[Development and learning outcomes of an e-learning ECT for psychiatry residents]. / Ontwikkeling en leeropbrengsten van een e-learning ECT voor aiossen psychiatrie.

BACKGROUND: Education in electroconvulsive therapy (ECT) has become mandatory in the Dutch psychiatry training. ECT is still relatively rarely used. To increase knowledge about ECT, we have developed a training module about ECT for psychiatrist training. To promote flexible learning, we opted for e-learning, where educational principles have been applied in the design. AIM: In this article we discuss how this e-learning ECT was developed and analyze the learning outcomes for psychiatry residents. METHOD: The e-learning has been developed based on the ADDIE model and consists of an entrance test, various assignments and a final test. The learning outcomes of the first 216 residents have been analyzed quantitatively and qualitatively using test results, self-assessments of their expertise in ECT (before and after) and evaluations. RESULTS: Of the participating residents, 94% found this education relevant to practice. The e-learning was rated with an average of 8.3. Afterwards, one’s own knowledge about ECT was estimated to be significantly higher than before. Afterwards, 72% thought they can indicate ECT more quickly and 99% reported that they can better inform patients and families about ECT. CONCLUSION: The e-learning ECT is appreciated by residents and leads to an experienced improvement in knowledge about ECT.

International Health Electives: defining learning outcomes for a unique experience.

BACKGROUND: An International Health Elective (IHE) can be a unique learning experience for students. However, it has proven difficult to clearly define learning outcomes that capture the complexity of an IHE and are aligned with future professional performance. This study aimed to further define learning outcomes for IHEs in low- to middle-income countries (LMIC) from a student perspective. METHODS: We conducted a deductive analysis of pre-departure and post-elective reflective reports of fifth-year medical students who participated in an IHE as part of their program. This provided possible learning objectives that were further explored in semi-structured individual interviews with medical students who had recently returned from an IHE. RESULTS: We analyzed 33 reports of students participating in an IHE from 2017-2019 and held 19 interviews. Thematic analysis revealed 9 themes: developing intercultural competence, developing appreciation for differences in health care delivery systems, understanding international health, understanding the global burden of disease, developing a career perspective, developing clinical skills in resource low settings, becoming cost conscious, developing social responsibility and self-actualization. CONCLUSIONS: We identified 9 learning outcomes that are directly and indirectly related to clinical practice. They add to the on-going discourse on the benefits of IHEs. These outcomes can be further developed by investigating the perspectives of home and host supervisors and educationalists, while taking the local context into account. Follow-up studies can evaluate to what extend these outcomes are achieve during an IHE.

[Dutch medical disciplinary law cases concerning psychiatry, 2015-2019]. / Uitspraken van regionale tuchtcolleges in zaken betreffende de psychiatrie, 2015-2019.

BACKGROUND: The aim of medical disciplinary law (as part of the Dutch law 'Wet BIG') is to safeguard the quality of professional practice in the health services. Quantitative data about Dutch medical disciplinary law is sparse: little is known about the nature, quantity and the verdicts of disciplinary law complaints against psychiatrists and residents. AIM: Gaining insight in Dutch medical disciplinary law, in particular with regard to number and nature of disciplinary law complaints against psychiatrists(-psychotherapist) and psychiatry residents. METHOD: Descriptive retrospective study. We examined all medical disciplinary law cases against psychiatrists(-psychotherapist) and psychiatry residents in the period 2015-2019. RESULTS: In the study period the regional medical disciplinary courts handled 353 cases against psychiatrists(-psychotherapist) and residents psychiatry, on average 70.6 per year. 321 of these cases were against psychiatrists and 32 against residents. Complaint density was 1.74 for psychiatrists and 0.37 for residents. Subject of most cases was 'wrong diagnosis', followed by 'wrong therapeutic plan' and 'incorrect communication'. The number of cases resulting in a disciplinary measure was on average 31%: warning (49%), reprimand (30%), (conditional) suspension (15%). In 17 cases the professional was (partially) denied to practice. CONCLUSIONS Within Dutch psychiatry little attention is paid to disciplinary law, despite the fact that psychiatrists are relatively often confronted with disciplinary law complaints. The current explorative analysis underlines the need for further research, especially on the difference between male/female psychiatrists and an international comparison with respect to complaints about (sexual) misconduct.

[The effects of covid-19 on psychiatry training in the Netherlands]. / De invloed van COVID-19 op de opleiding psychiatrie in Nederland.

Background The COVID-19 pandemic changes the training of residents and could offer new opportunities. Aim Gaining insight in the effects of the impact of the COVID-19-pandemic on psychiatry residents. Method A digital questionnaire was designed to evaluate the impact of the COVID-19 pandemic on educational activities. The experience of residents with regards to safety in the workplace, social cohesion with their peers and the involvement of supervisors were examined. Results We approached 34 training institutions. 24 chief residents of the resident group completed the questionnaire. The quality of regional education was considered unchanged by 20% and local education by 33%. Digital communication increased the participation of psychiatrists in the general report and education activities and ensured less travel time. Nevertheless, respondents missed contact with their peers, safety of residents was compromised at five institutions and half of all respondents indicated a lack of personal protective equipment. Conclusions A majority of the psychiatry residents are satisfied with their training during this historic pandemic, but the quality of local and regional education was considered changed, and not being beneficial. The challenge remains for stimulating contact with peers, monitoring the quality of education in general as in psychotherapy and providing personal protective equipment. Tijdschrift voor Psychiatrie 63(2021)1, 16-21.

[Trends and developments in medical education research]. / Trends en ontwikkelingen in het medisch-onderwijskundig onderzoek.

BACKGROUND: In medical educational research specific approaches and research methods are used, the risk being that the field becomes less accessible to clinicians and teachers.
AIM: To highlight the relevance of educational research for clinical practice.
METHOD: A description of the development of medical educational research as a field and of the different types of research questions and the role of theories from related social sciences such as psychology, pedagogy and sociology.
RESULTS: First, there are the descriptive studies, based on the question 'what has been done'. Second, there are justification studies that compare educational innovations with existing practice to provide insight into 'did the intervention work better?'. A third group of studies focuses on clarification of underlying learning processes, with the question 'why or how did it work?' Theory helps with the design of studies and interpretation of research results, thereby increasing the quality and relevance of medical educational research.
CONCLUSION: Medical educational research has developed rapidly, and the involvement of teachers and clinicians (such as psychiatrists) is necessary to ensure that it remains closely connected to practice.

[A different look at the quality of psychiatry education: trainee perspective]. / Kwaliteit van de opleiding tot psychiater anders bezien ­ de blik van de aios.

BACKGROUND: The (medical) educational literature does not contain an unequivocal answer to the question 'what is a good quality post-graduate education in psychiatry?'.
AIM: To describe the meaning of 'quality' and the role of psychiatrists in training (residents or trainees) in achieving and monitoring high-quality post-graduate psychiatry education in the Netherlands.
METHOD: Critical consideration of the current system of post-graduate education in psychiatry.
RESULTS: A qualitatively good post-graduate training system offers residents an optimal learning climate in which the individual development plan is central and there is opportunity to acquire a good basis for all competency domains. Possibilities for improvement concern the quality of supervisors, flexibility in internships and curricular education, and extra attention for management and policy skills.
CONCLUSION: Suggestions are made for further development of post-graduate psychiatry training in the Netherlands.

[Younger medical specialists and longer waiting time: cohort study of the duration of medical training]. / Jongere specialisten en langere wachttijd.

OBJECTIVE: To describe trends and developments in the total duration of training medical specialists in the Netherlands, including their ages upon completion of the components of medical education: undergraduate medical program, waiting time and further post-graduate specialist training. DESIGN: Population cohort study. METHOD: From the combined data from Statistics Netherlands and the Registration Committee for Medical Specialists for the period 1986 to 2018 relevant populations were selected and training trajectories were mapped. The population size was 40,604 individuals for undergraduate medical programs, 41,885 for the duration of post-graduate specialist training, 31,915 for the waiting periods and 21666 for the total duration of the trajectory from the start of medical school until registration as a specialist. RESULTS: The median duration of undergraduate medical programs was 7.1 years, which is longer than the nominal duration and this remained unchanged over the observation period. The average waiting time between graduating medical school and postgraduate specialist training has increased from 2010 onwards to 3.7 years in 2018. The average duration of postgraduate specialist training is increasing. The average age at graduation of medical school fell by 1.7 years to 26.1. The average age at the start of post-graduate specialist training decreased, as did the average age at registration as a specialist. CONCLUSION: The total duration of training of medical specialists is stable. Changes such as "dedicated transition year" and flexible arrangements for postgraduate training have had no discernible influence on the total duration of medical training. Because the average age at start of postgraduate specialist training has decreased, medical specialists are on average younger upon registration.

Teacher perceptions of desired qualities, competencies and strategies for clinical skills teachers.

INTRODUCTION: Clinical skills centres (or Skillslabs) prepare students for patient-encounters. Evidence on teaching skills in these centres is lacking. What teaching skills do teachers view as effective in supporting the acquisition of physical examination skills in undergraduate medical training? METHOD: Structured interviews of 10 teachers (1/3 of staff of Maastricht University, Skillslab) were conducted. Selection was based on even representation of age, years teaching experience, gender and previous experience at Maastricht University. A topic grid was used to ensure comparability. Interviews (average 70 min, range 33-95 min) were recorded and transcripts were analyzed independently by two researchers. RESULTS: Teaching skills identified include the ability to adapt content of the training, level of depth and teaching method according to the needs of any particular group. Thorough comprehension of students' context (level of knowledge,prior experience and insight in the curriculum) is considered helpful. Explicitly inviting students to ask questions and providing relevant literature is seen to stimulate learning. Providing constructive feedback is essential, as is linking physical examination skills training to clinical situations. The ideal attitude includes appropriate dress and behaviour, as well as the use of humour. Affinity for teaching is regarded as the most important reason to work as a teacher. CONCLUSION: Desired characteristics for undergraduate skills teachers resemble findings in other teaching roles. Affinity for teaching and flexibility in teaching methods are novel findings.

Sepsis in pregnancy.

Sepsis remains an uncommon, but potentially devastating problem in the previously healthy pregnant patient. Although septic sequelae, including organ failure and shock, are unusual, they are likely to lead to morbidity and mortality as high, or higher, than in the general population. At the present time, hemodynamic support, surgery, and antimicrobial therapy aimed at reducing polymicrobial aerobic and anaerobic infection remain the gold standard of therapy. New antimediator and anti-inflammatory therapies offer promise of improved survival in the general and obstetric population with severe sepsis.

Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac.

Fifteen animals with indirect inguinal hernias were treated by closure of the abdominal opening of the patent processus vaginalis by the application of staples laparoscopically. The satisfactory results confirm those obtained in a previous study, where similar openings found during laparotomy for abdominal surgery were closed by the application of metal clips. Laparoscopic closure of the abdominal opening of a hernial sac may have advantages over the present operative management.

Pelvic inflammatory disease after tubal sterilization: a review.

Exceptions ot the common notion that tubal occlusion protects from recurrent pelvic inflammatory disease (PID) do exist. Since 1975, 71 cases of salpingitis and 38 tubo-ovarian abscesses (TOA) in sterilized women have been published. The majority of cases of salpingitis after previous tubal occlusion (SPOT) developed more than a year after either laparoscopic or laparotomy sterilization procedures. For tubo-ovarian abscess after previous tubal occlusion (TOAPOT), this time interval ranged from several weeks to almost two decades. Most cases of salpingitis showed inflammation of both tubal segments. When only one segment was involved, it was generally the proximal segment. The appearance of the TOAPOT at the time of surgery was typical to TOA. The symptoms of salpingitis were not different from symptoms in any other case of PID, and those associated with TOAPOT were typical of TOA. Laboratory findings included leucocytosis and growth of Neisseria gonorrohoea and Chlamydia trachomatis from the cervix, the infected tube, and the peritoneal fluid. Pus cultures obtained from cases of TOAPOT grew mixed or single organisms. Detailed histopathologic studies in tubal specimens after the failure of an occlusion procedure are available from cases with no infection. They have demonstrated distortion, loss of musculature, and loss of lumen configuration, all of which may have been the result of compromised blood supply to the tube. These findings may be extrapolated to cases of SPOT and TOAPOT, assuming similar changes may be present before the development of infection. The mechanisms by which infection may develop in previously occluded tubes are divided into three groups: The first group consists of situations where there is persistence of free passage between the proximal and distal portions of the tube. These include toboperitoneal fistula, spontaneous anastomosis at the occlusion site, recanalization of the occluded site, incomplete tubal occlusion due to a faulty surgical technique or rupture of the weakened tubal wall. The second group consists of infections initiated by the surgical procedure itself, such as introduction of pathogens at surgery, exacerbation of chronic PID, and ascending infection secondary to surgical manipulation. In the third group, the infection is initiated systemically by hematogeneous spread, lymphatic spread, or change in immunologic status.

The uterine contractility index: a research and diagnostic tool in dysmenorrhea.

Women who experienced severe primary dysmenorrhea had 90 to 120 minutes of continuous uterine pressure monitoring during their peak period of discomfort. During the initial screening cycle, they were given 40 mg of piroxicam, a nonsteroidal anti-inflammatory drug which inhibits prostaglandin synthesis. The pressure tracings were analyzed by a newly proposed ratio, the contractility index. During the painful period, the contractility index averaged approximately 3. When relief was experienced, the contractility index fell to approximately 1.5. Women who experienced uncertain or slight relief had a contractility index of approximately 2. Relief was experienced by 69% of the women screened. A small double-blind, crossover study was carried out on seven of the women. This revealed different responses to the drug in consecutive cycles and suggests that increased prostaglandins are an expression of an underlying process, not consistent with a primary cause of dysmenorrhea.

Office Tubal Sterilization

We retrospectively studied 57 cases of laparoscopic bilateral tubal ligation (BTL) performed under local anesthesia at the obstetrics and gynecology outpatient center of Winthrop-University Hospital, between May 1987 and November 1992. The mean age of our patients was 34.3+10.22 years and the weight ranged between 48 to 109 kg. Contraindications included history of bleeding diathesis, severe cardiac disease, grand mal epilepsy, or unusually high anxiety level of the pt. All women were premedicated with Anaprox 500 mg po 30 minutes before the procedure. Local anesthesia was administered as follows: paracervical block; periumbilical and suprapubic injection with 1% lidocaine (10 ml); and intrauterine infusion of 4% lidocaine (5-6 ml). Insufflation of the peritoneal cavity was performed with 1 to 2 L nitrous oxide. We used a 7-mm clip applicator for the BTL. The mean operative time was 34.7 minutes. The reduction of cost compared with the same procedure performed under general anesthesia was 40%. No major complications or hospitalizations occurred. Eighty-five percent of the women expressed a high degree of satisfaction when questioned about the procedure. We conclude that office tubal sterilization under local anesthesia is safe and acceptable to both patients and physicians, offering reduced cost, elimination of general anesthesic complications, rapid recovery, and accommodation of patient preference and physician convenience.

Vaginal birth after two or more previous cesarean sections.

The recommendation from the American College of Obstetricians and Gynecologists is to allow vaginal delivery after one cesarean section. This report is an update of our experience of 57 women with two or more cesarean sections who were allowed to labor.