Round robin testing of a percolation column leaching procedure.

Round robin test results of a percolation column leaching procedure (CEN/TS 14405:2004), organised by the Flemish Institute for Technological Research (VITO), over a time span of 13years with a participation of between 8 and 18 different laboratories are presented and discussed. Focus is on the leachability of heavy metals As, Cd, Cr, Cu, Hg, Ni, Pb and Zn from mineral waste materials. By performing statistical analyses on the obtained results, insight into the reproducibility and repeatability of the column leaching test is gathered. A ratio of 1:3 between intra- and inter-laboratory variability is found. The reproducibility of the eluates' element concentrations differ significantly between elements, materials and fractions (i.e. different liquid-to-solid ratios). The reproducibility is discussed in light of the application of the column leaching test for legal and environmental policy purposes. In addition, the performances of laboratories are compared.

'More shades of grey in my answers': an interview study revisiting attitude erosion during clerkships.

CONTEXT: Small declines in patient-centred attitudes during medical education have caused great concern. Although some of the self-report scales applied have solid psychometric foundations, validity evidence for the interpretation of attitude erosion during clerkships remains weak. OBJECTIVES: We sought to address this gap in a qualitative study of the relationships between scores on four commonly used attitude scales and participants' experiences and reflections. Our aim was to gain a better understanding of the score changes from the participants' perspectives. METHODS: We conducted semi-structured interviews with 15 junior doctors from a cohort (n = 37) that had previously shown a small decline in patient-centred attitudes during clerkships, measured on four self-report scales. In the interviews, we explored interviewees' experiences of their development of patient-centredness and subsequently discussed their scale scores, particularly for those items that contributed to a rise or decline in scores. We analysed the data using a process of constant comparison among personal experiences, scale scores and participants' explanations of score changes, applying the coding techniques of grounded theory. RESULTS: The analysis revealed important response distortions that might be responsible for small declines in scores during clerkships separately from changes in attitudes. The drastic alterations to the participants' frame of reference, attributable to the transition to clinical practice, represented the most prominent cause of distortion. More nuanced, context-specific, patient-centred reasoning resulted in more neutral responses after clerkships, paradoxically causing a decline in scores. In addition to response distortions, the interviews revealed shortcomings in content validity such as an 'extreme' construct of patient-centredness. CONCLUSIONS: This study calls into question the validity of the interpretation of attitude erosion during clerkships. The findings suggest that small declines in scores on self-report attitude scales are related to a recalibration of trainees' understandings of patient-centredness as they grow more clinically experienced. The evolved construct of patient-centredness and the way attitudes are measured require special attention in the development of future instruments.

Guanosine triphosphate cyclohydrolase 1 promoter deletion causes dopa-responsive dystonia.

BACKGROUND: Autosomal dominant dopa-responsive dystonia (AD-DRD) is caused by a biochemical defect primarily resulting from guanosine triphosphate cyclohydrolase 1 gene (GCH1) mutations. Few families have been reported without mutations in GCH1. METHODS: Genome-wide linkage analysis and positional cloning to identify the genetic defect in a Belgian AD-DRD family was carried out. RESULTS AND CONCLUSION: In this study, we report on the identification and characterization of a novel 24-kb deletion spanning exon 1 and the 5' regulatory region of GCH1 causing a wide spectrum of motor and nonmotor symptoms in a large Belgian AD-DRD family. This large-scale deletion of regulatory sequences leads to decreased GCH1 activity in all carriers, most probably resulting from allelic loss of transcription. We mapped the breakpoints of this deletion to the nucleotide level, allowing the development of a straightforward polymerase chain reaction assay for fast, efficient detection of this large deletion, which will prove valuable for preimplantation genetic diagnosis.

Patient-centredness from education to practice: the 'lived' impact of communication skills training.

BACKGROUND: Although communication skills training (CST) enhances patient-centred skills and attitudes, the literature indicates a problematic transfer of these from education into practice. AIM: We explored 'lived' experiences of medical students and doctors to gain a better understanding of the impact of CST on patient-centredness in the transition to real practice. METHODS: From a phenomenological perspective, we conducted 15 interviews and 11 focus groups with 4-9 participants/group (n = 67) at two universities and carried out constant comparative analysis. RESULTS: The gap between education and practice is the central phenomenon. Although CST raises students' communication awareness and self-efficacy in an 'ideal' context, this paradoxically seems to jeopardize their ability to bridge the gulf. In addition, CST does not come to grips with students' attitudes. However, CST appears to be successful in equipping students with long-lasting 'handles'. Yet students need more support to mould the provided 'ideal' models into their own unique style of context-specific patient-centred behaviour. This implies: raising students' awareness of own attitudes and communication styles, offering a more realistic training ground, integrating CST with clinical experience and translating the primary-care-rooted concept of patient-centredness into various specialization contexts. CONCLUSION: CST could raise its impact by supporting students' recycling processes towards a personal style of context-sensitive patient-centredness.

Medical students trained in communication skills show a decline in patient-centred attitudes: an observational study comparing two cohorts during clinical clerkships.

OBJECTIVE: Literature indicates a decline in patient-centredness in medical students, especially during clinical clerkships. We examined the impact of preclinical communication skills training (CST) on students' development of patient-centred attitudes and attitudes toward CST during clerkships. METHODS: We prospectively compared two cohorts before and after clerkships: one cohort (n=48) had not received CST, whereas the other (n=37) had received a five-year CST. We assessed the impact using five validated questionnaires. RESULTS: Communication trained students slightly but significantly declined in patient-centred attitudes (3/4 scales) and attitudes toward CST during clerkships, whereas the scores of the untrained students remained stable (5/5 scales). Both cohorts did not differ in attitudes before clerkships. In the trained cohort, males mostly showed a sharper decline than females. In the total group (n=85), females demonstrated higher attitude scores toward CST, and in 1/4 scales measuring patient-centred attitudes. CONCLUSION: This cohort study suggests that CST might make students more vulnerable to decline in attitude scores during clerkships. PRACTICE IMPLICATIONS: These remarkable findings, contrary to what educators would expect to result from their efforts, challenge medical education to address the new questions that are raised about the validity of the questionnaires, the impact of CST and the learning processes involved in the development of patient-centredness.

Help, I'm losing patient-centredness! Experiences of medical students and their teachers.

OBJECTIVES: Despite all educational efforts, the literature shows an ongoing decline in patient-centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient-centredness in order to gain a better understanding of the factors that determine its development. METHODS: We conducted 11 focus groups on the subject of learning and teaching about patient-centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the 'sensitising concepts' provided by the Attitude-Social Influence-Self-Efficacy (ASE) model. RESULTS: Although students express positive attitudes towards patient-centredness and acquire patient-centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today's challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient-centred skills. However, when students lack self-efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non-patient-centred role models and are overwhelmed by powerful experiences, they lose their patient-centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self-awareness and self-care are important qualities of the central phenomenon of the 'doctor-as-person', which is identified as a missing concept in the ASE model. The student-supervisor relationship is found to be key to learning patient-centredness and has several functions: it facilitates the direct transmission of patient-centred skills, knowledge and attitudes; it provides social support of students' patient-centred behaviour; it provides support of the 'student-as-person'; it mirrors patient-centredness by being student-centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student-centred education and guidance be offered, self-awareness be fostered and more opportunities to encounter patients be created, including more time in general practice. CONCLUSIONS: Supportive student-doctor relationships, student-centred education and guidance that addresses the needs of the doctor-as-person are central to the development of patient-centredness. Medical education requires patient-centred, self-caring and self-aware role models.

Empowering patients or general practitioners? A randomised clinical trial to improve quality in reproductive health care in Belgium.

BACKGROUND: Evidence-based clinical guidelines on contraceptive use were developed and distributed among all Flemish general practitioners (GPs) in Belgium. OBJECTIVES: To evaluate the effectiveness of two strategies for implementing a guideline on oral contraceptives in order to enhance the quality of the first contraception consultation in general practice, by either empowering patients or by introducing a computer decision support system (CDSS). METHOD: A random sample of 45 GPs was distributed among three study groups. One group was visited by an 'empowered patient', one group's electronic medical record was supplemented with a CDSS, and one group served as the control group. Simulated patients (SPs) assessed the performance of GPs in daily practice before and after the interventions, using a validated 48-point checklist. RESULTS: The baseline mean score of the 43 GPs was 26.16 (SD = 5.76). The SPs received sufficient information about correct pill usage, but not concerning factors associated with pill failure and drug interaction. After the intervention, the GPs' mean score was 26.39 (SD = 6.86). Only the intervention group with the 'empowered patient' scored significantly better (29.92 [SD = 7.11]). The computer group and control group scored lower (24.36 [SD = 6.60] and 24.82 [SD = 5.65], respectively). CONCLUSION: Developing and distributing an evidence-based guideline did not change GPs' behaviour. However, empowering patients to participate more proactively significantly improved GPs' performance during a contraception consultation. A CDSS did not.

Intimate examination teaching with volunteers: implementation and assessment at the University of Antwerp.

OBJECTIVES: Teaching intimate physical examinations in medical schools generates practical, didactical and ethical problems. At the University of Antwerp, a unique program with intimate examination assistants (IEA) was implemented for fifth year's undergraduate students. They learn gynaecological and urological skills in healthy volunteers. Technical, communicative and attitude aspects are taken into account. METHODS: Description of the implementation of the project. Assessment of the project by questionnaires, written reflections and round table conferences. RESULTS: The results provide detailed information about the student's perceptions of each component of the program as well as the perceptions of the IEA's and the teachers. CONCLUSION: The multilevel evaluation of the program supports the surplus value of working with IEA's in medical education. The eye-catcher in this program is the integration of clinical skills with communicative skills and attention for students' attitude. PRACTICE IMPLICATIONS: Working with IEA's for intimate examinations represents a benefit in medical education by lowering the student's threshold to perform the intimate physical examination on both men and women during their fulltime clerkships.

Adolescents demanding a good contraceptive: a study with standardized patients in general practices.

To assess how Flemish general practitioners (GPs) are handling the first contraception consultation, we used standardized patients (SPs) as the best method to assess the performance of GPs in daily practice. Thirty GPs got a visit from one of the three SPs. Based on a validated checklist, the SPs scored the performance of GPs and they registered the circumstances and the duration of the consultation. Twenty-eight consultations were analyzed. General practitioners scored moderately on the content level of the consultation. Rarely, GPs asked about attitude regarding safe sex, took gynecological history or discussed contraindications. None of the GPs took a personal history to exclude pregnancy. The SPs received enough information about correct pill use, but there was minimal discussion on factors associated with pill intake and interactions with other medications. Few GPs (6/28) gave a prescription corresponding to the Flemish guidelines. The others were influenced by the pharmaceutical representatives. The girls felt, however, very satisfied with the consultation with the GPs.

A short educational intervention on communication skills improves the quality of screening for Chlamydia in GPs in Belgium: a cluster randomised controlled trial.

An accurate algorithm for screening for chlamydial infections is available in general practice, but GPs experience numerous barriers to sexually transmitted infections (STI) counselling. In this study we assessed if a short educational package, under the form of a commented video footage on communication skills, was helpful in implementing the screening strategy. A cluster randomised controlled trial was carried out in 36 general practitioners in Antwerp, Belgium. Main outcome measures were: number of patients included in the risk assessment, number of patients tested, and proportion of appropriately tested patients. The results show that GPs in the intervention group did not include more patients overall, but that the quality of the screening process was significantly better (81.6% versus 56.2% appropriate tests, P = 0.02). Conclusively, GPs who participated in a short educational package on communication skills, selected eligible candidates for screening more accurately and decreased the risk of overscreening.