Exploring collaboration and leadership in postgraduate medical education (PME) in a London teaching hospital: A Self-Study approach

There is a dearth of research on leadership experiences in postgraduate medical education (PME). This work examined the lived experience and performance of a leader (director) in PME in a large London teaching hospital. The objective was to improve training and gain generalizable insights to assist others in PME leadership roles. Uniquely, the study followed a self-study (SS) paradigm, not used previously in healthcare education. There were three distinct research components. The first a continuous autoethnographic appraisal of the researcher’s leadership performance in PME. The second a collaborative action research (CAR) project with two Trust education leads (TELs) and the third a further CAR project that emerged during the first COVID-19 pandemic surge in 2020 and involved a sizeable and diverse group of hospital colleagues and trainees. In line with SS and CAR methodology, a variety of mainly qualitative tools were employed to generate data for iterative analysis and cyclical action. These included diaries, recorded and transcribed research meetings, action logs, recalled meetings and encounters, e-mails, some artefacts and frequent timed stream of consciousness writings (termed ‘free writing’ FW) that served to tap into subconscious thoughts related to the DME role. The findings revealed previously hidden gaps between the author’s aspirations and practice and evidenced the effect of changes enacted. Considerable tensions around operational pragmatism, control, relationships, acting as the conduit between education policy makers and those at the coalface, were evidenced and considered. Further, the emotional capital of PME leadership was exposed and critiqued. When faced with the COVID-19 crisis, lessons from the first CAR study enabled the enactment of a flat, collaborative, compassionate and effective leadership style purposefully harnessing trainee intellectual potential and ‘local’ knowledge to solve new and complex problems. This leadership strategy proved successful and impacted positively on many areas of hospital function during the crisis. Crucially, placing trust in younger colleagues was highly effective and valued by the trainees. The model has potential to transfer to other circumstances. The study identified four key interconnected themes: context, tensions and emotions, complex relationships, and self-actualization as a leader, as important in the evolution of the authors DME journey from dissatisfied struggling leader through to mobilizing collaborative actions to enacting a new leadership style during the COVID pandemic. After-action reflections make the case for reimagining the DME role and how the key themes could be used as a starting framework. The unique contribution of this study is the use and value of SS in medical education, the novel exploration of the lived experience of a DME and the demonstration that ‘collaborative’ leadership in PME was effective during crisis and non-crisis times. It exposes the invidious position DMEs, and trainees are placed in and concludes that increased trust and autonomy with decreased bureaucracy will enable better trainee experience and so could impact on retention

Effect of ethnicity and socioeconomic deprivation on uptake of renal supportive care and dialysis decision making in older adults

Background Renal supportive care has become an increasingly relevant treatment option as the renal patient population ages. Despite the prevalence of kidney disease amongst ethnic minority and socioeconomically deprived patients, evidence focused on supportive care and dialysis decision making in these groups is limited. Methods This retrospective study selected older patients referred to a low clearance or supportive care service between 1 January 2015 and 31 December 2019. A descriptive analysis of clinical and socioeconomic characteristics according to treatment choice was produced and multivariate logistic regression models used to identify predictive factors for choosing supportive care. Surrogate markers for the success of decision making processes were evaluated, including time taken to reach a supportive care decision and risk of death without making a treatment decision or within 3 months of starting kidney replacement therapy (KRT). Finally, the association between ethnicity and socioeconomic status and hospital admission rates were compared between treatment groups. Results Amongst 1768 patients, 515 chose supportive care and 309 chose KRT. Predictive factors for choosing supportive care included age, frailty and a diagnosis of cognitive impairment. However, there was no association with ethnicity or deprivation. Similarly, these factors were not associated with time taken to make a supportive care decision or the mortality outcome. Amongst those on KRT, more socially advantaged patients had decreased rates of hospital admissions compared with those less adavantaged (IRR 0.96, 95% CI 0.92–0.99)

The Prepare for Kidney Care Study:prepare for renal dialysis vs responsive management in advanced chronic kidney disease

Shared decision making in advanced chronic kidney disease requires unbiased information on survival and person-centred outcomes known to matter to patients: quality of life, symptom burden and support from family and healthcare professionals. To date, when deciding between dialysis and conservative care, patients have had to rely on evidence from small observational studies. Clinicians recognise that like is not being compared with like in these studies and interpret the results differently. Further, support differs considerably between renal units. What patients choose therefore depends on which renal unit they attend. To address this, a programme of work has been underway in the UK. After reports on survival and symptoms from a small number of renal units, a national, mixed-methods study – conservative kidney management: assessing practice patterns – mapped out conservative care practices and attitudes in the UK. This led to the Prepare for Kidney Care study, a randomised controlled trial comparing preparation for dialysis versus preparation for conservative care. Although powered to detect a positivist 0.345 difference in quality adjusted life years between the two treatments, this trial also takes a realist approach with a range of person-centred secondary outcomes and embedded qualitative research. To understand generalisability it is nested in an observational cohort study, which is nested in a chronic kidney disease registry. Challenges to recruitment and retention have been rapidly identified and addressed using an established embedded mixed methods approach - the QuinteT recruitment intervention. This review considers the background to and progress with recruitment to the trial

Quality of life among caregivers of people with end-stage kidney disease managed with dialysis or comprehensive conservative care

BACKGROUND: To measure health-related and care-related quality of life among informal caregivers of older people with end-stage kidney disease (ESKD), and to determine the association between caregiver quality of life and care recipient's treatment type. METHODS: A prospective cross-sectional study was conducted. Three renal units in the UK and Australia were included. Informal caregivers of people aged ≥75 years with ESKD managed with dialysis or comprehensive conservative non-dialytic care (estimated glomerular filtration (eGFR) ≤10 mL/min/1.73m2) participated. Health-related quality of life (HRQoL) was assessed using Short-Form six dimensions (SF-6D, 0-1 scale) and care-related quality of life was assessed using the Carer Experience Scale (CES, 0-100 scale). Linear regression assessed associations between care-recipient treatment type, caregiver characteristics and the SF-6D utility index and CES scores. RESULTS: Of 63 caregivers, 49 (78%) were from Australia, 26 (41%) cared for an older person managed with dialysis, and 37 (59%) cared for an older person managed with comprehensive conservative care. Overall, 73% were females, and the median age of the entire cohort was 76 years [IQR 68-81]. When adjusted for caregiver sociodemographic characteristics, caregivers reported significantly worse carer experience (CES score 15.73, 95% CI 5.78 to 25.68) for those managing an older person on dialysis compared with conservative care. However, no significant difference observed for carer HRQoL (SF-6D utility index - 0.08, 95% CI - 0.18 to 0.01) for those managing an older person on dialysis compared with conservative care. CONCLUSIONS: Our data suggest informal caregivers of older people on dialysis have significantly worse care-related quality of life (and therefore greater need for support) than those managed with comprehensive conservative care. It is important to consider the impact on caregivers' quality of life when considering treatment choices for their care recipients

Health-related quality of life and well-being in people over 75 years of age with end-stage kidney disease managed with dialysis or comprehensive conservative care: A cross-sectional study in the UK and Australia

© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Objective To measure health-related quality of life (HRQoL) and well-being in older people with end-stage kidney disease (ESKD) and to determine the association between treatment type and sociodemographic characteristics on these outcome measures. In addition, to assess the convergent validity between the HRQoL and well-being measure and their feasibility and acceptability in this population. Design Prospective cross-sectional study. Setting Three renal units in the UK and Australia. Participants 129 patients with ESKD managed with dialysis or with an estimated glomerular filtration ≤10 mL/min/1.73 m 2 and managed with comprehensive conservative, non-dialytic care. Outcome measures HRQoL and well-being were assessed using Short-Form six dimensions (SF-6D, 0-1 scale); Kidney Disease Quality of Life (KDQOL-36) (0-100 scale) and Investigating Choice Experiments Capability Measure-Older people (ICECAP-O, 0-1 scale). Linear regression assessed associations between treatment, HRQoL and well-being. Pearson's correlation coefficient assessed convergent validity between instruments. Results Median age of 81 years (IQR 78-85), 65% males; 83 (64%) were managed with dialysis and 46 (36%) with conservative care. When adjusted for treatment type and sociodemographic variables, those managed on dialysis reported lower mean SF-6D utility (-0.05, 95% CI-0.12 to 0.01); lower KDQOL Physical Component Summary score (-3.17, 95% CI-7.61 to 1.27); lower Mental Component Summary score (-2.41, 95% CI-7.66 to 2.84); lower quality of life due to burden (-28.59, 95% CI-41.77 to-15.42); symptoms (-5.93, 95% CI-14.61 to 2.73) and effects of kidney disease (-16.49, 95% CI-25.98 to-6.99) and lower overall ICECAP-O well-being (-0.07, 95% CI-0.16 to 0.02) than those managed conservatively. Correlation between ICECAP-O well-being and SF-6D utility scores was strong overall, 0.65 (

Cocaine-induced granulomatosis with polyangiitis—an under-recognized condition

Objectives: Cocaine and cocaine mixed with levamisole are increasingly used in the UK and result in significant direct nasal damage in addition to promoting vasculitis. Our aims were as follows: (1) to identify the main symptoms and presentation of cocaine-induced vasculitis; (2) to provide evidence regarding the best practice for the investigation and diagnosis of cocaine-induced vasculitis; and (3) to analyse the clinical outcomes of patients in order to understand the optimal management for the condition./ Methods: We performed a retrospective case series analysis of patients presenting with cocaine-induced midline destructive lesions or vasculitis compatible with granulomatosis with polyangiitis (GPA) from two large tertiary vasculitis clinics between 2016 and 2021./ Results: Forty-two patients (29 Birmingham, 13 London) with cocaine-induced midline lesions or systemic disease were identified. The median age was 41 years (range 23–66 years). Current cocaine use was common, and 20 of 23 samples provided were positive when routine urine toxicology was performed; 9 patients who denied ever using cocaine were identified as using cocaine based on urine toxicology analysis, and 11 who stated they were ex-users still tested positive. There was a high incidence of septal perforation (75%) and oronasal fistula (15%). Systemic manifestations were less common (27%), and only one patient had acute kidney injury. Fifty-six per cent of our patients were PR3-ANCA positive, with none testing positive for MPO-ANCA. Symptom remission required cocaine discontinuation even when immunosuppression was administered./ Conclusion: Patients with destructive nasal lesions, especially young patients, should have urine toxicology performed for cocaine before diagnosing GPA and considering immunosuppressive therapy. The ANCA pattern is not specific for cocaine-induced midline destructive lesions. Treatment should be focused on cocaine cessation and conservative management in the first instance in the absence of organ-threatening disease

Preparing for responsive management versus preparing for renal dialysis in multimorbid older people with advanced chronic kidney disease (Prepare for Kidney Care): study protocol for a randomised controlled trial.

BackgroundChronic kidney disease (CKD) prevalence is steadily increasing, in part due to increased multimorbidity in our aging global population. When progression to kidney failure cannot be avoided, people need unbiased information to inform decisions about whether to start dialysis, if or when indicated, or continue with holistic person-centred care without dialysis (conservative kidney management). Comparisons suggest that while there may be some survival benefit from dialysis over conservative kidney management, in people aged 80 years and over, or with multiple health problems or frailty, this may be at the expense of quality of life, hospitalisations, symptom burden and preferred place of death. Prepare for Kidney Care aims to compare preparation for a renal dialysis pathway with preparation for a conservative kidney management pathway, in relation to quantity and quality of life in multimorbid, frail, older people with advanced CKD.MethodsThis is a two-arm, superiority, parallel group, non-blinded, individual-level, multi-centre, pragmatic trial, set in United Kingdom National Health Service (NHS) kidney units. Patients with advanced CKD (estimated glomerular filtration rate &lt; 15 mL/min/1.73 m2, not due to acute kidney injury) who are (a) 80 years of age and over regardless of frailty or multimorbidity, or (b) 65–79 years of age if they are frail or multimorbid, are randomised 1:1 to ‘prepare for responsive management’, a protocolised form of conservative kidney management, or ‘prepare for renal dialysis’. An integrated QuinteT Recruitment Intervention is included. The primary outcome is mean total number of quality-adjusted life years during an average follow-up of 3 years. The primary analysis is a modified intention-to-treat including all participants contributing at least one quality of life measurement. Secondary outcomes include survival, patient-reported outcomes, physical functioning, relative/carer reported outcomes and qualitative assessments of treatment arm acceptability. Cost-effectiveness is estimated from (i) NHS and personal social services and (ii) societal perspectives.DiscussionThis randomised study is designed to provide high-quality evidence for frail, multimorbid, older patients with advanced CKD choosing between preparing for dialysis or conservative kidney management, and healthcare professionals and policy makers planning the related services.Trial registrationISRCTN, ISRCTN17133653 (https://doi.org/10.1186/ISRCTN17133653). Registered 31 May 2017.<br/

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570