The threat of the dyscompetent resident: A plea to make the implicit more explicit!

Although several examples of frameworks dealing with students' unprofessional behaviour are available, guidance on how to deal locally or regionally with dysfunctional residents is limited (Hickson et al. in Acad Med 82(11):1040-1048, 2007b; Leape and Fromson in Ann Intern Med 144(2):107-115, 2006). Any 'rules' are mostly unwritten, and often emerge by trial and error within the specialty training programme (Stern and Papadakis in N Engl J Med 355(17):1794-1799, 2006). It is nevertheless of utmost importance that objectives, rules and guidelines comparable to those existing in undergraduate training (Project Team Consilium Abeundi van Luijk in Professional behaviour: teaching, assessing and coaching students. Final report and appendices. Mosae Libris, 2005; van Mook et al. in Neth J Crit Care 16(4):162-173, 2010a) are developed for postgraduate training. And that implicit rules are made explicit. This article outlines a framework based on the lessons learned from contemporary postgraduate medical training programmes.

Workplace learning from a socio-cultural perspective: creating developmental space during the general practice clerkship.

Workplace learning in undergraduate medical education has predominantly been studied from a cognitive perspective, despite its complex contextual characteristics, which influence medical students' learning experiences in such a way that explanation in terms of knowledge, skills, attitudes and single determinants of instructiveness is unlikely to suffice. There is also a paucity of research which, from a perspective other than the cognitive or descriptive one, investigates student learning in general practice settings, which are often characterised as powerful learning environments. In this study we took a socio-cultural perspective to clarify how students learn during a general practice clerkship and to construct a conceptual framework that captures this type of learning. Our analysis of group interviews with 44 fifth-year undergraduate medical students about their learning experiences in general practice showed that students needed developmental space to be able to learn and develop their professional identity. This space results from the intertwinement of workplace context, personal and professional interactions and emotions such as feeling respected and self-confident. These forces framed students' participation in patient consultations, conversations with supervisors about consultations and students' observation of supervisors, thereby determining the opportunities afforded to students to mind their learning. These findings resonate with other conceptual frameworks and learning theories. In order to refine our interpretation, we recommend that further research from a socio-cultural perspective should also explore other aspects of workplace learning in medical education.

Workplace learning in general practice: supervision, patient mix and independence emerge from the black box once again.

BACKGROUND: Medical students increasingly participate in rotations in primary care settings, such as general practices. Although general practices can differ markedly from hospital settings, research on the instructional quality of general practice rotations is relatively scarce. AIM: We conducted a study to identify which aspects make a significant contribution to the instructional quality of general practice clerkships, as perceived by students. METHOD: After completing their general practice attachment, 155 fifth-year medical students filled out an evaluation questionnaire. Exploratory factor analysis and reliability analysis identified clusters of correlated independent variables. Subsequent regression analysis revealed the relations between the reduced set of independent variables and the dependent variable 'Instructional quality'. RESULTS: Both the quality of supervision and the size and diversity of the patient mix substantially affected students' experienced instructional quality. Opportunities and facilities to perform independently were correlated with instructional quality, but did not affect the instructiveness directly. CONCLUSIONS: Supervision, patient mix and independence are crucial factors for learning in general practice. This is consistent with findings in hospital settings. The perceived quality of instruction hinges on supervision, which is not only the variable most strongly related to instructional quality, but which also affects both the patient mix and students' independence.

Alcohol intake and cardiovascular disease and mortality: the role of pre-existing disease.

OBJECTIVES: Pre-existing conditions have been postulated as possible causes of the J-shaped relationship between alcohol intake and cardiovascular disease. Two research questions have been addressed in this paper. First, whether never drinkers and former drinkers differ from moderate drinkers in terms of health, and if so, which health problems contribute to this difference. Second, whether the U-shaped relationship between current alcohol intake and cardiovascular disease or all-cause mortality could in part be explained by difference in pre-existing disease burden. DESIGN, SETTING AND PARTICIPANTS: A prospective case-cohort, the Lifestyle and Health Study, consisting of 16,210 men and women aged between 45 and 70 years. Alcohol intake and risk factors were assessed at baseline with a self-administered questionnaire. Medical information was obtained from general practitioners. Cardiovascular events and mortality were followed for a period of 5 years (1996-2001). MAIN RESULTS: Never drinkers and former drinkers were less healthy than moderate drinkers. They rated their health more often as poor, and often had more diseases, such as cardiovascular disease, diabetes, and also alcohol-related diseases. The difference in disease burden did not change the observed relationship between alcohol intake and cardiovascular events, and only partially changed the U-shaped relationship between alcohol intake and all-cause mortality. CONCLUSIONS: The found difference in health between never drinkers and former drinkers compared with moderate drinkers appeared to be only a partial explanation of the observed relationships between alcohol intake and cardiovascular disease, and between alcohol intake and all-cause mortality.

Lower prevalence of heart disease but higher mortality risk during follow-up was found among nonrespondents to a cohort study.

OBJECTIVE: The primary aim was to assess the association between response behavior and health status at baseline, and survival in a 5-year follow-up period. A secondary aim was to assess whether reasons for nonresponse were associated with health status at baseline. STUDY DESIGN AND SETTING: Data came from a prospective study cohort consisting of 31,349 men and women aged 45-70 years. Objective retrospective and prospective health information derived from general practitioner registries was available for both respondents and nonrespondents. RESULTS: Results show that among respondents coronary heart disease was more prevalent. Compared with respondents, noncontacts had a higher mortality risk during follow-up. Refusals had hypercholesterolemia more often than did noncontacts, and coronary heart disease or diabetes mellitus less often. CONCLUSION: The paradoxical results that respondents are less healthy at baseline but prospectively have a lower mortality risk may point to a selection effect indicating that the 'worried ill' are more inclined to participate. This effect could imply that observed relationships between risk factors or behaviors and outcomes in cohort studies may be attenuated.

Patient satisfaction with out-of-hours primary care in the Netherlands.

BACKGROUND: In recent years out-of-hours primary care in the Netherlands has changed from practice-based to large-scale cooperatives. The purpose of this study is to determine patient satisfaction with current out-of-hours care organised in general practitioner (GP) cooperatives, and gain insight in factors associated with this satisfaction. METHODS: From March to June 2003, 2805 questionnaires were sent to patients within three weeks after they had contacted the GP cooperative in their region. The study was conducted in the province of Limburg in the South of the Netherlands. One-third of these questionnaires was sent to patients who had only received telephone advice, one-third to patients who attended the GP cooperative for consultation, and one-third to patients who received a home visit. Four weeks after the first reminder, a non-respondents telephone interview was performed among a random sample of 100 patients. Analyses were performed with respect to the type of consultation. RESULTS: The total response was 42.4% (1160/2733). Sixty-seven percent of patients who received telephone advice only reported to be satisfied with out-of-hours care. About 80% of patients who went to the GP cooperative for consultation or those receiving a home visit, reported to be satisfied. Factors that were strongly associated with overall satisfaction included, the doctor's assistant's attitude on the phone, opinion on GP's treatment, and waiting time. CONCLUSION: Patients seem generally satisfied with out-of-hours primary care as organised in GP cooperatives. However, patients who received telephone advice only are less satisfied compared to those who attended the GP cooperative or those who received a home visit.

Arrhythmias in general practice: diagnostic value of patient characteristics, medical history and symptoms.

BACKGROUND: Complaints possibly caused by arrhythmias are frequently seen in general practice. It is unclear to what extent such complaints can differentiate between arrhythmias and other pathology in general practice. OBJECTIVES: We aimed to assess the value of symptoms (a) in diagnosing arrhythmias in general practice and (b) in identifying patients with clinically relevant arrhythmias. METHOD: During a 2-year period, a structured history from 762 patients with new complaints possibly related to an arrhythmia was taken by the GP, and a transtelephonic electrocardiogram (ECG) was made. RESULTS: In 28.3% of the patients, arrhythmias were detected and 8.8% were clinically relevant. Several patient characteristics, symptoms and medical history findings have high predictive values in diagnosing arrhythmias. In the logistic regression analysis, age and, to a lesser extent, male gender, palpitations and dyspnoea during consultation and the use of cardiovascular drugs are associated with the presence of arrhythmias. In detecting clinically relevant arrhythmias the same parameters apart from gender are important, as well as a history of arrhythmias. The use of central nervous system medication and frequent psychosomatic complaints are negatively associated with the presence of clinically relevant arrhythmias. CONCLUSIONS: In general practice, patient characteristics, symptoms and medical history findings can be used in the detection of arrhythmias and the assessment of their severity. They can help in the decision of whether to make an ECG recording.

Measurement of lifetime alcohol intake: utility of a self-administered questionnaire.

Prior epidemiologic research revealing cardioprotective effects of alcohol intake has systematically neglected lifetime exposure to alcohol, which may cause serious bias in conclusions regarding drinking and heart disease risk. Departing from use of an earlier interview schedule, the authors of the present 1996-2001 cohort study developed a self-administered Lifetime Drinking History questionnaire (LDH-q). A total of 16,211 Dutch men and women older than age 45 years participated by completing the baseline questionnaire. A random sample of 3,255 men and women was used to determine the reliability and validity of the LDH-q. Test-retest reliability was assessed by means of the intraclass correlation coefficient and kappa scores. Correlations between lifetime and current intake scores were used to assess discriminant and convergent validity. Both reliability and validity appeared to be reasonably high compared with results obtained by using interview formats to measure lifetime alcohol intake. Reliability of the LDH-q was higher for men than for women, probably because of the more frequent and regular drinking of men. Indices of validity were similar for men (0.75) and women (0.70). Results show that the LDH-q can be a useful instrument in large-scale cohort studies.