Fostering the clinician as teacher: A realist review.

BACKGROUND: Clinician-teachers, physicians with educational responsibilities in either classroom or clinical setting, are assumed to add value by virtue of their dual role. The clinical responsibilities are often prioritised over the educational tasks. How and under which circumstances clinician-teachers are able to perform their educational role and create added value for different stakeholders is currently unclear. OBJECTIVES: To identify for whom, how and under which circumstances educational activities executed by CTs by virtue of their dual role add value to others. SCOPE: CTs activities linking the system of education and clinical practice beyond direct patient interactions and purposefully executed. METHODS: A realist review was conducted. Databases were searched in two stages: a narrow conventional search, followed by a comprehensive artificial intelligence-aided search. Studies concerning clinician-teachers' dual role were included. Realist analysis was applied to identify in which contexts resource mechanisms triggered reasoning mechanisms, which led to specific outcomes for different stakeholders. RESULTS: Sixty-six studies were included. In contexts where clinician-teachers' dual role was formally recognised and valued, clinician-teachers benefitted from the credibility and legitimacy bestowed on them, making the transfer of domain-specific knowledge more impactful. In contexts where sociocultural differences between both systems existed, CTs were able to mediate and adjust recommendations aligned with stakeholders' perceived relevance. Also, contexts organised to support both roles made resource mechanisms more impactful. Clinician-teachers added value to students' clinical competency and learning environment, and to educational organisations' curricular innovation. In their clinical workspace, clinician-teachers added value by enhancing colleague physicians' teaching expertise, implementing educational innovations and recruiting students for scarce specialisms. CONCLUSION: Clinician-teachers add value to students, colleague physicians and the clinical and educational contexts at large. Domain-specific knowledge of both systems was important to gain credibility and achieve added value. Openness, formal recognition and allocated time for both roles in educational and clinical contexts towards the dual role are important to strengthen the impact of the dual role.

Advancing collaboration in health professions education in the general practice domain, developing a national research agenda.

BACKGROUND: Health professions education (HPE) research in the General Practice domain (GP-HPE) is vital for high-quality healthcare. Collaboration among GP-HPE researchers is crucial but challenging. Formulating a research agenda, involving stakeholders, and fostering inter-institutional collaboration can address these challenges and connect educational research and practice. METHODS: We used Q-methodology to explore perspectives on GP-HPE research of participants from all Dutch postgraduate GP training institutes. Participants individually sorted statements based on the relevance of future GP-HPE research for educational practice. Data analysis comprised inverted factor analysis, rotation, and qualitative interpretation of configurations of all statements. The National Meeting on Educational Research took a participatory approach. RESULTS: We included 73 participants with diverse involvement in GP-HPE research. We identified five distinct perspectives, each representing a research focus area for developing and innovating GP education: the clinician scientist, the socially engaged GP, the specific GP identity, the GP as an entrepreneur, and the GP engaged in lifelong learning. DISCUSSION: The resulting five perspectives align with General Practice hallmarks. Q-methodology and a participatory approach facilitated collaboration among stakeholders. Successful inter-institutional collaboration requires a common goal, neutral leadership, participant commitment, regular meetings, audit trail support, process transparency, and reflexivity. Future research should address evidence gaps within these perspectives. CONCLUSION: Using Q-methodology turned out to be valuable for compiling a national research agenda for GP-HPE research. The research process helped to cross boundaries between researchers in different institutions, thus putting inter-institutional collaborative advantage center stage. Our approach could provide a conceivable procedure for HPE researchers worldwide.

Interprofessional education for healthcare professionals. A BEME realist review of what works, why, for whom and in what circumstances in undergraduate health sciences education: BEME Guide No. 83.

AIM: To provide an evidence-informed program theory (PT) for Interprofessional Education (IPE) that adds to the knowledge base of how IPE in undergraduate health sciences education works. METHODS: We undertook a realist review of the literature and synthesis of the evidence combined with stakeholder experience. Our initial program theory (IPT), built around development, delivery and evaluation of IPE interventions, was tested and refined following an in-depth search of the literature and consultation with stakeholders. The literature (2010-2022) was selected based on the realist criteria of relevance and rigor, as well as on conceptual richness of the studies. RESULTS: Our PT is built upon 124 CMOs (Context of IPE interventions, Mechanisms that fired within that context, and IPE Outcomes), from 58 studies. Our PT comprises an array of elements found in the Context, including traits and behavioral displays of students and facilitators, and discusses four Mechanisms (feeling responsible, feeling enthusiastic/excited, feeling safe to take risks, and feeling ready), which are likely to lead to outcomes related to the Interprofessional Education Collaborative (sub)competencies. DISCUSSION: Results were linked to learning theories to further build our understanding. The PT can serve as a guide for the development, delivery, and evaluation of IPE interventions.

The Role of Language in Remote Healthcare Triage: A Meta-Aggregative Review.

AIM(S): To provide an overview of evidence on the role of language in remote healthcare services prioritisation, from now on termed triage. This study synthesises literature, to better understand how language affects triage interactions, aiming to improve these processes. DESIGN: We conducted a meta-aggregative review. METHODS: A systematic search in Scopus from inception to September 2023 identified 437 studies on language in remote healthcare triage, of which 23 were included. Information was selected using both inductive and deductive coding, focusing on six linguistic features of interaction that have been described in the literature on studies using conversation analysis: turn-taking organisation, overall structure, sequence organisation, turn design, lexical choice, and epistemological and other forms of asymmetry. The process followed the RAMESES Publication Standards for Meta-narrative Reviews. RESULTS: Two main findings emerged. First, all six linguistic features are present in triage conversations, indicating that language involves more than just what is said. It also matters, for example, how and when a question is asked. Second, computerised decision support systems (CDSS) significantly affect conversation flow and dynamics. CONCLUSION: Language in triage involves more than literal speech and is heavily influenced by CDSS. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Our study suggests that quality assessments of triage conversations should consider not only what is said but cover all relevant aspects of language. The influence of computerised decision support systems (CDSS) on linguistic features highlights the need for systems to be adaptable, to improve conversation quality and better addressing caller needs rather than focusing on one-size-fits-all questions. IMPACT: This review highlights the complex role of language in triage conversations and its impact on interaction. It calls for a broader view of language in quality assessments, recognising that both call-takers and callers contribute to call quality. Insights from this review can help developers enhance question types, sequence, and delivery methods of computerised decision support systems. Finally, education for call-takers in healthcare sectors may be improved based on our findings. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Learning patient-centredness with simulated/standardized patients: A realist review: BEME Guide No. 68.

BACKGROUND: Given the positive outcomes of patient-centred care on health outcomes, future doctors should learn how to deliver patient-centred care. The literature describes a wide variety of educational interventions with standardized patients (SPs) that focus on learning patient-centredness. However, it is unclear which mechanisms are responsible for learning patient-centredness when applying educational interventions with SPs. OBJECTIVE: This study aims to clarify how healthcare learners and professionals learn patient-centredness through interventions involving SPs in different healthcare educational contexts. METHODS: A realist approach was used to focus on what works, for whom, in what circumstances, in what respect and why. Databases were searched through 2019. Nineteen papers were included for analysis. Through inductive and deductive coding, CIC'MO configurations were identified to build partial program theories. These CIC'MOs describe how Interventions with SPs change the Context (C→C') such that Mechanisms (M) are triggered that are expected to foster patient-centredness as Outcome. RESULTS: Interventions with SPs create three contexts which are 'a safe learning environment,' 'reflective practice,' and 'enabling people to learn together.' These contexts trigger the following seven mechanisms: feeling confident, feeling a sense of comfort, feeling safe, self-reflection, awareness, comparing & contrasting perspectives, combining and broadening perspectives. A tentative final program theory with mechanisms belonging to three main learning components (cognitive, regulative metacognitive and affective) is proposed: Interventions with SPs create a safe learning environment (C') in which learners gain feelings of confidence, comfort and safety (affective M). This safe learning environment enables two other mutual related contexts in which learners learn together (C'), through comparing & contrasting, combining and broadening their perspectives (cognitive M) and in which reflective practice (C') facilitates self-reflection and awareness (metacognitive M) in order to learn patient-centeredness. CONCLUSION: These insights offer educators ways to deliberately use interventions with SPs that trigger the described mechanisms for learning patient-centredness.

Designing the learning of intraprofessional collaboration among medical residents.

BACKGROUND: To preserve quality and continuity of care, collaboration between primary-care and secondary-care physicians is becoming increasingly important. Therefore, learning intraprofessional collaboration (intraPC) requires explicit attention during postgraduate training. Hospital placements provide opportunities for intraPC learning, but these opportunities require interventions to support and enhance such learning. Design-Principles guide the design and development of educational activities when theory-driven Design-Principles are tailored into context-sensitive Design-Principles. The aim of this study was to develop and substantiate a set of theory-driven and context-sensitive Design-Principles for intraPC learning during hospital placements. METHODS: Based on our earlier research, we formulated nine theory-driven Design-Principles. To enrich, refine and consolidate these principles, three focus group sessions with stakeholders were conducted using a Modified Nominal Group Technique. Next, two work conferences were conducted to test the feasibility and applicability of the Design-Principles for developing intraPC educational activities and to sharpen the principles into a final set of Design-Principles. RESULTS: The theoretical Design-Principles were discussed and modified iteratively. Two new Design-Principles were added during focus group 1, and one more Design-Principle was added during focus group 2. The Design-Principles were categorised into three clusters: (i) Culture: building collaborative relations in a psychologically safe context where patterns or feelings of power dynamics between primary and secondary care physicians can be discussed; (ii) Connecting Contexts: making residents and supervisors mutually understand each other's work contexts and activities; and (iii) Making the Implicit Explicit: having supervising teams act as role models demonstrating intraPC and continuously pursuing improvement in intraPC to make intraPC explicit. Participants were unanimous in their view that the Design-Principles in the Culture cluster were prerequisites to facilitate intraPC learning. CONCLUSION: This study led to the development of 12 theory-driven and context-sensitive Design-Principles that may guide the design of educational activities to support intraPC learning during hospital placements.

Bidirectional learning opportunities: How GP-supervisors and trainees exchange knowledge.

INTRODUCTION: Workplace-based learning conversations can be a good opportunity for supervisors and trainees to learn from each other. When both professionals discuss their specific knowledge openly with each other, learning conversations may be a useful educational tool, for instance for learning how to apply evidence-based medicine (EBM) in the workplace. We do, however, need a better understanding of how the exchange of knowledge provides opportunities for such bidirectional learning. The aim of this study was therefore to analyse how trainees and supervisors currently handle bidirectional learning opportunities by describing in detail how supervisors respond to knowledge expressed by trainees during a learning conversation. METHOD: We video-recorded learning conversations between supervisors and trainees in general practice (GP). Within these learning conversations, EBM discussions on medical topics were selected and transcribed. We then identified, analysed using Conversation Analysis (CA) and categorised each expression of knowledge by the trainee and the supervisor's subsequent response. RESULTS: We found that when a trainee expresses knowledge during the learning conversation, supervisors either (a) refute the expressed knowledge, (b) immediately suggest an alternative or (c) pose (additional) questions. These responses have consequences for the learning opportunities of both trainee and supervisor: it is only when supervisors pose further questions that trainees are encouraged to elaborate on their knowledge, leading to a bidirectional learning opportunity. DISCUSSION: Improving EBM learning opportunities for both supervisors and trainees requires more than simply instructing trainees to express knowledge-based-for instance-on recent evidence more often. Inflexible institutional roles related to historical claims of supervisors' epistemic authority hamper bidirectional learning. Posing open questions during learning conversations enhances the flexibility of institutional roles while also creating bidirectional learning opportunities.

Learning Conversations with Trainees: An Undervalued but Useful EBM Learning Opportunity for Clinical Supervisors.

Phenomenon: Supervisors and trainees can learn skills related to evidence-based medicine from each other in the workplace by collaborating and interacting, in this way benefiting from each other's strengths. This study explores supervisors' perceptions of how they currently learn evidence-based medicine by engaging in learning conversations with their trainee. Approach: Semi-structured, video-stimulated elicitation interviews were held with twenty-two Dutch and Belgian supervisors in general practice. Supervisors were shown fragments of their video-recorded learning conversations, allowing them to reflect. Recorded interviews were analyzed using a grounded theory-based approach.Findings: Supervisors did not immediately perceive workplace learning conversations as an opportunity to learn evidence-based medicine from their trainee. They mostly saw these conversations as a learning opportunity for trainees and a chance to maintain the quality of care within their practice. Nevertheless, during the interviews, supervisors did acknowledge that learning conversations help them to gain up-to-date knowledge and search skills or more awareness of their own knowledge or gaps in their knowledge. Not identified as a learning outcome was how to apply evidence-based medicine within a clinical practice by combining evidence with clinical expertise and the patient's preferences. Insights: Supervisors acknowledge that they learn elements of the three aspects of evidence-based medicine by having learning conversations with their trainee, but they currently see this as secondary to the trainee's learning process. Emphasizing opportunities for bidirectional learning could improve learning of evidence-based medicine during workplace learning conversations.

Transcending boundaries for collaborative patient care.

Dutch general practitioners (GPs) and medical specialists (MSs) create collaborative patient care agreements (CPCAs) to improve intraprofessional collaboration. We set out to identify contradictions between the activity systems of primary and secondary care that could result in expansive learning and new ways of working collaboratively. We analysed nineteen semi-structured interviews using activity theory (AT) as a theoretical framework and using these two activity systems as the units of analysis. There were contradictions within and between the activity systems related, for example, to different understandings of 'care' in generalist and specialist settings. GPs and MSs were able to identify contradictions and learn expansively when they iteratively co-created CPCAs in groups. They found it much harder to tackle contradictions, however, when they disseminated these tools within their respective professional communities, leaving unresolved contradictions and missed opportunities for collaboration. This research shows the educational benefits of taking collective responsibility for improving collaborative patient care.

Supervisors' pedagogies for supporting interns to learn intra- and interprofessional collaboration: a qualitative and quantitative ego network analysis.

This work aims to understand intra- and interprofessional networks of general practitioners (GPs) and ear, nose, and throat specialists (ENT specialists), and in what manner supervisors in these specialties involve interns in their professional network to help them learn intra- and interprofessional collaboration. An egocentric social network approach was used to collect and analyze quantitative as well as qualitative data. For this, semi-structured interviews were held with ten GP and ten ENT specialists. GPs had significantly more interprofessional contacts than ENT specialists (p < .01), with no significant difference in the network sizes of both professions (p = .37). All supervisors involved interns in their (ego)network actively as well as more passively. They actively discussed how collaboration with other professionals evolved, or passively assumed that an intern would learn from observing the supervisors' network interactions. Many supervisors considered the interns' initiative essential in deciding to involve an intern in their network. Although the workplace of GPs differed notably from hospital settings where ENT specialists work, the network sizes of both were comparable. Clerkships at the general practice seemed to provide more opportunities to learn interprofessional collaboration, for example with the medical nurse. Supervisors in both specialties could involve interns more actively in their intra- and interprofessional network while interns could take more initiative to learn collaboration from their supervisors' network.

Frailty and functional outcomes after open and endovascular procedures for patients with peripheral arterial disease: A systematic review.

BACKGROUND: Frailty has been associated with postoperative complications and mortality across surgical specialties, including vascular surgery. However, the influence of frailty on postoperative functional outcomes is unclear. We sought to determine the influence of frailty on functional outcomes after open or endovascular vascular procedures in patients with peripheral arterial disease. METHODS: This systematic review was conducted according to the PRISMA guidelines. Eligible articles were identified through database searches of Pubmed and EMBASE in April 2017. Studies reporting on frailty and functional outcomes after vascular interventions for peripheral artery disease (PAD) were included. Outcomes of interest were dependency in activities of daily living (ADL), dependent mobility, discharge destination, disability-free survival, and quality of life. Individual studies were assessed for quality and risk of bias using the Quality in Prognosis Studies tool. RESULTS: Eight studies met the eligibility criteria and were included. The risk of bias was low in two studies, intermediate in three studies, and high in three studies. Methods for frailty assessment were different for each study. Frailty was a predictor for discharge to a higher level of care, dependent mobility, and dependency in ADL after vascular procedures for PAD. Both frailty models and individual frailty characteristics seem to be associated with these adverse functional outcomes. CONCLUSIONS: Despite a limited amount of literature and an overall intermediate quality of the included studies, this systematic review shows an association between frailty and adverse functional outcomes after peripheral arterial procedures for PAD, including discharge to a care facility, dependent mobility, and a decline in ADL functioning.

Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations.

BACKGROUND: During telephone triage, it is difficult to assign adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful. OBJECTIVE: To assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk. METHODS: Cross-sectional study of 1655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient's general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 to 9 am) was calculated by comparing to the risk at other hours and was adjusted for gender and age. RESULTS: The mean age of callers was 58.9 (standard deviation ±19.5) years, 55.5% were women and, in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (confidence interval 1.39-2.34, P < 0.001): 2.33 (1.68-3.22, P < 0.001) for men and 1.29 (0.83-1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07-3.10, P = 0.039). CONCLUSIONS: Patients calling the OHS-PC for chest discomfort between 0 and 9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more 'straightaway' could be considered for these patients with chest discomfort. TRIAL NUMBER: NTR7331.

Chances for learning intraprofessional collaboration between residents in hospitals.

CONTEXT: Intraprofessional collaboration (intraPC) between primary care (PC) doctors and medical specialists (MSs) is becoming increasingly important. Patient safety issues are often related to intraPC. In order to equip doctors well for their task of providing good quality and continuity of care, intraPC needs explicit attention, starting in postgraduate training. Worldwide, PC residents undertake a hospital placement during their postgraduate training, where they work in proximity with MS residents. This placement offers the opportunity to learn intraPC. It is yet unknown whether and how residents learn intraPC and what barriers to and opportunities for exist in learning intraPC during hospital placements. METHODS: We performed an ethnographic non-participatory observational study in three emergency departments and three geriatric departments of five hospitals in the Netherlands. This was followed by 42 in-depth interviews with the observed residents and supervisors. The observations were used to feed the questions for the in-depth interviews. We analysed the interviews iteratively following the data collection using template analysis. RESULTS: Hospital wards are rich in opportunities for learning intraPC. These opportunities, however, are seldom exploited for various reasons: intraPC receives limited attention when formulating placement goals, so purposeful learning of intraPC hardly takes place; residents lack awareness of the learning of intraPC; MS residents are not accustomed to searching for expertise from PC residents; PC residents adapt to the MS role and they contribute very little of their PC knowledge, and power dynamics in the hospital department negatively influence the learning of intraPC. Therefore, improvements in mindset, professional identity and power dynamics are crucial to facilitate and promote intraPC. CONCLUSIONS: Intraprofessional collaboration is not learned spontaneously during hospital placements. To benefit from the abundant opportunities to learn intraPC, adjustments to the set-up of these placements are necessary. Learning intraPC is promoted when there is a collaborative culture, hierarchy is limited, and there is dedicated time for intraPC and support from the supervisor.

Accuracy of telephone triage in patients suspected of transient ischaemic attack or stroke: a cross-sectional study.

BACKGROUND: The Netherlands Triage Standard (NTS) is a widely used decision support tool for telephone triage at Dutch out-of-hours primary care services (OHS-PC), which, however, has never been validated against clinical outcomes. We aimed to determine the accuracy of the NTS urgency allocation for patients with neurological symptoms suggestive of a transient ischaemic attack (TIA) or stroke, with the clinical outcomes TIA, stroke, and other (neurologic) life-threatening events (LTEs) as the reference. METHOD: A cross-sectional study of telephone triage recordings of patients with neurological symptoms calling the OHS-PC between 2014 and 2016.The allocated NTS urgencies were derived from the electronic medical records of the OHS-PC. The clinical outcomes were retrieved from the electronic medical records of the patients' own general practitioners. The accuracy of a high NTS urgency allocation (medical help within 3 h) was calculated in terms of sensitivity, specificity, positive and negative predictive values (PPV and NPV) with the clinical outcomes TIA/stroke/other LTEs as the reference. RESULTS: Of 1269 patients, 635 (50.0%) received the diagnosis TIA/stroke (34.2% TIA/minor stroke, 15.8% major ischaemic or haemorrhagic stroke), and 4.8% other LTEs. For TIA/stroke/other LTEs, the sensitivity and specificity of the NTS urgency allocation were 0.72 (95%CI 0.68-0.75) and 0.48 (95%CI 0.43-0.52), and the PPV and NPV were 0.62 (95%CI 0.60-0.64) and 0.58 (95%CI 0.54-0.62). CONCLUSIONS: The NTS decision support tool used in Dutch OHS-PC performed poor to moderately regarding safety (sensitivity) and efficiency (specificity) in allocating adequate urgencies to patients with and without TIA/stroke/other LTEs. TRIAL REGISTRATION: The Netherlands National Trial Register, identification number NTR7331 /Trial NL7134 .

Applying evidence-based medicine in general practice: a video-stimulated interview study on workplace-based observation.

BACKGROUND: Evidence-based medicine (EBM) in general practice involves applying a complex combination of best-available evidence, the patient's preferences and the general practitioner's (GP) clinical expertise in decision-making. GPs and GP trainees learn how to apply EBM informally by observing each other's consultations, as well as through more deliberative forms of workplace-based learning. This study aims to gain insight into workplace-based EBM learning by investigating the extent to which GP supervisors and trainees recognise each other's EBM behaviour through observation, and by identifying aspects that influence their recognition. METHODS: We conducted a qualitative multicentre study based on video-stimulated recall interviews (VSI) of paired GP supervisors and GP trainees affiliated with GP training institutes in Belgium and the Netherlands. The GP pairs (n = 22) were shown fragments of their own and their partner's consultations and were asked to elucidate their own EBM considerations and the ones they recognised in their partner's actions. The interview recordings were transcribed verbatim and analysed with NVivo. By comparing pairs who recognised each other's considerations well with those who did not, we developed a model describing the aspects that influence the observer's recognition of an actor's EBM behaviour. RESULTS: Overall, there was moderate similarity between an actor's EBM behaviour and the observer's recognition of it. Aspects that negatively influence recognition are often observer-related. Observers tend to be judgemental, give unsolicited comments on how they would act themselves and are more concerned with the trainee-supervisor relationship than objective observation. There was less recognition when actors used implicit reasoning, such as mindlines (internalised, collectively reinforced tacit guidelines). Pair-related aspects also played a role: previous discussion of a specific topic or EBM decision-making generally enhanced recognition. Consultation-specific aspects played only a marginal role. CONCLUSIONS: GP trainees and supervisors do not fully recognise EBM behaviour through observing each other's consultations. To improve recognition of EBM behaviour and thus benefit from informal observational learning, observers need to be aware of automatic judgements that they make. Creating explicit learning moments in which EBM decision-making is discussed, can improve shared knowledge and can also be useful to unveil tacit knowledge derived from mindlines.

Learning from patients about patient-centredness: A realist review: BEME Guide No. 60.

Background: Patient-centred work is an essential part of contemporary medicine. Literature shows that educational interventions contribute to developing patient-centredness, but there is a lack of insight into the associated learning processes.Objective: Through reviewing articles about educational interventions involving patients, we aspire to develop a program theory that describes the processes through which the educational interventions are expected to result in change. The processes will clarify contextual elements (called contexts) and mechanisms connected to learning patient-centredness.Methods: In our realist review, an initial, rough program theory was generated during the scoping phase, we searched for relevant articles in PubMed, PsycINFO, ERIC, CINAHL and Embase for all years before and through 2016. We included observational studies, case reports, interviews, and experimental studies in which the participants were students, residents, doctors, nurses or dentists. The relevance and rigour of the studies were taken into account during analysis. With deductive as well as inductive coding, we extended the rough program theory.Results: In our review, we classified five different contexts which affect how upcoming professionals learn patient-centredness. These aspects are influenced through components in the intervention(s) related to the learner, the teacher, and the patient. We placed the mechanisms together in four clusters - comparing and combining as well as broadening perspectives, developing narratives and engagement with patients, self-actualisation, and socialisation - to show how the development of (dimensions of) patient-centredness occurs. Three partial-program-theories (that together constituting a whole program theory) were developed, which show how different components of interventions within certain contexts will evoke mechanisms that contribute to patient-centredness.Translation into daily practice: These theories may help us better understand how the roles of patients, learners and teachers interact with contexts such as the kind of knowledge that is considered legitimate or insight in the whole illness trajectory. Our partial program theories open up potential areas for future research and interventions that may benefit learners, teachers, and patients.

Fostering patient-centredness by following patients outside the clinical setting: an interview study.

BACKGROUND: Patient-centredness is considered a core competency for health professionals. To support faculty in designing courses focused on patient-centredness, an understanding of how educational interventions lead to patient-centredness is required. This study aims to show how learning mechanisms, which potentially contribute to patient-centredness, are triggered. METHODS: Thirty-five third-year medical students at the UMC Utrecht followed four different patients for two years. The intervention took place in an out-of-hospital setting. Students visited patients in their home circumstances and accompanied them to clinical events. Twelve students were interviewed. The realist approach was used to construct configurations which relate components of the intervention to the context and learning mechanisms. RESULTS: Following patients in their home circumstances for a prolonged period supported the development of meaningful relationships between students and patients and provided continuity. In the context of a meaningful relationship and continuity, mechanisms contributing to learning patient-centredness were triggered. The most important learning mechanisms found in this study were: reflecting, contextualising disease in a real persons' life, broadening perspectives and engaging with the patients. CONCLUSIONS: Learning mechanisms are triggered by continuity and by meaningful student-patient relationships. These can be enhanced by an out-of-hospital setting and longitudinal contact. Thus, a relationship between students and patients is an important enabler for the development of patient-centredness.

GP trainees' perceptions on learning EBM using conversations in the workplace: a video-stimulated interview study.

BACKGROUND: To be able to practice evidence-based medicine (EBM) when making decisions for individual patients, it is important to learn how to combine the best available evidence with the patient's preferences and the physician's clinical expertise. In general practice training, these skills can be learned at the workplace using learning conversations: meetings between the supervising general practitioner (GP) and GP trainee to discuss medical practice, selected topics or professional performance. This study aimed to give insight into the perceptions of GP trainees on their EBM learning processes during learning conversations. METHODS: We held semi-structured video-stimulated elicitation interviews (n = 22) with GP trainees affiliated to GP training institutes in the Netherlands and Belgium. GP trainees were shown fragments of their learning conversations, enabling reflection during the interview. Taking an inductive approach, interview recordings were transcribed verbatim and analysed with NVivo software. RESULTS: GP trainees perceived learning conversations as useful for learning and discussing EBM. Multiple EBM learning activities were identified, such as discussing evidence together, relating evidence to cases in daily practice and discussing the supervisor's experience and the specific local context in the light of what the evidence recommends. However, for learning to occur, trainees need and expect specific behaviour, both from their supervisors and themselves. Supervisors should supply well-substantiated answers that are applicable in practice and give the trainee confirmation. In turn, the trainee needs to prepare well in order to ask focused, in-depth questions. A safe space allowing equal and open discussion between trainee and supervisor is perceived as an essential context for optimal EBM learning. CONCLUSIONS: Our findings show that trainees find learning conversations useful for EBM learning in general practice. To bring EBM learning to its full potential, attention should be paid to optimising the behavioural and contextual factors found relevant to enhancing EBM learning.

Tinkering and overruling the computer decision support system: Working strategies of telephone triage nurses who assess the urgency of callers suspected of having an acute cardiac event.

AIMS AND OBJECTIVES: To understand clinical reasoning and decision-making of triage nurses during telephone conversations with callers suspected of having acute cardiac events, and support from a computer decision support system (CDSS) herewith. BACKGROUND: In telephone triage, nurses assess the urgency of callers' conditions with clinical reasoning, often supported by CDSS. The use of CDSS may trigger interactional workability dilemmas. DESIGN: Qualitative study using principles of a grounded theory approach following COREQ criteria for qualitative research. METHODS: Audio-stimulated recall interviews were conducted amongst twenty-four telephone triage nurses at nine out-of-hours primary care centres (OHS-PC). RESULTS: Telephone triage nurses use clinical reasoning elements for urgency assessment. Typically in telephone triage, they interpret the vocal-but not worded-elements in communication (paralanguage) such as tone of voice and shortness of breath and create a mental image to compensate for lack of visual information. We confirmed that interactional workability dilemmas occur. Congruence, established when the CDSS supports the triage nurses' decision-making, is essential for the CDSS' value. If congruence is absent, triage nurses may apply four working strategies: (a) tinker to make CDSS final recommendation align with their own assessment, (b) overrule the CDSS recommendation, (c) comply with the CDSS recommendation or (d) transfer responsibility to the GP. CONCLUSION: Triage nurses who assess urgency may experience absence of congruence between the CDSS and their decision-making. Awareness of how triage nurses reason and make decisions about urgency and what aspects influence their working strategies can help in achieving optimal triage of callers suspected of acute cardiac events at OHS-PC. RELEVANCE TO CLINICAL PRACTICE: Triage nurses' reasoning and their working strategies are vital for outcome of triage decisions. Understanding these processes is essential for CDSS developers and OHS-PC managers, who should value how triage nurses interact with the CDSS, while they have the benefit of callers in mind.

The Feasibility of Longitudinal Patient Contacts in a Large Medical School.

PROBLEM: Longitudinal patient contacts are being implemented worldwide as a way to enhance a patient-centered orientation among medical students. In large medical schools, longitudinal integrated clerkships may not be feasible, so other ways must be sought to expose students to prolonged contact with patients. INTERVENTION: Medical students were attached to a family practice and assigned a panel of 4 patients to follow over the 3 years of their clinical training. Their role was that of companion on the patient's medical journey. The program consisted of several encounters, joining the patient in the medical setting for significant events, and written assignments. This intervention was piloted with 35 students. We describe our experiences from the 1st pilot year of this program. CONTEXT: The intervention was performed with 3rd-year students-of a 6-year curriculum-at a large medical school in the Netherlands. OUTCOME: Finding enough patients per practice was feasible. On the whole, students fulfilled the program's expectations regarding frequency of patient encounters and assignments. The most frequent problems encountered by the students were uncertainty about their role and setting boundaries in their contact with the patients. They needed more preceptor supervision and coaching than they received. LESSONS LEARNED: For junior students, close and structured supervision led by the faculty is necessary to help them navigate and learn from a panel of patients. Students need guidance about what role they should take on and on how to manage both their own and their patient's expectations. Guided reflection is necessary to help students give meaning to their experiences with patients.