General Medical Services Research Articles

Developments in the health situation in Germany during the initial stage of the COVID-19 pandemic for selected indicators of GEDA 2019/2020-EHIS.

SARS-CoV-2, the novel coronavirus, has posed major challenges in Germany in 2020. It is unclear whether the pandemic and containment measures will have an impact on the health of the population beyond the point of infection. The German Health Update (GEDA 2019/2020-EHIS) is a nationwide survey of the population aged 15 years and older (n=23,001) that was conducted between April 2019 and September 2020. The focus of the analysis was on indicators for which pandemic-related changes could be expected. Based on regression models, adjusted proportions and mean values were estimated as trends over time. Any differences in the values found for the time period of containment measures in spring 2020 and the reference period 2019 were statistically tested. Since the implementation of containment measures, both body weight and body mass index (BMI) have increased. The utilisation of general and specialist medical services decreased temporarily. The number of tobacco smokers during the observation period also decreased, yet without revealing a clear link to the pandemic situation. No differences were found in the general population for depressive symptoms and household assistance received and provided. During the period of containment measures, changes to the health situation beyond the occurrence of infections can be observed. However, a more differentiated explanation of these findings will require further analyses.

What information do patients want about their medicines? An exploration of the perspectives of general medicine inpatients

BackgroundMedicines are one of the most common healthcare interventions, yet evidence shows patients often do not receive the information they want about their medicines. This affects their adherence and healthcare engagement. There is limited research exploring what information patients want about their medicines, from whom and in what format. The aim of this study was to determine the medicines information needs of patients admitted to the general medical service of a large New Zealand (NZ) hospital, and identify the barriers and enablers to meeting these needs.MethodsA descriptive exploratory approach using semi-structured interviews was used to understand the needs and preferences of patients for information about their regular medicines and the barriers and facilitators to obtaining this information. Patients admitted to a general medical ward at a large NZ hospital, aged 18 years and over, prescribed one or more regular medicines, and self-managing their own medicines prior to hospitalisation were included. Semi-structured interviews were conducted with each participant (n = 30) and transcribed, then analysed using a general inductive thematic analysis approach.ResultsFive overarching themes captured the medicines information needs of patients: (1) autonomy; (2) fostering relationships; (3) access; (4) communication; and (5) minimal information needs. Patients desired information to facilitate their decision-making and self-management of their health. Support people, written information, and having good relationships with health providers enabled this. Having access to information at the right time, communicated in a clear and consistent way with opportunities for follow-up, was important. A significant portion of participants were satisfied with receiving minimal information and had no expectations of needing more medicines information.ConclusionsAlthough patients’ medicines information needs varied between individuals, the importance of receiving information in an accessible, timely manner, and having good relationships with health providers, were common to most. Considering these needs is important to optimise information delivery in general medical patients.

Impact of primary care funding on patient satisfaction: a retrospective longitudinal study of English general practice, 2013-2016.

BackgroundProviding high-quality clinical care and good patient experience are priorities for most healthcare systems.AimTo understand the relationship between general practice funding and patient-reported experience.Design and settingRetrospective longitudinal study of English general practice-level data for the financial years 2013–2014 to 2016–2017.MethodData for all general practices in England from the General and Personal Medical Services database were linked to patient experience data from the GP Patient Survey (GPPS). Panel data multivariate regression was used to estimate the impact of general practice funding (current or lagged 1 year) per patient on GPPS-reported patient experience of access, continuity of care, professionalism, and overall satisfaction. Confounding was controlled for by practice, demographic, and GPPS responder characteristics, and for year effects.ResultsInflation-adjusted mean total annual funding per patient was £133.66 (standard deviation [SD] = £39.46). In all models, higher funding was associated with better patient experience. In the model with lagged funding and practice fixed effects (model 6), a 1 SD increase in funding was associated with increases in scores in the domains of access (1.18%; 95% confidence interval [CI] = 0.89 to 1.47), continuity (0.86%; 95% CI = 0.19 to 1.52), professionalism of GP (0.47%; 95% CI = 0.22 to 0.71), professionalism of nurse (0.51%; 95% CI = 0.24 to 0.77), professionalism of receptionist (0.51%; 95% CI = 0.24 to 0.78), and in overall satisfaction (0.88%; 95% CI = 0.52 to 1.24).ConclusionBetter-funded general practices were more likely to have higher reported patient experience ratings across a wide range of domains.

Prescribing patterns and outcomes of venous thromboembolism prophylaxis in hospitalized medical and cancer patients: Observations from the Ottawa Hospital

Guidelines suggest broad use of pharmacologic prophylaxis to prevent venous thromboembolism (VTE) in hospitalized medical patients, however little ‘real-world’ data exists to support this. Our goal was to describe the use of thromboprophylaxis among general medical and cancer patients admitted to hospital, compare VTE and bleeding outcomes according to use of thromboprophylaxis, and to determine what variables influence prescribing patterns and outcomes. Patients admitted to the general medical and oncology services at The Ottawa Hospital between 2010 and 2015 were retrospectively reviewed and classified according to whether they received initial, delayed, or no pharmacologic thromboprophylaxis during their first hospitalization. Patients with an alternate indication for anticoagulation or those admitted with a bleeding event were excluded from analysis. The primary efficacy outcome was any symptomatic VTE during index hospitalization or within 90 days of discharge, and the primary safety outcome was clinically relevant bleeding during the index hospitalization. 17,262 patients were included in our final analysis. General medical patients selected to receive no, initial, or delayed thromboprophylaxis had 0.4%, 0.7%, and 2.4% rates of VTE; and 0.2%, 0.7%, and 1.5% rates of clinically relevant bleeding complications, respectively. Cancer patients had significantly higher rates of VTE: 3.3%, 3.9%, and 5.0%; and 0.9%, 0.7%, and 3.0% rates of clinically relevant bleeding among those selected to receive no, initial, or delayed thromboprophylaxis, respectively. Overall, our study suggests that broad use of pharmacologic thromboprophylaxis may be unnecessary in select low-risk general medical patients and may be less effective in cancer patients in whom new studies are indicated.

Public consultation on postnatal care guidelines

British Journal of MidwiferyVol. 28, No. 11 EditorialPublic consultation on postnatal care guidelinesSuzannah AllkinsSuzannah AllkinsActing EditorSearch for more papers by this authorSuzannah AllkinsPublished Online:2 Nov 2020https://doi.org/10.12968/bjom.2020.28.11.749AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References National Institute for Health and Care Excellence. Guideline. Postnatal care. Draft for consultation. 2020a. https://www.nice.org.uk/guidance/GID-NG10070/documents/short-version-of-draft-guideline-2 (accessed 26 October 2020) Google ScholarNational Institute for Health and Care Excellence. Postnatal care. 2020b. https://www.nice.org.uk/guidance/indevelopment/gid-ng10070 (accessed 26 October 2020) Google ScholarNHS England. GP contract. 2020. https://www.england.nhs.uk/gp/investment/gp-contract/ (accessed 26 October 2020) Google Scholar FiguresReferencesRelatedDetails 2 November 2020Volume 28Issue 11ISSN (print): 0969-4900ISSN (online): 2052-4307 Metrics History Published online 2 November 2020 Published in print 2 November 2020 Information© MA Healthcare LimitedPDF download

The failed theses of successful neurologists

While practising as a young doctor in the university hospitals of Paris, Jean Martin Charcot defended his dissertation entitled Of Exception in Medicine on April 17, 1857, at the aggregation competition examinations (ie, to obtain a tenure position of full professor). His scepticism of available therapeutics was clear: “daily observation demonstrates that the economic animal is very often itself enough to repair the disorders which happen to it and to recover in the regular exercise of its functions”. He did not succeed. He would successfully defend a new dissertation, this time on chronic pneumonia, in 1860, with the support of Pierre Rayer, who sat on the examination jury. Rayer had already facilitated Charcot's career by recommending him as family doctor to the banker Benoit Fould. 1 Walusinski O Jean-Martin Charcot membre de jurys de thèses à la Faculté de Médecine de Paris (1862–1893). Oscitatio, Brou, France2020 Google Scholar Whilst waiting to become a professor, Charcot had formed a wealthy and socialite clientele. On Nov 13, 1861, Charcot and Edmé Félix Alfred Vulpian were promoted to heads of department for the two general medical services at the Salpêtrière, Paris, which had been known as the Hospice for Old Women (Hospice de la Vieillesse-Femmes) since 1837.

Use of anti-reflux medications in infants under 1 year of age: a retrospective drug utilization study using national prescription reimbursement data

Non-specific symptoms such as irritability, vomiting, and back arching during the infant period are often attributed to gastroesophageal reflux. While numerous studies have shown no significant benefit to the use of acid suppressant medications in this population, these medications are frequently prescribed in response to these symptoms. Our goals were to understand how often children were being prescribed this medication. To do this, data was extracted from a national database for reimbursement of prescribed medications through the General Medical Services scheme (GMS). Infants aged less than 1 year and eligible for reimbursement under GMS were included for analysis. A total of 450 infants per 10,000 eligible population received an anti-reflux preparation from the following drug classes (H2 antagonists, proton pump inhibitors, or alginate preparations) in 2018. This is compared with that in 2009 where only 137 per 10,000 eligible infants received these medications. This increase was predominantly attributable to an increase in ranitidine prescriptions.Conclusion: Despite a change in clinical guidelines, anti-reflux preparations are increasingly being prescribed to infants aged less than 1 year. The reasons behind the increase in prescriptions containing these medications cannot be ascertained from this data. This may suggest a proportion of these prescriptions may be unwarranted in this population. What is Known: • The prescription of PPIs in infants has increased in a number of countries. • Use of anti-reflux medications has a very poor evidence base in infancy. What is New: • This data focuses only on an infant age group in a "well" cohort. • Ranitidine may contribute to increased acid-suppressant use in infancy.

Stroke patient's alarm choice: General practitioner or emergency medical services.

ObjectivesStroke patients should be treated as soon as possible since the benefit of reperfusion therapies is highly time‐dependent. The proportion of patients eligible for reperfusion therapy is still limited, as many patients do not immediately alarm healthcare providers. The choice of healthcare system entrance influences the time of arrival in the hospital. Therefore, we assessed differences in these choices to obtain insight for strategies to reduce time delays in acute stroke patients.Materials and MethodsPatients with suspected acute stroke admitted to the participating hospitals received a questionnaire. We assessed differences between patients who initially alarmed the general practitioner (GP) and patients who directly alarmed the emergency medical services (EMS). Additionally, we assessed regional differences and patient trajectories after medical help was sought.ResultsWe included 163 patients. Most patients alarmed the GP as primary healthcare provider (n = 104; 64%), and median onset‐to‐door times were longer in these patients (466 minutes [IQR 149–1586]) compared to patients directly alarming the EMS (n = 59; 36%) (90 minutes [IQR 45–286]). This was even more pronounced in less densely populated areas. Patients who alarmed the GP first, more often had patient delay >15 minutes, hesitated to burden healthcare providers and underestimated symptomatology.ConclusionsOur results showed that patients who alarmed the GP first instead of the EMS differed in several factors that are potentially modifiable. Strategies to achieve reduction of vital prehospital time delays and to improve patient outcome are optimizing public awareness campaigns and GP triage along with adjusting current guidelines by enabling and focusing on immediate involvement of the EMS once acute stroke is suspected.

A Multisite Study of Interprofessional Teamwork and Collaboration on General Medical Services

Teamwork and collaboration are essential to providing high-quality care. Prior research has found discrepancies between nurses' and physicians' perceptions in operating rooms, ICUs, and labor and delivery units. Less is known about health care professionals' perceptions of teamwork and collaboration on general medical services. This cross-sectional study included nurses, nurse assistants, and physicians working on general medical services in four mid-sized hospitals. Researchers assessed teamwork climate using the Safety Attitudes Questionnaire and asked respondents to rate the quality of collaboration experienced with their own and other professional categories. Data for 380 participants (80 hospitalists, 13 resident physicians, 193 nurses, and 94 nurse assistants) were analyzed. Hospitalists had the highest median teamwork climate score (83.3, interquartile range [IQR] = 72.3-91.1), and nurses had the lowest (78.6, IQR = 69.6-87.5), but the difference was not statistically significant (p = 0.42). Median teamwork climate scores were significantly different across the four sites (highest = 83.3, IQR = 75.0-91.1; lowest = 76.8, IQR = 66.7-88.4; p = 0.003). Ratings of the quality of collaboration differed significantly based on professional category. Specifically, 63.3% (50/79) of hospitalists rated the quality of collaboration with nurses as high or very high, while 48.7% (94/193) of nurses rated the quality of collaboration with hospitalists as high or very high. This study found significant differences in perceptions of teamwork climate across sites and in collaboration across professional categories on general medical services. Given the importance in providing high-quality care, leaders should consider conducting similar assessments to characterize teamwork and collaboration on general medical services within their own hospitals.

Improving care in care homes: what can Primary Care Networks learn from the Vanguards?

PurposeWe trace the evolution of a new integrated care policy in the English NHS (enhanced health in care homes, EHCH) from pilot model to wider roll out, over a 4-year period, into the circumstances of COVID-19.Design/methodology/approachUsing published evidence and official documentation we compared and contrasted the original EHCH model/framework, subsequent draft specifications and the final proposals, ahead of implementation.FindingsThe Primary Care Network EHCH service specification has clearly arisen from the Vanguard programme; however, problems related to GP contracts and COVID-19 means, at least initially, there is likely to be some variability over who will be responsible for delivery. It is unknown whether this service, delivered at pace in the current circumstances, will achieve or affect the outcomes envisaged by the pilots.Research limitations/implicationsThis is our interpretation of the developing policy for enhanced health in care homes, which requires further follow-up research. We are beginning our final fieldwork phase in Summer 2020, to report on the Vanguard legacy.Practical implicationsEvaluations of policy success/failure should consider the context and the differing power relations that are present and may impact subsequent take-up and roll-out across the system. We recommend a longitudinal approach to enable a holistic view of policy implementation.Originality/valueThis paper reveals the fragility of health and care policymaking in the current climate. From initial concept, through development and testing, into forced early roll out, our observations reflect the unique impact of a global pandemic shock.

Making practices more sustainable in Scotland

The Scottish GMS Contract 2018 and the introduction of government sustainability loans could prompt Scottish GPs to consider converting their practices to limited liability partnerships. The profession south of the border should follow developments with interest

What do patients want? A qualitative exploration of patients' needs and expectations regarding online access to their primary care record.

Primary care records have traditionally served the needs and demands of clinicians rather than those of the patient. GP contracts in England state practices must promote and offer registered patients online access to their primary care record and research has shown benefits to both patients and clinicians of doing so. Despite this, we know little about patients' needs and expectations regarding online access. To explore patients' views about accessing online primary care records and to find out how patients would like to interact with their records and what support they may need. Interviews and focus groups with a sample of 50 patients from a variety of socio-demographic backgrounds who were either; eligible for the NHS Health Check; had multimorbidities or were carers. Thematic analysis of data identified major themes impacting upon patients' wishes and needs as well as highlighting population-specific issues. Participants highlighted a wide range of views about the benefits and drawbacks of accessing their records online. The majority of participants indicated that they would be more likely to access their online primary care record if improvements were made to the design, reliability and functionality of existing online record services. Carers found accessing online records particularly useful. Consultation with patients and carers about their experiences of accessing online records; support needs and preferred functions can provide useful insights to inform the future design of online record services.

Incorrect Provider Directories Associated With Out-Of-Network Mental Health Care And Outpatient Surprise Bills.

Mental health services are up to six times more likely than general medical services to be delivered by an out-of-network provider, in part because many psychiatrists do not accept commercial insurance. Provider directories help patients identify in-network providers, although directory information is often not accurate. We conducted a national survey of privately insured patients who received specialty mental health treatment. We found that 44percent had used a mental health provider directory and that 53percent of these patients had encountered directory inaccuracies. Those who encountered inaccuracies were more likely (40percent versus 20percent) to be treated by an out-of-network provider and four times more likely (16percent versus 4percent) to receive a surprise outpatient out-of-network bill (that is, they did not initially know that a provider was out of network). A federal standard for directory accuracy, stronger enforcement of existing laws with insurers liable for directory errors, and additional monitoring by regulators may be needed.

GP views on the routine identification of older people living with frailty in primary care.

To meet the challenges of an ageing population, the updated 2017/18 NHS GP contract requires primary care providers to use evidence-based frailty identification tools to risk-stratify all patients aged >65 years. Those patients flagged as moderately or severely frail should be clinically reviewed and if severe frailty is confirmed, providers have been asked to consider offering relevant interventions, with the overall aim of enabling these patients to live well for longer. However, there is limited knowledge about how this frailty contractual requirement is being operationalised in primary care. To improve understanding of the barriers and facilitators GPs encounter when routinely identifying, risk-stratifying and providing interventions for people living with frailty in primary care. This was a two-part study: an initial survey via online questionnaire, with participants selected by maximum variation sampling to be followed up with a semi-structured telephone interview. All GPs working in the East Midlands region (Derbyshire, Leicestershire, Lincolnshire, Nottinghamshire, and Northamptonshire) were eligible to take part. The online questionnaire was analysed using descriptive statistics. Interview transcripts were analysed using framework analysis to identify key themes. In total, 188 GPs responded to the survey. Eighteen GPs were interviewed. Four themes were identified: 1) beliefs about stratification and pro-active identification of frailty; 2) frailty stratification tools; 3) managing complexity, resources and models of care; and 4) drivers of GP behaviour. The study findings will inform the further development of NHS England policy on the frailty contractual requirement for primary care providers.

Evaluating the relational continuity of care of four GP practices, one of which uses personalised lists.

Continuity of care is a fading type of care because GPs are working more flexibly and at reduced working hours. The GP Contract gave a financial incentive to provide prompt GP appointments, but to the detriment of continuity of care. Increased patient demand for appointments has seemingly led to patients favouring 'any' appointment with a GP rather than 'an appointment with the same GP'. Continuity of care in general practice is associated with greater patient satisfaction and is the preferred type of care for patients with chronic disease or psychological problems. In the Northeast of England there is a multi-partner GP practice that operates a true personalised list system. Other GP practices in the area do offer a degree of continuity of care, but this has not been measured. To measure and compare the relational continuity of care index of four matched GP practices, one of which operates a personalised list. A written protocol enabled the authors to extract comparable anonymised data from four GP practices over a year (January to December 2019). Two standardised indexes of continuity of care (UPC and SLICC) were calculated and compared. Continuity of care was consistently higher with personalised lists. UPC index results show that all GP practices provide surprisingly high continuity of care, albeit not with patients' assigned GPs. Higher monthly UPC scores versus overall scores indicate patients are receiving continuity of care in relation to their condition. Continuity of care is still observed in GP practices that do not have personalised lists.

Prevalence and outcome of delirium among acute general medical inpatients in Cape Town, South Africa.

Delirium is a common, serious, underdiagnosed condition in medical and surgical inpatients with acute conditions. It is associated with increased risk of mortality and morbidity. Data of geriatric cohorts are largely limited to developed countries. To describe prevalence, risk factors and outcomes of delirium among general medical patients admitted to two hospitals in Cape Town, South Africa. This was a prospective cohort study of patients with acute conditions admitted to a general medical inpatient service in secondary- and tertiary-level public hospitals in the Metro West area of Cape Town. Patients ≥18 years of age were recruited daily from all acute medical admissions. Patients were excluded if they were aphasic or their Glasgow coma scale was <8/15. Delirium was diagnosed using the validated confusion assessment method (CAM) tool and performed by trained neuropsychologists. Demographic data were collected by a clinical team and short- and long-term mortality data were obtained using linkage analysis of hospitalised patients and routinely collected provincial death certification records. The median age of inpatients was 51 (interquartile range 36 - 65) years, 29% were HIV-infected and the overall prevalence of delirium was 12.3%. Multivariate predictors of delirium included the presence of an indwelling urinary catheter (odds ratio (OR) 4.47; confidence interval (CI) 2.43 - 8.23), admission with a central nervous system disease (OR 4.34; CI 2.79 - 7.90), pre-existing cognitive impairment (OR 3.02; CI 1.22 - 7.43) and immobility (OR 1.88; CI 1.01 - 3.51). HIV infection was not associated with increased risk of delirium. Delirium was associated with an increased risk of inhospital (delirium v. no delirium: 29% v. 12%; p<0.01) and 12-month (30% v. 20%; p<0.01) mortality, as well as increased length of hospital stay (7 days v. 5 days; p<0.01). In this cohort of medical inpatients (relatively young and with a high HIV prevalence) 1 of 8 (12.3%) patients was delirious. Delirium was associated with adverse outcomes. Delirium risk factors in this young cohort were similar to those in geriatric cohorts in developed countries, and neither HIV nor opportunistic infections increased risk.

GP home visits: essential patient care or disposable relic?

The GP home visit has long been regarded as an integral element of NHS general practice that is needed to support both proactive and reactive care to patients in the community.1,2 There are increasing numbers of people living with multimorbidity and frailty, many of whom have complex healthcare needs and limited levels of social support. Now with the new challenges around providing care at home due to the COVID-19 pandemic, it could be argued that home visits or virtual consultations with patients in their homes are set to become a more essential element of general practice, including in the provision of acute care out of hours. Consulting with patients in their homes provides unique opportunities to develop insights into how illness affects their lives. However, with workloads in NHS primary care rising, and increasing pressures on the GP workforce, the place of home visits in core general practice provision is facing increasing challenge. The requirements of the current GP General Medical Services (GMS) contract in relation to home visiting are broad.3 The contract is not prescriptive about who should visit or where the visit should take place, and states that the decision to visit is dependent on the opinion and agreement of the GP contractor. In November 2019, the Local Medical Committee (LMC) conference debated the current contractual requirements and a motion was narrowly passed to instruct the General Practitioners Committee (GPC) (the negotiating arm of the British Medical …

Opening up while locking down: how an Irish independent sector mental health service is responding to the COVID-19 crisis.

The COVID-19 pandemic poses a particular set of challenges for health services. Some of these are common across all services (e.g. strategies to minimise infections; timely testing for patients and staff; and sourcing appropriate personal protective equipment (PPE)) and some are specific to mental health services (e.g. how to access general medical services quickly; how to safely deliver a service that traditionally depends on intensive face to face contact; how to isolate someone who does not wish to do so; and how to source sufficient PPE in the face of competing demands for such equipment). This paper describes how St Patrick's Mental Health Services (SPMHS) chose to address this unfolding and ever-changing crisis, how it developed its strategy early based on a clear set of objectives and how it adapted (and continues to adapt) to the constantly evolving COVID-19 landscape.

Effect of an Online Reimbursement Application System on Prescribing of Lidocaine 5% Medicated Plaster in the Republic of Ireland.

The lidocaine 5% medicated plaster, Versatis®, has one therapeutic indication listed on the Summary of Product Characteristics-symptomatic relief of post-herpetic neuralgia (PHN) in adults. Increased expenditure on Versatis® suggests that there is considerable off-label use. To support the appropriate use of Versatis®, the Health Service Executive's Primary Care Reimbursement Service (PCRS) introduced a reimbursement application system for Versatis® from 1 September 2017. The aim of this study was to investigate the effect of introducing a reimbursement application system on Versatis® prescribing under the General Medical Services (GMS) scheme. This study was carried out using prescription dispensing data from the PCRS pharmacy claims database. We carried out segmented linear regression to assess changes in the Versatis® prescribing rate per 1000 GMS eligible population, before and after the introduction of the online reimbursement application system. The results of the segmented regression analysis show that there was a statistically significant level (- 4.91, p < 0.001) and trend change (- 0.69, p < 0.001) in the rate of Versatis® prescribing post-introduction of the reimbursement application system. In the year prior to the introduction of the system, 2016, the annual GMS expenditure on Versatis® lidocaine 5% patches was over €27 million, whereas the GMS expenditure in 2018 was reduced to just over €2 million. In our study, a substantial decrease in the dispensing of Versatis® was seen after the implementation of a reimbursement application system. Prescribing of Versatis® should be restricted to patients with a diagnosis of PHN not only to reduce costs, but to ensure evidence-based use of this medication.

Undergraduate learning in psychiatry: can we prepare our future medical graduates better?

Irish medical schools attract an increasingly diverse student population and produce graduates who will practise in many parts of the world. There are particular implications in this for the planning and delivery of the undergraduate psychiatry curriculum. In all countries, mental health services struggle for equitable resourcing, and mental health care within general medical services remains relatively neglected. The traditional undergraduate psychiatry offering has been justifiably criticised for being excessively oriented towards secondary care when the vast majority of medical graduates will pursue careers in primary care or in specialties other than psychiatry. Recently published articles in the Irish Journal of Psychological Medicine address the current challenges and opportunities in providing an undergraduate experience that better prepares students for the mental health aspects of medical practice in a global context. We summarise and discuss these contributions and the recent Royal College of Psychiatrists publication Choose Psychiatry: Guidance for Medical Schools.