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Background Healthcare workers (HCWs), particularly those from ethnic minority groups, have been shown to be at disproportionately higher risk of infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) compared to the general population. However, there is insufficient evidence on how demographic and occupational factors influence infection risk among ethnic minority HCWs. Methods and findings We conducted a cross-sectional analysis using data from the baseline questionnaire of the United Kingdom Research study into Ethnicity and Coronavirus Disease 2019 (COVID-19) Outcomes in Healthcare workers (UK-REACH) cohort study, administered between December 2020 and March 2021. We used logistic regression to examine associations of demographic, household, and occupational risk factors with SARS-CoV-2 infection (defined by polymerase chain reaction (PCR), serology, or suspected COVID-19) in a diverse group of HCWs. The primary exposure of interest was self-reported ethnicity. Among 10,772 HCWs who worked during the first UK national lockdown in March 2020, the median age was 45 (interquartile range [IQR] 35 to 54), 75.1% were female and 29.6% were from ethnic minority groups. A total of 2,496 (23.2%) reported previous SARS-CoV-2 infection. The fully adjusted model contained the following dependent variables: demographic factors (age, sex, ethnicity, migration status, deprivation, religiosity), household factors (living with key workers, shared spaces in accommodation, number of people in household), health factors (presence/absence of diabetes or immunosuppression, smoking history, shielding status, SARS-CoV-2 vaccination status), the extent of social mixing outside of the household, and occupational factors (job role, the area in which a participant worked, use of public transport to work, exposure to confirmed suspected COVID-19 patients, personal protective equipment [PPE] access, aerosol generating procedure exposure, night shift pattern, and the UK region of workplace). After adjustment, demographic and household factors associated with increased odds of infection included younger age, living with other key workers, and higher religiosity. Important occupational risk factors associated with increased odds of infection included attending to a higher number of COVID-19 positive patients (aOR 2.59, 95% CI 2.11 to 3.18 for ≥21 patients per week versus none), working in a nursing or midwifery role (1.30, 1.11 to 1.53, compared to doctors), reporting a lack of access to PPE (1.29, 1.17 to 1.43), and working in an ambulance (2.00, 1.56 to 2.58) or hospital inpatient setting (1.55, 1.38 to 1.75). Those who worked in intensive care units were less likely to have been infected (0.76, 0.64 to 0.92) than those who did not. Black HCWs were more likely to have been infected than their White colleagues, an effect which attenuated after adjustment for other known risk factors. This study is limited by self-selection bias and the cross sectional nature of the study means we cannot infer the direction of causality. Conclusions We identified key sociodemographic and occupational risk factors associated with SARS-CoV-2 infection among UK HCWs, and have determined factors that might contribute to a disproportionate odds of infection in HCWs from Black ethnic groups. These findings demonstrate the importance of social and occupational factors in driving ethnic disparities in COVID-19 outcomes, and should inform policies, including targeted vaccination strategies and risk assessments aimed at protecting HCWs in future waves of the COVID-19 pandemic. Trial registration The study was prospectively registered at ISRCTN (reference number: ISRCTN11811602).

IntroductionThe COVID-19 pandemic has resulted in significant morbidity and mortality and devastated economies globally. Among groups at increased risk are healthcare workers (HCWs) and ethnic minority groups. Emerging evidence suggests that HCWs from ethnic minority groups are at increased risk of adverse COVID-19-related outcomes. To date, there has been no large-scale analysis of these risks in UK HCWs or ancillary workers in healthcare settings, stratified by ethnicity or occupation, and adjusted for confounders. This paper reports the protocol for a prospective longitudinal questionnaire study of UK HCWs, as part of the UK-REACH programme (The United Kingdom Research study into Ethnicity And COVID-19 outcomes in Healthcare workers).Methods and analysisA baseline questionnaire will be administered to a national cohort of UK HCWs and ancillary workers in healthcare settings, and those registered with UK healthcare regulators, with follow-up questionnaires administered at 4 and 8 months. With consent, questionnaire data will be linked to health records with 25-year follow-up. Univariate associations between ethnicity and clinical COVID-19 outcomes, physical and mental health, and key confounders/explanatory variables will be tested. Multivariable analyses will test for associations between ethnicity and key outcomes adjusted for the confounder/explanatory variables. We will model changes over time by ethnic group, facilitating understanding of absolute and relative risks in different ethnic groups, and generalisability of findings.Ethics and disseminationThe study is approved by Health Research Authority (reference 20/HRA/4718), and carries minimal risk. We aim to manage the small risk of participant distress about questions on sensitive topics by clearly participant information that the questionnaire covers sensitive topics and there is no obligation to answer these or any other questions, and by providing support organisation links. Results will be disseminated with reports to Government and papers submitted to pre-print servers and peer reviewed journals.Trial registration numberISRCTN11811602; Pre-results.

Does reading and writing direction (RWD) influence the aesthetic appreciation of photography? Pérez González showed that nineteenth-century Iranian and Spanish professional photographers manifest lateral biases linked to RWD in their compositions. The present study aimed to test whether a population sample showed similar biases. Photographs with left-to-right (L-R) and right-to-left (R-L) directionality were selected from Pérez González's collections and presented in both original and mirror-reversed forms to Spanish (L-R readers) and Moroccan (R-L readers) participants. In Experiment 1, participants rated each picture for its aesthetic pleasingness. The results showed neither effects of lateral organization nor interactions with RWD. In Experiment 2, each picture and its mirror version were presented together and participants chose the one they liked better. Spaniards preferred rightward versions and Moroccans preferred leftward versions. RWD therefore affects aesthetic impressions of photography in our participants when people pay attention to the lateral spatial dimension of pictures. The observed directional aesthetic preferences were not sensitive to the sex of the model in the photographs, failing to support expectations from the hypotheses of emotionality and agency. Preferences were attributable to the interaction between general scanning strategies and scanning habits linked to RWD.

A structured online survey was used to establish the views of 2,684 practising clinicians of all ages in multiple countries about the value of the physical examination in the contemporary practice of internal medicine. 70% felt that physical examination was 'almost always valuable' in acute general medical referrals. 66% of trainees felt that they were never observed by a consultant when undertaking physical examination and 31% that consultants never demonstrated their use of the physical examination to them. Auscultation for pulmonary wheezes and crackles were the two signs most likely to be rated as frequently used and useful, with the character of the jugular venous waveform most likely to be rated as -infrequently used and not useful. Physicians in contemporary hospital general medical practice continue to value the contribution of the physical examination to assessment of outpatients and inpatients, but, in the opinion of trainees, teaching and demonstration could be improved.

Structural brain differences in relation to expertise have been demonstrated in a number of domains including visual perception, spatial navigation, complex motor skills and musical ability. However no studies have assessed the structural differences associated with representational skills in visual art. As training artists are inclined to be a heterogeneous group in terms of their subject matter and chosen media, it was of interest to investigate whether there would be any consistent changes in neural structure in response to increasing representational drawing skill. In the current study a cohort of 44 graduate and post-graduate art students and non-art students completed drawing tasks. Scores on these tasks were then correlated with the regional grey and white matter volume in cortical and subcortical structures. An increase in grey matter density in the left anterior cerebellum and the right medial frontal gyrus was observed in relation to observational drawing ability, whereas artistic training (art students vs. non-art students) was correlated with increased grey matter density in the right precuneus. This suggests that observational drawing ability relates to changes in structures pertaining to fine motor control and procedural memory, and that artistic training in addition is associated with enhancement of structures pertaining to visual imagery. The findings corroborate the findings of small-scale fMRI studies and provide insights into the properties of the developing artistic brain.

The programs iMAP and iMAP2, developed by Caldara and Miellet (2011 Behavior Research Methods 43 846–878), have attempted to implement a general approach to the analysis of eye-movement data, providing not only ‘heat maps’ of areas of greater and lesser activity but also, and potentially of great practical importance, significance tests which take into account spatial autocorrelation in fixation locations. The tests in particular allow different groups to be compared, as in one of Caldara and Miellet's example datasets where fixation patterns of Western Caucasian and East Asian participants are said to be significantly different. The present paper argues that the significance tests, as implemented, used an inappropriate algorithm and therefore gave erroneous results. In particular, if participants are randomly allocated to two groups, which is a conventional randomization test, then in every case the program claimed to find ‘significant differences‘, which cannot be correct. A simple, modified statistical technique, based around a simple two-group t-test, with error functions and spatial autocorrelation taken into account, finds no differences between the example groups of participants. That conclusion is reinforced by analyzing simulated data with or without true differences, when iMAP/ iMAP2 always finds significant differences, irrespective of sample size, whereas the modified method finds significant differences for only the largest sample sizes. Previous research using iMAP/ iMAP2 may have come to erroneous conclusions about differences in fixation patterns between groups.

UK-trained medical students and doctors from minority ethnic groups underperform academically. It is unclear why this problem exists, which makes it difficult to know how to address it.To investigate whether demographic and psychological factors mediate the relationship between ethnicity and final examination scores.Two consecutive cohorts of Year 5 (final year) UCL Medical School students (n= 703; 51% minority ethnic). A total of 587 (83%) had previously completed a questionnaire in Year 3.Participants were administered a questionnaire in 2005 and 2006 that included a short version of the NEO-PI-R, the Study Process Questionnaire, and the General Health Questionnaire (GHQ) as well as socio-demographic measures. Participants were then followed up to final year (2007-2010). White and minority ethnic students' questionnaire responses and final examination grades were compared using univariate tests. The effect of ethnicity on final year grades after taking into account the questionnaire variables was calculated using hierarchical multiple linear regression.Univariate ethnic differences were found on age, personality, learning styles, living at home, first language, parental factors, and prior education. Minority ethnic students had lower final exam scores, were more likely to fail, and less likely to achieve a merit or distinction in finals. Multivariate analyses showed ethnicity predicted final exam scores even after taking into account questionnaire factors.Ethnic differences in the final year performance of two cohorts of UCL medical students were not due to differences in psychological or demographic factors, which suggests alternative explanations are responsible for the ethnic attainment gap in medicine.

Background Ethnic minority (EM) medical students and doctors underperform academically, but little evidence exists on how to ameliorate the problem. Psychologists Cohen et al. recently demonstrated that a written self-affirmation intervention substantially improved EM adolescents' school grades several months later. Cohen et al.'s methods were replicated in the different setting of UK undergraduate medical education. Methods All 348 Year 3 white (W) and EM students at one UK medical school were randomly allocated to an intervention condition (writing about one's own values) or a control condition (writing about another's values), via their tutor group. Students and assessors were blind to the existence of the study. Group comparisons on post-intervention written and OSCE (clinical) assessment scores adjusted for baseline written assessment scores were made using two-way analysis of covariance. All assessment scores were transformed to z-scores (mean = 0 standard deviation = 1) for ease of comparison. Comparisons between types of words used in essays were calculated using t-tests. The study was covered by University Ethics Committee guidelines. Results Groups were statistically identical at baseline on demographic and psychological factors, and analysis was by intention to treat [intervention group EM n = 95, W n = 79; control group EM n = 77; W n = 84]. As predicted, there was a significant ethnicity by intervention interaction [F(4,334) = 5.74; p = 0.017] on the written assessment. Unexpectedly, this was due to decreased scores in the W intervention group [mean difference = 0.283; (95% CI = 0.093 to 0.474] not improved EM intervention group scores [mean difference = -0.060 (95% CI = -0.268 to 0.148)]. On the OSCE, both W and EM intervention groups outperformed controls [mean difference = 0.261; (95%CI = -0.047 to -0.476; p = 0.013)]. The intervention group used more optimistic words (p < 0.001) and more "I" and "self" pronouns in their essays (p < 0.001), whereas the control group used more "other" pronouns (p < 0.001) and more negations (p < 0.001). Discussion Cohen et al.'s finding that a brief self-affirmation task narrowed the ethnic academic achievement gap was replicated on the written assessment but against expectations, this was due to reduced performance in the W group. On the OSCE, the intervention improved performance in both W and EM groups. In the intervention condition, participants tended to write about themselves and used more optimistic words than in the control group, indicating the task was completed as requested. The study shows that minimal interventions can have substantial educational outcomes several months later, which has implications for the multitude of seemingly trivial changes in teaching that are made on an everyday basis, whose consequences are never formally assessed.

Background Anecdotes abound about doctors' personal illness experiences and the effect they have on their empathy and care of patients. We formally investigated the relationship between doctors' and medical students' personal illness experiences, their examination results, preparedness for clinical practice, learning and professional attitudes and behaviour towards patients. Methods Newly-qualified UK doctors in 2005 (n = 2062/4784), and two cohorts of students at one London medical school (n = 640/749) participated in the quantitative arm of the study. 37 Consultants, 1 Specialist Registrar, 2 Clinical Skills Tutors and 25 newly-qualified doctors participated in the qualitative arm. Newly-qualified doctors and medical students reported their personal illness experiences in a questionnaire. Doctors' experiences were correlated with self-reported preparedness for their new clinical jobs. Students' experiences were correlated with their examination results, and self-reported anxiety and depression. Interviews with clinical teachers, newly-qualified doctors and senior doctors qualitatively investigated how personal illness experiences affect learning, professional attitudes, and behaviour. Results 85.5% of newly-qualified doctors and 54.4% of medical students reported personal illness experiences. Newly-qualified doctors who had been ill felt less prepared for starting work (p < 0.001), but those who had only experienced illness in a relative or friend felt more prepared (p = 0.02). Clinical medical students who had been ill were more anxious (p = 0.01) and had lower examination scores (p = 0.006). Doctors felt their personal illness experiences helped them empathise and communicate with patients. Medical students with more life experience were perceived as more mature, empathetic, and better learners; but illness at medical school was recognised to impede learning. Conclusion The majority of the medical students and newly qualified doctors we studied reported personal illness experiences, and these experiences were associated with lower undergraduate examination results, higher anxiety, and lower preparedness. However reflection on such experiences may have improved professional attitudes such as empathy and compassion for patients. Future research is warranted in this area.

Evidence shows that medical students from Minority Ethnic (ME) backgrounds and male medical students underperform in undergraduate examinations. Our study confirmed these findings in first year clinical (year 3) medical students, and further explored this disparity in performance. We conducted a series of meta-analyses to measure the effects of sex and ethnic group on the written examination and Objective Structured Clinical Examination (OSCE) scores of three groups of year 3 medical students at two London UK medical schools (n = 1,051; 46.0% male; 48.7% White). Male and ME students scored lower on written and OSCE assessments. Both assessments were statistically significantly correlated (mean r = 0.45) and therefore the effects of sex and ethnic group were measured on each exam after being adjusted for the effect of the other. Although sex and ethnic differences remained on the OSCE when adjusted for written performance, these differences disappeared on the written when it was adjusted for OSCE performance. These findings may reflect a relative deficit in practical clinical knowledge in male and ME year 3 students. Results were unlikely to be due to examiner bias, as the machine-marked unadjusted written exam results showed significant sex and ethnic differences.