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Background/Aims Anticipatory prescribing (AP) of injectable medications at the end-of-life for community patients is good practice to achieve timely symptom control (National Institute for Health and Care Excellence. Care of dying adults in the last days of life, 2015). However robust evidence to support current practice is lacking. We evaluated baseline AP practices at a South London hospice against current local guidelines. Methods This retrospective audit looked at patient case notes and anticipatory charts (June-August 2020) using a standardised proforma including: drug choice, dose, indication and subsequent patient clinical trajectory. Anticipatory drug use, drug wastage and themes from case vignettes are presented. Results 76 patients were reviewed, median age 80 (41-107), 66% male. 52% had a cancer diagnosis. All patients were prescribed and dispensed four medications for: pain, agitation, secretions and nausea/vomiting. There was close adherence to local guidelines (choice of drug, dose). Most commonly used drugs were: morphine 61%, midazolam 99%, glycopyrronium 97% and haloperidol 88%. 94% of patients died within three months (median 9 days). Eleven patients required admission to hospital or hospice. 64% had stats given at end-of-life, 53% for pain, 41% for agitation, 24% for secretions; only 16% needed an anti-emetic. We saw wide variation in prescribing practices for seizures at end-of-life (11 patients). Multiple health care professionals (Clinical Nurse Specialists, District Nurses and the London Ambulance Service) administered stats in and out of hours. Further training is required to ensure appropriate dose escalation and titration. Dispensing all four medications costs approximately £50 per patient; haloperidol alone accounts for 3/5ths of that cost and is not often used. Conclusions Few patients required all four medications, where anti-emetics are needed the choice of drug warrants further review with likely cost savings. At least 50% of our medications could be dispensed by GPs rather than hospice pharmacy. Further education/training will improve individualised AP and tailored administration of medications at end-of-life, including improved confidence around seizure management. We are currently updating our guidelines to reflect this.

Background: School-based HIV/STI prevention initiatives can reduce sexual risk behaviors and prevent teen pregnancy among school-age youth. However, only 27 states and D.C. mandate both sex education and HIV education, and access to formal sexual health education continues to decline. The American Academy of Pediatrics (AAP) emphasizes the importance of age-appropriate sexual health education, and the 2016 Sexuality Education for Children and Adolescents clinical report recommends dissemination through three learning domains: “cognitive (information), affective (feelings, values, and attitudes), and behaviors (communication, decision-making, and other skills)”. Sex Ed by Brown Med was …

The authors retrospectively evaluated the impact of ultrasound enhancing agent (UEA) use in the first transthoracic echocardiographic (TTE) examination, regardless of baseline image quality, on the number of repeat TTEs and length of stay (LOS) during a heart failure (HF) admission.There were 9,115 HF admissions associated with admission TTE examinations over a 4-year period (5,337 men; mean age, 67.6 ± 15.0 years). Patients were grouped into those who received UEAs (contrast group) in the first TTE study and those who did not (noncontrast group). Repeat TTE examinations were classified as justified if performed for concrete clinical indications during hospitalization.In the 9,115 admissions for HF (5,600 in the contrast group, 3,515 in the noncontrast group), 927 patients underwent repeat TTE studies (505 in the contrast group, 422 in the noncontrast group), which were considered justified in 823 patients. Of the 104 patients who underwent unjustified repeat TTE studies, 80 (76.7%) belonged to the noncontrast group and 24 to the contrast group. Also, UEA use increased from 50.4% in 2014 to 74.3%, and the rate of unjustified repeat studies decreased from 1.3% to 0.9%. The rates of unjustified repeat TTE imaging were 2.3% and 0.4% (in the noncontrast and contrast groups, respectively), and patients in the contrast group were less likely to undergo unjustified repeat examinations (odds ratio, 0.18; 95% CI, 0.12-0.29; P .0001). The mean LOS was significantly lower in the contrast group (9.5 ± 10.5 vs 11.1 ± 13.7 days). The use of UEA in the first TTE study was also associated with reduced LOS (linear regression, βThe routine use of UEA in the first TTE examination for HF irrespective of image quality is associated with reduced unjustified repeat TTE testing and may reduce LOS during an index HF admission.

Background and Objectives: Physician discomfort, embarrassment, and perceived lack of time and/or training all play a role in preventing physicians from discussing sexual health with patients. Past research shows this discomfort begins in medical school. We aimed to determine whether teaching sexual health education increases medical students’ self-efficacy in discussing sexual health topics with adolescents. Methods: We emailed a retrospective pre/postsurvey to all medical students who taught sexual health education in a local middle school through Sex Ed by Brown Med (N=61). Results: Participation in Sex Ed by Brown Med improves self-efficacy in discussing nine sexual health topics and in performing nine advanced interviewing skills relevant to sexual health in a retrospective analysis using self-reported data. Conclusions: Programs similar to Sex Ed by Brown Med may be useful in improving medical students’ ability to adequately care for their patients’ sexual health by making future clinicians more comfortable when discussing the important topic of sexuality, and concurrently providing evidence-based comprehensive sexual health education to middle school students. Further research is needed to determine the impact of our program (and similar programs) before disseminating this model of sexual education.

Background: The ‘Primary Care SHOPping Intervention for Cardiovascular Disease Prevention’ (PCSHOP) trial tested the effectiveness and feasibility of a behavioural intervention to reduce saturated fat in food purchases. The intervention offered feedback from data collected through a supermarket loyalty card to supplement brief advice from a nurse. This qualitative study aimed to describe participants’ experiences of receiving this intervention. Methods: We conducted semi-structured, one-to-one, telephone interviews with participants from the PCSHOP trial. Interviews were audio-recorded and transcribed verbatim. We employed the one sheet of paper technique and a thematic analysis to develop high-level themes in NVivo software. Results: Twenty-four participants were interviewed (mean age: 63 years (SD 12)). They reported that the brief advice did not provide any new information but they welcomed the sense of accountability the nurse provided. The personalised shopping feedback and healthier swap suggestions provided novel information that challenged previously held beliefs about the saturated fat content of food purchases and encouraged some positive dietary changes. However, the taste preferences of the participant or other household members were a barrier to changing food shopping behaviours. Conclusion: Harnessing loyalty card data is a novel and acceptable method to offering personalised dietary feedback. Yet, issues on the suitability of the healthier swap suggestions limited the extent of dietary change. Trial registration: ISRCTN14279335. Registered 1 September 2017.

This article situates China's local policy experimentation in the broader context of policy experiments in decentralized political systems, through a case study which represents a local state response to China's transition to a market economy. With growing regional and urban–rural inequalities evident after the initial reform period (1978–1994), local party leaders of inland provinces devised strategies for addressing these inequalities and encouraging public–private sector mobility among party officials. County and township-level leaders pursued local policy experiments in which they selected and sent officials to find private-sector work in China's booming coastal cities. Initiated in the 1990s and peaking in the 2000s, these policy experiments and inter-provincial transfers demonstrate the discretion that local officials possess to conduct programmatic/policy experiments in a unitary political system and show how officials resort to extra-institutional strategies in order to bridge perceived knowledge gaps. The ultimate demise of these programmes illuminates the challenges to extra-institutional policy innovations in transitioning states.

This study considers how, in the absence of elections for national office, authoritarian ruling parties create organizational channels for selecting officials. Through a case study of the Chinese Communist Party (CCP), I examine the selection problem facing the ruling party. Within the CCP, special training academies, also known as party schools, serve as a pipeline to higher party and government posts. An examination of selection patterns for these schools reveals that there exists a mix of political and professional factors which determine invitation to a party school training program, suggesting the coexistence of patronage and meritocratic processes in promotion for higher office. Empirical analysis of these selection processes takes three parts. Individual-level characteristics, such as party membership, frequency of interaction with superiors, and educational background, are significant predictors of selection for a party school program. Second, to control for selection bias, I employ a matching procedure and find that the “treatment” of enrollment in a party school training program significantly increases the likelihood that an individual will be promoted to a higher rank in comparison to those without party school training experience. Third, additional tests indicate that these schools serve a screening function for the party, thus providing an organizational means for CCP leaders to manage who enters the highest ranks of political leadership. In this sense, the training process itself serves an informational function for party authorities, beyond the ritual these organizations are long thought to embody.

We extend the logic of the democratic peace to query whether information about a foreign country's regime type affects US citizens' opinions of that country. We contrast this with the suggestion in other areas of international relations theorizing, such as the “clash of civilizations” thesis and constructivist frameworks, that a country's culture, especially its dominant religious tradition, may be more salient in citizen attitudes toward foreign countries. We designed a survey experiment to test the effects of randomly assigned cues regarding the regime type (democracy/nondemocracy) and religious culture (Islam/Christianity) of a foreign country on respondents' attitudes. Religious cultural cues outperformed regime type cues in determining respondents' perceptions of threat or expressions of trust, but respondents' views did not conform to maximalist claims of either the democratic peace or the clash of civilizations frameworks. These findings suggest that the need for a more synergetic approach to understanding the microfoundations of public foreign policy opinion formation.

Dear editor Singagireson et al1 explored the contentious issue of allocating Foundation Programme posts using the Situational Judgement Test (SJT), a system that has been criticized on the basis of fairness.2,3 The authors found evidence4 that suggested academic performance at medical school did not correlate with SJT scores, and suggested that relative success on the SJT could artificially inflate academic scores attained at medical school. They concluded that the SJT was a fair means of assessing other skills required in the role of a physician. Whilst we are in agreement, the argument they present fails to examine the reasoning behind using the SJT. The reliability of SJTs in general is fairly good,5–7 and it is a system used in general practice national training allocation in the UK and abroad.8 However, the statement “logic suggests if you have done well throughout medical school, you would have gained the knowledge and aptitude to perform well in the SJT” is a straw-man argument. The evidence the authors use to refute this did not show a statistically significant correlation between academic performance and SJT score. The data set was limited by its sample size (n=239), and there was risk of selection bias with inclusion of data from 36% of all UK medical schools (n=12), in addition to reporting bias.4 However, this is irrelevant, as the SJT is not something you can revise for. Indeed, the SJT does not require aptitude or knowledge, nor should it be expected to assess academic rigor. It is an interdisciplinary psychometric test used to assess a candidate’s behavioral tendencies in different workplace situations. Within this context, it tests commitment to professionalism, coping under pressure, effective communication, patient focus, and effective teamwork.9 These are skills that form gradually, and cannot be learned from a textbook. Becoming a good doctor goes beyond academic rating. Moreover, in stark contrast to their claim that an “off day” during the SJT would detrimentally affect deanery allocation, statistics from this year identified that 90.5% of medical students were allocated one of their top five deanery choices (n=8119).10 They also postulated on the “selective advantage” when an academically gifted student enrolls at a less competitive university, altogether insinuating that somehow medical school applicants strategically calculate which university to attend on the basis of academic competition. One would imagine that according to their article, the SJT would have a large spread in scores to be able to mitigate for the variability in academic ranking. This year, average SJT scores were between 37.4 and 40.9 (out of 50) in UK medical schools. This is less than a 9% variation; significant, but not sweeping.10 Finally, we would like to call into question the importance of there being interuniversity variability in quality of graduates. Perhaps the authors were alluding to the degree of preparedness a medical student felt in being able to practise confidently as a Foundation Year 1 (F1) doctor. A report compiled by the regulating authority, the General Medical Council (GMC), stated that overall medical graduates are good F1s, despite wide variation in the proportion of medical students feeling prepared for Foundation practice.11 The GMC looked at past research12 and commissioned a rapid review by Monrouxe et al.13 Preparedness among newly qualified F1s is improving: 70% felt prepared for their new posts in 2014 compared to 51% in 2012. Changes in question wording could have been a factor in this; however, graduate preparedness has been steadily increasing since 2009.11 More importantly, the number of doctors in difficulty has declined from 4.6% in 2010 to 2.6% in 2013 for F1s.11 Daily working life requires interpersonal skills and emotional durability that ought to be assessed. Greater engagement from medical students in the realities of ward work can be a challenge, and any pressure to shift the focus away from theoretical knowledge is welcome. The context-dependent syllabus of the SJT could incentivize students to spend time shadowing on the wards. Medicine is a vocation; preparedness or quality of F1s is dependent on experience. Surely the goal of the SJT is to motivate better comprehension of the GMC Code of Conduct through application, not study.

Dear editor We read the article by Singh et al1 with great interest and agree with the broad stroke sentiments expressed in the letter. However, we would like to debate the conflation of a qualification with applicable real-world skills and the assumption that this creates cost efficiency in the National Health Service (NHS). The author uses anecdotal personal experience to make the case for the compulsory delivery of an intercalated BSc (iBSc) in Management. He uses the following points: 1) the NHS leadership drive, 2) the problem of productivity and cost efficiency in hospitals, and 3) the WHO definition of health as human right to build a slippery slope argument for the merits of the iBSc in creating cost efficiency. A compulsory iBSc in Management may not directly translate to creating cost efficiency in the NHS. Such a degree program may provide insight into management theories to manage local teams and provide conceptual models of best practice, but is unlikely to equip medical students with the realities of rationing in the NHS and the ethical dilemmas faced during local commissioning. In addition, there are obstacles to a universal iBSc in Management at both an organizational level and a physician level. At an organizational level, 27% (n=9) of all UK Medical schools (n=33) offer an intercalated degree in Management to external students, which in itself pose a logistical hindrance and require rearrangement of existing university resources and creation of new degree programs. In contrast, at a physician level, the benefits of an iBSc are unlikely to be realized after medical degree qualification but require individual innovation and dedication. A junior doctor, for example, has limited resources of time and experience to implement a management project and thus would require much investment from a supporting team. A management qualification detracts from the skills demonstrated in clinical management such as negotiation, communication, charisma, and political astuteness that cannot be expected to evolve from a 1-year iBSc. In addition, one could argue that such qualities cannot be taught. A secondary benefit to a universal intercalated degree program could be improved academic performance,2,3 but such a program would force a debt upon students already within an expensive undergraduate Medicine degree. Tuition fees for English-domiciled undergraduate Medicine degree are £9000 per year; the average cost of living expenses are £5,299 per year.4 The average debt for an English medical student after 5-year study is £17,351.4 Each medical student costs the tax payer £250,0005 not including an iBSc. With issues surrounding widening participation, we feel such debt would act as a deterrent for prospective medical students.6,7 Furthermore, impressing a universal management iBSc may push students away from their “natural” interests that they may wish to pursue through an intercalated degree. This is of detriment to the future of academic medicine as a whole and is not cost effective for the taxpayer. There are many avenues for postgraduate management opportunities within local hospital initiatives and programs delivered by the NHS Leadership Academy. The 5-year forward view8 promotes the concept of clinical leadership, pledging investment into the NHS Leadership Academy in aligning its work with other major leadership bodies. Furthermore, the report9 by the Institute of Education praises the Darzi Clinical Leadership Fellows, describing their substantial impact as a social movement in changing the culture of NHS management. Such fellowship opportunities can help develop the skills of motivated individuals after they have spent time within the health care system, into which they seek to implement improvement. Despite this, we accept that there are limited undergraduate opportunities for management; however, we believe that a universal iBSc management program is not a feasible short-or long-term solution. Six-to-eight week elective placements rotating around Public Health departments, Clinical Commissioning Groups, or shadowing the hospital chief executive may be beneficial to expose those interested medical students to the practical aspects of health management. Transferable skills can be learned holding positions of responsibility in a student society. An alternative possibility is the integration of a Leadership and Management module into our already congested undergraduate medical degrees. Foundation Program10 recognized undergraduate management programs in addition to publications and previous degrees are likely to attract the next generation.11 However, we emphasize that no theory-based degree will replace the key skills of communication and partnership working, skills that will benefit the NHS in the long term, not just balance the books.