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Medical ethics changed dramatically in the past 30 years because physicians and humanists actively engaged each other in discussions that sometimes led to confrontation and controversy, but usually have improved the quality of medical decision-making. Before then medical ethics had been isolated for almost two centuries from the larger philosophical, social, and religious controversies of the time. There was, however, an earlier period where leaders in medicine and in the humanities worked closely together and both fields were richer for it. This volume begins with the 18th century Scottish Enlightenment when professors of medicine such as John Gregory, Edward Percival, and the American, Benjamin Rush, were close friends of philosophers like David Hume, Adam Smith, and Thomas Reid. They continually exchanged views on matters of ethics with each other in print, at meetings of elite intellectual groups, and at the dinner table. Then something happened, physicians and humanists quit talking with each other. In searching for the causes of the collapse, this book identifies shifts in the social class of physicians, developments in medical science, and changes in the patterns of medical education. Only in the past three decades has the dialogue resumed as physicians turned to humanists for help just when humanists wanted their work to be relevant to real-life social problems. Again, the book asks why, finding answers in the shift from acute to chronic disease as the dominant pattern of illness, the social rights revolution of the 1960’s, and the increasing dissonance between physician ethics and ethics outside medicine. The book tells the critical story of how the breakdown in communication between physicians and humanists occurred and how it was repaired when new developments in medicine together with a social revolution forced the leaders of these two fields to resume their dialogue.

This paper examines the UK Supreme Court decision in Montgomery v Lanarkshire Health Board, which deals with consent and information disclosure in medical treatment and care. It signaled a move away from a ‘doctor knows best’ approach to one that focuses on disclosing information to which particular patients would attach significance. Notwithstanding concerns about increased litigation and loss of professional autonomy, the reality is that the decision will make little difference to healthcare practice and consent in the UK. The Supreme Court has endorsed a view that most lawyers and doctors thought already prevailed, and it reflects the General Medical Council's guidance on the issue of consent in any case. Given recent healthcare scandals in the National Health Service (NHS), the Supreme Court's legal recognition of the importance of recognizing patient autonomy in disclosing risks about medical treatment and care is a welcome development.

Background Previous studies have identified tensions medical faculty encounter in their roles but not specifically those with a qualification in medical education. It is likely that those with postgraduate qualifications may face additional tensions (i.e., internal or external conflicts or concerns) from differentiation by others, greater responsibilities and translational work against the status quo. This study explores the complex and multi-faceted tensions of educators with qualifications in medical education at various stages in their career. Methods The data described were collected in 2013–14 as part of a larger, three-phase mixed-methods research study employing a constructivist grounded theory analytic approach to understand identity formation among medical educators. The over-arching theoretical framework for the study was Communities of Practice. Thirty-six educators who had undertaken or were undertaking a postgraduate qualification in medical education took part in semi-structured interviews. Results Participants expressed multiple tensions associated with both becoming and being a healthcare educator. Educational roles had to be juggled with clinical work, challenging their work-life balance. Medical education was regarded as having lower prestige, and therefore pay, than other healthcare career tracks. Medical education is a vast speciality, making it difficult as a generalist to keep up-to-date in all its areas. Interestingly, the graduates with extensive experience in education reported no fears, rather asserting that the qualification gave them job variety. Conclusion This is the first detailed study exploring the tensions of educators with postgraduate qualifications in medical education. It complements and extends the findings of the previous studies by identifying tensions common as well as specific to active students and graduates. These tensions may lead to detachment, cynicism and a weak sense of identity among healthcare educators. Postgraduate programmes in medical education can help their students identify these tensions in becoming and develop coping strategies. Separate career routes, specific job descriptions and academic workload models for medical educators are recommended to further the professionalisation of medical education. (Tensions, Fears, Healthcare Educators, Medical Education, Postgraduate Programmes, Identity, Career Choice, Faculty Development, Communities of Practice).

Background This paper seeks to contribute to a reputable evidence base for required competencies across different topics in statistics and probability (statistical topics) in preparing medical graduates for clinical practice. This is in order to inform the prioritization of statistical topics within future undergraduate medical curricula, while exploring the need for preparing tomorrow’s doctors to be producers, and not merely consumers, of statistics. Methods We conducted a comprehensive online survey from July 2013 to August 2014 for a target group of 462 medical graduates with current or prior experience of teaching undergraduate medical students of the University of Edinburgh of whom 278 (60.2%) responded. Statistical topics were ranked by proportion of respondents who identified the practice of statistics, performing statistical procedures or calculations using appropriate data , as a required competency for medical schools to provide in preparing undergraduate medical students for clinical practice. Mixed effects analyses were used to identify potential predictors for selection of the above competency and to compare the likelihood of this selection for a range of statistical topics versus critical appraisal. Results Evidence was gleaned from medical graduates’ experiences of clinical practice for the need for, not only a theoretical understanding of statistics and probability but also, the ability to practice statistics. Nature of employment and statistical topic were highly significant predictors of choice of the practice of statistics as a required competency ((F = 3.777, p < 0.0005) and (F = 45.834, p < 0.0005), respectively). The most popular topic for this competency was graphical presentation of data (84.3% of respondents) in contrast to cross-over trials for the competency understanding the theory only (70.5% of respondents). Several topics were found to be more popular than critical appraisal for competency in the practice of statistics. Conclusions The model of medical graduates as mere consumers of statistics is oversimplified. Contrary to what has been suggested elsewhere, statistical learning opportunities in undergraduate medicine should not be restricted to development of critical appraisal skills. Indeed, our findings support development of learning opportunities for undergraduate medical students as producers of statistics across a wide range of statistical topics.

Background Guideline producers are increasingly producing versions of guidelines for the public. The aim of this study was to explore what patients and the public understand about the purpose and production of clinical guidelines, and what they want from clinical guidelines to support their healthcare decisions. Methods Participants were purposively selected to represent a range of the likely users of patient versions of guidelines, including individuals with health conditions (diabetes and depression), general members of the public, health communication professionals and a group of young people. Participants were asked about their awareness and understanding of clinical guidelines and presented with scenario recommendations, or draft materials from patient guidelines to prompt discussion. Each discussion was facilitated by one or two researchers. All focus groups were recorded and transcribed prior to analysis. Data were analysed using framework analysis. Results We ran nine focus groups involving 62 individuals, supplemented by four interviews with people experiencing homelessness. Eight groups were held in Scotland, one in England. The four interviews were held in Scotland. The framework analysis yielded five themes: access and awareness; what patients want to know; properties of guidelines; presenting evidence; and format. Awareness of guidelines was low. Participants emphasised the need for information that enables them to choose between treatment options, including harms. They would like help with this from healthcare professionals, especially general practitioners. Participants differed in their support for the inclusion of numerical information and graphs. Conclusions Members of the public want information to help them choose between treatments, including information on harms, particularly to support shared decisions with health professionals. Presenting numerical information is a challenge and layered approaches that present information in stages may be helpful. Ignoring the themes identified in this study is likely to lead to materials that fail to support public and patient healthcare decision making.

The COVID-19 pandemic has exacerbated already high rates of poor psychological wellbeing in doctors. Many doctors perceive a stigma associated with acknowledging psychological wellbeing concerns, resulting in a reluctance to seek support for those concerns. The aim of this study was to develop a theoretically-informed and evidence-based composite narrative animation (CNA) to encourage doctors to access support for psychological wellbeing, and to evaluate the acceptability of the CNA. A composite narrative was developed from an evidence-base of interviews with 27 GP participants across Scotland (May–July 2020). The Behaviour Change Wheel was used to identify behaviour change techniques (BCTs) to be embedded within the CNA. The narrative was turned into a script in collaboration with an animation company. A brief animation ‘Jane the GP’ was developed reflecting specific BCTs. Scottish doctors ( n  = 83) were asked for their views on acceptability of the CNA concept, and subsequently asked to provide views on the acceptability of the CNA after viewing it. Participants thought the concept of a CNA was novel but may not appeal to all. After viewing the CNA, the widespread view was that it portrayed an authentic experience, could reduce stigma around seeking support for psychological wellbeing, and highlighted formal routes to access such support. CNAs are a novel and acceptable intervention method for encouraging doctors to access support for psychological wellbeing. The use of a theory driven intervention development framework to create the CNA facilitates the link between theory and practice.

Background Widening access to medicine in the UK is a recalcitrant problem of increasing political importance, with associated strong social justice arguments but without clear evidence of impact on service delivery. Evidence from the United States suggests that widening access may enhance care to underserved communities. Additionally, rural origin has been demonstrated to be the factor most strongly associated with rural practice. However the evidence regarding socio-economic and rural background and subsequent practice locations in the UK has not been explored. The aim of this study was to investigate the association between general practitioners’ (GPs) socio-economic and rural background at application to medical school and demographic characteristics of their current practice. Method The study design was a cross-sectional email survey of general practitioners practising in Scotland. Socio-economic status of GPs at application to medical school was assessed using the self-coded National Statistics Socio-Economic Classification. UK postcode at application was used to define urban–rural location. Current practice deprivation and remoteness was measured using NHS Scotland defined measures based on registered patients’ postcodes. Results A survey was sent to 2050 Scottish GPs with a valid accessible email address, with 801 (41.5 %) responding. GPs whose parents had semi-routine or routine occupations had 4.3 times the odds of working in a deprived practice compared to those with parents from managerial and professional occupations (95 % CI 1.8–10.2, p  = 0.001). GPs from remote and rural Scottish backgrounds were more likely to work in remote Scottish practices, as were GPs originating from other UK countries. Conclusion This study showed that childhood background is associated with the population GPs subsequently serve, implying that widening access may positively affect service delivery in addition to any social justice rationale. Longitudinal research is needed to explore this association and the impact of widening access on service delivery more broadly.

Abstract Objective To explore health professionals' decision making in a critical care scenario when there is an advance directive. Design Qualitative study. Setting Scotland. Participants Interviewees (n = 12) comprising general practitioners, hospital specialists, and nurses, and six focus groups (n = 34 participants) comprising general practitioners, geriatricians (consultants and specialist registrars), hospital nurses, and hospice nurses. Results When presented with an advance directive that applied to the same hypothetical scenario, health professionals came to divergent conclusions as to the “right thing to do.” Arguments opposing treatment centred on the supremacy of autonomy as an ethical principle. Other arguments were that the decision to treat was consistent with the terms of the advance directive, or that, notwithstanding the advance directive, the patient's quality of life was sufficient to warrant treatment. Conclusion Advance directives are open to widely varying interpretation. Some of this variability is related to the ambiguity of the directive's terminology whereas some is related to the willingness of health professionals to make subjective value judgments concerning quality of life.

Background Health care professionals with positive attitudes towards the functional abilities of patients with low back pain are more likely to encourage activity and avoidance of rest as per recommended guidelines. This study investigated whether medical student training fosters positive attitudes towards patients with back pain and their ability to function. Methods First (n = 202) and final (n = 146) year medical students at the University of Glasgow completed the Health Care Professionals' Pain and Impairment Relationship Scale (HC-PAIRS) questionnaire. This measures attitudes of clinicians towards the functional ability of patients with back pain. A group of first (n = 62) and final year (n = 61) business students acted as non-health care controls. Attitudes were compared using two-way ANOVA with year of study and discipline of degree as independent variables. Results Both year of study [F(1,465) = 39.5, p < 0.01] and discipline of degree [F(1,465) = 43.6, p < 0.01] had significant effects on total HC-PAIRS scores and there was a significant interaction effect [F(1,465) = 9.5, p < 0.01]. Medical students commenced their course with more positive attitudes than non-health care students (65.7 vs. 69.2 respectively; p < 0.01) - lower scores translating into more positive attitudes. In their final year, the difference between the two student groups had widened (56.4 vs. 65.3; p < 0.01). Conclusions Undergraduate medical training promotes positive attitudes towards the functional ability of patients with back pain, suggesting that students may be more likely to develop an evidence-based approach to this patient group after qualification. Some adjustments to training may be warranted to encourage a more positive shift in attitudes.

The aim of this study was to discover the views of health professionals in the Greater Glasgow area on advance directives, using semi-structured interviews and focus groups. The twelve participants interviewed included four hospital doctors, four general practitioners (GPs) and four nurses. The six focus groups comprised hospice nurses, GPs, consultant geriatricians, geriatricians in training grades and an interdisciplinary group. Participants were purposively selected to reflect a range of personal experiences with, and attitudes toward, the advance directive using key informants and a short questionnaire. Participants were asked to comment on a specially constructed sample advance directive. All research encounters were recorded, transcribed and analysed using accepted methods in qualitative research. The advance directive was seen as a means of promoting peace of mind in will makers, of allowing carers to honour the patients' wishes and of stimulating communication between all parties. Conversely the advance directive was seen as generating certain risks for the will maker – including those of coercion, misunderstanding, paradoxical overintervention and inadvertent undertreating. A core concern surrounded the issue of ‘informedness’ in will makers and the ethics of deciding for a future demented self.