Can a mobile app improve the quality of patient care provided by trainee doctors? Analysis of trainees case reports

OBJECTIVES: To explore how a medical textbook app (‘iDoc’) supports newly qualified doctors in providing high-quality patient care. DESIGN: The iDoc project, funded by the Wales Deanery, provides new doctors with an app which gives access to key medical textbooks. Participants’ submitted case reports describing self-reported accounts of specific instances of app use. The size of the data set enabled analysis of a subsample of ‘complex’ case reports. Of the 568 case reports submitted by Foundation Year 1s (F1s)/Year 2s (F2s), 142 (25%) detailed instances of diagnostic decision-making and were identified as ‘complex’. We analysed these data against the Quality Improvement (QI) Framework using thematic content analysis. SETTING: Clinical settings across Wales, UK. PARTICIPANTS: Newly qualified doctors (2012–2014; n=114), F1 and F2. INTERVENTIONS: The iDoc app, powered by Dr Companion software, provided newly qualified doctors in Wales with a selection of key medical textbooks via individuals’ personal smartphone. RESULTS: Doctors’ use of the iDoc app supported 5 of the 6 QI elements: efficiency, timeliness, effectiveness, safety and patient-centredness. None of the case reports were coded to the equity element. Efficiency was the element which attracted the highest number of case report references. We propose that the QI Framework should be expanding to include ‘learning’ as a 7th element. CONCLUSIONS: Access to key medical textbooks via an app provides trusted and valuable support to newly qualified doctors during a period of transition. On the basis of these doctors’ self-reported accounts, our evidence indicates that the use of the app enhances efficiency, effectiveness and timeliness of patient-care in addition consolidating a safe, patient-centred approach. We propose that there is scope to extend the QI Framework by incorporating ‘learning’ as a 7th element in recognition of the relationship between providing high-quality care through educational engagement

A mixed-methods evaluation of the Educational Supervision Agreement for Wales

Objectives In a bid to promote high-quality postgraduate education and training and support the General Medical Council’s (GMC) implementation plan for trainer recognition, the Wales Deanery developed the Educational Supervision Agreement (EdSA). This is a three-way agreement between Educational Supervisors, Local Education Providers and the Wales Deanery which clarifies roles, responsibilities and expectations for all. This paper reports on the formative evaluation of the EdSA after 1 year. Design Evaluation of pan-Wales EdSA roll-out (2013–2015) employed a mixed-methods approach: questionnaires (n=191), interviews (n=11) with educational supervisors and discussion with key stakeholders (GMC, All-Wales Trainer Recognition Group, Clinical Directors). Numerical data were analysed in SPSS V.20; open comments underwent thematic content analysis. Participants The study involved Educational Supervisors working in different specialties across Wales, UK. Results At the point of data collection, survey respondents represented 14% of signed agreements. Respondents believed the Agreement professionalises the Educational Supervisor role (85%, n=159 agreed), increases the accountability of Educational Supervisors (87%; n=160) and health boards (72%, n=131), provides leverage to negotiate supporting professional activities’ (SPA) time (76%, n=142) and continuing professional development (CPD) activities (71%, n=131). Factor analysis identified three principal factors: professionalisation of the educational supervisor role, supporting practice through training and feedback and implementation of the Agreement. Conclusions Our evidence suggests that respondents believed the Agreement would professionalise and support their Educational Supervisor role. Respondents showed enthusiasm for the Agreement and its role in maintaining high standards of training

Technology in postgraduate medical education: a dynamic influence on learning?

The influence of technology in medical workplace learning is explored by focusing on three uses: m-learning (notably apps), simulation and social media. Smartphones with point-of-care tools (such as textbooks, drug guides and medical calculators) can support workplace learning and doctors’ decision-making. Simulations can help develop technical skills and team interactions, and ‘in situ’ simulations improve the match between the virtual and the real. Social media (wikis, blogs, networking, YouTube) heralds a more participatory and collaborative approach to knowledge development. These uses of technology are related to Kolb's learning cycle and Eraut's intentions of informal learning. Contentions and controversies with these technologies exist. There is a problem with the terminology commonly adopted to describe the use of technology to enhance learning. Using learning technology in the workplace changes the interaction with others and raises issues of professionalism and etiquette. Lack of regulation makes assessment of app quality a challenge. Distraction and dependency are charges levelled at smartphone use in the workplace and these need further research. Unless addressed, these and other challenges will impede the benefits that technology may bring to postgraduate medical education

Mobile learning devices in the workplace: 'as much a part of the junior doctors' kit as a stethoscope'?

Background Smartphones are ubiquitous and commonly used as a learning and information resource. They have potential to revolutionize medical education and medical practice. The iDoc project provides a medical textbook smartphone app to newly-qualified doctors working in Wales. The project was designed to assist doctors in their transition from medical school to workplace, a period associated with high levels of cognitive demand and stress. Methods Newly qualified doctors submitted case reports (n = 293) which detail specific instances of how the textbook app was used. Case reports were submitted via a structured online form (using Bristol Online Surveys - BOS) which gave participants headings to elicit a description of: the setting/context; the problem/issue addressed; what happened; any obstacles involved; and their reflections on the event. Case reports were categorised by the purpose of use, and by elements of the quality improvement framework (IoM 2001). They were then analysed thematically to identify challenges of use. Results Analysis of the case reports revealed how smartphones are a viable tool to address clinical questions and support mobile learning. They contribute to novice doctors’ provision of safe, effective, timely, efficient and patient-centred care. The case reports also revealed considerable challenges for doctors using mobile technology within the workplace. Participants reported concern that using a mobile phone in front of patients and staff might appear unprofessional. Conclusion Mobile phones blur boundaries between the public and private, and the personal and professional. In contrast to using a mobile as a communication device, using a smartphone as an information resource in the workplace requires different rituals. Uncertain etiquette of mobile use may reduce the capacity of smartphone technology to improve the learning experience of newly qualified doctors

"He's going to be a doctor in August": A narrative interview study of medical students' and their educators' experiences of aligned and misaligned assistantships

Objective To explore final-year students’ and clinical supervisors’ experiences of alignment and misalignment with future Foundation Year 1 (F1) posts in an assistantship programme in the UK. Setting Assistantships are clinical placements in which students assist junior doctors by undertaking similar duties under supervision. Models of assistantship programmes vary across curricula. Some actively seek to align with students’ initial postgraduate F1 post. To date, no research has examined the implications of this association for teaching and learning. Qualitative individual and group narrative interviews were conducted with students and supervisors of 2 Welsh medical schools to address: RQ1: How do students and supervisors understand the purpose of the longitudinal assistantship? RQ2: Does alignment/misalignment of the assistantship with students’ initial F1 post influence students’ and supervisors’ teaching and learning experiences? Audio-recordings of interviews were transcribed, participants anonymised and framework analysis was used. Participants A convenience sample of 4 participant groups comprised (1) final-year medical students whose assistantship and F1 post were aligned (n=27), (2) final-year medical students whose assistantship and F1 post were misaligned (n=18) and (3) supervisors (n=10, junior doctors; n=11, consultants). Results All participant groups highlighted increased student confidence in undertaking the duties of an F1 doctor arising from their assistantship period. Learning transferable skills was also highlighted. Many students considered themselves to be team members, ‘learning the trade’ as they shadowed their F1. Opportunities for caring for acutely unwell patients were scarce. The evidence shows enhanced engagement for students aligned to their first F1 post with greater opportunities for workplace acclimatisation. Those who were misaligned were perceived as being disadvantaged. Conclusions Our findings suggest that alignment with students’ first F1 post enhances the assistantship experience. Further longitudinal assessment is required to examine whether and how this translates into improvement

The Undergraduate preparation of dentists: Confidence levels of final year dental students at the School of Dentistry in Cardiff

Objective To investigate the self-reported confidence and preparedness of final year undergraduate students in undertaking a range of clinical procedures. Methods A questionnaire was distributed to final year dental students at Cardiff University, six months prior to graduation. Respondents rated their confidence in undertaking 39 clinical procedures using a 5-point scale (1 = can undertake on own with confidence, 5 = unable to undertake). Students also responded yes/no to experiencing four difficulties and to three statements about general preparedness. Results 71% (N = 51) responded of which 55% (N = 28) were female. Over half reported being 'anxious that the supervisor was not helping enough' (57%) and 'relying heavily on supervisor for help' (53%). Eighty percent 'felt unprepared for the clinical work presented' and gender differences were most notable here (male: 65% N = 33; females: 93% N = 47). Mean confidence scores were calculated for each clinical procedure (1 = lowest; 5 = highest). Confidence was highest in performing 'simple scale' and 'fissure sealant' (mean-score = 5). Lowest scores were reported for 'surgical extractions involving a flap (mean-score = 2.28)', 'simple surgical procedures' (mean-score = 2.58) and the 'design/fit/adjustment of orthodontic appliances' (mean-score = 2.88). Conclusions As expected complex procedures that were least practised scored the lowest in overall mean confidence. Gender differences were noted in self-reported confidence for carrying out treatment unsupervised and feeling unprepared for clinical work

Clinical skills of a new foundation dentist: the expectations of dental foundation educational supervisors

Aim To investigate dental foundation (DF) educational supervisors' (ES) expectations of the level of clinical ability expected of a foundation dentist (FD) on entry into foundation training. Methods Following ethical approval, a pre-piloted online questionnaire was circulated to ESs across England and Northern Ireland (n = 959), requiring respondents to rate their expectations of their FDs' ability at the beginning of the training year, in relation to undertaking 104 clinical skills. A five-point scale and descriptors were provided, ranging from 'on own with confidence' to 'unable to undertake'. Respondents were invited to comment further. Data were imported into IBM SPSS (v20) and descriptive analysis was undertaken. Expectations were assigned values and a mean, 'skill rank score' was generated for each skill. A ranking score closer to five indicated high expectation; closer to one indicated low expectation. Results A total of 510 (53%) questionnaires were completed. The study highlighted a range of expectations which were used to identify 'upper-level' (core) skills expected of a new FD. The majority of expectations were in line with UG curriculum guidance; however, certain skills were identified as having overly high expectations and these may need to be modified to align with current guidance. Conclusions Understanding the expectations ESs have of a new FD is useful for both dental schools and those involved in DF training. Findings add to the existing evidence base and should generate discussion for those within the education continuum to enhance the successful development of the FD

‘It's surprising how differently they treat you’: a qualitative analysis of trainee reflections on a new programme for generalist doctors

Objectives An increase in patients with long-term conditions and complex care needs presents new challenges to healthcare providers around the developed world. In response, more broad-based training programmes have developed to better prepare trainees for the changing landscape of healthcare delivery. This paper focuses on qualitative elements of a longitudinal, mixed-methods evaluation of the postgraduate, post-Foundation Broad-Based Training (BBT) programme in England. It aims to provide a qualitative analysis of trainees' evaluations of whether the programme meets its intentions to develop practitioners adept at managing complex cases, patient focused care, specialty integration and conviction in career choice. We also identify unintended consequences. Setting 9 focus groups of BBT trainees were held over a 12-month period. Discussions were audio-recorded and subjected to directed content analysis. Data were collected from trainees across all 7 participating regions: East Midlands; West Midlands; Severn; Northern; North Western; Yorkshire and Humber; Kent, Surry and Sussex. Participants Focus group participants (61 in total) from the first and second cohorts of BBT. Results Evidence from trainees indicated that the programme was meeting its aims: trainees valued the extra time to decide on their onward career specialty, having a wider experience and developing a more integrated perspective. They thought of themselves as different and perceived that others they worked alongside also saw them as different. Being different meant benefitting from novel training experiences and opportunities for self-development. However, unintended consequences were feelings of isolation, and uncertainty about professional identity. Conclusions By spanning boundaries between specialties, trainee generalists have the potential to improve experiences and outcomes for patients with complex health needs. However, the sense of isolation will inhibit this potential. We employ the concept of ‘belongingness’ to identify challenges related to the implementation of generalist training programmes within existing structures of healthcare provision

Interventions to improve the self-management support health professionals provide for people with progressive neurological conditions: protocol for a realist synthesis

Introduction Supporting self-management among people with long term conditions is recognised as an important component of health care. Progressive neurological conditions (PNCs), for example, Parkinson’s disease and Multiple Sclerosis are associated with problems such as fatigue and cognitive impairment which may make self-management more challenging. Health professionals may need to develop specific skills in order to provide effective self-management support for these patients. The review aims to develop explanatory theories about how health professional-targeted interventions to improve self-management support provision for people with PNCs operate in different circumstances. Methods and Analysis A realist synthesis of the evidence is proposed. There are two priority questions for the review to address. These relate to the role of a shared concept of self-management support within the healthcare team, and the need to tailor the support provided to the requirements of people with PNCs. Key stakeholders will be involved throughout the process. The initial search strategy uses terms relating to 1) self-management, 2) health professionals and 3) PNCs. Searching, data extraction and synthesis will occur in parallel. Studies will be prioritised for inclusion based on anticipated contribution to generating explanatory theories. Key informant interviews are planned to direct supplementary searches and help further refine the theories developed. Results will be expressed in the form of context-mechanism-outcome configurations. Dissemination Publication guidelines on realist synthesis will be followed. The results will be published in a peer-reviewed journal and made available to organisations involved in the provision of health professional training