BACKGROUND:Depression severity is a well-established risk factor for suicidal ideation, but the extent to which sociodemographic and employment-related factors contribute independently remains unclear. AIMS:Complete data from doctors (N = 4055) presenting to National Health Service Practitioner Health (NHS-PH) in 2022-2023 were used to test the hypothesis that depression severity is the largest determinant of suicide ideation risk (defined by Patient Health Questionnaire 9 (PHQ-9) question 9 score) among doctors. METHOD:Using PHQ-8 score (PHQ-9, excluding the item on suicide ideation) as a proxy for depression severity, the case-control discriminatory capacity of receiver operating characteristic curves (AUCs) were evaluated for (a) a univariable model studying modified PHQ-9 alone as the predictor of severe suicide ideation; and (b) a multivariable model integrating modified PHQ-9 and multiple sociodemographic and employment factors as the predictor of severe suicide ideation. Models were compared both descriptively and through a likelihood ratio test. RESULTS:The univariable model using depression severity alone as the predictor of severe suicide ideation yielded an AUC of 0.921. The addition of sociodemographic and employment factors improved the fit significantly (likelihood ratio test with (χ2(14) = 50.26, P < 0.001), amended AUC 0.930). Having both a disability and a relationship status of 'no partner' was significantly independently associated with suicide ideation in the multivariable model. CONCLUSIONS:In this national cohort of doctors, depression severity was strongly associated with suicidal ideation. However, disability and lack of a partner were also independently linked to increased risk, suggesting that suicidal ideation is not solely driven by symptom severity. Social and functional factors may help identify higher-risk individuals and inform targeted support.

OBJECTIVES:The London School of Paediatrics (LSP) surveys trainees annually regarding their training placements. There is a wide variation in satisfaction. We explored the last 5 years of data to identify trends and determine predictors of overall trainee satisfaction. METHODS:The survey is distributed annually to all London paediatric trainees with response rates of 86-90%. It explores overall placement satisfaction, followed by key questions covering staffing, supervision, teaching, facilities and other facets. The survey blends both quantitative and qualitative feedback.Satisfaction levels were analysed using time series trend analysis. Overall levels were compared using t-tests. Associations between satisfaction and components of the survey were identified using a convergence of multiple regression and other multivariate analyses. RESULTS:Overall trainee satisfaction increased steadily until 2020. There was a considerable variation across sites, some having consistently higher or lower scores than the median, while others showed an upward or downward trend, or very variable pattern.By training levels, ST3 trainees consistently rated their placement below average and ST7 trainees above average. There was also a considerable variation in responses by training level with regard to perceived staffing levels and teaching.To understand the influences on overall satisfaction, regression coefficients were derived between specific metrics and overall satisfaction using multiple regression and then normalised to 100%. The explanatory power of this list to explain satisfaction overall is high at 82% R2.Trainee satisfaction was most strongly correlated with workplace atmosphere and consultant support. Staffing, educational supervision, facilities and wider MDT (Multidisciplinary Team) support are associated with overall satisfaction, but to a lesser degree. CONCLUSIONS:Trainee satisfaction is crucial, affecting patient safety, retention and trainee mental health. Our analysis identified significant associations with satisfaction including modifiable elements such as consultant engagement and team morale. Staffing levels were less related to satisfaction than expected.Experimental data exploring the components of clinical training in real-world situations are lacking. These data use the natural experiment of placing trainees in different training locations to explore the factors that relate to their overall experience.

Objectives The London School of Paediatrics (LSP) surveys trainees regarding their placements and there is wide variation in satisfaction. We explored the last five years of data to identify predictors of overall trainee satisfaction. Methods The survey is distributed annually to London paediatric trainees (approx. 1200) with response rates of 88–90%. It explores overall placement satisfaction, followed by key questions covering staffing, supervision, teaching, facilities and other facets. The survey blends both quantitative and qualitative (free text) feedback. Satisfaction levels were analysed using time series trend analysis. Overall levels were compared using t-test. Associations between satisfaction and components of the survey were identified using a convergence of multiple regression and other multivariate analyses. Results Overall trainee satisfaction increased steadily until 2020 (figure 1). There was considerable variation across sites, some having consistently higher or lower scores than the median while others showed an upward or downward trend or very variable pattern. By training levels, in the past 2 years. ST1 trainees and ST5 were least satisfied overall, recording 68% and 67% good or excellent ratings respectively (2022). Conversely 94% of ST6 trainees rated placements good or excellent. To understand the influences on overall satisfaction, regression coefficients were derived between specific metrics vs overall satisfaction using multiple regression and then normalised to 100% (figure 2). The explanatory power of this list to explain satisfaction overall is high at 82% R2. Trainee satisfaction was most strongly correlated with workplace atmosphere and consultant support. Staffing, educational supervision, facilities and wider MDT support are associated with overall satisfaction, but to a lesser degree. Conclusion Trainee satisfaction is crucial, affecting patient safety,1 retention,2 and trainee mental health. Our analysis identified significant associations with satisfaction including modifiable elements such as consultant engagement and team morale. Staffing levels were less related to satisfaction. Experimental data exploring the components of clinical training in real world situations is lacking. This data uses the natural experiment of placing trainees in different training locations to explore the factors that relate to their overall experience. We have analysed trainee opinion rather than actual measurements of training (skillset or performance of trainees). Our findings do not indicate causality. This analysis highlights that when parameters such as staffing or workload are challenging, focusing on workplace environment and consultant support is likely to still improve overall satisfaction. The variation between placement and peer comparison and learning has been seen to be highly motivational in supporting this change. References Barton, et al. Hospital mortality and trainee experiences: how general medical council survey findings correlate with summary hospital-level mortality indicator. J Patient Saf. 2023 Mar 1;19(2):79–85. Bimpong KAA, et al. Relationship between labour force satisfaction, wages and retention within the uk national health service: a systematic review of the literature. BMJ Open 2020; 10:e034919. doi: 10.1136/bmjopen-2019-034919

BACKGROUND:We sought to explore associations between trainee doctor perception and excess patient mortality.METHODS:Data from two publicly available databases reflecting mortality and components of trainee satisfaction within 81 NHS healthcare institutions between the years 2012 and 2019 were analysed. Pearson's correlation coefficients were calculated.RESULTS:All domains of trainee perception were correlated with excess mortality. Clinical supervision out of hours (R=-0.44; p<0.0001), teamwork (R=-0.36; p<0.0001) and clinical supervision at any time (R=-0.35; p<0.0001) were most strongly correlated. Most associations remained consistent year on year.CONCLUSION:Trainee doctor perceptions of clinical supervision, rota design and teamwork within the NHS are consistently correlated with excess patient mortality. Further exploration of these associations could identify opportunities for interventions to reduce excess patient mortality. Given the clinical significance of our findings, organisations should consider rapid implementation of evidence-based interventions where they exist.

ObjectivesThis study aimed to investigate whether components of junior doctor satisfaction are associated with patient mortality within the United Kingdom.MethodsWe conducted a cross-sectional study of publicly available data (the General Medical Council [GMC] National Survey and the Summary Hospital-level Mortality Indicator [SHMI]) pertaining to subjective physician trainee satisfaction and patient mortality within 80 United Kingdom-based healthcare institutions. The direction and strength of correlation between components of the GMC National Survey and relative patient mortality as described by the SHMI were calculated. Additional outcomes included mean GMC survey scores for reported domains and mean SHMI by healthcare institution.ResultsSHMI for included healthcare institutions ranged from 0.69 to 1.21 (mean [SD], 1.01 [0.1]). Mean GMC domain scores ranged between 44.61 and 88.62 (mean [SD], 71.16 [10.84]). Statistically significant correlations were observed for clinical supervision, clinical supervision out of hours, rota design, overall satisfaction, and teamwork. After application of Bonferroni correction, statistically significant correlations remained for both clinical supervision and clinical supervision out of hours.ConclusionsThere is a significant association between components of subjective trainee satisfaction and patient mortality within the United Kingdom. Further investigation to examine these relationships, perhaps to target intervention, may prevent avoidable patient harm.

ABSTRACT Background Shielding during the COVID-19 pandemic impacted postgraduate medical training, likely affecting between 7% and 14% of trainees. We examine the burden of shielding on this cohort and provide strategies for future working practices. Methods Seventeen postgraduate doctors in training took part in non-incentivised, virtual focus groups or interviews. Focus group content underwent thematic analysis. Results were validated in subsequent focused interviews. Results Shielding trainees reported guilt, limited support and occasionally stigmatisation. Rotational changes and returning to work were also difficult and led to contractual challenges. Departmental support, IT provision and proactivity were key to successful shielding. Early discussion with training bodies was deemed essential to plan objective onward progression. Conclusion As we enter an era of endemic COVID-19, adjusted working practices will continue. Embedding successful working practices for shielding at national and local levels will minimise the long-term impact on postgraduate medical training.

The Clinical TeacherVolume 18, Issue 5 p. 487-489 INSIGHTS Author gender bias in paediatric journals and FOAM Antonia Round, Corresponding Author Antonia Round [email protected] orcid.org/0000-0003-0204-9329 Leicester Medical School, University of Leicester, Leicester, UK Correspondence Antonia Round, Leicester Medical School, University of Leicester, Lancaster Rd, Leicester LE1 7HA. Email: [email protected]Search for more papers by this authorJack Barton, Jack Barton orcid.org/0000-0002-7376-4197 St George’s, University of London, London, UKSearch for more papers by this authorAshvin Kuri, Ashvin Kuri orcid.org/0000-0003-0125-4806 Barts and The London School of Medicine and Dentistry, London, UKSearch for more papers by this authorTien Tran, Tien Tran orcid.org/0000-0002-6601-3299 St George’s, University of London, London, UKSearch for more papers by this authorJonathan Round, Jonathan Round orcid.org/0000-0002-7404-2006 St George’s, University of London, London, UKSearch for more papers by this authorKatie Knight, Katie Knight orcid.org/0000-0001-9277-4916 North Middlesex Hospital, London, UKSearch for more papers by this author Antonia Round, Corresponding Author Antonia Round [email protected] orcid.org/0000-0003-0204-9329 Leicester Medical School, University of Leicester, Leicester, UK Correspondence Antonia Round, Leicester Medical School, University of Leicester, Lancaster Rd, Leicester LE1 7HA. Email: [email protected]Search for more papers by this authorJack Barton, Jack Barton orcid.org/0000-0002-7376-4197 St George’s, University of London, London, UKSearch for more papers by this authorAshvin Kuri, Ashvin Kuri orcid.org/0000-0003-0125-4806 Barts and The London School of Medicine and Dentistry, London, UKSearch for more papers by this authorTien Tran, Tien Tran orcid.org/0000-0002-6601-3299 St George’s, University of London, London, UKSearch for more papers by this authorJonathan Round, Jonathan Round orcid.org/0000-0002-7404-2006 St George’s, University of London, London, UKSearch for more papers by this authorKatie Knight, Katie Knight orcid.org/0000-0001-9277-4916 North Middlesex Hospital, London, UKSearch for more papers by this author First published: 06 May 2021 https://doi.org/10.1111/tct.13365Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume18, Issue5October 2021Pages 487-489 RelatedInformation

Purpose Self-directed learning (SDL) has been increasingly emphasized within medical education. However, little is known about the SDL resources medical students use. This study aimed to identify patterns in medical students’ SDL behaviors, their SDL resource choices, factors motivating these choices, and the potential impact of the coronavirus disease 2019 (COVID-19) pandemic on these variables. Methods An online cross-sectional survey comprising multiple-choice, ranked, and free-text response questions were disseminated to medical students across all 41 UK medical schools between April and July 2020. Independent study hours and sources of study materials prior to and during the COVID-19 pandemic were compared. Motivational factors guiding resource choices and awareness of Free Open Access Meducation were also investigated. Results The target sample was 75 students per medical school across a total of 41 medical schools within the United Kingdom (3,075 total students), and 1,564 responses were analyzed. University-provided information comprised the most commonly used component of independent study time, but a minority of total independent study time. Independent study time increased as a result of the COVID-19 pandemic (P<0.001). All sub-cohorts except males reported a significant increase in the use of resources such as free websites and question banks (P<0.05) and paid websites (P<0.05) as a result of the pandemic. Accessibility was the most influential factor guiding resource choice (Friedman’s μrank=3.97, P<0.001). Conclusion The use of learning resources independent of university provision is increasing. Educators must ensure equitable access to such materials while supporting students in making informed choices regarding their independent study behaviors.

Introduction Free Open Access Meducation (FOAM) describes online resources assisting learning in medicine. Little is known about users or their behaviours. Methods Using Google Analytics for a popular FOAM site (www.paedatricfoam.com), we explored user demographics and patterns of behaviour. We analysed these further with descriptive and statistical tests using SPSS (version 26). Data are presented as mean (SD). Results There were 181.44 (75.16) mean daily users accessing the site throughout a 4-month period during 2018/2019. 68.9% of users were female; 44% were 25–34 years; 57.3% used a mobile device. The mean session duration was 73.55 (9.41) seconds, with more time spent per session and a greater number of pages per session observed in users accessing the site from a desktop or tablet as opposed to a mobile phone. 84.3% of mobile users left the site after viewing a single page. Referral source was also associated with device used (p<0.001). Age was not related to user behaviours (p>0.05). Discussion FOAM is a rapidly developing form of medical education, with large user numbers seen for a site just 2 years old. The site is being used by many beyond its intended readership. Rather than accessing multiple pages from a desktop, users have varied online behaviours, with the majority viewing a single page on a mobile phone, referred by social media or Google. Conclusions Google Analytics can powerfully display usage of medical websites but has important limitations if statistical exploration is required. FOAM users are a heterogenous group, and thus content should be designed with this in mind. Further research must be prioritised focussing on the scope, curriculum coverage, accuracy of information and the effectiveness of FOAM as an educational resource.

Dear Editor We read with great interest ‘Training disrupted: Practical tips for supporting competency-based medical education during the COVID-19 pandemic’ (Hall et al. 2020). We believe that the t...

ABSTRACT The General Medical Council (GMC) national trainee survey (NTS) monitors junior doctor training experience annually, which is then used by organisations such as Health Education England to inform quality management. Its validity as an assessment of the learning environment to drive improvement is frequently questioned; currently there are no published evidence-based studies to demonstrate its impact. To explore the effects of the GMC survey, we carried out a retrospective cohort study using publicly available GMC NTS survey data. We compared 2018 and 2019 scores in paediatrics in London across all 18 survey indicators, to identify any relationship between these 2 consecutive years of data. Our findings demonstrate that results of the GMC NTS in 1 year are associated with a change in the NTS the following year, with both an improvement in below average departments and deterioration in above average units. These findings suggest that annual GMC NTS results may have an impact on the quality of learning environments as measured in subsequent surveys – therefore they act as both a measure and a potential modifier of outcome.

Introduction/Aims Free Open Access Meducation (FOAM) is a movement built around freely available (mostly online) medical education resources. Over the past decade its popularity has increased exponentially, to begin with primarily in critical care and emergency medicine, but more recently in paediatrics. However, little is known about FOAM users or their behaviours. This study aimed to investigate the user behaviours of one of the most popular paediatric FOAM websites. Methods Using Google analytics for the website we explored user demographics and their patterns of behaviour. Descriptive statistics were used to identify early trends and highlight areas of potential future research. Results 5,583 sessions were logged over four months in 2018/19. Users came from 146 countries, although the site is primarily written and promoted in the UK. 68.9% of users were female; most were 25–34 years; 57.3% used a mobile device, the remainder using desktop and tablet devices. Those using mobile devices spent less time using the website and were less likely to access the website via the homepage, instead landing on an article directed by an internet search. Fewer sessions were logged during the weekends than on weekdays. Discussion FOAM is a rapidly developing form of medical education, demonstrated by large user numbers accessing this site which is just 2 years old. The site is being used by many beyond its intended readership and primarily being accessed from search engines. The behaviours of users suggest potential motivating factors for use, such as the need for timely, succinct information. Google Analytics has the ability to provide rich and meaningful data. To date, the understanding of FOAM as a learning aid has not kept pace with its increasing popularity, we hope that this study encourages others to share their readily available data and contribute to our understanding. Conclusions Google analytics can powerfully explore FOAM usage. Site curators should develop materials suitable for mobile or desktop usage, mindful also that their readership may well not be healthcare professionals. Given its popularity, further evaluation of user motivations and the effectiveness of FOAM should be prioritised.

ObjectivesMedical error is a significant cause of patient harms in clinical practice, but education and training are recognised as having a key role in minimising their incidence. The use of virtual patient (VP) activities targeting training in medical error allows learners to practice patient management in a safe environment. The inclusion of branched decision-making elements in the activities has the potential to drive additional generative cognitive processing and improved learning outcomes, but the increased cognitive load on learning risks negatively affecting learner motivation. The aim of this study is to better understand the impact that the inclusion of decision-making and inducing errors within the VP activities has on learner motivation.MethodsUsing a repeated study design, over a period of six weeks we provided undergraduate medical students at six institutions in three countries with a series of six VPs written around errors in paediatric practice. Participants were divided into two groups and received either linearly structured VPs or ones that incorporated branched decision-making elements. Having completed all the VPs, each participant was asked to complete a survey designed to assess their motivation and learning strategies.ResultsOur analysis showed that in general, there was no significant difference in learner motivation between those receiving the linear VPs and those who received branched decision-making VPs. The same results were generally reflected across all six institutions.ConclusionsThe findings demonstrated that the inclusion of decision-making elements did not make a significant difference to undergraduate medical students' motivation, perceived self-efficacy or adopted learning strategies. The length of the intervention was sufficient for learners to overcome any increased cognitive load associated with branched decision-making elements being included in VPs. Further work is required to establish any immediate impact within periods shorter than the length of our study or upon achieved learning outcomes.

Aims Acute leukaemia presenting with hyperleukocytosis (white cell count (WCC) >50×109/L) is associated with organ dysfunction due to hyperviscosity. However, there is little evidence to guide which children are at highest risk and who might benefit from aggressive leukoreduction, including leukapheresis. We explored whether it is possible to risk stratify children based on initial WCC and evaluated the role of leukapheresis in preventing complications of hyperleukocytosis. Methods A retrospective analysis of all children with ALL or AML who were admitted to our tertiary paediatric oncology and critical care centre with an initial WCC >50×109/L, 2007–2017. Results 37 patients were identified (ALL: 28; AML: 9). Median age 6 years, 54% were male. All patients were treated with immediate hyperhydration and chemotherapy within 48 hours. 5 patients were treated with leukapheresis. 11 children (30%) developed complications (21% of ALL; 55% of AML): 27% respiratory, 14% neurological and 8% renal. Children who presented with hyperleukocytic complications tended to have a higher initial WCC than those without complications at presentation (Median: 332 vs. 175 × 109/L). The initial WCC of children who developed complications later in their admission did not differ from the WCC of those without complications (Median: 161 vs. 175 × 109/L), suggesting that later complications cannot be related to WCC at presentation. Severe events (stroke or early mortality) occurred in 4 children (11%). All 4 had complications at presentation and 3 were treated with leukapheresis. Conclusions Several findings may be useful for risk stratification: Complications are more likely in AML than in ALL Complications did not occur with WCC <100 x109/L Severe events occurred only in children with complications at presentation – those who present without complications appear to be low risk for the most dangerous events regardless of their initial WCC. 4 children with complications on admission were treated with leukapheresis yet all 4 developed further complications including 3 severe events. Therefore, leukapheresis did not help to avoid further complications. Early chemotherapy thus remains the most important aspect of clinical management and further research into the prevention of severe events is required.

Dear EditorWe have read with interest the article “Social-media-enabled learning in emergency medicine: a case study of the growth, engagement, and impact of a free open access medical education bl...

Aims Typical primary care practice is to refer all children with persistent heart murmurs for further assessment. Although most of these murmurs are benign, those with serious underlying pathology are at risk of having their care delayed because of the number of patients referred. This practise may also lead to unnecessary anxiety for parents and patients. We sought to analyse GP referral letters to establish if patients at risk of structural disease could be identified to enable them to be seen sooner. Method GP referral letters to a tertiary hospital paediatric cardiology clinic requesting evaluation of a murmur of a tertiary hospital in the period from January 2016 to May 2017 (n=90) were identified. They were analysed for features suggestive of significance of the murmur. These were then compared to the echocardiography findings in the subsequent clinic letter. Results Of the letters analysed, 10% of patients had underlying structural abnormalities. 5/90 referrals (5.5%) specified a grade of murmur, and 31/90 (34%) specified a location of the murmur. 23/90 (25.5%) referrals mentioned the presence or absence of associated features. No characteristics of the murmur were associated with the presence of a structural cause. Conclusion This study demonstrates that it is currently impossible to prioritise patients based on information provided in GP referral letters. This suggests either provision of cardiology screening outpatient clinics should be increased, or more attention paid to learning about children’s heart disease in undergraduate and GP curricula. Referral using a specific form may also prompt referrers to seek specific findings and improve triage.

Vocal cord palsy (VCP) is a rare but potentially life-threatening complication in children with cancer. This study reviews UK Intensive Care admissions for children with cancer and VCP using data obtained from the Pediatric Intensive Care Audit Network (PICANet) database. 26 children with cancer and VCP were admitted to intensive care from 2002 to 2012. The majority of admissions (23/26) required respiratory intervention (17 invasive ventilation, 8 noninvasive ventilation, and 5 tracheostomy). VCP should be considered early in children with cancer who present with signs of upper airway obstruction, especially in those receiving vinca-alkaloids as VCP is likely to be reversible.