Joe Rosenthal

Pharmacological manipulations of arousal and memory for emotional material: effects of a single dose of methylphenidate or lorazepam

Benzodiazepines produce robust impairments of memory alongside global decreases in physiological and subjective arousal. Recently one benzodiazepine (triazolam) has been found to disproportionately impair memory for emotionally arousing material (Buchanan et al., 2003). The extent to which this effect may be mediated by the drugs sedative action is unclear. The present study aimed to assess how pharmacologically decreasing physiological arousal with a benzodiazepine and increasing arousal with a stimulant impact on memory for emotional material. A double-blind placebo controlled trial with 48 volunteers was used to investigate the effects of methylphenidate (40 mg) and Lorazepam (1.5 mg) on incidental memory for emotional material in Cahill and McGaughs (1995) slide-story task. The slide-story was presented to participants administered either active drug or placebo and retrieval was assessed one week later. Methylphenidate produced stimulant effects and Lorazepam produced sedative effects. Significantly enhanced memory for emotional material was observed in participants given placebo, but not in those given either methylphenidate or Lorazepam. Despite producing opposite effects upon arousal, both methylphenidate and Lorazepam lessen the impact of emotionally arousing material on memory. The effects of Lorazepam add to a growing literature that benzodiazepines may exert their clinical, anxiolytic effects in part via altering emotionaL cognitive function.

Provision of medical student teaching in UK general practices: a cross-sectional questionnaire study

BACKGROUND Health care is increasingly provided in general practice. To meet this demand, the English Department of Health recommends that 50% of all medical students should train for general practice after qualification. Currently 19% of medical students express general practice as their first career choice. Undergraduate exposure to general practice positively influences future career choice. Appropriate undergraduate exposure to general practice is therefore highly relevant to workforce planning AIM This study seeks to quantify current exposure of medical students to general practice and compare it with past provision and also with postgraduate provision. DESIGN AND SETTING A cross-sectional questionnaire in the UK. METHOD A questionnaire regarding provision of undergraduate teaching was sent to the general practice teaching leads in all UK medical schools. Information was gathered on the amount of undergraduate teaching, how this was supported financially, and whether there was an integrated department of general practice. The data were then compared with results from previous studies of teaching provision. The provision of postgraduate teaching in general practice was also examined. RESULTS General practice teaching for medical students increased from <1.0% of clinical teaching in 1968 to 13.0% by 2008; since then, the percentage has plateaued. The total amount of general practice teaching per student has fallen by 2 weeks since 2002. Medical schools providing financial data delivered 14.6% of the clinical curriculum and received 7.1% of clinical teaching funding. The number of departments of general practice has halved since 2002. Provision of postgraduate teaching has tripled since 2000. CONCLUSION Current levels of undergraduate teaching in general practice are too low to fulfil future workforce requirements and may be falling. Financial support for current teaching is disproportionately low and the mechanism counterproductive. Central intervention may be required to solve this.

A BEME systematic review of UK undergraduate medical education in the general practice setting: BEME Guide No. 32

Abstract Background: General practice is increasingly used as a learning environment in undergraduate medical education in the UK. Aim: The aim of this project was to identify, summarise and synthesise research about undergraduate medical education in general practice in the UK. Methods: We systematically identified studies of undergraduate medical education within a general practice setting in the UK from 1990 onwards. All papers were summarised in a descriptive report and categorised into two in-depth syntheses: a quantitative and a qualitative in-depth review. Results: 169 papers were identified, representing research from 26 UK medical schools. The in-depth review of quantitative papers (n = 7) showed that medical students learned clinical skills as well or better in general practice settings. Students receive more teaching, and clerk and examine more patients in the general practice setting than in hospital. Patient satisfaction and enablement are similar whether a student is present or not in a consultation, however, patients experience lower relational empathy. Two main thematic groups emerged from the qualitative in-depth review (n = 10): the interpersonal interactions within the teaching consultation and the socio-cultural spaces of learning which shape these interactions. The GP has a role as a broker of the interactions between patients and students. General practice is a socio-cultural and developmental learning space for students, who need to negotiate the competing cultures between hospital and general practice. Lastly, patients are transient members of the learning community, and their role requires careful facilitation. Conclusions: General practice is as good, if not better, than hospital delivery of teaching of clinical skills. Our meta-ethnography has produced rich understandings of the complex relationships shaping possibilities for student and patient active participation in learning.

How can medical schools encourage students to choose general practice as a career

The NHS faces a continuing rise in volume and complexity of population health needs, with care moving increasingly from hospital to community. National reviews of medical training and workforce requirements report a critical need for an increase in the NHS GP workforce, and NHS England has now responded with a welcome promise of investment in primary care.1 This may provide funding for GPs, but where will these GPs come from? Medical schools and the Royal College of General Practitioners are working to promote general practice as a career, but the current uptake of GP training is disappointing, with only 17.4% of F2 doctors appointed to GP training in the UK in 2015.2 Health Education England’s GP training recruitment targets for 2016 are likely to be missed. Many questions must be asked. What explains the wide variations across medical schools in graduates’ choice of general practice as a career (range 7.3–30.0%)?2 Is there a cultural bias against primary care in medical schools? How important is the quantity and quality of undergraduate general practice exposure? Are we taking the wrong approach to selection processes in order to meet the needs of contemporary society? Undergraduate experience has a major influence on career choice. Evidence from the UK and abroad shows that undergraduate exposure to general practice has a positive influence on students considering general practice as a career.3 Yet, following a steady increase over the past 20 years, the percentage of teaching in general practice in UK medical schools has plateaued (mean 13%) since 2008 and the average amount of clinical contact in general practice settings has decreased overall.4 Capacity for undergraduate general practice placements is now a serious …

Teaching about medically unexplained symptoms at medical schools in the United Kingdom

Background: Medically unexplained symptoms (MUS) are very common in primary and secondary care. They are often inappropriately managed, resulting in potential harm to patients as well as wasted resources. To bring about change, it is important that newly qualified doctors are equipped with the skills to manage MUS effectively. We do not know if and how this topic is currently taught at UK medical schools. Aim: To document whether, how and when this topic is currently taught in UK medical schools. To assess potential barriers to this teaching and consider how it can be improved. Methods: A questionnaire survey emailed to GP and psychiatry teaching leads at all 31 UK medical schools. Results: Responses received from 24/31 schools showed that MUS teaching across UK medical schools is very variable in terms of amount, method, assessment and integration of the teaching within the curriculum. Most respondents identified a need for a greater quantity of cross-discipline teaching and for greater value to be attributed to the topic. Conclusion: Inconsistent and disparate teaching across medical schools may lead to very variable practice amongst qualified clinicians. In order to overcome this, consensus is needed as to how and where in the undergraduate curriculum there should be teaching about MUS.

General Practice: The Future Teaching Environment: A report on undergraduate primary care education in London

Readers of The Back Pages may be interested to know that an important report on undergraduate primary care education has been produced by the Heads of Departments of General Practice and Primary Care at Londons five undergraduate medical schools; Barts and the London, Imperial College, Kings College London, St Georges and UCL. It is entitled General Practice: The Future Teaching Environment. The report is based on a study which included scrutiny of the relevant medical education research literature, analysis of faculty teaching material, and personal interviews with education leads from the five London medical schools. The study emerged from growing concern in medical school …

Funding the teaching of medical students in general practice: a formula for the future?

UK general practice faces a recruitment challenge.1 The major policy intervention in England has been for the Department of Health to task Health Education England to ensure that 50% of UK graduates enter general practice training.2 Given that historically the proportion who enter general practice has fallen short of this target,3 the recent GP Taskforce report is important and timely.4 It has made multiple recommendations which include increasing the number of GPs and promotion of general practice as a career. We know that undergraduate experiences shape career choices in the USA5,6 and UK;7,8 and that high-quality undergraduate experiences in general practice encourage recruitment.7,8 This emphasises the current importance of undergraduate medical education in general practice. However, undergraduate education in general practice is under pressure from increasing service demand, the introduction of foundation placements in general practice and large increases in postgraduate teaching. In another paper we have shown that the steady increase in the proportion of undergraduate curricula delivered in general practice between the 1970s and the early 2000s has stalled and that the average general practice placement duration has dropped by 2 weeks in the last 10 years.9 While doctors are often attracted to teaching because it is enjoyable and important to them, as teaching load increases, teaching needs to be adequately resourced otherwise motivation to teach may wane.10,11 It is important, therefore, that the formula for funding teaching in general practice is realistic and faithfully reflects the costs. At present, the funding for teaching medical students in general practice is being reviewed. In this paper, we propose a model that may faithfully reflects the costs of this teaching.

UK academic general practice and primary care

Visible? Viable? Invaluable

Use of chaperones by obstetricians and gynaecologists: A cross-sectional survey

Summary The Royal College of Obstetrics and Gynaecologists (RCOG) recommends that a chaperone should be offered to every patient for an intimate examination. The use of chaperones has risen in primary care, but little is known about the practice of obstetricians and gynaecologists. Our aim was to determine the current attitudes and practices of Fellows and Members of the RCOG regarding chaperones during intimate examinations, both in public and private practice. A total of 800 Fellows and Members were asked to complete a 45-item questionnaire on their use of chaperones and how important a range of issues were in deciding whether or not to offer and provide a chaperone. A total of 449 questionnaires were returned. In summary, 23% of respondents never or occasionally offered a chaperone; 24% of NHS units have no agreed NHS policy and a further 16% did not know if a policy existed. In NHS practice, 77% used a chaperone with only 62% of women using a chaperone. Of those who did private practice, 34% never or occasionally offered a chaperone with 31% actually using a chaperone. In conclusion, obstetricians and gynaecologists use chaperones more than general practitioners but there is significant room for improvement. Chaperones are used more in NHS than private practice.

Improving teaching about medically unexplained symptoms for newly qualified doctors in the UK: findings from a questionnaire survey and expert workshop

Objectives Medically unexplained symptoms (MUS) present frequently in healthcare, can be complex and frustrating for clinicians and patients and are often associated with overinvestigation and significant costs. Doctors need to be aware of appropriate management strategies for such patients early in their training. A previous qualitative study with foundation year doctors (junior doctors in their first 2 years postqualification) indicated significant lack of knowledge about this topic and appropriate management strategies. This study reviewed whether, and in what format, UK foundation training programmes for newly qualified doctors include any teaching about MUS and sought recommendations for further development of such training. Design Mixed-methods design comprising a web-based questionnaire survey and an expert consultation workshop. Setting Nineteen foundation schools in England, Wales and Northern Ireland Participants Questionnaire administered via email to 155 foundation training programme directors (FTPDs) attached to the 19 foundation schools, followed by an expert consultation workshop attended by 13 medical educationalists, FTPDs and junior doctors. Results The 53/155 (34.2%) FTPDs responding to the questionnaire represented 15 of the 19 foundation schools, but only 6/53 (11%) reported any current formal teaching about MUS within their programmes. However, most recognised the importance of providing such teaching, suggesting 2–3 hours per year. All those attending the expert consultation workshop recommended case-based discussions, role-play and the use of videos to illustrate positive and negative examples of doctor–patient interactions as educational methods of choice. Educational sessions should cover the skills needed to provide appropriate explanations for patients’ symptoms as well as avoid unnecessary investigations, and providing information about suitable treatment options. Conclusions There is an urgent need to improve foundation level training about MUS, as current provision is very limited. An interactive approach covering a range of topics is recommended, but must be delivered within a realistic time frame for the curriculum.