Comparison of expectations and beliefs about good teaching in an academic day release medical education program: a qualitative study.

BACKGROUND: In a professional learner-centered(ness) educational environment, communication and alignment of expectations about teaching are indispensable. Professional education of residents could benefit from an analysis and comparison of teachers' and residents' educational expectations and beliefs. Our purpose is to identify success factors and barriers related to aligning expectations and beliefs and building a supportive professional learner-centered educational environment. METHODS: We conducted semi-structured individual interviews with teachers and semi-structured focus groups with residents. A single interview format was used to make it possible to compare the results. Data were analysed using a qualitative software package (AtlasTi). Data analysis steps were followed by the author team, which identified four domains of good teaching: personal traits, knowledge, relationships and teaching qualities. RESULTS: Teachers and residents agreed about the importance of personal professional characteristics like being a role model and having an open and enthusiastic attitude. They all thought that having a specific knowledge base was essential for teaching. Approaching residents as adult learners was found to be an important element of the learner-centred environment and it was agreed that teachers should take practical experiences to a higher level. However, teachers and residents had different expectations about the practical consequences of being a role model, adult learning, coaching and openness, and the type of knowledge that was needed in the professional development program. Communication about different expectations appeared to be difficult. CONCLUSIONS: Teachers and residents agreed on a conceptual level about expectations and beliefs regarding good teaching, but disagreed on an executive level. According to the residents, the disagreement about good teaching was not the biggest barrier to creating alignment and a supportive professional relationship; instead, it was the absence of a proper dialogue regarding issues about expectations and beliefs.

Teachers' ideas versus experts' descriptions of 'the good teacher' in postgraduate medical education: implications for implementation. A qualitative study.

BACKGROUND: When innovations are introduced in medical education, teachers often have to adapt to a new concept of what being a good teacher includes. These new concepts do not necessarily match medical teachers' own, often strong beliefs about what it means to be a good teacher.Recently, a new competency-based description of the good teacher was developed and introduced in all the Departments of Postgraduate Medical Education for Family Physicians in the Netherlands. We compared the views reflected in the new description with the views of teachers who were required to adopt the new framework. METHODS: Qualitative study. We interviewed teachers in two Departments of Postgraduate Medical Education for Family Physicians in the Netherlands. The transcripts of the interviews were analysed independently by two researchers, who coded and categorised relevant fragments until consensus was reached on six themes. We investigated to what extent these themes matched the new description. RESULTS: Comparing the teachers' views with the concepts described in the new competency-based framework is like looking into two mirrors that reflect clearly dissimilar images. At least two of the themes we found are important in relation to the implementation of new educational methods: the teachers' identification and organisational culture. The latter plays an important role in the development of teachers' ideas about good teaching. CONCLUSIONS: The main finding of this study is the key role played by the teachers' feelings regarding their professional identity and by the local teaching culture in shaping teachers' views and expectations regarding their work. This suggests that in implementing a new teaching framework and in faculty development programmes, careful attention should be paid to teachers' existing identification model and the culture that fostered it.

Incorporating and evaluating an integrated gender-specific medicine curriculum: a survey study in Dutch GP training.

BACKGROUND: We recently set standards for gender-specific medicine training as an integrated part of the GP training curriculum. This paper describes the programme and evaluation of this training. METHODS: The programme is designed for GP registrars throughout the 3-year GP training. The modules emphasize interaction, application, and clinically integrated learning and teaching methods in peer groups. In 2005 - 2008, after completion of each tutorial, GP registrars were asked to fill in a questionnaire on a 5-point Likert scale to assess the programme's methods and content. GP registrars were also asked to identify two learning points related to the programme. RESULTS: The teaching programme consists of five 3-hour modules that include gender themes related to and frequently seen by GPs such as in doctor-patient communication and cardiovascular disease. GP registrars evaluated the training course positively. The written learning points suggest that GP registrars have increased their awareness of why attention to gender-specific information is relevant. CONCLUSION: In summary, gender-specific medicine training has been successfully integrated into an existing GP training curriculum. The modules and teaching methods are transferable to other training institutes for postgraduate training. The evaluation of the teaching programme shows a positive impact on GP registrars' gender awareness.

Spirometry expert support in family practice: a cluster-randomised trial.

AIM: To assess the impact of two modes of spirometry expert support on Family physicians' (FPs') diagnoses and planned management in patients with apparent respiratory disease. METHOD: A cluster-randomised trial was performed with family practices as the unit of randomisation. FPs from 44 family practices recorded their diagnosis and planned management before and after spirometry for 868 patients. Intervention consisted of spirometry interpretation support by either a chest physician or expert software. Both interventions were compared with usual care (i.e. no additional interpretation support). Change in FPs' diagnoses after spirometry served as the primary outcome. Secondary outcomes were referral rate, additional diagnostic tests, and disease management changes. Effects were expressed as percentages and Odds Ratios (OR) with 95% confidence intervals. RESULTS: Diagnoses changed after intervention in all groups: 47.8% (95% CI 41.8 to 53.9) for chest physician support; 45.0% (95% CI 39.5 to 50.6) for software support; and 53.3% (95% CI 47.2 to 59.4) for usual care. Differences in the proportions of changed diagnosis were not statistically significant: chest physician support versus usual care OR 0.79 (95%CI 0.49 to 1.30); software support versus usual care OR 0.72 (95% CI 0.45 - 1.15). There were no differences in secondary outcomes. CONCLUSION: Neither chest physician spirometry support nor expert software spirometry support had a significant impact on FPs' diagnosis of respiratory conditions or management decisions. TRIAL NUMBER: http://www.clinicaltrials.gov/ct/show/NCT00131157?order=1.

Effect of an integrated primary care model on the management of middle-aged and old patients with obstructive lung diseases.

OBJECTIVE: To investigate the effect of a primary care model for COPD on process of care and patient outcome. DESIGN: Controlled study with delayed intervention in control group. SETTING: The GP delegates tasks to a COPD support service (CSS) and a practice nurse. The CSS offers logistic support to the practice through a patient register and recall system for annual history-taking and lung function measurement. It also forms the link with the chest physician for diagnostic and therapeutic advice. The practice nurse's most important tasks are education and counselling. SUBJECTS: A total of 44 practices (n =22 for intervention and n =22 for control group) and 260 of their patients > or = 40 years with obstructive lung diseases. RESULTS: Within the intervention group planned visits increased from 16% to 44% and from 19% to 25% in the control condition (difference between groups p =0.014). Annual lung function measurement rose from 17% to 67% in the intervention and from 11% to 18% in the control group (difference between groups p =0.001). Compared with control, more but not statistically significant smokers received periodic advice to quit smoking (p =0.16). At baseline 41% of the intervention group were using their inhalers correctly and this increased to 54% after two years; it decreased in the control group from 47 to 29% (difference between groups p =0.002). The percentage of patients without exacerbation did not change significantly compared with the control condition. The percentage of the intervention group not needing emergency medication rose from 79% to 84% but decreased in the controls from 81 to 76% (difference between groups p =0.08). CONCLUSION: Combining different disciplines in one model has a positive effect on compliance with recommendations for monitoring patients, and improves the care process and some patient outcomes.

General practitioners' needs for ongoing support for the interpretation of spirometry tests.

BACKGROUND: Although one out of three general practitioners (GPs) carries out spirometry, the diagnostic interpretation of spirometric test results appears to be a common barrier for GPs towards its routine application. METHODS: Multivariate cross-sectional analysis of a questionnaire survey among 137 GPs who participated in a spirometry evaluation programme in the Netherlands. We identified characteristics of GPs and their practice settings associated with GPs' need for ongoing support for spirometry interpretation. RESULTS: Response rate on the survey questionnaire was 98%. The need for ongoing support among the participating GPs was 69%. GPs' recent spirometry training showed a statistically significant association with the need for ongoing support for the interpretation of spirometry (odds ratio 0.43, 95% CI 0.20-0.92). CONCLUSION: There is a need for ongoing support for spirometry interpretation among GPs. Recent spirometry training partially diminished this need.

The feasibility of a primary care model for the management of COPD.

AIMS: To investigate the feasibility of a primary care model to improve the management of COPD. METHODS: An intervention study on 1,497 patients with documented COPD from 22 general practices, involving 11 practice nurses and a COPD Support Service (CSS). Outcome measures included the successful delegation of tasks from general practitioners (GPs) to the CSS and practice nurse, and performance in daily practice according to the model components -- keeping a patient register with a recall system, periodical history taking and lung function measurements, asking diagnostic and therapeutic advice, and performing regular follow-up visits with education and counselling. RESULTS: In the 22 general practices, all components of the model were performed systematically, with the exception of 'asking for diagnostic and therapeutic advice' which occurred in 10 practices only. Of the 1,497 patients, 374 (25%) were treated by chest physicians. Of the remaining patients 88% were included in the primary care model and 12% refused regular follow-up. CONCLUSION: This primary care model for COPD management proved to be very feasible; GPs delegated the tasks, almost all patients were included in the control system, and a large majority of patients accepted follow-up according to the model.

Variation in spirometry utilization between trained general practitioners in practices equipped with a spirometer.

OBJECTIVE: To explore spirometry utilization among general practitioners and identify practitioner and practice-related factors associated with spirometry utilization. DESIGN: Multivariate multilevel cross-sectional analysis of a questionnaire survey. SETTING: Some 61 general practices involved in a spirometry evaluation programme in the Netherlands. All practices owned a spirometer and were trained to perform spirometry. SUBJECTS: A total of 144 general practitioners and 179 practice assistants. MAIN OUTCOME MEASURES: Extent of spirometry utilization for five indications from national COPD/asthma guidelines, practitioner and practice-related factors associated with spirometry utilization. RESULTS: The response rate was 97%. General practitioners used spirometry mostly to evaluate treatment with inhaled steroids (58%). Significant practitioner-related factors associated with spirometry utilization were: general practitioners' job satisfaction, general practitioners' general interest in research, and prior participation in spirometry training. Practice-related factors associated with spirometry utilization were: presence of a practice nurse, delegation of medical tasks to practice assistants, use of spirometry in different rooms, and use of protocols in practice. CONCLUSION: Practitioner- as well as practice-related factors were associated with the extent of spirometry utilization. In particular, it is essential to improve practice-related factors (e.g. presence of a practice nurse, more delegation of medical tasks to the practice assistant).

Smoking cessation in patients with COPD in daily general practice (SMOCC): six months' results.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) forms an increasing health problem. Despite smoking cessation improving the prognosis of the disease, many patients persist smoking. The present study presents the results of a smoking cessation counseling protocol in general practice (Smoking Cessation in patients with COPD in general practice (SMOCC)). METHODS: A randomized controlled trial of patients with COPD compared smoking cessation counseling according to an intensified minimal intervention strategy with usual care. In total 43 general practices with 392 patients participated in Nijmegen, The Netherlands, in 2001-2002. RESULTS: Significantly more smokers in the experimental group made a quit attempt (44.9% versus 36.5%) and actually quit smoking than in the control group (16.0% versus 8.8%). The motivation to stop smoking at baseline was not associated with smoking cessation. CONCLUSION: The SMOCC strategy doubled the self-reported quit rates and was complied well by the general practitioners. Implementation in general practice is recommended.

Coughing in pre-school children in general practice: when are RAST's for inhalation allergy indicated?

To identify patterns of clinical history associated with extreme (high or low) probabilities of allergic sensitization in coughing children so as to restrict allergy testing to those with an intermediate probability of sensitization. A total of 752 children, aged 1-4, visiting their GPs for coughing (>or=5 days), were tested for IgE-antibodies to house dust mite, cat and dog [RadioAllergoSorbent Test (RAST)]. Parents completed a questionnaire on family history of atopy, breastfeeding, smoking, pets, and floor covering. Data of 640 children could be analyzed, 83 (13%) were IgE-positive. In a logistic regression analysis, a scoring formula for the prediction of being IgE-positive was constructed using variables from the patient's history. Significant contributors for sensitization were: age (3-4 yr), infantile eczema, positive family history of mite-allergy, sibling(s) with pollen-allergy, and smoking by parents. If only one of these characteristics is present, the probability of sensitization is < 25%. In such cases watchful waiting may be preferred over allergy testing. In other cases, a negative RAST may help to exclude sensitization, whereas a positive RAST helps to establish the diagnosis. Thus, acting on clinical history alone may save approximately 80% of RAST's. Patient history-derived information contributes to distinguishing children who are at low risk for sensitization to house dust mite, cat, and dog. The scoring formula may help GPs to identify children with a low probability of being sensitized. This may form the basis for watchful waiting. In others, allergy testing may be useful to gain more diagnostic certainty.

How to conceptualize professionalism: a qualitative study.

The aim of this study was to clarify which themes and elements constitute professionalism in medicine. Three consecutive steps were taken: (a) a systematic search of the literature to identify constituent elements of professionalism mentioned in definitions and descriptions of the concept; (b) analysis of these elements using the constant comparison technique to reveal possible themes covering these elements; and (c) validating the results using an expert panel. A total of 90 separate elements of professionalism were identified in the 57 articles included in our study. Three themes within professionalism were uncovered: (1) interpersonal professionalism; (2) public professionalism; and (3) intrapersonal professionalism. These themes were considered accurate by the expert panel which supports the validity of the results. Our findings show that the concept of professionalism is multidimensional and should be conceptualized as such.