Objectives The educational alliance is argued to be at the heart of supervision in medical education. This review aims to map the research field and develop a conceptualisation of the nature of such educational alliances within postgraduate supervision for general practitioners. Methods An integrative review of the international literature on supervision from 2011 to 2018 was undertaken, and papers assessed for relevance and quality. Data analysis incorporated framework analysis techniques. Bordin's working alliance‐based model of supervision was used as a springboard for synthesis, as well as allowing for the emergence of new ideas, theories and concepts from the literature. Results A total of 49 full texts were included for analysis. There was evidence of the importance of trust, agreement and bond in accordance with Bordin's model. The results also highlighted the importance of greater clarity on supervisory goals, and the tasks to support these goals, to effectively address competing priorities and roles within supervision. Non‐hierarchical relationships were advocated, although supervisors must remain impartial in their assessment and monitoring roles. The influence of the wider practice community and situated learning through legitimate peripheral participation are documented. A model of General practice (GP) supervision is proposed that integrates the findings. Conclusions GP supervision requires a greater emphasis than is suggested by the working alliance model, both on the clarity of expectations and the appreciation of the multiple roles and competing priorities of both trainee and supervisor. Furthermore, as GP supervision develops within the rising workload of contemporary general practice, the role of the wider community of practice may become more prominent. We have adapted the working alliance model for postgraduate General practice (GP) supervision, emphasising the explicit sharing of expectations relating to goals, tasks and roles to facilitate negotiation and agreement.

Background Struggling at medical school incorporates academic failure, course disruption and early course exit. Struggling is usually multi-factorial involving academic, personal, financial and health factors. Struggling students may fail to engage with available support. First year students are particularly susceptible as they transition to university and a professional career. Methods The study aim was to explore medical students’ own voices on struggling and assess how they match up to existing literature. During one academic year, all first year medical students at the University of Birmingham (UK) who opted to leave or were required to withdraw (n = 52) were asked to participate in an individual exit interview. Fifteen students responded and fourteen (27%) agreed to be interviewed. Interviews were face to face (n = 10), telephone (n = 3) and via email (n = 1). Interviews were unstructured and led by a general open question. Framework analysis identified key data themes. Results Students described year one of medical school as a critical transition. They simultaneously needed to adapt to being a university student, a medical student and a doctor. A six-group typology of students emerged, each of which struggled with one or more of these adaptations. The groups were: wrong degree choice, mental health problems, acute crisis, at capacity, slow starter and family rock. Some students experienced an isolated problem from within this typology. Most had a multi-factorial story of struggling. Mental health problems and acute crises were the most common issues. Early professional identity formation was a key hurdle. Help-seeking behaviours were varied. Conclusions This study explores the narratives of medical students who struggled from an early stage and presents a data-driven typology of their issues. It advances existing qualitative understanding of this topic, which to date is predominantly derived from educator perceptions and not specific to early course issues. Although our results broadly cohere with existing knowledge, we also present novel findings which may reflect our focus on first year students. Issues around early professional identity formation may reflect the increasing emphasis on professionalism in medical school curricula. Listening to these narratives could help university staff to identify students at risk of struggling for targeted support.

Background Work-life balance is a key contributor to doctors’ wellbeing and consequently is a central factor in their career decisions. General Medical Council guidance outlines the importance of work-life balance as part of compassionate self-care. Learning self-care should begin as an undergraduate, when academic and clinical workload can contribute to stress, anxiety and burnout. Methods Sequential mixed methods study of medical students in Years 3–5 at the University of Birmingham, UK. Students (n = 145) defined work-life balance in free-text answers and self-assessed their current work-life balance via questionnaires. Following this, a sub-sample of students (n = 44) participated in exploratory individual mini-interviews. Results Work-life balance emerged as a broad and multifactorial concept. Questionnaire respondents most frequently referenced enjoyment, meeting work requirements and time management in their definitions. Interview participants highlighted additional influencing factors such as peer groups, study skills, family and professional culture. Students expect a significant shift towards work after graduating and expressed concerns about the stresses of delivering patient care. 42% (n = 60) of students felt they had received support with their work-life balance during their training, mostly from family and friends. Most students had not received support or advice on their work-life balance from University or hospital staff. Conclusion Self-care and work-life balance are essential for medical students and doctors to cope with lifelong learning and deliver effective care. Medical school staff should be pro-active in supporting students to develop these skills, particularly during critical transition periods. Early interventions targeting study skills and time management may be beneficial. Further research should include students in Years 1–2 and compare different institutions.

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The majority of male students perceived that their gender impacted their clinical experience in O&G and GUM. Self-reported confidence levels were unaffected, which could reflect varying approaches to competence between genders. The link between observing examinations and subsequent opportunities to practise is key. This could demonstrate students developing rapport and trust with patients, and clinicians' roles as gatekeepers.

Background Direct ophthalmoscopy (DO) is an essential skill for medical graduates but there are multiple barriers to learning this. Medical students and junior doctors typically lack confidence in DO. Most students do not own an ophthalmoscope and learn via ward devices that vary in design and usability. The Arclight ophthalmoscope (AO) is an easy to use, low-cost and portable device that could help address device access. This study aimed to assess the impact of personal ownership of an AO on DO skill acquisition and competency amongst medical students in the clinical environment. Methods Method comparison study with 42 medical students randomised to either traditional device ophthalmoscope (TDO) control or AO intervention group during an 18-week medical placement. Three objective assessments of DO competency were performed at the beginning and end of the placement: vertical cup to disc ratio (VCDR) measurement, fundus photo multiple-choice questions (F-MCQ) and model slide examination (MSE). DO examinations performed during the placement were recorded via an electronic logbook. Results Students in both groups recorded a median number of six examinations each during an eighteen-week placement. There was no statistically significant difference between the groups in any of the objective assessment measures (VCDR p = 0.561, MCQ p = 0.872, Model p = 0.772). Both groups demonstrated a minor improvement in VCDR measurement but a negative performance change in F-MCQ and MSE assessments. Conclusions Students do not practice ophthalmoscopy often, even with constant access to their own portable device. The lack of significant difference between the groups suggests that device access alone is not the major factor affecting frequency of DO performance and consequent skill acquisition. Improving student engagement with ophthalmoscopy will require a more wide-ranging approach.

BackgroundHypophosphatasia (HPP) is a rare inherited disorder affecting bone and teeth development. Perinatal HPP is the most severe form and associated with a high mortality. Features include respiratory distress, skeletal abnormalities and low alkaline phosphatase (ALP) activity.CaseA baby boy developed respiratory distress, hypotonia and seizures within an hour of birth. Blood gas showed mixed acidosis and abnormal base deficit. Hypoxic–ischaemic encephalopathy (HIE) was suspected and managed with therapeutic hypothermia. Subsequent investigations identified low ALP activity and abnormal bone mineralisation, leading to a diagnosis of HPP. On day 5 of life, enzyme replacement therapy (ERT) was commenced, its first use via direct NHS England funding since UK licensing in 2017.ConclusionsEarly hypotonia is an atypical presentation for perinatal HPP. Combined with acidosis and encephalopathy, it can clinically mimic HIE. Early recognition of biochemical and radiological features of HPP is essential for rapid diagnosis and timely initiation of life-saving ERT.

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