BackgroundTo support professional development of medical students faced with challenges of the clinical phase, collaborative reflection sessions (CRSs) are used to share and reflect on workplace... Show moreBackgroundTo support professional development of medical students faced with challenges of the clinical phase, collaborative reflection sessions (CRSs) are used to share and reflect on workplace experiences. Facilitation of CRSs seems essential to optimise learning and to provide important skills for lifelong learning as a professional. However, little is known about which workplace experiences students share in CRSs without advance guidance on specific topics, and how reflecting on these experiences contributes to students’ professional development. Therefore, we explored which workplace experiences students shared, what they learned from reflection on these experiences, and how they perceived the value of CRSs.MethodsWe conducted an exploratory study among medical students (N = 99) during their General Practice placement. Students were invited to openly share workplace experiences, without pre-imposed instruction. A thematic analysis was performed on shared experiences and student learning gains. Students’ perceptions of CRSs were analysed using descriptive statistics.ResultsAll 99 students volunteered to fill out the questionnaire. We found four themes relating to students’ shared experiences: interactions with patients, complex patient care, diagnostic or therapeutic considerations, and dealing with collegial issues. Regarding students’ learning gains, we found 6 themes: learning from others or learning from sharing with others, learning about learning, communication skills, self-regulation, determination of position within the healthcare team, and importance of good documentation. Students indicated that they learned from reflection on their own and peer’s workplace experiences. Students valued the CRSs as a safe environment in which to share workplace experiences and helpful for their professional development.ConclusionsIn the challenging General Practice placement, open-topic, guided CRSs provide a helpful and valued learning environment relevant to professional development and offer opportunities for vicarious learning among peers. CRSs may also be a valuable tool to incorporate into other placements. Show less
BackgroundAs there is a need to prepare doctors to minimize errors, we wanted to determine how doctors go about reflecting upon their medical errors.MethodsWe conducted a thematic analysis of the... Show moreBackgroundAs there is a need to prepare doctors to minimize errors, we wanted to determine how doctors go about reflecting upon their medical errors.MethodsWe conducted a thematic analysis of the published reflection reports of 12 Dutch doctors about the errors they had made. Three questions guided our analysis: What triggers doctors to become aware of their errors? What topics do they reflect upon to explain what happened? What lessons do doctors learn after reflecting on their error?ResultsWe found that the triggers which made doctors aware of their errors were mostly death and/or a complication. This suggests that the trigger to recognize that something might be wrong came too late. The 12 doctors cited 20 topics’ themes that explained the error and 16 lessons-learnt themes. The majority of the topics and lessons learnt were related more to the doctors’ inner worlds (personal features) than to the outer world (environment).ConclusionTo minimize errors, doctors should be trained to become earlier and in time aware of distracting and misleading features that might interfere with their clinical reasoning. This training should focus on reflection in action and on discovering more about doctors’ personal inner world to identify vulnerabilities. Show less
Aimed to gain insight into patients’ expectations regarding the professionalism of GPs, we first studied unsolicited patient complaints. It appeared that a substantial proportion of unsolicited... Show moreAimed to gain insight into patients’ expectations regarding the professionalism of GPs, we first studied unsolicited patient complaints. It appeared that a substantial proportion of unsolicited complaints concern professionalism issues. This dissertation provides insight into how patients experience unprofessional behaviour of physicians.Further, it provides educators with appropriate language to describe the unprofessional behaviour of residents, which matches that of the 4 I’s model. This language can contribute to the early identification of professionalism issues and the remediation of lapses in professionalism.This dissertation also provides insights into the PIF of GP residents from the perspectives of both supervisors and residents. According to residents, identity formation occurs primarily in the workplace as they move from doing the work of to becoming a GP and negotiate perceived norms. Residents feel that a tapestry of interrelated influencing factors – most prominently clinical experiences, clinical supervisors, and self-assessments – which changes over time, is felt to exert its influence predominantly in the workplace. Their supervisors have an image of the professional identity they are supporting and work toward that goal through role-modeling and mentoring. Supervisors believe that a bond of trust between supervisor and resident is a prerequisite to properly support residents’ PIF. Show less
Background: Psychosocial problems in children and youth are common and may negatively impact their lives and the lives of their families. Since general practitioners (GPs) play a crucial role in... Show moreBackground: Psychosocial problems in children and youth are common and may negatively impact their lives and the lives of their families. Since general practitioners (GPs) play a crucial role in detecting and intervening in such problems, it is clinically necessary to improve our insight into their clinical decision-making (CDM). The objective of this study was to explore which mechanisms underlie GPs' everyday CDM and their options for management or referral. Material and methods: This was a mixed methods study in which qualitative (interview substudy) and quantitative (online survey substudy) data were collected from GPs. Using a question framework and vignettes representative of clinical practice, GPs' CDM was explored. GPs were selected by means of an academic research network and purposive sampling. Data collection continued in constant comparison between both substudies. Using grounded theory, data from both substudies were triangulated into a flowchart consisting of mechanisms and management/referral options. Results: CDM-mechanisms were divided into three groups. GP-related mechanisms were GPs' primary approach of the problem (somatically or psychosocially) and their self-assessed competence to solve the problem based on interest in and knowledge about youth mental health care. Mechanisms related to the child and its social context included GPs' assessment whether there was psychiatric (co)morbidity, their sense of self-limitedness of the problem and assessed complexity of the problem. Whether GPs' had existing collaboration agreements with youth care providers and how they experienced their collaboration were collaboration-related mechanisms. Conclusion: The current study contributes to a relatively unexplored research area by revealing GP's in-depth thought processes regarding their CDM. However, existing research in this area supports the identified CDM mechanisms. Future initiatives should focus on validating CDM mechanisms in a larger population. If confirmed, mechanisms could be integrated into GP training and may offer guidelines for regulating proper access to mental health care services. Show less
Purpose Supporting the development of a professional identity is a primary objective in postgraduate education. Few empirical studies have explored professional identity formation (PIF) in... Show morePurpose Supporting the development of a professional identity is a primary objective in postgraduate education. Few empirical studies have explored professional identity formation (PIF) in residency, and little is known about supervisors' perceptions of their roles in residents' PIF. In this study, we sought to understand how supervisors perceive their roles in the PIF of General Practice (GP) residents. Materials and methods Guided by principles of qualitative description, we conducted eight focus groups with 55 supervisors at four General Practice training institutes across the Netherlands. Informed by a conceptual framework of PIF, we performed a thematic analysis of focus group transcripts. Results Three themes related to how GP supervisors described their roles in supporting residents' PIF: supervising with the desired goal of GP training in mind; role modeling and mentoring as key strategies to achieve that goal; and the value of developing bonds of trust to support the process. Conclusions To our knowledge, this study is the first to explore PIF in GP training from the perspective of clinical supervisors. The identified themes mirror the components of the therapeutic alliance between doctors and patients from a supervisor's perspective and highlight the pivotal roles of the supervisor in a resident's PIF. Show less
Objectives: To move beyond professionalism as a measurable competency, medical educators have highlighted the importance of forming a professional identity, in which learners come to 'think, act,... Show moreObjectives: To move beyond professionalism as a measurable competency, medical educators have highlighted the importance of forming a professional identity, in which learners come to 'think, act, and feel like physicians'. This socialisation process is known as professional identity formation (PIF). Few empirical studies on PIF in residency have been undertaken. None of these studies focused on PIF during the full length of GP training as well as the interplay of concurrent socialising factors. Understanding the socialisation process involved in the development of a resident's professional identity and the roles of influencing factors and their change over time could add to a more purposeful approach to PIF. Therefore, we aimed to investigate the process of PIF during the full length of General Practice (GP) training and which factors residents perceive as influential. Design: A qualitative descriptive study employing focus group interviews. Setting: Four GP training institutes across the Netherlands. Participants: Ninety-two GP residents in their final training year participated in 12 focus group interviews. Results: Study findings indicated that identity formation occurs primarily in the workplace, as residents move from doing to becoming and negotiate perceived norms. A tapestry of interrelated influencing factors-most prominently clinical experiences, clinical supervisors and self-assessments-changed over time and were felt to exert their influence predominantly in the workplace. Conclusions: This study provides deeper empirical insights into PIF during GP residency. Doing the work of a GP exerted a pivotal influence on residents' shift from doing as a GP to thinking, acting and feeling like a GP, that is, becoming a GP. Clinical supervisors are of utmost importance as role models and coaches in creating an environment that supports residents' PIF. Implications for practice include faculty development initiatives to help supervisors be aware of how they can perform their various roles across different PIF stages. Show less
Background: Chronic diseases are often associated with sexual dysfunction (SD). Little is known about the practice patterns of general practitioners (GPs) regarding sexual care for chronically ill... Show moreBackground: Chronic diseases are often associated with sexual dysfunction (SD). Little is known about the practice patterns of general practitioners (GPs) regarding sexual care for chronically ill patients. Therefore, the aim of this study was to examine; to what extent GPs discuss SD with chronically ill patients; the barriers that may stop them; and the factors associated with discussing SD. Methods: A cross-sectional survey using a 58-item questionnaire was sent to 604 Dutch GPs. Descriptive statistics and associations were used for analysis of the data. Results: Nearly 58% (n = 350) of all GPs approached gave a response and 204 questionnaires were analysable (33.8%). Almost 60% of respondents considered discussing SD with patients important (58.3%, n = 119). During the first consultation, 67.5% (n = 137) of the GPs reported that they never discussed SD. The most important barrier stopping them was lack of time (51.7%, n = 104). The majority (90.2%, n = 184) stated that the GP was responsible for addressing SD; 70.1% (n = 143) indicated that the GP practice somatic care nurse (GPN) was also responsible. Nearly 80% (n = 161) of respondents were unaware of agreements within the practice on accountability for discussing SD. This group discussed SD less often during first and follow-up consults (p = 0.002 and p < 0.001, respectively). Of the respondents, 61.5% (n = 116) felt that they had received insufficient education in SD and 74.6% (n = 150) stated that the subject is seldom discussed during training. Approximately 62% of the GPs (n = 123) wanted to increase their knowledge, preferably through extra training. According to 53.2% of the GPs (n = 107) it was important to improve the knowledge of the GPN. The most frequently mentioned tool that could help improve the conversation about SD was the availability of information brochures for patients (n = 123, 60.3%). Conclusions: This study indicates that Dutch GPs do not discuss SD with chronically ill patients routinely, mainly due to lack of time. An efficient tool is needed to enable GPs to address SD in a time-saving manner. Increased availability of informational materials, agreements on accountability within GP practices, and extra training for the GPs and GPNs could improve the discussion of SD. Show less
Background Lapses in professionalism have profound negative effects on patients, health professionals, and society. The connection between unprofessional behaviour during training and later... Show moreBackground Lapses in professionalism have profound negative effects on patients, health professionals, and society. The connection between unprofessional behaviour during training and later practice requires timely identification and remediation. However, appropriate language to describe unprofessional behaviour and its remediation during residency is lacking. Therefore, this exploratory study aims to investigate which behaviours of GP residents are considered unprofessional according to supervisors and faculty, and how remediation is applied. Methods We conducted eight semi-structured focus group interviews with 55 broadly selected supervisors from four Dutch GP training institutes. In addition, we conducted individual semi-structured interviews with eight designated professionalism faculty members. Interview recordings were transcribed verbatim. Data were coded in two consecutive steps: preliminary inductive coding was followed by secondary deductive coding using the descriptors from the recently developed 'Four I's' model for describing unprofessional behaviours as sensitising concepts. Results Despite the differences in participants' professional positions, we identified a shared conceptualisation in pinpointing and assessing unprofessional behaviour. Both groups described multiple unprofessional behaviours, which could be successfully mapped to the descriptors and categories of the Four I's model. Behaviours in the categories 'Involvement' and 'Interaction' were assessed as mild and received informal, pedagogical feedback. Behaviours in the categories 'Introspection' and 'Integrity', were seen as very alarming and received strict remediation. We identified two new groups of behaviours; 'Nervous exhaustion complaints' and 'Nine-to-five mentality', needing to be added to the Four I's model. The diagnostic phase of unprofessional behaviour usually started with the supervisor getting a 'sense of alarm', which was described as either a 'gut feeling', 'a loss of enthusiasm for teaching' or 'fuss surrounding the resident'. This sense of alarm triggered the remediation phase. However, the diagnostic and remediation phases did not appear consecutive or distinct, but rather intertwined. Conclusions The processes of identification and remediation of unprofessional behaviour in residents appeared to be intertwined. Identification of behaviours related to lack of introspection or integrity were perceived as the most important to remediate. The results of this research provide supervisors and faculty with an appropriate language to describe unprofessional behaviours among residents, which can facilitate timely identification and remediation. Show less
Background: Professionalism is a key competence for physicians. Patient complaints provide a unique insight into patient expectations regarding professionalism. Research exploring the exact nature... Show moreBackground: Professionalism is a key competence for physicians. Patient complaints provide a unique insight into patient expectations regarding professionalism. Research exploring the exact nature of patient complaints in general practice, especially focused on professionalism, is limited. Aim: To characterise patient complaints in primary care and to explore in more detail which issues with professionalism exist. Design & setting: A retrospective observational study in which all unsolicited patient complaints to a representative out- of- hours general practice (OOH GP) service provider in The Netherlands were analysed over a 10- year period (2009–2019). Method: Complaints were coded for general characteristics and thematically categorised using the CanMEDS Physician Competency Framework (CanMEDS) as sensitising concepts. Complaints categorised as professionalism were subdivided using open coding. Results: Out of 746 996 patient consultations (telephone, face- to- face, and home visits) 484 (0.065%) resulted in eligible complaint letters. The majority consisted of two or more complaints, resulting in 833 different complaints. Most complaints concerned GPs (80%); a minority (19%) assistants. Thirty- five per cent concerned perceived professionalism lapses of physicians. A rich diversity in the wording of professionalism lapses was found, where 'not being taken seriously' was mentioned most often. Forty- five per cent related to medical expertise, such as missed diagnoses or unsuccessful clinical treatment. Nineteen per cent related to management problems, especially waiting times and access to care. Communication issues were only explicitly mentioned in 1% of the complaints. Conclusion: Most unsolicited patient complaints were related to clinical problems. A third, however, concerned professionalism issues. Not being taken seriously was the most frequent mentioned theme within the professionalism category. Show less
Background. Assessment of sexual health is important in chronically ill patients, as many experience sexual dysfunction (SD). The general practice nurse (GPN) can play a crucial part in addressing... Show moreBackground. Assessment of sexual health is important in chronically ill patients, as many experience sexual dysfunction (SD). The general practice nurse (GPN) can play a crucial part in addressing SD.Objective. The aim of this cross-sectional study was to examine to which extent GPNs discuss SD with chronically ill patients and what barriers may refrained them from discussing SD. Furthermore, we examined which factors had an association with a higher frequency of discussing SD.Methods. A cross-sectional survey using a 48-item questionnaire was send to 637 GPNs across the Netherlands.Results. In total, 407 GPNs returned the questionnaire (response rate 63.9%) of which 337 completed the survey. Two hundred and twenty-one responding GPNs (65.6%) found it important to discuss SD. More than half of the GPNS (n = 179, 53.3%) never discussed SD during a first consultation, 60 GPNs (18%) never discussed SD during follow-up consultations. The three most important barriers for discussing SD were insufficient training (54.7%), 'reasons related to language and ethnicity' (47.5%) and 'reasons related to culture and religion' (45.8%). More than half of the GPNs thought that they had not enough knowledge to discuss SD (n = 176, 54.8%). A protocol on addressing SD would significantly increase discussing during SD.Conclusions. This study indicates that GPNs do not discuss SD with chronically ill patients routinely. Insufficient knowledge, training and reasons related to cultural diversity were identified as most important reasons for this practice pattern. Implementation of training in combination with guidelines on SD in the general practice could improve on the discussing of sexual health with chronic patients. Show less
The finding in the article by Driever et al.; "Shared decision,making: Physicians' preferred role, usual role and their perception of its key components" of lower preferred and practiced SDM role... Show moreThe finding in the article by Driever et al.; "Shared decision,making: Physicians' preferred role, usual role and their perception of its key components" of lower preferred and practiced SDM role in residents in favour of a paternalistic role, compared to their more seasoned colleagues deserves more in depth, qualitative research. Because our residents are tomorrows doctors, I would strongly encourage the authors of this insightful article to consider research focused on residents as the next step in their research on SDM and to see this future research through a 'medical-education-PIF-lens'. The multi-level professionalism framework, designed as a framework for reflection and development in medical education might be of help is this future research. Show less
