May 11

The performance of junior doctors in applying clinical pharmacology knowledge and prescribing skills to standardised clinical cases

I have recently submitted a thesis for a masters of philosphy, entitled: The Design and Validation of assessment tools for use with Junior Doctors in Applying Clinical Pharmacology.  Part of this work has been written up and will be published in the next edition (June 2010) of the peer reviewed academic journal British Journal of Clinical Pharmacology.

Entitled: The performance of junior doctors in applying clinical pharmacology knowledge and prescribing skills to standardised clinical cases. This paper builds on the fact that safe prescribing is a core competency in undergraduate medical education. That a large proportion of undergraduate medical students and recently graduated doctors in the UK are not confident in their ability to effectively and safely prescribe and that errors are common in all healthcare settings and prescribing errors are the most common type.

This study produced twelve valid and statistically reliable assessments of Clinical Pharmacology and Therapeutics (CPT) knowledge and prescribing skills in areas that pose a high risk to patient safety. The findings show that a large proportion of Foundation Year 1 (FY1) doctors fail to demonstrate the level of CPT knowledge and prescribing ability judged by a subject matter expert (SME) panel to be required at this stage of their careers. My co-authors (Prof Nicky Britten & Dr David Bristow) suggest strategies and areas where teaching can be focused to improve the safety and effectiveness of FY1 doctors’ prescribing.

If this is an area of interest then below is the abstract related to the article and a link to the journal.

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Aims

Recent studies suggest a worryingly high proportion of final year medical students and new doctors feel unprepared for effective and safe prescribing.  Little research has been undertaken on UK junior doctors to see if these perceptions translate into unsafe prescribing practice.  We aimed to measure the performance of foundation year 1 (FY1) doctors in applying clinical pharmacology and therapeutics (CPT) knowledge and prescribing skills using standardised clinical cases.

Methods

A subject matter expert (SME) panel constructed a blueprint and from this twelve assessments focussing on areas posing high risk to patient safety and deemed as essential for FY1 doctors to know. Assessments comprised six Extended Matching Questions (EMQ) and six Written Unobserved Structured Clinical Examinations (WUSCE) covering seven CPT domains.  Two of each assessment types were administered over three time points to 128 FY1 doctors.

Results

The twelve assessments were valid and statistically reliable. Across seven CPT areas tested 51-75% of FY1 doctors failed EMQs and 27-70% failed WUSCEs. The WUSCEs showed three performance trends; 30% of FY1 doctors consistently performing poorly, 50% performing around the passing score, and 20% performing consistently well.  Categorical rating of the WUSCEs revealed 5% (8/161) of scripts contained errors deemed as potentially lethal.

Conclusions

This study shows that a large proportion of FY1 doctors fail to demonstrate the level of CPT knowledge and prescribing ability required at this stage of their careers. We identify areas of performance weakness that pose high risk to patient safety and suggest ways to improve FY1 doctors’ prescribing.

Nov 11

Clinical Assessment Tools need to be user friendly

Doctor-Patient contact time is vitally important for diagnosis and treatment.  To aid doctors thousands of ‘tools’ have been developed for use in various fields of medical practice.  But as new technology (including physical assessment and validated questionnaires) is introduced assessment tools become redundent and others are introduced. However technological advances tend to be expensive and time consuming to train medical staff to use.  It is also the case that they often require additional physical space, time to administer and a level of health of the patient.

CigarettesThe aim of Dr Rupert Jones and collegues (including me) was to derive a multi-component assessment index for use with patients with COPD to gain a measure of severity. The index was intended to include items that are clinically important, applicable to all grades of disease severity and all healthcare settings, and simple and clear to use.

Traditionally, the forced expiratory volume in one second (FEV1) has been the main measure of COPD severity for clinicians and still has a prominent place in international guidelines. While patients are mainly concerned with symptoms, exacerbations and functional capacity, airflow obstruction is important to clinicians in order to measure the lung damage and determine treatment. A composite measure could account for various dimensions of the disease, and take into account both the patient’s and the physician’s perspectives.

One highly regarded composite measure is the BODE index which was originally designed to predict mortality in COPD. However, the BODE index involves a Six Minute Walking Test (6MWT) which limits its use in routine clinical settings as it takes time, supervision, and space. Another validated prognostic index, the COPD Prognostic Index is also cumbersome to use in routine clinical settings as it includes seven items, one of which is a health status questionnaire.

Therefore we have derived and validated a composite index of severity in chronic obstructive pulmonary disease, which has recently been accepted for publication by the American Journal of Respiratory and Critical Care Medicine.  We hope the index will be widley adopted by the medical profession.

If you are unsure of its relevance or usfulness to your practice, below is the abstract associated with the journal article.

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Rationale: COPD is increasingly recognized as a multi-component disease with systemic consequences and effects on quality of life. Single measures such as lung function provide a limited reflection of how the disease affects patients. Composite measures have the potential to account for many of the facets of COPD.

Objective: To derive and validate a multi-component assessment tool of COPD severity which is applicable to all patients and healthcare settings.

Methods/ Measurements: The index was derived using data from 375 COPD patients in primary care. Regression analysis led to a model explaining 48% of the variance in health status as measured by the Clinical COPD questionnaire with four components: dyspnea (D), airflow obstruction (O), smoking status (S) and exacerbation frequency (E). The DOSE index was validated in cross-sectional and longitudinal samples in different healthcare settings in Holland, Japan, and the United Kingdom.

Main results: The DOSE index correlated with health status in all datasets. A high DOSE index score (> = 4) was associated with a greater risk of hospital admission (odds ratio 8.3 (4.1 – 17) or respiratory failure 7.8 (3.4 – 18.3). The index predicted exacerbations in the subsequent year (p ≤ 0.014).

Conclusions: The DOSE index is a simple valid tool for assessing the severity of COPD. The index is related to a range of clinically important outcomes such as healthcare consumption and predicts future events.

Oct 25

New Perspectives – Is the Leaning Tower of Pisa always inclined?

Recently I posted about an area of research I am interested in and mentioned that we were going to Pisa to present the results at the European Health Psychology Society Annual Conference.

I jokingly asked if Psychology could help the leaning tower and we concluded that the research I was offering up for scrutiny probably wouldn’t.

However the “Inclined Tower“, as a Swiss friend calls it, offers up an obvious, and visual, comparison with some of the benefits from attending conferences.

Its actually quite unusual to learn astounding new facts at academic conferences. Most of the formats involved are just too short and the programme too crowded to allow for a long and detailed examination of new research (that’s what Journal papers are really for). In Pisa there were nearly 1,300 separate pieces of research being presented, either in 15 min oral presentations, posters, symposia, or round table discussions. And all this over 4 days [programme in pdf format].

While you may not spend a lot of of time learning new material, you are forced to look at things from new angles and applying your thoughts and feelings in new ways.  In other words from a ‘New Perspective’!

You’re exposed to the work of people with very different, though equally valid, research philosophies.You can see how they tackled similar questions but from different perspectives (sometimes wildly different).

Studies in psychology provide and require multiple perspectives to be applied in order to understanding people as individuals and as individuals in a community. Research findings and implications about the mind and mental processes as well as studies of the development and behaviour, maintenance and change of socially significant behaviour are all of importance in understand and explaining (at least in part) the world we live in and how we situate ourselves within it.

p.s. John here, I sat in on some of the presentations and there were a couple of very interesting points. Traditionally the shift change in hospitals has been seen as a vulnerability and has resulted in a culture of long shifts. Some research indicated that safety might actually be improved with more shift changes, since they were more often catching problems than causing them. It was the act of explaining what was going on to someone new, a fresh pair of eyes, that caught these oversights. Equally, they sometimes gave people the impetus to make a decision. For a start up company that’s charging along eyes on the prize, taking time out occasionally to explain that bigger picture to an impartial observer, is a huge benefit.

It was also notable the lack of technology awareness in health care messages and communications. Not just the use of social media but viral gaming, mobile data capture & evaluation, and general webbiness. As I tweeted from the conference (I was in the minority having a mobile data device with me), online avatars working from fixed scripts do not make for very convincing ‘companions’. There is a lot this community could learn from places like the Pervasive Media Studio here in Bristol and the ecosystem around them.

For a technical civil engineering description of the tower and various attempts to ‘straighten’ it check out this page. 🙂

Sep 06

Can Psychology help the Leaning Tower of Pisa?

leaning-tower-of-pisa

As part of Sam’s interest and research into the effect of Oral and Maxillofacial Cancer, and its treatment on patients, she has been investigating the knowledge and attitudes of General Dental Practitioners (GDP).  In particular she was interested in GDP’s expereince of treatment of this patient group following completion of their cancer treatment. So she performed a small postal survey. The results of which have been submitted and accepted for presentation at two conferences (British Assocation of Oral Maxillofacial Surgeon Annual Conference & European Health Psychology Conference Annual Conference).

The abstract accepted for these conferences tell you about the study and the results:

Incidents of Oral Cancer are increasing, coupled with campaigns to raise the awareness of symptoms, diagnosis and treatment. To date, no study has investigated the General Dental Practitioner’s (GDP) frequency of exposure to this type of patient or their current knowledge and attitudes in relation to the treatment and potential complications of these patients post cancer. This study investigated these areas and the requirements/requests for further training and education. A questionnaire was constructed and posted to 183 GDP in the South West (UK), with a stamped returned addressed envelop. A subsequent posting was sent out a month later to the non-respondents. The analysis of numerical data was limited to descriptive statistics using SPSS V16. Free text was analysed using content analysis with the aid of NUD*IST V5. A total of sixty-one percent (n=114) of potential participants responded. On average they had been qualified and registered as GDP’s for 20.5 years. Seventy-Six percent (n=87) of respondents reported having a patient post treatment for oral cancer. Thirty-five percent were not confident treating these patients (depending on their morbidities). The reasons given could be categorised from free text responses as due to; 1) Lack of Training, 2) Poor Communication with the hospital, 3) Finance. A minority of GDPs reported the need for further education on the treatment of these patients and for better communication between themselves and hospital consultants. The findings suggest the need for a larger study to validate this pilot and indicate future interventions with GDPs.

We hope you find this research as interesting as we do, as it has implications for the training of future GDP, and improving the communication betwen patients, GDP and hospital based dentists and surgeons. The hope is that it will improve the treatment of this patient group, reduce the amount of time they have to wait for treatment, as well as the lenght of time they need to have assisted feeding through things such as Percutaneous Endoscopic Gastronomy (PEG) feeding tubes.

As for Psychology helping the Leaning Tower of Pisa. This research probably won’t help, but we’ll keep you informed as to it’s progress once the conference is over!

Jul 15

Supersonic cafe

[Disclosure: I was attending last night’s Science Cafe in my role as Manager of Science City Bristol.]

At last night’s Science Cafe, a broad group of Bristolians heard about CFD, Pitch drips, carbon footprint of cows, and road spray from lorries; all from a talk about a 1,000mph rocket car!

Pitch drop experiment on Wikipedia

Pitch drop experiment on Wikipedia

Computational Fluid Dynamics is the particular research discipline of Dr Clare Wood and Dr Ben Evans from Cardiff University. Clare began with a basic introduction to CFD, some of the history of the Navier-Stokes equations and the other uses they get put to. This was where the Pitch Drop came in; an experiment started in 1930 to measure the viscosity of pitch (which looks like a solid), there have been 8 drips of pitch since then as it very slowly flows into the catching beaker. Unfortunately, no one has ever witnessed a pitch-drip, there was a technical hiccup with the video feed [requires Windows Media Player] on the last drop (28 November, 2000). Clare also talked about ‘proper’ science and using CFD to model blood flow in hearts and the bio-medical applications.

Ben then picked up the topic and began talking about the pressure waves that develop as you move from sub-sonic through to super-sonic. A major challenge is the incredible pressure that will occur around the rear wheels as the third shock wave develops. This is potentially so strong it could physically lift the back-end of the car into the air, obviously a bad thing at 1,000mph!

There’s a limit to what can be done with the mini-winglets that are being used to trim the car aerodynamically, so Ben and the CFD team are leading the engineering design changes to the rear suspension & underside to try and reduce these pressure waves to make the car safe to drive. There was some more about the research development of new CFD algorithms and the promo-video (embedded at the end of this post).

After a short break, the Q&A began. The first question was about the environmental impact of a 1,000mph rocket car with follow up comments about the 19th Century’ness of a fast car. Although this wasn’t Ben’s area of specific expertise its obviously something that comes up fairly regularly. An environmental economist (or something like that) has looked at the car, the project and worked out their carbon footprint for the whole 4 year project. Apparently it comes to around 4 cows farting for a year; now I’d never entered the term “cow fart” into Google before this morning (who would) but it seems quite a research topic, even the Telegraph are reporting it!

As to the choice of a rocket car (rather than a green car); this had been intended from the outset to be an engineering adventure. The car & the 1,000mpt target are almost incidental, the primary aim is to get children (and the young at heart) excited about science & engineering and thinking about careers in the sciences. Rockets are still exciting to young kids!

The topics moved around and one that came up was the legacy of the project, what will we have after the final run (other than a very expensive museum exhibit)? Ben explained that much of the research involved in the CFD modelling is directly transferable. The example he used was how spray is formed at the back of lorries in the rain. One of the challenges of Bloodhound is the generation of a dust spray from the wheels and shock wave, and modelling how this mix of air & particles grows and affects the car. The same physics are (they think) involved in road spray from lorries, but no one has developed a good model of how spray forms and moves around the lorry. When you drive into this spray, in overtaking for example, it can be a real safety hazard, by modelling this and proposing different designs for the lorries, they might be able to reduce this spray and improve road safety.

There were tons of other questions (about an hour’s worth), it was a really great evening. Thanks to John and At-Bristol for hosting and to Bob Foster for his Science Cafe website where I found out about the event from Bob’s Calendar.