Short- and Long-Term Evaluation of General Practitioners' Competences After a Training in Melanoma Diagnosis: Refresher Training Sessions May Be Needed.

General practitioners (GPs) are first-line clinicians in melanoma diagnosis. It is, therefore, important to ensure that they maintain their melanoma diagnostic accuracy over time. The objective of this study was to assess the short- and long-term competences of GPs after a training session in naked-eye melanoma diagnosis. An interventional prospective study was conducted whereby, over a 6-month period, GPs attended a 1-h melanoma diagnostic training session. To assess their acquired competences, GPs were asked to fill in a questionnaire on basic melanoma knowledge and to evaluate 10 clinical images of pigmented skin lesions prior to training, immediately after and 1 year later. In total, 89 GPs completed the questionnaire prior and immediately after training. As expected, the number of GPs who appropriately managed [Formula: see text] 50% of the melanoma cases increased after training (P < 0.001). One year after training, only 27 (30%) of the 89 GPs completed the questionnaire. This number of participants was too low to obtain significant figures but the GPs' mean overall score of appropriately managed clinical cases was much lower than in the immediate post-test. In conclusion, although this short training improved the GPs' diagnostic accuracy and management of melanoma in the short-term, participating GPs do not seem to have maintained these competences in the long-term. Further studies are needed to assess whether refresher training sessions are able to sustain acquired diagnostic and management skills.

In Brief: Validity of Case Summaries in Written Examinations of Clinical Reasoning.

Construct: The purpose of this study was to provide initial evidence of the validity of written case summaries as assessments of clinical problem representation in a classroom setting. BACKGROUND: To solve clinical problems, clinicians must gain a clear representation of the issues. In the clinical setting, oral case presentations-or summaries-are used to assess learners' ability to gather, synthesize, and "translate" pertinent case information. This ability can be assessed in Objective Structured Clinical Examination and Virtual Patient settings using oral or written case summaries. Evidence of their validity in these settings includes adequate interrater agreement and moderate correlation with other assessments of clinical reasoning. We examined the use of written case summaries in a classroom setting as part of an examination designed to assess clinical reasoning. APPROACH: We developed and implemented written examinations for 2 preclerkship general practice courses in Years 4 and 5 of a 7-year curriculum. Examinations included 8 case summary questions in Year 4 and 5 in Year 5. Seven hundred students participated. Cases were scored using 3 criteria: extraction of pertinent findings, semantic quality, and global ratings. We examined the item parameters (using classical test theory) and generalizability of case summary items. We computed correlations between case summary scores and scores on other questions within the examination. RESULTS: Item parameters were acceptable (average item difficulty = 0.49-0.73 and 0.59-0.68 in Years 4 and 5; average point-biserials = 0.21-0.24 and 0.18-0.21). Scores were moderately generalizable (G coefficients = 0.40-0.50), with case-specificity a substantial source of measurement error (10.2%-19.5% of variance). Scoring and rater had small effects. Correlations with related constructs were low to moderate. CONCLUSIONS: There is good evidence regarding the scoring and generalizability of written case summaries for assessment of clinical problem representation. Further evidence regarding the extrapolation and implications of these assessments is warranted.

Validated methods of cough assessment: a systematic review of the literature.

BACKGROUND: Cough is a common symptom for which patients often seek medical advice and consume vast amounts of drugs. It is a real challenge for both the physician and the clinical researcher to evaluate a cough's clinical importance and its precise response to treatment. OBJECTIVES: This systematic literature review has the following objectives: first, to make an inventory of the validated tools for assessing cough, and second, to investigate the extent to which the results of various assessment methods can be correlated. METHODS: Two independent investigators searched the Medline, Embase, and Cochrane databases for validation studies on cough assessment tools. RESULTS: Thirty-four studies were included. Several ambulatory cough monitors automatically identify cough and have been validated in a limited number of patients. Three cough-specific quality-of-life scales (Leicester Cough Questionnaire, Cough Quality of Life Questionnaire, and Burden of Cough Questionnaire) have been validated. No validation studies of descriptive scores or visual analogue scales were found. The correlations between quality-of-life scores and cough frequency were good. The correlations between descriptive scores or visual analogue scales and more objective methods, such as cough frequency monitoring or quality-of-life scores, were inconsistent. CONCLUSION: Cough-specific quality-of-life questionnaires can provide valid outcomes for research into cough. Although the current developments in cough monitoring devices are promising, further studies on a larger scale, under more realistic conditions, and for different patterns of cough are required before they can be recommended for widespread use.

Exploring the diverse career trajectories of general practice graduates in the French-speaking part of Belgium: An interview study.

BACKGROUND: Several European countries face a shortage of general practitioners (GPs), in part due to GP attrition. Most studies of GP attrition have focussed on why GPs decide to leave. Yet understanding why GPs decide to remain may also elicit potential interventions to reduce attrition. OBJECTIVES: This study examined GP graduates' career trajectories and underlying decisions to elucidate the factors influencing GP attrition. METHODS: We conducted semi-structured interviews of early to mid-career general practice graduates having completed training in Belgian French-speaking universities between 1999 and 2013. We sampled participants from three categories: full-time GPs, part-time GPs, no longer working as GPs. We analysed each participant's career trajectory and broke it down into major phases. We performed thematic analysis of the factors influencing participants' trajectories. We compared and contrasted trajectories to develop a typology of career trajectories. RESULTS: We identified six types of career trajectories: 'stable' (never considered leaving general practice), 'reaffirmed' (had considered leaving but made substantial changes whilst remaining), 'reactional reorientations' (had left to escape the challenges of general practice), 'inspired reorientations' (had left to pursue a different job), 'reorientations out of loyalty' (had never wanted to practice as GPs and had remained true to their original professional aspirations) and 'mobiles' (valued change and did not want to set-up practice). CONCLUSION: Reasons GPs leave the profession are multiple. The typology that emerged indicates that only some of the career trajectories would benefit from interventions to reduce attrition such as improving working conditions and providing psychological support for GPs.

A novel assessment of an evidence-based practice course using an authentic assignment.

BACKGROUND: Evidence-based practice (EBP) is now a component of most medical curricula. Summative assessment instruments are often of debatable quality, do not cover the full spectrum of EBP or lack authenticity. AIM: To develop and evaluate the quality of an authentic assessment instrument for use in summative assessment of general practice trainees. METHODS: An assignment was designed based on the ask, acquire, appraise and apply steps of EBP. Content validity was evaluated by external EBP experts. Concurrent validity was tested with the Fresno test. Inter-rater agreement and internal consistency were measured. Acceptability and feasibility were also assessed. RESULTS: EBP experts agreed that the instrument had good content validity. Concurrent validity was good (disattenuated intraclass correlation coefficient 0.75). Inter-rater agreement varied from 0.70 to 0.83. Internal consistency was high (Cronbach's alpha 0.70-0.86). The procedure was feasible but only moderately acceptable to students. CONCLUSION: Our authentic assignment provided a valid, reliable and feasible procedure to assess our students. Acceptability was moderate, probably due to teething problems in instructions given and unfamiliarity with the format. Consequential validity data are lacking and would be of value. Our instrument could be an interesting alternative to other validated tests that may be less authentic.

Prolonged Cough in Pediatric Population First Line Care, Belgian Guidelines.

BACKGROUND: The clinical approach to a prolonged cough, i.e. a cough lasting more than three weeks, is challenging for general practitioners as well for primary care pediatricians. What the recommended clinical approach in primary care is, how cough duration or cough characteristics impact the diagnosis, and what the efficiency and safety of antibiotics or symptomatic treatments are remain in question for primary care physicians. OBJECTIVE: The last Belgian guidelines were published in 2006 and needed to be reviewed. Those background questions were used to conduct our guideline updating procedure. METHODS: We systematically performed a pyramidal literature search between the periods 2006-2014 in order to write evidence based guidelines. The data of the literature was summarized, discussed by the authors, experts and the Belgian primary care guidelines committee. Recommendations were formulated and scored following the GRADE classification. RESULTS: The consultation history as well as the physical examination should be directed towards searching for warning signs (GRADE 1B) and towards the common etiologies depending on cough duration (GRADE 2C). If the cough lasts for more than eight weeks, chest radiography and spirometry should be considered (GRADE 2C). An antibiotic is recommended for a prolonged wet cough (over eight weeks) if prolonged bacterial bronchitis is suspected (GRADE 1B). In the absence of clinical signs of a specific etiology of a cough, no drug can be recommended (GRADE 1B). For all cases, it is initially suggested to avoid irritants (GRADE 1C) as well as to take into account the concerns of parents and inform them about the natural development of a cough. CONCLUSIONS: More research is needed to provide evidence on the clinical pathway on prolonged cough for primary care. Cough duration of more than eight weeks and prolonged wet cough are the most useful cough characteristics. Regarding a specific cough treatment, no medication has proved any effect greater than placebo. Attention to environmental triggers and patient-centered care remain the keystones of interventions.

Young general practitioners' professional activities: a survey in the French-speaking part of Belgium.

INTRODUCTION: This study described the professional activities of graduates of the Advanced Master of General Practice of the Belgian French-speaking universities from 1999 to 2013 and identified factors influencing their situation. METHODS: Between November 2014 and June 2015, all graduates were asked to complete a questionnaire concerning their professional activities. The first part of the analysis described the respondent's socio-demographic and professional characteristics. The second part aimed at detecting possible factors influencing GPs' professional situation. RESULTS: The main results of the study showed that 78.5% of graduates still worked as GPs and 21.5% left and had another activity. The way graduates worked in General Practice was also highly diverse in terms of both working time and types of activities. Only a minority of them were exclusively performing General Practice (8.5%). 45.8% of GPs worked part-time, and were more commonly women and GPs in group practice. This survey confirmed feminisation of the profession and increasing work in associations. Among factors influencing retention in General Practice, preference for specialising in General Practice at time of graduation in medicine and duration of practice influence retention in practice. CONCLUSION: Our survey put the emphasis on the evolution of practice: job and vocational training planning should not be performed based only on previous generations. There is no one predefined way to practise; the blurred boundaries of General Practice activities do not allow for the drafting of a reference frame that could help workforce planning.

The objective assessment of cough frequency: accuracy of the LR102 device.

BACKGROUND: The measurement of cough frequency is problematic and most often based on subjective assessment. The aim of the study was to assess the accuracy of the automatic identification of cough episodes by LR102, a cough frequency meter based on electromyography and audio sensors. METHODS: Ten adult patients complaining of cough were recruited in primary care and hospital settings. Participants were asked to wear LR102 for 4 consecutive hours during which they were also filmed. RESULTS: Measures of cough frequency by LR102 and manual counting were closely correlated (r = 0.87 for number of cough episodes per hour; r = 0.89 for number of single coughs per hour) but LR102 overestimated cough frequency. Bland-Altman plots indicate that differences between the two measurements were not influenced by cough frequency. CONCLUSIONS: LR102 offers a useful estimate of cough frequency in adults in their own environment, while significantly reducing the time required for analysis.

Prolonged cough in children: a summary of the Belgian primary care clinical guideline.

Prolonged cough is a frequent problem in the community. Several studies in the school setting have found that as many as 4.8% to 10.4% of children suffer from prolonged cough. There is no consensual definition of prolonged cough. In this guideline, we define prolonged cough as a daily cough lasting for more than three weeks. The literature review did not identify any quality study on the aetiology of prolonged cough in children in primary care. A diagnostic decision-tree based on the systematic literature review and expert opinion is proposed. Doctors should seek signs of any serious underlying condition. Chronic productive purulent cough should always be investigated. A careful evaluation of the impact of cough on the quality of life of the child is necessary. In absence of signs of specific underlying illness, coughing is generally a self-limiting condition. Symptomatic treatments have not yet been proven to be effective, and many of them may cause serious side effects. Their use should therefore be limited.