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ObjectiveTo understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload.MethodsSingle centre prospective observational evaluation of 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. A proforma including frequency, nature, magnitude and level of procedural risk at the time of each distraction/interruption was completed for each case. The primary operator completed a National Aeronautical and Space Administration (NASA) task load questionnaire rating mental/physical effort, level of frustration, time-urgency, and overall effort and performance.Results264 distractions occurred in 106 (55%) out of 194 procedures observed; 80% were not relevant to the case being undertaken; 14% were urgent including discussions of potential ST-elevation myocardial infarction requiring emergency angioplasty. In procedures where distractions were observed, frequency per case ranged from 1 to 16 (mean 2.5, SD ±2.2); 43 were documented during high-risk stages of the procedure. Operator rating of NASA task load parameters demonstrated higher levels of mental and physical workload and effort during cases in which distractions occurred.ConclusionsIn this first description of HF in adult cardiac catheter laboratories, we found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. We propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.

Purpose The role that human factors (HF) play in contributing to medical error is increasingly being recognised by healthcare professionals. Surprisingly, much less is known about the possible effects of HF including boredom, fatigue and organisational influences, on performance outside of the clinical environment such as examining or assessing candidates in other high stakes situations. Methods The authors used a validated 38 response questionnaire based around the HF analysis and classification system (HFACS) to assess factors including stress and pressure, care and support and working within the rules for surgeon interviewers at the UK national trainee selection process in Trauma and Orthopaedic surgery. Results 121 completed questionnaires were analysed (86% response rate). No statistically significant differences were found between interviewer experience, grade or role at the interview and the mean scores obtained for all four factor items. Overall interviewers had a positive experience during national selection with mean factor scores ranging from 3.80 to 3.98 (out of a maximum satisfaction score of 5). Conclusions Careful planning by organisations and recognising the importance of the human element are essential to ensure assessors are looked after properly during high stakes assessment processes. Our data suggests that a positive experience for examiners is likely to benefit candidate performance and contribute to a fair and reliable recruitment process. The relationship between examiner experience and candidate performance merits further investigation.

Background Human factors are important causes of error, but little is known about their possible effect during objective structured clinical examinations (OSCE). We have previously identified stress and pressure in OSCE examiners in the postgraduate intercollegiate Membership of the Royal College of Surgeons (MRCS) examination. After modifying examination delivery by changing OSCE stations at lunchtime with no demonstrable effect on candidate outcome, we resurveyed examiners to ascertain whether examiner experience was improved. Method Examiners ( n = 180) from all 4 surgical colleges in the United Kingdom and Ireland were invited to complete the previously validated human factors questionnaire used in 2014. Aggregated scores for each of 4 previously identified factors were compared with the previous data. Unit-weighted z -scores and nonparametric Kruskal-Wallis methods were used to test the hypothesis that there was no difference among the median factor z -scores for each college. Individual Mann-Whitney-Wilcoxon tests (with appropriate Bonferonni corrections) were used to determine any differences between factors and the respective colleges. Results 141 Completed questionnaires were evaluated (78% response rate) and compared with 108 responses (90%) from the original study. Analysis was based on 26 items common to both studies. In 2014, the college with the highest candidate numbers (England) was significantly different in 1 factor (stress and pressure), compared with Edinburgh (Mann-Whitney-Wilcoxon: W = 1524, p W = 104, p=0.004). No differences were found among colleges in the same factor in 2016, Kruskall-Wallis: ( χ 2 (3) = 1.73, p=0.63). Analysis of responses found inconsistency among examiners regarding mistakes or omissions made when candidates were performing well. Conclusion After making changes to OSCE delivery, factor scores relating to examiner stress and pressure are now improved and consistent across the surgical colleges. Stress and pressure can occur in OSCE examiners and examination delivery should ideally minimize these issues, thereby improving morale is also likely to benefit candidates.

Objective. To design, deliver and evaluate a National Pharmacy Internship Programme to meet the educational needs of pharmacy graduates for registration as competent pharmacists, recognising the learning by way of an educational award. Methods. The programme was designed as a twelve month, full-time, blended-learning, competency-based programme leading to an educational award at Master’s Level. Intern performance was assessed academically and by pharmacy tutor (preceptor) appraisals. Interns who demonstrated competency were invited to sit the Professional Registration Examination (PRE). Feasibility and performance were evaluated and a longitudinal approach allowed intern and tutor views to be compared to the former pre-registration year. Results. Overall performance in the PRE was good and relatively consistent with almost all interns proceeding to register as pharmacists. Interns expressed a view that the programme had enabled them to develop the knowledge, skills and overall competencies required for future independent practice as a pharmacist. Tutors considered the programme to have built on prior learning and provided a sufficiently rounded experience for professional practice. Tutors also expressed the view that the programme was an improved educational experience over the former, less structured, pre-registration training. Conclusion. The National Pharmacy Internship Programme was a structured, competency-based programme at Master’s Level. The education and training was perceived to be an improvement on the previous pre-registration year. The programme quality assured pharmacy education outcomes at entry-to-practice on a national basis, and uniquely recognised the learning by way of an educational award.

There has been significant reform of the Continuing Professional Development (CPD) requirements for Irish pharmacists over the past five years. In 2015, a new system was established that includes quality assurance of practitioner engagement in CPD and quality assurance of practitioner competence. Pharmacists must now plan and document their learning activities in an electronic portfolio (ePortfolio) and they must participate in an ePortfolio Review process once every five-year period. A random sample is chosen each year to participate in a review of their practice for pharmacists in patient-facing roles. This paper provides an overview of the development and implementation of these quality assurance processes and it considers the outcomes that were observed in the first four years of implementation. By April 2019, almost 3000 pharmacists had participated in the ePortfolio Review process over the preceding three years, of which 96.2% demonstrated appropriate engagement in CPD. In the preceding two years, almost 200 pharmacists had participated in Practice Review, of which 97.5% have demonstrated the required level of competence across four competencies. All of the pharmacists who did not demonstrate the required level of competence in one or more competency area during Practice Review had previously demonstrated appropriate engagement in CPD through the ePortfolio Review process. This raises interesting questions regarding the use of engagement in continuing education (CE) or CPD as a surrogate measure for competence by professions.

Background: The Physician Associate (PA) role was introduced in Ireland in 2015 in an effort to bolster medical services. From the perspective of the patient and staff they have been well received. However, the attitude of medical students about PAs is not known. Objective: To investigate the willingness of medical students to refer patients to a PA or a doctor. Methods: A quantitative study was undertaken using an online survey with a sample of 1,909 undergraduate and graduate entry medical students. Based on three outpatient scenarios, they were asked, in their role as future intern (PGY1), to choose a referral to a PA or a doctor, with six time trade-off options offered. Year of study, country of residence and working or treatment experience with PAs and Nurse Practitioners were recorded. Descriptive statistics, and logistic regression models were used. Results: In 2019, in Dublin, 177 medical students took part in the survey. Those surveyed were international and domestic nationals. Overall the PA option was chosen where the patient’s wait time was shorter and the clinical condition was perceived more serious. The doctor option was selected more readily when the wait time difference was less significant. Respondents from countries with established PA roles may have had experience to choose PAs than naive ones. Conclusion: This study confirms that medical students’ willingness to refer a patient is influenced by familiarity with the PA role and severity of the medical condition. In addition wait time is a primary motivator for selecting the PA over doctor option. These findings suggest a need to improve communication about the PA role among Irish medical students.

The objective was to challenge cross-species extrapolation factors with which to scale animal doses to human by any route for non-carcinogenic endpoints. The conventional hypothesis of the toxicokinetics (TK)-toxicodynamics (TD) relationship was equal toxicity at equal plasma level of the total drug moiety in each species, but this should also follow the free drug assumption, which states that only the unbound drug moiety in plasma may elicit a TD effect in tissue. Therefore, a protein binding factor (PBF) was combined with the Chemical-Specific Adjustment Factor (CSAF) (i.e., CSAF x PBF). The value of PBF of each drug was set equal to the ratio between human and animals of the unbound fraction in plasma (fup). Recent drug datasets were investigated. Our results indicate that any CSAF value would be increased or decreased while PBF deviates to the unity, and this required more attention. Accordingly, further testing indicated that the CSAF values set equal to basic allometric uncertainty factors according to the conventional hypothesis (dog∼2, monkey∼3.1, rat∼7, mouse∼12) would increase by including PBF for 30% of the drugs tested that showed a superior fup value in human compared to animals. However, default uncertainty factors in the range of 10-100 were less frequently exceeded. Overall, PBF could be combined with any other uncertainty factor to get reliable estimate of CSAF for each bound drug in deriving health-based exposure limits.

Objective\ud \ud Objective structured clinical examinations (OSCE) are widely used for summative assessment in surgery. Despite standardizing these as much as possible, variation, including examiner scoring, can occur which may affect reliability. In study of a high-stakes UK postgraduate surgical OSCE, we investigated whether examiners changing stations once during a long examining day affected marking, reliability, and overall candidates’ scores compared with examiners who examined the same scenario all day.\ud \ud Design, Setting, and Participants\ud \ud An observational study of 18,262 examiner-candidate interactions from the UK Membership of the Royal College of Surgeons examination was carried at 3 Surgical Colleges across the United Kingdom. Scores between examiners were compared using analysis of variance. Examination reliability was assessed with Cronbach’s alpha, and the comparative distribution of total candidates’ scores for each day was evaluated using t-tests of unit-weighted z scores.\ud \ud Results\ud \ud A significant difference was found in absolute scores differences awarded in the morning and afternoon sessions between examiners who changed stations at lunchtime and those who did not (p < 0.001). No significant differences were found for the main effects of either broad content area (p = 0.290) or station content area (p = 0.450). The reliability of each day was not affected by examiner switching (p = 0.280). Overall, no difference was found in z-score distribution of total candidate scores and categories of examiner switching.\ud \ud Conclusions\ud \ud This large study has found that although the range of marks awarded varied when examiners change OSCE stations, examination reliability and the likely candidate outcome were not affected. These results may have implications for examination design and examiner experience in surgical OSCEs and beyond.

To investigate the histomorphology of the canine tear drainage system and to show the distribution of mucin MUC5AC within the tissue.Conjunctiva and tear drainage systems of 19 long-nosed dogs were investigated histologically and ultrastructurally. The tissues were stained with eight different antibodies reactive against less glycosylated and highly-glycosylated MUC5AC. Results were compared with findings in human tissue received from 12 body donors.Except for a distinctly longer nasolacrimal duct and several accessory openings of the duct into the nasal cavity, the morphology of the canine tear drainage system is very similar to that of humans. MUC5AC in less- and highly-glycosylated forms was present in the conjunctival tissue of dogs as well of humans. Within the tear sac and the nasolacrimal duct only less-glycosylated MUC5AC could be found in dogs and in human.These findings demonstrate that the canine tear drainage system is very similar to its human equivalent. In particular the distribution of MUC5AC, supposed to play an important role within the pathogenesis of dry eye syndrome (DES), is the same as in humans. Therefore the canine model seems to be an appropriate model for further DES research.

Background: The physician associate (PA) role was piloted in Dublin, Ireland between 2015 and 2017. However, the concept of a PA and the acceptance of their role in Ireland had not been explored. Objective: To investigate the willingness of Irish citizens to be seen by a PA based on medical scenarios in a typical clinical setting. Design: A mixed methods study was undertaken. A preference survey, with three medical scenarios, gave participants a choice to be treated by a PA or a doctor, with two time trade-off options offered. Responses were supported with qualitative text. Four hundred people were invited to participate as surrogate patients. Setting and participants: In 2017 a total of 270 respondents took part in the study (67.5%) in two hospitals (one private and one public) in Dublin. The mean age was 60; male (n = 142) and female (n = 128) respondents. Findings: In total, 95% of the respondents chose to see a PA over a doctor based on the scenarios presented and a wait time of 30 minutes. Wait time, trust, competency and the severity or seriousness of the medical condition were categorized into three themes for choosing the PA over the doctor. The “surrogate patient” decisions made by this sample were influenced by knowing that the PA is supervised and can check decisions with his/her supervizing physician. Conclusion: These findings are consistent with studies carried out in other countries where willingness to be seen by a PA is neither age nor gender specific. Patient preference seems to concur around the importance of trust and confidence in the medical provider.

The first graduate-entry programmes to Irish medicine were established at the Royal College of Surgeons in Ireland (RCSI) and the University of Limerick (UL) in 2007. There were over 400 applications across both institutions and 306 people sat a special aptitude test (GAMSAT) in Ireland in 2007. Ultimately, 61 Irish/EU students were admitted to one or other programme.We describe the demographic profile, academic background and aggregated GAMSAT performance of 306 people who sat GAMSAT in Ireland in 2007 and of the 61 people admitted to the RCSI/UL programmes.While more females than males sat GAMSAT, slightly more males were admitted. Over 90% of those admitted were aged in their 20s, almost 20% had a higher degree and they came from a wide range of academic backgrounds.Among others, this information should be of interest to prospective students and to government policy makers.

A significant proportion of medical students in Ireland have demonstrated strong intentions to migrate following their graduation. Factors influencing these intentions are poorly understood. Our study aimed to investigate ‘push’ and ‘stay’ factors that may influence the migration plans of medical students. Cross-sectional survey of 2273 medical students in Ireland using a mixed methods approach. Survey was completed by 2273 medical students, of which 263 provided free text data that are analysed in this paper. Identified push factors include negative perception regarding career opportunities, working conditions and lifestyle, while family was the only identified strong stay factor. Qualitative analysis of free text responses revealed themes that included training, career, personal and financial factors. This study has provided insight into the factors that influence medical student migration intentions. There is a strong need for all stakeholders to collectively discuss and engage in possible solutions.

Background: Advances in cognitive load theory have led to greater understanding of how we process verbal and visual material during learning, but the evidence base with regard to the use of images within written assessments is still sparse. This study examines whether the inclusion of images within the stimulus format of multiple choice questions (MCQs) has a predictable or consistent influence on psychometric item properties, such as difficulty or discrimination. Methods: Item analysis data from three consecutive years of histology multiple choice examinations were included in this study. All items were reviewed and categorised according to whether their stem, or stimulus format, was purely textual or included an associated image. Results: A total of 195 MCQs were identified for inclusion and analysed using classical test theory; 95 used text alone and 100 included an image within the question stem. The number of students per examination ranged from 277 to 347, with a total of 60,850 student-question interactions. We initially examined whether the inclusion of an image within the item stem altered the item difficulty using Mann–Whitney U. The median item difficulty for images with purely textual stems was 0.77, while that for items incorporating an appropriate image was 0.80; this difference was not significant (0.77 vs. 0.80; p = 0.862, Mann–Whitney-U = 4818.5). Mean values showed that the Item Discrimination Index appeared unaffected by the inclusion of an image within the stem, and Item point biserial correlation also showed no difference in means between these two groups (Independent samples t-test; 2-tailed). Conclusion: We demonstrate that the addition of illustrations within undergraduate histology Multiple Choice Question stems has no overall influence on item difficulty, or measures of item discrimination. We conclude that the use of images in this context is statistically uncritical, and suggest that their inclusion within item stems should be based upon the principles of constructive alignment. However, further research with respect to the effect of images within item stems on cognitive processing, particularly with regard to image complexity or type, would enable the development of more informed guidelines for their use.

Background: To provide the optimum level of healthcare, it is important that the supply of well-trained doctors meets the demand. However, despite many initiatives, Ireland continues to have a shortfall of physicians, which has been projected to persist. Our study aimed to investigate the migration intentions of Irish medical students and identify the factors that influence their decisions in order to design appropriate interventions to sustain the supply of trained doctors in order to maintain a viable medical system. Methods: An online cross-sectional survey was undertaken of all Irish medical students studying in the Republic of Ireland. The survey included nominal, ordinal, and scale items to determine migration intentions, factors influencing their decisions, and understanding of the Irish healthcare system. Results: A total of 2 273 medical students responded (37% response rate), of whom 1 519 were classified as Irish medical students (having completed secondary school in Ireland). Of these, 88% indicated they were either definitely migrating or contemplating migrating following graduation or completion of the pre-registration intern year. Forty percent expressed an intention of returning to Ireland within 5 years. The factors most influencing their decision to leave were career opportunities (85%), working conditions (83%), and lifestyle (80%). Conclusion: The migration intentions expressed in this study predict an immediate and severe threat to the sustainability of the Irish healthcare service. Urgent interventions such as providing information about career options and specialty training pathways are required. These must begin in the undergraduate phase and continue in postgraduate training and are needed to retain medical school graduates.

The aim of this project was to determine the effect of patient position on the L5-L6 mid-laminar distance (MLD). The lumbar area of 22 recently euthanatized dogs of various breeds was radiographed in three positions: lateral recumbency with the spine in neutral position, lateral recumbency with the spine flexed in a kyphotic position, and sternal recumbency with the spine flexed in a kyphotic position. Digital images of the radiographs were analyzed using a computer program that allowed measurement of the MLD between L5-L6 in the three positions. The L5 and L6 MLD was significantly larger in sternal recumbency with the spine flexed (142.3 units) than both in lateral recumbency with the spine flexed (138.7 units; P= 0.001) and lateral recumbency with the spine in the neutral position (135.8 units; P < or = 0.001). The MLD in lateral recumbency with the spine flexed was significantly larger than in lateral recumbency with the spine in neutral position (P = 0.005). Positioning a dog in sternal recumbency with the spine flexed produces a significantly larger MLD than in lateral recumbency with the spine flexed; this should simplify needle placement when performing a lumbar puncture.

Otoliths from the stomachs of 138 by-caught grey seals (Halichoerus grypus) from the west coast of Ireland were compared with otoliths from the stomachs of 364 commercially caught cod(Gadus morhua) to determine if there were any overlaps in type, number and size of prey that might be attributable to secondary ingestion. A total of 19 species/groups were common to both cod and seal stomachs accounting for 99·6% and 95·8% of the otoliths from cod and seal stomachs respectively. There were significant differences between the otolith/fish lengths of all six species/groups compared but there were overlaps in the size distributions. Analysis of the diet composition of the cod stomachs suggested that larger cod consumed mainly fish and smaller cod consumed mainly crustaceans. Cod and seals were utilizing the same fish prey but the seals were generally consuming larger fish. Overlaps between the size distributions of prey species/groups suggest that secondary ingestion was possible and should be considered in future seal diet studies.

Background In 2006 the Royal College of Surgeons in Ireland, (RCSI), introduced the first four year Graduate Entry Programme (GEP) in medicine in Ireland in line with national policy to broaden access to medical education. One concern considered at the time, was whether the GEP students could be trained to the same standard as their undergraduate Direct Entry Programme (DEP, five/six year duration) counterparts in the shorter time frame. Since students from both cohorts undertake the same examinations in the final two years, it is possible to directly compare GEP vs DEP outcomes. The primary aim of the current study was to analyse the comparative performance of GEP and DEP students undergoing these examinations between 2008 and 2013. Methods Scores from five assessments performed during the final two years were transformed to z scores for each student and 4 scores for the penultimate year were summed to create a unit weighted composite score. The resultant scores for each of the two years were used to assess the comparative performance of GEP vs DEP cohorts and to perform sub-cohort analyses of GEP outcomes. Results In all cohorts/years examined, evidence demonstrated significantly better assessment outcomes for the GEP group for the final two years’ examinations as compared with the DEP group. In all but one cohort examined, this advantage was retained when nationality factors were excluded. Further analyses showed no difference in outcomes between GEP students having science vs. non-science backgrounds and/or between those from EU vs non-EU backgrounds. Finally, data suggested weak correlations between total composite scores and entry scores in American (r = 0.15) and Australian (r = 0.08) medical school admissions tests. Conclusions We have shown for the first time in Ireland, that graduate-entry students perform at least as well, or even better, than a corresponding undergraduate-entry group. Moreover, having a scientific background on entry to the GEP confers no advantage in final assessments. These data provide evidence of the viability of the graduate entry route into medical education in Ireland.