The literature on breaking bad news (BBN) tends to focus on professional consensus rather than empirical patient evidence--the 'giver' rather than the 'receiver'. Using semi-structured interviews, this study explores the experiences of patients with haematological cancer as they reflect on the process and content of receiving bad news. Fifteen patients with a diagnosis of leukaemia or lymphoma were recruited through a haematology service during a routine clinical visit, with the decision to participate being made later. Interviews were audiotaped, transcribed and analysed using thematic content analysis. Patients place importance on not being rushed during the bad news consultation and the doctor's manner. Receiving bad news was the first step on a journey, not an isolated incident. Doctors were regarded as the best judge of their information needs, with leaflets and written summaries as supplements. Patients had strong preferences about continuity and language use. Displays of empathy were important, but must be genuine. Patients wanted to know about likely emotional reactions and future support. Where patients brought a companion, they found this valuable. Patients concur with much of the content of the guidelines, but place more emphasis on their illness journey, the doctor's ability to adapt to their emotional needs, language used, information leaflets, having a companion and genuinely personalizing the approach. Reflection on these patient-derived factors may help health professionals better serve patients with serious illness.

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Although studies have begun to shed light on medical students' attitudes towards peer physical examination (PPE), they have been conducted at single sites, and have generally not examined changes in medical students' attitudes over time. Employing both cross-sectional and longitudinal designs, the current study examines medical students' attitudes towards PPE at schools from different geographical and cultural regions and assess changes in their attitudes over their first year of medical study. Students at six schools (Peninsula, UK; Durham, UK; Auckland, New Zealand; Flinders, Australia; Sapporo, Japan and Li Ka Shing, Hong Kong) completed the Examining Fellow Students (EFS) questionnaire near the start of their academic year (T1), and students at four schools (Peninsula, Durham, Auckland and Flinders) completed the EFS for a second time, around the end of their academic year (T2). Univariate and multivariate analyses revealed a high level of acceptance for PPE of non-intimate body regions amongst medical students from all schools (greater than 83%, hips, at T1 and 94.5%, hips and upper body, at T2). At T1 and T2, students' willingness to engage in PPE was associated with their gender, ethnicity, religiosity and school. Typically, students least comfortable with PPE at T1 and T2 were female, non-white, religious and studying at Auckland. Although students' attitudes towards PPE were reasonably stable over their first year of study, and after exposure to PPE, we did find some statistically significant differences in attitudes between T1 and T2. Interestingly, attitude changes were consistently predicted by gender, even when controlling for school. While male students' attitudes towards PPE were relatively stable over time, females' attitudes were changeable. In this paper, we discuss our findings in light of existing research and theory, and discuss their implications for educational practice and further research.

Although over 90% of patient contacts within the NHS occur in primary care, many of the interventions used in this setting remain unproved.1 The relevance of research undertaken in secondary or tertiary care to general practice is questionable, and more research based in primary care is needed.2 Increasing research in primary care will inevitably increase demand for randomised controlled trials in this setting. Some of the trials will be of health service interventions (pragmatic trials), 3 where the focus lies in assessing the cost effectiveness of an intervention rather than efficacy or safety. The difficulties experienced in doing randomised controlled trials in primary care have been reported 4-6 and are not restricted to this setting. 7 8 We discuss some of the issues that must be considered when conducting and interpreting the results of trials in primary care using examples generated during a trial of the management of dyspepsia (box).Dyspepsia is a common clinical problem. About 2% of the population consult their general practitioner each year with dyspeptic symptoms, 9 and it costs the NHS more than £1bn a year, with a large proportion of these costs relating to drug prescription.

Background Medical student wellbeing – a consensus statement from Australia and New Zealand outlines recommendations for optimising medical student wellbeing within medical schools in our region. Worldwide, medical schools have responsibilities to respond to concerns about student psychological, social and physical wellbeing, but guidance for medical schools is limited. To address this gap, this statement clarifies key concepts and issues related to wellbeing and provides recommendations for educational program design to promote both learning and student wellbeing. The recommendations focus on student selection; learning, teaching and assessment; learning environment; and staff development. Examples of educational initiatives from the evidence-base are provided, emphasising proactive and preventive approaches to student wellbeing. Main recommendations The consensus statement provides specific recommendations for medical schools to consider at all stages of program design and implementation. These are: Design curricula that promote peer support and progressive levels of challenge to students. Employ strategies to promote positive outcomes from stress and to help others in need. Design assessment tasks to foster wellbeing as well as learning. Provide mental health promotion and suicide prevention initiatives. Provide physical health promotion initiatives. Ensure safe and health-promoting cultures for learning in on-campus and clinical settings. Train staff on student wellbeing and how to manage wellbeing concerns. Conclusion A broad integrated approach to improving student wellbeing within medical school programs is recommended. Medical schools should work cooperatively with student and trainee groups, and partner with clinical services and other training bodies to foster safe practices and cultures. Initiatives should aim to assist students to develop adaptive responses to stressful situations so that graduates are prepared for the realities of the workplace. Multi-institutional, longitudinal collaborative research in Australia and New Zealand is needed to close critical gaps in the evidence needed by medical schools in our region.