How do we teach clinicians to talk about the end of life?

Image of Doctor and patient

Image credit: Doctor and patient – Government of Alberta. Creative Commons License 2.0 (Non-commercial No Derivatives). Source: Flickr

By Dr Lucy Selman Research Fellow (Qualitative Research in Randomised Trials) Centre for Academic Primary Care  University of Bristol

In a systematic review published this month, we identified 153 communication skills training interventions for generalists in end of life care. In randomised controlled trials, training improved showing empathy and discussing emotions in simulated interactions (i.e. with actor patients) but evidence of effect on clinician behaviours during real patient interactions, and on patient-reported outcomes, was inconclusive.

The global increase in the proportion of older people and length of life means providing end of life care is now increasingly the responsibility of generalist as well as specialist palliative care providers. But many clinicians find communicating about end of life issues challenging: how do you best discuss imminent mortality, limited treatment options, what to expect when you’re dying, or a patient’s preferences for end of life care?

When this communication is done poorly, or not done at all, patients are confused and less satisfied with their care, experience inadequate symptom relief, and have worse quality of life. Staff who feel insufficiently trained in communication skills are more likely to provide depersonalised care and suffer from burnout.

While research in clinical communication has grown in recent years, there is little consensus on optimal training strategies and the most effective teaching methods. Continue reading

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Using administrative data for labour market research: getting the balance right

Isabel Stockton, PhD Student, School of Economics, Finance and Management, and panel participant in Research without Borders 2017

Administrative data: it’s one of those phrases that can generate much excitement among economists and some other social scientists, but will never make for scintillating party conversation in any other setting.

However, the possibilities and limits on the use of administrative data for research can have a big impact on the policymaking process and raise tricky ethical questions, so it is important that the conversation is as broad as it can possibly be.

What is administrative data?

Administrative data is collected by the government for a non-research purpose.

For example, as part of my doctoral research I analyse national insurance data on jobs, wages and commuting distances in Germany.

Whenever someone starts or leaves a job, starts to claim unemployment benefits, is assigned to a jobseekers’ training programme or goes on parental or sick leave, this leaves a paper trail.

Economists in particular are very interested in this information: Many of us still subscribe to the traditional credo “Believe what people do, not what they say”. Continue reading

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Why everyone benefits from the scrapping of employment tribunal fees

Professor Michael Ford QC, Professor of Law, University of Bristol Law School

Unfairly dismissed from your job? Seeking unpaid wages? For the last few years, if you wanted your case heard at an employment tribunal in the UK, you had to pay up front. For unfair dismissal, the fees amounted to £1,200, and for unpaid wages £390.

Introduced in 2013, the fees were designed to ensure that “users” of the system were the ones who funded it. The other justifications were to incentivise early settlements, and to deter weak or vexatious claims.

Underlying all these motivations was a concern that too many cases were being brought. And in that sense, the fees sort of worked.

That was mainly because the high level of fees (for workers who hadn’t been paid or had lost their job) compared unfavourably with the low level of sums awarded. A survey in 2013 found the median award for claims for unpaid wages was only £900. Put simply, it just wasn’t worth it. Continue reading

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Multimorbidity could cause a healthcare crisis – here’s what we can do about it

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Older patients often suffer from multiple conditions.
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Professor Chris Salisbury profile picture

Professor Chris Salisbury, Primary Health Care, University of Bristol

Multimorbidity is one of the biggest challenges facing healthcare. In recent years, a succession of research studies have shown that people with multiple health problems are more likely to have a worse quality of life, worse mental health and reduced life expectancy. The more health problems someone has, the more drugs they are likely to be prescribed and the more frequently they are likely to consult a GP or be admitted to hospital.

You might think this is all rather self-evident – it’s hardly a surprise that sick people get ill, take medicines and go to doctors more often than healthy people.

So why has multimorbidity become so prominent in discussions about healthcare over the last decade?

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Statins and venous thromboembolism: should statins use extend beyond lowering cholesterol?

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Dr Setor Kunutsor, Research Fellow in Evidence Synthesis/ Epidemiologist, School of Clinical Sciences, University of Bristol

Statins are well known and established for their role in the prevention of cardiovascular disease (heart attack, strokes, or angina) and this is based on their ability to lower levels of cholesterol in the blood.

However, there is evidence to suggest that statins have multiple effects and these include potential beneficial impacts on other disease conditions.

Venous thromboembolism is a condition involving the formation of blood clots in the veins of the lungs and lower limbs. It affects millions of people globally and is a preventable cause of hospital-related deaths.

Standard techniques for the prevention of venous thromboembolism include the use of elastic stockings, compression devices, patient mobility and rehabilitation, and anticoagulant therapy (blood thinning medications).

Blausen 0290 DeepVeinThrombosis

Deep Vein Thrombosis. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014“. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010.  ISSN 2002-4436

Evidence now suggests that statins also have the ability to reduce inflammation in the body and prevent the formation of blood clots. Based on these properties, there have been suggestions that statins may prevent venous thromboembolism.

Several studies have investigated this, however the evidence has not been conclusive until now.

We decided it was time to bring all the evidence together and evaluate if statins really did have a protective effect on the risk of developing venous thromboembolism.

Altogether we analysed 36 studies (13 observational cohort designs and 23 randomised controlled trials) with data on more than 3.2 million participants.

Our results showed a clear link between the use of statins and a reduced risk of developing venous thromboembolism. Continue reading

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If academics are serious about research impact they need to learn from monitoring, evaluation and learning teams

The impact of academic research, particularly on policy and the private sector, is an increasingly important component of research assessment exercises and funding distribution. However, Duncan Green argues that the way many researchers think about their impact continues to be pretty rudimentary. A lack of understanding of who key decision-makers are, a less-than-agile response to real-world events, and difficulties in attributing credit are all hampering progress in this area. Looking at how impact is measured by aid agencies, there is much academics could learn from their monitoring, evaluation and learning teams.

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Global Health: Antibiotics and Superbugs

In 1928 Alexander Fleming discovered penicillin, thus bringing one of the greatest medical advances of our time: antibiotics.

Innocuous infections, operations and injuries were no longer a death sentence.

Since then, antibiotics have been developed to treat an array of diseases but this slowed, and then stopped in the 1980s. Although our arsenal of development ceased, the bacteria, viruses and fungi did not stop evolving.

This asymmetric development has resulted in an antimicrobial resistance problem: bacteria causing common infections and illnesses are now increasingly resistant to the drugs used to treat them.

By 2050, the death toll could be a staggering one person every three seconds if AMR is not tackled now. Infographic from the AMR review

Creative Commons Attribution 4.0 International Public License. Attribution notice: ‘Review on Antimicrobial Resistance.’ From the O’Neill Report in 2016.

Solving this issue is not straightforward.

It involves a complex landscape of policy makers, clinicians, vets, law makers, and many others.

As part of Bristol Doctoral College’s Research without Borders Festival 2017, a public discussion was held exploring the problem of superbugs and antibiotic resistance, in both the context of research happening at the university of Bristol, and from a wider perspective.

Discussions revolved around patent law, and how it may affect development of new drugs and solutions, the role of agriculture, in particular dairy farming, in reducing antimicrobial resistance, and what we can do as individuals to help address this problem.

Below is a brief snapshot of the research relating to antimicrobial resistance being undertaken across the University of Bristol by the postgraduate researchers who took part in the RWB discussion panel. Continue reading

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It’s time to put mature students at the heart of widening participation

Why should we care about mature students?

It has become almost routine to read stories giving ‘more bad news’ about part-time student numbers in universities.

Tom Sperlinger is Reader in English Literature and Community Engagement at the University of Bristol.

Lizzie Fleming is Widening Participation and Student Recruitment Officer, and a postgraduate student, at the University of Bristol

On 29 June, the Office for Fair Access (OFFA), which monitors access to universities in the UK, published its outcomes for 2015-16. The report highlights a ‘crisis’ in part-time numbers, which have fallen for a seventh consecutive year, a decline of 61% since 2010-11. Since more than 90% of part-time students are over 21, this has also led to a significant decline in the number of mature students in the sector.

This also means that, overall, the number of students entering universities has fallen significantly since 2012. Continue reading

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Scoping the impact of Brexit for NHS procurement

Dr Albert Sanchez Graells, Senior Lecturer in Law, University of Bristol Law School

Dr Albert Sanchez Graells, Senior Lecturer in Law, University of Bristol Law School

NHS England spends over £20 billion every year on goods and services. A significant part of the remainder of NHS non-salary budget involves the commissioning of health care services. This expenditure and commissioning is controlled by NHS procurement rules, which in part derive from EU law. NHS procurement rules are regularly criticised for imposing excessive red tape and compliance costs, and calls for NHS procurement reform to free it from such strictures are common.

In this context, Brexit could be seen as an opportunity to overhaul NHS procurement and to move away from the perceived excesses of EU law. This post concentrates on two issues. First, does EU law prevent significant reforms of NHS procurement and, if so, can Brexit suppress such constraints? Second, is the way Brexit is unfolding conducive to an improvement of NHS procurement? Continue reading

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Why healthcare services have a problem with gambling

Image of electronic gambling machines.

“I have a problem with gambling. There’s not enough of it.”

Dr  Sean Cowlishaw, Research Fellow at the Centre for Academic Primary Care, University of Bristol

That was the admission from billionaire Steve Wynn, a major figure in the casino industry, speaking at a recent gambling research conference in (where else?) Las Vegas. And sure, it made for a good quote. But it’s also a rather glib dismissal of a serious issue that affects many thousands of people across the world.

The UK certainly has a problem with gambling. At least it has since 2007, when laws were changed to allow for huge growth in gambling opportunities and exposure. It has been hard to ignore the subsequent explosion in industry advertising, which increased by around 500% between 2007 and 2013. By contrast, you may have missed the increased numbers of high intensity electronic gambling machines, called Fixed-Odds Betting Terminals (FOBTs), which now occupy the high street (within betting shops) and allow punters to wager up to £100 every 20 seconds.

Yet Britain doesn’t have much insight into its problem with gambling. Compared to most other addictive behaviours, involving drugs or alcohol for example, gambling is largely ignored by health services and public health agencies. This is partly because gambling is a hidden concern. It does not manifest with physical warning signs. Indicators are usually visible in extreme cases only, and generally following major life crises such as extreme debt or relationship breakdown. Continue reading

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