Child participation during outpatient consultations: a mixed methods study

Although children wish to be included in their own healthcare, they recognize a gap between their right to be heard and their ability to become involved. Despite adaptation of medical consultation styles which suit a more patient-centered approach, data on the current state of child participation in clinical encounters are missing. We aimed to assess actual child participation in a Dutch pediatric clinic. Children aged 4-18 years visiting a pediatric outpatient clinic for consultation after general practitioner's referral were included. Sixteen consultations of six pediatricians were recorded and transcribed verbatim. Quantitative measurement included word count and speech turn; conversation analysis with qualitative appraisal provided data on participatory behavior. Quantitative child participation equaled parent participation in turns (28% vs 29%, respectively), but remained limited in words (relative contribution 11% for child, 23% for parent and 66% for pediatrician). Children spoke on average six words per speech turn. Child age correlated positively with participation in words (p = 0.022, r = 0.566) and turns (p =  < 0.001, r = 0.746). Children were mostly involved during social history taking, introduction, and physical examination but did not actively speak during the decision-making process. Children took an active role by instigating talks. Qualitative facilitators included appropriate language and verbal or non-verbal child allocated turns. Adults involved children by asking them questions and verifying their opinions or plans with the child. Teenagers participated most during the entire consultation, while younger children were more likely to lose their focus by the end of the conversation.

CONCLUSION

Despite increased turn taking, children's verbal participation remains low in pediatric consultations. If pediatricians and parents maintain a triadic conversation style throughout every stage of the medical encounter, child participation may increase.

WHAT IS KNOWN

• Verbal child participation varies between 4 and 17%, measured in turns, words, speech time, or utterances. • Child participation is limited to social talk, laughter, and providing medical information.

WHAT IS NEW

• Child speech turns equal parental speech turns (28%), but average relative word count remains low (11%). • Three percent of the children's turns are defined a "contributing in decision making, giving their opinion or give consent," which equals three turns per consultation.

Simulation-based bronchoscopy training: Randomized trial comparing worked example to video introduction

INTRODUCTION

Learning the complex skill of bronchoscopy involves the integration of cognitive domains and motor skills. The development of simulators has opened up new possibilities in bronchoscopy training. This study aimed at evaluating how effective the modeling example methodology is in training this skill and assessed its effect on cognitive load in learning.

METHODS

Forty-seven medical students participating in a simulator-based bronchoscopy training program were randomly allocated to a control group, receiving a video lesson, and the modeling example group. They were evaluated by the simulator's metrics at different time points: pre-, posttest, and 15 days and 12 months after training. Cognitive load was assessed with the modified Paas scale.

RESULTS

Simulation-based training was effective for both groups, based on simulator metrics (p < .05). The modeling example group outperformed the control group in all measures at posttest and after 15 days (p < .001). After 12 months, there was a decline in skill in both groups, but the modeling example group performed better (p < .001). Simulation-based training reduced cognitive load, more strongly so in the modeling example group (p < .001).

CONCLUSION

The modeling example group showed substantial benefits over the control group, both in reducing the cognitive load in learning and in retaining knowledge and skill after 15 days and 12 months.

Observational study on the timing and method of interruption by hospital consultants during the opening statement in outpatient consultations

OBJECTIVE

To analyse verbal interruptions by Dutch hospital consultants during the patient's opening statement in medical encounters.

DESIGN

Cross-sectional descriptive study.

SETTING

Isala teaching hospital in Zwolle, the Netherlands.

PARTICIPANTS

94 consultations by 27 consultants, video recorded in 2018 and 2019.

MAIN OUTCOME MEASURES

Physicians' verbal interruptions during patients' opening statements, rate of completion of patients' opening statements, time to first interruption and the effect of gender, age and physician specialty on the rate and type of physicians' verbal interruptions.

RESULTS

Patients were interrupted a median of 9 times per minute during their opening statement, the median time to the first interruption was 6.5 s. Most interruptions (67%) were backchannels (such as 'hm hm' or 'go on'), considered to be encouraging the patient to continue. In 52 consultations (55%), patients could not finish their opening statement due to a floor changing interruption by the consultant. The median time to such an interruption was 31.4 s, on average 20 s shorter than a finished opening statement (p=0.004). Female consultants used more backchannels (median 9, IQR 5-12) than male consultants (median 7, IQR 2-11, p=0.028).

CONCLUSIONS

Hospital-based consultants use various ways to interrupt patients during their opening statements. Most of these interruptions are encouraging backchannels. Still, consultants change the conversational floor in more than half of their patients during their opening statements after a median of 31 s.

Child participation in triadic medical consultations: A scoping review and summary of promotive interventions

OBJECTIVES

To promote patient centered care, children with health issues should be supported to participate in consultations with health care professionals. We aimed to summarize, in a scoping review, the evidence on child participation in triadic encounters and its promotive interventions.

METHODS

Two researchers systematically searched four major databases, and included studies on child participation in medical consultations. A synthesis of quantitative and qualitative data was made.

RESULTS

Of 1678 retrieved records, 39 papers were included: 22 quantitative, 14 qualitative and 3 mixed-methods studies. Child participation, measured by utterances, turns or speech time, ranged between 4% and 14%. Participation increased with age. Equidistant seating arrangements, child-directed gaze and finding the appropriate tone of voice by the physician promoted child participation. Despite all facilitative efforts of doctors and parents, such as social talk, eHealth tools or consultation education, no increase in child participation was observed over the last 50 years.

CONCLUSIONS

Children continue to participate only marginally in medical consultations, despite their desire to be involved in various aspects of the clinical encounter and their right to have their voice heard.

PRACTICE IMPLICATIONS

Health care professionals should provide more opportunities for children to participate in triadic medical encounters and create an inclusive environment.

A framework to improve quality of hospital-based physiotherapy: a design-based research study

BACKGROUND

A quality framework for hospital-based physiotherapy is lacking. This study aims to design a framework, building on the currently available literature, to improve the quality of hospital-based physiotherapy.

METHODS

A multidisciplinary panel of six representatives of hospital-based physiotherapy and their key stakeholders (patients, medical specialists, hospital management and professional association) was set up. We used brainwriting to sample ideas and the 'decision-matrix' to select the best ideas.

RESULTS

The first round of brainwriting with an online panel of six experienced participants yielded consensus on seven possible methods for quality improvement of hospital-based physiotherapy [1]: continuing education [2] ,feedback on patient reported experience measures and patient reported outcome measures [3] ,a quality portfolio [4] ,peer observation and feedback [5] ,360 degree feedback [6] ,a management information system, and [7] intervision with intercollegiate evaluation. Placing these methods in a decision matrix against four criteria (measurability, acceptability, impact, accessibility) resulted in a slight preference for a management information system, with almost equal preference for five other methods immediately thereafter. The least preference was given to a 360-degree feedback.

CONCLUSIONS

In the design of a framework for improving the quality of hospital-based physiotherapy, all seven suggested methods were perceived as relevant but differed in terms of advantages and disadvantages. This suggests that, within the framework, a mixture of these methods may be desirable to even out respective advantages and disadvantages.

Shared Decision-making in Different Types of Decisions in Medical Specialist Consultations

BACKGROUNDS

Research on shared decision-making (SDM) has mainly focused on decisions about treatment (e.g., medication or surgical procedures). Little is known about the decision-making process for the numerous other decisions in consultations.

OBJECTIVES

We assessed to what extent patients are actively involved in different decision types in medical specialist consultations and to what extent this was affected by medical specialist, patient, and consultation characteristics.

DESIGN

Analysis of video-recorded encounters between medical specialists and patients at a large teaching hospital in the Netherlands.

PARTICIPANTS

Forty-one medical specialists (28 male) from 18 specialties, and 781 patients.

MAIN MEASURE

Two independent raters classified decisions in the consultations in decision type (main or other) and decision category (diagnostic tests, treatment, follow-up, or other advice) and assessed the decision-making behavior for each decision using the Observing Patient Involvement (OPTION)5 instrument, ranging from 0 (no SDM) to 100 (optimal SDM). Scheduled and realized consultation duration were recorded.

KEY RESULT

In the 727 consultations, the mean (SD) OPTION5 score for the main decision was higher (16.8 (17.1)) than that for the other decisions (5.4 (9.0), p < 0.001). The main decision OPTION5 scores for treatment decisions (n = 535, 19.2 (17.3)) were higher than those for decisions about diagnostic tests (n = 108, 14.6 (16.8)) or follow-up (n = 84, 3.8 (8.1), p < 0.001). This difference remained significant in multilevel analyses. Longer consultation duration was the only other factor significantly associated with higher OPTION5 scores (p < 0.001).

CONCLUSION

Most of the limited patient involvement was observed in main decisions (versus others) and in treatment decisions (versus diagnostic, follow-up, and advice). SDM was associated with longer consultations. Physicians' SDM training should help clinicians to tailor promotion of patient involvement in different types of decisions. Physicians and policy makers should allow sufficient consultation time to support the application of SDM in clinical practice.

Patients' preferred and perceived decision-making roles, and observed patient involvement in videotaped encounters with medical specialists

OBJECTIVE

To assess how patients prefer and perceive medical decision making, which factors are associated with their preferred and perceived decision-making roles, and whether observed involvement reflects patients' perceived role.

METHODS

We asked 781 patients visiting a medical specialist from 18 different disciplines to indicate their preferred and perceived decision-making roles. Patient involvement in videotaped consultations was assessed with the OPTION5 instrument.

RESULTS

Most patients preferred and perceived decision making as shared (SDM; 58% and 43%, respectively), followed by paternalistic (26% and 38%), and informative (16% and 15%). A large minority (n = 103, 21%) of patients preferring shared or informative decision making (n = 482) experienced paternalistic decision making. Mean (SD) OPTION5 scores were highest in consultations which patients perceived as informative (26.0 (19.7)), followed by shared (19.1 (17.2)) and lowest in paternalistic decision making (11.8 (13.4) p < 0.001).

CONCLUSIONS

Most patients want to be involved in decision making. Patients perceive that the physician makes the decision more often than they prefer, and perceive more involvement in the decision than objective assessment by an independent researcher shows.

PRACTICE IMPLICATIONS

A clearer understanding of patients' medical decision-making experiences is needed to optimize physician SDM training programmes and patient awareness campaigns.

Shared decision making, patient-centered communication and patient satisfaction - A cross-sectional analysis

OBJECTIVES

The integration of shared decision making (SDM) and patient-centered communication (PCC) is needed to actively involve patients in decision making. This study examined the relationship between shared decision making and patient-centered communication.

METHODS

In 82 videotaped hospital outpatient consultations by 41 medical specialists from 18 disciplines, we assessed the extent of shared decision making by the OPTION⁵ score and patient-centered communication by the Four Habits Coding Scheme (4HCS), and analyzed the occurrence of a high versus low degree (above or below median) of SDM and/or PCC, and its relation to patient satisfaction scores.

RESULTS

In comparison to earlier studies, we observed comparable 4HCS scores and relatively low OPTION⁵ scores. The correlation between the two was weak (r = 0.29, p = 0.009). In 38% of consultations, we observed a combination of high SDM and low PCC scores or vice versa. The combination of a high SDM and high PCC, which was observed in 23% of consultations, was associated with significantly higher patient satisfaction scores.

CONCLUSION

Shared decision making and patient-centered communication are not synonymous and do not always co-exist.

PRACTICE IMPLICATIONS

The value of integrated training of shared decision making and patient-centered communication should be further explored.

[Feedback in medical education - separate coaching for improvement from summative assessment]

A supervisor's feedback can change a medical learner's behaviour consistently if the learner views the supervisor as a credible role model. A learner's trust in the supervisor is a prerequisite for feedback to contribute to effective learning. In current educational practice, coaching for improvement and summative assessment are frequently mixed, which leads medical learners to experience workplace based assessments as tests and makes them unresponsive to formative feedback. Carefully separating coaching for improvement from summative assessment is required to allow the learner to accept and apply the feedback given by the supervisor. Supervisors should focus their attention to providing formative feedback, not to documenting it. The R2C2 model (rapport - receptivity - content - coaching) is a useful tool to effectively provide constructive formative feedback.

Shared decision-making in the Netherlands: Progress is made, but not for all. Time to become inclusive to patients

Dutch initiatives targeting shared decision-making (SDM) are still growing, supported by the government, the Federation of Patients' Organisations, professional bodies and healthcare insurers. The large majority of patients prefers the SDM model. The Dutch are working hard to realise improvement in the application of SDM in daily clinical practice, resulting in glimpses of success with objectified improvement on observed behavior. Nevertheless, the culture shift is still ongoing. Large-scale uptake of SDM behavior is still a challenge. We haven't yet fully reached the patients' needs, given disappointing research data on patients' experiences and professional behavior. In all Dutch implementation projects, early adopters, believers or higher-educated persons have been overrepresented, while patients with limited health literacy have been underrepresented. This is a huge problem as 25% of the Dutch adult population have limited health literacy. To further enhance SDM there are issues to be addressed: We need to make physicians conscious about their limited application of SDM in daily practice, especially regarding preference and decision talk. We need to reward clinicians for the extra work that comes with SDM. We need to be inclusive to patients with limited health literacy, who are less often actually involved in decision-making and at the same time more likely to regret their chosen treatment compared to patients with higher health literacy.

Hypoallergenicity assessment of an extensively hydrolyzed whey-protein formula in cow's milk allergic infants

BACKGROUND

Extensively hydrolyzed formulas are recommended for the dietary management of infants with cow's milk allergy (CMA).

OBJECTIVES

Hypoallergenicity, growth, and gastrointestinal (GI) tolerability of a new extensively hydrolyzed whey-protein formula (eHWF) in CMA children were assessed.

METHODS

In this prospective, randomized, international, multi-center study (Trial NL3889), 34 children with confirmed CMA (74% IgE-mediated) underwent a double-blind, placebo-controlled food challenge (DBPCFC) with an eHWF developed with non-porcine enzymes, supplemented with prebiotic short-chain galacto- and long-chain fructo-oligosaccharides (0.8 g/L, ratio 9:1), arachidonic acid (0.35/100 g), and docosahexaenoic acid (0.35/100 g). If tolerant to the eHWF, children participated in a 7-day open food challenge with this eHWF. Anthropometrics and GI tolerability were assessed in an optional 16-weeks follow-up.

RESULTS

Of the 34 children who started the DBPCFC with the eHWF, 25 subjects (19 boys, mean age: 61 weeks, 18 with IgE-mediated CMA) completed the DBPCFC and 7-day open challenge without major protocol deviations and tested negative at both challenges. One child experienced a late moderate eczematous allergic reaction in the optional follow-up period, indicating the need for close monitoring of subjects starting new formula. Weight and length gain followed the World Health Organization growth curves. Changes in frequency and consistency of stools upon test formula intake were transient.

CONCLUSIONS

The newly developed eHWF is a suitable option in CMA treatment as all subjects tolerated the product. This result is in line with the international criteria for hypoallergenicity (American Academy of Pediatrics) that state that more than 90% of CMA children must tolerate the formula. Use of the formula is also associated with normal growth curves and GI tolerability.

TRIAL REGISTRATION

Trial NL3889, https://www.trialregister.nl/trial/3889.

Why are children with asthma bullied? A risk factor analysis

The links between bullying and asthma have not been explored in children. We wanted to determine the child/parent factors and attitudes associated with asthma-related bullying. Individual child/parent responses of children with asthma (N=943) from the Room to Breathe survey were analysed. 1 in 10 children reported asthma-related bullying/teasing (n=93). Children with well-controlled asthma were less likely to report being a victim of asthma-related bullying/teasing (OR 0.51, 95% CI 0.23 to 0.84, p=0.006). Being a victim of bullying/teasing was more common in children reporting activity restriction (OR 1.74, 95% CI 1.11 to 2.75, p=0.010), who described their asthma as 'bad' (OR 3.02, 95% CI 1.86 to 4.85, p<0.001) and those whose parents reported ongoing asthma-related health worries (OR 1.64, 95% CI 1.04 to 2.58, p=0.024). Asthma consultations should incorporate specific questions about bullying and be child-focused in order to gain a representative appreciation of asthma control and its impact on the child's life.

Why do medical residents prefer paternalistic decision making? An interview study

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.

[Development and validation of a uniform QUality Instrument for ClerKship (QUICK)]

OBJECTIVE

Because both clerks and medical faculty quality management workers expressed the need for it, we aimed to develop a compact, valid and uniform instrument to assess the quality of Dutch clinical clerkships across all medical faculties in the Netherlands.

METHOD

We divided all 249 items from existing published and unpublished clerkship quality instruments into the three essential learning environment domains: content, atmosphere and organisation. In a 3-stage Delphi procedure, the 45 most relevant items from this list were selected that comprehensively covered the three domains. All clinical clerks in the country's northeastern educational region were invited to evaluate their last clerkship using this draft instrument. We used half of these data for item reduction and the other half to validate the final instrument, the QUality Instrument for ClerKships (QUICK).

RESULTS

After the Delphi procedure and further item reduction, the QUICK comprises 15 items, 5 in each domain. The internal consistency of the QUICK and each of the three domains was satisfactory (Cronbach's α 0.88, 0.73, 0.84 and 0.67, respectively). The variance of the draft instrument domain scores were explained for >80% by item variance of the final QUICK. A panel of educational experts and medical faculty quality management workers evaluated QUICK's face validity as good.

CONCLUSION

The QUICK is a concise and valid instrument to assess the quality of Dutch clinical clerkships. Its repeated use in a quality cycle can contribute to monitoring and ongoing development of the quality of this key phase in the medical education curriculum.

[Observing a resident doing a consultation with a patient: goal determines form]

Observation of residents by supervisors is a highly recommended, but underused educational tool in postgraduate medical education. Observation can be performed indirectly (using video recordings of residents performing clinical tasks) or directly (supervisor is present when the resident performs the task). The choice of the observation method depends on aim and context of the observation. In general practice, patients tend to involve the supervisor when the resident performs the consultation. They value such participatory direct observation because they know the supervisor and appreciate their input. For specific residents' learning aims (e.g. consultation efficiency), it may be more useful if the supervisor takes a "fly on the wall" approach. Supervisors wishing to take a "fly on the wall" approach to direct observation need to inform the patient about their role and position themselves outside the patient's field of view. Indirect observation by reviewing video-recorded consultations is an alternative for this purpose.

Do consultants do what they say they do? Observational study of the extent to which clinicians involve their patients in the decision-making process

OBJECTIVES

To assess whether consultants do what they say they do in reaching decisions with their patients.

DESIGN

Cross-sectional analysis of hospital outpatient encounters, comparing consultants' self-reported usual decision-making style to their actual observed decision-making behaviour in video-recorded encounters.

SETTING

Large secondary care teaching hospital in the Netherlands.

PARTICIPANTS

41 consultants from 18 disciplines and 781 patients.

PRIMARY AND SECONDARY OUTCOME MEASURE

With the Control Preference Scale, the self-reported usual decision-making style was assessed (paternalistic, informative or shared decision making). Two independent raters assessed decision-making behaviour for each decision using the Observing Patient Involvement (OPTION)⁵ instrument ranging from 0 (no shared decision making (SDM)) to 100 (optimal SDM).

RESULTS

Consultants reported their usual decision-making style as informative (n=11), shared (n=16) and paternalistic (n=14). Overall, patient involvement was low, with mean (SD) OPTION⁵ scores of 16.8 (17.1). In an unadjusted multilevel analysis, the reported usual decision-making style was not related to the OPTION⁵ score (p>0.156). After adjusting for patient, consultant and consultation characteristics, higher OPTION⁵ scores were only significantly related to the category of decisions (treatment vs the other categories) and to longer consultation duration (p<0.001).

CONCLUSIONS

The limited patient involvement that we observed was not associated with the consultants' self-reported usual decision-making style. Consultants appear to be unconsciously incompetent in shared decision making. This can hinder the transfer of this crucial communication skill to students and junior doctors.

The application of the tracer method with peer observation and formative feedback for professional development in clinical practice: a scoping review

INTRODUCTION

The tracer method, commonly used for quality assessment, can also be used as a tool for peer observation and formative feedback on professional development. This scoping review describes how, by whom, and with what effect the tracer method is applied as a formative professional development instrument between healthcare professionals of equal status and aims to identify the types of scientific evidence for this use of the tracer method.

METHODS

The authors searched four electronic databases for eligible articles, which were screened and assessed for eligibility by two independent researchers. From eligible studies, data were extracted to summarize, collate, and make a narrative account of the findings.

RESULTS

The electronic search yielded 1757 unique studies, eight of which were included as valid and relevant to our aim: five qualitative, two mixed methods, and one quantitative study. Seven studies took place in hospitals and one in general practice. The tracer method was used mainly as a form of peer observation and formative feedback. Most studies evaluated the tracer method's feasibility and its impact on professional development. All but one study reported positive effects: participants described the tracer method generally as being valuable and worth continuing.

DISCUSSION

Although the body of evidence is small and largely limited to the hospital setting, using the tracer method for peer observation and formative feedback between healthcare professionals of equal status appears sufficiently useful to merit further rigorous evaluation and implementation in continuous professional development in healthcare.

The physiology of learning: strategies clinical teachers can adopt to facilitate learning

Almost all pediatricians working in a hospital or office environment have teaching responsibilities to learners such as medical students and residents. Although teaching and supporting learning in a busy work environment imposes challenges to clinical teachers, these clinical settings provide an ideal setup for experiential learning, learning from daily experiences with patients. Advances in the science of learning derived from various fields have informed us how adults learn best. Many techniques and strategies based on this "physiology of learning" have shown their educational values in everyday pediatric practice. This article outlines how clinical teachers can create the conditions to optimize experiential learning for individual or a group of learners. We highlight practical implications of educational theories and evidence-based educational practices for clinical teachers seeking to enhance their teaching effectiveness. These include promoting active learning and engaging learners in deliberate practice; retrieval of knowledge and prior experiences to enhance motivation; supporting a psychologically safe learning environment; helping learners to set goals; fostering collaborative learning; structuring teaching to link it to authentic roles and tasks; and customizing content to individual learners.Conclusion: Applying adult learning principles in everyday teaching activities will support busy pediatricians to be successful in their tasks as clinical teachers, and contribute to work satisfaction. What is Known: • Most pediatricians provide clinical teaching to medical students and residents, but few have had formal training in educational techniques. • Learning from clinical experiences (experiential learning) is of key importance to becoming and maintaining a competent pediatrician. What is New: • This review presents an up-to-date overview of the physiology of learning, i.e., how people learn. • Knowledge of the principles of how people learn helps pediatricians shape their clinical teaching effectively and contribute to their work satisfaction.

Patient coaching in secondary care: healthcare professionals' views on target group, intervention and coach profile

BACKGROUND

Not all patients are able to communicate effectively during consultations with medical specialists. Patient coaching has shown to be effective for enhancing communication.

OBJECTIVE

We aimed to get healthcare professionals' views on target groups for patient coaching, on supportive elements in patient coaching and on the necessary qualifications and profile of a patient coach, to further our knowledge on the concept of patient coaching as supportive intervention for patients in consultations with medical specialists.

METHODS

We chose a qualitative research design and interviewed 18 healthcare professionals (six medical specialists, four family physicians, four community nurses and four nurse specialists/physician assistants) and analysed the verbatim transcripts using Qualitative Analysis Guide of Leuven. After a short introduction of the global concept of patient coaching and presentation of patients' perceived barriers, two interviewers structured the interview around three research questions: which patients could benefit from a patient coach, what should such a coach do and who could act like such a coach?

RESULTS

Participants describe patients who could benefit from patient coaching as generally vulnerable (e.g. older age, insufficiently accompanied, lower socioeconomic status, co-morbidity and cognitive problems) but also patients who are situationally vulnerable (e.g. elicited by bad news). Patient coaching should comprise emotional and instrumental support, aiming at reducing stress and improving the processing of medical information. Patient coaching should start from the patient's home and include preparing questions, navigating to and in the hospital, recording information during the consultation, checking understanding and recalling information. Patient coaches should have at least basic medical knowledge and a higher education.

CONCLUSION

Healthcare professionals believe that patient coaching by a trained professional with medical knowledge could be beneficial to patients who are stressed when visiting a medical specialist. Future research should involve the views of patients on patient coaching, focus on investigating to what extent patient coaching is able to reduce stress and support a patient in processing medical information and the preferred patient coach's profile.

[Updated Dutch law demands shared decision-making]

In January 2020, the Dutch law on the medical treatment agreement was updated. In this update, shared decision-making is explicitly mentioned as a prerequisite during doctor-patient encounters. This entails explicit exploration of the patient's wishes, views and preferences and their integration in medical decision-making. There is growing interest in shared decision-making from patient advocacy and professional societies, the government, and healthcare insurers. However, both care professionals and patients are not yet used to applying this in their encounters. Creating awareness, training and organisational changes are essential aspects to foster shared decision-making. Various (umbrella) organisations in healthcare have developed (digital) tools for both care professionals and patients to support shared decision-making. This article addresses these tools to nudge all stakeholders towards shared decision-making.

Impact of deliberate practice on evidence-based medicine attitudes and behaviours of health care professionals

INTRODUCTION

Although evidence-based medicine (EBM) teaching activities may improve short-term EBM knowledge and skills, they have little long-term impact on learners' EBM attitudes and behaviour. This study examined the effects of learning EBM through stand-alone workshops or various forms of deliberate EBM practice.

METHODS

We assessed EBM attitudes and behaviour with the evidence based practice inventory questionnaire, in paediatric health care professionals who had only participated in a stand-alone EBM workshop (controls), participants with a completed PhD in clinical research (PhDs), those who had completed part of their paediatric residency at a department (Isala Hospital) which systematically implemented EBM in its clinical and teaching activities (former Isala residents), and a reference group of paediatric professionals currently employed at Isala's paediatric department (current Isala participants).

RESULTS

Compared to controls (n = 16), current Isala participants (n = 13) reported more positive EBM attitudes (p < 0.01), gave more priority to using EBM in decision making (p = 0.001) and reported more EBM behaviour (p = 0.007). PhDs (n = 20) gave more priority to using EBM in medical decision making (p < 0.001) and reported more EBM behaviour than controls (p = 0.016).

DISCUSSION

Health care professionals exposed to deliberate practice of EBM, either in the daily routines of their department or by completing a PhD in clinical research, view EBM as more useful and are more likely to use it in decision making than their peers who only followed a standard EBM workshop. These findings support the use of deliberate practice as the basis for postgraduate EBM educational activities.

Question 6: What is the use of allergy testing in children with asthma?

Disagreement exists between asthma guidelines on the routine use of allergy testing in the diagnostic work-up of a child with persistent asthma, although the important role of inhalant allergy in the pathophysiology of asthma and allergic rhinitis is undisputed. The usefulness of screening for inhalant allergies in asthma is connected to the efficacy of allergen reduction measures and specific immunotherapy, both of which appear to be more effective in children than in adults. Allergen-specific exposure reduction recommendations are therefore an essential part of childhood asthma management. Such recommendations should be guided by appropriate diagnosis of inhalant allergy, based on a structured allergy history and results of sensitization tests. Specific IgE testing and skin prick testing show comparable results in identifying clinically important sensitizations. Although a therapeutic medication trial can be started pragmatically in children with asthma without diagnosing their inhalant allergy, we recommend making or excluding an accurate diagnosis of inhalant allergy.

Driving lesson or driving test? : A metaphor to help faculty separate feedback from assessment

Although there is consensus in the medical education world that feedback is an important and effective tool to support experiential workplace-based learning, learners tend to avoid the feedback associated with direct observation because they perceive it as a high-stakes evaluation with significant consequences for their future. The perceived dominance of the summative assessment paradigm throughout medical education reduces learners' willingness to seek feedback, and encourages supervisors to mix up feedback with provision of 'objective' grades or pass/fail marks. This eye-opener article argues that the provision and reception of effective feedback by clinical supervisors and their learners is dependent on both parties' awareness of the important distinction between feedback used in coaching towards growth and development (assessment for learning) and reaching a high-stakes judgement on the learner's competence and fitness for practice (assessment of learning). Using driving lessons and the driving test as a metaphor for feedback and assessment helps supervisors and learners to understand this crucial difference and to act upon it. It is the supervisor's responsibility to ensure that supervisor and learner achieve a clear mutual understanding of the purpose of each interaction (i.e. feedback or assessment). To allow supervisors to use the driving lesson-driving test metaphor for this purpose in their interactions with learners, it should be included in faculty development initiatives, along with a discussion of the key importance of separating feedback from assessment, to promote a feedback culture of growth and support programmatic assessment of competence.

Case presentation methods: a randomized controlled trial of the one-minute preceptor versus SNAPPS in a controlled setting

INTRODUCTION

One-minute preceptor (OMP) and SNAPPS (a mnemonic for Summarize history and findings; Narrow the differential; Analyze the differential; Probe the preceptor about uncertainties; Plan management; and Select case-related issues for self-study) are educational techniques developed to promote learners' expression of clinical reasoning during the case presentation in the workplace. The aim of this present study was to compare the content of the case presentation between the SNAPPS and the OMP methods.

METHODS

This was a randomized controlled trial comparing SNAPPS and OMP in 60 medical students at the beginning of their fifth year of medical school. After an introduction session, students presented and discussed two cases based on real patients and provided in written format. All case presentations were recorded and evaluated by two researchers. The assessed elements of the case presentations were divided into three subgroups related to expression of clinical reasoning, time and initiative to guide the presentation.

RESULTS

There were 30 participants in each group. There was no difference in the expression of clinical reasoning between OMP and SNAPPS groups (number of differential diagnoses, justification of most likely diagnosis and differential diagnosis, expression of comparing and contrasting hypotheses). However, students in the SNAPPS group expressed significantly more questions and uncertainties (p < 0.001), and more often took the initiative to present and justify the most likely diagnosis, differential diagnosis and management plan than students in the OMP group, both in simple and complex cases (all p values <0.001) without extending the length of the teaching session.

CONCLUSION

OMP and SNAPPS equally promote medical students' expression of clinical reasoning. The SNAPPS technique was more effective than the OMP technique in helping students to take on an active role during case presentation. We propose SNAPPS as an effective learning tool, engaging students and promoting the expression of their clinical reasoning as part of a case presentation.

COVID-19: a unique learning opportunity if the well-being of learners and frontline workers is adequately supported

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Room Sharing in Hospitalized Children With Bronchiolitis and the Occurrence of Hospital-Acquired Infections: A Prospective Cohort Study

OBJECTIVES

To determine the prevalence and severity of hospital-acquired infections (HAIs) in children hospitalized for bronchiolitis when patients share a room, irrespective of the causative virus.

METHODS

A prospective cohort study during 4 winter seasons (2012-2016) was conducted in a Dutch general pediatric ward including otherwise healthy children <2 years of age hospitalized for bronchiolitis. Patients shared a 1-to-4-bed hospital room irrespective of virological diagnosis. The main outcome measures were HAIs assessed through multiplex polymerase chain reaction and disease severity.

RESULTS

HAIs occurred in 28 of 218 included patients (12.8%), most frequently with rhinovirus (17 of 28; 60.7%). In 3 (10.7%) of 28 HAIs, the same virus was identified in roommates. Only 1 patient became cross-infected with respiratory syncytial virus, although this patient never shared a room with a patient infected with respiratory syncytial virus. HAI was not associated with more severe disease. The median length of hospitalization was 3.5 days (interquartile range [IQR] 1-6) compared with 3 days (IQR 2-6; P = .86); the number of PICU admissions was 0% versus 5.3% (P = .21); the median days of oxygen supplementation was 2.5 (IQR 1-4) versus 2 (IQR 1-4; P = .58); the median days of tube feeding was 2 (IQR 0-5) versus 2 (interquartile range: 0-5; P = .77); and the readmission rate was 0% versus 5.8% (P = .19) in patients with and without HAI, respectively.

CONCLUSIONS

HAIs among patients with bronchiolitis are common but not associated with more severe disease. Room sharing with appropriate hygiene does not play a relevant role in the transmission of viruses between patients with bronchiolitis, regardless of the viruses involved. On the basis of these findings, we suggest that room sharing of patients with bronchiolitis is safe.

Shared decision making: Physicians' preferred role, usual role and their perception of its key components

OBJECTIVE

To investigate physicians' preferred and usual roles in decision making in medical consultations, and their perception of shared decision making (SDM).

METHODS

A cross-sectional survey of 785 physicians in a large Dutch general teaching hospital was undertaken in June 2018, assessing their preferred and usual decision making roles (Control Preference Scale), and their view on SDM key components (SDMQ9 questionnaire).

RESULTS

Most physicians (n = 232, 58%) preferred SDM, but more often performed paternalistic decision making (n = 121, 31%) in daily practice than they preferred (n = 80, 20%, p < 0.0001), most commonly because they judged the patient to be incapable of participating in decision making. Most physicians preferring SDM presented different options for treatment (n = 213, 92%) with their advantages and disadvantages (n = 209, 90%) but fewer made clear that a decision had to be made (n = 104, 45%) or explored the patient's wish how to be involved in decision making (n = 80, 34%).

CONCLUSION

Although most physicians prefer SDM, they often revert to a paternalistic approach and tend to limit SDM to discussing treatment options.

PRACTICE IMPLICATION

Teaching physicians in SDM should include raising awareness about discussing the decision process itself and help physicians to counter their tendency to revert to paternalistic decision making in daily practice.

Adherence to insulin pump treatment declines with increasing age in adolescents with type 1 diabetes mellitus

AIM

This study assessed the impact of illness perceptions, emotional responses to the disease and its management, and patient characteristics on the adherence to optimal insulin pump management in adolescents with type 1 diabetes mellitus.

METHODS

From May to December 2013 and May 2015 to September 2016, we investigated 90 adolescents (50% boys), 12-18 years with type 1 diabetes. We analysed the association of optimal adherence to insulin pump therapy to age, gender, diabetes duration, results of questionnaires relating to fear and problems of self-testing, illness perceptions, emotional distress and family conflicts. Optimal adherence was defined as bolusing insulin on average ≥2.5/3 main meals/d.

RESULTS

Adolescents with suboptimal adherence were on average 1.8 years older (95% Confidence Interval 1.09-2.50 years, P < .001) than those with optimal adherence. After adjustment for age, no other patient or parent factors were related to optimal adherence.

CONCLUSION

Adherence to insulin pump self-management in adolescents with type 1 diabetes declined with increasing age, illustrating the challenges of transition of self-management from parents to the adolescent patient themselves.

Reliability of residents' assessments of their postgraduate medical education learning environment: an observational study

BACKGROUND

Even in anonymous evaluations of a postgraduate medical education (PGME) program, residents may be reluctant to provide an honest evaluation of their PGME program, because they fear embarrassment or repercussions from their supervisors if their anonymity as a respondent is endangered. This study was set up to test the hypothesis that current residents in a PGME program provide more positive evaluations of their PGME program than residents having completed it. We therefore compared PGME learning environment evaluations of current residents in the program to leaving residents having completed it.

METHODS

This observational study used data gathered routinely in the quality cycle of PGME programs at two Dutch teaching hospitals to test our hypothesis. At both hospitals, all current PGME residents are requested to complete the Scan of Postgraduate Education Environment Domains (SPEED) annually. Residents leaving the hospital after completion of the PGME program are also asked to complete the SPEED after an exit interview with the hospital's independent residency coordinator. All SPEED evaluations are collected and analysed anonymously. We compared the residents' grades (on a continuous scale ranging from 0 (poor) to 10 (excellent)) on the three SPEED domains (content, atmosphere, and organization of the program) and their mean (overall department grade) between current and leaving residents.

RESULTS

Mean (SD) overall SPEED department grades were 8.00 (0.52) for 287 current residents in 39 PGME programs and 8.07 (0.48) for 170 leaving residents in 39 programs. Neither the overall SPEED department grades (t test, p = 0.53, 95% CI for difference - 0.16 to 0.31) nor the department SPEED domain grades (MANOVA, F(3, 62) = 0.79, p = 0.51) were significantly different between current and leaving residents.

CONCLUSIONS

Residents leaving the program did not provide more critical evaluations of their PGME learning environment than current residents in the program. This suggests that current residents' evaluations of their postgraduate learning environment were not affected by social desirability bias or fear of repercussions from faculty.

Episodic viral wheeze and multiple-trigger wheeze in preschool children are neither distinct nor constant patterns. A prospective multicenter cohort study in secondary care

OBJECTIVES

To evaluate whether episodic viral wheeze (EVW) and multiple-trigger wheeze (MTW) are clinically distinguishable and stable preschool wheezing phenotypes.

METHODS

Children of age 1 to 4 year with recurrent, pediatrician-confirmed wheeze were recruited from secondary care; 189 were included. Respiratory and viral upper respiratory tract infection (URTI) symptoms were recorded weekly by parents in an electronic diary during 12 months. Every 3 months, diary-based symptoms were classified as EVW or MTW and compared to phenotypes assigned by pediatricians based on clinical history. We collected nasal samples for respiratory virus PCR during URTI, respiratory symptoms and in absence of symptoms.

RESULTS

Of 660 3-month periods, the diary-based phenotype was EVW in 11%, MTW in 54% and 35% were free from respiratory episodes. Pediatrician-based classification showed 59% EVW and 26% MTW. The Kappa measure of agreement between diary-based and pediatrician-assigned phenotypes was very low (0.12, 95%CI, 0.07-0.17). Phenotypic instability was observed in 32% of cases. PCR was positive in 71% during URTI symptoms, 66% during respiratory symptoms and 38% in the absence of symptoms.

CONCLUSION

This study shows that EVW and MTW are variable over time within patients. Pediatrician classification of these phenotypes based on clinical history does not correspond to prospectively recorded symptom patterns. The applicability of these phenotypes as a basis for therapeutic decisions and prognosis should be questioned.

Patient coaching in specialist consultations. Which patients are interested in a coach and what communication barriers do they perceive?

OBJECTIVE

To characterize patients interested in support by a patient coach to guide them in medical specialist consultations.

METHODS

We compared 76 patients interested in a patient coach with 381 patients without such an interest, using a representative panel of patients with a chronic disease in the Netherlands. Independent variables were demographic factors, socio-economic status, perceived efficacy in patient-provider interaction, communication barriers, health literacy, (duration and type of) disease(s) and activation level.

RESULTS

In univariate analyses, patients who are interested in a coach were significantly older, had lower health literacy skills and less self-efficacy and, overall, experienced more communication barriers (>4), than patients without such interest (1-2 barriers). Multivariate analyses indicated three communications barriers as determinants of patient interest in a coach: feeling tense, uncertainty about own understanding, and believing that a certain topic is not part of a healthcare providers' task.

CONCLUSION

Patients interested in a coach perceive specific barriers in communicating with their medical specialist. In addition, patients who are > = 65 years, have lower health literacy and low self-efficacy may have interest in a coach.

PRACTICE IMPLICATIONS

Characterizing patients interested in a patient coach facilitates identification of those who could benefit from such a coach in clinical practice.

Role modelling in the training of hospital-based medical specialists: a validation study of the Role Model Apperception Tool (RoMAT)

INTRODUCTION

Role modelling is a key component in the training of doctors that influences professional behaviour, identity and career choices. Clinical teachers and residents are often unaware of this, thereby risking transmission of negative behaviour. On the other hand, awareness positively affects role model behaviour. To assess role model behaviour, the Role Model Apperception Tool (RoMAT) was developed and validated in general practice training. The aim of the current study was to validate the RoMAT in the hospital-based training setting.

METHODS

The authors asked first to last year residents, regardless of their specialty, to participate after written approval from their clinical teachers. The tool was completed online in 2017. The authors performed a principal component analysis and investigated internal consistency, construct validity, inter-rater reliability, known-groups comparisons and floor and ceiling effects.

RESULTS

Of the 473 residents contacted, 187 (40%) completed the questionnaire. As in the primary validation study, the authors extracted two components: 'Caring Attitude' and 'Effectiveness', explaining 67% of the variation with a Cronbach's alpha of 0.94 and 0.93 respectively. Evidence for construct validity was found and there were no floor or ceiling effects, but inter-rater reliability was low.

DISCUSSION

The RoMAT was internally consistent and valid to assess role model behaviour of the clinical teacher towards the resident in the hospital-based training of medical specialists. The poor inter-rater reliability, most likely due to homogeneous RoMAT responses, should be borne in mind when evaluating RoMAT scores on individual clinical teachers.

Practice variation among Dutch paediatricians in palivizumab prescription rates: the importance of parental counselling approach

AIM

To investigate differences in palivizumab prescription rates between Dutch paediatricians, and the role of parent counselling in this practice variation.

METHODS

A retrospective chart review of premature infants <32 weeks of gestation, aged less than six months at the start of the winter season, born between January 2012 and July 2014, in three secondary hospital-based paediatric practices in the Netherlands.

RESULTS

We included 208 patients, 133 (64%) of whom received palivizumab. Prescription rates varied considerably between the three hospitals: 8% (6/64), 89% (32/36) and 99% (97/98). A noticeable difference in the way parents were counselled about palivizumab was the use of the number needed to treat (NNT). In the hospital with the lowest prescription rate (8%), an NNT of 20 to prevent one hospitalisation was explicitly discussed with parents. Bronchiolitis-related hospital admissions occurred in 11.3% of patients receiving palivizumab compared to 20.0% in nonimmunised infants (p = 0.086).

CONCLUSION

Considerable practice variation exists among Dutch paediatricians regarding palivizumab prescription rates. The counselling method seems to play an important role. Presenting palivizumab prophylaxis as a preference-sensitive decision, combined with the explicit use and explanation of an NNT, leads many parents to refrain from respiratory syncytial virus immunisation.

The relationship between burnout, personality traits, and medical specialty. A national study among Dutch residents

Purpose: To examine the associations between residents' personality traits, type of specialty, and symptoms of burnout. Method: A cross-sectional online survey among Dutch residents was conducted (see Supplementary Material ). The 20-item Dutch translation of the Maslach Burnout Inventory was used to ascertain burnout. Personality traits were assessed with the 44-item Dutch Big Five Inventory. Logistic regression analyses, including all five personality traits, were used to assess associations with burnout. Analyses were stratified by specialties. Results: One thousand two hundred thirty one residents participated, 185 (15.0%) of whom met the criteria for burnout. Neuroticism was significantly associated with resident burnout in all specialties, more strongly in supportive (odds ratio (OR) 6.19, 95% CI 2.12-18.12) and surgical (OR 4.37, 95% CI 1.76-10.86) than in medical residents (OR 1.99, 95% CI 1.22-3.24). Extraversion was significantly associated with less burnout in surgical residents (OR 0.26, 95% CI 0.13-0.58). These findings remained highly significant after controlling for gender, overtime, autonomy at work, satisfaction between work and private life, and the perceived quality of the learning environment. Conclusions: Burnout risk was associated with personality traits in residents. Consistently, residents scoring high on neuroticism reported more burnout. Extraverted surgical residents were less susceptible to burnout. Residents scoring high on neuroticism may require more intense monitoring during their training years.

Correction to: Mealtime insulin bolus adherence and glycemic control in adolescents on insulin pump therapy

The Abstract section and the in the Results sections of the original version of this article, unfortunately, contained errors. The correct data are now shown in this article.

Role of intuitive knowledge in the diagnostic reasoning of hospital specialists: a focus group study

BACKGROUND AND OBJECTIVE

Intuition is an important part of human decision-making and can be explained by the dual-process theory where analytical and non-analytical reasoning processes continually interact. These processes can also be identified in physicians' diagnostic reasoning. The valuable role of intuition, including gut feelings, has been shown among general practitioners and nurses, but less is known about its role among hospital specialists. This study focused on the diagnostic reasoning of hospital specialists, how they value, experience and use intuition.

DESIGN AND PARTICIPANTS

Twenty-eight hospital specialists in the Netherlands and Belgium participated in six focus groups. The discussions were recorded, transcribed verbatim and thematically coded. A circular and iterative analysis was applied until data saturation was achieved.

RESULTS

Despite initial reservations regarding the term intuition, all participants agreed that intuition plays an important role in their diagnostic reasoning process. Many agreed that intuition could guide them, but were cautious not to be misguided. They were especially cautious since intuition does not have probative force, for example, in medicolegal situations. 'On-the-job experience' was regarded as a precondition to relying on intuition. Some participants viewed intuition as non-rational and invalid. All participants said that intuitive hunches must be followed by analytical reasoning. Cultural differences were not found. Both the doctor as a person and his/her specialty were seen as important determinants for using intuition.

CONCLUSIONS

Hospital specialists use intuitive elements in their diagnostic reasoning, in line with general human decision-making models. Nevertheless, they appear to disagree more on its role and value than previous research has shown among general practitioners. A better understanding of how to take advantage of intuition, while avoiding pitfalls, and how to develop 'skilled' intuition may improve the quality of hospital specialists' diagnostic reasoning.

Treatment adherence and level of control in moderate persistent asthma in children and adolescents treated with fluticasone and salmeterol

OBJECTIVE

There is a scarcity of studies that assessed the association between adherence to combination therapy and asthma control in pediatric patients. The authors investigated the association between adherence to fluticasone propionate/salmeterol xinafoate combination-metered aerosol and the level of asthma control in children.

METHODS

This was a prospective observational study of 84 patients aged 5-16 years with moderate persistent asthma, who remained uncontrolled despite the use of 1000μg/day of inhaled nonextrafine-hydrofluoric alkane-beclomethasone dipropionate in the three months prior to study enrollment. Participants were prescribed two daily doses of FP (125μg)/salmeterol xinafoate (25μg) combination by metered aerosol/spacer for six months. Adherence rates were assessed using the device's dose counter after the 2nd, 4th, and 6th months of follow up. Asthma control was assessed using a simplified Global Initiative for Asthma 2014 Report classification.

RESULTS

Mean adherence rates after the second, fourth, and sixth months were 87.8%, 74.9%, and 62.1% respectively, for controlled asthma, and 71.7%, 56.0%, and 47.6% respectively, for uncontrolled asthma (all p-values≤0.03). The proportion of children achieving asthma control increased to 42.9%, 67.9% and 89.3% after the 2nd, 4th and 6th months of follow-up, respectively (p≤0.001).

CONCLUSION

Adherence rates between 87.8% in the 2nd month and 62.1% in the 6th month were strong determinants of asthma control.

Mealtime insulin bolus adherence and glycemic control in adolescents on insulin pump therapy

Poor self-management contributes to insufficient glycemic control in adolescents with type 1 diabetes (T1DM). We assessed the effects on glycemic control of adherence to self-measurement of blood glucose (SMBG) and insulin boluses in 90 adolescents with T1DM on insulin pump therapy over a 2-month period. We compared the number of insulin boluses and SMBGs around main meals to the "gold standard" of optimal diabetes management (SMBGs and a bolus before each main meal and SMBG before bedtime). The mean (95% CI) HbA1c levels were 2.9(1.7 to 4.0) mmol/mol lower for every additional insulin bolus and 3.1(1.6 to 4.5) mmol/mol lower for every additional SMBG. Patients performing SMBG and bolusing around each main meal had considerably lower HbA1c levels than those unable to do (95% CI for difference 4.3 to 10.4 mmol/mol and 11.5 to 20.1 mmol/mol respectively). For each additional mealtime bolus/day, the odds ratio of achieving target HbA1c levels of <58 mmol/mol was 6.73 (95% CI 2.94-15.38), after adjustment for gender, age, diabetes duration, and affective responses to SMBG in a multiple logistic regression model.Conclusion: Glycemic control in adolescents with T1DM on insulin pump therapy is strongly dependent on adherence to insulin boluses around mealtimes. What is Known: • In mixed groups of children and adolescents, insulin bolus frequency and self-monitoring of blood glucose (SMBG) frequency were determinants of HbA1c levels. • Adherence to insulin boluses and SMBG is particularly challenging in adolescents. What is New: • In adolescents on insulin pump therapy, each additional insulin bolus, particularly around mealtime, was significantly associated with approximately 3 mmol/mol lower HbA1c levels. • This beneficial effect of mealtime bolusing was strongest for the evening meal.

Changes in Perceived Supervision Quality After Introduction of Competency-Based Orthopedic Residency Training: A National 6-Year Follow-Up Study

OBJECTIVE

To evaluate the perceived quality of the learning environment, before and after introduction of competency-based postgraduate orthopedic education.

DESIGN

From 2009 to 2014, we conducted annual surveys among Dutch orthopedic residents. The validated Dutch Residency Educational Climate Test (D-RECT, 50 items on 11 subscales) was used to assess the quality of the learning environment. Scores range from 1 (poor) to 5 (excellent).

SETTING

Dynamic cohort follow-up study.

PARTICIPANTS

All Dutch orthopedic residents were surveyed during annual compulsory courses.

RESULTS

Over the 6-year period, 641 responses were obtained (response rate 92%). Scores for "supervision" (95% CI for difference 0.06-0.28, p = 0.002) and "coaching and assessment" (95% CI 0.11-0.35, p < 0.001) improved significantly after introduction of competency-based training. There was no significant change in score on the other subscales of the D-RECT.

CONCLUSIONS

After the introduction of some of the core components of competency-based postgraduate orthopedic education the perceived quality of "supervision" and "coaching and assessment" improved significantly.

Workplace mentoring of residents in generic competencies by an independent coach

INTRODUCTION

During postgraduate education in pulmonology, supervisors are responsible for training residents in generic competencies such as communication, professionalism and collaboration, but their focus commonly lies more on medical-technical competencies. As an alternative approach to supporting residents to develop generic skills, we developed a personal mentoring program with a non-medical professional as mentor. In this study, the residents' experiences with the mentoring program were evaluated.

METHODS

After an introductory session in which individual learning goals were established, pulmonology residents received at least six, 60-90-minute, individual, mentoring sessions largely consisting of feedback after being observed during daily clinical activities, over a period of 9 months. The residents' experiences with mentoring were explored through in-depth interviews followed by a qualitative content analysis.

RESULTS

From March to November 2016, ten residents in pulmonology completed the program. Despite initial scepticism, mentoring encouraged residents to reflect deeply on their professional interactions. This caused an increased awareness of the effects of their communication and behaviour on patients. Experimenting with communication and different behaviours in subsequent interactions felt rewarding and contributed to further development, resulting in increased self-confidence and job satisfaction.

DISCUSSION

Mentoring residents by non-medical coaching was associated with improved residents' proficiency in generic competencies.

Implementing evidence-based medicine in a busy general hospital department: results and critical success factors

Implementing evidence-based medicine (EBM) in a busy hospital department is challenging, but when successful, may contribute to quality of care. This paper is a narrative review of the successes and challenges of deliberate implementation of EBM in a paediatric department in a general teaching hospital in Zwolle, the Netherlands. Key elements in this project were providing basic EBM education to the entire team of consultants and nurse practitioners, structurally embedding EBM activities into our weekly schedule and development of local practice guidelines. This deliberate practice of EBM principles has changed the way we treat common paediatric problems. It likely reduced unwarranted practice variation and promoted a reserved attitude towards the use of unnecessary diagnostics, which might improve delivery of effective, cost-conscious care. The project also positively influenced our group culture and learning environment. In accordance with previous reports, lack of time and reluctance to change routines and habits hindered the practice of EBM in our department. In our experience, these barriers can be overcome by promoting a team-wide endorsement of EBM, a willingness to acknowledge uncertainty and by deliberate practice. If these can be achieved, systematic application of EBM principles in a busy hospital department is feasible and worthwhile.

[Need for a uniform clinical placement quality cycle]

OBJECTIVE

To investigate how quality control of clinical placements in the Netherlands is organised, which tools are available for this purpose, and what Dutch clinical placement students think about current clinical placement assessment.

DESIGN

Document analysis, literature search and questionnaire.

METHOD

In 2017, we asked all 8 medical schools to share their procedures and tools for assessing clinical placement quality with us. We searched various databases to find all published tools developed to measure clinical placement quality. In the same year, we also conducted a survey of 15 clinical placement students per school with questions about current and desired clinical placement assessment.

RESULTS

All 8 schools sent detailed information about clinical placement quality assessment contents and procedures. All schools indicated that they are cyclically measuring each clinical placement's quality using evaluations by the clinical placement students. Each school uses its own questionnaire, none of these questionnaires have been validated. Literature search only found two tools specifically developed for assessing clinical placement quality, none of which have been validated for the Dutch language and situation. Clinical placement students feel that not enough noticeable improvement actions are being taken as a result of their evaluations. They preferred a short, uniform questionnaire with questions about clinical placement content, atmosphere and organisation.

CONCLUSION

The quality cycle of clinical placements in the Netherlands could be improved with respect to uniformity and implementation of actions for improvement. There is a need for standardisation of the clinical placement quality cycle and for development of a validated Dutch measuring tool for this.

Asthma exacerbations in a subtropical area and the role of respiratory viruses: a cross-sectional study

BACKGROUND

Multiple factors are involved in asthma exacerbations, including environmental exposure and viral infections. We aimed to assess the association between severe asthma exacerbations, acute respiratory viral infections and other potential risk factors.

METHODS

Asthmatic children aged 4-14 years were enrolled for a period of 12 months and divided into two groups: those with exacerbated asthma (group 1) and non-exacerbated asthma (group 2). Clinical data were obtained and nasopharyngeal samples were collected through nasopharyngeal aspirate or swab and analysed via indirect fluorescent immunoassays to detect influenza A and B viruses, parainfluenza 1-3, adenovirus and respiratory syncytial virus. Rhinovirus was detected via molecular assays. Potential risk factors for asthma exacerbation were identified in univariate and multivariate analyses.

RESULTS

In 153 children (group 1: 92; group 2: 61), median age 7 and 8 years, respectively, the rate of virus detection was 87.7%. There was no difference between groups regarding the frequency of virus detection (p = 0.68); however, group 1 showed a lower frequency (19.2%) of inhaled corticosteroid use (91.4%, p < 0.01) and evidence of inadequate disease control. In the multivariate analysis, the occurrence of three or more visits to the emergency room in the past 12 months (IRR = 1.40; p = 0.04) and nonadherence to inhaled corticosteroid (IRR = 4.87; p < 0.01) were the only factors associated with exacerbation.

CONCLUSION

Our results suggest an association between asthma exacerbations, poor disease control and nonadherence to asthma medication, suggesting that viruses may not be the only culprits for asthma exacerbations in this population.

The learning environment and resident burnout: a national study

INTRODUCTION

Concerns exist about the negative impact of burnout on the professional and personal lives of residents. It is suggested that the origins of burnout among residents are rooted in the learning environment. We aimed to evaluate the association between the learning environment and burnout in a national sample of Dutch residents.

METHODS

We conducted a cross-sectional online survey among all Dutch residents in September 2015. We measured the learning environment using the three domain scores on content, organization, and atmosphere from the Scan of Postgraduate Educational Environment Domains (SPEED) and burnout using the Dutch version of the Maslach Burnout Inventory (UBOS-C).

RESULTS

Of 1,231 responding residents (33 specialties), 185 (15.0%) met criteria for burnout. After adjusting for demographic (age, gender and marital status) and work-related factors (year of training, type of teaching hospital and type of specialty), we found a consistent inverse association between SPEED scores and the risk of burnout (aOR 0.54, 95% CI 0.46 to 0.62, p < 0.001).

DISCUSSION

We found a strong and consistent inverse association between the perceived quality of the learning environment and burnout among residents. This suggests that the learning environment is of key importance in preventing resident burnout.

Resident burnout: evaluating the role of the learning environment

BACKGROUND

Although burnout is viewed as a syndrome rooted in the working environment and organizational culture, the role of the learning environment in the development of resident burnout remains unclear. We aimed to evaluate the association between burnout and the learning environment in a cohort of Belgian residents.

METHODS

We conducted a cross-sectional online survey among residents in a large university hospital in Belgium. We used the Dutch version of the Maslach Burnout Inventory (UBOS-C) to assess burnout and the Dutch Residency Educational Climate Test (D-RECT) to assess the learning environment.

RESULTS

A total of 236 residents (29 specialties) completed the survey (response rate 34.6%), of which 98 (41.5%) met standard criteria for burnout. After multivariate regression analysis adjusting for hours worked per week, quality of life and satisfaction with work-life balance, we found an inverse association between D-RECT scores and the risk of burnout (adjusted odds ratio; 0.47 for each point increase in D-RECT score; 95% CI, 0.23 - 0.95; p = 0.01).

CONCLUSIONS

Resident burnout is highly prevalent in our cohort of Belgian residents. Our results suggest that the learning environment plays an important role in reducing the risk of burnout among residents.

Increase in atopic sensitization rate among Dutch children with symptoms of allergic disease between 1994 and 2014

BACKGROUND

The prevalence of symptoms of allergic diseases has increased significantly during the last decades. However, studies into time trends of atopic sensitization among children are limited and have focused on aeroallergen sensitization. We aimed to investigate time trends in the prevalence and degree of atopic sensitization to inhalant and food allergens among children (0-17 years) with symptoms of allergic disease.

METHODS

Sensitization data of all children tested in our clinical laboratory during 1994-2014 were analyzed. Sensitization was detected using the ImmunoCAP system and defined as a specific IgE level of ≥0.35 kU/L. Trends in sensitization rates to 5 food and 5 aeroallergens for different age categories were investigated with logistic regression, adjusted for age and sex.

RESULTS

Sensitization data of 18 199 children were analyzed. Between 1994 and 2014, a steady and statistically significant increase in overall sensitization rate was found (from 40.5% in 1994 to 48.9% in 2014, adjusted odds ratio [aOR] 1.01 per year, 95% confidence interval [CI] 1.00 to 1.01, P = .003). This increase in sensitization rate was mainly explained by increasing aeroallergen sensitization among 4- to 11-year-old children (aOR 1.02, 95% CI 1.01 to 1.02, P < .001). We found no increase in sensitization rates to food and aeroallergens in other age categories. The degree of sensitization did not change significantly during the study period (all tests P > .15).

CONCLUSION

We observed a statistically significant increase in sensitization rate between 1994 and 2014 among children with symptoms of allergic disease. This was mainly explained by increasing aeroallergen sensitization among 4- to 11-year-olds.

Applicability of evidence from previous systematic reviews on immunotherapy in current practice of childhood asthma treatment: a GRADE (Grading of Recommendations Assessment, Development and Evaluation) systematic review

OBJECTIVE

Because most children with asthma now use inhaled corticosteroids (ICS), the added benefit of immunotherapy in asthmatic children needs to be examined. We re-assessed the effectiveness of subcutaneous (SCIT) and sublingual immunotherapy (SLIT) in childhood asthma treatment focusing on studies with patient-relevant outcome measures and children using ICS.

METHODS

We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to systematically search and appraise the evidence using predefined critical patient-relevant outcomes (asthma symptoms, asthma control and exacerbations). We searched to retrieve systematic reviews and randomised controlled trials on immunotherapy for asthma in children (1960-2017). We assessed the quality of the body of evidence with GRADE criteria.

RESULTS

The quality of the evidence for SCIT was very low due to a large risk of bias and indirectness (dated studies in children not using ICS). No effect of SCIT was found for asthma symptoms; no studies reported on asthma control. For asthma exacerbations, studies favoured SCIT. We have little confidence in this effect estimate, due to the very low quality of evidence. For SLIT, quality of the evidence was very low due to a large risk of bias, indirectness and imprecision. The outcome 'asthma symptoms' could not be calculated due to lack of standardisation and large clinical heterogeneity. Other predefined outcomes were not reported.

CONCLUSION

The beneficial effects of immunotherapy in childhood asthma found in earlier reviews are no longer considered applicable, because of indirectness (studies performed in children not being treated according to current asthma guidelines with ICS). There was absence of evidence to properly determine the effectiveness or lack thereof of immunotherapy in asthma treatment in children with ICS.