Kathleen Kendall

Implementing the undergraduate mini-CEX: a tailored approach at Southampton University.

Objectives  The mini‐clinical evaluation exercise (mini‐CEX) is widely used in the UK to assess clinical competence, but there is little evidence regarding its implementation in the undergraduate setting. This study aimed to estimate the validity and reliability of the undergraduate mini‐CEX and discuss the challenges involved in its implementation.

Decolonising medical curricula through diversity education: Lessons from students

Abstract Introduction: The General Medical Council (GMC) expects that medical students graduate with an awareness of how the diversity of the patient population may affect health outcomes and behaviours. However, little guidance has been provided on how to incorporate diversity teaching into medical school curricula. Research highlights the existence of two different models within medical education: cultural competency and cultural humility. The Southampton medical curriculum includes both models in its diversity teaching, but little was known about which model was dominant or about the students’ experience. Methods: Fifteen semi-structured, in-depth interviews were carried out with medical students at the University of Southampton. Data were analysed thematically using elements of grounded theory and constant comparison. Results: Students identified early examples of diversity teaching consistent with a cultural humility approach. In later years, the limited diversity teaching recognised by students generally adopted a cultural competency approach. Students tended to perceive diversity as something that creates problems for healthcare professionals due to patients’ perceived differences. They also reported witnessing a number of questionable practices related to diversity issues that they felt unable to challenge. The dissonance created by differences in the largely lecture based and the clinical environments left students confused and doubting the value of cultural humility in a clinical context. Conclusions: Staff training on diversity issues is required to encourage institutional buy-in and establish consistent educational and clinical environments. By tackling cultural diversity within the context of patient-centred care, cultural humility, the approach students valued most, would become the default model. Reflective practice and the development of a critical consciousness are crucial in the improvement of cultural diversity training and thus should be facilitated and encouraged. Educators can adopt a bidirectional mode of teaching and work with students to decolonise medical curricula and improve medical practice.

Resisting blame and managing emotion in general practice: The case of patient suicide

UK Governing bodies are imposing increased forms of regulation on General Practitioners (GPs). This paper explores one example of such governance - the audit of GP practice through Critical Incident Reviews (CIRs) following patient suicide. Drawing on interviews with 16 GPs about their involvement in a CIR of a patients suicide, we found that the review process initially provoked strong emotions of sadness and guilt as well as fear of blame. Ultimately, however, most GPs felt comforted by the CIRs because their findings confirmed that they were not responsible for the suicide. At the same time, the GPs indicated that such comfort was tenuous due to the broader blame culture and because they foresaw many future audits as part of an inflationary spiral of surveillance and risk management. While the GPs adopted strategies to manage and resist surveillance, the effects of CIRs on patient care may be mixed, with the potential both to improve clinical practice and contribute to adverse outcomes. We argue that CIRs paradoxically contain and create anxieties about suicide among GPs and society more broadly.

General practice critical incident reviews of patient suicides: benefits, barriers, costs, and family participation

Aim: To explore the feasibility of holding critical incident reviews (CIRs) after patient suicides in general practice and their ability to change practice. Methods: Thirteen practices were invited to conduct a facilitated CIR on 18 current patient suicides. Next of kin views were sought. All staff attending a CIR were interviewed after the review. Results: Ten practices reviewed 12 deaths. Twenty six staff attended reviews; all were interviewed. Next of kin contributed to six reviews; only one criticised care. Changes following the reviews included steps to improve internal communication and bereavement support to set up internal CIRs and review prescribing policies. Communications between practices and other agencies were clarified. Conclusion: Practices were willing to hold CIRs and appreciated the potential positive value but need reassurance that they will not be blamed for suicides, and that the cost in time and resources will be recognised.

After the Asylum in Canada: Surviving Deinstitutionalisation and Revising History

Psychiatric deinstitutionalisation began in Canada in earnest during the 1960s and continues today. The downsizing and closure of custodial mental hospitals did not occur uniformly across the country, and regional variations in government, healthcare staff and community care policies profoundly shaped the process. The Saskatchewan Mental Hospital at Weyburn, the last asylum built in the Victorian style in the British Commonwealth, was the first to shut its doors, which it did dramatically in 1963. Others closed in stages, emptying wings and transitioning into outpatient care facilities or, as was the case in Alberta, repurposing the buildings for brain injured patients requiring shorter-term stays. Some facilities remained open with a reduced patient population and abandoned sections of the hospital that no longer conformed to the standards for privacy or health and safety regulations. Eastern Canadian provinces like Nova Scotia had not subscribed to large-scale custodial institutions in the first place, and while deinstitutionalisation from cottage-style facilities also occurred, the pace and impact of that change was profoundly different for staff, communities and ex-patients. Several Ontario-based institutions centralised their services, closing some and enlarging others. British Columbia’s iconic Riverview mental hospital continued to exist partially until 2012, looming large in cultural memory, as did many of these other monuments to what soon became a bygone era of psychiatric care. This regional variation in service delivery has in part characterised deinstitutionalisation in Canada, and also helps to underscore how patients from place to place may have encountered very different circumstances as they moved out of institutional care.

The power of the latte: sustaining leaders of change

Context and setting As teachers and coordinators on a 5-year medical programme, we were given the task of leading a curriculum change in Years 1 and 2. Although the existing curriculum was highly rated in quality audits and by students and staff, there were a number of important drivers for change. We prepared for the role by undertaking a review of the relevant literature, participating in staff development courses and seeking guidance from experts. We implemented key steps, such as: creating a vision; communicating the vision; identifying the learning outcomes; and aligning assessments with these. Why the idea was necessary Despite feeling that we were well prepared for leading the curriculum change and for managing obstacles and resistance from others, we were surprised by the toll this took upon us. We were particularly astonished when following good educational practice undermined rather than supported our credibility. Some teachers with leverage among students and staff labelled us as ‘trendy medical educationalists’ and accused us of operating from an ivory tower rather than from the real world of the classroom and clinic. The literature we consulted recognised the importance of emotion in curricular and organisational change, but rarely referred to the emotions experienced by those leading the change, focusing instead on how leaders can address the emotions of the individuals they lead. Although we acknowledged others’ emotions and developed strategies to deal with them, we did not know how best to manage our own increasing exhaustion, anxiety, self-doubt, frustration and anger. We knew that we needed to address our own emotions or they would negatively affect our ability to effectively lead the change. What was done We took the innovative step of developing a formal strategy to positively manage our own emotions and sustain our leadership. This is outlined here in the hope that others will find our ideas useful and be encouraged to develop their own strategies.