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Fan J, Li S, Qiang Y, Duan Z, Wu A, Wang R. Barriers and Stimulus in Shared Decision Making Among Aesthetic Dermatologists in China: Findings from a Cross-Sectional Study. Clin Cosmet Investig Dermatol 2024; 17:1153-1164. [PMID: 38800355 PMCID: PMC11119500 DOI: 10.2147/ccid.s457802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/06/2024] [Indexed: 05/29/2024]
Abstract
Introduction Shared decision making (SDM) is a collaborative process involving both healthcare providers and patients in making medical decisions, which gains increasing prominence in healthcare practice. But evidence on the level of SDM in medical practice and barriers as well as stimulus during the SDM implementation among aesthetic dermatologists is limited in China. Methods From July to August 2023, 1938 dermatologists were recruited online in China. Data were collected through an electronic questionnaire covering: (1) demographic features; (2) SDM questionnaire physician version (SDM-Q-Doc); and (3) stimulus and barriers in SDM implementation. Logistic regression was applied to explore factors associated with SDM practice, barriers, and stimulus of SDM implementation, respectively. Results The 1938 dermatologists included 1329 females (68.6%), with an average age of 35 years. The total SDM score ranged from 0 to 45, with a median value of 40 (IQR: 35-44), and the median stimulus score and barriers scores were 28 (IQR: 24-32) and 19 (IQR: 13-26), respectively. The prevalence of good SDM was 27.2%, logistic regression indicated that female dermatologists (odds ratio, OR=1.21, 95% confidence interval, CI: 0.96-1.51), and dermatologists with more years of aesthetic practice had a higher proportion of good SDM practice (OR was 1.44 for 5-9 years, 1.58 for 10-15 years and 1.77 for over 15 years). Moreover, female dermatologists and dermatologists with higher education level and serviced in private settings had lower barrier scores; female dermatologists and dermatologists with more years of aesthetic practice had higher stimulus scores. Conclusion Chinese aesthetic dermatologists appear to implement SDM at an active level, with more stimulus and less barriers in SDM implementation. The integration of SDM into clinical practice among dermatologists is beneficial both for patients and dermatologists. Moreover, SDM practice should be strongly promoted and enhanced during medical aesthetics, especially among male dermatologists, dermatologists with less working experience, and those who work at public institutions.
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Affiliation(s)
- Jing Fan
- Clinical Research Center, Shanghai Skin Diseases Hospital, School of Medicine, Tongji University, Shanghai, People’s Republic of China
- Bloomberg School of Public Health, University of Johns Hopkins, Baltimore, MD, USA
| | - Shiyuan Li
- School of Public Health, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Yan Qiang
- Clinical Research Center, Shanghai Skin Diseases Hospital, School of Medicine, Tongji University, Shanghai, People’s Republic of China
| | - Zhen Duan
- School of Public Health, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Albert Wu
- Bloomberg School of Public Health, University of Johns Hopkins, Baltimore, MD, USA
| | - Ruiping Wang
- Clinical Research Center, Shanghai Skin Diseases Hospital, School of Medicine, Tongji University, Shanghai, People’s Republic of China
- Bloomberg School of Public Health, University of Johns Hopkins, Baltimore, MD, USA
- School of Public Health, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
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Bossen JKJ, Wesselink JA, Heyligers IC, Jansen J. Implementation of a Decision Aid for Hip and Knee Osteoarthritis in Orthopedics: A Mixed-Methods Process Evaluation. Med Decis Making 2024; 44:112-122. [PMID: 37902570 PMCID: PMC10714711 DOI: 10.1177/0272989x231205858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 09/19/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND In orthopedics, the use of patient decision aids (ptDAs) is limited. With a mixed-method process evaluation, we investigated patient factors associated with accepting versus declining the use of the ptDA, patients' reasons for declining the ptDA, and clinicians' perceived barriers and facilitators for its use. METHODS Patients with an indication for joint replacement surgery (N = 153) completed questionnaires measuring demographics, physical functioning, quality of life (EQ-5D-3L), and a visual analog scale (VAS) pain score at 1 time point. Subsequently, their clinician offered them the relevant ptDA. Using a retrospective design, we compared patients who used the ptDA (59%) with patients who declined (41%) on all these measures as well as the chosen treatment. If the use of the ptDA was declined, patients' reasons were recorded by their clinician and analysed (n = 46). To evaluate the experiences of clinicians (n = 5), semistructured interviews were conducted and thematically analyzed. Clinicians who did not use the ptDA substantially (<10 times) were also interviewed (n = 3). RESULTS Compared with patients who used the ptDA, patients who declined use had higher VAS pain scores (7.2 v. 6.2, P < .001), reported significantly worse quality of life (on 4 of 6 EQ-5D-3L subscales), and were less likely to receive nonsurgical treatment (4% v. 28%, P < .001). Of the patients who declined to use the ptDA, 46% said they had enough information and felt ready to make a decision without the ptDA. The interviews revealed that clinicians considered the ptDAs most useful for newly diagnosed patients who had not received previous treatment. CONCLUSION These results suggest that the uptake of a ptDA may be improved if it is introduced in the early disease stages of hip and knee osteoarthritis. HIGHLIGHTS Patients who declined the use of a patient decision aid (ptDA) for hip and knee osteoarthritis reported more pain and worse quality of life.Most patients who declined to use a ptDA felt sufficiently well informed to make a treatment decision.Patients who declined the ptDA were more likely to have received prior treatment in primary care.Clinicians found the ptDA to be a helpful addition to the consultation, particularly for newly diagnosed patients.
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Affiliation(s)
- Jeroen Klaas Jacobus Bossen
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen/Geleen, the Netherlands
- Orthopedic Department of University Hospitals Leuven, Leuven, Belgium
| | - Julia Aline Wesselink
- School for Public Health and Primary Care CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Ide Christiaan Heyligers
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen/Geleen, the Netherlands
| | - Jesse Jansen
- School for Public Health and Primary Care CAPHRI, Maastricht University, Maastricht, the Netherlands
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Burstein DS, Chretien KC, Puchalski C, Teufel K, Aivaz M, Kaboff A, Tuck MG. Internal Medicine Residents' Experience Performing Routine Assessment of What Matters Most to Patients Upon Hospital Admission. TEACHING AND LEARNING IN MEDICINE 2023; 35:83-94. [PMID: 35067146 DOI: 10.1080/10401334.2021.2018696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 11/24/2021] [Indexed: 06/14/2023]
Abstract
PROBLEM Failure to elicit patients' values, goals, and priorities can result in missed opportunities to provide patient-centered care. Little is known about resident physicians' direct experience of eliciting patients' values, goals, and priorities and integrating them into routine hospital care. INTERVENTION In 2017, we asked resident physicians on general internal medicine wards rotations to elicit and document a "Personal History" from patients upon hospital admission, in addition to a traditional social history. We defined a Personal History as documenting "what matters most to the patient and why." The purpose of the Personal History was to understand and consider patients' values, goals, and priorities. We then conducted qualitative interviews of the resident physicians to understand their experiences eliciting and integrating patients' values, goals, and priorities in routine hospital care. CONTEXT We performed this exploratory intervention at a large high-volume urban hospital. Two teams from general medicine wards participated in the Personal History intervention. We conducted voluntary interviews of eligible residents (n = 14/15; 93%) about their experience after they completed their general wards rotations. Using the coproduction model, our aim was to explore how patients' self-expertise can be combined with physicians' medical expertise to achieve patient-centered care. IMPACT Four major themes were identified: 1) Taking a Personal History had value, and eliciting patients' self-expertise had the potential to change medical decision making, 2) Situational and relational factors created barriers to obtaining a Personal History, 3) Variability in buy-in with the proposed intervention affected effort, and 4) Meaningful Personal History taking could be an adaptive and longitudinal process. Perceived benefits included improved rapport with patients, helpful for patients with complex medical history, and improved physician-patient communication. Barriers included patient distress, lack of rapport, and responses from patients which did not add new insights. Accountability from attending physicians affected resident effort. Suggested future applications were for patients with serious illness, integration into electronic health records, and skills taught in medical education. LESSONS LEARNED Resident physicians had generally positive views of eliciting a Personal History from patients upon admission to the hospital. Overall, many residents conveyed the perceived ability to elicit and consider patient's values, goals, and priorities in certain situations (e.g., patient not in distress, adequate rapport, lack of competing priorities such as medical emergencies or overwhelming workloads). External factors, such as electronic health record design and accountability from attending physicians, may further promote residents' efforts to routinely incorporate patients' values, goals, and priorities in clinical care. Increasing familiarity among both resident physicians and patients in routinely discussing patients' values, goals, and priorities may facilitate patient-centered practice.
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Affiliation(s)
- David S Burstein
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Katherine C Chretien
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christina Puchalski
- Department of Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Karolyn Teufel
- Department of Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Marudeen Aivaz
- General Surgery, Northwell Health, New York, New York, USA
| | - Austin Kaboff
- Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Matthew G Tuck
- Department of Medicine, The George Washington University School of Medicine and Health Sciences, Veterans Affairs Medical Center, Washington, DC, USA
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Grevnerts HT, Krevers B, Kvist J. Treatment decision-making process after an anterior cruciate ligament injury: patients', orthopaedic surgeons' and physiotherapists' perspectives. BMC Musculoskelet Disord 2022; 23:782. [PMID: 35974318 PMCID: PMC9380364 DOI: 10.1186/s12891-022-05745-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
Objective To investigate the treatment decision-making process after an anterior cruciate ligament (ACL) injury from patients’, orthopaedic surgeons’ and physiotherapists’ perspectives. Methods The study is a part of the NACOX study, which is designed to describe the natural corollaries after ACL injury. For the present study, a subgroup 101 patients were included. Patients, their orthopaedic surgeons and their physiotherapists, answered a Shared Decision-Making Process (SDMP) questionnaire, when treatment decision for ACL reconstruction surgery (ACLR) or non-reconstruction (non-ACLR) was taken. The SDMP questionnaire covers four topics: “ informed patient”, “ to be heard”, “ involvement” and “ agreement”. Results Most (75–98%) patients considered their needs met in terms of being heard and agreement with the treatment decision. However, fewer in the non-ACLR group compared to the ACLR group reported satisfaction with information from the orthopaedic surgeon (67% and 79%), or for their own involvement in the treatment decision process (67% and 97%). Conclusion and practice implications Most patients and caregivers considered that patients’ needs to be informed, heard and involved, and to agree with the decision about the treatment process, were fulfilled to a high extent. However, patients where a non-ACLR decision was taken experienced being involved in the treatment decision to a lower extent. This implies that the non-ACLR treatment decision process needs further clarification, especially from the patient involvement perspective.
Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05745-4.
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Affiliation(s)
- Hanna Tigerstrand Grevnerts
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden. .,Division of Physiotherapy, Department of Activity and Health, Linköping University, Linkoping, Sweden.
| | - Barbro Krevers
- Department of Health, Medicine and Caring Sciences, Unit of Health Care Analysis and National Centre for Priorities in Health, Linköping University, Linkoping, Sweden
| | - Joanna Kvist
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden.,Stockholm Sports Trauma Research Center, Dept of Molecular Medicine & Surgery, Karolinska Institute, Stockholm, Sweden
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Bossen JKJ, Jansen J, van der Weijden T, Heyligers IC. Disappointing evaluation of a shared decision-making intervention for residents and orthopaedic surgeons. PATIENT EDUCATION AND COUNSELING 2022; 105:1066-1074. [PMID: 34654592 DOI: 10.1016/j.pec.2021.09.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/01/2021] [Accepted: 09/27/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate a shared decision-making (SDM) intervention in orthopaedic hip and knee osteoarthritis care. METHODS Using a pre- post intervention design study, we tested an intervention, that included a decision aid for patients (ptDA) and a SDM training course for residents in training and orthopaedic surgeons. The theory of planned behaviour was used for intervention development. Primary outcomes included patient reported decisional conflict, SDM, and satisfaction. Secondary outcomes were physicians' attitude and knowledge, and uptake of the ptDA. RESULTS 317 patients were included. The intervention improved physicians' knowledge about SDM but had no effect on the primary outcomes. 19 eligible patients used the ptDA (17%). SDM was higher for middle educated patients compared to lower educated (mean difference 9.91, p=0.004), patients who saw surgeons instead of residents (mean difference 5.46, p=0.044) and when surgery was chosen and desired by patients compared to situations where surgery was desired but not chosen (mean difference 15.39, p=0.036). CONCLUSION Our multifaceted intervention did not improve SDM and ptDA uptake was low. PRACTICE IMPLICATIONS In orthopaedic hip and knee osteoarthritic care other ways should be explored to successful implement SDM. Since residents received lower SDM scores, special focus should go to this group.
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Affiliation(s)
- Jeroen K J Bossen
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands; Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen/Geleen , the Netherlands.
| | - Jesse Jansen
- School for Public Health and Primary Care CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Trudy van der Weijden
- School for Public Health and Primary Care CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Ide C Heyligers
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands; Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen/Geleen , the Netherlands
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Driever EM, Tolhuizen IM, Duvivier RJ, Stiggelbout AM, Brand PLP. Why do medical residents prefer paternalistic decision making? An interview study. BMC MEDICAL EDUCATION 2022; 22:155. [PMID: 35260146 PMCID: PMC8903731 DOI: 10.1186/s12909-022-03203-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 01/19/2022] [Indexed: 05/19/2023]
Abstract
BACKGROUND Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice remains limited. We previously showed that residents more often prefer paternalistic decision making than their supervisors. Because both the views of residents on the decision-making process in medical consultations and the reasons for their 'paternalism preference' are unknown, this study explored residents' views on the decision-making process in medical encounters and the factors affecting it. METHODS We interviewed 12 residents from various specialties at a large Dutch teaching hospital in 2019-2020, exploring how they involved patients in decisions. All participating residents provided written informed consent. Data analysis occurred concurrently with data collection in an iterative process informing adaptations to the interview topic guide when deemed necessary. Constant comparative analysis was used to develop themes. We ceased data collection when information sufficiency was achieved. RESULTS Participants described how active engagement of patients in discussing options and decision making was influenced by contextual factors (patient characteristics, logistical factors such as available time, and supervisors' recommendations) and by limitations in their medical and shared decision-making knowledge. The residents' decision-making behavior appeared strongly affected by their conviction that they are responsible for arriving at the correct diagnosis and providing the best evidence-based treatment. They described shared decision making as the process of patients consenting with physician-recommended treatment or patients choosing their preferred option when no best evidence-based option was available. CONCLUSIONS Residents' decision making appears to be affected by contextual factors, their medical knowledge, their knowledge about SDM, and by their beliefs and convictions about their professional responsibilities as a doctor, ensuring that patients receive the best possible evidence-based treatment. They confuse SDM with acquiring informed consent with the physician's treatment recommendations and with letting patients decide which treatment they prefer in case no evidence based guideline recommendation is available. Teaching SDM to residents should not only include skills training, but also target residents' perceptions and convictions regarding their role in the decision-making process in consultations.
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Affiliation(s)
- Ellen M Driever
- Department of Innovation and Research, Isala Hospital, Dokter van Heesweg 2, 8025, AB, Zwolle, the Netherlands.
- Lifelong Learning Education and Assessment Research Network (LEARN), University Medical Centre Groningen, Groningen, the Netherlands.
| | - Ivo M Tolhuizen
- Faculty of Medical Science, University Medical Centre of Groningen, Groningen, the Netherlands
| | - Robbert J Duvivier
- Centre for Education Development and Research in Health Professions (CEDAR), University Medical Centre Groningen, Groningen, the Netherlands
- Parnassia Psychiatric Institute, The Hague, the Netherlands
| | - Anne M Stiggelbout
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Paul L P Brand
- Lifelong Learning Education and Assessment Research Network (LEARN), University Medical Centre Groningen, Groningen, the Netherlands
- Department of Medical Education and Faculty Development, Isala Hospital, Zwolle, the Netherlands
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Berkowitz J, Martinez-Camblor P, Stevens G, Elwyn G. The development of incorpoRATE: A measure of physicians' willingness to incorporate shared decision making into practice. PATIENT EDUCATION AND COUNSELING 2021; 104:2327-2337. [PMID: 33744056 DOI: 10.1016/j.pec.2021.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To develop 'incorpoRATE', a brief and broadly applicable measure of physicians' willingness to incorporate shared decision making (SDM) into practice. METHODS incorpoRATE was developed across three phases: 1) A review of relevant literature to inform candidate domain and item development, 2) Cognitive interviews with US physicians to iteratively refine the measure, and 3) Pilot testing of the measure across a larger sample of US physicians to explore item and measure performance. RESULTS The final measure consists of seven items that assess physician perspectives on various components of SDM use that may present as barriers in practice. During pilot testing, the majority of physicians expressed positive opinions about the overall concept of SDM, yet were less comfortable acting on informed patient choices when there was known incongruence with their own recommendations. CONCLUSIONS incorpoRATE is a novel physician-reported measure that assesses physicians' willingness to incorporate SDM in practice. PRACTICE IMPLICATIONS incorpoRATE has the potential to help us further understand the limited adoption of SDM and areas of focus for improving the use of SDM in the future. We recommend that incorpoRATE be subject to further psychometric, real-world testing, in order to explore its performance across different samples of physicians and organizations.
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Affiliation(s)
- Julia Berkowitz
- The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Pablo Martinez-Camblor
- The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Gabrielle Stevens
- The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, 1 Medical Center Drive, Lebanon, NH 03756, USA.
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Bossen JKJ, van der Weijden T, Driessen EW, Heyligers IC. Experienced barriers in shared decision-making behaviour of orthopaedic surgery residents compared with orthopaedic surgeons. Musculoskeletal Care 2019; 17:198-205. [PMID: 30811094 PMCID: PMC6850155 DOI: 10.1002/msc.1390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/09/2019] [Accepted: 01/12/2019] [Indexed: 01/22/2023]
Abstract
INTRODUCTION In shared decision-making (SDM), physicians encourage the patient to participate in the care process. The theory of planned behaviour describes that behaviour is dependent on intention. In its turn, intention is explained by attitude, subjective norm and perceived behavioural control. In orthopaedics, little is known about current SDM behaviour and how to promote it.The aim of the present study was to gain insight into the SDM behaviour of orthopaedic residents and supervisors by measuring levels of intention, attitudes, subjective norms and perceived behavioural control. Furthermore, we aimed to determine the predictors of intention for SDM. METHODS A questionnaire survey study was conducted among orthopaedic surgeons and residents working in the care of hip and knee osteoarthritis, to determine their intentions, attitudes, subjective norms and perceived behavioural control regarding SDM. RESULTS Of the 385 physicians approached, 71 residents and 64 orthopaedic surgeons participated. Residents and the supervisors alike had positive intentions regarding SDM. Intention for SDM behaviour was explained by attitude, subjective norm and perceived behavioural control, with perceived behavioural control having the strongest association. In residents, the intention to engage in SDM was more hampered by a lower level of perceived behavioural control than in surgeons. CONCLUSIONS Physicians are willing to perform SDM and consider SDM as favourable in the orthopaedic clinic. The implementation of SDM is mainly hampered by experienced barriers that they cannot control. These findings underline the importance of incorporating SDM in the curriculum of postgraduates. Possibilities for efficient SDM implementation should be explored, to overcome perceived barriers.
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Affiliation(s)
- Jeroen K J Bossen
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands.,Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - Trudy van der Weijden
- Department of Family Medicine, School CAPHRI, Care and Public Health Research Institute, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Erik W Driessen
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
| | - Ide C Heyligers
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands.,Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen, the Netherlands
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