Variation in Experiences and Attainment in Surgery Between Ethnicities of UK Medical Students and Doctors (ATTAIN): Protocol for a Cross-Sectional Study

BACKGROUND

The unequal distribution of academic and professional outcomes between different minority groups is a pervasive issue in many fields, including surgery. The implications of differential attainment remain significant, not only for the individuals affected but also for the wider health care system. An inclusive health care system is crucial in meeting the needs of an increasingly diverse patient population, thereby leading to better outcomes. One barrier to diversifying the workforce is the differential attainment in educational outcomes between Black and Minority Ethnic (BME) and White medical students and doctors in the United Kingdom. BME trainees are known to have lower performance rates in medical examinations, including undergraduate and postgraduate exams, Annual Review of Competence Progression, as well as training and consultant job applications. Studies have shown that BME candidates have a higher likelihood of failing both parts of the Membership of the Royal Colleges of Surgeons exams and are 10% less likely to be considered suitable for core surgical training. Several contributing factors have been identified; however, there has been limited evidence investigating surgical training experiences and their relationship to differential attainment. To understand the nature of differential attainment in surgery and to develop effective strategies to address it, it is essential to examine the underlying causes and contributing factors. The Variation in Experiences and Attainment in Surgery Between Ethnicities of UK Medical Students and Doctors (ATTAIN) study aims to describe and compare the factors and outcomes of attainment between different ethnicities of doctors and medical students.

OBJECTIVE

The primary aim will be to compare the effect of experiences and perceptions of surgical education of students and doctors of different ethnicities.

METHODS

This protocol describes a nationwide cross-sectional study of medical students and nonconsultant grade doctors in the United Kingdom. Participants will complete a web-based questionnaire collecting data on experiences and perceptions of surgical placements as well as self-reported academic attainment data. A comprehensive data collection strategy will be used to collect a representative sample of the population. A set of surrogate markers relevant to surgical training will be used to establish a primary outcome to determine variations in attainment. Regression analyses will be used to identify potential causes for the variation in attainment.

RESULTS

Data collected between February 2022 and September 2022 yielded 1603 respondents. Data analysis is yet to be competed. The protocol was approved by the University College London Research Ethics Committee on September 16, 2021 (ethics approval reference 19071/004). The findings will be disseminated through peer-reviewed publications and conference presentations.

CONCLUSIONS

Drawing upon the conclusions of this study, we aim to make recommendations on educational policy reforms. Additionally, the creation of a large, comprehensive data set can be used for further research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40545.

Gene Mutations in Cushing's Syndrome

Background

Prolonged exposure to glucocorticoids can result in the development of Cushing's syndrome. Excess serum cortisol can occur due to several factors including exogenous steroids, pituitary and adrenal adenoma, and ectopic ACTH secretion.

Summary

The last 2 decades have seen significant progress in identifying new genetic and molecular mechanisms underlying hypercortisolemia. This has implicated mutations seen in a multitude of aberrant pathways that underpin the pathophysiology of Cushing's syndrome.

Key Messages

There is much overlap between the different, with mutations affecting well-understood molecular pathways such as the cAMP/PKA/MAPK and Wnt signalling systems. Further work should delineate the exact involvement of specific mutations in Cushing's syndrome and the effect of epigenetic/microenvironmental interactions. This could have implications for screening, as the identification of specific mutations may lead to earlier identification and subsequently improved prognosis.

Contemporary Considerations in the Evolution of Wearable Technology for Arrhythmia Detection

Arrhythmias are an increasingly common cause of hospital admissions worldwide. Late detection of arrhythmias is associated with a significantly increased risk of cardiovascular complications. Early identification and management of life-threatening arrhythmias is paramount to reduce mortality. Wearable technologies are now widespread among the general population, providing a continuous output of healthcare data. However, this data are not routinely integrated into clinical practice. Here, we begin by outlining the current landscape in wearable technology for aiding arrhythmia detection; we then consider the clinical impact of wearable technology for both clinicians and patients; we further highlight the latest and emerging trials in wearable technology for arrhythmia detection and finally postulate the wider implications of the expansion of such cardiac devices.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

225 First Contact: A Series of Zoom-Based, Virtual on Call Shifts

Aim

COVID-19 has resulted in reduced exposure to on-call shifts where medical students could increase confidence and proficiency in task prioritisation and decision making. Existing ‘simulated on-calls’ provide a substitute in a controlled environment, however in person teaching has also been limited by COVID-19. Our virtual on-call sessions use ZOOM to replicate the higher-level learning experiences normally conferred by live simulation.

Method

We designed a series of virtual ‘on-calls’ for medical students. Participants were ‘on-call’, receiving ‘bleeps’ which were ‘answered’ by calling a facilitator via ZOOM. The facilitator would roleplay a scenario and the ‘Electronic Patient Record’ (EPR) on Google Forms contained patient notes and observations. Students needed to collect information from the facilitator and document a management plan into the EPR. Participants received ‘bleeps’ of varying complexity, urgency and relevance and were expected to prioritise and triage tasks accordingly. Evaluation was via a pre/post session quiz with separate feedback forms.

Results

23 students from 18 universities participated. Students reported increased confidence in managing on-call scenarios, and average scores improved in the post session quiz. Positive feedback was paid to the variety of scenarios, the EPR system and the feeling of realism elicited from the need to triage and prioritise jobs.

Conclusions

Our framework uses readily accessible technology to provide interactive learning experience. Feedback suggested students engaged in higher order learning and thinking, achieving our stated aims. We aim to incorporate technologies such as automation software which will allow for a scalable, free, and accessible virtual on call.

Breast cancer: presentation, investigation and management

Breast cancer is the most common global malignancy and the leading cause of cancer deaths. Despite this, undergraduate and postgraduate exposure to breast cancer is limited, impacting on the ability of clinicians to accurately recognise, assess and refer appropriate patients. This article provides a comprehensive review of the pathology, epidemiology, clinical presentation, referral pathways and management of breast cancer in the UK. It also describes how to conduct a thorough clinical breast examination.

Recent Updates and Technological Developments in Evaluating Cardiac Syncope in the Emergency Department

Syncope is a commonly encountered problem in the emergency department (ED), accounting for approximately 3% of presenting complaints. Clinical assessment of syncope can be challenging due to the diverse range of conditions that can precipitate the symptom. Annual mortality for patients presenting with syncope ranges from 0-12%, and if the syncope is secondary to a cardiac cause, then this figure rises to 18-33%. In ED, it is paramount to accurately identify those presenting with syncope, especially patients with an underlying cardiac aetiology, initiate appropriate management, and refer them for further investigations. In 2018, the European Society of Cardiology (ESC) updated its guidelines with regard to diagnosing and managing patients with syncope. We highlight recent developments and considerations in various components of the workup, such as history, physical examination, investigations, risk stratification, and novel biomarkers, since the establishment of the 2018 ESC guidelines. We further discuss the emerging role of artificial intelligence in diagnosing cardiac syncope and postulate how wearable technology may transform evaluating cardiac syncope in ED.

The genetic and epigenetic contributions to the development of nutritional rickets

Nutritional rickets is an important disease in global health. Although nutritional rickets commonly manifests as bony deformities, there is an increased risk of life-threatening seizures secondary to hypocalcaemia. Dietary vitamin D deficiency is associated with the development of nutritional rickets among children and infants. This is especially true in populations of darker skinned individuals in high-latitude environments due to decreased ultraviolet light exposure, and in populations in tropical and subtropical climates due to cultural practices. A growing body of evidence has demonstrated that genetic factors might influence the likelihood of developing nutritional rickets by influencing an individual's susceptibility to develop deficiencies in vitamin D and/or calcium. This evidence has been drawn from a variety of different techniques ranging from traditional twin studies to next generation sequencing techniques. Additionally, the role of the epigenome in the development of rickets, although poorly understood, may be related to the effects of DNA methylation and non-coding RNAs on genes involved in bone metabolism. This review aims to provide an overview of the current evidence that investigates the genetic and epigenetic determinants of nutritional rickets.

168 A Novel Approach to Interactive, Online History-Taking in Medical Education During the COVID-19 Pandemic

The COVID-19 pandemic resulted in an unprecedented shift from face-to-face to online teaching with a subsequent deleterious impact on the quality of teaching delivery within medical education

Our aim was to demonstrate the feasibility of utilizing a novel approach to interactive, online simulated history-taking.

The session was designed for students attending a virtual work-experience programme and is founded upon gamification principles. History-taking is a humanistic social process requiring effective communication skills and recognition of verbal and non-verbal cues. The session enabled students to directly instruct a passive clinician to take a history from a simulated patient actor, incorporating both verbal and non-verbal actions. This novel teaching method is analogous to Freire’s work, highlighting the importance of the learner being an active participant, thus enabling experiential learning

This interactive approach required a simulated patient actor, a passive clinician and a verbal instructor to be present. Students were presented with a case scenario and viewed the interaction between the simulated patient actor and passive clinician online via a video conferencing service (in this case, Zoom). Students provided instructions to the passive clinician using the typed chat function. These typed instructions were relayed by the verbal instructor to the passive clinician via an earpiece and the passive clinician would then embody these instructions. This allowed students to work as a group to directly elicit a history and witness their instructions being actioned. Examples of instructions included questions to verbalize, adjustments to body language and alteration of the tone of voice. Following good student instruction, the passive clinician gradually grew in competence and confidence throughout the scenario, thus allowing real-time, interactive feedback of their history-taking approach. The session concluded with a reflection of the communication traits that helped to gain an effective history from the patient using a debrief model.

169 Managing The Acutely Unwell Patient: An Interactive and Gamified Approach to Online Simulation During The COVID-19 Pandemic

The COVID-19 pandemic has necessitated a transition from traditional face-to-face teaching to virtual equivalents, sometimes at the expense of teaching quality and student engagement

Our aim was to demonstrate the feasibility of a novel gamified online simulation approach to teaching the management of acutely unwell patients.

Using elements of gamification and interactive film, this virtual session was designed to teach prospective medical students the ‘A to E’ approach of managing an acutely unwell patient. The management of an acutely unwell patient is an iterative and dynamic process that requires one to manage uncertainty and constantly re-evaluate the clinical situation. The session was designed using interactive film, with students given the ability to influence a clinician’s actions and subsequent changes of clinical scenario dictated by student live-vote. This interactive and engaging approach allowed students to reflect-in-action and be active learners, in line with an experiential pedagogy

Students attended a live session using a video conferencing service (Zoom) and their responses to clinical scenarios were recorded using an online voting tool (Mentimeter). Students were provided with a case history of an unwell patient and presented with an opening video. The session required video options to be pre-recorded to reflect the numerous potential avenues within the scenario as dictated by the students’ chosen actions. Depending on overall student voting consensus, pre-recorded videos of the clinician’s actions and changes to the clinical scenario were subsequently shown. For example, if the appropriate clinical action was selected, students would progress through the A-E approach. Students effectively guided the clinician to manage the unwell patient, with iterative and real-time feedback provided throughout the scenario. The session was concluded with a debrief, explanation of the case and key learning points.