Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development.

BACKGROUND: There is a growing acknowledgement that doctors need to develop leadership and management competences to become more actively involved in the planning, delivery and transformation of patient services. We undertook a systematic review of what is known concerning the knowledge, skills and attitudes of medical students regarding leadership and management. Here we report the results pertaining to the attitudes of students to provide evidence to inform curriculum development in this developing field of medical education. METHODS: We searched major electronic databases and citation indexes within the disciplines of medicine, education, social science and management. We undertook hand searching of major journals, and reference and citation tracking. We accessed websites of UK medical institutions and contacted individuals working within the field. RESULTS: 26 studies were included. Most were conducted in the USA, using mainly quantitative methods. We used inductive analysis of the topics addressed by each study to identity five main content areas: Quality Improvement; Managed Care, Use of Resources and Costs; General Leadership and Management; Role of the Doctor, and Patient Safety. Students have positive attitudes to clinical practice guidelines, quality improvement techniques and multidisciplinary teamwork, but mixed attitudes to managed care, cost containment and medical error. Education interventions had variable effects on students' attitudes. Medical students perceive a need for leadership and management education but identified lack of curriculum time and disinterest in some activities as potential barriers to implementation. CONCLUSIONS: The findings from our review may reflect the relatively little emphasis given to leadership and management in medical curricula. However, students recognise a need to develop leadership and management competences. Although further work needs to be undertaken, using rigorous methods, to identify the most effective and cost-effective curriculum innovations, this review offers the only currently available summary of work examining the attitudes of students to this important area of development for future doctors.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

Stability of empathy among undergraduate medical students: a longitudinal study at one UK medical school.

BACKGROUND: Empathy is important to patient care. The prevailing view is that empathy declines during university medical education. The significance of that decline has been debated.This paper reports the findings in respect of two questions relating to university medical education: 1. Do men and women medical students differ in empathy? 2. Does empathy change amongst men and women over time? METHODS: The medical course at the University of Cambridge comprises two components: Core Science (Years 1-3) and Clinical (Years 4-6). Data were obtained from repeated questionnaire surveys of medical students from each component over a period of four years: 2007-2010. Participation in the study was voluntary.Empathy was measured using two subscales of the Interpersonal Reactivity Index: IRI-EC (affective empathy) and IRI-PT (cognitive empathy). We analysed data separately for men and women from the Core Science and Clinical components. We undertook missing value analyses using logistic regression separately, for each measure of empathy, to examine non-response bias. We used Student's t-tests to examine gender differences and linear mixed effects regression analyses to examine changes over time. To assess the influence of outliers, we repeated the linear mixed effects regression analyses having excluded them. RESULTS: Women displayed statistically significant higher mean scores than men for affective empathy in all 6 years of medical training and for cognitive empathy in 4 out of 6 years - Years 1 and 2 (Core Science component) and Years 4 and 5 (Clinical component).Amongst men, affective empathy declined slightly during both Core Science and Clinical components. Although statistically significant, both of these changes were extremely small. Cognitive empathy was unchanged during either component. Amongst women, neither affective empathy nor cognitive empathy changed during either component of the course.Analysis following removal of outliers showed a statistically significant slight increase in men's cognitive empathy during the Core Science component and slight decline in women's affective empathy during the Clinical component. Again, although statistically significant, these changes were extremely small and do not influence the study's overall conclusions. CONCLUSIONS: Amongst medical students at the University of Cambridge, women are more empathetic than men (a generally observed phenomenon). Men's affective empathy declined slightly across the course overall, whilst women's affective empathy showed no change. Neither men nor women showed any change in cognitive empathy during the course. Although statistically significant, the size of such changes as occurred makes their practical significance questionable. Neither men nor women appear to become meaningfully less empathetic during their medical education at the University of Cambridge.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

Developing a pragmatic medical curriculum for the 21st century.

Medical education within a hospital setting presents both opportunities and challenges. The range of educational experiences on offer is often vast, though may be lost in the overworked and convoluted environment of a tertiary centre. As our learners are increasingly consumed by the literal and figurative labyrinths of hospitals and electronic learning logs, are we failing to train them in the skills they need to deliver 21st century health care? In response to this problem we propose a FARCICAL approach: Fostering A Relevant Curriculum that Is Closer to Actual Life.This is the author accepted manuscript. It is currently under an indefinite embargo pending publication by Wiley

Taking care of our future doctors: a service evaluation of a medical student mental health service

Funder: NIHR ARC East of ENGLANDAbstract: Background: Studies suggest medical students experience high levels of mental distress during training but are less likely, than other students, to access care due to stigma and concerns regarding career progression. In response, The School of Clinical Medicine, University of Cambridge supported the development of the ‘Clinical Student Mental Health Service’ to provide specialist input for this vulnerable group. This study evaluates the efficiency and effectiveness of this service. Methods: Using mixed-methods, cross-sectional analysis of validated psychiatric rating scales and qualitative feedback, 89 responses were analysed from 143 clinical students referred, between 2015 and 2019. The care pathway included initial review by a psychiatrist, who triaged students to psychologists delivering therapies including: Cognitive Behavioural Therapy, Interpersonal Therapy, Eye Movement Desensitization Reprocessing Therapy or Cognitive Analytic Therapy. Efficiency was assessed by waiting times for psychiatry and psychology interventions, and number of sessions. Academic outcomes included school intermission and graduation. Clinical effectiveness was analysed by measuring global distress, depression, anxiety, functioning and suicidal risk. Pre/post intervention changes were captured using t-test and McNemar test with thematic analysis of qualitative feedback. Results: Referral rates increased from 3.93% (22/560) in 2015 to 6.74% (45/668) in 2018. Median waiting times for initial psychiatric assessment and start of therapy was 26 and 33 days, respectively. All graduating students moved on to work as junior doctors. Levels of distress, (t = 7.73, p < 0.001, df = 31), depression (t = 7.26, p < 0.001, df = 34) anxiety (Z = − 4.63, p < 0.001) and suicide risk (Z = − 3.89, p < 0.001) were significantly reduced. Participant’s functioning was significantly improved (p < 0.001, 99.5% CI 4.55 to 14.62). Feedback indicated high satisfaction with the rapid access and flexibility of the service and the team clinicians. Conclusions: A significant proportion of medical students attending the service scored highly on validated rating scales measuring emotional distress, suicidality and mental illness. Reassuringly they benefitted from timely specialist mental health input, showing improvements in mental well-being and improved functioning. The development and design of this service might serve as an exemplar for medical schools developing similar support for their students

Vernalization-Repression of Arabidopsis FLC Requires Promoter Sequences but Not Antisense Transcripts

The repression of Arabidopsis FLC expression by vernalization (extended cold) has become a model for understanding polycomb-associated epigenetic regulation in plants. Antisense and sense non-coding RNAs have been respectively implicated in initiation and maintenance of FLC repression by vernalization. We show that the promoter and first exon of the FLC gene are sufficient to initiate repression during vernalization; this initial repression of FLC does not require antisense transcription. Long-term maintenance of FLC repression requires additional regions of the gene body, including those encoding sense non-coding transcripts

Predictive modeling of indoor dust lead concentrations: Sources, risks, and benefits of intervention

Lead (Pb) contamination continues to contribute to world-wide morbidity in all countries, particularly low- and middle-income countries. Despite its continued widespread adverse effects on global populations, particularly children, accurate prediction of elevated household dust Pb and the potential implications of simple, low-cost household interventions at national and global scales have been lacking. A global dataset (∼40 countries, n = 1951) of community sourced household dust samples were used to predict whether indoor dust was elevated in Pb, expanding on recent work in the United States (U.S.). Binned housing age category alone was a significant (p < 0.01) predictor of elevated dust Pb, but only generated effective predictive accuracy for England and Australia (sensitivity of ∼80%), similar to previous results in the U.S. This likely reflects comparable Pb pollution legacies between these three countries, particularly with residential Pb paint. The heterogeneity associated with Pb pollution at a global scale complicates the predictive accuracy of our model, which is lower for countries outside England, the U.S., and Australia. This is likely due to differing environmental Pb regulations, sources, and the paucity of dust samples available outside of these three countries. In England, the U.S., and Australia, simple, low-cost household intervention strategies such as vacuuming and wet mopping could conservatively save 70 billion USD within a four-year period based on our model. Globally, up to 1.68 trillion USD could be saved with improved predictive modeling and primary intervention to reduce harmful exposure to Pb dust sources

The Baryon Oscillation Spectroscopic Survey of SDSS-III

The Baryon Oscillation Spectroscopic Survey (BOSS) is designed to measure the scale of baryon acoustic oscillations (BAO) in the clustering of matter over a larger volume than the combined efforts of all previous spectroscopic surveys of large scale structure. BOSS uses 1.5 million luminous galaxies as faint as i=19.9 over 10,000 square degrees to measure BAO to redshifts z<0.7. Observations of neutral hydrogen in the Lyman alpha forest in more than 150,000 quasar spectra (g<22) will constrain BAO over the redshift range 2.15<z<3.5. Early results from BOSS include the first detection of the large-scale three-dimensional clustering of the Lyman alpha forest and a strong detection from the Data Release 9 data set of the BAO in the clustering of massive galaxies at an effective redshift z = 0.57. We project that BOSS will yield measurements of the angular diameter distance D_A to an accuracy of 1.0% at redshifts z=0.3 and z=0.57 and measurements of H(z) to 1.8% and 1.7% at the same redshifts. Forecasts for Lyman alpha forest constraints predict a measurement of an overall dilation factor that scales the highly degenerate D_A(z) and H^{-1}(z) parameters to an accuracy of 1.9% at z~2.5 when the survey is complete. Here, we provide an overview of the selection of spectroscopic targets, planning of observations, and analysis of data and data quality of BOSS.Comment: 49 pages, 16 figures, accepted by A

Lithium Decreases Glial Fibrillary Acidic Protein in a Mouse Model of Alexander Disease.

Alexander disease is a fatal neurodegenerative disease caused by mutations in the astrocyte intermediate filament glial fibrillary acidic protein (GFAP). The disease is characterized by elevated levels of GFAP and the formation of protein aggregates, known as Rosenthal fibers, within astrocytes. Lithium has previously been shown to decrease protein aggregates by increasing the autophagy pathway for protein degradation. In addition, lithium has also been reported to decrease activation of the transcription factor STAT3, which is a regulator of GFAP transcription and astrogliogenesis. Here we tested whether lithium treatment would decrease levels of GFAP in a mouse model of Alexander disease. Mice with the Gfap-R236H point mutation were fed lithium food pellets for 4 to 8 weeks. Four weeks of treatment with LiCl at 0.5% in food pellets decreased GFAP protein and transcripts in several brain regions, although with mild side effects and some mortality. Extending the duration of treatment to 8 weeks resulted in higher mortality, and again with a decrease in GFAP in the surviving animals. Indicators of autophagy, such as LC3, were not increased, suggesting that lithium may decrease levels of GFAP through other pathways. Lithium reduced the levels of phosphorylated STAT3, suggesting this as one pathway mediating the effects on GFAP. In conclusion, lithium has the potential to decrease GFAP levels in Alexander disease, but with a narrow therapeutic window separating efficacy and toxicity

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London