Balance or tension? Walking the tightrope between training and patient care

In this commentary, Sholl offers an alterantive metaphor to further the discussion about Cleland et al.'s data regarding service-training tension

Learning and coping through reflection: Exploring patient death experiences of medical students

Background: Existing studies have explored many aspects of medical students’ experiences of patient death and propose the importance of faculty support for coping. However, UK-based literature on this subject and research concerning learning through reflection as part of coping are relatively limited. This study, through the lens of reflection, aims to explore student’s experiences with patient death in a UK context. These include coping strategies, support from faculty following patient death and the relationship between these experiences and learning. Our research questions were: How do medical students cope with and learn from their experiences?How does support from ward staff and the medical school help them cope with and learn from these experiences?How can students best be supported following patient death?”Methods: We employed narrative inquiry to explore how medical students made sense of their experiences of patient death. Twelve students participated in our study via an online narrative questionnaire. Thematic analysis and complementary narrative analysis of an exemplar were applied to address our research aim.Results: Coping strategies comprised internal and external strategies. Internal strategies included (1) re-interpretation of the death into a meaningful experience including lessons learned; (2) normalization; (3) staying busy and (4) enduring negative emotions. External strategies included speaking to someone, which was found to influence normalization, and lessons learned. Both satisfactory and unsatisfactory support from ward staff was identified. Satisfactory support was characterized by the inclusion of emotional and professional support. Unsatisfactory support was often characterized by a lack of emotional support. Narrative analysis further demonstrated how the experience with patient death was re-interpreted meaningfully. Students suggested that support should be structured, active, sensitive, and include peers and near-peers.Conclusion: Many coping strategies, internal and external, were employed in students’ experiences with patient death. Student reflections, enhanced by support from ward staff, were shown to be important for learning from patient death. We encourage faculty to have regular sessions in which medical students can reflect on the death incident and discuss appropriately with others, including peers and near-peers

Understanding the healthcare workplace learning culture through safety and dignity narratives: a UK qualitative study of multiple stakeholders’ perspectives

Objectives: While studies at the undergraduate level have begun to explore healthcare students’ safety and dignity dilemmas, none have explored such dilemmas with multiple stakeholders at the postgraduate level. The current study therefore explores the patient and staff safety and dignity narratives of multiple stakeholders to better understand the healthcare workplace learning culture. Design: A qualitative interview study using narrative interviewing.Setting: Two sites in the UK ranked near the top and bottom for raising concerns according to the 2013 General Medical Council National Training Survey.Participants: Using maximum variation sampling, 39 participants were recruited representing 4 different groups (10 public representatives, 10 medical trainees, 8 medical trainers, and 11 nurses and allied health professionals) across the two sites. Methods: We conducted one group and 35 individual semi-structured interviews. Data collection was completed in 2015. Framework analysis was conducted to identify themes. Theme similarities and differences across the two sites and four groups were established. Results: We identified five themes in relation to our three research questions: (1) Understandings of safety and dignity (RQ1); (2) Experiences of safety and dignity dilemmas (RQ2); (3) resistance and/or complicity regarding dilemmas encountered (RQ2); (4) Factors facilitating safety and/or dignity (RQ3); and (5) Factors inhibiting safety and/or dignity (RQ3). The themes were remarkably similar across the two sites and four stakeholder groups. Conclusions: While some of our findings are similar to previous research with undergraduate healthcare students, our findings also differ, for example, illustrating higher levels of reported resistance in the postgraduate context. We provide educational implications to uphold safety and dignity at the level of the individual (e.g. stakeholder education), interaction (e.g. stakeholder communication and teamwork) and organisation (e.g. institutional policy)

Balancing health care education and patient care in the UK workplace: a realist synthesis

Introduction: Patient care activity has recently increased without a proportionate rise in workforce numbers, impacting negatively on healthcare workplace learning. Healthcare professionals are prepared in part by spending time in clinical practice, and for medical staff this constitutes a contribution to service. While stakeholders have identified the balance between healthcare professional education and patient care as a key priority for medical education research, there have been very few reviews to date on this important topic.Methods: We conducted a realist synthesis of the UK literature from 1998 to answer two research questions: (1) What are the key workplace interventions designed to help achieve a balance between healthcare professional education and patient care delivery? (2) In what ways do interventions enable or inhibit this balance within thehealthcare workplace, for whom and in what contexts? We followed Pawson's five stages of realist review: clarifying scope, searching for evidence, assessment of quality, data extraction, and data synthesis.Results: The most common interventions identified to balance healthcare professional education and patient care delivery were ward round teaching, protected learning time and continuous professional development. The most common positive outcomes were simultaneous improvements in learning and patient care or improved learning or improved patient care. The most common contexts in which interventions were effective were primary care, postgraduate trainee, nurse, and allied health professional contexts. By far the most common mechanisms through which interventions worked were organisational funding, workload management and support.Discussion: Our novel findings extend existing literature in this emerging area of healthcare education research. We provide recommendations for the development of educational policy and practice at the individual, interpersonal and organisational levels and call for more research using realist approaches to evaluate the increasing range of complex interventions to help balance healthcare professional education and patient care delivery

Validation of a 40-Gene Expression Profile Test to Predict Metastatic Risk in Localized High-Risk Cutaneous Squamous Cell Carcinoma

Background: Current staging systems for cutaneous squamous cell carcinoma (cSCC) have limited positive predictive value (PPV) for identifying patients who will experience metastasis. Objective: To develop and validate a gene expression profile (GEP) test for predicting risk for metastasis in localized, high-risk cSCC with the goal of improving risk-directed patient management. Methods: Archival formalin-fixed paraffin-embedded primary cSCC tissue and clinicopathologic data (n=586) were collected from 23 independent centers in a prospectively designed study. A GEP signature was developed using a discovery cohort (n=202) and validated in a separate, non-overlaping, independent cohort (n=324). Results: A prognostic, 40-gene expression profile (40-GEP) test was developed and validated, stratifying high-risk cSCC patients into classes based on metastasis risk: Class 1 (low-risk), Class 2A (high-risk), and Class 2B (highest-risk). For the validation cohort, 3-year metastasis-free survival (MFS) rates were 91.4%, 80.6%, and 44.0%, respectively. A PPV of 60% was achieved for the highest-risk group (Class 2B), an improvement over staging systems; while negative predictive value, sensitivity, and specificity were comparable to staging systems. Limitations: Potential understaging of cases could affect metastasis rate accuracy.Conclusion: The 40-GEP test is an independent predictor of metastatic risk that can complement current staging systems for patients with high-risk cSCC

Mechanosensing is critical for axon growth in the developing brain.

During nervous system development, neurons extend axons along well-defined pathways. The current understanding of axon pathfinding is based mainly on chemical signaling. However, growing neurons interact not only chemically but also mechanically with their environment. Here we identify mechanical signals as important regulators of axon pathfinding. In vitro, substrate stiffness determined growth patterns of Xenopus retinal ganglion cell axons. In vivo atomic force microscopy revealed a noticeable pattern of stiffness gradients in the embryonic brain. Retinal ganglion cell axons grew toward softer tissue, which was reproduced in vitro in the absence of chemical gradients. To test the importance of mechanical signals for axon growth in vivo, we altered brain stiffness, blocked mechanotransduction pharmacologically and knocked down the mechanosensitive ion channel piezo1. All treatments resulted in aberrant axonal growth and pathfinding errors, suggesting that local tissue stiffness, read out by mechanosensitive ion channels, is critically involved in instructing neuronal growth in vivo.This work was supported by the German National Academic Foundation (scholarship to D.E.K.), Wellcome Trust and Cambridge Trusts (scholarships to A.J.T.), Winston Churchill Foundation of the United States (scholarship to S.K.F.), Herchel Smith Foundation (Research Studentship to S.K.F.), CNPq 307333/2013-2 (L.d.F.C.), NAP-PRP-USP and FAPESP 11/50761-2 (L.d.F.C.), UK EPSRC BT grant (J.G.), Wellcome Trust WT085314 and the European Research Council 322817 grants (C.E.H.); an Alexander von Humboldt Foundation Feodor Lynen Fellowship (K.F.), UK BBSRC grant BB/M021394/1 (K.F.), the Human Frontier Science Program Young Investigator Grant RGY0074/2013 (K.F.), the UK Medical Research Council Career Development Award G1100312/1 (K.F.) and the Eunice Kennedy Shriver National Institute Of Child Health & Human Development of the National Institutes of Health under Award Number R21HD080585 (K.F.).This is the author accepted manuscript. The final version is available from Nature Publishing Group via https://doi.org/10.1038/nn.439

Clinical Sequencing Exploratory Research Consortium: Accelerating Evidence-Based Practice of Genomic Medicine

Despite rapid technical progress and demonstrable effectiveness for some types of diagnosis and therapy, much remains to be learned about clinical genome and exome sequencing (CGES) and its role within the practice of medicine. The Clinical Sequencing Exploratory Research (CSER) consortium includes 18 extramural research projects, one National Human Genome Research Institute (NHGRI) intramural project, and a coordinating center funded by the NHGRI and National Cancer Institute. The consortium is exploring analytic and clinical validity and utility, as well as the ethical, legal, and social implications of sequencing via multidisciplinary approaches; it has thus far recruited 5,577 participants across a spectrum of symptomatic and healthy children and adults by utilizing both germline and cancer sequencing. The CSER consortium is analyzing data and creating publically available procedures and tools related to participant preferences and consent, variant classification, disclosure and management of primary and secondary findings, health outcomes, and integration with electronic health records. Future research directions will refine measures of clinical utility of CGES in both germline and somatic testing, evaluate the use of CGES for screening in healthy individuals, explore the penetrance of pathogenic variants through extensive phenotyping, reduce discordances in public databases of genes and variants, examine social and ethnic disparities in the provision of genomics services, explore regulatory issues, and estimate the value and downstream costs of sequencing. The CSER consortium has established a shared community of research sites by using diverse approaches to pursue the evidence-based development of best practices in genomic medicine

The investigation of the relationship of familial factors in ear prints and photographs for the purposes of human identification

SIGLEAvailable from British Library Document Supply Centre- DSC:DXN063205 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Injustice: News You Don\u27t See on the News

2003/05/01. A focus on international injustice, Christian faith, and what Christians can do to help. Panel includes an SPU student leader and leaders within the international justice community