Medical Colleagues Research Articles

Revisiting the conceptualisation and implications of medicine's 'hidden curriculum'.

In medical training and practice, our professional attributes, attitudes, perceptions, character traits and identities are fundamentally shaped by our lived experiences and observations in clinical and para-clinical settings instead of being inculcated through formal curriculum or classroom teaching. For instance, clinical acumen, communication skills and bedside manners are learnt through role modelling and experiential learning in the course of clinical rotations. Likewise, one's attitudes, professional behaviours and inclinations are often also influenced by direct/indirect observations of the actions of others in the medical fraternity in various clinical and non-clinical settings. This is also what is often termed as the 'hidden curriculum' of medicine. In this article, we sought to provide a practical conceptualisation of the hidden curriculum in medical training, which we describe as lived experiences and personal observations of medical trainees and residents in clinical and para-clinical spaces, which shape their perceptions of the medical profession (vocational identity and purpose), patients (patient-physician relationship) and colleagues (intra- and inter-professional relationships), with downstream implications on physician well-being and clinical decision-making. Although this idea of a 'hidden curriculum' has conventionally carried predominantly negative connotations in medical literature, we suggest that it is an inevitable part of medical education and practice, which, through deliberate regulation, can potentially be shaped to create more positive and meaningful effects in the professional development of medical trainees.

Mildred Codding (1902–1991): Neurosurgery Medical Illustrator at Harvard Medical School, Peter Bent Brigham Hospital, and Boston's Children Hospital

This historical account reviews the life and times of Mildred Codding (1902-1991) in neurosurgery and medical illustration. The writing of this project was sparked by the discovery of original scientific and bibliographical information about Codding, testimony on personal relationships, and viewpoints after comprehensive compilation of information. Mildred Codding learned the carbon dust technique from Max Brödel at the Johns Hopkins Hospital (JHH) (Baltimore, Maryland USA), and worked at Peter Bent Brigham Hospital, now Brigham and Women's Hospital (Boston, Massachusetts, USA). Codding was Dr. Cushing's medical illustrator, colleague, and friend. She provided photographs, diagrams, and sketches for the majority of Cushing's collection of intracranial tumors from 1929 to 1932. A 1991 interview of Codding was hosted by Brigham and Women's Hospital and Boston Children's Hospital for the permanent collection of the Archives of the American Association of Neurological Surgeons and provides additional photographs and insignia, drawings with pen and ink method, multi-stepped layering, and illustration implements. Importantly, the Brigham Surgical Alumni insignia showing a surgeon's hand with scalpel was modeled after Codding's left hand. Outside of the operating room, Codding's interests included Pediatrics, Zoology and Genetics, atlantes of surgical operations, teatime, and paint with watercolor, particularly seascapes, lighthouses and dunes. This article provides glimpses into the personality and marked influence of Mildred Codding on neurosurgery and medical education and adds to the growing literature on her person.

An Interpretative Phenomenological Analysis That Seeks to Describe and Understand the Personal Experience of Burnout in General Practitioners.

Minimal research has explored the personal experience of burnout in doctors from any medical speciality. Consequently, we aimed to provide a relatable description and understanding of this globally recognised problem. We employed an interpretative phenomenological analysis (IPA) of face-to-face interviews with seven general practitioners (GPs) in Northern Ireland, having selected interviewees best able to speak about burnout. We sought to understand how these GPs understood their burnout experiences. Our participants' continuous work involved more than their busy weekdays and also working on supposedly off evenings and weekends. In addition, draining intrusive thoughts of work filled most, if not all, of their other waking moments. There was no respite. Work was 'always there.' Being constantly busy, they had no time to think or attend to patients as doctors. Instead, participants were going through the motions like GP automatons. Their effectiveness, efficiency, and caring were failing, while their interactions with patients had changed as they tried to conserve their now-drained energy and empathy. There was no time left for their families or themselves. They now "existed" to continuously work rather than "living" their previous, more balanced lives that at one time included enjoying being a doctor. Worryingly, participants were struggling, isolated, and vulnerable, yet unwilling to speak to someone they trusted. We intend our burnout narrative to promote discussion between medical colleagues and assist in its recognition by GPs and other doctors. Our findings warn against working excessively, prioritising work ahead of family and oneself, and self-isolation rather than seeking necessary support.

The emergence of bromazolam in Jefferson County, AL: a case series.

Postmortem toxicology is an ever-changing landscape presenting challenges for toxicologists and medical examiners. Trends can vary for certain benzodiazepines. While diazepam use tends to remain constant, alprazolam and clonazepam ebb and flow depending on prescription trends and street popularity. Novel benzodiazepines like etizolam vary in casework depending on legal restrictions and black market availability. In May 2022, the first case of the designer benzodiazepine, bromazolam, was detected in Jefferson County Coroner/Medical Examiner's Office casework. Between then and December 2023, an additional nine cases have been observed. Bromazolam is the brominated analog of the low-dose benzodiazepine, alprazolam, and is likely similar in potency. As bromazolam is a potent benzodiazepine, low concentrations of this novel drug are likely to contribute to central nervous system depression in opioid overdose cases. We present 10 cases in which bromazolam was detected in postmortem samples at the University of Alabama at Birmingham toxicology laboratory. The decedents ranged in age from 20 to 41 years. Most of the decedents were White (n = 8; 80%) and male (n = 7; 70%). Bromazolam concentrations ranged from 21 to 3220 ng/mL (mean 401 ng/mL). All but one case were polydrug, and all deaths were related to drug toxicity. Fentanyl was detected in 8 of the 10 decedents, with concentrations ranging from <2.5 to 97 ng/mL (mean 30 ng/mL). Additional drugs detected were methamphetamine, ethanol, oxycodone, methadone, cocaine, amphetamine, morphine, and diphenhydramine. While all manners of death were ruled as accidental, bromazolam was included in the cause of death statements in 9 of the 10 cases. Capturing important emerging drug trends in the death certificate is critical to help inform public health and medical colleagues for preventive measures and treatment in the continued drug epidemic.

Words Matter: Why Distinguishing Medical Aid in Dying From Suicide Should Matter to a Consultation-Liaison Psychiatrist

As more and more American states legalize medical aid in dying (MAID), Consultation-Liaison Psychiatrists will increasingly be asked to assist medical and surgical colleagues in differentiating this end-of-life practice from suicide. Where suicide is traditionally understood as an act clouded by depression, desperation, or both, MAID represents a terminally medically ill patient's effort to take control of their dying process when death is imminent, likely to occur within 6 months, and inevitable. Rendering opinions on patient suicidality in the setting of a complex co-occurring medical illness is a Consultation-Liaison Psychiatrist's bread and butter. This paper seeks to elucidate 4 points that distinguish MAID from suicide: (1) Hastening death when the end of natural life is approaching is not synonymous with suicide in the vernacular American usage of the term. (2) Unlike suicide, MAID is a highly collaborative process in which dying, mentally capable adults involve their doctors and loved ones in legally recognized decisions to hasten death. (3) The clinical presentation of patients requesting MAID differs from that of individuals whose suicidality is driven by psychopathology. (4) Certain behavioral traits differentiate such MAID patients from suicidal ones. Understanding and applying these distinctions in the consultation-liaison arena will help remove the stigma of suicide from end-of-life care deliberations where it does not belong while ensuring appropriate end-of-life care for dying individuals for whom MAID is the culmination of a carefully considered process of self-determination rather than suicide.

55 years of devoted service to medicine, morphology and pedagogy (on the 80th anniversary of the birth of Professor N.R. Karelina)

A long and long way of professional development has been done so that in 2023 we would congratulate Natalia Rafailovna Karelina, Doctor of Medical Sciences, Professor, member of the Board of the Scientific Medical Society of Anatomists, Histologists and Embryologists of Russia on the 80th anniversary. For more than 21 years, she has been the head of the Department of Human Anatomy at St. Petersburg State Pediatric Medical University and inspires the younger generation to scientific achievements. The staff of the Department of Human Anatomy of St. Petersburg State Medical University, friends and colleagues, as well as numerous students cordially congratulate Natalia Rafailovna and wish her long life, good health, professional longevity and enthusiasm for the benefit of her beloved medical science and pedagogy

Diabetes Mellitus and Periodontal Disease: A New Perspective.

First recorded in 1928, people living with diabetes mellitus (DM) are at a three to four times higher risk of developing periodontal disease (PD) than non-diabetics; for those who smoke this risk increases up to ten times. However, many doctors are unaware of this.DM and PD are bidirectionally linked, the one affecting the other and vice versa, although the mechanism is not fully understood and may be linked to chronic infection. PD has an adverse effect on glycaemic control. That improves when periodontitis is successfully treated.Doctors should consider PD when their patients have persistently high glycated haemoglobin (HbA1c) levels, and dentists should consider diabetes or pre-diabetes when they have patients with unstable or progressive periodontitis.Doctors, dentists, and their teams need to share results. A traffic light system of red, amber and green for both medical and dental risks is proposed, and a pro forma designed, so that diabetics themselves can share them with their professional advisors until such times as there are reliable methods of interprofessional communication and a paradigm shift in working practices is achieved.Dentists need to find ways to teach their medical colleagues about the basics of PD, update their medical records, and understand more about medical risks. More research is required.

Decoding Alphabet Soup

We should consider whether it is necessary to use acronyms as opposed to the full terminology. With advancements in smartphrase technology in our electronic health record (EHR) systems perhaps we can move to using full terminology in our clinical notes to decode the alphabet soup for the sake of our fellow medical colleagues.

Les soins palliatifs au Liban, un essor freiné mais une résilience à toute épreuve

The history of palliative care in Lebanon is marked by resilience and perseverance. Supported by personal initiatives, legislative battles and private donations, Palliative Care has managed to gradually anchor itself in the medical landscape, despite the meager means offered by the State. The delivery of Palliative Care in Lebanon has the particularity of being supported mainly by non-profit NGOs, whose operation is halfway between French HAD (Home hospitalization) and EMSP (Mobile palliative care units) and which offer free care to patients. More than 30% of patients followed by the NGO BALSAM suffer from chronic non-cancerous diseases. Pediatric palliative care is almost non-existent, with BALSAM being the only NGO providing support for children in their homes. Faced with the major financial difficulties facing the country, these NGOs are now turning to international partnerships, both to ensure the means to pursue their missions, and to reserve a place on the world stage. The Lebanese model developed by BALSAM is presented in developing countries as a possible example of operation in a crisis context. A delegation from the Medical-Chirurgical Center for Rehabilitation of Massues (CMCR) in Lyon also intervened at the Rafik Hariri Hospital Center in Beirut to discuss three themes: management, rehabilitation and palliative care. The same difficulties that we encounter in France regarding the temporality of intervention in care could be noted: It is uncommon for Lebanese medical colleagues to seek palliative care support early. The place of palliative care within the hospital institution is still new, and the resources allocated are too low, both in terms of nursing time and suitable premises. The road remains long, but everything is being done to ensure that palliative care continues to be talked about and extends ever deeper within the Lebanese health system.

Psychiatric brain gain in Switzerland. Competency-based onboarding.

IntroductionIn the last 30 years, Switzerland has been established as a destination country for psychiatric trainees. The needed competences for the work as a trainee deviate regarding colleagues from foreign countries though, hindering a viable solid development professional without specific on-boarding program. A similar approach to the figure of tutor anchored in the Spanish postgraduate medical training is still missing in the Swiss medical System. Hereby we performed a survey in the new colleagues who are part from the medical team in an observer status before beginning with the responsibilities as a trainee.ObjectivesRecognizing competences and needs of the onboarding in current trainees that are still allocating because of the work conditions as stated in the following paper, (Bischof et al. Swiss Arch Neurol Psychiatr Psychother. 2021;172:w03198)MethodsSurvey with open questions collecting needs and competences expected to fulfil in Switzerland were distributed in 5 different medical colleagues in an observer status between August 2022 and September 2023.ResultsResponse rate was 62,5 %. Main reasons for the migration were considering better perspectives in education and professional development in the goal country, coming push factors as the current work situation in the original country to the fore. Support regarding the local language and an overview of the interprofessional communication were outlined as the advantage of the internship prior to the duties as a psychiatric trainee.ConclusionsAn structured on-boarding program is a demand for the newcomers - majority of trainees from foreign countries - to step in better in the Swiss health system. Elements of the Spanish trainee system could be adapted for a suitable allocation and integration process in the goal country.Disclosure of InterestNone Declared

Charles Waller and Edward Doubleday-Colleagues of James Blundell and early supporters of blood transfusion.

The obstetrician James Blundell performed the first human-to-human blood transfusion in England during the early part of the 19th century arguing that it could be used as a treatment for post-partum haemorrhage. During this period, Blundell personally acknowledged two of his medical colleagues Charles Waller and Edward Doubleday as being strong supporters of the use of blood transfusion. This paper outlines the roles that these two men played in the early history of blood transfusion.

Mitigating the impact of blood shortages in England.

The supply of blood components and products in sufficient quantities is key to any effective health care system. This report describes the challenges faced by the English blood service, NHS Blood and Transplant (NHSBT), towards the end of the COVID-19 pandemic, which in October 2022 led to an Amber Alert being declared to hospitals indicating an impending blood shortage. The impact on the hospital transfusion services and clinical users is explained. The actions taken by NHSBT to mitigate the blood supply challenges and ensure equity of transfusion support for hospitals in England including revisions to the national blood shortage plans are described. This report focuses on the collaboration and communication between NHSBT, NHS England (NHSE), Department of Health and Social Care (DHSC), National Blood Transfusion Committee (NBTC), National Transfusion Laboratory Managers Advisory Group for NBTC (NTLM), National Transfusion Practitioners Network, the medical Royal Colleges and clinical colleagues across the NHS.

Plastering-A technique fallen into obscurity

Immobilization of fractures and dislocations is abasic technique in orthopedic trauma surgery care. The orthopedic surgeon should be familiar with the various materials, techniques and possible complications. Despite other techniques, the classical white plaster cast remains an integral part of orthopedic trauma surgery care. The application of such acast must be learned as failure to observe the basic principles can result in harm to the patient. In many hospitals, the application of aplaster cast is delegated to the nursing staff according to the physician's instructions. As aresult, many young medical colleagues lack the knowledge of how to apply aplaster cast. In addition to the treatment of fractures, immobilization after dislocation, inflammation and ligamentous injuries are some of the areas of application. In this article the application of aplaster cast is described based on acase study, from the indications to the execution and possible complications.

Are Australian Cancer and Palliative Care Nurses Ready to Prescribe Medicines? A National Survey

Registered nurse prescribing has been put forth, for decades, as an innovative approach to meet growing healthcare needs, particularly in areas of care where medications are essential and highly controlled such as for patients requiring cancer and palliative care. However, the adoption of innovative health delivery models requires acceptance by key stakeholders. This study explores cancer and palliative care nurses' attitudes toward nurse prescribing and their perceptions about educational requirements for a nurse prescriber. A cross-sectional survey was distributed to Australian nurses between March and July 2021. Data were collected using the Advancing Implementation of Nurse Prescribing in Australia online survey. Pearson χ2 tests were used to examine associations between nurses in cancer care, palliative care, and all other specialties on demographics, attitudes to nurse prescribing, and educational perspectives to become prescribers. Of the 4,424 nurses who participated in the survey, 161 nurses identified they worked in cancer care and 109 in palliative care settings. Although nurses have a common set of core capabilities, their work contexts and their professional experiences shape their attitudes toward practice. Nurses in cancer care were significantly less certain than nurses in palliative care [χ2(2) = 6.68, P = .04], and nurses from all other specialties [χ2(2) =13.87, P = <.01] of the benefits of nurse prescribing (ie, nurse prescribing would decrease health care system costs, reduce patient risk). Nurses in cancer care were more certain that successfully implementing nurse prescribing requires strong support from their medical and pharmacy colleagues. In addition, nurses working in cancer and palliative care agreed that improving patient care was their primary motivator for becoming a prescriber. Open to expanding their role and responsibilities, nurses in cancer and palliative care settings reported that successfully adopting nurse prescribing must be supported by their other healthcare colleagues within the same environment, which demands strong interprofessional collaborative efforts.

Dentists' Attitudes to the Preprocedural Safety Checklist "Time-Out" in Saudi Arabia.

Before performing medical procedures, there is a patient safety initiative process (also referred to as "time-out"), part of this process is the use of a preprocedural safety checklist. This initiative was envisioned by the World Health Organization, supported by various accreditation bodies who include the process in their standards. Dentistry lags behind its medical colleagues in using it presurgical or invasive procedure. Our aim was to understand dentists' attitudes and knowledge about the process and their adherence to it. A cross-sectional questionnaire was distributed between September and December 2021 and 102 dentists responded. Seventy three of the respondents (71.5%) claimed to be familiar with the time-out process, and 87 (85.3%) felt that it was an important or somewhat important process; however, only 62 (60.7%) were always performing the process before surgical or invasive outpatient procedures. Patient safety must be given priority, as such it has been shown that preprocedural checklists help reduce medical errors. Recognizing the value of performing such a process, accreditation bodies have included the process in their standards and indeed in the Joint Commission focused patient safety goals.

Nurse practitioners' use of diagnostic imaging: A scoping review.

To explore the nature and extent of peer-reviewed literature related to the use of diagnostic imaging by nurse practitioners (NPs) to inform future practice and research. Nurse practitioners undertake advanced assessment, diagnosis, and management of patients, including requesting and interpretation of diagnostic imaging. It is unclear what evidence exists related to the quality use of radiological investigations by NPs in recent years. A scoping review based on the steps suggested by the Joanna Briggs Institute. A structured review of the databases Medline, CINAHL and Embase was undertaken using the keywords and MESH terms 'nurse practitioner', 'medical imaging', 'diagnostic imaging', 'scan' and 'radiography'. Only English language articles were included, and no date limit was applied. Database review was completed on 30 May 2021. Eight themes were identified-country and clinical context, requesting diagnostic imaging, performing diagnostic imaging, image-guided interventions, interpreting diagnostic imaging, training education and knowledge, impact on resource usage and comparison with medical practitioners. There were more studies across a greater breadth of clinical specialties and imaging modalities in the United States than in other countries. Nurse practitioner practice is frequently benchmarked against that of medical colleagues. There is a paucity of studies focusing on educational preparation and the lack of relevant university curricula for NPs around diagnostic imaging. There are significant gaps in the evidence outside of the United States across several of the identified themes. Further studies are needed to explore NP access to and use of diagnostic imaging and to understand the barriers and facilitators to this. Studies from four countries were included in this review. The evidence suggests that, where studied, nurse practitioners (NPs) can safely and appropriately request and interpret plain x-rays in the emergency and minor injuries setting. Further research is needed to evaluate the educational needs of NPs in relation to diagnostic imaging and their use of advanced imaging techniques, particularly outside of the United States. No patient or public contribution.

The Change of Complement Deposition after Complement Inhibitor Treatment in Paroxysmal Nocturnal Hemoglobinuria Patients

Background: Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired hematopoietic stem cell disease in which abnormal complement activation results in hemolysis and thromboembolic events (TEE). Complement inhibitors (CI) have been proved to be able to suppress intravascular hemolysis (IVH) and reduce the risk of TEE. Few studies were available on the changes of complement deposition after CI and their relationship with efficacy. Methods: PNH patients treated with full dose eculizumab, crovalimab or iptacopan at Peking Union Medical Colleague Hospital from Oct 2021 to Jul 2023 were enrolled.Patients' clinical information and blood samples were collected after 0, 1, 3, 6, 9 and 12 months of treatment. The deposition of C5b-9, C3, C4b and factor B (FB) on peripheral red blood cells (RBC), white blood cells (WBC) and platelets (PLT) was detected by double-color staining flow cytometric assay. The efficacy of each CI was correlated with complement deposition levels on three blood lineages. Results: 23 PNH patients were enrolled. Among them, 13 patients were treated with C5 inhibitors (4 with eculizumab and 9 with crovalimab), 10 were treated with iptacopan (FB inhibitor). For patients treated with eculizumab, C5b-9+/RBC and C5b-9+/WBC significantly decreased after 3, 6 and 12 months of treatment(P&amp;lt;0.05); however, C3+/WBC and C3+/PLT significantly increased after 12 months (P&amp;lt;0.05). For covalimab-treated patients, C5b-9+/RBC significantly decreased after 6 and 12 months (P&amp;lt;0.05), while C3+/RBC, C3+/WBC, C4b+/RBC and C4b+/WBC increased (P&amp;lt;0.05) after 6 months. For those treated with iptacopan, after 1, 3, 6, 9 and 12 months, the deposition of C5b-9 on all three blood lineages significantly decreased (P&amp;lt;0.05), meanwhile, C3 and FB on all three lineages decreased (P&amp;lt;0.05); moreover, C4b+/WBC and C4b+/PLT decreased after 3, 6, 9 and 12 months (P&amp;lt;0.05). C5b-9+/RBC and C5b-9+/WBC were significantly associated with hemoglobin improvement after eculizumab treatment (P=0.004 and 0.018, respectively). C5b-9+/RBC was positively correlated with bilirubin (P=0.023) and C3+/RBC was positively correlated with absolute reticulocyte counts (Ret, P=0.001) after crovalimab treatment. After iptacopan treatment, C3+/RBC was positively correlated with Ret (P=0.010), C4b+/RBC was positively correlated with Ret (P=0.032) and lactose dehydrogenase (LDH, P=0.003), and FB+/RBC was positively correlated with LDH. Conclusion: Complement inhibitors could effectively reduce C5b-9 deposition. Unlike C5 inhibitors, iptacopan also reduced the deposition of C3, C4b, and FB. C5b-9+/RBC may be correlated with the efficacy of inhibiting intravascular hemolysis. Upstream complement deposition is probably associated with breakthrough hemolysis or extravascular hemolysis. 【Key words】Paroxysmal nocturnal hemoglobinuria, complement inhibitor, complement deposition, flow cytometric assay, hemolysis

Psychiatric Treatment of Medical Colleagues and Their Families: Potential Risks.

Clinicians treating "very important persons" face potential problems that can negatively impact the quality of care they provide. Mental health professionals face similar pressures, particularly when asked to treat a particular kind of patient who is a very important person: medical colleagues or their family members. The authors present 3 cases that exemplify possible risks associated with the psychiatric treatment of these individuals, including negative effects on the physician-patient relationship, lapses in patient confidentiality, and violations of medical ethics. Preventive and mitigative steps to avoid these pitfalls are discussed. Awareness of these issues when treating fellow physicians or their family members is an important consideration for any mental health clinician.

Personal Actions to Create a Culture of Inclusion: Navigating Difficult Conversations With Medical Colleagues.

Microaggressions between members of a team occur often in medicine, even despite good intentions. Such situations call for difficult conversations that restore inclusivity, diversity, and a healthy work culture. These conversations are often hard because of the unique background, experiences, and biases of each person. In medicine, skillful navigation of these interactions is paramount as it influences patient care and the workplace culture. Although much has been published about difficult interactions between providers and patients, significantly less information is available to help navigate provider-to-provider interactions, despite their critical role in improving multidisciplinary patient care teams and organizational environments. This article is intended to serve as a guide for medical professionals who are interested in taking personal responsibility for promoting a safe and inclusive culture by engaging in and modeling difficult conversations with colleagues. The article outlines important considerations to assist with intentional preparation and modulation of responses for all parties involved: conversation initiators, observers of the incident, and conversation receivers. Although these interactions are challenging, together as medical professionals we can approach each other with humility and compassion to achieve our ultimate goal of promoting humanity, not only for our patients but for ourselves and one another.

Piloting a shared decision-making clinician training intervention in maternity care in Australia: A mixed methods study

ProblemImplementation of woman-centred care in evidence-based maternity practice requires clinicians to be skilled in shared decision-making, yet there is limited training or research into such interventions. BackgroundShared decision-making enables women to make informed decisions in partnership with clinicians where there are varied clinical options in relation to indications for and timing of planned birth. AimWe aimed to develop a shared decision-making training intervention and evaluate its feasibility and acceptability to midwives and obstetricians. MethodsThe intervention was co-designed by midwifery and medical clinician-researchers, and a consumer representative. Online training and demonstration videos were distributed to midwives and obstetricians in three Sydney hospitals, followed by two online workshops in 2021 and 2022 where participants practised shared decision-making in roleplaying scenarios tailored to timing of birth. Training was evaluated using post-workshop and post-training surveys and semi-structured qualitative interviews. FindingsThe training workshop format, duration and content were well received. Barriers to the uptake of shared decision-making were time, paternalistic practices and fear of repercussions of centring women in the decision-making process. DiscussionThe intervention enabled midwifery and medical colleagues to learn communication repertoires from each other in woman-centred discussions around timing of birth. Roleplay scenarios enabled participants to observe and provide feedback on their colleagues’ shared decision-making practices, while providing a space for collective reflection on ways to promote, and mitigate barriers to, its implementation in practice. ConclusionShared decision-making training supports maternity clinicians in developing skills that implement woman-centred care in the timing of planned birth.