How do ageism, death anxiety and ageing anxiety among medical students and residents affect their attitude towards medical care for older patients: a systematic review.

BACKGROUND: Although the number of older patients requiring medical care is increasing, caring for older patients is often seen as unattractive by medical trainees (i.e., medical students, residents, interns, and fellows). Terror Management Theory states that people have a negative attitude towards older people, because they remind people of their own mortality. We hypothesize that ageism, death anxiety, and ageing anxiety among medical trainees negatively affect their attitude towards medical care for older patients. This review aimed to examine and generate an overview of available literature on the relationship between ageism, death anxiety, and ageing anxiety among medical trainees and their attitude towards medical care for older patients. METHODS: A systematic review was performed with a review protocol based on the PRISMA Statement. PubMed, Ebsco/PsycInfo, Ebsco/ERIC and Embase were searched from inception to August 2022, using the following search terms, including their synonyms and closely related words: "medical trainees" AND "ageism" OR "death anxiety" OR "ageing anxiety" AND "(attitude AND older patient)". RESULTS: The search yielded 4072 different studies; 12 eligible studies (10 quantitative and 2 qualitative) were identified and synthesized using narrative synthesis. Findings suggest that a positive attitude towards older people was related to a positive attitude towards medical care for older patients among medical students. The available literature on the relationship between death anxiety and/or ageing anxiety and attitude towards medical care for older patients among medical trainees was limited and had a heterogeneity in focus, which hindered comparison of results. CONCLUSION: Our findings suggest that a positive attitude towards older people in general is related to a positive attitude towards medical care for older patients among medical students. Future research should focus on further exploring underlying mechanisms affecting the attitude towards medical care for older patients among medical trainees.

Longitudinal training models for entrusting students with independent patient care?: A systematic review.

OBJECTIVE: The participation of students from both undergraduate medical education (UGME) and postgraduate medical education (PGME) in independent patient care contributes to the development of knowledge, skills and the professional identity of students. A continuing collaboration between students and their preceptor might contribute to opportunities for students to independently provide patient care. In this systematic review, we aim to evaluate whether longitudinal training models facilitate the independent practice of students and what characteristics of longitudinal training models contribute to this process. METHOD: This systematic review was performed according to the PRISMA guidelines. In May 2020, we performed a search in three databases. Articles evaluating the impact of longitudinal training models on the independent practice of students from both UGME and PGME programmes were eligible for the study. A total of 68 articles were included in the study. Quality of the included studies was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). RESULTS: Both UGME and PGME students in longitudinal training models are more frequently allowed to provide patient care independently when compared with their block model peers, and they also feel better prepared for independent practice at the end of their training programme. Several factors related to longitudinal training models stimulate opportunities for students to work independently. The most important factors in this process are the longitudinal relationships with preceptors and with the health care team. CONCLUSION: Due to the ongoing collaboration between students and their preceptor, they develop an intensive and supportive mutual relationship, allowing for the development of a safe learning environment. As a result, the professional development of students is fostered, and students gradually become part of the health care team, allowing them the opportunity to engage in independent patient care.

Feasibility, and validity aspects of Entrustable Professional Activity (EPA)-based assessment in general practice training.

INTRODUCTION: Entrustable Professional Activities (EPAs) are developed to support the practical application of competency frameworks in postgraduate medical education (PGME) programmes. EPAs are used for the assessment of the trainees' competence development, which takes place by means of an entrustment decision, aiming to stimulate learning and independent practice in trainees. In this pilot study, we explore the feasibility and validity of EPA-based assessment in a General Practice (GP) training programme. METHODS: We used questionnaires to evaluate trainers' and trainees' experiences with the use of six EPAs for trainee learning, assessment and independent practice at the Out-of-Hours GP Center. Data were analysed quantitatively and qualitatively. Additionally, we examined the inter-item correlation between scores on EPA-based assessment and competency-based assessment using Spearman's Rho. RESULTS: EPA-based assessment provided opportunities for giving concrete feedback and substantiating competency-based assessment. No consistent correlation between EPA-based assessment and competency-based assessment could be detected. Only later in the course of the training programme a correlation was found between the EPA scores and the degree of independence of trainees. DISCUSSION: Results of this pilot study confirm the theories behind EPAs, as well as earlier research on EPAs in the workplace regarding trainee learning, assessment and independent practice. An important limitation of this study was the COVID-19 pandemic, as it influenced the results through reduced inclusion and follow-up, and through the impact on the workplace and trainee learning possibilities. Further research is needed to determine how EPAs support independent practice of trainees, as well as the assessment of trainee competency development.

Complaint-driven preferences & trust: patient's views on consulting GP trainees.

BACKGROUND: Work-based learning depends on patients' consent to have trainees involved in their care. However, patients can refuse trainees, which might lead to the loss of learning experiences. Improved understanding of patients' views on consulting trainees may provide useful insights to further optimise learning for trainees. METHODS: We performed a qualitative study with 28 patients in The Netherlands. Participants were recruited from GP practices, and were purposively sampled on (un)willingness to consult GP trainees. In semi-structured interviews patients' perspectives and willingness to consult a trainee were explored. Transcripts were thematically analysed using an inductive approach. RESULTS: Two themes explained patients' views on consulting GP trainees: Presenting complaint-driven preferences and Trust in trainees' capabilities. Patients select their doctor based on complaint-driven preferences and chose trainees if they fulfilled these preferences. For urgent, gender-specific and minor complaints, patients prefer timeliness, gender concordance or availability. Patients with more complex, long-term problems prefer to consult a trusted doctor with whom they have a longitudinal relationship. Through repeated visits and empathic behaviour trainees can become this doctor. Before patients consider consulting a trainee, they need to have trust in the trainee's capabilities. This trust is related to the basic trust patients have in the education of the trainee, their knowledge about trainees' capabilities and supervisory arrangements. CONCLUSIONS: Patients' decision to visit a trainee is fluid. Patients will visit a trainee when their complaint-driven preferences are satisfied. Influencing trainees' fulfilment of these preferences and patients' trust in trainees can make patients more willing to consult trainees.

Diagnostic yield and accuracy in a tertiary referral syncope unit validating the ESC guideline on syncope: a prospective cohort study.

AIMS: To assess in patients with transient loss of consciousness the diagnostic yield, accuracy, and safety of the structured approach as described in the ESC guidelines in a tertiary referral syncope unit. METHODS AND RESULTS: Prospective cohort study including 264 consecutive patients (≥18 years) referred with at least one self-reported episode of transient loss of consciousness and presenting to the syncope unit between October 2012 and February 2015. The study consisted of three phases: history taking (Phase 1), autonomic function tests (AFTs) (Phase 2), and after 1.5-year follow-up with assessment by a multidisciplinary committee (Phase 3). Diagnostic yield was assessed after Phases 1 and 2. Empirical diagnostic accuracy was measured for diagnoses according to the ESC guidelines after Phase 3. The diagnostic yield after Phase 1 (history taking) was 94.7% (95% CI: 91.1-97.0%, 250/264 patients) and increased to 97.0% (93.9-98.6%, 256/264 patients) after Phase 2. The overall diagnostic accuracy (as established in Phase 3) of the Phases 1 and 2 diagnoses was 90.6% (95% CI: 86.2-93.8%, 232/256 patients). No life-threatening conditions were missed. Three patients died, two unrelated to the cause of transient loss of consciousness, and one whom remained undiagnosed. CONCLUSION: A clinical work-up at a tertiary syncope unit using the ESC guidelines has a high diagnostic yield, accuracy, and safety. History taking (Phase 1) is the most important diagnostic tool. Autonomic function tests never changed the Phase 1 diagnosis but helped to increase the certainty of the Phase 1 diagnosis in many patients and yield additional diagnoses in patients who remained undiagnosed after Phase 1. Diagnoses were inaccurate in 9.4%, but no serious conditions were missed. This is adequate for clinical practice.

Rationale, design and initial results of an educational intervention to improve provider-initiated HIV testing in primary care.

OBJECTIVES: In the Netherlands, general practitioners (GPs) perform two-thirds of sexually transmitted infection (STI) consultations and diagnose one-third of HIV infections. GPs are, therefore, a key group to target to improve provider-initiated HIV testing. We describe the design and implementation of an educational intervention to improve HIV testing by Amsterdam GPs and explore trends in GPs' testing behaviour. METHODS: Interactive sessions on HIV and STI using graphical audit and feedback started in 2015. Participating GPs developed improvement plans that were evaluated in follow-up sessions. Laboratory data on STI testing by Amsterdam GPs from 2011 to 2017 were collected for graphical audit and feedback and effect evaluation. The primary outcome was the HIV testing rate: number of HIV tests per 10 000 person-years (PY). Secondary endpoints were chlamydia and gonorrhoea testing rates and HIV positivity ratios. RESULTS: Since 2015, 41% of GPs participated. HIV testing rate declined from 2011 to 2014 (from 175 to 116 per 10 000 PY), more in women than men (176 to 101 versus 173 to 132), and stabilized from 2015 to 2017. The HIV positivity ratio declined from 0.8% in 2011 to 0.5% in 2017. From 2011 to 2017, chlamydia and gonorrhoea testing rates declined in women (from 618 to 477 per 10 000 PY) but remained stable in men (from 270 to 278). CONCLUSIONS: The stabilization of the downward trend in HIV testing coincided with this educational intervention. Follow-up data are needed to formally assess the intervention's impact on GP testing behaviour whilst considering contextual factors and secular trends.

Trainers' and trainees' expectations of entrustable professional activities (EPAs) in a primary care training programme.

Introducing Entrustable Professional Activities (EPAs) into primary care postgraduate medical education (PGME) programmes may be challenging, due to the general nature of primary care medicine, but trainers and trainees both stand to benefit from their use. We investigated the expectations of trainers and trainees in a primary care PGME programme regarding the use of EPAs. We held two focus group discussions with trainers and four with trainees from the Dutch General Practice training programme, to explore their views on the use of EPAs in their training programme. Focus group discussions were audio-recorded and transcribed verbatim. The transcripts were analysed using conventional content analysis. Trainers and trainees felt that the large number of EPAs in the training programme, and the general way they are formulated, made them unsuitable for use in formal assessments. However, they felt that EPAs can be a useful aid to trainee learning. EPAs may help trainers to give trainees specific feedback on their performance. While the use of the classic EPA method in primary care PGME programmes may be challenging, EPAs in such programmes might be more suitable as design and learning tools than as a tool for formal assessment.

Self-regulated learning in the clinical context: a systematic review.

OBJECTIVES: Research has suggested beneficial effects of self-regulated learning (SRL) for medical students' and residents' workplace-based learning. Ideally, learners go through a cyclic process of setting learning goals, choosing learning strategies and assessing progress towards goals. A clear overview of medical students' and residents' successful key strategies, influential factors and effective interventions to stimulate SRL in the workplace is missing. This systematic review aims to provide an overview of and a theoretical base for effective SRL strategies of medical students and residents for their learning in the clinical context. METHODS: This systematic review was conducted according to the guidelines of the Association for Medical Education in Europe. We systematically searched PubMed, EMBASE, Web of Science, PsycINFO, ERIC and the Cochrane Library from January 1992 to July 2016. Qualitative and quantitative studies were included. Two reviewers independently performed the review process and assessed the methodological quality of included studies. A total of 3341 publications were initially identified and 18 were included in the review. RESULTS: We found diversity in the use of SRL strategies by medical students and residents, which is linked to individual (goal setting), contextual (time pressure, patient care and supervision) and social (supervisors and peers) factors. Three types of intervention were identified (coaching, learning plans and supportive tools). However, all interventions focused on goal setting and monitoring and none on supporting self-evaluation. CONCLUSIONS: Self-regulated learning in the clinical environment is a complex process that results from an interaction between person and context. Future research should focus on unravelling the process of SRL in the clinical context and specifically on how medical students and residents assess their progress towards goals.

Effectiveness of an individual, online e-learning program about sexually transmitted infections: a prospective cohort study.

BACKGROUND: Primary health-care professionals play an important role in the treatment and prevention of Sexually Transmitted Infections (STI). Continuing Medical Education (CME)-courses can influence the knowledge and behavior of health-care professionals concerning STI. We performed a prospective cohort study to evaluate if the individual and online e-learning program "The STI-consultation", which uses the Commitment-to-Change (CtC)-method, is able to improve the knowledge, attitude and behavior of Dutch General Practitioners (GPs), concerning the STI-consultation. This e-learning program is an individual, accredited, online CME-program, which is freely available for all GPs and GP-trainees in the Netherlands. METHODS: In total 2192 participants completed the questionnaire before completing the e-learning program and 249 participants completed the follow-up questionnaire after completing the e-learning program. The effect of the program on their knowledge, attitude and behavior concerning the STI-consultation was evaluated. RESULTS: In total 193 participants formulated 601 learning points that matched the learning objectives of the program. The knowledge and attitude of the participants improved, which persisted up to two years after completing the program. Another 179 participants formulated a total of 261 intended changes concerning the sexual history taking, additional investigation and treatment of STI, 97.2% of these changes was partially or fully implemented in daily practice. Also, 114 participants formulated a total of 180 "unintended" changes in daily practice. These changes concerned the attitude of participants towards STI and the working conditions concerning the STI-consultation. CONCLUSION: The individual, online e-learning program "The STI-consultation", which uses the CtC-method, has a small but lasting, positive effect on the knowledge, attitude, and behavior of GPs concerning the STI-consultation.

The development of a collective quality system: challenges and lessons learned; a qualitative study.

BACKGROUND: The ongoing professionalization of medical education means that quality systems (QSs) aimed at improving medical education also continuously have to improve. The aim of this paper is to describe the development of a collective QS for eight Dutch General Practitioner (GP) specialty training institutes to provide insights into the considerations that are involved in developing a QS in medical education. METHODS: Experts in the field of GP education and quality assurance developed the QS. They studied the literature, prior QSs and involved stakeholders. The team interviewed the directors, and all meetings and steps in the development process were transcribed. All interviews and relevant documentation were analyzed. Results were checked by the developers. RESULTS: Stakeholders agreed on the goals, the relevance of the resulting domains, and the methods to assess. However, one major theme emerged. To enable benchmarking, the team developed detailed quantifiable indicators. Especially the development of these indicators gave discussion. CONCLUSIONS: Involving stakeholders was crucial as they directed the development of the QS. The framework of the World Federation for Medical Education (WFME) provided guidance in covering all the relevant processes. The major challenge consisted of formulating indicators. Our experience indicates that the process of quantifying indicators is not straightforward. The detailed level of the indicators chosen is perhaps not always suitable for QSs in the field of medical education.

The implementation of a quality system in the Dutch GP specialty training: barriers and facilitators; a qualitative study.

BACKGROUND: Quality assurance programs in medical education are introduced to gain insight into the quality of such programs and to trigger improvements. Although of utmost importance, research on the implementation of such programs is scarce. The Dutch General Practice (GP) specialty training institutes used an implementation strategy to implement a quality system (QS), and we aimed to study the success of this strategy and to learn about additional facilitators and barriers. METHODS: Seventeen structured interviews were conducted with the directors and quality coordinators (QCs) of the eight Dutch GP training institutes. A five-stage process model of implementation was used to structure these interviews and analyze the data. Two researchers analyzed the data with a framework approach. RESULTS: The strategy supported the institutes in implementing the QS. However, after the introduction of the QS, staff experienced the QS as demanding, although they noticed almost no concrete short-term results. Moreover, they experienced difficulties in integrating the QS into their local situation. Collectively working with the QS and following common deadlines did create a sense of commitment towards each other that appeared to be a true stimulus to the introduction of the QS. CONCLUSIONS: The implementation strategy focused mainly on the introduction of the QS in the GP specialty training, and it was, as such, rather successful. An important barrier concerned the acceptance of the QS and the integration of the QS into local structures, which suggests that there is a need for guidance on the translation of the QS to local contexts. All in all, we recommend more focus on the benefits of a QS.

Assessment of motivational interviewing: a qualitative study of response process validity, content validity and feasibility of the motivational interviewing target scheme (MITS) in general practice.

BACKGROUND: The Motivational Interviewing target Scheme (MITS) is an instrument to assess competency in Motivational Interviewing (MI) and can be used to assess MI in long and brief consultations. In this qualitative study we examined two sources of the Unified Model of Validity, the current standard of assessment validation, in the context of General Practice. We collected evidence concerning response process validity and content validity of the MITS in general practice. Furthermore, we investigated its feasibility. METHODS: Assessing consultations of General Practitioners and GP-trainees (GPs), the assessors systematically noted down their considerations concerning the scoring process and the content of the MITS in a semi-structured questionnaire. Sampling of the GPs was based on maximum variation and data saturation was used as a stopping criterion. An inductive approach was used to analyse the data. In response to scoring problems the score options were adjusted and all consultations were assessed using the original and the adjusted score options. RESULTS: Twenty seven assessments were needed to reach data saturation. In most consultations, the health behaviour was not the reason for encounter but was discussed on top of discussing physical problems. The topic that was most discussed in the consultations was smoking cigarettes. The adjusted score options increased the response process validity; they were more in agreement with theoretical constructs and the observed quality of MI in the consultations. Concerning content validity, we found that the MITS represents the broad spectrum and the current understanding of MI. Furthermore, the MITS proved to be feasible to assess MI in brief consultations in general practice. CONCLUSIONS: Based on the collected evidence the MITS seems a promising instrument to measure MI interviewing in brief consultations. The evidence gathered in this study lays the foundation for research into other aspects of validation.

Learning from a role model: A cascade or whirlpool effect?

BACKGROUND: Continuing Professional Development (CPD) and Faculty Development (FD) courses have been designed in the expectation that a cascade effect will occur, consisting of a conveyance of information from the courses to clinical trainers to daily practice and/or to trainees by means of role modeling. PURPOSE: The aims of this study were to gain insight into factors that encourage clinical trainers to incorporate what they have learned in CPD/FD into their role model function and the factors that influence conveyance from master to apprentice. METHOD: We conducted a qualitative study using semi-structured interviews with GP trainers and their trainees. RESULTS: Twenty-four GP trainers who completed a CPD/FD course and sixteen of their trainees participated in the study. Analysis of their statements enabled the identification of factors that affect the amplification of the competences of clinical trainers and their awareness of being a role model, the applicability in training practice and conveyance to the trainee. CONCLUSIONS: As a result of interactions between the trainer, trainee and patient, it seems more accurate to represent the conveyance of competences from master to apprentice using the image of a whirlpool rather than a cascade, with the influential factors and interactions functioning as filters, causing a decline in the effectiveness of CPD/FD. Using the filters as a basis for turning-points for improvements around the whirlpool could increase the effectiveness of CPD/FD.

Learning results of GP trainers in a blended learning course on EBM: a cohort study.

BACKGROUND: General practitioners (GPs) experience barriers to the use of evidence-based medicine (EBM) related to a negative attitude and to insufficient knowledge and skills. We therefore designed a blended learning intervention to develop the competence of GP trainers in EBM. This study investigated the effectiveness of this intervention in increasing the trainers' EBM competencies (i.e. knowledge, skills, attitude and behaviour). METHODS: In total 129 GP trainers participated in the blended learning course on EBM consisting of four 3-h face-to-face meetings and an intensive preparatory e-course before each meeting over a 12-month period. The primary outcomes were changes in knowledge and skills (Fresno test), changes in attitude (McColl test) and intentions to change behaviour. Secondary outcomes were changes in self-rated knowledge, skills and attitude, and the relation between personal characteristics and changes in knowledge, skills and attitude. Data were collected before the start of the intervention (T0), at the end of the last day of the intervention (T1) and four months after the end of the intervention (T2). RESULTS: The mean changes in scores on the Fresno test were ∆T1-T0 = 40.8 (SD ±36.7, p < .001) and ∆T2-T0 = 20.8 (±39.9, p < .001). The mean changes in scores on the McColl test were ∆T1-T0 = 2.2 (SD ±12.8, p = .16) and ∆T2-T0 = -.87 (±10.0, p = .49). Of the GP trainers, 16.7 % fulfilled their intentions to change in behaviour, 47.6 % partly fulfilled them and 35.7 % did not fulfil them at all. Female trainers scored significantly higher on the Fresno test after the intervention compared to male trainers. There was a weak positive correlation between self-rated knowledge and the scores on the Fresno test. A moderate correlation was found between the overall score on the McColl test and self-rated attitude. CONCLUSION: An intensive blended learning course on EBM for GP trainers induces an increase in knowledge and skills that, although decreased, remains after four months. Attitude and behaviour towards EBM show no differences before and after the intervention, although GPs' intention to use EBM more often in their practice is present.

Physical counter-pressure manoeuvres in preventing syncopal recurrence in patients older than 40 years with recurrent neurally mediated syncope: a controlled study from the Third International Study on Syncope of Uncertain Etiology (ISSUE-3)†.

AIMS: Physical counter-pressure manoeuvres (PCM) are effective in young patients with vasovagal syncope and recognizable prodromal symptoms. The aim of this study was to investigate their effectiveness in patients ≥40 years with severe neurally mediated syncope (NMS) enroled in the Third International Study on Syncope of Uncertain Etiology (ISSUE-3). METHODS AND RESULTS: In the ISSUE-3 study, 63 out of 162 patients had a diagnosis of hypotensive NMS (Types 2, 3, and 4A) documented by implantable loop recorder; of these, 40 were instructed to perform isometric leg and arm PCM therapy. Their mean age was 62 ± 13 years; 47% of patients had a history of some episodes without prodrome. A group of 45 untreated patients acted as controls. The primary endpoint was the time to first syncope recurrence. During follow-up, syncope recurred in 15 PCM patients (37%) and in 24 control patients (53%) (P = 0.14). At 21 months, the modelled syncope recurrence rates were 42% [95% confidence interval (CI): 27-61] and 64% (95% CI: 48-80), respectively (P = 0.27). CONCLUSION: In conclusion, many ISSUE-3 patients affected by hypotensive NMS have syncopal recurrence despite PCM. Older age and the absence of sufficiently long recognizable prodromal symptoms in the ISSUE-3 population might have hampered the effectiveness of PC therapy.

Priorities for emergency department syncope research.

STUDY OBJECTIVES: There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research. METHODS: We recruited a multinational panel of syncope experts. A preconference survey identified research priorities, which were refined during and after the conference through an iterative review process. RESULTS: There were 31 participants from 7 countries who represented 10 clinical and methodological specialties. High-priority research recommendations were organized around a conceptual model of ED decisionmaking for syncope, and they address definition, cohort selection, risk stratification, and management. CONCLUSION: We convened a multispecialty group of syncope experts to identify the most pressing knowledge gaps and defined a high-priority research agenda to improve the care of patients with syncope in the ED.

Competencies of specialised wound care nurses: a European Delphi study.

Health care professionals responsible for patients with complex wounds need a particular level of expertise and education to ensure optimum wound care. However, uniform education for those working as wound care nurses is lacking. We aimed to reach consensus among experts from six European countries as to the competencies for specialised wound care nurses that meet international professional expectations and educational systems. Wound care experts including doctors, wound care nurses, lecturers, managers and head nurses were invited to contribute to an e-Delphi study. They completed online questionnaires based on the Canadian Medical Education Directives for Specialists framework. Suggested competencies were rated on a 9-point Likert scale. Consensus was defined as an agreement of at least 75% for each competence. Response rates ranged from 62% (round 1) to 86% (rounds 2 and 3). The experts reached consensus on 77 (80%) competences. Most competencies chosen belonged to the domain 'scholar' (n = 19), whereas few addressed those associated with being a 'health advocate' (n = 7). Competencies related to professional knowledge and expertise, ethical integrity and patient commitment were considered most important. This consensus on core competencies for specialised wound care nurses may help achieve a more uniform definition and education for specialised wound care nurses.

Risk factors associated with visiting or not visiting the accident & emergency department after a fall.

BACKGROUND: Little is known about the prevalence of modifiable risk factors of falling in elderly persons with a fall-history who do not visit the Accident and Emergency (A&E) Department after one or more falls. The objective of this study was to determine the prevalence of modifiable risk factors in a population that visited the A&E Department after a fall (A&E group) and in a community-dwelling population of elderly individuals with a fall history who did not visit the A&E Department after a fall (non-A&E group). METHODS: Two cohorts were included in this study. The first cohort included 547 individuals 65 years and older who were visited at home by a mobile fall prevention team. The participants in this cohort had fall histories but did not visit the A&E Department after a previous fall. These participants were age- and gender-matched to persons who visited the A&E Department for care after a fall. All participants were asked to complete the CAREFALL Triage Instrument. RESULTS: The mean number of modifiable risk factors in patients who did not visit the A&E Department was 2.9, compared to 3.8 in the group that visited the A&E Department (p<0.01). All risk factors were present in both groups but were more prevalent in the A&E group, except for the risk factors of balance and mobility (equally prevalent in both groups) and orthostatic hypotension (less prevalent in the A&E group). The risk factors of polypharmacy, absence of orthostatic hypotension, fear of falling, impaired vision, mood and high risk of osteoporosis were all independently associated with visiting the A&E Department. CONCLUSION: All modifiable risk factors for falling were found to be shared between community-dwelling elderly individuals with a fall history who visited the A&E Department and those who did not visit the Department, although the prevalence of these factors was somewhat lower in the A&E group. Preventive strategies aimed both at patients presenting to the A&E Department after a fall and those not presenting after a fall could perhaps reduce the number of recurrent falls, the occurrence of injury and the frequency of visits to the A&E Department.

A systematic review of the relationship between patient mix and learning in work-based clinical settings. A BEME systematic review: BEME Guide No. 24.

BACKGROUND: Clinical workplace-based learning has been the means to becoming a medical professional for many years. The importance of an adequate patient mix, as defined by the number of patients and the types of medical problems, for an optimal learning process is based on educational theory and recognised by national and international accreditation standards. The relationship between patient mix and learning in work-based curricula as yet remains unclear. AIM: To review research addressing the relationship between patient mix and learning in work-based clinical settings. METHOD: The search was conducted across Medline, Embase, Web of Science, ERIC and the Cochrane Library from the start date of the database to July 2011. Original quantitative studies on the relationship between patient mix and learning for learners at any level of the formal medical training/career were included. Methodological quality was assessed and two reviewers using pre-specified forms extracted results. RESULTS: A total of 10,420 studies were screened on title and abstract. Of these, 298 articles were included for full-text analysis, which resulted in the inclusion of 22 papers. The quality of the included studies, scored with the Medical Education Research Study Quality Instrument (MERSQI), ranged from 8.0 to 14.5 (of 18 points). A positive relationship was found between patient mix and self-reported outcomes evaluating the progress in competence as experienced by the trainee, such as self-confidence and comfort level. Patient mix was also found to correlate positively with self-reported outcomes evaluating the quality of the learning period, such as self-reported learning benefit, experienced effectiveness of the rotation, or the instructional quality. Variables, such as supervision and learning style, might mediate this relationship. A relationship between patient mix and formal assessment has never been demonstrated. CONCLUSION: Patient mix is positively related to self-reported learning outcome, most evidently the experienced quality of the learning programme.