Forging a new identity: a qualitative study exploring the experiences of UK-based physician associate students.
ABSTRACT: OBJECTIVE:To explore student physician associates' (PAs) experiences of clinical training to ascertain the process of their occupational identity formation. SETTING:The role of the PA is relatively new within the UK. There has been a rapid expansion in training places driven by National Health Service (NHS) workforce shortages, with the Department of Health recently announcing plans for the General Medical Council to statutorily regulate PAs. Given such recent changes and the relative newness of their role, PAs are currently establishing their occupational identity. Within adjacent fields, robust identity development improves well-being and career success. Thus, there are implications for recruitment, retention and workplace performance. This qualitative study analyses the views of student PAs to ascertain the process of PA occupational identity formation through the use of one-to-one semistructured interviews. A constructivist grounded theory approach to data analysis was taken. Research was informed by communities of practice and socialisation theory. PARTICIPANTS:A theoretical sample of 19?PA students from two UK medical schools offering postgraduate PA studies courses. RESULTS:A conceptual model detailing student PA identity formation is proposed. Factors facilitating identity formation include clinical exposure and continuity. Barriers to identity formation include ignorance and negativity regarding the PA role. Difficulties navigating identity formation and lacking support resulted in identity dissonance. CONCLUSIONS:Although similarities exist between PA and medical student identity formation, unique challenges exist for student PAs. These include navigating a new role and poor access to PA role models. Given this, PA students are turning to medicine for their identity. Educators must provide support for student PA identity development in line with this work's recommendations. Such support is likely to improve the job satisfaction and retention of PAs within the UK NHS.
Project description:To examine nurse practitioner (NP) and physician assistant (PA) practice in nursing homes (NHs) during 2000-2010.Data were derived from the Online Survey Certification and Reporting system and Medicare Part B claims (20 percent sample).NP/PA state average employment, visit per bed year (VPBY), and providers per NH were examined. State fixed-effect models examined the association between state regulations and NP/PA use.NHs using any NPs/PAs increased from 20.4 to 35.0 percent during 2000-2010. Average NP/PA VPBY increased from 1.0/0.3 to 3.0/0.6 during 2000-2010. Average number of NPs/PAs per NH increased from 0.2/0.09 to 0.5/0.14 during 2000-2010. The impact of state scope-of-practice regulations was mixed.NP and PA scope-of-practice regulations impact their practice in NHs, not always as intended.
Project description:BACKGROUND:The number of physician associates (PAs) training and working in the UK has increased over the last few years following the proliferation of postgraduate courses. Understanding early experiences and what impacts on engagement is important if we are to appropriately support this relatively new professional group. METHODS:This paper reports on a cross-sectional analysis of the first year of data from a prospective 10-year longitudinal cohort study. First year PA students (n = 89) were enrolled from five universities in one UK region where the training programmes were less than 2 years old. Data collected were: demographic information, wellbeing, burnout and engagement, expectations, placement experience, performance and caring responsibilities. Pearson's correlations were used to examine relationships between variables and to select variables for a hierarchical regression analysis to understand which factors were associated with engagement. Descriptive statistics were calculated for questions relating to experience. RESULTS:The experiences of PA students during their first 3-6 months were mixed. For example, 78.7% of students felt that there were staff on placement they could go to for support, however, 44.8% reported that staff did not know about the role and 61.3% reported that staff did not know what clinical work they should undertake. Regression analysis found that their level of engagement was associated with their perceived career satisfaction, overall well-being, and caring responsibilities. CONCLUSIONS:The support systems required for PAs may need to be examined as results showed that the PA student demographic is different to that of medical students and caring responsibilities are highly associated with engagement. A lack of understanding around the PA role in clinical settings may also need to be addressed in order to better support and develop this workforce.
Project description:Background:While the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines advise exercise to reduce disease progression, little investment in promoting physical activity (PA) is made by health care authorities. The purpose of this study was to estimate the cost-effectiveness of regular PA vs sedentary lifestyle in people with COPD in the UK. Methods:Efficacy, quality of life, and economic evidence on the PA effects in COPD patients were retrieved from literature to serve as input for a Markov microsimulation model comparing a COPD population performing PA vs a COPD population with sedentary lifestyle. The GOLD classification defined the model health states. For the base case, the cost of PA was estimated at zero, a lifetime horizon was used, and costs and effects were discounted at 3.5%. Analyses were performed from the UK National Health Service (NHS) perspective. Uncertainty around inputs and assumptions were explored via scenario and sensitivity analyses, including a cost threshold analysis. Outcomes were cost/quality-adjusted life year (QALY) gained and cost/year gained. Results:Based on our model, the effects of PA in the UK COPD population would be lower mortality (-6%), fewer hospitalizations (-2%), gains in years (+0.82) and QALYs (+0.66), and total cost savings of £2,568. The cost/QALY and cost/year gained were dominant. PA was cost-saving at costs <£35/month and cost-effective at cost <£202/month. The main model drivers were age and PA impact on death and hospital-treated exacerbations. Conclusion:Including PA in the management of COPD leads to long-term clinical benefits. If the NHS promotes only exercise via medical advice, this would lead to health care cost savings. If the NHS chose to fund PA, it would still likely be cost-effective.
Project description:Instability in ventricular repolarization in the presence of premature activations (PA) plays an important role in arrhythmogenesis. However, such instability cannot be detected clinically. This study developed a methodology for detecting QT interval (QTI) dynamics instability from the ECG and explored the contribution of PA and QTI instability to ventricular tachycardia (VT) onset.To examine the contribution of PAs and QTI instability to VT onset, ECGs of 24 patients with acute myocardial infarction, 12 of whom had sustained VT (VT) and 12 nonsustained VT (NSVT), were used. From each patient ECG, 2 10-minute-long ECG recordings were extracted, 1 right before VT onset (onset epoch) and 1 at least 1 hour before it (control epoch). To ascertain how PA affects QTI dynamics stability, pseudo-ECGs were calculated from an MRI-based human ventricular model. Clinical and pseudo-ECGs were subdivided into 1-minute recordings (minECGs). QTI dynamics stability of each minECG was assessed with a novel approach. Frequency of PAs (f(PA)) and the number of minECGs with unstable QTI dynamics (N(us)) were determined for each patient. In the VT group, f(PA) and N(us) of the onset epoch were larger than in control. Positive regression relationships between f(PA) and N(us) were identified in both groups. The simulations showed that both f(PA) and the PA degree of prematurity contribute to QTI dynamics instability.Increased PA frequency and QTI dynamics instability precede VT onset in patients with acute myocardial infarction, as determined by novel methodology for detecting instability in QTI dynamics from clinical ECGs.
Project description:Pharmaceutical agents (PAs) are commonly prescribed in companion animal practice in the United Kingdom. However, little is known about PA prescription on a population-level, particularly with respect to PAs authorised for human use alone prescribed via the veterinary cascade; this raises important questions regarding the efficacy and safety of PAs prescribed to companion animals. This study explored new approaches for describing PA prescription, diversity and co-prescription in dogs, cats and rabbits utilising electronic health records (EHRs) from a sentinel network of 457 companion animal-treating veterinary sites throughout the UK over a 2-year period (2014-2016). A novel text mining-based identification and classification methodology was utilised to semi-automatically map practitioner-defined product descriptions recorded in 918,333 EHRs from 413,870 dogs encompassing 1,242,270 prescriptions; 352,730 EHRs from 200,541 cats encompassing 491,554 prescriptions, and 22,526 EHRS from 13,398 rabbits encompassing 18,490 prescriptions respectively. PA prescription as a percentage of booked consultations was 65.4% (95% confidence interval, CI, 64.6-66.3) in dogs; in cats it was 69.1% (95% CI, 67.9-70.2) and in rabbits, 56.3% (95% CI, 54.7-57.8). Vaccines were the most commonly prescribed PAs in all three species, with antibiotics, antimycotics, and parasiticides also commonly prescribed. PA prescription utilising products authorised for human use only (hence, 'human-authorised') comprised 5.1% (95% CI, 4.7-5.5) of total canine prescription events; in cats it was 2.8% (95% CI, 2.6-3.0), and in rabbits, 7.8% (95% CI, 6.5-9.0). The most commonly prescribed human-authorised PA in dogs was metronidazole (antibiotic); in cats and rabbits it was ranitidine (H2 histamine receptor antagonist). Using a new approach utilising the Simpson's Diversity Index (an ecological measure of relative animal, plant etc. species abundance), we identified differences in prescription based on presenting complaint and species, with rabbits generally exposed to a less diverse range of PAs than dogs or cats, potentially reflecting the paucity of authorised PAs for use in rabbits. Finally, through a novel application of network analysis, we demonstrated the existence of three major co-prescription groups (preventive health; treatment of disease, and euthanasia); a trend commonly observed in practice. This study represents the first time PA prescription has been described across all pharmaceutical families in a large population of companion animals, encompassing PAs authorised for both veterinary and human-only use. These data form a baseline against which future studies could be compared, and provides some useful tools for understanding PA comparative efficacy and risks when prescribed in the varied setting of clinical practice.
Project description:Peptide amphiphiles (PAs) are self-assembling molecules that form interwoven nanofiber gel networks. They have gained a lot of attention because of their excellent biocompatibility, adaptable peptide structure that allows for specific biochemical functionality, and nanofibrous assembly that mimics natural tissue formation. However, variations in molecule length, charge, and intermolecular bonding between different bioactive PAs cause contrasting mechanical properties. This potentially limits cell-delivery therapies because scaffold durability is needed to withstand the rigors of clinician handling and transport to wound implant sites. Additionally, the mechanical properties have critical influence on cellular behavior, as the elasticity and stiffness of biomaterials have been shown to affect cell spreading, migration, contraction, and differentiation. Several different PAs have been synthesized, each endowed with specific cellular adhesive ligands for directed biological response. We have investigated mechanical means for modulating and stabilizing the gelation properties of PA hydrogels in a controlled manner. A more stable, biologically inert PA (PA-S) was synthesized and combined with each of the bioactive PAs. Molar ratio (M(r) = PA/PA-S) combinations of 3:1, 1:1, and 1:3 were tested. All PA composites were characterized by observed nanostructure and rheological analysis measuring viscoelasticity. It was found that the PAs could be combined to successfully control and stabilize the gelation properties, allowing for a mechanically tunable scaffold with increased durability. Thus, the biological functionality and natural degradability of PAs can be provided in a more physiologically relevant microenvironment using our composite approach to modulate the mechanical properties, thereby improving the vast potential for cell encapsulation and other tissue engineering applications.
Project description:Peptide amphiphiles (PAs) provide a versatile platform for the design of complex and functional material constructs for biomedical applications. The hierarchical self-assembly of PAs with biopolymers is used to create robust hybrid membranes with molecular order on the micron scale. Fabrication of membranes by assembling hyaluronic acid with positively charged PA nanostructures containing anti-cancer PAs bearing a (KLAKLAK)(2) peptide sequence is reported here. Changes in membrane microstructure as the positively charged PA nanostructures vary from cylindrical nanofibers to spherical aggregates are characterized. Results indicate that formation of highly aligned fibrous membranes requires a threshold concentration of nanofibers in solution. Additionally, variation of PA nanostructure morphology from spherical aggregates to cylindrical nanofibers allows membranes to act either as reservoirs for sustained release of cytotoxicity upon enzymatic degradation or as membranes with surface-bound cytotoxicity, respectively. Thus, the self-assembly processes of these PA-biopolymer membranes can be potentially used to design delivery platforms for anti-cancer therapeutics.
Project description:Pyrrolizidine alkaloids (PA) are secondary metabolites of certain flowering plants. The ingestion of PAs may result in acute and chronic effects in man and livestock with hepatotoxicity, mutagenicity, and carcinogenicity being identified as predominant effects. Several hundred PAs sharing the diol pyrrolizidine as a core structure are formed by plants. Although many congeners may cause adverse effects, differences in the toxic potency have been detected in animal tests. It is generally accepted that PAs themselves are biologically and toxicologically inactive and require metabolic activation. Consequently, a strong relationship between activating metabolism and toxicity can be expected. Concerning PA susceptibility, marked differences between species were reported with a comparatively high susceptibility in horses, while goat and sheep seem to be almost resistant. Therefore, we investigated the in vitro degradation rate of four frequently occurring PAs by liver enzymes present in S9 fractions from human, pig, cow, horse, rat, rabbit, goat, and sheep liver. Unexpectedly, almost no metabolic degradation of any PA was observed for susceptible species such as human, pig, horse, or cow. If the formation of toxic metabolites represents a crucial bioactivation step, the found inverse conversion rates of PAs compared to the known susceptibility require further investigation.
Project description:OBJECTIVES:This study aims to assess the prevalence of health problems (eg, insomnia, binge-eating, substance use and ill health) among UK doctors and to investigate whether occupational distress increases the risk of health problems. DESIGN:This study reports the analysis of data collected at the baseline stage of a randomised controlled trial (protocol #NCT02838290). SETTING:Doctors were invited through medical Royal Colleges, the British Medical Association's research panel and a random selection of NHS trusts across various UK regions. PARTICIPANTS:417 UK doctors with an equivalent split of gender (48% males) and seniority (49% consultants). MAIN OUTCOMES AND MEASURES:Outcomes were sleep problems (eg, insomnia), alcohol/drug use (eg, binge-drinking), ill health (eg, backache) and binge-eating (eg, uncontrollable eating). Predictor variables were occupational distress (psychiatric morbidity, burnout, job effort, work-life imbalance, coping with stress through self-blame or substances) and work factors (workplace and years practising medicine). RESULTS:44% of doctors binge-drank and 5% met the criteria for alcohol dependence; 24%-29% experienced negative emotions after overeating and 8% had a binge-eating disorder; 20%-61% had some type of sleep problem and 12% had severe/moderate insomnia; 69% had fatigue and 19%-29% experienced other types of ill health problems. The results show that occupational distress and job factors increase the odds of doctors using substances, having sleep problems, presenting with frequent symptoms of ill health and binge-eating. For example, burnout increased the risk of all types of sleep problems, eg, difficulty falling/staying asleep, insomnia (OR ≥1.344; p≤0.036). Even taking into consideration whether or not a doctor works in a hospital, the risk of health problems still rises when doctors have signs of occupational distress. CONCLUSION:Early recognition of occupational distress can prevent health problems among UK doctors that can reduce the quality of patient care because of sickness-related absence.
Project description:Proanthocyanidins (PAs) are fundamental nutritional metabolites in different types of grape products consumed by human beings. Although the biosynthesis of PAs in berry of Vitis vinifera has gained intensive investigations, the understanding of PAs in other Vitis species is limited. In this study, we report PA formation and characterization of gene expression involved in PA biosynthesis in leaves of V. bellula, a wild edible grape species native to south and south-west China. Leaves are collected at five developmental stages defined by sizes ranging from 0.5 to 5 cm in length. Analyses of thin layer chromatography (TLC) and high performance liquid chromatography-photodiode array detector (HPLC-PAD) show the formation of (+)-catechin, (-)-epicatechin, (+)-gallocatechin and (-)-epigallocatechin during the entire development of leaves. Analyses of butanol-HCl boiling cleavage coupled with spectrometry measurement at 550 nm show a temporal trend of extractable PA levels, which is characterized by an increase from 0.5 cm to 1.5 cm long leaves followed by a decrease in late stages. TLC and HPLC-PAD analyses identify cyanidin, delphinidin and pelargonidin produced from the cleavage of PAs in the butanol-HCl boiling, showing that the foliage PAs of V. bellula include three different types of extension units. Four cDNAs, which encode VbANR, VbDFR, VbLAR1 and VbLAR2, respectively, are cloned from young leaves. The expression patterns of VbANR and VbLAR2 but not VbLAR1 and VbDFR follow a similar trend as the accumulation patterns of PAs. Two cDNAs encoding VbMYBPA1 and VbMYB5a, the homologs of which have been demonstrated to regulate the expression of both ANR and LAR in V. vinifera, are also cloned and their expression profiles are similar to those of VbANR and VbLAR2. In contrast, the expression profiles of MYBA1 and 2 homologs involved in anthocyanin biosynthesis are different from those of VbANR and VbLAR2. Our data show that both ANR and LAR branches are involved in PA biosynthesis in leaves of V. bellula.