Aneez Esmail

Comparison of teleconsultations and face-to-face consultations: preliminary results of a United Kingdom multicentre teledermatology study.

The objective of this multicentre study was to undertake a systematic comparison of face‐to‐face consultations and teleconsultations performed using low‐cost videoconferencing equipment. One hundred and twenty‐six patients were enrolled by their general practitioners across three sites. Each patient underwent a teleconsultation with a distant dermatologist followed by a traditional face‐to‐face consultation with a dermatologist. The main outcome measures were diagnostic concordance rates, management plans and patient and doctor satisfaction. One hundred and fifty‐five diagnoses were identified by the face‐to‐face consultations from the sample of 126 patients. Identical diagnoses were recorded from both types of consultation in 59% of cases. Teledermatology consultations missed a secondary diagnosis in 6% of cases and were unable to make a useful diagnosis in 11% of cases. Wrong diagnoses were made by the teledermatologist in 4% of cases. Dermatologists were able to make a definitive diagnosis by face‐to‐face consultations in significantly more cases than by teleconsultations (P = 0.001). Where both types of consultation resulted in a single diagnosis there was a high level of agreement (κ = 0.96, lower 95% confidence limit 0.91–1.00). Overall follow‐up rates from both types of consultation were almost identical. Fifty per cent of patients seen could have been managed using a single videoconferenced teleconsultation without any requirement for further specialist intervention. Patients reported high levels of satisfaction with the teleconsultations. General practitioners reported that 75% of the teleconsultations were of educational benefit. This study illustrates the potential of telemedicine to diagnose and manage dermatology cases referred from primary care. Once the problem of image quality has been addressed, further studies will be required to investigate the cost‐effectiveness of a teledermatology service and the potential consequences for the provision of dermatological services in the U.K.

Patient safety culture in primary care: developing a theoretical framework for practical use

Objective: Great importance has been attached to a culture of safe practice in healthcare organisations, but it has proved difficult to engage frontline staff with this complex concept. The present study aimed to develop and test a framework for making the concept of safety culture meaningful and accessible to managers and frontline staff, and facilitating discussion of ways to improve team/organisational safety culture. Setting: Eight primary care trusts and a sample of their associated general practices in north west England. Methods: In phase 1 a comprehensive review of the literature and a postal survey of experts helped identify the key dimensions of safety culture in primary care. Semistructured interviews with 30 clinicians and managers explored the application of these dimensions to an established theory of organisational maturity. In phase 2 the face validity and utility of the framework was assessed in 33 interviews and 14 focus groups. Results: Nine dimensions were identified through which safety culture is expressed in primary care organisations. Organisational descriptions were developed for how these dimensions might be characterised at five levels of organisational maturity. The resulting framework conceptualises patient safety culture as multidimensional and dynamic, and seems to have a high level of face validity and utility within primary care. It aids clinicians’ and managers’ understanding of the concept of safety culture and promotes discussion within teams about their safety culture maturity. Conclusions: The framework moves the agenda on from rhetoric about the importance of safety culture to a way of understanding why and how the shared values of staff working within a healthcare organisation may be operationalised to create a safe environment for patient care.

Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis

Importance Burnout is prevalent in physicians and can have a negative influence on performance, career continuation, and patient care. Existing evidence does not allow clear recommendations for the management of burnout in physicians. Objective To evaluate the effectiveness of interventions to reduce burnout in physicians and whether different types of interventions (physician-directed or organization-directed interventions), physician characteristics (length of experience), and health care setting characteristics (primary or secondary care) were associated with improved effects. Data Sources MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane Register of Controlled Trials were searched from inception to May 31, 2016. The reference lists of eligible studies and other relevant systematic reviews were hand searched. Study Selection Randomized clinical trials and controlled before-after studies of interventions targeting burnout in physicians. Data Extraction and Synthesis Two independent reviewers extracted data and assessed the risk of bias. The main meta-analysis was followed by a number of prespecified subgroup and sensitivity analyses. All analyses were performed using random-effects models and heterogeneity was quantified. Main Outcomes and Measures The core outcome was burnout scores focused on emotional exhaustion, reported as standardized mean differences and their 95% confidence intervals. Results Twenty independent comparisons from 19 studies were included in the meta-analysis (n = 1550 physicians; mean [SD] age, 40.3 [9.5] years; 49% male). Interventions were associated with small significant reductions in burnout (standardized mean difference [SMD] = −0.29; 95% CI, −0.42 to −0.16; equal to a drop of 3 points on the emotional exhaustion domain of the Maslach Burnout Inventory above change in the controls). Subgroup analyses suggested significantly improved effects for organization-directed interventions (SMD = −0.45; 95% CI, −0.62 to −0.28) compared with physician-directed interventions (SMD = −0.18; 95% CI, −0.32 to −0.03). Interventions delivered in experienced physicians and in primary care were associated with higher effects compared with interventions delivered in inexperienced physicians and in secondary care, but these differences were not significant. The results were not influenced by the risk of bias ratings. Conclusions and Relevance Evidence from this meta-analysis suggests that recent intervention programs for burnout in physicians were associated with small benefits that may be boosted by adoption of organization-directed approaches. This finding provides support for the view that burnout is a problem of the whole health care organization, rather than individuals.

Patient satisfaction with teledermatology is related to perceived quality of life

Background There is a lack of good data about patient satisfaction with teledermatology and about its potential interaction with quality‐of‐life factors.

Academic performance of ethnic minority candidates and discrimination in the MRCGP examinations between 2010 and 2012: analysis of data

Objective To determine the difference in failure rates in the postgraduate examination of the Royal College of General Practitioners (MRCGP) by ethnic or national background, and to identify factors associated with pass rates in the clinical skills assessment component of the examination. Design Analysis of data provided by the Royal College of General Practitioners and the General Medical Council. Participants Cohort of 5095 candidates sitting the applied knowledge test and clinical skills assessment components of the MRCGP examination between November 2010 and November 2012. A further analysis was carried out on 1175 candidates not trained in the United Kingdom, who sat an English language capability test (IELTS) and the Professional and Linguistic Assessment Board (PLAB) examination (as required for full medical registration), controlling for scores on these examinations and relating them to pass rates of the clinical skills assessment. Setting United Kingdom. Results After controlling for age, sex, and performance in the applied knowledge test, significant differences persisted between white UK graduates and other candidate groups. Black and minority ethnic graduates trained in the UK were more likely to fail the clinical skills assessment at their first attempt than their white UK colleagues (odds ratio 3.536 (95% confidence interval 2.701 to 4.629), P<0.001; failure rate 17% v 4.5%). Black and minority ethnic candidates who trained abroad were also more likely to fail the clinical skills assessment than white UK candidates (14.741 (11.397 to 19.065), P<0.001; 65% v 4.5%). For candidates not trained in the UK, black or minority ethnic candidates were more likely to fail than white candidates, but this difference was no longer significant after controlling for scores in the applied knowledge test, IELTS, and PLAB examinations (adjusted odds ratio 1.580 (95% confidence interval 0.878 to 2.845), P=0.127). Conclusions Subjective bias due to racial discrimination in the clinical skills assessment may be a cause of failure for UK trained candidates and international medical graduates. The difference between British black and minority ethnic candidates and British white candidates in the pass rates of the clinical skills assessment, despite controlling for prior attainment, suggests that subjective bias could also be a factor. Changes to the clinical skills assessment could improve the perception of the examination as being biased against black and minority ethnic candidates. The difference in training experience and other cultural factors between candidates trained in the UK and abroad could affect outcomes. Consideration should be given to strengthening postgraduate training for international medical graduates.

Asian doctors are still being discriminated against.

Editor—Five years ago, when we published our research on the discrimination faced by ethnic minority doctors applying for posts as senior house officers,1 the Department of Health considered using our methodology to monitor progress in tackling discrimination. At a recent BMA conference to discuss racial discrimination in the medical profession several speakers pointed out that racial discrimination was still endemic in the NHS and that direct policy initiatives to tackle specific examples of discrimination–for example, in the shortlisting of job applications for hospital posts–were lacking.2 …

Culture of safety.

We welcome Singer and colleague’s contribution to developing the concept of a safety culture.1 Policy makers, managers, and clinicians are slowly realising that patient safety will not be improved solely by counting adverse events or by introducing technical innovations. History tells us that, when these initiatives are evaluated, the results will probably show a marginal impact on patient safety and one that is likely to be poorly sustained. In order to …

Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire?

abstract Objectives: To determine the number and geographical distribution of general practitioners in the NHS who qualified medically in South Asia and to project their numbers as they retire. Design: Retrospective analysis of yearly data and projection of future trends. Setting: England and Wales. Subjects: General practitioners who qualified medically in the countries of Bangladesh, India, Pakistan, and Sri Lanka and who were practising in the NHS on 1 October 1992. Main outcome measures: Proportion and age of general practitioners who qualified in South Asia by health authority; the Benzeval and Judge measure of population need at the health authority level. Results: 4192 of 25 333 (16.5%) of all unrestricted general practitioners practising full time on 1 October 1992 qualified in South Asian medical schools. The proportion varied by health authority from 0.007% to 56.5%. Roughly two thirds who were practising in 1992 will have retired by 2007; in some health authorities this will represent a loss of one in four general practitioners. The practices that these doctors will leave seem to be in relatively deprived areas as measured by deprivation payments and a health authority measure of population need. Conclusion: Many general practitioners who qualified in South Asian medical schools will retire within the next decade. The impact will vary greatly by health authority. Those health authorities with the greatest number of such doctors are in some of the most deprived areas in the United Kingdom and have experienced the most difficulty in filling vacancies. Various responses will be required by workforce planners to mitigate the impact of these retirements.

Patient Satisfaction with Store-and-Forward Teledermatology

We assessed patient satisfaction with a nurse-led store-and-forward teledermatology service in Manchester. A teledermatology nurse obtained the patients history, took digital photographs of the patients skin lesion and then sent the information to a hospital dermatologist, who responded with management advice the following week. Of 141 patients who attended their teledermatology appointment, 123 (50 male, 73 female) completed the study questionnaire (87%). The average age of respondents was 42 years (SD 17, range 18–90 years). Ninety-three per cent reported that they were happy with the teleconsultation while 86% reported that it was more convenient than going to the outpatient clinic. Forty per cent agreed that they would feel more comfortable seeing the dermatologist in person while only 58% were comfortable with not speaking to the dermatologist about their skin condition. The absence of interaction with the dermatologist and the delay in receiving management advice may have contributed to the somewhat low satisfaction rates.

Tackling racism in the NHS.

A BMA conference held last week to discuss racial discrimination in the medical profession highlighted a range of reports and publications written since 1987 that have documented the problem. Racial discrimination occurs at all levels in the medical profession, from applications to medical school,1 2 3 through the examination process,4 to job applications.5 6 It also affects the manner in which complaints are made against doctors.7 8 Our problem is not a lack of evidence but the lack of political will to tackle the problem. That racial discrimination within the medical profession is widespread is a view many doctors may find hard to accept. But it is an accusation that must be taken seriously. With 23% of the medical workforce and, in some medical schools, 30% of the current intake classifying themselves as ethnic minorities, the issue is not necessarily one of under-representation of ethnic minorities but of equal opportunities–potentially affecting a quarter of doctors in Britain. The problem of discrimination in the profession is first and foremost an ethical and moral issue, and, as a profession, we should …