Placement overlap with other students: Effects on medical student learning experience

Phenomenon: In the United Kingdom (UK) the government has increased the number of places at university to study medicine in England to meet workforce demands. In parallel, there have been growing student numbers in other healthcare professions and new professions whose roles overlap with doctors, such as advanced nurse practitioners and physician associates, have been introduced. These increasing numbers of medical students and other healthcare professions training in the same clinical setting have led to questions about the effect on the student experience. We aimed to investigate the impact of student-student encounters on the learning experience during clinical placements before student numbers increase further. Approach: In this investigation medical student perceptions were collected retrospectively at Norwich Medical School, University of East Anglia in the UK, during the 2018/19 academic year following two clinical placements in secondary care settings. Through mandatory online course evaluations, all medical students were asked if their learning had been positively or negatively affected by other students, and how frequently they had certain student-student experiences. Findings: Responses from 786 (of 844) medical students (93% response rate) demonstrated that most students felt their learning had been affected in some way by the presence of others while on their secondary care placements. Students experienced both positive and negative impacts of encounters with other students. Final year students tended to report more negative experiences, with first year students reporting more positive. while some students had experienced competition for learning opportunities and lower quality interactions with patients and doctors due to “overcrowding,” more students reported benefits from learning from and with other students. However, it also was found that any negative encounters with other students, even if accompanied by positive experiences, detrimentally affected student satisfaction with the placement. Insights: This investigation indicates that student-student interactions influence the clinical learning experience of medical students both positively and negatively. Given the overriding influence of negative encounters, the findings suggest a need to maximize the beneficial effects of encountering other students on clinical placements; while protecting against missed or poor-quality learning opportunities due to competition between students, particularly for more senior students. Medical educators need to consider where their clinical attachments are at risk from multiple students being present at the same time and work to alleviate the negative impacts of such student-student encounters, while actively encouraging peer learning experiences between the medical students and collaborative activities between students of different healthcare professions. This is likely to become increasingly important as student numbers in medicine and other healthcare professions continue to grow

Doctors are inconsistent in estimating survival after CPR and are not using such predictions consistently in determining DNACPR decisions

Background: It is unclear whether doctors base their resuscitation decisions solely on their perceived outcome. Through the use of theoretical scenarios, we aimed to examine the ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decision-making. Methods: A questionnaire survey was sent to consultants and specialty trainees across two Norfolk (UK) hospitals during December 2013. The survey included demographic questions and six clinical scenarios with varying prognosis. Participants were asked if they would resuscitate the patient or not. Identical scenarios were then shown in a different order and doctors were asked to quantify patients’ estimated chance of survival. Results: A total of 137 individuals (mean age 41 years (SD 7.9%)) responded. The response rate was 69%. Approximately 60% were consultants. We found considerable variation in clinician estimates of median chance of survival. In three out of six of our scenarios, the survival estimated varied from <1% to 95%. There was a statistically significant difference identified in the estimated median survival between those clinicians who would or would not resuscitate in four of the six scenarios presented. Conclusion: This study has highlighted the wide variation between clinicians in their estimates of likely survival and little concordance between clinicians over their resuscitation decisions. The diversity in clinician decision-making should be explored further

Attitudes to E-Cigarettes and Cessation Support for Pregnant Women from English Stop Smoking Services: A Mixed Methods Study

Smoking in pregnancy remains a public health problem. In the UK e-cigarettes are the most popular aid to quitting smoking outside of pregnancy, but we don’t know the extent of e-cigarette use in pregnancy or how English Stop Smoking Services (SSS) respond to pregnant women who vape. In 2015 we surveyed SSS managers about cessation support for pregnant women and responses to clients who vaped. Subsequently we interviewed a sub-sample of managers to seek explanations for the SSS’ position on e-cigarettes; interviews were thematically analysed. Survey response rate was 67.8% (72/106); overall managers reported 2.2% (range 1.4–4.3%) of pregnant clients were using e-cigarettes. Most SSS reported supporting pregnant women who already vaped, but would not recommend e-cigarette use; for women that were still smoking and not using e-cigarettes, 8.3% of SSS were likely/very likely to advise using e-cigarettes, with 56.9% of SSS unlikely/very unlikely to advise using them. Fifteen respondents were interviewed; interviewees were generally positive about the potential of e-cigarettes for cessation in pregnancy although concerns about perceived lack of evidence for safety were expressed and most wanted research on this. Clear guidance on e-cigarette use informed by pregnancy specific research will assist SSS to provide consistent evidence-based support

Views on and experiences of electronic cigarettes: a qualitative study of women who are pregnant or have recently given birth.

Background Electronic cigarettes (ECs) are increasingly used for reducing or stopping smoking, with some studies showing positive outcomes. However, little is known about views on ECs during pregnancy or postpartum and previous studies have nearly all been conducted in the US and have methodological limitations, such as not distinguishing between smokers and ex/non-smokers. A greater understanding of this topic will help to inform both clinicians and EC interventions. We elicited views and experiences of ECs among UK pregnant or recently pregnant women. Methods We conducted semi-structured telephone interviews, using topic guides, with pregnant or recently pregnant women, who were current or recent ex-smokers. To ensure broad views of ECs were obtained, recruitment was from several geographical locations and via various avenues of recruitment. This included stop smoking services, antenatal and health visitor clinics, a pregnancy website and an informal network. Participants were 15 pregnant and 15 postpartum women, including nine current EC users, 11 ex-users, and 10 never-users. Five women who were interviewed in pregnancy were later interviewed in postpartum to explore if their views had changed. Audio data was transcribed verbatim and framework analysis was applied. Results Five main themes emerged: motivations for use (e.g., for stopping or reducing smoking), social stigma (e.g., avoiding use in public, preferring ‘discrete’ NRT), using the EC (e.g., mostly used at home); consumer aspects (e.g., limited advice available), and harm perceptions (e.g., viewed as less harmful than smoking; concerns about safety and addiction). Conclusions ECs were viewed positively by some pregnant and postpartum women and seen as less harmful than smoking and useful as aids for reducing and stopping smoking. However, due to perceived social stigma, some women feel uncomfortable using ECs in public, especially during pregnancy, and had concerns about safety and nicotine dependence. Health professionals and designers of EC interventions need to provide women with up-to-date and consistent information and advice about safety and dependence, as well as considering the influence of social stigma

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Practical and ethical issues involved in decisions about life-sustaining treatments in older patients

A retrospective study of a consecutive set of patients (n=264) undergoing CPR revealed that pre-arrest factors measured by three different morbidity scores can accurately predict a subset of patients for whom CPR attempts are futile.  These morbidity scores have low sensitivity but high specificity. Whilst there is widespread acceptance that the patient’s views about CPR should be sought there is little evidence about patient’s opinions.  Three different populations of elderly patients (mixed medical inpatients n=214, patients in the community following an admission with stroke n=100 and inpatients with acute stroke n=60) were interviewed to determine which life-sustaining treatments they would accept/refuse.  Inclusion rates for the hospital-based studies were low (36%, 75%) because many inpatients were physically or mentally unable to participate in decisions about CPR.  Patients had poor knowledge of techniques and success rates of CPR and following education around 10% refused CPR who had previously accepted it.  The acceptance rate for CPR in the three groups was 60% to 82% for CPR, and 60% to 72% for artificial feeding.  A significant number of patients had changed their minds about CPR between admission and follow-up at discharge from hospital (16%), or in community (17%).  Although competency rates were higher at follow-up this factor alone could not account for changes in view about CPR.  There was no significant relationship found between age, sex, disability or quality of life and wish for CPR.  Eight qualitative interviews were carried out which allowed a more detailed investigation of the influences and reasoning behind CPR decisions.  Advance directives are advocated as a means of improving patient involvement in CPR decisions.  A questionnaire revealed that General Practitioners are often ignorant of their legal status.  Only 70% of inpatients questioned following stroke were competent to reasons why they were reluctant to complete advance directives.</p

The slow death of the clinical post-mortem examination: implications for clinical audit, diagnostics and medical education

The adult clinical post-mortem examination has seriously declined in Norwich recently, with only 34 of them (representing 1.4% of deaths in hospital) having been undertaken in 2003. Moreover, the next-of-kin are increasingly restricting the extent of the examination when they give consent. Analogous but less severe changes have occurred in the post-mortem examination of stillbirths and perinates. Many clinicians are unaware of these events, which may come to have wide-ranging detrimental effects. One possible cause is the lack of training of junior medical staff in obtaining consent for postmortem examination, though other factors are also important