The impacts of profound gender discrimination on the survival of girls and women in son-preference countries - A systematic review

Amartya Sen first used the phrase 'missing women' to describe a survival disadvantage for women exposed to extreme gender discrimination in son-preference countries. In 1989 he estimated that, despite a biological survival advantage for females, there were 100 million fewer women in Asia and north Africa than expected. He blamed corrosive gender discrimination restricting the resources needed for survival. This systematic review examined demographic evidence on the impacts of profound gender discrimination on the survival of girls and women in son-preference countries. Thirty-four included studies provided consistent evidence of lower-than-expected female survival in 15 societies. Male-to-female sex ratios rose particularly in China and India between the 1980s and 2010s, despite general improvements in female mortality. High sex ratios in South Korea, however, returned to biologically normal levels. The number of 'missing women' rose steadily from 61 million in 1970 to 126 million in 2010 and was predicted to continue to rise until 2035. The number of 'missing women' in the world increased in relative and absolute terms between 1980 and 2020. Profound discrimination reduces female survival at every stage of life. Future research is needed to understand the complete pathways and mechanisms leading to poorer survival and the major policy drivers of these trends to devise the best possible ways of preventing the tragedy of 'missing women'.

Mediators of socioeconomic inequalities in preterm birth: a systematic review

BACKGROUND

Rates of preterm birth are substantial with significant inequalities. Understanding the role of risk factors on the pathway from maternal socioeconomic status (SES) to preterm birth can help inform interventions and policy. This study therefore aimed to identify mediators of the relationship between maternal SES and preterm birth, assess the strength of evidence, and evaluate the quality of methods used to assess mediation.

METHODS

Using Scopus, Medline OVID, "Medline In Process & Other Non-Indexed Citation", PsycINFO, and Social Science Citation Index (via Web of Science), search terms combined variations on mediation, socioeconomic status, and preterm birth. Citation and advanced Google searches supplemented this. Inclusion criteria guided screening and selection of observational studies Jan-2000 to July-2020. The metric extracted was the proportion of socioeconomic inequality in preterm birth explained by each mediator (e.g. 'proportion eliminated'). Included studies were narratively synthesised.

RESULTS

Of 22 studies included, over one-half used cohort design. Most studies had potential measurement bias for mediators, and only two studies fully adjusted for key confounders. Eighteen studies found significant socioeconomic inequalities in preterm birth. Studies assessed six groups of potential mediators: maternal smoking; maternal mental health; maternal physical health (including body mass index (BMI)); maternal lifestyle (including alcohol consumption); healthcare; and working and environmental conditions. There was high confidence of smoking during pregnancy (most frequently examined mediator) and maternal physical health mediating inequalities in preterm birth. Significant residual inequalities frequently remained. Difference-of-coefficients between models was the most common mediation analysis approach, only six studies assessed exposure-mediator interaction, and only two considered causal assumptions.

CONCLUSIONS

The substantial socioeconomic inequalities in preterm birth are only partly explained by six groups of mediators that have been studied, particularly maternal smoking in pregnancy. There is, however, a large residual direct effect of SES evident in most studies. Despite the mediation analysis approaches used limiting our ability to make causal inference, these findings highlight potential ways of intervening to reduce such inequalities. A focus on modifiable socioeconomic determinants, such as reducing poverty and educational inequality, is probably necessary to address inequalities in preterm birth, alongside action on mediating pathways.

An exploration of the statutory Healthy Start vitamin supplementation scheme in North West England

BACKGROUND

Government nutritional welfare support from the English 'Healthy Start' scheme is targeted at low-income pregnant women and preschool children, but take-up of its free food vouchers is much better than its free vitamin vouchers. While universal implementation probably requires a more extensive scheme to be cost-effective, the everyday experience of different ways of receiving or facilitating Healthy Start, especially via children's centres, also requires further evidence. This study therefore aimed to explore (in the context of low take-up levels) perceptions of mothers, health professionals, and commissioners about Healthy Start vitamin and food voucher take-up and compare experiences in a targeted and a universal implementation-area for those vitamins.

METHODS

Informed by quantitative analysis of take-up data, qualitative analysis focused on 42 semi-structured interviews with potentially eligible mothers and healthcare staff (and commissioners), purposively sampled via children's centres in a similarly deprived universal and a targeted implementation-area of North West England.

RESULTS

While good food voucher take-up appeared to relate to clear presentation, messaging, practicality, and monetary (albeit low) value, poor vitamin take-up appeared to relate to overcomplicated procedures and overreliance on underfunded centres, organizational goodwill, and families' resilience.

CONCLUSION

Higher 'universal' vitamin take-up may well have reflected fewer barriers when it became everyone's business to be vitamin-aware. Substantive Healthy Start reform in England (not just cosmetic tinkering) is long overdue. Our study highlights that 'policy, politics, and problem' should be aligned to reach considerable unmet need.

Age-Adjusted Associations Between Comorbidity and Outcomes of COVID-19: A Review of the Evidence From the Early Stages of the Pandemic

Objectives: Early in the COVID-19 pandemic, people with underlying comorbidities were overrepresented in hospitalised cases of COVID-19, but the relationship between comorbidity and COVID-19 outcomes was complicated by potential confounding by age. This review therefore sought to characterise the international evidence base available in the early stages of the pandemic on the association between comorbidities and progression to severe disease, critical care, or death, after accounting for age, among hospitalised patients with COVID-19.

Methods: We conducted a rapid, comprehensive review of the literature (to 14 May 2020), to assess the international evidence on the age-adjusted association between comorbidities and severe COVID-19 progression or death, among hospitalised COVID-19 patients – the only population for whom studies were available at that time.

Results: After screening 1,100 studies, we identified 14 eligible for inclusion. Overall, evidence for obesity and cancer increasing risk of severe disease or death was most consistent. Most studies found that having at least one of obesity, diabetes mellitus, hypertension, heart disease, cancer, or chronic lung disease was significantly associated with worse outcomes following hospitalisation. Associations were more consistent for mortality than other outcomes. Increasing numbers of comorbidities and obesity both showed a dose-response relationship. Quality and reporting were suboptimal in these rapidly conducted studies, and there was a clear need for additional studies using population-based samples.

Conclusions: This review summarises the most robust evidence on this topic that was available in the first few months of the pandemic. It was clear at this early stage that COVID-19 would go on to exacerbate existing health inequalities unless actions were taken to reduce pre-existing vulnerabilities and target control measures to protect groups with chronic health conditions.

Analysing synthesis of evidence in a systematic review in health professions education: observations on struggling beyond Kirkpatrick

Background: Systematic reviews in health professions education may well under-report struggles to synthesize disparate evidence that defies standard quantitative approaches. This paper reports further process analysis in a previously reported systematic review about mobile devices on clinical placements.Objective: For a troublesome systematic review: (1) Analyse further the distribution and reliability of classifying the evidence to Maxwell quality dimensions (beyond 'Does it work?') and their overlap with Kirkpatrick K-levels. (2) Analyse how the abstracts represented those dimensions of the evidence-base. (3) Reflect on difficulties in synthesis and merits of Maxwell dimensions.Design: Following integrative synthesis of 45 K2-K4 primary studies (by combined content-thematic analysis in the pragmatism paradigm): (1) Hierarchical cluster analysis explored overlap between Maxwell dimensions and K-levels. Independent and consensus-coding to Maxwell dimensions compared (using: percentages; kappa; McNemar hypothesis-testing) pre- vs post-discussion and (2) article abstract vs main body. (3) Narrative summary captured process difficulties and merits.Results: (1) The largest cluster (five-cluster dendrogram) was acceptability-accessibility-K1-appropriateness-K3, with K1 and K4 widely separated. For article main bodies, independent coding agreed most for appropriateness (good; adjusted kappa = 0.78). Evidence increased significantly pre-post-discussion about acceptability (p = 0.008; 31/45→39/45), accessibility, and equity-ethics-professionalism. (2) Abstracts suggested efficiency significantly less than main bodies evidenced: 31.1% vs 44.4%, p = 0.031. 3) Challenges and merits emerged for before, during, and after the review.Conclusions: There should be more systematic reporting of process analysis about difficulties synthesizing suboptimal evidence-bases. In this example, Maxwell dimensions were a useful framework beyond K-levels for classifying and synthesizing the evidence-base.

A Best Evidence Medical Education (BEME) systematic review of: What works best for health professions students using mobile (hand-held) devices for educational support on clinical placements? BEME Guide No. 52

BACKGROUND

Ingrained assumptions about clinical placements (clerkships) for health professions students pursuing primary basic qualifications might undermine best educational use of mobile devices.

QUESTION

What works best for health professions students using mobile (hand-held) devices for educational support on clinical placements?

METHODS

A Best Evidence Medical Education (BEME) effectiveness-review of "justification" complemented by "clarification" and "description" research searched: MEDLINE, Educational Resource Information Center, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Cochrane Central, Scopus (1988-2016). Reviewer-pairs screened titles/abstracts. One pair coded, extracted, and synthesized evidence, working within the pragmatism paradigm.

SUMMARY OF RESULTS

From screening 2279 abstracts, 49 articles met inclusion-criteria, counting four systematic reviews for context. The 45 articles of at least Kirkpatrick K2 primary research mostly contributed K3 (39/45, 86.7%), mixed methods (21/45, 46.7%), and S3-strength (just over one-half) evidence. Mobile devices particularly supported student: assessment; communication; clinical decision-making; logbook/notetaking; and accessing information (in about two-thirds). Informal and hidden curricula included: concerns about: disapproval; confidentiality and privacy; security;-distraction by social connectivity and busy clinical settings; and mixed messages about policy.

DISCUSSION AND CONCLUSION

This idiosyncratic evidence-base of modest robustness suggested that mobile devices provide potentially powerful educational support on clinical placement, particularly with student transitions, metalearning, and care contribution. Explicit policy must tackle informal and hidden curricula though, addressing concerns about transgressions.

Mixing it but not mixed-up: mixed methods research in medical education (a critical narrative review)

BACKGROUND

Some important research questions in medical education and health services research need 'mixed methods research' (particularly synthesizing quantitative and qualitative findings). The approach is not new, but should be more explicitly reported.

AIM

The broad search question here, of a disjointed literature, was thus: What is mixed methods research - how should it relate to medical education research?, focused on explicit acknowledgement of 'mixing'.

METHODS

Literature searching focused on Web of Knowledge supplemented by other databases across disciplines.

FINDINGS

Five main messages emerged: - Thinking quantitative and qualitative, not quantitative versus qualitative - Appreciating that mixed methods research blends different knowledge claims, enquiry strategies, and methods - Using a 'horses for courses' [whatever works] approach to the question, and clarifying the mix - Appreciating how medical education research competes with the 'evidence-based' movement, health services research, and the 'RCT' - Being more explicit about the role of mixed methods in medical education research, and the required expertise

CONCLUSION

Mixed methods research is valuable, yet the literature relevant to medical education is fragmented and poorly indexed. The required time, effort, expertise, and techniques deserve better recognition. More write-ups should explicitly discuss the 'mixing' (particularly of findings), rather than report separate components.

Medical students' and prospective medical students' uncertainties about career intentions: cross-sectional and longitudinal studies

BACKGROUND

Policy prompts medical students' earlier career awareness.

AIM

To explore changes and uncertainty in medical (and prospective medical) students' career intentions in a 5-year problem-based curriculum.

METHODS

Six postal questionnaire surveys of medical students and one survey of prospective medical students sought career intentions from three entry-cohorts (one also seeking why they chose medicine, and one, the reason for the career intention).

RESULTS

From the 973 (91.4%) 2001/02 admission interviewees responding, 74/189 (39.2%) of those admitted and remaining 'in-year' re-reported career intentions 5 years later (2006/07). Of the 1999 entrants (start-Year 1; end-Year 1; and mid-Year 3) and 2001 entrants (start-Year 1 and end-Year 1), 61.2-77.9% responded. Up to mid-programme, only 9.5-18.8% reported general practice, significantly more of whom described altruistic reasons for choosing medicine (2001 entrants). Tracked longitudinally, career intentions stayed relatively stable, but a small significant retreat from general practice over Year 1 predated clinical placements. From pre-admission to mid-Year 5, uncertainty decreased significantly, but 14.9% replied 'do not know' both times. Significantly more prospective students from the least affluent English or Welsh postcodes specified a career intention.

CONCLUSION

Many students might delay considering career intentions, particularly general practice. Socioeconomic determinants of early medical career decision making merit further study.

Public health education for medical students: rising to the professional challenge

Public health competencies, especially as they relate to the management of chronic disease, will be of increasing importance to the global health-care workforce. The General Medical Council's recommendations on basic medical education have helped to entrench the position of public health and related disciplines. Tomorrow's Doctors has recently been updated. This article describes the indicative goals that should underpin the development of undergraduate medical education in public health, presented in a national statement. The statement was originally produced on behalf of academic departments of public health and related disciplines in UK medical schools. The dearth of evidence in this field leaves many questions for future educational research.

Problem-based learning at the receiving end: a 'mixed methods' study of junior medical students' perspectives

Qualitative insights about students' personal experience of inconsistencies in implementation of problem-based learning (PBL) might help refocus expert discourse about good practice.

AIM

This study explored how junior medical students conceptualize: PBL; good tutoring; and less effective sessions.

METHODS

Participants comprised junior medical students in Liverpool 5-year problem-based, community-orientated curriculum. Data collection and analysis were mostly cross-sectional, using inductive analysis of qualitative data from four brief questionnaires and a 'mixed' qualitative/quantitative approach to data handling. The 1999 cohort (end-Year 1) explored PBL, generated 'good tutor' themes, and identified PBL (dis)advantages (end-Year 1 then mid-Year 3). The 2001 cohort (start-Year 1) described critical incidents, and subsequently (end-Year 1) factors in less effective sessions. These factors were coded using coding-frames generated from the answers about critical incidents and 'good tutoring'.

RESULTS

Overall, 61.2% (137), 77.9% (159), 71.0% (201), and 71.0% (198) responded to the four surveys, respectively. Responders perceived PBL as essentially process-orientated, focused on small-groupwork/dynamics and testing understanding through discussion. They described 'good tutors' as knowing when and how to intervene without dominating (51.1%). In longitudinal data (end-Year 1 to mid-Year 3), the main perceived disadvantage remained lack of 'syllabus' (and related uncertainty). For less effective sessions (end-Year 1), tutor transgressions reflected unfulfilled expectations of good tutors, mostly intervening poorly (42.6% of responders). Student transgressions reflected the critical incident themes, mostly students' own lack of work/preparation (54.8%) and other students participating poorly (33.7%) or dominating/being self-centred (31.6%).

CONCLUSION

Compelling individual accounts of uncomfortable PBL experiences should inform improvements in implementation.

Patients bringing information to primary care consultations: a cross-sectional (questionnaire) study of doctors' and nurses' views of its impact

OBJECTIVES

To explore the perceived frequency and impact of patients bringing health information from the Internet to primary care consultations.

METHOD

A questionnaire was sent to all general practitioners (GPs) and practice nurses (nurses) in a primary care trust in the North-west of England.

RESULTS

The response was 52.3%, more nurses responding than GPs (61.2% vs 46.8%). A substantial majority (93.9% and 78.0%) had experienced patients bringing such information in the last 6 months, which often lengthened the consultations. Significantly more nurses than GPs felt that the information helped the consultation (87.1% vs 37.7%), but also reported that patients bringing such information was off-putting (21.9% vs 6.3%).

CONCLUSIONS

Both GPs and nurses experienced patients bringing health information to consultations and significantly differed in their views about whether it helped or hindered. Primary care staff should anticipate patients' use of the Internet for health information and should actively manage patients introducing it into the consultation.

Time to think? Questionnaire survey of pre-registration house officers' experiences of critical appraisal in the Mersey Deanery

CONTEXT

Workload pressures may lead pre-registration house officers (PRHOs) to undervalue critical appraisal and thinking skills. This study aimed to explore Mersey Deanery PRHOs' attitudes, experiences and perceived readiness for practising evidence-based medicine with critical appraisal skills.

METHODS

A cross-sectional survey of 157 PRHOs from 5 postgraduate centres in the UK, using a semistructured questionnaire, at the beginning and end of the pre-registration year. Main outcome measures were level of agreement with closed statements exploring experiences and opinions about critical appraisal skills and evidence-based practice. Open questions explored personal experiences.

RESULTS

Most PRHOs (69%) felt medical school prepared them to use critical appraisal skills and perceived such skills as relevant (63%). Fewer felt that their clinical work was based on best available evidence (57%). The busier the PRHOs, the less likely they were to agree that their practice followed best evidence. The PRHOs were more likely to feel supported and that their practice was evidence-based at the end of the year. Responders identified several reasons for their practice not being evidence-based, including workload, lack of skills, deferring to senior colleagues, and non-conducive hospital culture.

CONCLUSIONS

The nature of PRHO work still mitigates against critical thinking and appraising evidence, with a lack of protected time and perceived inconsistent support from educational supervisors. Many PRHOs rely entirely on evidence-based summaries and guidelines from others. The PRHO year is a period of crucial transition, however, and critical appraisal skills and evidence-based approaches need developing post-qualification, with sufficient protected time for their integration into practice. Foundation year reforms reinforce such requirements.

Junior medical students' notions of a 'good doctor' and related expectations: a mixed methods study

OBJECTIVE

To explore junior medical students' notions of a 'good doctor', given their ideas about: success in Year 1, house jobs, and their attraction to medicine.

METHODS

Study participants were junior medical students (1999 and 2001 entry cohorts studied thrice and twice, respectively) and prospective students of the University of Liverpool's 5-year, problem-based, community-orientated curriculum. Data collection and analysis used a 'mixed methods' approach, cross-sectional design, and brief questionnaire surveys. In an index survey, open questions (analysed inductively) explored house jobs and Year 1 success. They also generated 'good doctor' themes, which a second survey confirmed and 3 surveys ranked. A sixth survey explored motivation for choosing medicine (open question). Good doctor rankings were analysed by postcode for prospective medical students classified as school-leaver residents of England and Wales.

RESULTS

Response rates were: 91.4% (973) of the 2001-02 admission candidates, on interview days; 68.0% (155), 61.2% (137) and 77.9% (159) of the 1999 cohort (at entry, end-Year 1 and mid-Year 3, respectively), and 71.0% (201) and 71.0% (198) of the 2001 cohort (at entry and end-Year 1, respectively). From 9 themes generally compatible with self-reported motivations and expectations, junior and prospective medical students consistently valued a good doctor as a 'compassionate, patient-centred carer' and a 'listening, informative communicator' over an 'exemplary, responsible professional'. Prospective students from less affluent English and Welsh postcodes valued 'efficient, organised self-manager' very slightly more highly (r(s) = - 0.140, P = 0.003).

CONCLUSIONS

This research provided empirical evidence to support ongoing commentary about patients mostly seeking qualities related to communication, caring, and competence in doctors. Weak evidence that socio-economic status might affect notions of a good doctor is worth pursuing.

The limits of tutors' comfort zones with four integrated knowledge themes in a problem-based undergraduate medical curriculum (Interview study)

PURPOSE

To explore how a cohort of problem-based learning (PBL) tutors (with diverse medical and other content expertise) conceptualised their students' integrated learning agenda, particularly for content less familiar to the vast majority, such as public health elements.

SETTING

Problem-based undergraduate medical curriculum, The University of Liverpool, in its first-ever year.

PARTICIPANTS

Foundation PBL tutors for Year 1 students, Semester 1.

METHOD

A cross-sectional, semistructured telephone interview study was undertaken during spring 1997, with open-ended questions about Semester 1 experience of the four main themes. Qualitative data were analysed inductively and iteratively for emerging patterns and instances.

RESULTS

All 34 tutors responded. Of these, 26/34 (76%) were male and 23 (68%) were medically qualified. Towards the end of each approximately (median) 20-minute interview, reflecting on the curriculum themes, tutors mostly identified with the basic/clinical science theme (Structure and Function). Almost half articulated a clear division (implicitly or explicitly 'fact' versus 'non-fact') between it and the 'other three' themes of behavioural science, population science, and ethicolegal aspects of professional practice, respectively. Only 14/34 (41%) of tutors (including both public health doctors) outlined the public health-based theme adequately without disclosing confusion, antagonism/indifference or difficulties/uncertainty.

CONCLUSION

This study provides baseline qualitative insights about new PBL tutors' insecurities when facilitating student discussion across integrated content. Given the difficulties of recruiting suitable educators into this role and potential resource limitations, staff retention and development strategies still must confront the reality of PBL tutors' bemusement when they are placed outwith their usual comfort zones.

Making sense of trying not to teach: an interview study of tutors' ideas of problem-based learning

PURPOSE

To explore how a cohort of first-ever "foundation" tutors in a new problem-based curriculum characterized and made sense of problem-based learning (PBL).

METHOD

The sample consisted of all foundation tutors (n = 34) from The University of Liverpool's undergraduate medical curriculum, 1996-97, the first semester of the first year that PBL became a main vehicle for knowledge acquisition. The cross-sectional study design involved semistructured telephone interviews with the tutors about PBL and problem solving. The author taped and transcribed the interviews and conducted an inductive analysis of these qualitative data.

RESULTS

All tutors responded, with interviews lasting about 20 minutes: 26/34 (76%) were men and 23 (68%) were medically qualified. Twenty-nine (85%) facilitated 19-21 of the 21 PBL sessions. Most tutors conceptualized PBL as being student-centered (68%), involving small-group work (53%), but ignored its reflective component. They conceptualized good PBL tutors diversely, but mostly as "knowing" when and how to intervene (41%) and empathizing with students (29%). Few tutors characterized PBL in terms of problem solving, yet over half agreed, cursorily, that they were intimately related. The tutors were generally unclear about this relationship.

CONCLUSION

These tutors mostly characterized PBL positively as a philosophy, yet missed its reflective elements and were particularly challenged by their own fallibility in knowing when and how to intervene without teaching. Internal motivation and direct experience of PBL helped balance some of the tutors' confusion with the educational rationale, highlighting possibilities for future staff development.

What issues are raised by evaluating problem-based undergraduate medical curricula? Making healthy connections across the literature

There have been various waves and ripples of undergraduate medical curricular reform over recent decades. Such programme-wide innovation can attract exceptional suspicion and scrutiny about its worth, fueled by adverse reactions to change. It also raises expectations of what programme evaluation can reveal about the experience, achievements and 'added value' of the medical students or doctors. Problem-based undergraduate medical curricula are expected, for example, to fulfil elusive 'true' (outcome) descriptors of educational quality. The aim here was to explore the rationale, approach and challenges for undergraduate medical programme evaluation, particularly for problem-based curricula. The main focus was on internal, formative evaluation: Why undertake educational evaluation? What is the evaluative context of problem-based learning? What philosophy has guided programme evaluation of innovative undergraduate medical curricula? What can educational, health care and other evaluation frameworks offer? What can be learned from examples of published accounts of problem-based undergraduate medical programme evaluation? Where to from here? Ideally, evaluators of medical education should be explicit about their rationale, highlight local curricular context and special features, balance process-measures with outcome-measures (including unplanned outcomes), and be eclectic in methods. 'Healthier links' with the health care evaluation and educational evaluation literature could be beneficial. It remains to be seen, however, whether the medical educational changes that the General Medical Council's Tomorrow's Doctors triggered in the United Kingdom will stimulate important advances in educational evaluation.

Student assessment in undergraduate medical education in the United Kingdom, 1998

This report describes the results of the project 'Assessment of Undergraduate Medical Education: Re-inventing the Wheel?' funded by the Nuffield Trust. The project was initiated in order to obtain information on current assessment practices in medical schools across the UK, to determine the extent of change as a consequence of the curricular reforms recommended by the General Medical Council (GMC) in 1993 and, if necessary, to stimulate debate about assessment and provide an impetus for change. The data obtained provide a detailed profile of the timing and nature of assessments used in medical schools and provide information for comparison with the survey of basic medical education in the British Isles carried out in 1977 and any subsequent studies. The study provides confirmatory and unexpected evidence. Schools are clearly revising their curricula consistent with recommendations made by the GMC. The main components of the study were as follows: a postal questionnaire sent to all UK medical schools, a national workshop, and four case studies of innovative assessment practices.

Promoting professional knowledge, experiential learning and critical thinking for medical students

It has been recognized internationally that undergraduate medical education must adapt to changing needs, as illustrated by the Tomorrow's Doctors recommendations from the General Medical Council. This paper aims to relate contemporary educational theory to under-graduate medical educational requirements, specifically highlighting conditions (e.g. experiential learning) for: professional knowledge acquisition; critical thinking, problem-solving and clinical problem-solving; and lifelong professional learning. Furthermore, problem-based learning (PBL) is highlighted as potentially providing such conditions. There are lessons from contemporary educational theory for the reform of undergraduate medical education. These include valuing prior knowledge and experience; promoting learner responsibility through facilitating rather than directing learning; encouraging learners to test out and apply new knowledge, and using small-group work to foster explicitly the elusive skills of critical thinking and reflection. Contemporary educational theory contributes valuable insights, but cannot dictate the ultimate 'mix'; at best it provides some principles for reflective analysis of the learning experiences created for tomorrow's doctors.

'Science', 'critical thinking' and 'competence' for tomorrow's doctors. A review of terms and concepts

CONTEXT

The recommendations of the General Medical Council in Tomorrow's Doctors renewed efforts to define core knowledge in undergraduate medical education. They also encouraged better use of the medical knowledge base in nurturing clinical judgement, critical thinking, and reflective practice. What then does the medical world understand by 'science', 'critical thinking' and 'competence', given the need to address both growth and uncertainty in the knowledge base and to practise evidence-based healthcare?

AIM AND OBJECTIVES

This review aims to outline the role of these key concepts in preparing undergraduate medical students for professional practice. Specifically, it explores: the fallibility of the 'scientific' foundations of medical practice; the role of understanding and thinking in undergraduate medical education; the need for a broad interpretation of competence and its relationship to transferability, and the nature of clinical judgement.

COMMENT

Tensions are seen to lie in the varying interpretations of clinical decision making as art or science; the varying characterizations of the nature of skilled performance in the novice, the competent and the expert practitioner, and the varying reactions to the acceptability and usefulness of 'meta-' concepts in capturing the essence of professional practice. Habitual self-conscious monitoring of mental processes may be the key to the flexible transfer and application of knowledge and skills across the contexts, characterized by uncertainty and incomplete evidence, for which doctors must be prepared.

Cause of death in cerebral palsy: a descriptive study

BACKGROUND

Cause specific research on death certification in chronic disease has rarely involved cerebral palsy.

AIMS

To evaluate cause of death information in people known to have cerebral palsy by: describing the cause of death distribution; determining case ascertainment using death certification as the data source; and analysing the choice of wording and its arrangement in the "cause of death statement". STUDY CASES AND SETTING: People with early or late impairment cerebral palsy who died by 30 June 1998, on the population based Mersey Cerebral Palsy Register born 1966-91 to mothers resident locally.

STUDY DESIGN

Descriptive study of the multiply coded cause of death statements from National Health Service Central Register flagging.

RESULTS

Death certificate copies were acquired for all 282 (13.4%) of the 2102 registered cases who died. Cerebral palsy was the most common "underlying cause of death" (95 of 282; 33.7%) and was mentioned in a further 61 cases. The underlying cause of death was more likely to be cerebral palsy with increasingly severe disability and was derived from Part II in 16 of 95 cases.

CONCLUSIONS

The potential of death certification for case ascertainment of cerebral palsy is important, but limited, even with multiple cause coding. Mortality data need careful interpretation as a proxy source for examining trends and patterns in cerebral palsy.

What lessons can be learned for cancer registration quality assurance from data users? Skin cancer as an example

BACKGROUND

In cancer registration, data cleaning (i.e. amendments made by data users to datasets released by registries) is potentially informative for quality assurance, but generally underreported.

AIM

To assess the scope for learning lessons about cancer registration quality assurance from a data user (using skin cancer as the example).

METHODS

The main design features were: (i) A descriptive study identifying, qualitatively and quantitatively, the breadth, depth, and impact of quality assurance issues raised by a user cleaning Merseyside and Cheshire Cancer Registry skin cancer data. Errors were rectified and pitfalls for interpretation were identified. (ii) A nested validation of morphology and site coding on random samples of cutaneous malignant melanomas, basal cell carcinomas (BCC), and squamous cell carcinomas. The 33132-record dataset comprised: all registered skin lesions, except metastases; most recorded variables (about patient, lesion, treatment, outcome); for Merseyside and Cheshire residents diagnosed 1970-1991.

RESULTS

(i) Ineligible cases represented 0.3% (97/33132), and were detected best by morphology checks. Most quality assurance issues identified related to local custom and practice, staff training, and computerization, being particularly illustrated by problematic BCC registration practice (e.g. records written over unchallenged by range checks; and idiosyncratic use of variables). (ii) Post-cleaning, morphology coding errors were minimal in the random samples.

CONCLUSION

There is great scope for data users to contribute to cancer registration quality assurance. Ultimately, the study dataset appeared fit for epidemiological analysis and important quality assurance messages emerged. Shared explicit standard guidelines for data preparation and validation are needed by users, whose insights could and should be better recognized by cancer registries.

Do we all mean the same thing by "problem-based learning"? A review of the concepts and a formulation of the ground rules

Problem-based learning (PBL) has emerged as a useful tool of epistemological reform in higher education, particularly in medical schools. Indeed, PBL has spent most of its career inducing revolutionary undergraduate medical reform. Nevertheless, obtaining informed agreement on the characteristics of the PBL "genus" is a challenge when the label is vulnerable to being borrowed for prestige or subversion. Many "PBL" single-subject courses within traditional curricula do not use PBL at all. Such semantic uncertainty compromises the evidence-base on the added value of problem-based versus traditional approaches and the main messages for good practice. This literature review explores what is meant by the term PBL by aiming to answer the following questions: What difficulties are inherent in the "problem-based" tag? What does the term "problem-based curriculum" imply? How has PBL been characterized and validated by focusing on its purpose? How else has PBL been characterized? How does PBL relate to problem solving? How does PBL relate to epistemological reform? In conclusion, what ground rules can be formulated for PBL? Despite much conceptual fog lingering over the PBL literature, useful ground rules can be formulated.

Microdosimetry spectra of the Loma Linda proton beam and relative biological effectiveness comparisons

Protons have long been recognized as low LET radiation in radiotherapy. However, a detailed account of LET (linear energy transfer) and RBE (relative biological effectiveness) changes with incident beam energy and depth in tissue is still unresolved. This issue is particularly important for treatment planning, where the physical dose prescription is calculated from a RBE using cobalt as the reference radiation. Any significant RBE changes with energy or depth will be important to incorporate in treatment planning. In this paper we present microdosimetry spectra for the proton beam at various energies and depths and compare the results to cell survival studies performed at Loma Linda. An empirically determined biological weighting function that depends on lineal energy is used to correlate the microdosimetry spectra with cell survival data. We conclude that the variations in measured RBE with beam energy and depth are small until the distal edge of the beam is reached. On the distal edge, protons achieve stopping powers as high as 100 keV/micron, which is reflected in the lineal energy spectra taken there. Lineal energy spectra 5 cm beyond the distal edge of the Bragg peak also show a high LET component but at a dose rate 600 times smaller than observed inside the proton field.

"Inaccuracy' in death certification--where are we now?

BACKGROUND

This review aims to document and analyse aspects of death certification that are relevant to public health.

METHODS

A literature review on death certification primarily used the computerized Index Medicus (1981 to mid-1995), and concentrated on completing death certificates, accuracy, standards, education and procedural requirements. Further sentinel publications pre-dating this were identified from the main literature base.

RESULTS

The uses of mortality data, historical and procedural context for recording death, the philosophy of Underlying Cause of Death and its relationship to the truth, the extent and impact of "inaccuracy', the certificate and the certifier, and possible ways forward are discussed. It is argued that the question "How inaccurate are cause of death data?' is harder to answer than the literature suggests. Deriving a useful estimate is difficult because of inter-study differences in (1) definition, measurement (how and by whom?) and practical importance of error, and standards used; (2) focus (e.g. death certificate or mortality data), observing everyday practice or simulation exercises, diagnostic and/or semantic issues.

CONCLUSION

The traditional perspective on improving the quality of death certification has not worked. There is a need for reorientated thinking rather than just urging more education. Evidence-based educational interventions are needed. The flaws in the theoretical framework of cause of death and the routine nature of death certification are unavoidable, but require consideration. Certifiers need practical feedback mechanisms, integral to continuing quality assurance at all levels and fostering an understanding of the construction of mortality data. Continued development should be a core public health medicine role.

A performance study of the Loma Linda proton medical accelerator

More than three years have passed since Loma Linda treated the first cancer patient with the world's first proton accelerator dedicated to radiation therapy. Since that time, over 1000 patients have completed treatments and the facility currently treats more than 45 patients per day. With a typical intensity of 3 x 10(10) protons per pulse and 27 pulses per minute, dose rates of 90-100 cGy/min are easily achieved on a 20-cm diameter field. In most cases, patient treatment times are 2 min, much less than the patient alignment time required before each treatment. Nevertheless, there is considerable medical interest in increasing field sizes up to 40-cm diameter while keeping dose rates high and treatment times low. In this article, beam measurements relevant to intensity studies are presented and possible accelerator modifications for upgrades are proposed. It is shown that nearly all intensity losses can be ascribed to the large momentum spread of the injected beam and occur at or near the injection energy of 2 MeV. The agreement between calculations and measurements appears quite good. In addition, optimum beam characteristics for a new injector are discussed based upon the momentum acceptance and space charge limits of the Loma Linda synchrotron.

Death certification by house officers and general practitioners--practice and performance

The objective of this study was to assess the knowledge, attitudes and behaviour of House Officers and General Practitioners (GPs) in relation to death certification, to determine the scope for future intervention. A postal questionnaire was used to survey all House Officers (174) and a 10 per cent random sample of GPs (131) in Mersey Region. The main outcome measures were: death certification experience; knowledge, attitudes and behaviour in relation to data uses and coding; and acceptability of Cause of Death statements. Response rates were comparable-119/174 House Officers (68.4 per cent) and 95/131 GPs (72.5 per cent). Most House Officers (78.8 per cent) and GPs (85.3 per cent) reported that they made the best possible Cause of Death statement but, respectively, 62.4 per cent and 59.3 per cent of these might modify a statement in some circumstances. Significantly more House Officers (70.3 per cent) than GPs (44.2 per cent) acknowledge room for improvement and were amenable to more training (86.6 per cent versus 52.5 per cent), but significantly fewer felt sufficiently instructed (23.7 per cent versus 52.6 per cent). Most respondents (> 90 per cent) considered accurate death certification important, but 46.2 per cent of House Officers had not read the death certificate book instructions. Knowledge was variable, especially concerning Underlying Cause of Death. Written Cause of Death statements were broadly similar in style and standard between groups. Experience did not appear to improve death certification practice. Better and co-ordinated undergraduate and early post-graduate education (which should be continuing and audited), and practical accessible guidance on death certificate completion, might improve standards of practice and performance within the existing framework. Alternative methods of presenting guidance on death certificate completion should be explored.

Rapid reporting on fine needle aspiration of breast lumps in outpatients

A retrospective analysis of the performance and value of fine needle aspiration of symptomatic breast masses in a special outpatient "breast clinic" within a district general hospital was carried out. All but a few aspirations were performed by a group of histopathologists, with, immediate cytological reporting. Fine needle aspiration was more sensitive for detecting malignancy than clinical assessment alone, the sensitivity increasing with the experience of the aspirator. The results compared favourably with those in reported series from specialist centres in the United Kingdom. The value of fine needle aspiration extends to the overall management of patients with breast masses but the results must be assessed in conjunction with the clinical context in view of the possibility of false negative or, more rarely, false positive cytological diagnoses.