Towards inclusive learning environments in post-graduate medical education: stakeholder-driven strategies in Dutch GP-specialty training

BACKGROUND

A recent study found that ethnic minority General Practice (GP)-trainees receive more negative assessments than their majority peers. Previous qualitative research suggested that learning climate-related factors play a pivotal role in unequal opportunities for trainees in post-graduate medical settings, indicating that insufficient inclusivity had put minority students at risk of failure and dropout.

STUDY OBJECTIVES

We aimed to develop broadly supported strategies for an inclusive learning climate in Dutch GP-specialty training.

METHODS

We employed Participatory Action Research (PAR)-methods, incorporating Participatory Learning and Action (PLA)-techniques to ensure equal voices for all stakeholders in shaping Diversity, Equity, and Inclusion (DEI)-strategies for GP-specialty training. Our approach engaged stakeholders within two pilot GP-specialty training institutes across diverse roles, including management, support staff, in-faculty teachers, in-clinic supervisors, and trainees, representing ethnic minorities and the majority population. Purposeful convenience sampling formed stakeholder- and co-reader groups in two Dutch GP-specialty training institutes. Stakeholder discussion sessions were based on experiences and literature, including two relevant frameworks, and explored perspectives on the dynamics of potential ethnic minority trainees' disadvantages and opportunities for inclusive strategies. A co-reader group commented on discussion outcomes. Consequently, a management group prioritized suggested strategies based on expected feasibility and compatibility.

RESULTS

Input from twelve stakeholder group sessions and thirteen co-readers led to implementation guidance for seven inclusive learning environment strategies, of which the management group prioritized three: • Provide DEI-relevant training programs to all GP-specialty training stakeholders; • Appoint DEI ambassadors in all layers of GP-specialty training; • Give a significant voice to minority GP-trainees in their education.

CONCLUSION

The study's participatory approach engaged representatives of all GP-specialty training stakeholders and identified seven inclusive learning climate strategies, of which three were prioritized for implementation in two training institutions.

Walking the line between assessment, improvement and learning: a qualitative study on opportunities and risks of incorporating peer discussion of audit and feedback within quality improvement in general practice

OBJECTIVES

There is a broad call for change towards 'new era' quality systems in healthcare, in which the focus lies on learning and improving. A promising way to establish this in general practice care is to combine audit and feedback with peer group discussion. However, it is not known what different stakeholders think of this type of quality improvement. The aim of this research was to explore the opinions of different stakeholders in general practice on peer discussion of audit and feedback and on its opportunities and risks. Second, their thoughts on transparency versus accountability, regarding this system, were studied.

DESIGN

An exploratory qualitative study within a constructivist paradigm. Semistructured interviews and focus group discussions were held and coded using thematic analysis. Included stakeholders were general practitioners (GP), patients, professional organisations and insurance companies.

SETTING

General practice in the Netherlands.

PARTICIPANTS

22 participants were purposively sampled for eight interviews and two focus group discussions.

RESULTS

Three main opportunities of peer discussion of audit and feedback were identified: deeper levels of reflection on data, adding context to numbers and more ownership; and three main risks: handling of unwilling colleagues, lacking a safe group and the necessity of patient involvement. An additional theme concerned disagreement on the amount of transparency to be offered: insurance companies and patients advocated for complete transparency on data and improvement of outcomes, while GPs and professional organisations urged to restrict transparency to giving insight into the process.

CONCLUSIONS

Peer discussion of audit and feedback could be part of a change movement, towards a quality system based on learning and trust, that is initiated by the profession. Creating a safe learning environment and involving patients is key herein. Caution is needed when complete transparency is asked, since it could jeopardise practitioners' reflection and learning in safety.

Complaint-driven preferences & trust: patient's views on consulting GP trainees

BACKGROUND

Work-based learning depends on patients' consent to have trainees involved in their care. However, patients can refuse trainees, which might lead to the loss of learning experiences. Improved understanding of patients' views on consulting trainees may provide useful insights to further optimise learning for trainees.

METHODS

We performed a qualitative study with 28 patients in The Netherlands. Participants were recruited from GP practices, and were purposively sampled on (un)willingness to consult GP trainees. In semi-structured interviews patients' perspectives and willingness to consult a trainee were explored. Transcripts were thematically analysed using an inductive approach.

RESULTS

Two themes explained patients' views on consulting GP trainees: Presenting complaint-driven preferences and Trust in trainees' capabilities. Patients select their doctor based on complaint-driven preferences and chose trainees if they fulfilled these preferences. For urgent, gender-specific and minor complaints, patients prefer timeliness, gender concordance or availability. Patients with more complex, long-term problems prefer to consult a trusted doctor with whom they have a longitudinal relationship. Through repeated visits and empathic behaviour trainees can become this doctor. Before patients consider consulting a trainee, they need to have trust in the trainee's capabilities. This trust is related to the basic trust patients have in the education of the trainee, their knowledge about trainees' capabilities and supervisory arrangements.

CONCLUSIONS

Patients' decision to visit a trainee is fluid. Patients will visit a trainee when their complaint-driven preferences are satisfied. Influencing trainees' fulfilment of these preferences and patients' trust in trainees can make patients more willing to consult trainees.

Impulsivity in the eye of the beholder: an analysis of teachers' concepts of impulsive and reflective behaviour

The aim of this research was to investigate teachers' perception of the concept of impulsivity and its relation to the concept of reflectivity. Teacher rating scales for both concepts were constructed by means of the prototype method (Study 1). It appeared that impulsivity refers to social behaviour, whereas reflectivity is more cognitive in character. A Principal Components Analysis (Study 2) showed that the item pools for impulsive and reflective behaviour account for separate components. It is concluded that impulsivity and reflectivity as perceived by teachers are not two extremes of one dimension, but refer to different behavioural domains: social and cognitive.

Assessment of motivational interviewing with the VASE-(Mental) Healthcare: Mixed-methods study to examine feasibility and validity in the general practice setting

OBJECTIVE

The VASE-(M)HC is an instrument to evaluate Motivational Interviewing (MI) skills. We adjusted the previous version for use in the broader (mental) healthcare context, incorporated new MI insights, expanded the scoring system and created a parallel version. Feasibility and validity evidence in the general practice setting was explored.

METHODS

The teaching staff of the GP specialty-training, GP-, and PN-trainees (N = 156) completed the VASE-(M)HC. In this mixed-methods study, we examined psychometric characteristics, compared parallel versions, and interviewed assessors.

RESULTS

Our adjustments enable assessment of a wider range of MI skills, and allow differentiation of basic and advanced skills. Inter-rater reliability was excellent and internal consistency of the total scale was good for both versions. The parallel versions are comparable in terms of difficulty.

CONCLUSION

The VASE-(M)HC is improved by our revisions and adds multiple advantages to the domain of available MI assessment tools.

PRACTICE IMPLICATIONS

Due to the adjustments, the instrument can be used in the GP setting (instead of sole focus on substance abuse). The parallel version is useful for research (pretest/posttest) and selective assessment (retake of a test). It is promising to further explore its applicability in the broader (mental) healthcare context and as training material.

Assessment of motivational interviewing: Psychometric characteristics of the MITS 2.1 in general practice

OBJECTIVE

Motivational Interviewing (MI) is increasingly used in healthcare. The Motivational Interviewing Target Scheme 2.1 (MITS) can be used to assess MI in short consultations. This quantitative validation study is a sequel to a qualitative study, which showed that the MITS is suitable for low-stakes assessment. We collected validity evidence to determine whether its suitability for high-stakes assessment in the GP-setting.

METHODS

Consultations of GPs and GP-trainees were assessed using the MITS. The internal structure was studied using generalizability theory; intra class correlation (ICC), convergent and divergent validity was determined.

RESULTS

Two coders and seven consultations were found to be necessary for high stakes assessment. We found higher ICCs as coders were more experienced. Convergent validity was found; results for divergent validity were mixed.

CONCLUSION

The MITS is a suitable instrument for high-stakes MI assessments in GP-setting. The number of consultations and coders that are needed for assessment are comparable to other instruments for assessing communication skills.

PRACTICE IMPLICATIONS

The MITS can be used to assess conversations for their MI consistency in GP-setting where most consultations are relatively short and are only partially dedicated to behaviour change. As the MITS assesses complex communication skills, experienced coders are needed.

Insight in the development of the mutual trust relationship between trainers and trainees in a workplace-based postgraduate medical training programme: a focus group study among trainers and trainees of the Dutch general practice training programme

OBJECTIVES

Trust plays an important role in workplace-based postgraduate medical education programmes. Trainers must trust their trainees for granting them greater independence. Trainees must trust their trainer for a safe learning environment. As trainers' and trainees' trust in each other plays an important role in trainee learning and development, the authors aimed to explore the development of the mutual trust relationship between trainers and trainees.

SETTING

This study was performed in a general practice training department in the Netherlands.

PARTICIPANTS

All trainers and trainees of the general practice training department were invited to participate. Fifteen trainers and 34 trainees, voluntarily participated in focus group discussions.

OUTCOME MEASURES

The authors aimed to gain insight in the factors involved in the development of the mutual trust relationship between trainers and trainees, in order to be able to create a model for the development of a mutual trust relationship between trainers and trainees. The risk-based view of trust was adopted as leading conceptual framework.

RESULTS

In the first stage of trust development, trainers and trainees develop basic trust in each other. Basic trust forms the foundation of the trust relationship. In the second stage, trainers develop trust in trainees taking into account trainees' working and learning performance, and the context in which the work is performed. Trainees trust their trainer based on the trainer'savailability and accessibility and the personal relationship between the trainee and their trainer. Trainee self-confidence modifies the development of a trust relationship.

CONCLUSION

The development of a mutual trust relationship between trainers and trainees is a complex process that involves various stages, goals, factors and interactive aspects. As the mutual trust relationship influences the learning environment for trainees, greater emphasis on the mutual trust relationship may improve learning outcomes. Further research may explore the effect of long-term and short-term educational relationships on the trust relationship between trainers and trainees.

Professionals' perspectives on factors affecting GP trainees' patient mix: results from an interview and focus group study among professionals working in Dutch general practice

INTRODUCTION

Seeing and treating patients in daily practice forms the basis of general practitioner (GP) training. However, the types of patients seen by GP trainees do not always match trainees' educational needs. Knowledge about factors that shape the mix of patient types is limited, especially with regard to the role of the professionals who work in the GP practice.

AIM

We investigated factors affecting the mix of patients seen by GP trainees from the perspective of professionals.

DESIGN AND SETTING

This qualitative study involved GP trainees, GP supervisors, medical receptionists and nurse practitioners affiliated with a GP Specialty Training Institute in the Netherlands.

METHODS

Twelve focus groups and seven interviews with 73 participants were held. Data collection and analysis were iterative, using thematic analysis with a constant comparison methodology.

RESULTS

The characteristics of patients' health problems and the bond between the doctor and patient are important determinants of GP trainees' patient mix. Because trainees have not yet developed bonds with patients, they are less likely to see patients with complex health problems. However, trainees can deliberately influence their patient mix by paying purposeful attention to bonding with patients and by gaining professional trust through focused engagement with their colleagues.

CONCLUSION

Trainees' patient mix is affected by various factors. Trainees and team members can take steps to ensure that this mix matches trainees' educational needs, but their success depends on the interaction between trainees' behaviour, the attitudes of team members and the context. The findings show how the mix of patients seen by trainees can be influenced to become more trainee centred and learning oriented.

Assessment of motivational interviewing: a qualitative study of response process validity, content validity and feasibility of the motivational interviewing target scheme (MITS) in general practice

BACKGROUND

The Motivational Interviewing target Scheme (MITS) is an instrument to assess competency in Motivational Interviewing (MI) and can be used to assess MI in long and brief consultations. In this qualitative study we examined two sources of the Unified Model of Validity, the current standard of assessment validation, in the context of General Practice. We collected evidence concerning response process validity and content validity of the MITS in general practice. Furthermore, we investigated its feasibility.

METHODS

Assessing consultations of General Practitioners and GP-trainees (GPs), the assessors systematically noted down their considerations concerning the scoring process and the content of the MITS in a semi-structured questionnaire. Sampling of the GPs was based on maximum variation and data saturation was used as a stopping criterion. An inductive approach was used to analyse the data. In response to scoring problems the score options were adjusted and all consultations were assessed using the original and the adjusted score options.

RESULTS

Twenty seven assessments were needed to reach data saturation. In most consultations, the health behaviour was not the reason for encounter but was discussed on top of discussing physical problems. The topic that was most discussed in the consultations was smoking cigarettes. The adjusted score options increased the response process validity; they were more in agreement with theoretical constructs and the observed quality of MI in the consultations. Concerning content validity, we found that the MITS represents the broad spectrum and the current understanding of MI. Furthermore, the MITS proved to be feasible to assess MI in brief consultations in general practice.

CONCLUSIONS

Based on the collected evidence the MITS seems a promising instrument to measure MI interviewing in brief consultations. The evidence gathered in this study lays the foundation for research into other aspects of validation.

Blended learning in CME: the perception of GP trainers

INTRODUCTION

Blended learning (the combination of electronic methods with traditional teaching methods) has the potential to combine the best of traditional education with the best of computer-mediated training. We chose to develop such an intervention for GP trainers who were undertaking a Continuing Medical Education (CME) course in evidence-based medicine (EBM). This study reports on our experience and investigated the factors influencing the perception on usefulness and logistics of blended learning for learners in CME.

METHODS

In total, 170 GP trainers participated in the intervention. We used questionnaires, observations during the four face-to-face meetings and evaluations in the e-course over one year. Additionally we organised focus groups to gain insight in some of the outcomes of the questionnaires and interpretations of the observations.

RESULTS

The GP trainers found the design and the educational method (e-course in combination with meetings) attractive, instructive and complementary. Factors influencing their learning were (1) educational design, (2) educational method, (3) topic of the intervention, (4) time (planning), (5) time (intervention), (6) learning style, (7) technical issues, (8) preconditions and (9) level of difficulty. A close link between daily practice and the educational intervention was considered an important precondition for the success of the intervention in this group of learners.

CONCLUSION

GP trainers were positive about blended learning: they found e-learning a useful way to gain knowledge and the meetings a pleasant way of transferring the knowledge into practice. Although some preconditions should be taken into consideration during its development and implementation, they would participate in similarly designed learning in the future.

Differential growth in doctor-patient communications skills

CONTEXT

Although doctor-patient communication is considered a core competency for medical doctors, the effect of training has not been unequivocally established. Moreover, knowledge about the variance in the growth of different skills and whether certain patterns in growth can be detected could help us to develop more efficient programmes. We therefore investigated the growth in general practitioner (GP) trainees' doctor-patient communication skills in their first year and whether the growth was different for distinct categories of skills.

METHODS

Seventy-one first-year GP trainees were invited to participate in a study aimed at measuring their consultation skills at the beginning (baseline) and at the end of their first year (follow-up). Consultation skills were assessed with the MAAS-Global rating list for consultation skills.

RESULTS

Data on 29 general practitioner trainees were collected. MAAS-Global scores showed a significant growth on all items but one. Patient-oriented skills showed significantly more growth than task-oriented skills. Empathy as a separate skill seems to be mastered predominantly before the start of training.

CONCLUSIONS

Three patterns in the growth in skills were distinguished: (i) low baseline, relatively high follow-up, (ii) moderate baseline, moderate growth and (iii) high baseline, hardly any growth. Patient-oriented skills follow either pattern (i) or (iii), whereas task-oriented skills follow pattern (ii). These findings may help to define where the focus should lie in the training of doctor-patient communication skills.

Steering the patient mix of GP trainees: results of a randomized controlled intervention

BACKGROUND

In studies exploring the patient mixes of general practitioner (GP) trainees, gaps were repeatedly found, as there were disparities between the patient mixes of GP trainers and trainees. This reduces the opportunities of trainees to acquire enough competence.

AIMS

To investigate whether steering the patient mix can be effectuated by instructing medical receptionist, trainer and trainee, and to study the effects of this intervention on trainee's self-efficacy (SE) and knowledge.

METHOD

Randomized Controlled Trial (RCT). After a six-month basic registration period, 73 trainees were randomized. Patients with skin conditions and psychosocial conditions were actively assigned to trainees in the intervention group (n=35) during two successive periods of three months. The patient mix was measured by extracting data from electronic patient records. Learning outcomes were measured by SE questionnaires and by a knowledge test.

RESULTS

No increase was found in patient volume and diversity of the steered conditions in the intervention group as compared to the control group. However, the percentual increase of exposure to skin conditions was greater in the intervention group. No difference in skin SE and psychiatric knowledge was found. The increase of psychosocial SE was greater in the intervention group. In a regression analysis, patient volume was a significant predictor of both skin and psychosocial SE.

CONCLUSIONS

Despite the difficulty in implementing steering in daily practice, tailoring the patient mix to the individual learning needs of trainees could be considered.

SMART, SMARTER, SMARTEST: the influence of peer groups compared to practice visits on the quality of action plans

BACKGROUND

It has been reported that appraisal by peers can be effective.

AIM

To investigate whether feedback from a peer group (PG) compared to that by a staff member during a practice visit (PV) is as effective in improving the quality of action plans.

METHODS

Seventy-three general practitioner (GP) trainers randomized into either a PG or PV were instructed to draw up action plans using the SMART criteria to realize the goals set in their personal development plans (PDPs). To improve action plans, feedback was given in either PG or PV. Quality of baseline and follow-up action plans, operationalized as the SMARTness with which plans were formulated, was assessed using a study-specific instrument.

RESULTS

Response rate for submitting both baseline and follow-up action plans was 89% in the PG versus 79% in the PV. It was feasible to determine scores on all SMART criteria, except for the criterion 'Acceptability'. Significant improvement was made on the remaining four criteria irrespective of the feedback setting.

CONCLUSIONS

PGs cost less and seem equally effective in improving the SMARTness of the action plans. Moreover, they also seem to stimulate GP trainers more to write a PDP. Therefore, they may be favoured over PVs.

Do GP trainers use feedback in drawing up their Personal Development Plans (PDPs)? Results from a quantitative study

BACKGROUND

General practice (GP) trainers play a key role GP trainees' education. To stimulate development of trainer competencies a Personal Development Plan (PDP) can be helpful, especially when feedback is incorporated.

AIMS

To investigate to what extent GP trainers use feedback in PDPs.

METHODS

GP trainers were provided with three feedback sources: trainees' rating scores, trainees' narrative comments, and self-assessment scores. Trainers were instructed to use these while drawing up PDP goals. With quantitative analyses the extent to feedback sources were used was determined.

RESULTS

Of the trainers 93% submitted a PDP. More than 75% of goals were based on provided feedback. Multiple sources addressing the same issue increased feedback use. If two sources pointed in the same direction, feedback was used more often if one of them concerned "narrative comments". Ratings were lowest for GP-related Expertise and Teaching Skills. Most goals defined concerned these domains. Fewer goals regarded Personal Functioning. Proportion of feedback used concerning Personal functioning was lowest.

CONCLUSIONS

GP trainers use most feedback and address issues most commented upon. Narrative comments deserve a profound place when eliciting feedback. Research into the quality with which feedback is used in PDP goals should complement these results.

Two-dimensional structure of the MAAS-Global rating list for consultation skills of doctors

BACKGROUND

The MAAS-Global (MG) is widely used to assess doctor-patient communication skills. Reliability and validity have been investigated, but little is known about its dimensionality. Assuming physicians tend to adopt certain styles or preferences in their communication with patients, a multi-dimensional structure of the MG can be hypothesized.

AIM

This study investigates the dimensional structure of the MG and explores the validity of this structure by studying the relationship between potential MG sub-scales and general practice speciality trainees' personal characteristics.

METHODS

Communication skills of 68 first-year trainees in a two-station objective structured clinical examination were assessed. Exploratory factor analysis was conducted on the resulting MG item-scores. With t-tests and correlational analysis, the relationship between MG scores and trainees' personal characteristics was examined.

RESULTS

Two well-interpretable factors were found, representing patient-oriented and task-oriented communication skills. Being born in the Netherlands and empathy were positively associated with overall communication skills. Prior communication skills training was exclusively related to task-oriented communication skills. Empathy was associated with patient-oriented, but not with task-oriented communication skills.

CONCLUSION

The two-dimensional structure of the MG may be valuable in gaining a better understanding of factors influencing the acquisition of communication skills. This may be used to optimize teaching methods in communication skills training.

Opening the black box of cancer patients' quality-of-life change assessments: a think-aloud study examining the cognitive processes underlying responses to transition items

Transition items are a popular approach to determine the clinical significance of patient-reported change. These items assume that patients (1) arrive at a change evaluation by comparing posttest and pretest functioning, and (2) accurately recall their pretest functioning. We conducted cognitive think-aloud interviews with 25 cancer patients prior to and following radiotherapy. Two researchers independently analysed their responses using an analysis scheme based on cognitive process models of Tourangeau et al. and Rapkin and Schwartz. In 112 of the 164 responses to transition items, patients compared current and prior functioning. However, in 104 of these responses, patients did not refer to their functioning at pretest and/or posttest according to transition design's first assumption, but rather used a variety of time frames. Additionally, in 79 responses, the time frame employed and/or description of prior functioning provided differed from those employed in the corresponding pretest items. Transition design's second assumption was therefore not in line with the patients' cognitive processes. Our findings demonstrate that in interpreting transition assessments, one needs to be aware that patients provide change assessments, which are not necessarily based on the cognitive processes intended by researchers and health care providers.

Who determines the patient mix of GP trainees? The role of the receptionist

BACKGROUND

During their specialty training, Dutch GP trainees work at a GP under the supervision of a GP trainer. Research suggests that the patient mix of GP trainees differs from that of their trainers. Receptionists assign patients to either the trainee or the trainer, thereby influencing the patient mix of the trainees. The decision to which doctor to assign is complex and depends on the latitude the receptionists have. Their considerations when assigning patients are unknown.

OBJECTIVE

To study receptionists' assigning behaviour.

METHODS

This was a questionnaire survey. To design the questionnaire, topics about assigning behaviour were identified in a focus group. The resulting questionnaire was sent to 478 GP training practices in the Netherlands.

RESULTS

Response rate was 68%. Of the receptionists, 95% asked for the reason for the consultation at least 'sometimes'. Most (86.3%) of the receptionists considered the patient mix of trainees and trainers to be similar. Almost all receptionists (97%) reported 'often' or 'always' assigning 'every possible problem' to the trainee and a similar picture arose regarding specific subpopulations. However, the receptionists reported that they assigned complex and new patients to the trainers more often than to trainees.

CONCLUSION

With some exceptions, receptionists try to assign trainees a varied patient mix.

Exploring differences in patient mix in a cohort of GP trainees and their trainers

Background During specialty training for general practice, trainees acquire the required competencies through work-based learning. Previous small-scale and older studies suggest that the patient mix of general practitioner (GP) trainees differs from that of their trainers: trainees are exposed to more minor illnesses, and fewer chronic diseases and severe conditions, which may influence the development of their competency. Research question What are the differences in the patient mix between trainees and trainers? Methods 49 first- and 24 third-year trainees and their trainers (n=114) were included in the study. International Classification of Primary Care (ICPC) contact and diagnosis codes were extracted from electronic patient records over 6 months. Results Trainers had double the number of face-to-face consultations, and treble the number of telephone consultations compared with trainees. The trainees' patient mix consisted of significantly more patients with eye diseases, ear diseases, respiratory diseases, skin diseases and minor illnesses compared with their trainers. Trainers encountered significantly more patients with circulatory diseases, psychiatric diseases, metabolic diseases, male genital conditions, social problems, and chronic and oncological diseases. Female trainers and trainees encountered almost twice the number of female conditions compared with their male counterparts, while for male conditions, the opposite was found. Discussion Considerable differences between the patient mix of trainers and trainees were found. Specialty trainers and teachers must be aware of areas of low exposure. Trainers should ensure trainees handle more chronic, complex, psychosocial and circulatory conditions.

A 'short walk' is longer before radiotherapy than afterwards: a qualitative study questioning the baseline and follow-up design

Background

Numerous studies have indirectly demonstrated changes in the content of respondents' QoL appraisal process over time by revealing response-shift effects. This is the first known study to qualitatively examine the assumption of consistency in the content of the cognitive processes underlying QoL appraisal over time. Specific objectives are to examine whether the content of each distinct cognitive process underlying QoL appraisal is (dis)similar over time and whether patterns of (dis)similarity can be discerned across and within patients and/or items.

Methods

We conducted cognitive think-aloud interviews with 50 cancer patients prior to and following radiotherapy to elicit cognitive processes underlying the assessment of 7 EORTC QLQ-C30 items. Qualitative analysis of patients' responses at baseline and follow-up was independently carried out by 2 researchers by means of an analysis scheme based on the cognitive process models of Tourangeau et al. and Rapkin & Schwartz.

Results

The interviews yielded 342 comparisons of baseline and follow-up responses, which were analyzed according to the five cognitive processes underlying QoL appraisal. The content of comprehension/frame of reference changed in 188 comparisons; retrieval/sampling strategy in 246; standards of comparison in 152; judgment/combinatory algorithm in 113; and reporting and response selection in 141 comparisons. Overall, in 322 comparisons of responses (94%) the content of at least one cognitive component changed over time. We could not discern patterns of (dis)similarity since the content of each of the cognitive processes differed across and within patients and/or items. Additionally, differences found in the content of a cognitive process for one item was not found to influence dissimilarity in the content of that same cognitive process for the subsequent item.

Conclusions

The assumption of consistency in the content of the cognitive processes underlying QoL appraisal over time was not found to be in line with the cognitive processes described by the respondents. Additionally, we could not discern patterns of (dis)similarity across and within patients and/or items. In building on cognitive process models and the response shift literature, this study contributes to a better understanding of patient-reported QoL appraisal over time.

Structural equation modeling of health-related quality-of-life data illustrates the measurement and conceptual perspectives on response shift

OBJECTIVE

To illustrate different perspectives on response shift with cancer patients' health-related quality-of-life (HRQL) data. In measurement perspective, the focus is on bias in the measurement of HRQL. In conceptual perspective, the focus is on bias in the explanation of HRQL.

STUDY DESIGN AND SETTING

Data came from a consecutive series of 202 newly diagnosed cancer patients, heterogeneous to cancer site, all undergoing surgery. A HRQL questionnaire was administered before and after surgery. Using structural equation modeling, biases and response shifts in measurement and explanation of HRQL were investigated with respect to patient's cancer site, health status, sex, age, optimism, and social comparison.

RESULTS

Six measurement biases were found, five of which were considered response shift. The "general health" (GH) scale appeared most susceptible to response shift. For example, GH scores were not fully determined by HRQL but also by optimism before surgery and female sex and downward social comparison after surgery. Additionally, two explanation biases were found, neither of which were considered response shift-before and after surgery the mental component of HRQL was not only affected by cancer site and health status but also by optimism and downward social comparison.

CONCLUSION

Our approach enables the distinction and testing of biases and response shifts in the measurement and explanation of HRQL.

Somatically ill persons' self-nominated quality of life domains: review of the literature and guidelines for future studies

OBJECTIVE

To review which domains somatically ill persons nominate as constituting their QoL. Specific objective is to examine whether the method of enquiry affect these domains.

METHODS

We conducted two literature searches in the databases PubMed/Medline, CINAHL and Psychinfo for qualitative studies examining patients' self-defined QoL domains using (1) SEIQoL and (2) study-specific questions. For each database, two researchers independently assessed the eligibility of the retrieved abstracts and three researchers subsequently classified all QoL domains.

RESULTS

Thirty-six eligible papers were identified: 27 studies using the SEIQoL, and nine presenting data derived from study-specific questions. The influence of the method of enquiry on patients' self-nominated QoL domains appears limited: most domains were presented in both types of studies, albeit with different frequencies.

CONCLUSIONS

This review provides a comprehensive overview of somatically ill persons' self-nominated QoL domains. However, limitations inherent to reviewing qualitative studies (e.g., the varying level of abstraction of patients' self-defined QoL domains), limitations of the included studies and limitations inherent to the review process, hinder cross-study comparisons. Therefore, we provide guidelines to address shortcomings of qualitative reports amenable to improvement and to stimulate further improvement of conducting and reporting qualitative research aimed at exploring respondents' self-nominated QoL domains.

Hirschsprung's disease: healthcare meets the needs

OBJECTIVE

The objective of this study was to examine the types of healthcare services used by children, adolescents, and adults with Hirschsprung Disease (HD) in relation to the severity of the initial defect (mild, severe), whether additional care was needed, the provision of information, transfer to adult care, and satisfaction with the care provided.

METHODS

Three hundred twenty (71%) HD patients, ages 6 to 54, completed a questionnaire that assessed the use of healthcare services, the need for more healthcare, the provision of information, the transfer to adult care and satisfaction with the provided care.

RESULTS

In 6 months, 45% of the children, 14% of the adolescents, and 15% of the adults consulted a medical specialist. Compared with patients with a mild form of HD in the age range of 6 to 16 years, only the more severely afflicted adult patients visited medical professionals more often (10% vs 29%) (P < .05). Of the children, the adolescents, and the adults 23%, 8%, and 6% respectively consulted a nonmedical professional. Less than 15% of all patients whould have liked more treatment. In 6 months 51% of the children, 24% of the adolescents, and 21% of the adults received treatment information, of which respectively 14, 8, and 20% wished they had received more information. Three (12%) patients who needed adult care encountered problems with the transfer. Almost all patients were satisfied with the care provided.

CONCLUSIONS

There is good access to medical healthcare services, especially for children. The only lacuna in the healthcare system we revealed was a lack of information, particularly for adult patients. Most parents and patients reported to be very satisfied with the provided care.

Quality of life in newly diagnosed cancer patients waiting for surgery is seriously impaired

BACKGROUND AND OBJECTIVES

Newly diagnosed cancer patients waiting for initial surgery experience a stressful time. Study objectives were (1) to examine the quality of life (QL) of these patients by comparing QL (a) between the four diagnostic groups included in this study, (b) to the QL of the general population, (2) to determine the factors that contribute most to patients' overall QL.

METHODS

One hundred ninety six patients with lung, periampullary, oesophageal and cervical cancer completed questionnaires on generic QL (SF-36), overall QL, cancer-site specific symptoms (EORTC-modules), anxiety (STAI), health expectations, demographics and comorbidity.

RESULTS

Between diagnostic groups no significant differences were found on generic QL. As compared to the general population, generic QL was impaired on all aspects except bodily pain. Using stepwise regression analysis, 46% of the variance in overall QL was explained with the SF-36 scales vitality (Beta = 0.43) and mental health (Beta = 0.23) being the most important predictors.

CONCLUSIONS

The QL of these patients is seriously impaired. In this stage, not cancer-site specific aspects but fatigue and emotions colour their lives. It is recommended to keep the waiting period brief. In addition, suggestions are offered by which physicians might help their patients in alleviating the distress.

An application of structural equation modeling to detect response shifts and true change in quality of life data from cancer patients undergoing invasive surgery

The objective is to show how structural equation modeling can be used to detect reconceptualization, reprioritization, and recalibration response shifts in quality of life data from cancer patients undergoing invasive surgery. A consecutive series of 170 newly diagnosed cancer patients, heterogeneous to cancer site, were included. Patients were administered the SF-36 and a short version of the multidimensional fatigue inventory prior to surgery, and 3 months following surgery. Indications of response shift effects were found for five SF-36 scales: reconceptualization of 'general health', reprioritization of 'social functioning', and recalibration of 'role-physical', 'bodily pain', and 'vitality'. Accounting for these response shifts, we found deteriorated physical health, deteriorated general fitness, and improved mental health. The sizes of the response shift effects on observed change were only small. Yet, accounting for the recalibration response shifts did change the estimate of true change in physical health from medium to large. The structural equation modeling approach was found to be useful in detecting response shift effects. The extent to which the procedure is guided by subjective decisions is discussed.

Methods to detect response shift in quality of life data: a convergent validity study

When measuring changes in quality of life (QL) with a pretest-posttest design, response shift can affect results. We investigated the convergent validity of three approaches to detect response shift. (1) In the thentest approach, response shift is measured using a retrospective judgment of pretest QL-levels (thentest). (2) In the anchor-recalibration approach response shift is measured, assessing shifts in patients' individual definitions of the scale-anchors (worst and best imaginable QL) over time. (3) In the Structural Equation Modeling (SEM) approach response shift is indicated by mathematically defined changes in factor solutions and variance-covariance matrices over time. Prior to and three months after invasive surgery, 170 cancer patients completed the SF-36, the Multidimensional Fatigue Inventory (as pre-, post-, and thentest), and the anchor-recalibration task (as pre-, and posttest). Results showed agreement between the thentest and SEM approach on the absence (6 scales) and presence (2 scales) of response shift in 8 of the 9 scales. For the ninth scale both methods detected response shift, but in opposite directions. Possible explanations for this discrepancy are discussed. The anchor-recalibration task agreed with the other approaches on only the absence of response shift in 4 of the 7 scales. The convergent results of thentest and SEM support their validity, especially because they use statistically independent operationalizations of response shift. In this study, recall bias did not invalidate thentest results.

Anorectal malformations: does healthcare meet the needs?

OBJECTIVES

The first aim was to identify the types of healthcare services used by children, adolescents, and adults with anorectal malformation (ARM) in relation to the severity of their disease and to examine whether additional care was needed. The second aim was to evaluate specific areas in the healthcare system, including provided information, transfer from pediatric to adult care, and satisfaction with the provided care.

METHODS

Three hundred eighty-six (61%) patients with ARM, ages 6 to 52, completed a questionnaire that assessed their use of healthcare services and the need for additional services. Also, questions were asked about specific areas in the healthcare system. Clinical and sociodemographic characteristics were extracted from medical records.

RESULTS

In the preceding 6 months 50% of the children, 24% of the adolescents, and 24% of the adults consulted a medical specialist. Compared with patients with a mild form of ARM in the age range of 6 to 16 years, the more severely afflicted patients visited medical professionals more often (18% vs. 32%). Particularly, adolescents in the age range of 12 to 16 years with a severe form of the disease more often visited the pediatric surgeon than their peers with a mild form (2% vs. 16%). Twenty-three percent of the children, 7% of the adolescents, and 8% of the adults consulted a nonmedical professional. Twenty percent of the children, 13% of the adolescents, and 17% of the adults would have liked additional or more treatment of a nonmedical professional. In 6 months, 40% of the children, 24% of the adolescents, and 20% of the adults received treatment information. One third of the adult patients who were transferred to "adult" surgeons encountered transfer problems. Almost all patients were satisfied with the care provided.

CONCLUSIONS

There is good access to medical healthcare services, especially for children. However, more psychosocial and paramedical care is considered necessary. As could be expected, children and adolescents with a severe form of the disease reported to have visited a medical specialist more often. Although healthcare for patients with ARM may be improved at certain points, most parents and patients were very satisfied with the care provided.

Quality of life after colon interposition by necessity for esophageal cancer replacement

BACKGROUND

After esophagectomy for cancer, the first choice for reconstruction of the gastrointestinal continuity is by gastric tube. When this is not feasible, a reconstruction by colon interposition can be performed. The aim of this study was to assess the quality of life in patients at least 6 months after esophageal cancer resection and colon interposition without signs of recurrent disease. The results were compared with previously published data of patients after esophageal cancer resection and gastric tube reconstruction.

PATIENTS AND METHODS

Between January 1993 and January 2002, 36 patients underwent esophageal cancer resection and gastrointestinal reconstruction by colon interposition. A one-time Quality of Life assessment was carried out in 14 patients who were still disease free after a median follow-up of 21 months (mean 35, range 7-97). The patients were visited at home and asked to fill in questionnaires which consisted of the Short Form-36 (SF-36) Health Survey to assess general quality of life, an adapted Rotterdam Symptom Checklist to assess disease-specific quality of life, a visual analogue scale, and an additional questionnaire concerning other specific effects of the operation.

RESULTS

All 14 patients returned the completed set of questionnaires. Compared to the previously published results of patients after gastric tube reconstruction patients with a colon interposition scored significantly (P < or = 0.05) lower in five of the eight subscales of the SF-36 questionnaire (i.e. general health, physical role, vitality, social functioning, and mental health). The most frequent symptoms measured by the Rotterdam Symptom Checklist were early satiety after a meal, dysphagia, diarrhea, loss of sexual interest, and fatigue. Six patients could not independently run their housekeeping and four patients still needed artificial enteral nutrition.

CONCLUSION

Based on the SF-36 questionnaire, patients after colon interposition by necessity have a poor general quality of life. Even long after the operation they have a broad spectrum of persisting symptoms. Prior to surgery, patients should be informed about the disabling long-term functional outcome of a colon interposition.

The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life

OBJECTIVE

To evaluate the effect of a prophylactic gastrojejunostomy on the development of gastric outlet obstruction and quality of life in patients with unresectable periampullary cancer found during explorative laparotomy.

SUMMARY BACKGROUND DATA

Several studies, including one randomized trial, propagate to perform a prophylactic gastrojejunostomy routinely in patients with periampullary cancer found to be unresectable during laparotomy. Others suggest an increase of postoperative complications. Controversy still exists in general surgical practice if a double bypass should be performed routinely in these patients.

METHODS

Between December 1998 and March 2002, patients with a periampullary carcinoma who were found to be unresectable during exploration were randomized to receive a double bypass (hepaticojejunostomy and a retrocolic gastrojejunostomy) or a single bypass (hepaticojejunostomy). Randomization was stratified for center and presence of metastases. Patients with gastrointestinal obstruction and patients treated endoscopically for more than 3 months were excluded. Primary endpoints were development of clinical gastric outlet obstruction and surgical intervention for gastric outlet obstruction. Secondary endpoints were mortality, morbidity, hospital stay, survival, and quality of life, measured prospectively by the EORTC-C30 and Pan26 questionnaires. It was decided to perform an interim analysis after inclusion of 50% of the patients (n = 70).

RESULTS

Five of the 70 patients randomized were lost to follow-up. From the remaining 65 patients, 36 patients underwent a double and 29 a single bypass. There were no differences in patient demographics, preoperative symptoms, and surgical findings between the groups. Clinical symptoms of gastric outlet obstruction were found in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%) with a single bypass (P = 0.001). In the double bypass group, one patient (2.8%) and in the single bypass group 6 patients (20.7%) required (re-)gastrojejunostomy during follow-up (P = 0.04). The absolute risk reduction for reoperation in the double bypass group was 18%, and the numbers needed to treat was 6. Postoperative morbidity rates, including delayed gastric emptying, were 31% in the double versus 28% in the single bypass group (P = 0.12). Median postoperative length of stay was 11 days (range 4-76 days) in the double versus 9 days (range 6-20 days) in the single bypass group (P = 0.06); median survival was 7.2 months in the double versus 8.4 months in the single bypass group (P = 0.15). No differences were found in the quality of life between both groups. After surgery most quality of life scores deteriorated temporarily and were restored to their baseline score (t = -1) within 4 months.

CONCLUSIONS

Prophylactic gastrojejunostomy significantly decreases the incidence of gastric outlet obstruction without increasing complication rates. There were no differences in quality of life between the two groups. Together with the previous randomized trial from the Hopkins group, this study provides sufficient evidence to state that a double bypass consisting of a hepaticojejunostomy and a prophylactic gastrojejunostomy is preferable to a single bypass consisting of only a hepaticojejunostomy in patients undergoing surgical palliation for unresectable periampullary carcinoma. Therefore, the trial was stopped earlier than planned.

Stress, satisfaction and burnout among Dutch medical specialists

BACKGROUND

Stress and stress-related illnesses are increasing among medical specialists. This threatens the quality of patient care. In this study we investigated (a) levels of job stress and job satisfaction among medical specialists, (b) factors contributing to stress and satisfaction and (c) the effect of stress and satisfaction on burnout.

METHODS

A questionnaire was mailed to a random sample of 2400 Dutch medical specialists. Measures included job stress, job satisfaction, burnout, personal characteristics, job characteristics and perceived working conditions.

RESULTS

The final response rate was 63%. Of the respondents, 55% acknowledged high levels of stress, and 81% reported high job satisfaction. Personal and job characteristics explained 2%-6% of the variance in job stress and satisfaction. Perceived working conditions were more important, explaining 24% of the variance in job stress and 34% of the variance in job satisfaction. Among perceived working conditions, the interference of work on home life (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.35-1.76) and not being able to live up to one's professional standards (OR 1.57, 95% CI 1.37-1.80) were most related to stress. Feeling poorly managed and resourced (OR 2.07, 95% CI 1.76-2.43) diminished job satisfaction. Burnout was explained by both high stress and low satisfaction (41% of variance explained) rather than by stress alone.

INTERPRETATION

Our study showed a protective effect of job satisfaction against the negative consequences of work stress as well as the importance of organizational rather than personal factors in managing both stress and satisfaction.

Sex differences in physician burnout in the United States and The Netherlands

OBJECTIVE

to determine if there are sex differences in physician burnout in the Netherlands and, if not, to explore why they are present in the United States.

METHODS

Separate physician surveys were conducted in the United States (n=2326) and the Netherlands (n=1426). Thirty-three percent of US respondents were female (adjusted response rate 52%); 18% of Dutch respondents were female (adjusted response rate 63%). Standardized mean sex differences (effect sizes) in burnout variables were calculated and compared crossnationally.

RESULTS

US women experienced more burnout than US men did (28% v 21%, p<.01), but the sex difference in burnout among Dutch physicians was not significant. Women in both countries worked fewer hours than men did (48 v 56 US, 44 v 56 NL, difference in effect sizes of sex differences between US and NL, p<.001). Although women in both countries described less work control than men, the effect size of the sex difference in the United States was more than twice that in the Netherlands (.34 US v .15 NL, p<.01). Children, home support, and work-home interference were comparable between sexes in the United States.

CONCLUSIONS

Gender parity in physician burnout in the Netherlands may be due to fewer work hours and greater work control of women compared to those in the United States.