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Sam Leinster

University of East Anglia, Norwich Medical School, Emeritus

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I am by clinical background a surgical oncologist with interests in breast cancer, malignant melanoma and soft tissue sarcoma. My research interests include the molecular biology of breast cancer and the psychological impact of breast disease. My major contributions have been in medical education with interests in curriculum design and delivery, assessment, and the accreditation of medical schools.

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Papers by Sam Leinster

Medical graduates’ preparedness to practice: a comparison of undergraduate medical school training

BMC Medical Education, Feb 6, 2017

Background: There is evidence that newly qualified doctors do not feel prepared to start work. Th... more Background: There is evidence that newly qualified doctors do not feel prepared to start work. This study examined views of first year Foundation doctors (F1s) regarding how prepared they felt by their undergraduate medical education for skills required during the first Foundation training year in relation to their type of training. Method: One-hundred and eighty two F1s completed a questionnaire during their first rotation of Foundation training. Analysis was conducted by type of medical school training: Problem-Based Learning (PBL), Traditional or Reformed. Results: F1s from medical schools with a PBL curriculum felt better prepared for tasks associated with communication and team working, and paperwork than graduates from the other medical school types; but the majority of F1s from all three groups felt well prepared for most areas of practice. Less than half of graduates in all three groups felt well prepared to deal with a patient with neurological/visual problems; write referral letters; understand drug interactions; manage pain; and cope with uncertainty. F1s also indicated that lack of induction or support on starting work was affecting their ability to work in some areas. Conclusions: Whilst F1s from medical schools with a PBL curriculum did feel better prepared in multiple areas compared to graduates from the other medical school types, specific areas of unpreparedness related to undergraduate and postgraduate medical training were identified across all F1s. These areas need attention to ensure F1s are optimally prepared for starting work.

Taking responsibility for cancer treatment

Social Science & Medicine, Sep 1, 2001

One hundred and fourteen consecutive patients with early breast cancer were entered into a study ... more One hundred and fourteen consecutive patients with early breast cancer were entered into a study on the psychological effects of involvement in treatment choice. All women were offered counselling throughout. One group of women (n ¼ 34), were advised to undergo mastectomy, due to the nature or position of the tumour. These women fared less well psychologically when compared on a battery of measures, before and after surgery, with women who were involved in choosing their own treatment (n ¼ 80). The latter group itself was randomly allocated into two groups for taking explicit responsibility for treatment choice, using a double-blind procedure. These were a Patient Decision Group (n ¼ 41) and a Surgeon Decision Group (n ¼ 39). Results support the hypothesis that over and above the benefits of receiving their preferred treatment, women can further benefit from taking explicit responsibility for their treatment choice.

Breast asymmetry and phenotypic quality in women

Evolution and Human Behavior, Jul 1, 1997

Breasts in humans are highly sexually dimorphic compared to other closely related primate species... more Breasts in humans are highly sexually dimorphic compared to other closely related primate species. One possible explanation for this increase in breast size is that breast asymmetry contains information regarding women's phenotypic quality. The purpose of this work was to consider the relationship between asymmetry and measures of body size, body composition, and fertility. We found significant associations between breast asymmetry and height, body mass, and breast volume (positive associations), breast "density" (negative association), and the woman's age and her age at first childbirth (positive associations). The relationship between asymmetry and breast volume showed evidence of negative ailometry, that is, women with large breasts had smaller asymmetry than expected for their breast size. Asymmetry was lower in married women compared to unmarried women and negatively related to offspring number. A multiple regression analysis, with breast asymmetry as the dependent variable, showed a strong significant relationship with breast volume (positive association) and significant relationships with age at first childbirth (positive association) and number of offspring (negative association). Asymmetric women therefore had fewer children later in life that did symmetric women. Simple linear and multiple regression analysis showed that breast volume was a strong predictor of body size and composition (weight, height, and breast density) and a weak predictor of age and age at menarche. It was not related to offspring number or age at first childbirth. Our data support the thesis that mammotropic hormones, particularly estrogen, are harmful because they suppress the immune system. Heavy women with high levels of body fat produce more estrogen and, therefore, bigger breasts. However, more estrogen leads to an increase in breast asymmetry. Women with "good genes" are able to produce symmetric breasts despite the presence of large quantities of

Postgraduate Medical Journal, Jul 1, 1996

Clinical biostatistics. An introduction to evidence-based medicine, G Dunn, B Everitt. pp vi+154,... more Clinical biostatistics. An introduction to evidence-based medicine, G Dunn, B Everitt. pp vi+154, illustrated. Edward Arnold, London, 1995. £10.99, paperback The textbook of total quality in healthcare, AF Al-Assaf, JA Schmele, eds. pp ix+301, illustrated. Kogan Page, London, 1995. £35.00, hardback Performance management and appraisal in health services, M Edis. pp 160, illustrated. Kogan Page, London, 1995. £12.95, paperback The healthcare management handbook, K Holdaway, ed. pp xxvii+323, illustrated.

Clinical Supervision with Confidence:Massive Open Online Course (MOOC)

“Clinical Supervision with Confidence”: Exploring the potential of MOOCs for faculty development

A comment on “T2QM (teaching and total quality management) for medical teachers” by R. G. Bing-You

Medical Teacher, 1997

Clinical skills as a vehicle for interprofessional learning

The Clinical Teacher, Jul 1, 2018

Interprofessional education (IPE) is defined as "occasions when two or more professions learn wit... more Interprofessional education (IPE) is defined as "occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care". 1 The World Health Organization (WHO) confirmed their commitment to IPE in their Framework For Action on Interprofessional Education and Collaborative Practice in 2010 by stating that "there is sufficient evidence to indicate that effective IPE enables effective collaborative practice" and that "collaborative practice strengthens health systems and improves health outcomes". Whilst not being prescriptive about how this is done, the WHO clearly requests a commitment to building IPE into new and existing health-related curricula. A wide variety of IPE models are now in existence and the challenges of setting up, maintaining and evaluating a sustainable IPE initiative are well documented. The global community therefore needs to share their experiences and lessons learnt so that educators can elicit best practice in delivering IPE. In 2016, The Clinical Teacher published a Clinical Teachers' Toolbox titled 'Developing interprofessional education: putting theory into practice', 5 which looked at IPE curriculum development, pitfalls and challenges and described the model at

Psychological Aspects of Breast Cancer Treatment

Springer eBooks, 1987

Breast cancer has been described as a “major health problem” (Kalache and Vessey, 1982); it is th... more Breast cancer has been described as a “major health problem” (Kalache and Vessey, 1982); it is the cause of death for 12,000 women each year in England and Wales. In Britain it is estimated that one woman in 17 will contract the disease; in the United States the figure is even higher, one in 14. Breast cancer is the major cause of death in women aged between 35 and 54 years. It is not surprising therefore that this century has seen numerous studies conducted in an attempt to find both cause and cure for the disease. Despite this endeavor the last 30 years have seen not a decrease but an increase in deaths from breast cancer in most countries (Office of Population Censuses and Surveys, 1977).

The value of guidelines in a breast screening service

Ejso, Apr 1, 1995

The use of agreed guidelines in the management of common surgical and medical conditions has rece... more The use of agreed guidelines in the management of common surgical and medical conditions has received much attention and enjoys varying degrees of support. In May 1992 the UK Breast Screening Programme produced guidelines with the intention of providing criteria for all units to attempt to achieve. We have investigated these guidelines as a means of comparative audit and stimulus for change. Two units were compared, one in a teaching centre and the other in a district general hospital. Although both units performed for the most part within the guidelines, areas where improvement could be made were identified and measures to correct deficiencies taken. This resulted in improved performance in those areas. The study demonstrates that guidelines can have considerable benefit in helping to identify problems in the provision of care and introducing measures to improve the situation.

Putting theory into practice – A case study in one UK medical school of the nature and extent of unprofessional behaviour over a 6-year period

Medical Teacher, Sep 20, 2010

Background: Producing a medical profession which is fit for the demands and expectations of socie... more Background: Producing a medical profession which is fit for the demands and expectations of society involves ensuring that practitioners learn what it means to behave in a 'professional' way. Codes of professional conduct have been developed for medical students in the UK, but the literature on how medical schools actually apply these is small. More detail is needed to evaluate approaches to assessing professionalism, or to analyse the extent to which students 'fail' this aspect. Aim: To describe one UK medical school's approach to monitoring and assessing aspects of professional behaviour; quantify the prevalence and severity of behaviours recognised as cause of concern in the first 6 years of the programme; evaluate whether there is evidence of any association between professional and academic underperformance and draw conclusions for further development of fitness to practice procedures. Methods: Mixed methods utilising exam board and administrative data for statistical and descriptive analysis. Results: Even under detailed scrutiny, only 3% of students received formal warnings for behavioural problems over the course of a 5-year programme, and notifications decreased as students entered the senior years. There was a trend towards association between academic and professional underperformance. Conclusion: Creating clear expectations, providing positive role models and monitoring student behaviour makes explicit what is expected of students as 'professionals in the making', and contributes to overall low rates of misdemeanour. The predictive value of recurrent and serious behavioural problems is not yet known as it is too soon for these graduates to have established careers. Students who are struggling academically may also present with unprofessional behaviours but the cause of this is unclear. Further research is needed to benchmark systems across the UK, and to know whether formalising expectations of undergraduates result in less problems in subsequent practice.

Identifying professional characteristics of the ideal medical doctor: The laddering technique

Medical Teacher, 2010

The aim was to examine the utility of the laddering interview technique to investigate complex is... more The aim was to examine the utility of the laddering interview technique to investigate complex issues in medical education, such as professionalism. The laddering technique was used to identify examples of professional behaviour associated with the ideal medical doctor, and to explain why participants thought these behaviours were important. Three groups were interviewed: doctors (n = 30), first-year medical students (n = 31) and patients (n = 33). All groups identified characteristics associated with a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;communication and interpersonal skills&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; theme. Data suggested the essence of the doctor-patient interaction was shared by the groups, with varying later emphases due to their different perspectives. Additionally, Doctors and Students generated characteristics associated with &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;team-working&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;competence&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; themes; Doctors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; conceptualization of each theme was more detailed. Positive and negative impacts of Doctor&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s professional behaviour on the patient, doctor and the wider medical arena were also identified. Use of laddering resulted in data-rich results for each of the three stakeholder groups, illustrating shared and divergent preferences as to the preferred characteristics of a medical doctor and effects of successful and less-successful doctor-patient interactions. The identified characteristics are relevant to the area under investigation and salient to these key stakeholders.

Learning in the clinical environment

Medical Teacher, 2009

Clinical learning is central to medical education. Learning theories suggest that it is most effe... more Clinical learning is central to medical education. Learning theories suggest that it is most effective when students are actively engaged with patient care and receiving timely feedback. Changes in health care delivery mean that learning must take place in a variety of clinical settings. The &amp;amp;amp;amp;amp;amp;#39;One Minute Preceptor&amp;amp;amp;amp;amp;amp;#39; approach allows teaching to take place in the course of routine delivery of care.

The Variation of Breast Parenchymal Patterns with Age

British Journal of Radiology, Apr 1, 1985

The Wolfe classification of mammographic parenchymal patterns has been applied to 9036 women atte... more The Wolfe classification of mammographic parenchymal patterns has been applied to 9036 women attending a Breast Cancer Screening Unit. Overall, two thirds fell into high risk categories (P 2 and DY). The incidence of DY decreases with age, while the low risk categories (N t and Pj) increase with age. P 2 remains constant over most of the age range. The implications of these findings are discussed and comparison is made with other series.

How medical students demonstrate their professionalism when reflecting on experience

Medical Education, Oct 1, 2009

This paper aims to examine the discourses used by students in a formal assessment of their abilit... more This paper aims to examine the discourses used by students in a formal assessment of their ability to demonstrate professional values when reflecting on their experiences. We carried out a discourse analysis of 50 randomly selected essays from a summative assessment undertaken by all five year groups of students in one UK medical school. Students were able to identify a wealth of relevant examples and to articulate key principles of professional practice. They were also able to critique behaviours and draw appropriate conclusions for their own intended professional development. Detailed textual analysis provided linguistic clues to the depth of apparent reflection: recurrent use of rhetorical language with minimal use of first-person reflections, lack of analysis of underlying factors, and simplistic views of solutions may all indicate students whose ability to learn by reflection on experience needs further development. There were also areas in which cohorts as a whole appeared to have a limited grasp of the important professional issues being addressed. CONCLUSIONS Assessing written reflections is a useful way of making students link their experiences with professional development. The detailed analysis of language usage may help to refine marking criteria, and to detect students and course components where reflective learning competencies are not being achieved.

Factors which influence the occurrence of vascular calcification in the breast

British Journal of Radiology, May 1, 1987

Breast arterial calcification, as seen on mammography, increases in frequency with advancing age,... more Breast arterial calcification, as seen on mammography, increases in frequency with advancing age, especially after menopause. No association was found with systemic hypertension. The number of diabetics in the series was too small for comparative purposes. An early menopause and a history of pregnancy were factors which influenced incidence. Oral contraception was associated with a lower incidence of calcification before, but not after menopause. On the other hand, hormonal preparations taken for menopausal symptoms were associated with a lower incidence of calcification in postmenopausal women.

Do doctors need statistics? Doctors' use of and attitudes to probability and statistics

Statistics in Medicine, May 19, 2009

There is little published evidence on what doctors do in their work that requires probability and... more There is little published evidence on what doctors do in their work that requires probability and statistics, yet the General Medical Council (GMC) requires new doctors to have these skills. This study investigated doctors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; use of and attitudes to probability and statistics with a view to informing undergraduate teaching.An email questionnaire was sent to 473 clinicians with an affiliation to the University of East Anglia&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Medical School.Of 130 respondents approximately 90 per cent of doctors who performed each of the following activities found probability and statistics useful for that activity: accessing clinical guidelines and evidence summaries, explaining levels of risk to patients, assessing medical marketing and advertising material, interpreting the results of a screening test, reading research publications for general professional interest, and using research publications to explore non-standard treatment and management options.Seventy-nine per cent (103/130, 95 per cent CI 71 per cent, 86 per cent) of participants considered probability and statistics important in their work. Sixty-three per cent (78/124, 95 per cent CI 54 per cent, 71 per cent) said that there were activities that they could do better or start doing if they had an improved understanding of these areas and 74 of these participants elaborated on this. Themes highlighted by participants included: being better able to critically evaluate other people&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s research; becoming more research-active, having a better understanding of risk; and being better able to explain things to, or teach, other people.Our results can be used to inform how probability and statistics should be taught to medical undergraduates and should encourage today&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s medical students of the subjects&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; relevance to their future careers.

Student assessment in undergraduate medical education in the United Kingdom, 1998

Medical Education, Sep 1, 2000

This report describes the results of the project &#39;Assessment of Undergraduate Medical Edu... more This report describes the results of the project &#39;Assessment of Undergraduate Medical Education: Re-inventing the Wheel?&#39; funded by the Nuffield Trust. The project was initiated in order to obtain information on current assessment practices in medical schools across the UK, to determine the extent of change as a consequence of the curricular reforms recommended by the General Medical Council (GMC) in 1993 and, if necessary, to stimulate debate about assessment and provide an impetus for change. The data obtained provide a detailed profile of the timing and nature of assessments used in medical schools and provide information for comparison with the survey of basic medical education in the British Isles carried out in 1977 and any subsequent studies. The study provides confirmatory and unexpected evidence. Schools are clearly revising their curricula consistent with recommendations made by the GMC. The main components of the study were as follows: a postal questionnaire sent to all UK medical schools, a national workshop, and four case studies of innovative assessment practices.

Prognostic significance of cathepsin-D in patients with breast cancer

British Journal of Cancer, Apr 1, 1993

The expression of the protease cathepsin-D has been evaluated using an immunohistochemical techni... more The expression of the protease cathepsin-D has been evaluated using an immunohistochemical technique with a polyclonal antibody in paraffin-embedded tissue from 359 patients treated between the years 1975-1981 for Stage I and II breast cancer. One hundred and twenty seven patients (35%) have strongly positive, granular staining, 138 (38%) are intermediately stained in the cytoplasm, and in 94 (26%) no staining is observed. There is a strong positive association between expression of cathepsin-D and the presence of tumour in axillary lymph nodes (P <0.006). Expression of the protease is associated with significantly poorer survival of patients in univariate analysis (P = 0.025); however, this is not independent of other tumour variables.

Coping with Cancer Surgery

Doctors and other professionals can easily underestimate the anxiety engendered in a patient by t... more Doctors and other professionals can easily underestimate the anxiety engendered in a patient by the prospect of an operation. What to the professional may be routine, is often a once in a lifetime experience for the patient dying in an alien environment away from the support of family and friends. Usually he has two main areas of concern: the first is the degree of pain and discomfort he might have to suffer and the second is fear of the outcome.

Medical graduates’ preparedness to practice: a comparison of undergraduate medical school training

BMC Medical Education, Feb 6, 2017

Background: There is evidence that newly qualified doctors do not feel prepared to start work. Th... more Background: There is evidence that newly qualified doctors do not feel prepared to start work. This study examined views of first year Foundation doctors (F1s) regarding how prepared they felt by their undergraduate medical education for skills required during the first Foundation training year in relation to their type of training. Method: One-hundred and eighty two F1s completed a questionnaire during their first rotation of Foundation training. Analysis was conducted by type of medical school training: Problem-Based Learning (PBL), Traditional or Reformed. Results: F1s from medical schools with a PBL curriculum felt better prepared for tasks associated with communication and team working, and paperwork than graduates from the other medical school types; but the majority of F1s from all three groups felt well prepared for most areas of practice. Less than half of graduates in all three groups felt well prepared to deal with a patient with neurological/visual problems; write referral letters; understand drug interactions; manage pain; and cope with uncertainty. F1s also indicated that lack of induction or support on starting work was affecting their ability to work in some areas. Conclusions: Whilst F1s from medical schools with a PBL curriculum did feel better prepared in multiple areas compared to graduates from the other medical school types, specific areas of unpreparedness related to undergraduate and postgraduate medical training were identified across all F1s. These areas need attention to ensure F1s are optimally prepared for starting work.

Taking responsibility for cancer treatment

Social Science & Medicine, Sep 1, 2001

One hundred and fourteen consecutive patients with early breast cancer were entered into a study ... more One hundred and fourteen consecutive patients with early breast cancer were entered into a study on the psychological effects of involvement in treatment choice. All women were offered counselling throughout. One group of women (n ¼ 34), were advised to undergo mastectomy, due to the nature or position of the tumour. These women fared less well psychologically when compared on a battery of measures, before and after surgery, with women who were involved in choosing their own treatment (n ¼ 80). The latter group itself was randomly allocated into two groups for taking explicit responsibility for treatment choice, using a double-blind procedure. These were a Patient Decision Group (n ¼ 41) and a Surgeon Decision Group (n ¼ 39). Results support the hypothesis that over and above the benefits of receiving their preferred treatment, women can further benefit from taking explicit responsibility for their treatment choice.

Breast asymmetry and phenotypic quality in women

Evolution and Human Behavior, Jul 1, 1997

Breasts in humans are highly sexually dimorphic compared to other closely related primate species... more Breasts in humans are highly sexually dimorphic compared to other closely related primate species. One possible explanation for this increase in breast size is that breast asymmetry contains information regarding women's phenotypic quality. The purpose of this work was to consider the relationship between asymmetry and measures of body size, body composition, and fertility. We found significant associations between breast asymmetry and height, body mass, and breast volume (positive associations), breast "density" (negative association), and the woman's age and her age at first childbirth (positive associations). The relationship between asymmetry and breast volume showed evidence of negative ailometry, that is, women with large breasts had smaller asymmetry than expected for their breast size. Asymmetry was lower in married women compared to unmarried women and negatively related to offspring number. A multiple regression analysis, with breast asymmetry as the dependent variable, showed a strong significant relationship with breast volume (positive association) and significant relationships with age at first childbirth (positive association) and number of offspring (negative association). Asymmetric women therefore had fewer children later in life that did symmetric women. Simple linear and multiple regression analysis showed that breast volume was a strong predictor of body size and composition (weight, height, and breast density) and a weak predictor of age and age at menarche. It was not related to offspring number or age at first childbirth. Our data support the thesis that mammotropic hormones, particularly estrogen, are harmful because they suppress the immune system. Heavy women with high levels of body fat produce more estrogen and, therefore, bigger breasts. However, more estrogen leads to an increase in breast asymmetry. Women with "good genes" are able to produce symmetric breasts despite the presence of large quantities of

Postgraduate Medical Journal, Jul 1, 1996

Clinical biostatistics. An introduction to evidence-based medicine, G Dunn, B Everitt. pp vi+154,... more Clinical biostatistics. An introduction to evidence-based medicine, G Dunn, B Everitt. pp vi+154, illustrated. Edward Arnold, London, 1995. £10.99, paperback The textbook of total quality in healthcare, AF Al-Assaf, JA Schmele, eds. pp ix+301, illustrated. Kogan Page, London, 1995. £35.00, hardback Performance management and appraisal in health services, M Edis. pp 160, illustrated. Kogan Page, London, 1995. £12.95, paperback The healthcare management handbook, K Holdaway, ed. pp xxvii+323, illustrated.

Clinical Supervision with Confidence:Massive Open Online Course (MOOC)

“Clinical Supervision with Confidence”: Exploring the potential of MOOCs for faculty development

A comment on “T2QM (teaching and total quality management) for medical teachers” by R. G. Bing-You

Medical Teacher, 1997

Clinical skills as a vehicle for interprofessional learning

The Clinical Teacher, Jul 1, 2018

Interprofessional education (IPE) is defined as "occasions when two or more professions learn wit... more Interprofessional education (IPE) is defined as "occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care". 1 The World Health Organization (WHO) confirmed their commitment to IPE in their Framework For Action on Interprofessional Education and Collaborative Practice in 2010 by stating that "there is sufficient evidence to indicate that effective IPE enables effective collaborative practice" and that "collaborative practice strengthens health systems and improves health outcomes". Whilst not being prescriptive about how this is done, the WHO clearly requests a commitment to building IPE into new and existing health-related curricula. A wide variety of IPE models are now in existence and the challenges of setting up, maintaining and evaluating a sustainable IPE initiative are well documented. The global community therefore needs to share their experiences and lessons learnt so that educators can elicit best practice in delivering IPE. In 2016, The Clinical Teacher published a Clinical Teachers' Toolbox titled 'Developing interprofessional education: putting theory into practice', 5 which looked at IPE curriculum development, pitfalls and challenges and described the model at

Psychological Aspects of Breast Cancer Treatment

Springer eBooks, 1987

Breast cancer has been described as a “major health problem” (Kalache and Vessey, 1982); it is th... more Breast cancer has been described as a “major health problem” (Kalache and Vessey, 1982); it is the cause of death for 12,000 women each year in England and Wales. In Britain it is estimated that one woman in 17 will contract the disease; in the United States the figure is even higher, one in 14. Breast cancer is the major cause of death in women aged between 35 and 54 years. It is not surprising therefore that this century has seen numerous studies conducted in an attempt to find both cause and cure for the disease. Despite this endeavor the last 30 years have seen not a decrease but an increase in deaths from breast cancer in most countries (Office of Population Censuses and Surveys, 1977).

The value of guidelines in a breast screening service

Ejso, Apr 1, 1995

The use of agreed guidelines in the management of common surgical and medical conditions has rece... more The use of agreed guidelines in the management of common surgical and medical conditions has received much attention and enjoys varying degrees of support. In May 1992 the UK Breast Screening Programme produced guidelines with the intention of providing criteria for all units to attempt to achieve. We have investigated these guidelines as a means of comparative audit and stimulus for change. Two units were compared, one in a teaching centre and the other in a district general hospital. Although both units performed for the most part within the guidelines, areas where improvement could be made were identified and measures to correct deficiencies taken. This resulted in improved performance in those areas. The study demonstrates that guidelines can have considerable benefit in helping to identify problems in the provision of care and introducing measures to improve the situation.

Putting theory into practice – A case study in one UK medical school of the nature and extent of unprofessional behaviour over a 6-year period

Medical Teacher, Sep 20, 2010

Background: Producing a medical profession which is fit for the demands and expectations of socie... more Background: Producing a medical profession which is fit for the demands and expectations of society involves ensuring that practitioners learn what it means to behave in a 'professional' way. Codes of professional conduct have been developed for medical students in the UK, but the literature on how medical schools actually apply these is small. More detail is needed to evaluate approaches to assessing professionalism, or to analyse the extent to which students 'fail' this aspect. Aim: To describe one UK medical school's approach to monitoring and assessing aspects of professional behaviour; quantify the prevalence and severity of behaviours recognised as cause of concern in the first 6 years of the programme; evaluate whether there is evidence of any association between professional and academic underperformance and draw conclusions for further development of fitness to practice procedures. Methods: Mixed methods utilising exam board and administrative data for statistical and descriptive analysis. Results: Even under detailed scrutiny, only 3% of students received formal warnings for behavioural problems over the course of a 5-year programme, and notifications decreased as students entered the senior years. There was a trend towards association between academic and professional underperformance. Conclusion: Creating clear expectations, providing positive role models and monitoring student behaviour makes explicit what is expected of students as 'professionals in the making', and contributes to overall low rates of misdemeanour. The predictive value of recurrent and serious behavioural problems is not yet known as it is too soon for these graduates to have established careers. Students who are struggling academically may also present with unprofessional behaviours but the cause of this is unclear. Further research is needed to benchmark systems across the UK, and to know whether formalising expectations of undergraduates result in less problems in subsequent practice.

Identifying professional characteristics of the ideal medical doctor: The laddering technique

Medical Teacher, 2010

The aim was to examine the utility of the laddering interview technique to investigate complex is... more The aim was to examine the utility of the laddering interview technique to investigate complex issues in medical education, such as professionalism. The laddering technique was used to identify examples of professional behaviour associated with the ideal medical doctor, and to explain why participants thought these behaviours were important. Three groups were interviewed: doctors (n = 30), first-year medical students (n = 31) and patients (n = 33). All groups identified characteristics associated with a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;communication and interpersonal skills&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; theme. Data suggested the essence of the doctor-patient interaction was shared by the groups, with varying later emphases due to their different perspectives. Additionally, Doctors and Students generated characteristics associated with &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;team-working&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;competence&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; themes; Doctors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; conceptualization of each theme was more detailed. Positive and negative impacts of Doctor&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s professional behaviour on the patient, doctor and the wider medical arena were also identified. Use of laddering resulted in data-rich results for each of the three stakeholder groups, illustrating shared and divergent preferences as to the preferred characteristics of a medical doctor and effects of successful and less-successful doctor-patient interactions. The identified characteristics are relevant to the area under investigation and salient to these key stakeholders.

Learning in the clinical environment

Medical Teacher, 2009

Clinical learning is central to medical education. Learning theories suggest that it is most effe... more Clinical learning is central to medical education. Learning theories suggest that it is most effective when students are actively engaged with patient care and receiving timely feedback. Changes in health care delivery mean that learning must take place in a variety of clinical settings. The &amp;amp;amp;amp;amp;amp;#39;One Minute Preceptor&amp;amp;amp;amp;amp;amp;#39; approach allows teaching to take place in the course of routine delivery of care.

The Variation of Breast Parenchymal Patterns with Age

British Journal of Radiology, Apr 1, 1985

The Wolfe classification of mammographic parenchymal patterns has been applied to 9036 women atte... more The Wolfe classification of mammographic parenchymal patterns has been applied to 9036 women attending a Breast Cancer Screening Unit. Overall, two thirds fell into high risk categories (P 2 and DY). The incidence of DY decreases with age, while the low risk categories (N t and Pj) increase with age. P 2 remains constant over most of the age range. The implications of these findings are discussed and comparison is made with other series.

How medical students demonstrate their professionalism when reflecting on experience

Medical Education, Oct 1, 2009

This paper aims to examine the discourses used by students in a formal assessment of their abilit... more This paper aims to examine the discourses used by students in a formal assessment of their ability to demonstrate professional values when reflecting on their experiences. We carried out a discourse analysis of 50 randomly selected essays from a summative assessment undertaken by all five year groups of students in one UK medical school. Students were able to identify a wealth of relevant examples and to articulate key principles of professional practice. They were also able to critique behaviours and draw appropriate conclusions for their own intended professional development. Detailed textual analysis provided linguistic clues to the depth of apparent reflection: recurrent use of rhetorical language with minimal use of first-person reflections, lack of analysis of underlying factors, and simplistic views of solutions may all indicate students whose ability to learn by reflection on experience needs further development. There were also areas in which cohorts as a whole appeared to have a limited grasp of the important professional issues being addressed. CONCLUSIONS Assessing written reflections is a useful way of making students link their experiences with professional development. The detailed analysis of language usage may help to refine marking criteria, and to detect students and course components where reflective learning competencies are not being achieved.

Factors which influence the occurrence of vascular calcification in the breast

British Journal of Radiology, May 1, 1987

Breast arterial calcification, as seen on mammography, increases in frequency with advancing age,... more Breast arterial calcification, as seen on mammography, increases in frequency with advancing age, especially after menopause. No association was found with systemic hypertension. The number of diabetics in the series was too small for comparative purposes. An early menopause and a history of pregnancy were factors which influenced incidence. Oral contraception was associated with a lower incidence of calcification before, but not after menopause. On the other hand, hormonal preparations taken for menopausal symptoms were associated with a lower incidence of calcification in postmenopausal women.

Do doctors need statistics? Doctors' use of and attitudes to probability and statistics

Statistics in Medicine, May 19, 2009

There is little published evidence on what doctors do in their work that requires probability and... more There is little published evidence on what doctors do in their work that requires probability and statistics, yet the General Medical Council (GMC) requires new doctors to have these skills. This study investigated doctors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; use of and attitudes to probability and statistics with a view to informing undergraduate teaching.An email questionnaire was sent to 473 clinicians with an affiliation to the University of East Anglia&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Medical School.Of 130 respondents approximately 90 per cent of doctors who performed each of the following activities found probability and statistics useful for that activity: accessing clinical guidelines and evidence summaries, explaining levels of risk to patients, assessing medical marketing and advertising material, interpreting the results of a screening test, reading research publications for general professional interest, and using research publications to explore non-standard treatment and management options.Seventy-nine per cent (103/130, 95 per cent CI 71 per cent, 86 per cent) of participants considered probability and statistics important in their work. Sixty-three per cent (78/124, 95 per cent CI 54 per cent, 71 per cent) said that there were activities that they could do better or start doing if they had an improved understanding of these areas and 74 of these participants elaborated on this. Themes highlighted by participants included: being better able to critically evaluate other people&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s research; becoming more research-active, having a better understanding of risk; and being better able to explain things to, or teach, other people.Our results can be used to inform how probability and statistics should be taught to medical undergraduates and should encourage today&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s medical students of the subjects&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; relevance to their future careers.

Student assessment in undergraduate medical education in the United Kingdom, 1998

Medical Education, Sep 1, 2000

This report describes the results of the project &#39;Assessment of Undergraduate Medical Edu... more This report describes the results of the project &#39;Assessment of Undergraduate Medical Education: Re-inventing the Wheel?&#39; funded by the Nuffield Trust. The project was initiated in order to obtain information on current assessment practices in medical schools across the UK, to determine the extent of change as a consequence of the curricular reforms recommended by the General Medical Council (GMC) in 1993 and, if necessary, to stimulate debate about assessment and provide an impetus for change. The data obtained provide a detailed profile of the timing and nature of assessments used in medical schools and provide information for comparison with the survey of basic medical education in the British Isles carried out in 1977 and any subsequent studies. The study provides confirmatory and unexpected evidence. Schools are clearly revising their curricula consistent with recommendations made by the GMC. The main components of the study were as follows: a postal questionnaire sent to all UK medical schools, a national workshop, and four case studies of innovative assessment practices.

Prognostic significance of cathepsin-D in patients with breast cancer

British Journal of Cancer, Apr 1, 1993

The expression of the protease cathepsin-D has been evaluated using an immunohistochemical techni... more The expression of the protease cathepsin-D has been evaluated using an immunohistochemical technique with a polyclonal antibody in paraffin-embedded tissue from 359 patients treated between the years 1975-1981 for Stage I and II breast cancer. One hundred and twenty seven patients (35%) have strongly positive, granular staining, 138 (38%) are intermediately stained in the cytoplasm, and in 94 (26%) no staining is observed. There is a strong positive association between expression of cathepsin-D and the presence of tumour in axillary lymph nodes (P <0.006). Expression of the protease is associated with significantly poorer survival of patients in univariate analysis (P = 0.025); however, this is not independent of other tumour variables.

Coping with Cancer Surgery

Doctors and other professionals can easily underestimate the anxiety engendered in a patient by t... more Doctors and other professionals can easily underestimate the anxiety engendered in a patient by the prospect of an operation. What to the professional may be routine, is often a once in a lifetime experience for the patient dying in an alien environment away from the support of family and friends. Usually he has two main areas of concern: the first is the degree of pain and discomfort he might have to suffer and the second is fear of the outcome.