Helping Clinical Educators Provide Effective Feedback to Medical Trainees on Their Diagnostic Decision Making: An Educational Design Research Approach

An educational design research approach (EDR) was adopted to understand what type of feedback is most effective to enhance medical trainees’ diagnostic decision making (DDM) in authentic clinical settings and how this understanding can be used to improve the feedback provided by clinical educators. Research was conducted within the three phases of EDR: 1) preliminary, 2) developmental and 3) assessment. Findings from the preliminary research phase indicated that more structured and specific feedback which focused on self-regulated learning (SRL) and contextual factors would be advantageous for medical trainees. A conceptual model of feedback that incorporated these findings was developed to inform a Personalised Model of Feedback (PFM) intervention in the development phase. Despite a positive response to the PFM intervention, recruitment was poor which highlighted barriers to involving clinical educators in research and training. Six clinical educators used the PFM intervention to provide feedback to their medical trainees after DDM in the authentic clinical setting. Using a mixed methods approach, the assessment phase evaluated participants’ perceptions of the PFM intervention. Participants found the PFM intervention useful, usable and effective for providing feedback on DDM. After participation more feedback was provided on SRL, confidence and the influence of contextual factors on DDM. Clinical educators and medical trainees also had an increased awareness of the influence of contextual factors on DDM. Medical trainees viewed SRL focused feedback as effective and useful for improving DDM and used more SRL skills on hypothetical reasoning cases. This research has added to current research on the use of SRL to provide feedback. It is the first research to specifically address how feedback after DDM can be better provided to medical trainees and shows that the PFM feedback can be given as an add on to feedback usually provided. Further research is necessary to modify the conceptual model and the PFM intervention to improve its ease of use in the authentic clinical setting, its receptivity by clinical educators and to determine whether it leads to an improvement in medical trainees’ DDM

Factors influencing streaming to General Practitioners in emergency departments: A qualitative study

Background: Emergency Department attendance is increasing internationally, of which a significant proportion could be managed in general practice. In England, policies backed by substantial capital funding require such patients attending Emergency Departments be directed or ‘streamed’ to general practitioners working in or parallel to Emergency Departments. However, evidence for streaming is limited and the processes of streaming patients attending Emergency Departments to general practitioners lacks exploration. Objectives: This paper explores streaming to general practitioners in and alongside Emergency Departments at ten sites across England. It highlights positive streaming practice, as well as issues that may contribute to poor streaming practice, in order to inform future service improvement. Methods: A longitudinal qualitative study was conducted with data collected between October 2017 and December 2019 across 10 case study sites throughout England as part of a broader mixed methods study. 186 non-participant observations and 226 semi-structured interviews with 191 health professionals working in Emergency Departments or related General Practitioner Services were thematically analysed in relation to streaming processes and experiences. Results: Six interconnected themes influencing streaming were identified: implementing and maintaining structural support; developing and supporting streaming personnel; implementing workable and responsive streaming protocols; negotiating primary/secondary care boundaries; developing and maintaining interprofessional relationships and concerns for patient safety. Streaming was considered central to the success of general practitioners in/parallel to Emergency Departments. The importance of the skills of streaming nurses in delivering an optimal and safety critical service was highlighted, as was the skillset of general practitioners and interprofessional relationships between streamers and general practitioners. There was no distinct streaming model or method associated with good streaming practice to general practitioners in/alongside Emergency Departments, instead factors for success were identified and key recommendations suggested. ‘Inappropriate’ streaming was identified as a problem, where patients streamed to general practitioners in or parallel to Emergency Departments required Emergency Department management, or patients suitable for general practitioner care were kept in the Emergency Department. Conclusion: Despite adopting differing methods, commonalities across case sites in the delivery of good streaming practice were identified, leading to identification of key recommendations which may inform development of streaming services. Study Registration: ISRCTN51780222. Tweetable Abstract: Workplace culture and the skillset of streamers and General Practitioners is crucial to streaming of patients to General Practitioners in Emergency Department

Whose Responsibility Is It Anyway? Exploring Barriers to Prevention of Oral Diseases across Europe

Introduction: Dental caries, gum disease, and tooth loss are all preventable conditions. However, many dental care systems remain treatment oriented rather than prevention oriented. This promotes the treatment of oral diseases over preventive treatments and advice. Exploring barriers to prevention and understanding the requirements of a paradigm shift are the first steps toward delivering quality prevention-focused health care. Objectives: To qualitatively explore perceived barriers and facilitators to oral disease prevention from a multistakeholder perspective across 6 European countries. Methods: A total of 58 interviews and 13 focus groups were undertaken involving 149 participants from the United Kingdom, Denmark, Germany, the Netherlands, Ireland, and Hungary. Interviews and focus groups were conducted in each country in its native language between March 2016 and September 2017. Participants were patients (n = 50), dental team members (n = 39), dental policy makers(n = 33), and dental insurers (n = 27). The audio was transcribed, translated, and analyzed via deductive thematic analysis. Results: Five broad themes emerged that were both barriers and facilitators: dental regulation, who provides prevention, knowledge and motivation, trust, and person-level factors. Each theme was touched on in all countries; however, cross-country differences were evident surrounding the magnitude of each theme. Conclusion: Despite the different strengths and weaknesses among the systems, those who deliver, organize, and utilize each system experience similar barriers to prevention. The findings suggest that across all 6 countries, prevention in oral health care is hindered by a complex interplay of factors, with no particular dental health system offering overall greater user satisfaction. Underlying the themes were sentiments of blame, whereby each group appeared to shift responsibility for prevention to other groups. To bring about change, greater teamwork is needed in the commissioning of prevention to engender its increased value by all stakeholders within the dental system. Knowledge Transfer Statement: The results from this study provide an initial first step for those interested in exploring and working toward the paradigm shift to preventive focused dentistry. We also hope that these findings will encourage more research exploring the complex relationship among dental stakeholders, with a view to overcoming the barriers. In particular, these findings may be of use to dental public health researchers, dentists, and policy makers concerned with the prevention of oral diseases. Keywords oral health, dental public health, qualitative, preventive dentistry, health services research, European Unio

Potential impacts of general practitioners working in or alongside emergency departments in England: Initial qualitative findings from a national mixed-methods evaluation

Objectives To explore the potential impacts of introducing General Practitioners into Emergency Departments (GPED) from the perspectives of service leaders, health professionals and patients. These 'expectations of impact' can be used to generate hypotheses that will inform future implementations and evaluations of GPED. Design Qualitative study consisting of 228 semistructured interviews. Setting 10 acute National Health Service (NHS) hospitals and the wider healthcare system in England. Interviews were undertaken face to face or via telephone. Data were analysed thematically. Participants 124 health professionals and 94 patients and carers. 10 service leaders representing a range of national organisations and government departments across England (eg, NHS England and Department of Health) were also interviewed. Results A range of GPED models are being implemented across the NHS due to different interpretations of national policy and variation in local context. This has resulted in stakeholders and organisations interpreting the aims of GPED differently and anticipating a range of potential impacts. Participants expected GPED to affect the following areas: ED performance indicators; patient outcome and experience; service access; staffing and workforce experience; and resources. Across these 'domains of influence', arguments for positive, negative and no effect of GPED were proposed. Conclusions Evaluating whether GPED has been successful will be challenging. However, despite uncertainty surrounding the direction of effect, there was agreement across all stakeholder groups on the areas that GPED would influence. As a result, we propose eight domains of influence that will inform our subsequent mixed-methods evaluation of GPED

What is important to adults after lower limb reconstruction surgery: a conceptual framework

Purpose Patient-reported outcome measures (PROMs) are used to understand the impact of lower limb reconstruction on patient’s Health-Related Quality of Life (HRQL). Existing measures have not involved this group of patients and their experiences during development. This study aimed to develop a conceptual framework to reflect what is important to patients requiring, undergoing or after undergoing reconstructive surgery. Methods Our population of interest was people requiring, undergoing or after undergoing reconstructive surgery due to trauma, malunion, nonunion, infection or congenital issues treated by internal or external fixation. We undertook semi-structured interviews with patients and orthopaedic healthcare professionals (surgeons, methodologists and patient contributors) in England. Results Thirty-two patients and 22 orthopaedic healthcare professionals (surgeons, methodologists and patient contributors) were interviewed between November 2020 and June 2021. Eight domains from a previously developed preliminary conceptual framework were used as a framework around which to code the interviews using thematic analysis. Six domains important to patients (from the perspective of patients and orthopaedic healthcare professionals) were included in the final conceptual framework: pain, perception-of-self, work and finances, daily lifestyle and functioning, emotional well-being, and support. These findings, plus meetings with our advisory panel led to the refinement of the conceptual framework. Conclusion The first five domains relate to important outcomes for patients; they are all inter-related and their importance to patients changed throughout recovery. The final domain—support (from work, the hospital, physiotherapists and family/friends)—was vital to patients and lessened the negative impact of the other domains on their HRQL. These new data strengthen our original findings and our understanding of the domains we identified in the QES. The next step in this research is to ascertain whether current PROMs used with this group of patients adequately capture these areas of importance

Atmospheric circulation of hot Jupiters: Coupled radiative-dynamical general circulation model simulations of HD 189733b and HD 209458b

We present global, three-dimensional numerical simulations of HD 189733b and HD 209458b that couple the atmospheric dynamics to a realistic representation of non-gray cloud-free radiative transfer. The model, which we call the Substellar and Planetary Atmospheric Radiation and Circulation (SPARC) model, adopts the MITgcm for the dynamics and uses the radiative model of McKay, Marley, Fortney, and collaborators for the radiation. Like earlier work with simplified forcing, our simulations develop a broad eastward equatorial jet, mean westward flow at higher latitudes, and substantial flow over the poles at low pressure. For HD 189733b, our simulations without TiO and VO opacity can explain the broad features of the observed 8 and 24-micron light curves, including the modest day-night flux variation and the fact that the planet/star flux ratio peaks before the secondary eclipse. Our simulations also provide reasonable matches to the Spitzer secondary-eclipse depths at 4.5, 5.8, 8, 16, and 24 microns and the groundbased upper limit at 2.2 microns. However, we substantially underpredict the 3.6-micron secondary-eclipse depth, suggesting that our simulations are too cold in the 0.1-1 bar region. Predicted temporal variability in secondary-eclipse depths is ~1% at Spitzer bandpasses, consistent with recent observational upper limits at 8 microns. We also show that nonsynchronous rotation can significantly alter the jet structure. For HD 209458b, we include TiO and VO opacity; these simulations develop a hot (>2000 K) dayside stratosphere. Despite this stratosphere, we do not reproduce current Spitzer photometry of this planet. Light curves in Spitzer bandpasses show modest phase variation and satisfy the observational upper limit on day-night phase variation at 8 microns. (abridged)Comment: 20 pages (emulate-apj format), 21 figures, final version now published in ApJ. Includes expanded discussion of radiative-transfer methods and two new figure

Do general practitioners working in or alongside the emergency department improve clinical outcomes or experience? A mixed-methods study

OBJECTIVES: To examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce. DESIGN: Mixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory's four main constructs of coherence, cognitive participation, collective action and reflexive monitoring. SETTING AND PARTICIPANTS: Data were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available. RESULTS: There was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient 'streaming' processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring). CONCLUSIONS: We found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience. TRIAL REGISTRATION NUMBER: ISCRTN5178022

Science and Technology Issues in the 115th Congress

Science and technology (S&T) have a pervasive influence over a wide range of issues confronting the nation. Public and private research and development spur scientific and technological advancement. Such advances can drive economic growth, help address national priorities, and improve health and quality of life. The constantly changing nature and ubiquity of science and technology frequently create public policy issues of congressional interest. The federal government supports scientific and technological advancement directly by funding and performing research and development and indirectly by creating and maintaining policies that encourage private sector efforts. Additionally, the federal government establishes and enforces regulatory frameworks governing many aspects of S&T activities. This report briefly outlines an array of science and technology policy issues that may come before the 115th Congress. Given the rapid pace of S&T advancement and its importance in many diverse public policy issues, S&T-related issues not discussed in this report may come before the 115th Congress. The selected issues are grouped into 9 categories: - Overarching S&T Policy Issues, - Agriculture, - Biomedical Research and Development, - Defense, - Energy, - Environment and Natural Resources, - Homeland Security, - Information Technology, - Physical and Material Sciences, and - Space. Each of these categories includes concise analysis of multiple policy issues. The material presented in this report should be viewed as illustrative rather than comprehensive. Each section identifies CRS reports, when available, and the appropriate CRS experts to contact for further information and analysis

General practitioners working in or alongside the emergency department : the GPED mixed-methods study

Background: Emergency care is facing a steadily rising demand. In response, hospitals have implemented new models of care that locate general practitioners in or alongside the emergency department. Objectives: We aimed to explore the effects of general practitioners working in or alongside the emergency department on patient care, the primary care and acute hospital team, and the wider system, as well as to determine the differential effects of different service models. Design: This was a mixed-methods study in three work packages. Work package A classified current models of general practitioners working in or alongside the emergency department in England. We interviewed national and local leaders, staff and patients to identify the hypotheses underpinning these services. Work package B used a retrospective analysis of routinely available data. Outcome measures included waiting times, admission rates, reattendances, mortality and the number of patient attendances. We explored potential cost savings. Work package C was a detailed mixed-methods case study in 10 sites. We collected and synthesised qualitative and quantitative data from non-participant observations, interviews and a workforce survey. Patients and the public were involved throughout the development, delivery and dissemination of the study. Results: High-level goals were shared between national policy-makers and local leads; however, there was disagreement about the anticipated effects. We identified eight domains of influence: performance against the 4-hour target, use of investigations, hospital admissions, patient outcome and experience, service access, workforce recruitment and retention, workforce behaviour and experience, and resource use. General practitioners working in or alongside the emergency department were associated with a very slight reduction in the rate of reattendance within 7 days; however, the clinical significance of this was judged to be negligible. For all other indicators, there was no effect on performance or outcomes. However, there was a substantial degree of heterogeneity in these findings. This is explained by the considerable variation observed in our case study sites, and the sensitivity of service implementation to local factors. The effects on the workforce were complex; they were often positive for emergency department doctors and general practitioners, but less so for nursing staff. The patient-streaming process generated stress and conflict for emergency department nurses and general practitioners. Patients and carers were understanding of general practitioners working in or alongside the emergency department. We found no evidence that staff concerns regarding the potential to create additional demand were justified. Any possible cost savings associated with reduced reattendances were heavily outweighed by the cost of the service. Limitations: The reliability of our data sources varied and we were unable to complete our quantitative analysis entirely as planned. Participation in interviews and at case study sites was voluntary. Conclusions: Service implementation was highly subject to local context and micro-level influences. Key success factors were interprofessional working, staffing and training, streaming, and infrastructure and support

General practitioners working in or alongside The emergency department: the GPED mixed-methods study

Background: Emergency care is facing a steadily rising demand. In response, hospitals have implemented new models of care that locate general practitioners in or alongside the emergency department.Objectives: We aimed to explore the effects of general practitioners working in or alongside the emergency department on patient care, the primary care and acute hospital team, and the wider system, as well as to determine the differential effects of different service models.Design: This was a mixed-methods study in three work packages. Work package A classified current models of general practitioners working in or alongside the emergency department in England. We interviewed national and local leaders, staff and patients to identify the hypotheses underpinning these services. Work package B used a retrospective analysis of routinely available data. Outcome measures included waiting times, admission rates, reattendances, mortality and the number of patient attendances. We explored potential cost savings. Work package C was a detailed mixed-methods case study in 10 sites. We collected and synthesised qualitative and quantitative data from non-participant observations, interviews and a workforce survey. Patients and the public were involved throughout the development, delivery and dissemination of the study.Results: High-level goals were shared between national policy-makers and local leads; however, there was disagreement about the anticipated effects. We identified eight domains of influence: performance against the 4-hour target, use of investigations, hospital admissions, patient outcome and experience, service access, workforce recruitment and retention, workforce behaviour and experience, and resource use. General practitioners working in or alongside the emergency department were associated with a very slight reduction in the rate of reattendance within 7 days; however, the clinical significance of this was judged to be negligible. For all other indicators, there was no effect on performance or outcomes. However, there was a substantial degree of heterogeneity in these findings. This is explained by the considerable variation observed in our case study sites, and the sensitivity of service implementation tolocal factors. The effects on the workforce were complex; they were often positive for emergency department doctors and general practitioners, but less so for nursing staff. The patient-streaming process generated stress and conflict for emergency department nurses and general practitioners. Patients and carers were understanding of general practitioners working in or alongside the emergency department. We found no evidence that staff concerns regarding the potential to create additional demand were justified. Any possible cost savings associated with reduced reattendances were heavily outweighed by the cost of the service.Limitations: The reliability of our data sources varied and we were unable to complete our quantitative analysis entirely as planned. Participation in interviews and at case study sites was voluntary.Conclusions: Service implementation was highly subject to local context and micro-level influences. Key success factors were interprofessional working, staffing and training, streaming, and infrastructure and support.Future work: Further research should study the longer-term effects of these services, clinician attitudes to risk and the implementation of streaming. Additional work should also examine the system effectsof national policy initiatives, develop methodologies to support rapid service evaluation and study the relationship between primary and secondary care.Trial registration: This trial is registered as ISRCTN51780222.Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 30. See the NIHR Journals Library website for further project information