Journal of the Royal Society of Medicine最新文献

Objectives: Significant differences in group-level performance have been identified in UK postgraduate medical examinations. However, few examinations have been investigated independently, and those that have, focus on a limited number of sociodemographic factors. This study addresses these gaps by identifying predictors of success in each UK postgraduate medical examination, accounting for prior academic attainment and other sociodemographic differences.

Design: Retrospective cohort study.

Setting: Secondary care.

Participants: Anonymised pass/fail data at the first attempt held within the General Medical Council Database were analysed for all candidates (UK medical school graduates [UKG] and international, non-UK graduates [IMG]) attempting a postgraduate examination between 2014 and 2020.

Main outcome measures: Multivariate logistic regression models identified independent predictors of success at each postgraduate examination.

Results: During the study period, 180,890 examination first-attempts were made by candidates, and 121,745 (67.3%) passed at their first attempt. Multivariate regression models revealed that place of primary qualification, gender, age, ethnicity, religion, sexual orientation, disability and LTFT status were all statistically significant independent predictors of success or failure in written and clinical examinations. The strongest independent predictors of failing written and clinical examinations were being an IMG, being from a minority ethnic background and having a registered disability.

Conclusions: This was the largest study to date investigating independent predictors of outcomes at each UK postgraduate medical examination. Significant differences in pass rates were seen according to sociodemographic differences in each examination. These data can be used by Medical Royal Colleges, the GMC and training institutions to guide more granular research and future interventions.

ObjectivesImmortal time bias (ITB) occurs when a period during which, by design, participants cannot experience the outcome (like death) is incorrectly included in the treatment group's follow-up, artificially making the treatment look better than it truly is. We aimed to identify a systematic sample of cases of ITB in the literature of studies using survival analysis and assess the impact of ITB on the results.DesignMeta-epidemiological study (PROSPERO[CRD42022356073]).SettingWe searched PubMed/MEDLINE, Embase and Cochrane Database of Systematic Reviews from database inception to August 2024. Systematic reviews with quantitative syntheses that allowed subgroup analysis by the presence of ITB for any available exposure-outcome pairs ('topics') were eligible for inclusion.ParticipantsParticipants included in the systematic reviews.Main outcome measuresInformation on ITB and effect sizes (ESs) with 95% confidence interval for individual studies in forest plots were extracted to run re-analysis using generic inverse variance fixed- and random-effects methods. After extracting data, we conducted subgroup analysis by the presence of ITB for all available topics and assessed the impact of ITB on the heterogeneity (I²), vulnerability of evidence (or conclusion), statistical significance of the finding, and altering ES in favour of intervention/exposure.ResultsThe median (interquartile range (IQR)) number of studies included for a topic was 6 (4-10). Across 25 topics (including 182 studies), 44.0% of the eligible studies (80 studies) were affected by ITB. Among the 21 topics where both studies with ITB and studies without ITB were available (four topics only had studies unaffected by ITB), 57.1% (12/21) demonstrated statistically significant results only in studies with ITB (n = 11 topics) or only in studies without ITB (one topic). In 23.8% (5/21), the overall summary results changed from statistically significant to non-statistically significant or vice versa after excluding studies with ITB. The ratio of ES - summary ES from studies with ITB relative to summary ES from studies without ITB - was 0.71 (95% CI, 0.66-0.78), suggesting that the ES from studies with ITB was larger by an average of 29% in favour of the intervention/exposure. Excluding studies involving ITB reduced between-study heterogeneity (I²) by 21.4% on average.ConclusionsITB can be common among studies in some medical areas, and its presence may substantially inflate the ESs and lead to misleading, exaggerated evidence.

ObjectivesTransgender people in the UK face uncertainties and inequalities in healthcare provision, especially for treatment required for gender transition. Existing studies have found that doctors' ideological tendencies, in particular socially normative conceptions of gender, influence their treatment of gender minority patients. This study explores doctors' understanding of their role in transgender care, their thoughts on the current processes in place to enable gender affirmation, and their theoretical views of sex/gender that underpin these conceptions.DesignOne-on-one, semi-structured online interviews. Clinicians were recruited through societies representing both specialties and then snowballed. Recruitment stopped with data sufficiency, according to the tenets of 'information power'. Data analysis was conducted in line with Braun and Clarke's Reflexive Thematic Analysis guidelines.SettingUK doctors working in general practice and endocrinology.ParticipantsConvenience and purposive sampling of 16 participants (8 endocrinologists and 8 general practitioners).Main outcome measuresOur dataset explores clinicians' conceptions of their role in transgender care and identifies current structural and organisational obstacles.ResultsThe interviews found that the division of labour in transgender care is contested. GPs felt their role was to understand the patient's narrative, and therefore were reluctant to prescribe, believing this to be within the purview of specialists. Endocrinologists described themselves as 'technicians' simply carrying out the task of providing hormonal treatment. Almost all interviewees emphasised the importance of multidisciplinary involvement, and none were willing to treat without a mental health professional.ConclusionsOur findings suggest that doctors may inadvertently communicate gender norms, but that they do so within the constraints of a system over which they have limited control, and that their conceptions of transgender care are informed by serious resource pressures. We offer some practical suggestions for how these pressures could be ameliorated.