Consternation, confrontation and collaboration: narratives of medical students broaching obesity in primary care

This thesis explores one of the most important but neglected areas of medical education: obesity. I have worked in this area in an educational capacity with final year medical students for five years. I have published and presented at conferences extensively, and have become increasingly critical of the prevailing research paradigm in this area. I have had time to reflect on my journey and the drivers behind my educational practice, which were reflective narratives of my students’ first consultations with obese patients. I have identified and analysed the stories that informed change to my academic practice through a retroductive explanatory narrative analysis: why might this student, in this context, write this story in this way? Why was it impactful on my practice at that time, and in what ways did it inform change? Finally, I have theorised about how practitioner narratives create educational value for the narrator, researcher and reader

Success and limiting factors in health service innovation: a theory generating mixed-methods evaluation of UK projects

Objectives: To explore and explain success and limiting factors in UK health service innovation. Design: Mixed methods evaluation of a series of health service innovations involving a survey and interviews, with theory-generating analysis. Setting: The research explored innovations supported by one of the UK’s Academic Health Science Networks which provides small grants, awards and structural support to health service innovators including clinical academics, health and social care professionals and third-sector organisations. Participants: All recipients of funding or support 2014–2018 were invited to participate. We analysed survey responses relating to 56 innovation projects. Results: Responses were used to conceptualise success along two axes: value creation for the intended beneficiaries and expansion beyond its original pilot. An analysis of variance between categories of success indicated that participation, motivation and evaluation were critical to value generation; organisational, educational and administrative support were critical to expansion; and leadership and collaborative expertise were critical to both value creation and expansion. Additional limiting factors derived from qualitative responses included difficulties navigating the boundaries and intersections between organisations, professions, sectors and cultures; a lack of support for innovation beyond the start-up phase; a lack of protected time; and staff burn-out and turnover. Conclusions: A nested hierarchy of innovation needs has been derived via an analysis of these factors, providing targeted suggestions to enhance the success of future innovations. Data availability statement Data are available upon reasonable request. Due to the highly individual nature of healthcare innovations and the limited geographic area of this study, we are unable to provide our raw data. We undertake to provide a redacted data set upon reasonable request

Intra- and interprofessional practices through fresh eyes: a qualitative analysis of medical students’ early workplace experiences

Background Professional identities are influenced by experiences in the clinical workplace including socialisation processes that may be hidden from academic faculty and potentially divergent from formal curricula. With the current educational emphasis on complexity, preparedness for practice, patient safety and team-working it is necessary to evaluate and respond to what students are learning about collaborative practices during their clinical placements. Methods 394 second year medical students at a London medical school were invited to submit a short formative essay as part of their coursework describing, evaluating and reflecting on their experiences of how healthcare professionals work together. Their experiences were derived from having spent two days each week for 25 weeks in clinical contexts across primary and secondary care. We consented 311 participants and used a Consensual Qualitative Research approach to analyse these essays, creating a ‘students-eye view’ of intra- and interprofessional practices in the workplace. Results We identified four overarching themes in students’ essays: Theme 1: analyses of contextual factors driving team tensions including staff shortages, shifting teams, and infrastructural issues; Theme 2: observations of hierarchical and paternalistic attitudes and behaviours; Theme 3: respect for team members’ ability to manage and mitigate tensions and attitudes; and Theme 4: take-forward learning including enthusiasm for quality improvement and system change. Conclusions Students are being socialised into a complex, hierarchical, pressurised clinical workplace and experience wide variations in professional behaviours and practices. They articulate a need to find constructive ways forward in the interests of staff wellbeing and patient care. We present educational recommendations including providing safe reflective spaces, using students’ lived experience as raw material for systems thinking and quality improvement, and closing the feedback loop with placement sites on behalf of students

Sustainability in quality improvement (SusQI): a case-study in undergraduate medical education

Background There is a pressing need for more sustainable healthcare. UK medical graduates are required to apply social, economic, and environmental principles of sustainability to their practice. The Centre for Sustainable Healthcare has developed a sustainability in quality improvement (SusQI) framework and educator’s toolkit to address these challenges. We aimed to develop and evaluate SusQI teaching using this toolkit at Bristol Medical School. Methods We facilitated a SusQI workshop for all third-year Bristol Medical School students. We used mixed methods including questionnaires, exit interviews and follow-up focus groups to evaluate the outcomes and processes of learning. Results Students reported: improvements in knowledge, confidence, and attitudes in both sustainable healthcare and quality improvement; increased self-rated likelihood to engage in SusQI projects; and willingness to change practices to reduce environmental impact in their healthcare roles. Factors for successful teaching included: interactivity; collaboration and participation; and real-life, relevant and tangible examples of projects delivered by credible role models. Conclusions Students reported that SusQI education supported by the toolkit was effective at building knowledge and skills, and reframed their thinking on sustainability in quality improvement. Combining the two topics provided enhanced motivation for and engagement in both. Further research is needed on the clinical impacts of SusQI learning

Sustainability in Quality Improvement (SusQI): challenges and strategies for translating undergraduate learning into clinical practice

Background The healthcare sector is a major contributor to climate change and there are international calls to mitigate environmental degradation through more sustainable forms of clinical care. The UK healthcare sector has committed to net zero carbon by 2040 and sustainable healthcare is a nationally mandated outcome for all UK graduating doctors who must demonstrate their ability to address social, economic and environmental challenges. Bristol Medical School piloted successful Sustainability in Quality Improvement (SusQI) workshop, but identified challenges translating classroom learning into clinical practice. This paper aims to identify and address those challenges. Methods We conducted five focus groups that identified and iteratively explored barriers and facilitators to practice among medical students, comparing a range of experiences to generate a conceptual framework. We then combined our findings with behaviour change theory to generate educational recommendations. Results Students that applied their learning to the clinical workplace were internally motivated and self-determined but needed time and opportunity to complete projects. Other students were cautious of disrupting established hierarchies and practices or frustrated by institutional inertia. These barriers impacted on their confidence in suggesting or achieving change. A minority saw sustainable healthcare as beyond their professional role. Conclusions We present a series of theoretically informed recommendations. These include wider curricular engagement with concepts of sustainable clinical practice; supportive workplace enablement strategies such as workplace champions and co-creation of improvement goals; and time and headspace for students to engage through structured opportunities for credit-bearing project work

Digital wellbeing: are educational institutions paying enough attention?

This commentary questions the impacts of over-using technology in medical education and highlights the consideration of digital wellbeing when developing new teaching strategie

"More than just a medical student”: a mixed methods exploration of a structured volunteering programme for undergraduate medical students

Background As a result of the COVID-19 pandemic Imperial College School of Medicine developed a structured volunteering programme involving 398 medical students, across eight teaching hospitals. This case study aims to illuminate the experiences of volunteers, mechanisms of learning and draw lessons for future emergencies and curriculum improvements. Methods Using an illuminative approach to evaluation we invited all volunteers and supervisors to complete a mixed-methods survey. This gathered nominal demographic information and qualitative data related to motivations, experiences, insights into learning, processual and contextual factors. Qualitative responses were coded, thematically organised, and categorised into an overarching framework. Mann-Whitney U tests determined whether volunteers’ overall rating of the experience varied according to demographic features and modulating factors. Spearman’s rank correlation assessed the relationship between aspects of induction and supervision, and overall volunteering rating. Follow up interviews were carried out with students to check back findings and co-create conclusions. Results Modulating factors identified through thematic analysis include altruistic motivation, engaged induction and supervision, feeling valued, having responsibility and freedom from the formal curriculum. Statistically significant positive correlations are identified between volunteers overall rating and being a year 1 or 2 student, ability to discuss role and ask questions during induction, being male, and having regular meetings and role support from supervisors. Qualitatively reported impacts include improved wellbeing, valuable contribution to service and transformative learning. Transformative learning effects included reframing of role within the multidisciplinary team, view of effective learning and view of themselves as competent clinicians. The number of weeks, number of shifts per week, and the role the volunteers performed, did not significantly impact experiences. Conclusions While acknowledging the uniqueness of the situation presented by the first wave COVID-19, we suggest the features of a successful service-learning programme include: a learner-centred induction, engaged and appreciative supervisors, and the entrustment of students with meaningful work with reciprocal benefits to services. Programmes in similar settings may find that 1) volunteering is best appreciated in years 1 or 2, 2) students with altruistic motivations and meaningful work may flourish without formal outcomes and assessments, and 3) that female volunteers may experience emergency learning differently to men

Time, the Written Record, and Professional Practice: The Case of Contemporary Social Work

Drawing on a three year ethnographically-oriented study exploring contemporary professional social work writing, this paper focuses on a key concern: the amount of time taken up with writing, or ‘paperwork’. We explore the relationship between time and professional social work writing in three key ways. Firstly, as a discrete, measurable phenomenon - how much time is spent on writing? Secondly, as a textual dimension to social work writing – how do institutional documents drive particular entextualisations of time and how do social worker texts entextualise time? Thirdly, as a particular timespace configuration of lived experience - how is time experienced by professional social workers? Findings indicate that a dominant institutional chronotope is governing social work textual practice underpinned by an ideology of writing which is at odds with social workers’ desired practice and professional goals. Methodologically, the paper illustrates the value of combining a range of data and analytic tools, using textual and contextual data, as well as qualitative and quantitative frames of analysis

NOX1 loss-of-function genetic variants in patients with inflammatory bowel disease.

Genetic defects that affect intestinal epithelial barrier function can present with very early-onset inflammatory bowel disease (VEOIBD). Using whole-genome sequencing, a novel hemizygous defect in NOX1 encoding NAPDH oxidase 1 was identified in a patient with ulcerative colitis-like VEOIBD. Exome screening of 1,878 pediatric patients identified further seven male inflammatory bowel disease (IBD) patients with rare NOX1 mutations. Loss-of-function was validated in p.N122H and p.T497A, and to a lesser degree in p.Y470H, p.R287Q, p.I67M, p.Q293R as well as the previously described p.P330S, and the common NOX1 SNP p.D360N (rs34688635) variant. The missense mutation p.N122H abrogated reactive oxygen species (ROS) production in cell lines, ex vivo colonic explants, and patient-derived colonic organoid cultures. Within colonic crypts, NOX1 constitutively generates a high level of ROS in the crypt lumen. Analysis of 9,513 controls and 11,140 IBD patients of non-Jewish European ancestry did not reveal an association between p.D360N and IBD. Our data suggest that loss-of-function variants in NOX1 do not cause a Mendelian disorder of high penetrance but are a context-specific modifier. Our results implicate that variants in NOX1 change brush border ROS within colonic crypts at the interface between the epithelium and luminal microbes