Irish Medical Council Research Articles

GPs' attitudes towards and experiences of using the Dermabuddy health app for the management of patients with dermatological conditions: a descriptive cross-sectional study.

Dermatological presentations are common in primary care. The digital health space is growing in investment, revenue, and in usership numbers. Doctors utilise mobile health apps for referencing, communicating, and for clinical decision making. Dermabuddy is a secure mobile health app by which information and expertise around skin problems can be shared among a group of medical professionals with the aim of finding the best treatment and management plan. To assess the utility of the Dermabuddy health app for GPs and associated trainees in the Republic of Ireland. This is a descriptive cross-sectional study, which involved a survey link distributed by email to GPs with Irish Medical Council membership. GPs were surveyed on their experiences of using the dermatology mobile application, Dermabuddy. In total, 203 members took this questionnaire (13.5% response rate). Ninety-six per cent who responded to the statement, 'The app was easy to use', agreed it was 'easy' or 'very easy'. Eighty-seven per cent of those who responded to the statement, 'I would use this app again', agreed they 'definitely would'. Fifty-eight per cent of those who responded to the statement, 'The app is useful for my healthcare practice', gave it a five-star rating. The content of 36 comments included advice for improvement and positive feedback. The Dermabuddy app was well received by participants in this study. Across all sections of the questionnaire looking at aspects of the app, including ease of use, interface and satisfaction, and usefulness, there was a positive response. Mobile health apps, such as Dermabuddy, may provide alternative solutions to meet the rising challenge of managing patients with dermatological conditions in primary care.

67 Audit of discharge summaries on a geriatric ward against the Health Information and Quality Authority (HIQA) National Standard

Abstract Background Discharge summaries are integral for safe transition of patient care. Complete, precise and succinct documentation can ensure improved quality of care and patient safety. Methods Retrospective data were collected from e-discharge summaries that were generated over a 7-month period from June-Dec 2022. A total of 20 samples were selected at random and assessed against the HIQA National Standard. The samples were compared to the physical medical records to countercheck if relevant information were present or omitted. There was a total of 78 outcomes measured as per the national standard. Results There were 8 (40%) discharge summaries with the complete clinical courses, in that they contained the main complaint, relevant clinical findings, relevant investigations results and the complete treatment courses. There were 4 (20%) summaries that had omitted documentation of inpatient complications or adverse events and 8 (40%) summaries had omissions present on medication prescriptions. There were 5 (25%) summaries whereby the list of stopped medications and the reasons for stopping the respective medications were omitted. There were 5 (25%) summaries with incomplete documentation of future plans. Only 4 (20%) discharge summaries had all the relevant information present. Conclusion Efforts to implement E-prescribing and electronic health records should be prioritised. The Irish Medical Council plans to introduce Entrustable Professional Activities (EPA), which are essential tasks that a trainee can be trusted to perform without direct supervision, once sufficient competence has been demonstrated. An entire EPA unit is dedicated to competent patient handover and discharge. A Discharge Summary Flowchart which highlights the inclusion of all the essential components of a complete discharge summary was introduced as a guide for the team. Finally, there is an ongoing continuous audit by Senior House Officers and Interns to assess the quality of discharge summaries after the recommendations have been implemented.

Persistence of inadequate consent training for interns.

Informed consent is a continuous process of communication with the patient and not merely the signing of a form. The Irish Medical Council's Guide to Good Practice and Ethics state that no part of the consent process should be delegated to an intern unless the procedure is a minor with which the intern is very familiar and all relevant information has first been explained to the intern. We aimed to evaluate whether practices regarding interns and consent had changed in the past five years. An anonymous Google Forms survey was distributed to interns from all intern networks between 24-August and 26-November 2021. Of 854 interns, there were 147(17.2%) survey responses. 129(87.8%) participants had consented for a procedure. 111(86%) responded that they had consented for procedures that they had not witnessed before. 92(71.3%) reported that their medical supervisor did not explain procedures to them prior to obtaining consent. 128(99.2%) of interns were not usually observed by a more senior doctor when obtaining consent. 116(89.9%) were expected to obtain consent from patients on a regular basis, with 78(60.5%) feeling pressured into doing so on at least one occasion. Results were largely unchanged compared to when the same survey was circulated in 2016. Interns remain routinely involved in the consent process without adequate training or supervision. This is unfair on our most junior doctors and on patients. Steps must be taken to ensure the IMC guidance is adhered to and this deficiency must be highlighted to Senior Clinicians.

WE6.10 Gender Balance at Surgical Meetings in Ireland

Abstract Aim To assess the genders of lead authors and primary investigators in major surgical research meetings over a 10-year period in Ireland. Method We gathered data from the 3 main surgical conferences in Ireland. We looked at the abstracts of each of the plenary sessions over the last 10 year. We used the Irish Medical Council, previous published research from these authors and ResearchGate to help identify the gender of the author. We complied and analysed the data using Excel. Results We analysed 306 papers over the last 10 years. We found that the primary investigator was male in 78% of the papers and female in 20%. The primary author was male in 52% and was female in 46% of the papers. There has been little change over each 5-year interval for who was the primary investigator. In 2010–2015, it was 77% male and 23% female while from 2016–2020, it was 82% male and 18% female. Furthermore, in relation to the primary author, it has shifted from being relatively equal to becoming more male dominant. In 2010–2015, it was 52% female and 48% female while from 2016–2020, it was 57% male and 43% female. Conclusion The gender gap has appeared to have widened at the non-consultant hospital doctor level and it is very apparent that there is a large inequality at consultant level regarding surgical research in Ireland.

Planetary health education in medical curricula in the Republic of Ireland

Background The World Health Organization considers climate change an urgent global health challenge requiring prioritised action. A recent global survey reported that only 15% of medical schools have incorporated climate change and health into the curriculum. Objectives This research study was carried out from November 2020 and April 2021 using the Planetary Health Report Card (PHRC) initiative to assess the current level of planetary health teaching in medical schools in the Republic of Ireland. PHRC is a student-led international public initiative, which aims to compare medical schools using a planetary health report card. The assessment was submitted as a final report to the Irish Medical Council and to the medical schools involved. Results Very few learning outcomes in Irish medical curricula directly address or include the concept of planetary health. Inclusion of specific topics remains reliant on individual lecturer interest. While most universities have excellent research centres which cover specific aspects of planetary health, the links between these institutes and medical schools have not been created. Conclusions Overall, there are promising examples of planetary health themes throughout the current Irish medical curricula, however, these remain poorly implemented or embedded within the curricula. Medical schools should incorporate education on planetary health to ensure graduates are equipped as to become medical leaders practising in a changing world.

Does continuing professional development enhance patient care? A survey of Irish based general practitioners

IntroductionThe Irish Medical Council has regulated mandatory continuing professional development (CPD) for doctors since 2011 to enhance the quality and safety of Irish healthcare. The Irish College of General Practitioners (ICGP), as the professional body for general practitioners (GPs) in Ireland, operates a Professional Competence Scheme (PCS) for doctors working in general practice. As PCS evolves over time, it is important to measure the impact of mandatory CPD on patient care. The ICGP undertook this study to answer the research question: Does CPD enhance patient care? Research has been conducted on the impact of CPD on the medical profession, both in Ireland and abroad, on GP engagement with existing CPD supports and on the impact of CPD for GPs in other countries. To date, no study has been carried out in Ireland on GP views on the impact of mandatory CPD on patient care or on which type of CPD activity is perceived to be the most effective in this regard.MethodsAll PCS enrollees on the 2018/2019 year who had provided an email address (n = 4,415) were asked to complete an anonymous online survey available in April and May 2019. The survey aimed to obtain feedback on existing CPD supports, enhancement of CPD supports, CPD impact on general practice and on patient care. The survey questions which related specifically to patient care were used to inform this paper.ResultsA total of 1,233 (27.9%) PCS enrolees participated in the survey. Overall, 73.9% (n = 836) of respondents agreed that CPD assisted them in improving the quality of patient care with females significantly more likely to consider that CPD improved patient care. A total of 74.9% (n = 848) reported changes to patient management as a result of CPD activity and over half (56.4%; n = 464) of these believed that external CPD activity (courses/conferences) had the most potential to benefit their patient care, however, differences were observed across gender and age group.ConclusionThe majority of GPs who completed the survey found CPD engagement beneficial to their patient care. The majority of respondents agree that peer engagement activities are most likely to impact patient care thus demonstrating that mandatory CPD has been successfully implemented in this respect in Irish general practice. However, there is a difference in response to the various CPD formats across different demographic cohorts and this should be considered when designing the format of educational activities.

142 The College of Anaesthesiologists of Ireland Return to Work Programme: An Innovative Approach to Support Trainees’ Well-Being and Patient Safety on Return to Work

Within the 6-year Specialist Anaesthesiology Training (SAT) programme overseen by the College of Anaesthesiologists of Ireland (CAI), there is now an option for trainees to take up to 12-month unaccredited professional or personal leave after years 2 and 4. There is also a cohort of trainees taking academic leave, maternity leave or other leave. There is growing recognition in the CAI and among other Training Bodies that returning to work following a period of absence can be daunting. It requires a comprehensive support package to help with the readjustment to the clinical and training environment, and rebuild confidence A CAI steering group was convened to design a Return to Programme (RTP) support package, with the following objectives: To develop a strategy for managing a return to anaesthesia following a period of absenceTo provide a blended content learning package aiming to ease SAT back into the clinical environmentTo rebuild confidence with/among the peers in a safe simulation environmentTo improve trainees’ well-being and patient safety by refamiliarization with anaesthesia guidelines and emergency algorithmsIt has been agreed that the RTP syllabus must reflect all eight domains of the Irish Medical Council (IMC) domains of Good Professional Practice, as in the following: Patient Safety and Quality of Patient Care; Relating to Patients; Communication and Interpersonal Skills; Collaboration and Teamwork; Management (including Self-Management); Scholarship; Professionalism, and Clinical Skills The lectures have been recorded and embedded in the CAI e-learning platform. A list of simulation scenarios reflecting the most common anaesthesiology emergencies has been selected and tailored towards the needs of the destination training sites and experience level. A first course will take place prior to trainees recommencing their clinical role in July 2021. On successful evaluation, it is aimed to conduct the RTP every 6 months going forward.

The development of a framework of entrustable professional activities for the intern year in Ireland

BackgroundEntrustable Professional Activities (EPAs) are units of professional practice that capture essential competencies in which trainees must become proficient before undertaking them independently. EPAs provide supervisors with a solid justification for delegating an activity to trainees. This study aimed to develop and ensure face validity of a set of EPAs for junior doctors in the first year of clinical practice in the Republic of Ireland.MethodsAn iterative eight stage consensus building process was used to develop the set of EPAs. This process was based on international best practice recommendations for EPA development. A series of surveys and workshops with stakeholders was used to develop a framework of EPAs and associated competencies. An external stakeholder consultation survey was then conducted by the Irish Medical Council. The framework of EPAs was then benchmarked against the 13 core EPAs developed by the Association of American Medical Colleges (AAMC).ResultsA framework of seven EPAs, and associated competencies resulted from this study. These EPAs address all core activities that junior doctors should be readily entrusted with at the end of the intern year, which is the first year of clinical practice in the Republic of Ireland. Each EPA contains a series of defined competencies. The final EPAs were found to be comparable to the AAMC core EPAs for entering residency.ConclusionsA framework of EPAs for interns in Ireland that are appropriate for the intern year has been developed by key stakeholders. The implementation of the EPAs in practice is the next step, and is likely to result in an improved intern training process and increased patient safety.

Burnout in consultants in child and adolescent mental health services (CAMHS) in Ireland: a cross-sectional study

Physician burnout has reached epidemic levels in many countries, contributing to adverse personal, patient and service outcomes. Adverse socioeconomic conditions, such as the economic downturn in the Ireland post 2008,...

312 Implementation of a Formalised Weekend Hospital Handover Process

Abstract Background Patient handover has been described as “one of the most perilous procedures in medicine” (British Medical Association, 2004). The Irish Medical Council underlines the importance of high-quality, relevant clinical information communication at shift changes. Methods On Friday January 26th 2018, the weekend handover practice for medical inpatients requiring medical registrar review was formalised in a large Dublin teaching hospital. Firstly, pertinent clinical information and the purpose of review were captured in an electronic order placed on the electronic patient record (EPR). A verbal handover meeting each Friday supported further discussion and patient handover. Data from the 26th of January to the 7th of July 2018 was analysed from the EPR. The purpose of weekend review was grouped under four categories - full clinical review, laboratory results review, review to facilitate discharge and patients who did not demand formal review but were handed over for information only. Results Over the 23 week period, 652 electronic orders for weekend review were placed on medical inpatients. This equated to an average of 27 reviews per weekend. The average age of patients reviewed was 63 years (SD 18.8 years). Median length of stay (LOS) was 4 days with a higher median LOS (6.7 days) observed for those aged 65 years and over. Over half (54%) of all weekend reviews required full clinical review whilst 27% of reviews were for laboratory results follow up only. Comparison between medical inpatients aged less than 65 and greater than 65 years noted little differences between the two cohorts in terms of the purpose of weekend review. Daily review was required for 73% of patents handed over to the medical registrar. Conclusion Weekend review of medical inpatients by medical registrars constitutes a significant workload. A formalised weekend handover practice complimented by an electronic process facilitates safer patient handover by improving the quality, transparency and accessibility of clinical information.

Disturbing and distressing: a mixed methods study on the psychological impact of end of life care on junior doctors.

The Irish Medical Council has identified gaps in knowledge and communications skills of new-entrant doctors in legal, ethical and practical aspects of end of life care. To determine the frequency with which junior doctors deal with end of life care and patient death and to evaluate the impact this has on their psychological wellbeing. A questionnaire was distributed to junior doctors to determine the frequency with which the participants had managed a patient at end of life. An abbreviated Posttraumatic Stress Disorder Checklist-Civilian version was used to evaluate psychological distress. Critical incident technique interviews explored the challenges of caring for patients at end of life. A total of 110 junior doctors in two teaching hospitals in Ireland completed the questionnaire: 39 (35.5%) interns and 71 (64.5%) senior house officers. In addition, 31 interviews were carried out with interns, senior house officers and registrars. The majority (81.8%) had pronounced a death with 39.4% of senior house officers doing so more than 10 times. Three quarters (75.5%) had discussed end of life with a patient's family. Of the 110 respondents that completed the posttraumatic stress disorder checklist, 11.8% screened positively for posttraumatic stress disorder. Challenges identified at interview included lack of knowledge and preparedness, difficulty communicating with family members, a lack of support and a feeling of failure. Junior doctors are regularly carrying out tasks related to end of life care, resulting in high levels of psychological distress. Further training and a change in culture are required.

Why Do Medical Professional Regulators Dismiss Most Complaints From Members of the Public? Regulatory Illiteracy, Epistemic Injustice, and Symbolic Power

Drawing on an analysis of complaint files that we conducted for the Irish Medical Council (Madden and O'Donovan 2015), this paper offers three possible explanations for the gap between the ubiquity of official commitments to taking patients' complaints seriously and medical professional regulators' dismissal-as not warranting an inquiry-of the vast majority of complaints submitted by members of the public. One explanation points to the "regulatory illiteracy" of many complainants, where the remit and threshold of seriousness of regulators is poorly understood by the general public. Another points to possible processes of "institutional epistemic injustice" (Fricker 2007; Anderson 2012) that unjustly undermine the credibility of certain complainants, such as those with low levels of formal education. A third explanation highlights the marginalization of the general public from "symbolic power" (Bourdieu 1989) to define what matters in medical professional regulation. The paper is offered in a spirit of ideas in progress and raising questions rather than definitive insights into the regulatory process.

Piloting online self-audit of methadone treatment in Irish general practice: results, reflections and educational outcomes

BackgroundWork based learning underpins the training and CPD of medical practitioners. Medical audit operates on two levels; individual self-assessment and professional/practice development. In Ireland, annual practice improvement audit is an essential requirement for the successful completion of continuous professional development (CPD) as determined by the regulatory body, the Irish Medical Council. All general practice (GP) doctors providing methadone maintenance treatment (MMT) in Ireland have a contractual obligation to partake in a yearly methadone practice audit. The Irish College of General Practitioners (ICGP) as national training provider is tasked to facilitate this annual audit process. The purpose of this audit is to assess the quality of care provided to patients against an agreed set of national standards, enhance learning, and promote practice improvement and reflective practice. The aim was to present an online MTP self-audit and evaluate results from a 12-month pilot among GPs providing MMT in Ireland.MethodsA mixed method study describing three phases (design and development, pilot/implementation and evaluation) of a new online self –audit tool was conducted. Descriptive and thematic analysis of audit and evaluation data was conducted.ResultsSurvey Monkey is a suitable software package for the development and hosting of an easy to use online audit for MMT providing doctors. Analysis of the audit results found that the majority of GPs scored 80% or over for the 25 identified essential criteria for MMT provision. The evaluation of the GP audit experience underscores the positive outcomes of the online self-audit in terms of improving practice systems, encouraging reflective practice, enhanced patient care and doctor commitment to continued provision of MMT in addiction clinics and in primary care.ConclusionsResults from this audit demonstrate a high level of compliance with best practise MMT guidelines by Irish GPs providing MMT. The online self-audit process was well received and encouraged reflective practice. The audit process hinged on the individual GP’s ability to review and critically analyse their professional practice, and manage change. This model of audit could be adapted and used to monitor the management of other chronic illnesses in general practice.

Management of paediatric acute appendicitis in the general hospital setting: a national survey of preferred surgical technique.

The advent of laparoscopic surgery has facilitated the management of acute appendicitis in the adult population. In the paediatric population (<12 years), management varies according to institution and/or consultant expertise. The aim of this study was to analyse consultant preference for laparoscopic versus open appendicectomy in the management of acute appendicitis in children under 12 years presenting to general hospitals. A 15-point questionnaire was distributed to 81 consultant surgeons identified from the specialist register of the Irish Medical Council and practicing as general surgeons outside of specialist paediatric centres. A response rate of 83 % (67/81) was obtained. Of the 67 surgeons surveyed, 11 (16 %) had formal paediatric training. Sixty percent (40/67) of surgeons expressed a preference for the open technique. The median frequency of on-call rota was >1 in 5 (32/67) and only 3 % (2/67) claimed that the on-call commitment influenced decision-making regarding surgical approach. The average minimum age (9.3 years, range 1-14) and average minimum weight (25 kg, range 12-70) at which the operating surgeon would perform a laparoscopic appendicectomy were also recorded. Thirty percent (20/67) of consultant general surgeons had immediate access to specialist paediatric laparoscopic equipment. This study has shown wide variability amongst consultant general surgeons when considering open versus laparoscopic appendicectomy in children under 12 years. Restricted access to specialist paediatric laparoscopic equipment, combined with declining exposure to paediatric surgical training, may continue to limit the numbers of paediatric laparoscopic appendicectomies performed in the general setting.

Medical students' knowledge of data protection legislation

PurposeMedical confidentiality derives from the Hippocratic Oath and has been affirmed in most codes of professional conduct, including the Irish Medical Council's guide to professional conduct and ethics. The Irish Data Protection Act 1988 and Amendment 2003 bring this responsibility into a legal forum. The aim of this audit is to assess how comprehensively medical tutors/consultants instilled knowledge and appreciation of confidentiality and data protection to medical students in a prominent Dublin University Hospital.Design/methodology/approachBreaches in data protection legislation by final year medical students were identified by means of a questionnaire. Changes were made to the curriculum (presentations, notices on students' e‐learning interface and induction manual) and to the exams in psychiatry, to increase awareness of data protection legislation. Students at the same point in their education were re‐assessed one year later to see if the interventions were helpful in increasing knowledge and improving adherence to data protection legislation.FindingsSignificant breaches of the data protection legislation at baseline and follow up were identified. Examples include: “Data shall be kept for one or more specified, explicit and legitimate purposes” – when asked if they would inform patients that assessments were for submission of a case report, 44 per cent at baseline and 56 per cent at follow‐up said yes. “Appropriate security measures shall be taken against unauthorised access” – 52 per cent password‐protected their computer at baseline and 59 per cent did at follow‐up. Of those that had no password protection at baseline, 70 per cent of their computers were used by others, with little change in this at follow‐up (68 per cent). At baseline 52 per cent kept a copy of reports on USB devices compared to 46 per cent at follow‐up. 26 per cent admitted to losing a USB device in the past. “Data should not be kept longer than is necessary for that purpose” – 63 per cent admitting keeping electronic copies of case reports on their computers following submission at baseline and 64 per cent at follow‐up. “Data should be made anonymous” – 96 per cent at baseline and 100 per cent at follow‐up used initials when submitting case reports to make the data anonymous.Practical implicationsWhat was disappointing was that, while knowledge and awareness of obligations under data protection legislation improved following intervention, breaches in compliance still remained.Originality/valueThis is the first such audit in Ireland on the provision of educational training in the area of data protection legislation to medical students. It is likely that that such breaches by medical students reflect the tip of the iceberg in relation to probable breaches amongst registered healthcare professionals. The challenge now facing the medical profession and healthcare services is to effect behavioural change to improve compliance with data protection legislation.

Development of sports and exercise medicine in Ireland and future challenges

Lecture 25The Faculty of Sports and Exercise Medicine was set up in September 2001 and is a joint Faculty of the Royal College of Physicians and Royal College of Surgeons...

Preparing for an institutional self review using the WFME standards – An International Medical School case study

Background: Curriculum reform poses significant challenges for medical schools across the globe. This paper describes the reforms that took place at the medical school of the Royal College of Surgeons in Ireland (RCSI) between 2005 and 2008 and the institutional self review process that accompanied these reforms.Results: Although fully accredited with the Irish Medical Council the RCSI sought additional detailed review of all aspects of its undergraduate medical program. Five medical educationalists were invited to visit the College in 2005 and again in 2008 to act as ‘critical friends’ and guide the self review using the World Federation for Medical Education (WFME) standards which had recently been adopted in Ireland.Conclusion: The process of institutional self review (as opposed to more high stakes accreditation) can bring about significant reform, especially when supported by a panel of ‘critical friends’ working alongside faculty to help guide and support sustained curriculum reform. The WFME standards continue to provide a useful framework to consider all medical education activities within a medical school engaged in continuous renewal. Adequate preparation for such reviews is critical to the success of such an undertaking and should be supported by a comprehensive communication strategy and project plan.

The effect of patient shield position on gonad dose during lumbar spine radiography

Background In an effort to standardise radiological practices in the Republic of Ireland, current legislation states that “written protocols for every type of standard radiological practice shall be established”. In order to fulfil this requirement the Irish Medical Council recommends the protocols issued by the Commission of European Communitees (CEC) for adoption in the country. Whilst this document does provide good guidance with regard to various radiographic factors, patient shielding instructions are notably ambiguous. The aim of this study was to remove some of this ambiguity by defining the optimal method of positioning patient shielding in antero-posterior (AP) and lateral lumbar spine radiographic examinations. These projections were chosen on the basis of their area of coverage being in close to and in some cases including the reproductive organs. They also represent the highest source of collective population dose of any conventional radiographic examination carried out in the UK. Method A dosimetry study was devised to establish organ dose to the male testes and female ovaries using various clinically advocated methodologies for positioning patient shielding these included: no apron; tube-side apron; receptor-side apron and a wrap-around apron. The study was carried out using a direct digital radiography unit, an anthropomorphic phantom, various lead aprons and lithium thermoluminescent dosimeters (TLD). Results For the AP projection, a statistically significant testes dose reduction of 42% ( p ≤ 0.01) was observed when a tube-sided apron was used. No testes dose reductions were noted for the lateral projection. Ovary dose savings were not observed for any of the shielding methods investigated. Conclusion This study found that the testes dose in AP examinations was reduced by 42% when patient shielding was positioned inferior to the imaged field and on the tube-side of the patient. This result validates the shielding methods used at the majority of centres surveyed in a recent study.

NOVEL METHOD FOR ASSESSMENT AND SELECTION OF TRAINEES FOR HIGHER SURGICAL TRAINING IN GENERAL SURGERY

The aim of the study was to select surgeons for a higher surgical training in general surgery programme at the Royal College of Surgeons in Ireland (RCSI) using an objective, transparent and fair assessment programme. Thirty-two individuals applied for higher surgical training in general surgery in Ireland in 2006. Sixteen applicants were short-listed for interview and further assessment. All applicants were required to report on their education performance at undergraduate level and their postgraduate professional development. Applicants were scored on their training record during basic surgical training, structures references, clinical experience, approved technical skills courses, validated logbook and consolidation sheet. Assessments of their research and academic surgery included, the award of a higher degree by thesis, and other surgically relevant degree's or diplomas that had been obtained through part-time studies and were awarded by educational establishments recognized by RCSI or the Irish Medical Council. Short-listed applicants completed validated objective assessment simulations of surgical skills, an interview and assessment of their suitability for a career in surgery. The nine individuals who were selected for higher surgical training in general surgery consistently scored higher than those candidates who were not, in post-graduate development (P < 0.001), surgical skills (P < 0.002), interview scores (P < 0.007) and suitability for a career in surgery (P < 0.002). All performance assessment elements except undergraduate education showed high internal reliability alpha = 0.89 and good statistical power (range 0.95-0.99). The statistical power of undergraduate education was 0.7. The objective assessment programme introduced by RCSI for selection of candidates for the programme in higher surgical training in general surgery reliably and consistently distinguished between candidates. Candidates selected for further training consistently outperformed those who were not in good concordance between measures. This common selection process for higher surgical training is now being rolled out for selection into higher surgical training across all surgical specialties in Ireland.

I am a consultant in medicine in the United States. I have General Medical Council and Irish Medical Council registration, have passed the PLAB tests, and have worked in the United Kingdom. How do I apply for consultant posts in the United Kingdom or Ireland?

Flow toxicity can be measured in terms of the probability that a liquidity provider is adversely selected by informed traders. In previous papers the authors introduced the concept of Volume-synchronized Probability of Informed Trading (the VPIN^* metric) and provided a robust estimation procedure. In this study, they discuss the asymmetric impact that an incorrect estimation of the VPIN metric has on a market maker’s performance. This asymmetry may be part of the explanation for the evaporation of liquidity witnessed on May 6th 2010. To mitigate that undesirable behavior, they present the specifications of a VPIN contract, which could be used to hedge against the risk of higher than expected levels of toxicity, as well as to monitor such risk. Among other applications, it would also work as an execution benchmark and a price discovery mechanism, since it allows for the externalization of market participants’ views of future toxicity. <b>TOPICS:</b>Statistical methods, financial crises and financial market history, tail risks