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Promoting reflection on experience and developing students' reflective skills is an important element of curricula across the health professions. Students often do not find reflection easy and educators use a range of approaches to facilitate this. This qualitative study analysed final year medical students' written reflections about important and difficult concepts they had encountered at medical school and personal change. As part of this, students were expected to look back on their written reflections from earlier years of the undergraduate programme. An initial analysis identified 'learning from past reflections' as an important theme. Here we report an in-depth analysis of this theme. Thirty-six final year volunteer students' reflections were analysed and 6 themes identified where students explicitly referred to earlier written reflections. These were: managing emotions; holistic, patient-centred care; uncertainty and ambiguity; self-regulation; growth in identity and sense of self efficacy; and reflective practice changes. Asking students to reflect on past reflections appeared to help students identify personal change, and how their understanding of 'important concepts' and their views and approach to reflective practice have developed. Experienced by students as a motivating, profound, sometimes cathartic process, this activity could be a useful addition to reflective writing training in health professions. [ABSTRACT FROM AUTHOR]

Integrated Training Posts (ITPs) were conceived in the 1990s and have recently increased in the Southwest of England. Most ITP evaluations have been small and undertaken over 13 years ago, so do not reflect the current training landscape. This qualitative study aimed to explore the views and experiences of ITPs amongst general practice trainees and educators. The location has increasing numbers of general practice trainees, International Medical Graduates (IMGs) and less-than-full-time trainees. Semi-structured interviews were undertaken with six trainees and two educators; all had experienced at least one ITP. Recordings were transcribed verbatim and coded. Thematic analysis was undertaken. Three themes were identified: 'The role: expectations versus reality', 'Relevance of ITPs to future GP role' and 'Educational Challenges'. Most trainees valued the additional clinical experiences ITPs offered, as well as being able to trial 'portfolio' working. Trainee and educator expectations varied considerably, particularly whether the role was primarily service or observational. Working across multiple settings could limit contact between educator and trainee and make it difficult to identify a struggling trainee. There is a need to clarify the roles of trainees and educators involved in ITPs and whether and how this might vary between posts. Further studies could explore whether choice of ITP influences retention of general practitioners, and whether all trainees including those working less-than-full-time or IMGs benefit from ITPs. [ABSTRACT FROM AUTHOR]

UK general practitioner (GP) trainees are taught a consultation model which elicits the patients' main reason for consulting 'today'. This approach will often miss important issues for the increasing number of patients with multimorbidity. We developed the SHERPA model as a person-centred biopsychosocial framework for consulting patients with multimorbidity to address this. We aimed to examine GPs trainees' responses to SHERPA when integrated into their vocational training. The research design was qualitative and participants were GPs trainees in vocational training from one UK training location. GP trainees were introduced to the SHERPA model through interactive workshops. Qualitative data were collected from 16 participants, through four hours of teaching observation, 24 feedback templates, six practical applications of SHERPA and eight one-to-one interviews. Data were transcribed, and, using the Framework approach, systematically analysed, focussing on trainees' learning and application of the model. The results demonstrated that all participants engaged well with the teaching sessions, brought observations from their own experience, and reflected on particularly complex consultations. Half of the participants applied SHERPA successfully with their patients, particularly repeat attenders. Barriers to this approach were: selecting appropriate patients; perceived time pressure; lack of familiarity using the model; viewing SHERPA as 'additional', rather than integral, to shared decision-making in complex situations. The SHERPA model was viewed as helpful by these GP trainees for patients with whom they had established a relationship. Earlier introduction and regular support from trainers, where trainees reflect on experience of SHERPA, could increase confidence in using this method. [ABSTRACT FROM AUTHOR]

Undergraduate education often leaves future healthcare professionals insufficiently prepared for the complex and unpredictable workplace. Competency-based medical education (CBME) is widely utilised in health professions' education, but a growing literature highlights its limitations. Capability is a complex concept which builds on competence, while embedding the integration and adaptation of knowledge, skills and personal qualities. While capability can prepare learners for uncertainty and complexity, the concept has been slow to progress within health professions' education. We introduced the concept of capability to over 110 international health profession educators through six conference workshops, using a visual model to facilitate understanding. Participants' post-workshop qualitative feedback was collated and thematically analysed. One hundred and thirty-three free text comments were received and four main themes identified: conceptualising capability, capability as curriculum goal, educating for capability, challenges to implementation. The need for capability resonated with participants, although most were unfamiliar with the concept prior to the workshop. The workshop enabled participants to recognise the limitations of CBME's 'tick box' culture when preparing learners to address complexity. The model helped educators grasp the concept of capability and its potential value in health professions' education. Participants were then able to identify challenges and suggest approaches for implementing capability in practice. Educating for capability is fundamental for preparing students successfully for the 'real world' of professional practice. Most participants agreed it should be the end goal of healthcare education curricula. Healthcare educators are likely, however, to need support to embrace this paradigm shift. [ABSTRACT FROM AUTHOR]

SUMMARY: Background: Shared decision making (SDM), whereby patients and clinicians work collaboratively to make health care decisions, brings multiple benefits. It has, however, been slow to integrate into clinical practice. There are some examples of SDM being embedded and evaluated within medical undergraduate curricula but, despite role models being important in promoting students' patient‐centred attitudes, these examples do not involve students reflecting on clinicians' use of SDM in practice. Methods: We undertook a qualitative evaluation of a small group educational intervention. A key element was the students' use of a structured reflective template, drawing on the SHARE (seek, help, assess, reach, evaluate) SDM tool, to analyse examples of clinicians using SDM in practice critically. We undertook a thematic analysis of students' completed templates and evaluated their engagement with the SHARE tool. Findings: A total of 44 templates were analysed. Four main themes were identified, including new learning about SDM, noticing and deconstructing SDM, participants' responses to SDM and struggles in learning. Students were positive about SHARE and used it to critique experiences and suggest specific ways that clinicians could have improved SDM. Discussion: A structured training intervention that promotes critical reflection on clinical role models can help to shift undergraduate medical students' understanding of, and attitudes towards, SDM. The ethical arguments for SDM, evidence for its benefits and the alignment of SDM with participants' own core values appeared to help achieve student 'buy in'. Students struggled with notions of power, risk and time constraints, and empathised with both patients and clinicians. They highlighted the scarcity of SDM in practice. [ABSTRACT FROM AUTHOR]

While undergraduate curricula should reflect populations' priority health needs and promote social accountability, evidence about the impact of such interventions is limited. To gain insights into students' lived experiences of social engagement pathways and associated learning. Medical and dental students spent four days with local organisations working with disadvantaged groups, recording audio-dairies after each session. These were transcribed, coded and analysed thematically. Fourteen students produced 50 audio-reflections. Key themes included emotions, learning and critical reflection. Students reported improved communication skills, better appreciation of others' lives and having their assumptions challenged. They questioned issues underpinning inequalities. Analysis revealed a three-act pathway structure, with students' emotional responses changing as projects progressed. Immersion in new contexts; connecting with others; having their views challenged and plans going wrong appeared to facilitate shifts in thinking, as did experiencing negative emotions. Feedback and support from organisations, facilitators and service users helped students overcome challenges, which was associated with positive emotion. Educators often work hard to make learning 'easier' for students. This study suggests that when exploring the social determinants of health within community settings, supporting students to experience such unsettling contexts and negative emotions may facilitate transformative learning. [ABSTRACT FROM AUTHOR]

Touch is an integral part of human life. Consequently, touching and being touched are also fundamental to healthcare practice. Despite a significant literature on touch, it is rarely conceptualized or discussed in terms of the student journey from layperson to practitioner. We chose to explore professional touch using the threshold concepts framework (TCF), which provides a theoretical model for exploring the way in which learners encounter, engage with and understand fundamental concepts in a discipline. This qualitative research synthesis (QRS) describes the use of the TCF to identify key issues involved in developing and using professional touch. Through a cross-professional analysis and synthesis of recent international literature, we aimed to identify key characteristics of the transitional journey for professional touch. Three orders of analysis were applied, employing a methodology described by Major and Savin-Baden (An introduction to qualitative research synthesis: managing the information explosion in social science research, Routledge, London, 2010). Following identification of threshold characteristics in the overall sample of articles, second order analysis revealed the nuances of professional touch associated with the characteristics. The final synthesis led to identification of five themes: touch as dialogue; being changed by touch; multiple boundaries of touch; multiple meanings of touch and influences on touch. Whilst providing support for some assertions within the literature, this QRS also offers new insights into the complexity of professional touch. Given the paucity of explicit learning and reflection around professional touch in training programmes of health professionals, the TCF reveals ways in which professional preparation might be improved to promote understanding of the role and impact of touch in practice. [ABSTRACT FROM AUTHOR]

Summary: Background: Doctors are increasingly expected to improve the health and well‐being of populations, as well as to care for individuals. However, despite extensive efforts to integrate population health into undergraduate programmes, engaging students in such learning is notoriously challenging. Threshold concepts are transformative, integrative, irreversible and fundamental to understanding a discipline. Grasping such concepts requires learners to cross a liminal space, which often involves struggle. Methods: We employed a form of transactional curriculum enquiry, involving qualitative and quantitative methods, with experienced population health medical educators to identify and explore threshold and troublesome concepts in population health. Results: Attributing causality, inequalities in health and doctors' responsibility for populations not just individuals were the concepts most participants thought were threshold. The value of qualitative research, health as politically and socially determined and not taking evidence at face value were the concepts ranked as most troublesome for learners. Participants found the notions of threshold and troublesome concepts helpful and empowering. They described ways these new ideas would influence how they taught population health. Discussion: Transactional curriculum enquiry can offer insights into which population health concepts may be threshold and troublesome. The number of such concepts identified in this study may help explain why students often struggle to engage in population health learning. Understanding which concepts are threshold and particularly which are troublesome can help teachers to better support learners and can also inform curriculum design. If our students are to ... take responsibility for populations as well as individuals ... it is vital that they cross these fundamental thresholds in learning [ABSTRACT FROM AUTHOR]

Threshold Concepts are fundamental ideas within a discipline which are transformative, integrative, irreversible and usually troublesome. This article describes the threshold concept framework and discusses how it can offer new insights into how we focus teaching and facilitate learning around these concepts, such as uncertainty. Relevant research from a range of health disciplines are explored to consider which concepts may be critical to thinking and practising effectively in primary care. In addition, it is proposed that threshold concepts may have relevance to the GP recruitment crisis. [ABSTRACT FROM AUTHOR]

Summary: Background: The hidden curriculum (HC) refers to unscripted, ad hoc learning that occurs outside the formal, taught curriculum and can have a powerful influence on the professional development of students. While this learning may be positive, it may conflict with that taught in the formal curriculum. Medical schools take a range of steps to address these negative effects; however, the existence and nature of the concept tends to be hidden from students. Methods: Since 2007, our medical school has incorporated into its small group programme an educational activity exploring the concept of the hidden curriculum. We undertook a qualitative evaluation of our intervention, conducting a thematic analysis of students' wiki reflections about the HC. We also analysed students' responses to a short questionnaire about the educational approach used. Findings: The majority of students felt that the HC session was important and relevant. Most appeared able to identify positive and negative HC experiences and consider how these might influence their learning and development, although a few students found the concept of the HC hard to grasp. Discussion: Revealing and naming the hidden curriculum can make students aware of its existence and understand its potential impact. The hidden curriculum may also be a useful tool for triggering debate about issues such as power, patient centredness, personal resilience and career stereotypes in medicine. Supporting students to think critically about HC experiences may empower them to make active choices about which messages to take on board. The hidden curriculum can have a powerful influence on the professional development of students [ABSTRACT FROM AUTHOR]

Summary: Aim: To understand the experiences of students and problem‐based learning (PBL) facilitators during an evidence‐based curriculum change to a PBL programme within an undergraduate medical course in South West England. Methods: Four novel PBL cases were designed and implemented, based on educational theory and evidence. Eight focus groups were undertaken with Year‐1 and ‐2 students (n = 18) and PBL facilitators (n = 14) to explore the experiences of participants. Thematic analysis and conceptual abstraction led to insights into the intended and unintended consequences of the change. Results: Participant responses to the change process were influenced by the perceived relevance and value of the change (e.g. benefit to student learning), which was shaped by individual beliefs and preferences (e.g. presumed purpose of PBL, relative value placed on different curriculum topics, and desire for uniform educational experience), and the wider education context (e.g. expectations of assessment). It appears that the three distinct elements must align for the changes to be received positively. We updated our PBL curriculum in response to new evidence Discussion: This study describes how we updated our PBL curriculum in response to new evidence, and demonstrates the importance of communicating the pedagogic rationale behind changes, and meticulous planning, preparation and alignment, even in distant parts of the curriculum. Engaging with existing views and attitudes is an essential requirement for successful curriculum change. [ABSTRACT FROM AUTHOR]

Professionalism is a core element of curricula in many disciplines but can be difficult to teach and learn. This study used audio-diary methodology to identify professionalism threshold concepts in a small group learning setting in undergraduate medicine and to understand factors that might facilitate students to ‘get’ such concepts. Fifteen students and seven tutors kept audio-diaries over two terms. Data were analysed qualitatively for content. The key themes were then cross referenced to threshold concept criteria (e.g. where language indicated that learning was troublesome, integrative or transformative). Seven potential threshold concepts were identified which centred on students’ developing professional identities including working with uncertainty, considering the bigger picture, not needing to know everything and professional culture. Reflection on workplace experiences within a small group helped students ‘get’ these concepts. The study concludes that threshold concepts and audio-diaries are useful tools for understanding lived experiences of professionalism learning. [ABSTRACT FROM AUTHOR]

The article discusses how to evaluate one's professionalism knowledge, values and behaviour, identify and address underperformance in professionalism, and transfer one's professionalism to different circumstances.

The notion of “threshold concepts” is being widely applied and researched in many disciplines but is rarely discussed within medical education. This article is written by three medical educators who regularly draw on threshold concept theory in their work. They explore here the nature of threshold concepts and describe how the theory can offer medical educators new perspectives in terms of how they design curricula, approach teaching and support learners. [ABSTRACT FROM PUBLISHER]

Background: The prevalence of obesity in families of patients seeking surgical treatment for their severe obesity was investigated. Methods: Patients listed for surgery (vertical gastroplasty) for severe obesity (BMI >35) were interviewed and asked for details of the numbers of members of the immediate family who were at least 6.5 kg overweight. The data collected on 87 morbidly obese patients were compared to data from a group of 50 patients, all of whom had a BMI of less than 25 and were not overweight, who were acting as controls. Results: Obese patients had significantly more overweight family members than normal weight controls ( p = 0.004). Conclusion: The prevalence of overweight in the families of obese patients may be genetically and environmentally influenced. [ABSTRACT FROM AUTHOR]

A prospective study of biochemical changes after vertical banded gastroplasty for morbid obesity, in 94 patients (10 males and 84 females, ages ranging from 18 to 59 years) has been carried out. Liver function tests and electrolyte estimations were performed preoperatively, during hospitalisation for surgery, at 6 weeks and at 6 months postoperatively, and demonstrated no significant changes in liver function in these patients 6 months after surgery. The study concludes that there is no increase in the risk of liver damage or electrolyte disturbance after vertical gastroplasty, but that there may be subtle hepatic changes present as gall bladder disease developed in 18 patients postoperation (19%). [ABSTRACT FROM AUTHOR]

Case reports are presented on three patients treated for morbid obesity by vertical gastroplasty. Prior to surgery the patients had diabetes which required insulin, up to 200 units per day, or oral hypoglycaemics for its control. Six months after surgery the diabetes had been resolved in all three patients, and they were no longer dependent on medication. Subjective reports from the patients suggests that their quality of life improved significantly. [ABSTRACT FROM AUTHOR]

Background: Nutritional complications following surgery for morbid obesity include both vitamin and mineral deficiency. Severe cases of zinc deficiency can lead to alopecia, diarrhoea, emotional disorders, weight loss, intercurrent infection, bullous-pustular dermatitis and hypogonadism in males. Hair loss may occur after vertical gastroplasty (VG). Methods: Diffuse hair loss occurred in 47 out of 130 patients who underwent VG. All patients had been routinely advised to take a multivitamin supplement, but 47 developed hair loss despite taking the supplement. These patients were then prescribed Zinc Sulphate 200 mg three times a day. There was no alteration in the vitamin supplementation. Results: Arrest of hair loss and regrowth occurred in all patients. However, five patients reported recurrence of hair loss after stopping zinc. This loss was reversed within 6 months of recommencing zinc 600 mg daily. Ten control patients had no hair loss after gastrointestinal surgery. Conclusion: Significant hair loss occurred in about one-third of patients after VG, and was reversed by zinc supplementation. [ABSTRACT FROM AUTHOR]

The author discusses the growing recognition for capability in higher education as a vital component of professional expertise. Topics discussed include how capability is distinct from the capability approach, what capability requires from individuals, and how can people educate for capability, as well as competency.

Editorial. Focuses on the advantages for general practitioners in Great Britain to more involved with the community. Provision of services in more equitable and acceptable ways for local people; Optimism for the reduction of the need for medical intervention.