the point-of-care is dependent on a range of organisational, patient and clinician-related factors. In particular, level of clinical experience is an important driver of electronic decision support uptake. Our objective was to examine the way in which Australian doctors at different stages of medical training use a web-based oncology system (http://www.eviq.org.au).
Methods
We used logfiles to examine the characteristics of eviQ registrants (2009–2012) and patterns of eviQ use in 2012, according to level of medical training. We also used a web-based survey to evaluate the way doctors at different levels of medical training use the online system and to elicit perceptions of the system’s utility in oncology care.
Results
Our study cohort comprised 2,549 eviQ registrants who were hospital-based medical doctors across all levels of training. 65% of the cohort used eviQ in 2012, with 25% of interns/residents, 61% of advanced oncology trainees and 47% of speciality-qualified oncologists accessing eviQ in the last 3 months of 2012. The cohort accounted for 445,492 webhits in 2012. On average, advanced trainees used eviQ up to five-times more than other doctors (42.6 webhits/month compared to 22.8 for specialty-qualified doctors and 7.4 webhits/month for interns/residents). Of the 52 survey respondents, 89% accessed eviQ’s chemotherapy protocols on a daily or weekly basis in the month prior to the survey. 79% of respondents used eviQ at least weekly to initiate therapy and to support monitoring (29%), altering (35%) or ceasing therapy (19%). Consistent with the logfile analysis, advanced oncology trainees report more frequent eviQ use than doctors at other stages of medical training.
Conclusions
The majority of the Australian oncology workforce are registered on eviQ. The frequency of use directly mirrors the clinical role of doctors and attitudes about the utility of eviQ in decision-making. Evaluations of this kind generate important data for system developers and medical educators to drive improvements in electronic decision support to better meet the needs of clinicians. This end-user focus will optimise the uptake of systems which will translate into improvements in processes of care and patient outcomes.
doi:10.1186/1472-6947-13-82
PMCID: PMC3750334  PMID: 23915178
Clinical decision support systems; Evidence-based practice; Medical education; Cancer chemotherapy protocols; Health personnel; ‘Medical staff; Hospital’
8.  ‘You feel you've been bad, not ill’: Sick doctors’ experiences of interactions with the General Medical Council 
BMJ Open  2014;4(7):e005537.
Objective
To explore the views of sick doctors on their experiences with the General Medical Council (GMC) and their perception of the impact of GMC involvement on return to work.
Design
Qualitative study.
Setting
UK.
Participants
Doctors who had been away from work for at least 6 months with physical or mental health problems, drug or alcohol problems, GMC involvement or any combination of these, were eligible for inclusion into the study. Eligible doctors were recruited in conjunction with the Royal Medical Benevolent Fund, the GMC and the Practitioner Health Programme. These organisations approached 77 doctors; 19 participated. Each doctor completed an in-depth semistructured interview. We used a constant comparison method to identify and agree on the coding of data and the identification of central themes.
Results
18 of the 19 participants had a mental health, addiction or substance misuse problem. 14 of the 19 had interacted with the GMC. 4 main themes were identified: perceptions of the GMC as a whole; perceptions of GMC processes; perceived health impacts and suggested improvements. Participants described the GMC processes they experienced as necessary, and some elements as supportive. However, many described contact with the GMC as daunting, confusing and anxiety provoking. Some were unclear about the role of the GMC and felt that GMC communication was unhelpful, particularly the language used in correspondence. Improvements suggested by participants included having separate pathways for doctors with purely health issues, less use of legalistic language, and a more personal approach with for example individualised undertakings or conditions.
Conclusions
While participants recognised the need for a regulator, the processes employed by the GMC and the communication style used were often distressing, confusing and perceived to have impacted negatively on their mental health and ability to return to work.
doi:10.1136/bmjopen-2014-005537
PMCID: PMC4120406  PMID: 25034631
MENTAL HEALTH; QUALITATIVE RESEARCH; OCCUPATIONAL & INDUSTRIAL MEDICINE
9.  Mobile technology supporting trainee doctors’ workplace learning and patient care: an evaluation 
Background
The amount of information needed by doctors has exploded. The nature of knowledge (explicit and tacit) and processes of knowledge acquisition and participation are complex. Aiming to assist workplace learning, Wales Deanery funded “iDoc”, a project offering trainee doctors a Smartphone library of medical textbooks.
Methods
Data on trainee doctors’ (Foundation Year 2) workplace information seeking practice was collected by questionnaire in 2011 (n = 260). iDoc baseline questionnaires (n = 193) collected data on Smartphone usage alongside other workplace information sources. Case reports (n = 117) detail specific instances of Smartphone use.
Results
Most frequently (daily) used information sources in the workplace: senior medical staff (80% F2 survey; 79% iDoc baseline); peers (70%; 58%); and other medical/nursing team staff (53% both datasets). Smartphones were used more frequently by males (p < 0.01). Foundation Year 1 (newly qualified) was judged the most useful time to have a Smartphone library because of increased responsibility and lack of knowledge/experience.
Preferred information source varied by question type: hard copy texts for information-based questions; varied resources for skills queries; and seniors for more complex problems. Case reports showed mobile technology used for simple (information-based), complex (problem-based) clinical questions and clinical procedures (skills-based scenarios). From thematic analysis, the Smartphone library assisted: teaching and learning from observation; transition from medical student to new doctor; trainee doctors’ discussions with seniors; independent practice; patient care; and this ‘just-in-time’ access to reliable information supported confident and efficient decision-making.
Conclusion
A variety of information sources are used regularly in the workplace. Colleagues are used daily but seniors are not always available. During transitions, constant access to the electronic library was valued. It helped prepare trainee doctors for discussions with their seniors, assisting the interchange between explicit and tacit knowledge.
By supporting accurate prescribing and treatment planning, the electronic library contributed to enhanced patient care. Trainees were more rapidly able to medicate patients to reduce pain and more quickly call for specific assessments. However, clinical decision-making often requires dialogue: what Smartphone technology can do is augment, not replace, discussion with their colleagues in the community of practice.
doi:10.1186/1472-6920-13-6
PMCID: PMC3552772  PMID: 23336964
Technology enhanced learning; Workplace learning; Workplace information source; Trainee doctors; Smartphones; Transitions
10.  Medical Students' Exposure to and Attitudes about the Pharmaceutical Industry: A Systematic Review 
PLoS Medicine  2011;8(5):e1001037.
A systematic review of published studies reveals that undergraduate medical students may experience substantial exposure to pharmaceutical marketing, and that this contact may be associated with positive attitudes about marketing.
Background
The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.
Methods and Findings
We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students' exposure to the drug industry, as well as students' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%–100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs.
Conclusions
Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The complex relationship between health professionals and the pharmaceutical industry has long been a subject of discussion among physicians and policymakers. There is a growing body of evidence that suggests that physicians' interactions with pharmaceutical sales representatives may influence clinical decision making in a way that is not always in the best interests of individual patients, for example, encouraging the use of expensive treatments that have no therapeutic advantage over less costly alternatives. The pharmaceutical industry often uses physician education as a marketing tool, as in the case of Continuing Medical Education courses that are designed to drive prescribing practices.
One reason that physicians may be particularly susceptible to pharmaceutical industry marketing messages is that doctors' attitudes towards the pharmaceutical industry may form early in their careers. The socialization effect of professional schooling is strong, and plays a lasting role in shaping views and behaviors.
Why Was This Study Done?
Recently, particularly in the US, some medical schools have limited students' and faculties' contact with industry, but some have argued that these restrictions are detrimental to students' education. Given the controversy over the pharmaceutical industry's role in undergraduate medical training, consolidating current knowledge in this area may be useful for setting priorities for changes to educational practices. In this study, the researchers systematically examined studies of pharmaceutical industry interactions with medical students and whether such interactions influenced students' views on related topics.
What Did the Researchers Do and Find?
The researchers did a comprehensive literature search using appropriate search terms for all relevant quantitative and qualitative studies published before June 2010. Using strict inclusion criteria, the researchers then selected 48 articles (from 1,603 abstracts) for full review and identified 32 eligible for analysis—giving a total of approximately 9,850 medical students studying at 76 medical schools or hospitals.
Most students had some form of interaction with the pharmaceutical industry but contact increased in the clinical years, with up to 90% of all clinical students receiving some form of educational material. The highest level of exposure occurred in the US. In most studies, the majority of students in their clinical training years found it ethically permissible for medical students to accept gifts from drug manufacturers, while a smaller percentage of preclinical students reported such attitudes. Students justified their entitlement to gifts by citing financial hardship or by asserting that most other students accepted gifts. In addition, although most students believed that education from industry sources is biased, students variably reported that information obtained from industry sources was useful and a valuable part of their education.
Almost two-thirds of students reported that they were immune to bias induced by promotion, gifts, or interactions with sales representatives but also reported that fellow medical students or doctors are influenced by such encounters. Eight studies reported a relationship between exposure to the pharmaceutical industry and positive attitudes about industry interactions and marketing strategies (although not all included supportive statistical data). Finally, student opinions were split on whether physician–industry interactions should be regulated by medical schools or the government.
What Do These Findings Mean?
This analysis shows that students are frequently exposed to pharmaceutical marketing, even in the preclinical years, and that the extent of students' contact with industry is generally associated with positive attitudes about marketing and skepticism towards any negative implications of interactions with industry. Therefore, strategies to educate students about interactions with the pharmaceutical industry should directly address widely held misconceptions about the effects of marketing and other biases that can emerge from industry interactions. But education alone may be insufficient. Institutional policies, such as rules regulating industry interactions, can play an important role in shaping students' attitudes, and interventions that decrease students' contact with industry and eliminate gifts may have a positive effect on building the skills that evidence-based medical practice requires. These changes can help cultivate strong professional values and instill in students a respect for scientific principles and critical evidence review that will later inform clinical decision-making and prescribing practices.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001037.
Further information about the influence of the pharmaceutical industry on doctors and medical students can be found at the American Medical Students Association PharmFree campaign and PharmFree Scorecard, Medsin-UKs PharmAware campaign, the nonprofit organization Healthy Skepticism, and the Web site of No Free Lunch.
doi:10.1371/journal.pmed.1001037
PMCID: PMC3101205  PMID: 21629685
11.  Vocation and avocation: leisure activities correlate with professional engagement, but not burnout, in a cross-sectional survey of UK doctors 
BMC Medicine  2011;9:100.
Background
Sir William Osler suggested in 1899 that avocations (leisure activities) in doctors are related to an increased sense of vocation (professional engagement) and a decreased level of burnout. This study evaluated those claims in a large group of doctors practicing in the UK while taking into account a wide range of background variables.
Methods
A follow-up questionnaire was sent to 4,457 UK-qualified doctors who had been included in four previous studies of medical school selection and training, beginning in 1980, 1985, 1990 and 1989/1991. A total of 2,845 (63.8%) doctors returned the questionnaire. Questions particularly asked about work engagement, satisfaction with medicine as a career, and personal achievement (Vocation/engagement), stress, emotional exhaustion, and depersonalization (BurnedOut), and 29 different leisure activities (Avocation/Leisure), as well as questions on personality, empathy, work experience, and demography.
Results
Doctors reporting more Avocation/Leisure activities tended to be women, to have older children, to be less surface-rational, more extravert, more open to experience, less agreeable, and to fantasize more. Doctors who were more BurnedOut tended to be men, to be more sleep-deprived, to report a greater workload and less choice and independence in their work, to have higher neuroticism, lower extraversion and lower agreeableness scores, and to have lower self-esteem. In contrast, doctors with a greater sense of Vocation/engagement, tended to see more patients, to have greater choice and independence at work, to have a deep approach to work, to have a more supportive-receptive work environment, to be more extravert and more conscientious, and to report greater self-esteem.
Avocation/Leisure activities correlated significantly with Vocation/engagement, even after taking into account 25 background variables describing demography, work, and personality, whereas BurnedOut showed no significant correlation with Avocation/Leisure activities. Popular Culture and High Culture did not differ in their influence on Vocation/engagement, although there was a suggestion that Depersonalization was correlated with more interest in Popular Culture and less interest in High Culture.
Conclusion
In this cross-sectional study there is evidence, even after taking into account a wide range of individual difference measures, that doctors with greater Avocation/Leisure activities also have a greater sense of Vocation/Engagement. In contrast, being BurnedOut did not relate to Avocation/Leisure activities (but did relate to many other measures). Osler was probably correct in recommending to doctors that, 'While medicine is to be your vocation, or calling, see to it that you also have an avocation'.
doi:10.1186/1741-7015-9-100
PMCID: PMC3196901  PMID: 21878123
12.  Country of training and ethnic origin of UK doctors: database and survey studies 
BMJ : British Medical Journal  2004;329(7466):597.
Objectives To report on the country of training and ethnicity of consultants in different specialties in the NHS, on trends in intake to UK medical schools by ethnicity, and on the specialty choices made by UK medical graduates in different ethnic groups.
Design Analysis of official databases of consultants and of students accepted to study medicine; survey data about career choices made by newly qualified doctors.
Setting and subjects England and Wales (consultants), United Kingdom (students and newly qualified doctors).
Results Of consultants appointed before 1992, 15% had trained abroad; of those appointed in 1992-2001, 24% had trained abroad. The percentage of consultants who had trained abroad and were non-white was significantly high, compared with their overall percentage among consultants, in geriatric medicine, genitourinary medicine, paediatrics, old age psychiatry, and learning disability. UK trained non-white doctors had specialty destinations similar to those of UK trained white doctors. The percentage of UK medical graduates who are non-white has increased substantially from about 2% in 1974 and will approach 30% by 2005. White men now comprise little more than a quarter of all UK medical students. White and non-white UK graduates make similar choices of specialty.
Conclusions Specialist medical practice in the NHS has been heavily dependent on doctors who have trained abroad, particularly in specialties where posts have been hard to fill. By contrast, UK trained doctors from ethnic minorities are not over-represented in the less popular specialties. Ethnic minorities are well represented in UK medical school intakes; and white men, but not white women, are now substantially under-represented.
doi:10.1136/bmj.38202.364271.BE
PMCID: PMC516656  PMID: 15347580
13.  ‘A world of difference’: a qualitative study of medical students’ views on professionalism and the ‘good doctor’ 
BMC Medical Education  2014;14:77.
Background
The importance of professional behaviour has been emphasized in medical school curricula. However, the lack of consensus on what constitutes professionalism poses a challenge to medical educators, who often resort to a negative model of assessment based on the identification of unacceptable behaviour. This paper presents results from a study exploring medical students’ views on professionalism, and reports on students’ constructs of the ‘good’ and the ‘professional’ doctor.
Methods
Data for this qualitative study were collected through focus groups conducted with medical students from one Western Australian university over a period of four years. Students were recruited through unit coordinators and invited to participate in a focus group. De-identified socio-demographic data were obtained through a brief questionnaire. Focus groups were audio-recorded, transcribed and subjected to inductive thematic analysis.
Results
A total of 49 medical students took part in 13 focus groups. Differences between students’ understandings of the ‘good’ and ‘professional’ doctor were observed. Being competent, a good communicator and a good teacher were the main characteristics of the ‘good’ doctor. Professionalism was strongly associated with the adoption of a professional persona; following a code of practice and professional guidelines, and treating others with respect were also associated with the ‘professional’ doctor.
Conclusions
Students felt more connected to the notion of the ‘good’ doctor, and perceived professionalism as an external and imposed construct. When both constructs were seen as acting in opposition, students tended to forgo professionalism in favour of becoming a ‘good’ doctor.
Results suggest that the teaching of professionalism should incorporate more formal reflection on the complexities of medical practice, allowing students and educators to openly explore and articulate any perceived tensions between what is formally taught and what is being observed in clinical practice.
doi:10.1186/1472-6920-14-77
PMCID: PMC3992127  PMID: 24725303
Professionalism; Medical students’ views; Good doctor; Qualitative study
14.  Perceptions of doctors to adverse drug reaction reporting in a teaching hospital in Lagos, Nigeria 
Background
Spontaneous adverse drug reaction (ADR) reporting is the cornerstone of pharmacovigilance. ADR reporting with Yellow Cards has tremendously improved pharmacovigilance of drugs in many developed countries and its use is advocated by the World Health Organization (WHO). This study was aimed at investigating the knowledge and attitude of doctors in a teaching hospital in Lagos, Nigeria on spontaneous ADR reporting and to suggest possible ways of improving this method of reporting.
Methods
A total of 120 doctors working at the Lagos State University Teaching Hospital (LASUTH), in Nigeria were evaluated with a questionnaire for their knowledge and attitudes to ADR reporting. The questionnaire sought the demographics of the doctors, their knowledge and attitudes to ADR reporting, the factors that they perceived may influence ADR reporting, and their levels of education and training on ADR reporting. Provision was also made for suggestions on the possible ways to improve ADR reporting.
Results
The response rate was 82.5%. A majority of the respondents (89, 89.9%) considered doctors as the most qualified health professionals to report ADRs. Forty (40.4%) of the respondents knew about the existence of National Pharmacovigilance Centre (NPC) in Nigeria. Thirty-two (32.3%) respondents were aware of the Yellow Card reporting scheme but only two had ever reported ADRs to the NPC. About half (48.5%) of the respondents felt that all serious ADRs could be identified after drug marketing. There was a significant difference between the proportion of respondents who felt that ADR reporting should be either compulsory or voluntary (χ2 = 38.9, P < 0.001). ADR reporting was encouraged if the reaction was serious (77, 77.8%) and unusual (70, 70.7%). Education and training was the most recognised means of improving ADR reporting.
Conclusion
The knowledge of ADRs and how to report them are inadequate among doctors working in a teaching hospital in Lagos, Nigeria. More awareness should be created on the Yellow Card reporting scheme. Continuous medical education, training and integration of ADR reporting into the clinical activities of the doctors would likely improve reporting.
doi:10.1186/1472-6904-9-14
PMCID: PMC2731723  PMID: 19671176
15.  First year doctors experience of work related wellbeing and implications for educational provision 
Objectives: To explore factors which affect newly qualified doctors’ wellbeing and look at the implications for educational provision.
Methods
Data were collected by free association narrative interviews of nine Foundation doctors and analysed using a grounded theory approach. Two Foundation programme directors were interviewed to verify data validity.
Results
Two main themes emerged: newly qualified doctors’ wellbeing is affected by 1) personal experience and 2) work related factors. They start work feeling unprepared by medical school, work experience (“shadowing”) or induction programmes at the beginning of the post. Senior colleague support and feedback are much valued but often lacking with little discussion of critical incidents and difficult issues. Challenges include sick patients, prescribing, patient/relative communication and no consistent team structure. Working shift patterns affects personal and social life. Enjoyment and reward come from helping patients, feelings of making a difference or teaching medical students.
Conclusions
Whilst becoming familiar with their roles, newly qualified doctors search for identity and build up resilience. The support given during this process affects their wellbeing including coping with day to day challenges, whether posts are experienced as rewarding and how work influences their personal and social lives.
doi:10.5116/ijme.5380.6ef1
PMCID: PMC4207178  PMID: 25341219
First year doctors; wellbeing; work related stress; educational supervision; career support
16.  GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice. 
BACKGROUND AND AIMS: General practice in the UK is experiencing difficulty with medical staff recruitment and retention, with reduced numbers choosing careers in general practice or entering principalships, and increases in less-than-full-time working, career breaks, early retirement and locum employment. Information is scarce about the reasons for these changes and factors that could increase recruitment and retention. The UK Medical Careers Research Group (UKMCRG) regularly surveys cohorts of UK medical graduates to determine their career choices and progression. We also invite written comments from respondents about their careers and the factors that influence them. Most respondents report high levels of job satisfaction. A noteworthy minority, however, make critical comments about general practice. Although their views may not represent those of all general practitioners (GPs), they nonetheless indicate a range of concerns that deserve to be understood. This paper reports on respondents' comments about general practice. ANALYSIS OF DOCTORS' COMMENTS: Training Greater exposure to general practice at undergraduate level could help to promote general practice careers and better inform career decisions. Postgraduate general practice training in hospital-based posts was seen as poor quality, irrelevant and run as if it were of secondary importance to service commitments. In contrast, general practice-based postgraduate training was widely praised for good formal teaching that met educational needs. The quality of vocational training was dependent upon the skills and enthusiasm of individual trainers. Recruitment problems Perceived deterrents to choosing general practice were its portrayal, by some hospital-based teachers, as a second class career compared to hospital medicine, and a perception of low morale amongst current GPs. The choice of a career in general practice was commonly made for lifestyle reasons rather than professional aspirations. Some GPs had encountered difficulties in obtaining posts in general practice suited to their needs, while others perceived discrimination. Newly qualified GPs often sought work as non-principals because they felt too inexperienced for partnership or because their domestic situation prevented them from settling in a particular area. Changes to general practice The 1990 National Health Service (NHS) reforms were largely viewed unfavourably, partly because they had led to a substantial increase in GPs' workloads that was compounded by growing public expectations, and partly because the two-tier system of fund-holding was considered unfair. Fund-holding and, more recently, GP commissioning threatened the GP's role as patient advocate by shifting the responsibility for rationing of health care from government to GPs. Some concerns were also expressed about the introduction of primary care groups (PCGs) and trusts (PCTs). Together, increased workload and the continual process of change had, for some, resulted in work-related stress, low morale, reduced job satisfaction and quality of life. These problems had been partially alleviated by the formation of GP co-operatives. Retention difficulties Loss of GPs' time from the NHS workforce occurs in four ways: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. Child rearing and a desire to pursue interests outside medicine were cited as reasons for seeking shorter working hours or career breaks. A desire to reduce pressure of work was a common reason for seeking shorter working hours, taking career breaks, early retirement or leaving NHS general practice. Other reasons for leaving NHS general practice, temporarily or permanently, were difficulty in finding a GP post suited to individual needs and a desire to work abroad. CONCLUSIONS: A cultural change amongst medical educationalists is needed to promote general practice as a career choice that is equally attractive as hospital practice. The introduction of Pre-Registration House Officer (PRHO) placements in general practice and improved flexibility of GP vocational training schemes, together with plans to improve the quality of Senior House Officer (SHO) training in the future, are welcome developments and should address some of the concerns about poor quality GP training raised by our respondents. The reluctance of newly qualified GPs to enter principalships, and the increasing demand from experienced GPs for less-than-full-time work, indicates a need for a greater variety of contractual arrangements to reflect doctors' desires for more flexible patterns of working in general practice.
PMCID: PMC2560447  PMID: 12049026
17.  Medical Professionalism: Conflicting Values for Tomorrow's Doctors 
Journal of General Internal Medicine  2010;25(12):1330-1336.
Background
New values and practices associated with medical professionalism have created an increased interest in the concept. In the United Kingdom, it is a current concern in medical education and in the development of doctor appraisal and revalidation.
Objective
To investigate how final year medical students experience and interpret new values of professionalism as they emerge in relation to confronting dying patients and as they potentially conflict with older values that emerge through hidden dimensions of the curriculum.
Methods
Qualitative study using interpretative discourse analysis of anonymized student reflective portfolios. One hundred twenty-three final year undergraduate medical students (64 male and 59 female) from the University of Cambridge School of Clinical Medicine supplied 116 portfolios from general practice and 118 from hospital settings about patients receiving palliative or end of life care.
Results
Professional values were prevalent in all the portfolios. Students emphasised patient-centered, holistic care, synonymous with a more contemporary idea of professionalism, in conjunction with values associated with the ‘old’ model of professionalism that had not be directly taught to them. Integrating ‘new’ professional values was at times problematic. Three main areas of potential conflict were identified: ethical considerations, doctor-patient interaction and subjective boundaries. Students explicitly and implicitly discussed several tensions and described strategies to resolve them.
Conclusions
The conflicts outlined arise from the mix of values associated with different models of professionalism. Analysis indicates that ‘new’ models are not simply replacing existing elements. Whilst this analysis is of accounts from students within one UK medical school, the experience of conflict between different notions of professionalism and the three broad domains in which this conflict arises are relevant in other areas of medicine and in different national contexts.
doi:10.1007/s11606-010-1485-8
PMCID: PMC2988149  PMID: 20740324
medical professionalism; medical education; qualitative research; students’ reflections
18.  Simulation-Based Learning to Teach Blood Pressure Assessment to Doctor of Pharmacy Students 
Objective
To assess the effect of simulation-based learning on doctor of pharmacy (PharmD) students' ability to perform accurate blood pressure assessments and to measure student satisfaction with this novel teaching method.
Methods
Didactic lectures on blood pressure assessment were combined with practical sessions using a high-fidelity computerized patient simulator. Before and after the simulation sessions, students completed a written objective examination to assess knowledge and completed a survey instrument to determine their attitudes regarding the learning experience. Individual clinical skills were assessed using the patient simulator.
Results
Ninety-five students completed the study. Significant improvement was seen in students' knowledge and their ability to accurately determine blood pressure following simulation sessions. Survey responses indicated that students felt confident that simulation-based learning would improve their ability to perform accurate blood pressure assessments.
Conclusion
Pharmacy students showed significant improvement in clinical skills performance and in their knowledge of the pharmacotherapy of hypertension. Students expressed high levels of satisfaction with this type of learning experience.
PMCID: PMC1913304  PMID: 17619648
patient simulation; cardiovascular disease; hypertension; blood pressure
19.  Experiences of non-UK-qualified doctors working within the UK regulatory framework: a qualitative study 
Objective
To explore the experience of non-UK-qualified doctors in working within the regulatory framework of the General Medical Council (GMC) document Good Medical Practice.
Design
Individual interviews and focus groups.
Setting
United Kingdom.
Participants
Non-UK-qualified doctors who had registered with the GMC between 1 April 2006 and 31 March 2008, doctors attending training/induction programmes for non-UK-qualified doctors, and key informants involved in training and support for non-UK-qualified doctors.
Main outcome measures
Themes identified from analysis of interview and focus group transcripts.
Results
Information and support for non-UK qualified doctors who apply to register to work in the UK has little reference to the ethical and professional standards required of doctors working in the UK. Recognition of the ethical, legal and cultural context of UK healthcare occurs once doctors are working in practice. Non-UK qualified doctors reported clear differences in the ethical and legal framework for practising medicine between the UK and their country of qualification, particularly in the model of the doctor–patient relationship. The degree of support for non-UK-qualified doctors in dealing with ethical concerns is related to the type of post they work in. European doctors describe similar difficulties with working in an unfamiliar regulatory framework to their non-European colleagues.
Conclusions
Non-UK-qualified doctors experience a number of difficulties related to practising within a different ethical and professional regulatory framework. Provision of information and educational resources before registration, together with in-practice support would help to develop a more effective understanding of GMP and its implications for practice in the UK.
doi:10.1258/jrsm.2011.110256
PMCID: PMC3343706  PMID: 22408082
20.  Prevalence of stress in junior doctors during their internship training: a cross-sectional study of three Saudi medical colleges’ hospitals 
Background
Medical science is perceived as a stressful educational career, and medical students experience monstrous stress during their undergraduate studies, internship, and residency training, which affects their cognitive function, practical life, and patient care. In the present study, an assessment of the prevalence of self-perceived stress among new medical graduates during their internship training has been performed, and correlations of self-perceived stress with sex, marital status, and clinical rotations have been evaluated.
Patients and methods
Interns of the King Khalid, King Abdulaziz, and King Fahd University hospitals in Saudi Arabia were invited to complete a stress inventory known as the Kessler 10, which is used for stress measurement. Apart from stress evaluation, the questionnaire collected personal data, such as age, sex, and marital status, in addition to information relevant to hospital training, assigned duties, and clinical training rotations.
Results
Our results showed that nearly 73.0% of interns were under stressed conditions. Most of the interns were affected by a severe level of stress (34.9%), followed by mild (19.3%) and moderate (18.8%) levels of stress. The stress level was significantly higher (84.0%) among female interns in comparison with male interns (66.5%) (odds ratio =2.64; confidence interval =1.59–4.39; P<0.0002). There were statistically significant differences between the percentages of male and female interns (P≤0.047) at mild, moderate, and severe stress levels. Marital status had no role in causing stress. The highest stress level was reported by interns during the clinical rotations of medicine (78.8%), followed by surgery (74.7%), pediatrics (72.4%), obstetrics and gynecology (70.1%), and emergency (58.3%). The prevalence of stress among the interns and their corresponding clinical rotations in all three hospitals had significant linear correlations (r≥0.829, P≤0.041).
Conclusion
We found a significantly high level of stress among the medical interns. High stress may have negative effects on cognitive functioning, learning, and patient care. Hence, medical interns need support and subsequent interventions to cope with stress.
Video abstract
doi:10.2147/NDT.S68039
PMCID: PMC4196886  PMID: 25328389
medical education; clinical rotation; medicine; surgery; pediatrics
21.  Medical Professional Values and Education: A Survey on Italian Students of the Medical Doctor School in Medicine and Surgery 
Background:
The values such as participation/empathy, communication/sharing, self-awareness, moral integrity, sensitivity/trustfulness, commitment to ongoing professional development, and sense of duty linked to the practice of the medical professionalism were defined by various professional oaths.
Aims:
The aim of this study was to evaluate how these values are considered by the students of the degree course of medicine.
Materials and Methods:
Four hundred twenty three students (254 females, 169 males) taking part of the first, fourth, and fifth years of the degree course in medicine were asked to answer seven questions. Pearson's Chi-square, Wilcoxon rank sum test, and Kruskal–Wallis test were used for the statistical analysis.
Results:
The survey showed a high level of knowledge and self-awareness about the values and skills of medical profession. In particular, the respect, accountability, and the professional skills of competence were considered fundamental in clinical practice. However, the students considered that these values not sufficiently present in their educational experience.
Conclusions:
Teaching methods should be harmonized with the contents and with the educational needs to ensure a more complex patient-based approach and the classical lectures of teachers should be more integrated with learning through experience methods.
doi:10.4103/1947-2714.107535
PMCID: PMC3624715  PMID: 23641376
Empathy; Ethical values; Influencing factors; Medical education; Teaching methods
22.  Determinants of Medical Students' Perceived Preparation To Perform End-of-Life Care, Quality of End-of-Life Care Education, and Attitudes Toward End-of-Life Care 
Journal of Palliative Medicine  2010;13(3):319-326.
Abstract
Background
Medical students' learning about end-of-life care can be categorized into three learning modalities: formal curriculum, taught in lectures; informal curriculum, conveyed through clinical experiences; and “hidden curriculum,” inferred from behaviors and implicit in medical culture. In this study, we evaluated associations between survey items assessing these learning modalities and students' perceptions of their preparation, quality of education, and attitudes toward end-of-life care.
Methods
Data were collected from a national survey of fourth-year medical students (n = 1455) at 62 medical schools in 2001. Linear regression analyses were performed to assess associations between formal, informal and hidden end-of-life care curricula and students' perceived preparedness to provide end-of-life care, quality of end-of-life care education and attitudes toward end-of-life, controlling for students' demographics and clustered by school.
Results
Students reporting more exposure to formal and informal curricula felt more prepared and rated their end-of-life care education higher. Students with more exposure to a hidden curriculum that devalued end-of-life care perceived their preparation as poorer and had poorer attitudes toward end-of-life care. Minority students had slightly more negative attitudes but no differences in perceived end-of-life care preparation.
Conclusions
Medical students' sense of preparedness for end-of-life care and perceptions of educational quality are greater with more coursework and bedside teaching. By contrast, the hidden curriculum conveying negative messages may impair learning. Our findings suggest that implicit messages as well as intentional teaching have a significant impact on students' professional development. This has implications for designing interventions to train physicians to provide outstanding end-of-life care.
doi:10.1089/jpm.2009.0293
PMCID: PMC2883506  PMID: 20178433
23.  The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey 
BMJ Open  2015;5(1):e006687.
Objectives
The primary aim was to investigate the impact of complaints on doctors’ psychological welfare and health. The secondary aim was to assess whether doctors report exposure to a complaints process is associated with defensive medical practise.
Design
This was a cross-sectional anonymous survey study. Participants were stratified into recent/current, past, no complaints. Each group completed tailored versions of the survey.
Participants
95 636 doctors were invited to participate. A total of 10 930(11.4%) responded, 7926 (8.3%) completed the full survey and were included in the complete analysis.
Main outcome measures
Anxiety and depression were assessed using the standardised Generalised Anxiety Disorder scale and Physical Health Questionnaire. Defensive practise was evaluated using a new measure. Single-item questions measured stress-related illnesses, complaints-related experience, attitudes towards complaints and views on improving complaints processes.
Results
16.9% of doctors with current/recent complaints reported moderate/severe depression (relative risk (RR) 1.77 (95% CI 1.48 to 2.13) compared to doctors with no complaints (9.5%)). Fifteen per cent reported moderate/severe anxiety (RR=2.08 (95% CI 1.61 to 2.68) compared to doctors with no complaints (7.3%)). Distress increased with complaint severity, with highest levels after General Medical Council (GMC) referral (26.3% depression, 22.3% anxiety). Doctors with current/recent complaints were 2.08 (95% CI 1.61 to 2.68) times more likely to report thoughts of self-harm or suicidal ideation. Most doctors reported defensive practise: 82–89% hedging and 46–50% avoidance. Twenty per cent felt victimised after whistleblowing, 38% felt bullied, 27% spent over 1 month off work. Over 80% felt processes would improve with transparency, managerial competence, capacity to claim lost earnings and action against vexatious complainants.
Conclusions
Doctors with recent/current complaints have significant risks of moderate/severe depression, anxiety and suicidal ideation. Morbidity was greatest in cases involving the GMC. Most doctors reported practising defensively, including avoidance of procedures and high-risk patients. Many felt victimised as whistleblowers or reported bullying. Suggestions to improve complaints processes included transparency and managerial competence.
doi:10.1136/bmjopen-2014-006687
PMCID: PMC4316558  PMID: 25592686
OCCUPATIONAL & INDUSTRIAL MEDICINE
24.  “Patient-Time,” “Doctor-Time,” and “Institution-Time”: Perceptions and Definitions of Time Among Doctors Who Become Patients 
Patient education and counseling  2006;66(2):147-155.
Objective
To examine views and experiences of conflicts concerning time in healthcare, from the perspective of physicians who have become patients.
Methods
We conducted two in-depth semi-structured two-hour interviews concerning experiences of being health care workers, and becoming a patient, with each of 50 doctors who had serious illnesses.
Results
These doctor-patients often came to realize as they had not before how patients experience time differently, and how “patient-time,” “doctor-time,” and “institution-time” exist and can conflict. Differences arose in both long and short term, regarding historical time (prior eras/decades in medicine), prognosis (months/years), scheduling delays (days/weeks), daily medical events and tasks (hours), and periods in waiting rooms (minutes/hours). Definitions of periods of time (e.g., “fast,” “slow,” “plenty,” and “soon”) also varied widely, and could clash. Professional socialization had heretofore impeded awareness of these differences. Physicians tried to address these conflicts in several ways (e.g., trying to provide test results promptly), though full resolution remained difficult.
Conclusions
Doctors who became patients often now realized how physicians and patients differ in subjective experiences of time. Medical education and research have not adequately considered these issues, which can affect patient satisfaction, doctor-patient relationships and communication, and care.
Practice Implications
Physicians need to be more sensitive to how their definitions, perceptions, and experiences concerning time can differ from those of patients.
doi:10.1016/j.pec.2006.10.005
PMCID: PMC2950119  PMID: 17125956
Doctor-patient relationships; doctor-patient communication; medical education; patient satisfaction; medical ethics; medical socialization; health care delivery
25.  Methods of appointment and qualifications of club doctors and physiotherapists in English professional football: some problems and issues 
Objective—To examine the methods of appointment, experience, and qualifications of club doctors and physiotherapists in professional football.
Methods—Semistructured tape recorded interviews with 12 club doctors, 10 club physiotherapists, and 27 current and former players. A questionnaire was also sent to 90 club doctors; 58 were returned.
Results—In almost all clubs, methods of appointment of doctors are informal and reflect poor employment practice: posts are rarely advertised and many doctors are appointed on the basis of personal contacts and without interview. Few club doctors had prior experience or qualifications in sports medicine and very few have a written job description. The club doctor is often not consulted about the appointment of the physiotherapist; physiotherapists are usually appointed informally, often without interview, and often by the manager without involving anyone who is qualified in medicine or physiotherapy. Half of all clubs do not have a qualified (chartered) physiotherapist; such unqualified physiotherapists are in a weak position to resist threats to their clinical autonomy, particularly those arising from managers' attempts to influence clinical decisions.
Conclusions—Almost all aspects of the appointment of club doctors and physiotherapists need careful re-examination.
Key Words: football clubs; doctors; physiotherapists; qualifications
doi:10.1136/bjsm.35.1.48
PMCID: PMC1724275  PMID: 11157462

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