BackgroundAgainst the background of the recruitment crisis in general practice, we aimed to determine what United Kingdom (UK) medical students value in their future careers, how they perceive careers in general practice (GP) and what influences them.MethodsCross-sectional survey of 280 final and penultimate year medical students at the University of Oxford, with questions relating to career choices, factors of importance when choosing a career and attitudes towards general practice as a career. Quantitative methods included cluster analysis, chi squared tests of independence and logistic regression analysis. Qualitative data were analysed thematically using the Framework method.ResultsResponse rate was 89% (280/315). 40% of participants said that general practice was an attractive or very attractive career option. Respondents valued job satisfaction, work-life balance and close relationships with patients. However, fewer than 20% of respondents agreed that community-based working was important to them and many (often citing particular GPs they had observed) felt that general practice as currently structured may not be satisfying or fulfilling because of high workload, financial pressures and externally imposed directives. 63% perceived GPs to have lower status than hospital specialties and 49% thought the overall culture of their medical school had negatively influenced their views towards general practice. Some respondents considered that general practice would not be intellectually challenging or compatible with a research career; some appeared to have had limited exposure to academic primary care.ConclusionsWith the caveat that this was a sample from a single medical school, medical students may be put off careers in general practice by three main things: low perceived value of community-based working and low status of general practice (linked to a prevailing medical school culture); observing the pressures under which GPs currently work; and lack of exposure to academic role models and primary care-based research opportunities. To improve recruitment of the next generation of GPs, medical schools must provide high quality placements in general practice, expose students to academic role models and highlight to policymakers the links between the current pressures in UK general practice and the recruitment crisis.Electronic supplementary materialThe online version of this article (10.1186/s12909-018-1197-z) contains supplementary material, which is available to authorized users.

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ObjectivesTo evaluate the effects of more intensive smoking cessation interventions compared to less intensive interventions on smoking cessation in people with type 1 or type 2 diabetes.DesignA systematic review and meta-analysis of randomised trials of smoking cessation interventions was conducted. Electronic searches were carried out on the following databases: MEDLINE, EMBASE, CINAHL and PsycINFO to September 2013. Searches were supplemented by review of trial registries and references from identified trials. Citations and full-text articles were screened by two reviewers. A random-effect Mantel-Haenszel model was used to pool data.SettingPrimary, secondary and tertiary care.ParticipantsAdults with type 1 or type 2 diabetes.InterventionsSmoking cessation interventions or medication (more intensive interventions) compared to usual care, counselling or optional medication (less intensive interventions).Outcome measuresBiochemically verified smoking cessation was the primary outcome. Secondary outcomes were adverse events and effects on glycaemic control. We also carried out a pooled analysis of self-reported smoking cessation outcomes.ResultsWe screened 1783 citations and reviewed seven articles reporting eight trials in 872 participants. All trials were of 6 months duration. Three trials included pharmacotherapy for smoking cessation. The risk ratio of biochemically verified smoking cessation was 1.32 (95% CI 0.23 to 7.43) for the more intensive interventions compared to less intensive interventions with significant heterogeneity (I2=76%). Only one trial reported measures of glycaemic control.ConclusionsThere is an absence of evidence of efficacy for more intensive smoking cessation interventions in people with diabetes. The more intensive strategies tested in trials to date include interventions used in the general population, adding in diabetes-specific education about increased risk. Future research should focus on multicomponent smoking cessation interventions carried out over a period of at least 1 year, and also assess impact on glycaemic control.

ObjectivesOut-of-hours (OOH) primary care services are a key element of community care at the end of life, yet there have been no previous attempts to describe the scope of this activity. We aimed to establish the proportion of Oxfordshire patients who were seen by the OOH service within the last 30 days of life, whether they were documented in a palliative phase of care and the demographic and clinical features of these groups.DesignPopulation-based study linking a database of patient contacts with OOH primary care with the register of all deaths within Oxfordshire (600 000 population) during 13 months.SettingOxfordshire.ParticipantsBetween 1 December 2014 and 30 November 2015 there were 102 877 OOH contacts made by 67 943 patients with the OOH service.Main outcome measuresProportion of patients dying in the Oxfordshire population who were seen by the OOH service within the last 30 days of life. Demographic and clinical features of these contacts.Results29.5% of all population deaths were seen by the OOH service in the last 30 days of life. Among the 1530 patients seen, patients whose palliative phase was documented (n=577, 36.4%) were slightly younger (median age=83.5 vs 85.2 years, P<0.001) and were seen closer to death (median days to death=2 vs 8, P<0.001). More were assessed at home (59.8% vs 51.9%, P<0.001) and less were admitted to hospital (2.7% vs 18.0%, P<0.001).ConclusionsOOH services see around one-third of all patients who die in a population. Most patients at the end of life are not documented as palliative by OOH services and are less likely to receive ongoing care at home.

AimsHeart failure (HF) is an important clinical problem. Expert consensus has defined HF as a primary care-sensitive condition for which the risk of unplanned admissions may be reduced by high quality primary care, but there is little supporting evidence. We analysed time trends in HF admission rates in England and risk and protective factors for admission. Methods and resultsWe used Hospital Episodes Statistics to produce indirectly standardized HF admission counts by general practice for 2004-2011. Clustered negative binomial regression analysis produced admission risk ratios and assessed the significance of potential explanatory covariates. These included population factors (deprivation; HF, coronary heart disease, and smoking prevalence), primary care resourcing [access; general practitioner (GP) supply], and primary care quality ('Quality and Outcomes Framework' indicator.) There were 327 756 HF admissions of patients registered with 8405 practices over the study period. There was a significant reduction in admissions over time, from 6.96/100 000 in 2004 to 5.60/100 000 in 2010 (P , 0.001). Deprivation and HF prevalence were risk factors for admission. GP supply and access protected against admission. However, these effects were small and did not explain the large and highly significant annual trend in falling admission rates. ConclusionsThe observed fall in admissions over time cannot be explained by the primary care covariates we included. This analysis suggests that the potential for further significant reduction in emergency HF admissions by improving clinical quality of primary care (as currently measured) may be limited. Further work is required to identify the reasons for the reduction in admissions.--

As a GP registrar, the MRCGP Clinical Skills Assessment (CSA) exam is currently at the forefront of my mind. Vocational Training Scheme teaching focuses on how to pass, evenings are spent revising, and my bank account, now £1700 lighter, still makes me shudder. And yet, perhaps naively, it was still a shock to me to find out that at no point in the CSA exam am I expected to accurately detect real clinical signs. Of course, the CSA assesses many other important skills, including problem-solving skills, personcentred care, and attitudinal aspects. 1 My argument is certainly not with the inclusion of these. However, given that 'The validity of the CSA resides in its realistic simulation of reallife consultations', 2 it seems strange that it includes no real patients, and consequently no real physical signs, both somewhat important components, I would argue, of many real-life consultations. By contrast, the clinical component of Membership of the Royal College of Physicians (MRCP), the PACES exam (Practical Assessment of Clinical Examination Skills), 3 involves real patients with a given condition. Candidates undertake a respiratory, abdominal, cardiovascular, and neurological exam, as well as a history station, communication and ethics station, and two brief clinical consultations. In these, candidates are given 8 minutes with a patient to take a focused history, carry out a relevant examination, respond to the patient's concerns, and explain a management plan. This PACES exam is robust, and considered a rite of passage for medical trainees, who often require multiple attempts to pass. To a GP trainee it often seems unattainably tough. When colleagues pass, we congratulate them, but we also breathe a sigh of relief that we don't have to go through the same arduous process, and, in doing so, we perhaps elevate our colleagues above ourselves. I would argue that this is wrong on many levels. This veneration of MRCP gives the impression that our exit exams are 'easier', or that we couldn't pass a more robust exam should we need to. As a GP trainee who decided to undertake my MRCP exam, I would argue this is far from the truth.

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ObjectivesOut-of-hours (OOH) primary care services are contacted in the last 4 weeks of life by nearly 30% of all patients who die, but OOH palliative prescribing remains poorly understood. Our understanding of prescribing demand has previously been limited by difficulties identifying palliative patients seen OOH. This study examines the volume and type of prescriptions issued by OOH services at the end of life.MethodsA retrospective cohort study was performed by linking a database of Oxfordshire OOH service contacts over a year with national mortality data, identifying patients who died within 30 days of OOH contact. Demographic, service and prescribing data were analysed.ResultsA prescription is issued at 14.2% of contacts in the 30 days prior to death, compared with 29.9% of other contacts. The most common prescriptions were antibiotics (22.2%) and strong opioids (19%). 41.8% of prescriptions are for subcutaneously administered medication. Patients who were prescribed a syringe driver medication made twice as many OOH contacts in the 30 days prior to death compared with those who were not.ConclusionAbsolute and relative prescribing rates are low in the 30 days prior to death. Further research is required to understand what occurs at these non-prescribing end of life contacts to inform how OOH provision can best meet the needs of dying patients. Overall, relatively few patients are prescribed strong opioids or syringe drivers. When a syringe driver medication is prescribed this may help identify patients likely to be in need of further support from the service.