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A call for action to come back and join the fight against COVID-19 has been issued to retired doctors around the world (CBS News, 2020). Many have responded to this call and have returned, or will return to the workforce. Conversely, some late-career doctors who are in practice are anxious about their risk and are understandably choosing now to retire. In this brief perspective, we explore the challenges of the bidirectional movement of older doctors returning to and exiting from the profession at this time of unprecedented stress, to inform solutions, and suggestions for the future.

IntroductionThe assistant in medicine is a new and paid role for final-year medical students that has been established in New South Wales, Australia, as part of the surge workforce management response to the COVID-19 pandemic. Eligibility requires the applicant to be a final-year medical student in an Australian Medical Council-accredited university and registered with the Australian Health Practitioner Regulation Agency. While there are roles with some similarities to the assistant in medicine role, such as assistantships (the UK) and physician assistants adopted internationally, this is completely new in Australia. Little is known about the functionality and success factors of this role within the health practitioner landscape, particularly within the context of the COVID-19 pandemic. Given the complexity of this role, a realist approach to evaluation has been undertaken as described in this protocol, which sets out a study design spanning from August 2020 to June 2021.Methods and analysisThe intention of conducting a realist review is to identify the circumstances and mechanisms that determine the outcomes of the assistant in medicine intervention. We will start by developing an initial programme theory to explore the potential function of the assistant in medicine role through realist syntheses of critically appraised summaries of existing literature using relevant databases and journals. Other data sources such as interviews and surveys with key stakeholders will contribute to the refinements of the programme theory. Using this method, we will develop a set of hypotheses on how and why the Australian assistants in medicine intervention might ‘work’ to achieve a variety of outcomes based on examples of related international interventions. These hypotheses will be tested against the qualitative and quantitative evidence gathered from all relevant stakeholders.Ethics and disseminationEthics approval for the larger study was obtained from the Western Sydney Local Health District (2020/ETH01745). The findings of this review will provide useful information for hospital managers, academics and policymakers, who can apply the findings in their context when deciding how to implement and support the introduction of assistants in medicine into the health system. We will publish our findings in reports to policymakers, peer-reviewed journals and international conferences.

Using an online tool, we report the association between tasks and ‘affect’ (underlying experience of feeling, emotion or mood) among 565 doctors in training, how positive and negative emotional intensity are associated with time of day, the extent to which positive affect is associated with breaks, and consideration about leaving the profession. Respondents spent approximately 25% of their day on paperwork or clinical work that did not involve patients, resulting in more negative emotions. Positive emotions were expressed for breaks, staff meetings, research, learning and clinical tasks that involved patients. Those having considered leaving the profession report more negative feelings. Systematic workplace changes (regular breaks, reducing paperwork and improved IT systems) could contribute to positive workday experiences and reduce intention to quit. Educators and employers have important roles in recognising, advocating for and implementing improvements at work to enhance wellbeing with potential to improve retention of doctors in training.

The delivery of healthcare is a major contributor to the climate crisis, with the NHS being the largest public sector contributor of carbon emissions in the UK. Physicians have an important role to play in the fight against climate change through the practice of sustainable healthcare. This involves maintaining the current and future quality of healthcare through balancing environmental, social and financial constraints. To this end, integrating these skills into medical education is crucial. A large number of medical schools have already embedded planetary health and sustainability theory into their curriculum, however, there is no formal sustainability curriculum in postgraduate education and training. This is vital for enabling clinicians to translate sustainability theory taught at undergraduate level into clinical practice. This article proposes which topics should be included in a postgraduate sustainability curriculum and explores various methods that could be used to incorporate these into the current educational framework.

Introducing performance measurement and management of clinicians’ practice may improve clinical productivity and quality of patient care; however the attitudes of doctors to such approaches are poorly defined. This was investigated through an anonymous qualitative postal questionnaire in a large district general hospital. A total of 93 from an invited cohort of 368 senior grade doctors participated. The results suggested that doctors understood the need to evaluate and manage their performance in medical practice, and address poor performance, but felt that current methods were inadequate. This principally related to poor validation and a lack of clinical ownership of data. The role of financial incentivisation was unclear but value was attributed to local clinical leadership, professional autonomy, recognition, and peer-group comparisons. This suggests that clinicians support the use of data-based performance measurement and management; however how it is undertaken is key to successful clinical engagement.

Introduction Improving the quality and activity of clinicians’ practice improves patient care. Performance-related human resource management (HRM) is an established approach to improving individual practice but with limited use among clinicians. A framework for performance-related HRM was developed from successful practice in non-healthcare organisations centred on distributive leadership and locally provided, validated and interpreted performance measurement. This study evaluated the response of medical and non-clinical managers to its implementation into a large secondary healthcare organisation. Methods A semistructured qualitative questionnaire was developed from themes identified during framework implementation and included attitudes to previous approaches to measuring doctors’ performance, and the structure and response to implementation of the performance-related HRM framework. Responses were analysed through a process of data summarising and categorising. Results A total of 29, from an invited cohort of 31, medical and non-clinical managers from departmental to executive level were interviewed. Three themes were identified: (1) previous systems of managing clinical performance were considered to be ineffective due to insufficient empowerment of medical managers and poor quality of available performance data; (2) the implemented framework was considered to address these needs and was positively received by medical and non-clinical managers; (3) introduction of performance-related HRM required the involvement of the whole organisation to executive level and inclusion within organisational strategy, structure and training. Conclusions This study suggests that a performance-related HRM framework may facilitate the management of clinical performance in secondary healthcare, but is dependent on the design and methods of application used. Such approaches contrast with those currently proposed for clinicians in secondary healthcare in the UK and suggest that alternative strategies should be considered.

Background Appraisal, or independent performance review (IPR) is used in human resources management in the commercial and public sectors to evaluate the performance of an employee against agreed local organisational expectations and objectives, and to identify their requirements for development and effective management. IPR for NHS consultants may provide essential information for job planning, contribute towards medical appraisal for revalidation, and facilitate productivity and quality improvement. Aims To develop a framework for IPR for consultants, and to determine attitudes on its value, process and content. Method Information from commercial, public and voluntary sector models and published and other literature sources were used to develop an IPR framework. This was assessed through a three-cycle action research methodology involving qualitative interviews with 22 consultants (predominantly with medical management roles). Results The domains of the IPR framework included: (1) performance against objectives; (2) behaviour and leadership; (3) talent management; (4) agreed future objectives. A number of themes were identified from the consultant interviews including: ineffective current appraisal systems reflecting a lack of valid performance data and allotted time; a lack of empowerment of medical managers to address performance issues; IPR as a more explicit system, offering value in evaluating doctors performance; and the dependence of successful implementation on the engagement of the Trust executive. Conclusions IPR may have value for performance evaluation of consultants, contributing toward job planning and complementing medical appraisal. Support by their employing organisation and engagement with medical managers in design and implementation is likely to be essential.

Purpose Patient satisfaction is increasingly recognized as an important component of quality. The expansion of health information technologies (HIT) might have an impact on patient satisfaction – either positively or negatively. We conducted a literature review to explore the impact of these technologies on patient satisfaction. Methods The database of PubMed was searched from inception through May 2010, using the MeSH terms "Medical Informatics" and "Patient Satisfaction". We included all original interventional studies regardless of their study design that were published in English and were evaluating HIT impact on patient satisfaction. Studies were categorized by technology type according to the American Medical Informatics Association framework and by study design. The major outcome of interest was the HIT impact on patient satisfaction. Results Of 1293 citations reviewed, 56 studies met our inclusion criteria. Design of these studies included mostly randomized controlled trials (RCTs) ( n =20, 36%), cross-sectional surveys ( n =17, 30%), and a pre and post studies ( n =14, 25%). Overall, 54% ( n =30) of the studies demonstrated a positive effect of HIT on patient satisfaction, 34% ( n =19) failed to show any effect, 11% ( n =6) had inconclusive results, and 2% ( n =1) revealed a negative effect. Of the 20 RCTs, 40% ( n =8) showed a positive effect of HIT on patient satisfaction, 50% ( n =10) failed to show any effect, and 10% (2) had inconclusive results. Conclusions Analysis suggested that while there is some evidence that HIT improves patient satisfaction, studies in this literature review, and in particularly RCTs, were not consistent in their findings. Although HIT may be a promising tool to improve patient satisfaction, more well-designed research studies are needed in order to get a better understanding of this domain and accordingly find new opportunities to improve quality of care.

Purpose – Improving Global Health is a one year leadership scheme which places trainee doctors and more experienced nurses, midwives and AHPs in a developing country (Cambodia or Tanzania) to develop leadership and quality improvement skills while contributing to Millennium goals in the developing countries. The purpose of this paper is to report on an independent evaluation of the programme, with the purpose of highlighting lessons learned to inform other leadership development initiatives, and in particular to highlight the vital importance of a receptive NHS environment if maximum value is to be gained from investment in clinical leadership.Design/methodology/approach – The evaluation methodology comprised literature review; review of documentation, including on line questionnaires to Fellows; interviews with stakeholders and attendance at key scheme events in July‐September 2011. Fellows who had completed an overseas placement in either Cambodia or Tanzania during 2009‐2010 were interviewed using a se...

Objective To explore the views of doctors in training about their current roles and their potential value to the National Health Service (NHS) in improving healthcare quality and productivity. Methods Online questionnaire sent via email to 3766 junior doctors (foundation year one to specialist trainee year 3+) in the NHS South Central region. Results The response rate was 1479/3766 (39.3%). Respondents recognised the importance of leadership (89.7%), team working (89.2%) and professionalism (97%). Only 3.4% of junior doctors stated they have never acted in a leadership capacity. However, respondents reported a lack of receptivity from their organisations: the majority responded that they do not feel valued by managers (83.3%), the chief executive (77.7%), the organisation (77.3%), the NHS (79.3%) and consultants (58.2%). 91.2% of respondents have had ideas for improvement in their workplace; however, only 10.7% have had their ideas for change implemented. Respondents who had been on a NHS South Central leadership development course were significantly more likely to feel valued by all groups of staff in their organisation. They were also significantly more likely to report having their ideas implemented. Conclusions Doctors in training have a desire and perceived ability to contribute to improvement in the NHS but do not perceive their working environment as receptive to their skills. Junior doctors who attend leadership training report higher levels of desire and ability to express these skills. This study suggests junior doctors are an untapped NHS resource and that they and their organisations would benefit from more formalised provision of training in leadership.

Managers in many healthcare systems are being compelled to increase productivity as a way of dealing with budgetary cutbacks and ageing populations. One approach to improving productivity may be to recognise more explicitly the high value of health professionals, and especially very expensive doctors. Considering doctors as assets allows the quantification of the health benefits that they generate for organisations and patients. Greater recognition of the magnitude of these benefits might encourage employers into recruiting, managing and maintaining doctors more carefully. Ultimately, this change of mindset might persuade healthcare managers to subject decisions regarding human capital to a similar degree of scrutiny as they currently apply to the purchase and maintenance of capital equipment. To increase productivity, the maxim for hospital managers should be to recruit doctors with caution and to manage them with care.

Ventilator-associated pneumonia (VAP) is a common hazardous complication in ICU patients. The aim of the current review is to give an update on the current status and future recommendations for VAP prevention.This article gives an updated review of the current literature on VAP. The first part briefly reviews pathogenesis and epidemiology while the second includes an in-depth review of evidence-based practice guidelines (EBPG) and new technologies developed for prevention of VAP.VAP remains a frequent and costly complication of critical illness with a pooled relative risk of 9-27% and mortality of 25-50%. Strikingly, VAP adds an estimated cost of more than $40,000 to a typical hospital admission. An important aetiological mechanism of VAP is gross or micro-aspiration of oropharyngeal organisms around the cuff of the endotracheal tube (ETT) into the distal bronchi. Prevention of VAP is preferable. Preventative measures can be divided into two main groups: the implemen- tation of EBPGs and use of device-based technologies. EBPGs have been authored jointly by the American Thoracic Society and the Infectious Diseases Society of America. The Canadian Critical Care Trials group also published VAP Guidelines in 2008. Their recommendations are detailed in this review. The current device-based technologies include drainage of subglottic secretions, silver coated ETTs aiming to influence the internal bio-layer of the ETT, better sealing of the lower airways with ultrathin cuffs and loops for optimal cuff pressure control.EBPG consensus includes: elevation of the head of the bed, use of daily "sedation vacations" and decontamination of the oropharynx. Technological solutions should aim to use the most comprehensive combination of subglottic suction of secretions, optimization of ETT cuff pressure and ultrathin cuffs. VAP is a type of hospital-acquired pneumonia that develops more than 48 h after endotracheal intubation. Its incidence is estimated to be 9-27%, with a mortality of 25-50% [Am J Respir Crit Care Med 171:388-416 (2005), Am J Med 85:499-506 (1988), Chest 122:2115-2121 (2002), Intensive Care Med 35:9-29 (2009)]. The most important target in VAP handling is its prevention. The aim of this article is to review the pathogenesis, epidemiology and the different strategies/technologies for prevention of VAP.

PurposeThe purpose of this paper is to describe a novel approach to leadership development for UK healthcare workers, while contributing to health service improvement in a developing country.Design/methodology/approachA quality improvement faculty are used to teach and mentor National Health Service (NHS) International Development Clinical Fellows in quality improvement (QI) methods. Using accepted QI methods, sensitive and practical improvement projects are selected in partnership with local people in Cambodia in order to start achieving United Nations Millennium Development Goals related to child and maternal health. Simultaneously, NHS International Fellows gain an unparalleled opportunity to develop their leadership skills, which should benefit the NHS on their return to the UK.FindingsHealthcare quality improvement methods, developed in First World countries, are transferable to the developing world and also function as a vehicle for developing leadership skills in experienced healthcare workers.Practical implicationsThis leadership development programme fits with the stated aims of the Global Health Partnerships report, which encourages the NHS to play a global role in healthcare development in the developing world. Other First World healthcare systems could adopt this leadership development method to both improve the leadership capability of their own staff while also making a significant contribution to less well‐developed healthcare systems.Originality/valueThe combination of leadership development through quality improvement is novel – promising to benefit both providers and recipients.

Progressive loss of lung function resulting from the inflammatory response to bacterial colonization is the leading cause of mortality in cystic fibrosis (CF) patients. A greater understanding of these bacterial infections is needed to improve lung disease management. As culture-based diagnoses are associated with fundamental drawbacks, we used terminal restriction fragment (T-RF) length polymorphism profiling and 16S rRNA clone data to characterize, without prior cultivation, the bacterial community in 71 sputa from 34 adult CF patients. Nineteen species from 15 genera were identified in 53 16S rRNA clones from three patients. Of these, 15 species have not previously been reported in CF lung infections and many were species requiring strict anaerobic conditions for growth. The species richness and evenness were determined from the T-RF length and volume for the 71 profiles. Species richness was on average 13.3 ± 7.9 per sample and 13.4 ± 6.7 per patient. On average, the T-RF bands of the lowest and highest volumes represented 0.6 and 59.2% of the total volume in each profile, respectively. The second through fifth most dominant T-RF bands represented 15.3, 7.5, 4.7, and 2.8% of the total profile volume, respectively. On average, the remaining T-RF bands represented 10.2% of the total profile volume. The T-RF band corresponding to Pseudomonas aeruginosa had the highest volume in 61.1% of the samples. However, 18 other T-RF band lengths were dominant in at least one sample. In conclusion, this reveals the enormous complexity of bacteria within the CF lung. Although their significance is yet to be determined, these findings alter our perception of CF lung infections.

Education and enforcement have been two contrasting ways of managing clinical performance. Both are needed but recently health policy has placed greater emphasis on the latter, possibly to the detriment of the former. This paper examines the ways in which education and other formative aspects of clinical practice can be conducted. The boundary between education and enforcement involves a distinction between public and private space. Private space is the territory within which clinicians can review their performance and improve it from an educational perspective. The boundary between public and private space is fluid, particularly since the advent of systems to ensure clinicians' competence. The sensitive management of this boundary will determine whether the benefits of transparent clinical practice will be realized in terms of improved patient care.

Pulmonary surfactant in bronchoalveolar lavage fluid (BALF) and induced sputum from adults with stable asthma ( n = 36) and healthy controls ( n = 12) was analyzed for phospholipid and protein compositions and function. Asthmatic subjects were graded as mild, moderate, or severe. Phospholipid compositions of BALF and sputum from control subjects were similar and characteristic of surfactant. For asthmatic subjects, the proportion of dipalmitoyl phosphatidylcholine (16:0/16:0PC), the major phospholipid in surfactant, decreased in sputum ( P < 0.05) but not in BALF. 1 In BALF, mole percent 16:0/16:0PC correlated with surfactant function measured in a capillary surfactometer, and sputum mole percent 16:0/16:0PC correlated with lung function (forced expiratory volume in 1 s). Neither surfactant protein A nor total protein concentration in either BALF or sputum was altered in asthma. These results suggest altered phospholipid composition and function of airway (sputum) but not alveolar (BALF) surfactant in stable asthma. Such underlying surfactant dysfunction may predispose asthmatic subjects to further surfactant inhibition by proteins or aeroallergens in acute asthma episodes and contribute to airway closure in asthma. Consequently, administration of an appropriate therapeutic surfactant could provide clinical benefit in asthma.

Background Achieving high levels of patient satisfaction requires hospital management to be proactive in patient-centred care improvement initiatives and to engage frontline clinicians in this process. Method We developed a survey to assess the attitudes of clinicians towards hospital management activities with respect to improving patient satisfaction and surveyed clinicians in four academic hospitals located in Denmark, Israel, the UK and the USA. Results We collected 1004 questionnaires (79.9% response rate) from four hospitals in four countries on three continents. Overall, 90.4% of clinicians believed that improving patient satisfaction during hospitalisation was achievable, but only 9.2% of clinicians thought their department had a structured plan to do so, with significant differences between the countries (p

Background: To achieve a high level of patient satisfaction, providers need to identify and address patients’ expectations. However, providers’ beliefs and attitudes regarding expectations, as well as how to manage them, are not well understood. Methods: The authors developed a survey to assess clinicians’ awareness, attitudes, competence and performance with respect to patient expectations. The authors surveyed clinicians in four academic hospitals located in Denmark, Israel, the UK and the USA. Results: The authors collected 1004 questionnaires (79.9% response rate) from four hospitals in four countries spanning three continents. Overall, 88.8% of respondents stated that clinician awareness regarding patient expectations was moderate to low, with significant differences between countries (p

The bacterial communities present in the oral cavity and the lungs of 19 adult cystic fibrosis (CF) patients were compared by using terminal restriction fragment length polymorphism analysis of 16S rRNA gene PCR products amplified from nucleic acids extracted directly from bacteria in clinical samples. Sputum samples were not found to be subject to profound contamination by oral cavity bacteria. Evidence of colonization of the CF lung by certain oral bacterial species was found.

Cystic fibrosis (CF) is characterised by inspissated airway secretions and chronic endobronchial infection associated with exuberant neutrophilic inflammation. Unfractionated heparin may be mucolytic and has demonstrated a number of anti-inflammatory properties; however, further safety data are needed in these subjects who are at risk of airway bleeding. The current study aimed to assess the medium-term safety and tolerability of moderately high-dose inhaled heparin in CF adults and to explore possible in vivo mucolytic and anti-inflammatory outcomes. A randomised, double-blind, placebo-controlled crossover study of twice daily inhalation of 50,000 IU of heparin for 2 weeks was undertaken in CF adults, with a 1-week washout period. Eighteen subjects were randomised and 14 (mean+/-sd age 23+/-7.8 yrs and percentage-predicted forced expiratory volume in one second 52.1+/-15.56%) completed the study protocol. Heparin neither affected blood coagulation parameters nor resulted in any increase in adverse events. Heparin inhalation had no significant effect upon forced expiratory volume in one second, symptoms of sputum clearance or sputum inflammatory markers. The current pilot study demonstrated no evidence of improved sputum clearance with 50,000 IU of inhaled heparin given twice daily to adult cystic fibrosis subjects. However, inhaled heparin was safe and the future evaluation of larger doses over a longer period may be warranted.

Background Chronic lung infections are the primary cause of morbidity and mortality in Cystic Fibrosis (CF) patients. Recent molecular biological based studies have identified a surprisingly wide range of hitherto unreported bacterial species in the lungs of CF patients. The aim of this study was to determine whether the species present were active and, as such, worthy of further investigation as potential pathogens. Methods Terminal Restriction Fragment Length Polymorphism (T-RFLP) profiles were generated from PCR products amplified from 16S rDNA and Reverse Transcription Terminal Restriction Fragment Length Polymorphism (RT-T-RFLP) profiles, a marker of metabolic activity, were generated from PCR products amplified from 16S rRNA, both extracted from the same CF sputum sample. To test the level of activity of these bacteria, T-RFLP profiles were compared to RT-T-RFLP profiles. Results Samples from 17 individuals were studied. Parallel analyses identified a total of 706 individual T-RF and RT-T-RF bands in this sample set. 323 bands were detected by T-RFLP and 383 bands were detected by RT-T-RFLP (statistically significant; P ≤ 0.001). For the group as a whole, 145 bands were detected in a T-RFLP profile alone, suggesting metabolically inactive bacteria. 205 bands were detected in an RT-T-RFLP profile alone and 178 bands were detected in both, suggesting a significant degree of metabolic activity. Although Pseudomonas aeruginosa was present and active in many patients, a low occurrence of other species traditionally considered to be key CF pathogens was detected. T-RFLP profiles obtained for induced sputum samples provided by healthy individuals without CF formed a separate cluster indicating a low level of similarity to those from CF patients. Conclusion These results indicate that a high proportion of the bacterial species detected in the sputum from all of the CF patients in the study are active. The widespread activity of bacterial species in these samples emphasizes the potential importance of these previously unrecognized species within the CF lung.

The authors regret that text from the article entitled ‘‘Implementing Quality in Improvements in the Intensive Care Unit: Ventilator Bundle as an Example’’ written by Marya D. Zilberberg, Andrew F. Shorr, Marin H. Kollef and published in Critical Care Medicine 37, 305–309 (2009) was copied in the original publication of the article published in J Clin Monit Comput on 2010 Apr; 24(2): 161–8. The proper course of action would have been to cite Dr Zilberberg’s text in appropriate quotational form, and include Dr. Zilberberg et al. article to the reference list. We deeply apologize for this mistake.

Background Improved management of clinicians’ time and practice is advocated to address increasing demands on healthcare provision in the UK National Health Service (NHS). Human resource management (HRM) is associated with improvements in organisational performance and outcomes within and outside of healthcare, but with limited use in managing individual clinicians. This may reflect the absence of effective and transferrable models. Methods The current systems of managing the performance of individual clinicians in a secondary healthcare organisation were reviewed through the study of practice in 10 successful partnership organisations, including knowledge worker predominant, within commercial, public and voluntary sector operating environments. Reciprocal visits to the secondary healthcare environment were undertaken. Results Six themes in performance related HRM were identified across the external organisations representing best practice and considered transferrable to managing clinicians in secondary care organisations. These included: performance measurement through defined outcomes at the team level with decision making through local data interpretation; performance improvement through empowered formal leadership with organisational support; individual performance review (IPR); and reward, recognition and talent management. The role of the executive was considered essential to support and implement effective HRM, with management of staff performance, behaviour and development integrated into organisational strategy, including through the use of universally applied values and effective communication. These approaches reflected many of the key aspects of high performance work systems and strategic HRM. Conclusions There is the potential to develop systems of HRM of individual clinicians in secondary healthcare to improve practice. This should include both performance measurement and performance improvement but also engagement at an organisational level. This suggests that effective HRM and performance management of individual clinicians may be possible but requires an alternative approach for the NHS.