Heather Brant

An exploration into physiological and self-report measures of stress in pre-registration doctors at the beginning and end of a clinical rotation

The first year practising medicine, pre-registration, is considered to be a stressful time for junior doctors. The aims of this study were to explore how levels of psychological distress were affected by changes in the working environment and to examine these effects across subjective (i.e. self-report) and objective (i.e. stress hormone cortisol) indices of psychological distress. A cohort of 36 pre-registration house officers (males = 15) completed a battery of psychosocial measures and collected salivary samples for the measurement of diurnal cortisol at the beginning and end of a 3–4-month clinical rotation with the assumption that the end of a rotation would be less stressful than the beginning. Results from the self-report measures remained constant over the two-time points suggesting no perceived change in emotional well-being on a subjective level. However, there is some evidence of neuro-endocrine changes across the two time points suggestive of hypothalamic–pituitary–adrenal axis dysregulation. In particular, there was a significant difference between the cortisol awakening rise with the greatest rise seen at the beginning of a rotation. In addition, the daily cortisol decline (diurnal slope) was also significantly less at this test time. These findings have implications for the discord apparent between self-report and physiological measures of psychological stress.

Maternal Mood and Neuroendocrine Programming: Effects of Time of Exposure and Sex

Adverse exposures that influence growth in prenatal and early postnatal periods are considered to influence vulnerability to chronic diseases via their effects on the neuroendocrine system. In humans, the assessment of the underlying mechanisms has been restricted. The present study aimed to investigate the effects of adverse early‐life exposures, specifically maternal mood, on hypothlamic‐pituitary‐adrenal (HPA) axis, sympathetic nervous system (SNS) and parasympathetic nervous system (PNS) responses to an acute physiological stressor. In addition, we conducted a preliminary examination into whether these effects varied by time of exposure and sex. One hundred and thity‐nine individuals (mean age 15.12 years) were recruited from the ALSPAC (Avon Longitudinal Study of Parents and Children) birth cohort. Participants underwent the CO2 stress test and indices of the PNS, SNS and HPA axis were measured. Pre‐existing data on demographic and psychosocial factors of the mothers during pregnancy (18 and 32 weeks) and postnatally (8 weeks and 8 months) were extracted, as were participants’ clinical and demographic data at birth. Increases in both pre‐ and postnatal anxiety and depression were associated with greater SNS reactivity to the stressor and slower recovery, as well as blunted HPA axis responses. Programming effects on the SNS appeared to be restricted to male offspring only. No consistent relationships were evident for any of the measures of pre‐stress function. We have found preliminary evidence that both pre‐ and postnatal maternal anxiety and depression have sustained programming effects on the SNS and HPA axis. Effects on the SNS were restricted to male offspring.

Refinement of the Distress Management Problem List as the basis for a holistic therapeutic conversation among UK patients with cancer

Originally devised in the USA, the Distress Thermometer is being deployed in many cancer settings in the UK. It is commonly used with a Problem List (PL), which has never been validated with a UK population. This study aimed to refine the PL items based upon the concerns of a sample of UK patients attending a regional cancer centre.

Using alternatives to face-to-face consultations: a survey of prevalence and attitudes in general practice

BACKGROUND The ubiquitous use of communication technologies has led to an expectation that a similar approach should extend to health care. Despite considerable rhetoric about the need for general practices to offer alternatives to face-to-face consultations, such as telephone, email, and internet video consultations, the extent to which such technologies are actually used at present is unclear. AIM The aim of the survey was to identify the frequency and range of ways in which general practices are providing (or planning) alternatives to face-to-face consultations. DESIGN AND SETTING A postal survey of practices around Bristol, Oxford, Lothian, the Highlands, and the Western Isles of Scotland. METHOD A postal questionnaire survey was sent to each of the GPs and practice managers of 421 practices between January and May 2015. RESULTS A response was received from 319/421 practices (76%). Although the majority of the practices reported that they were conducting telephone consultations frequently (n = 211/318, 66%), fewer were implementing email consultations (n = 18/318, 6%), and most (n = 169/318, 53%) had no plans to introduce this. None were currently using internet video, and 86% (n = 273/318) had no plans to introduce internet video consultations. These findings were repeated in the reported use of alternatives to face-to-face consultations at an individual GP level. Optional free text responses were completed by 28% of responders, and offered an explanation for the (often perceived) barriers and incentives for implementation. CONCLUSION Despite policy pressure to introduce consultations by email and internet video, there is a general reluctance among GPs to implement alternatives to face-to-face consultations. This identifies a substantial gap between rhetoric and reality in terms of the likelihood of certain alternatives (email, video) changing practice in the near future.

Alternatives to the face-to-face consultation in general practice: focused ethnographic case study

Background NHS policy encourages general practices to introduce alternatives to the face-to-face consultation, such as telephone, email, e-consultation systems, or internet video. Most have been slow to adopt these, citing concerns about workload. This project builds on previous research by focusing on the experiences of patients and practitioners who have used one or more of these alternatives. Aim To understand how, under what conditions, for which patients, and in what ways, alternatives to face-to-face consultations present benefits and challenges to patients and practitioners in general practice. Design and setting Focused ethnographic case studies took place in eight UK general practices between June 2015 and March 2016. Method Non-participant observation, informal conversations with staff, and semi-structured interviews with staff and patients were conducted. Practice documents and protocols were reviewed. Data were analysed through charting and the ‘one sheet of paper’ mind-map method to identify the line of argument in each thematic report. Results Case study practices had different rationales for offering alternatives to the face-to-face consultation. Beliefs varied about which patients and health issues were suitable. Co-workers were often unaware of each other’s practice; for example, practice policies for use of e-consultations systems with patients were not known about or followed. Patients reported benefits including convenience and access. Staff and some patients regarded the face-to-face consultation as the ideal. Conclusion Experience of implementing alternatives to the face-to-face consultation suggests that changes in patient access and staff workload may be both modest and gradual. Practices planning to implement them should consider carefully their reasons for doing so and involve the whole practice team.

Conducting a team-based multi-sited focused ethnography in primary care

Focused ethnography is an applied and pragmatic form of ethnography that explores a specific social phenomenon as it occurs in everyday life. Based on the literature a problem-focused research question is formulated before the data collection. The data generation process targets key informants and situations so that relevant results on the pre-defined topic can be obtained within a relatively short time-span. As part of a theory based evaluation of alternative forms of consultation (such as video, phone and email) in primary care we used the focused ethnographic method in a multisite study in general practice across the UK. To date there is a gap in the literature on using focused ethnography in healthcare research.The aim of the paper is to build on the various methodological approaches in health services research by presenting the challenges and benefits we encountered whilst conducing a focused ethnography in British primary care. Our considerations are clustered under three headings: constructing a shared understanding, dividing the tasks within the team, and the functioning of the focused ethnographers within the broader multi-disciplinary team.As a result of using this approach we experienced several advantages, like the ability to collect focused data in several settings simultaneously within in a short time-span. Also, the sharing of experiences and interpretations between the researchers contributed to a more holistic understanding of the research topic. However, mechanisms need to be in place to facilitate and synthesise the observations, guide the analysis, and to ensure that all researchers feel engaged. Reflection, trust and flexibility among the team members were crucial to successfully adopt a team focused ethnographic approach. When used for policy focussed applied healthcare research a team-based multi-sited focused ethnography can uncover practices and understandings that would not be apparent through surveys or interviews alone. If conducted with care, it can provide timely findings within the fast moving context of healthcare policy and research.

Receptionists’ role in new approaches to consultations in primary care: a focused ethnographic study

Background The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments. Aim The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care. Design and setting The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016. Method Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation. Results Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists’ involvement in implementation and planning for the introduction of alternative approaches to face-to-face consultations was minimal, despite the expectation that they would be involved in delivery. Conclusion A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations.