Learning collaboration at the primary-secondary care interface: a dual-method study to define design principles for interventions in postgraduate training programmes.

BACKGROUND: Collaboration between primary and secondary care (PSCC) is important to provide patient-centered care. Postgraduate training programmes should provide training to learn PSCC. With a design based research (DBR) approach design principles can be formulated for designing effective interventions in specific contexts. The aim of this study is to determine design principles for interventions aimed to learn PSCC in postgraduate training programmes. METHODS: DBR is characterised by multi-method studies. We started with a literature review on learning collaboration between healthcare professionals from different disciplines within the same profession (intraprofessional) to extract preliminary design principles. These were used to inform and feed group discussions among stakeholders: trainees, supervisors and educationalists in primary and secondary care. Discussions were audiotaped, transcribed and analysed using thematic analysis to formulate design principles. RESULTS: Eight articles were included in the review. We identified four preliminary principles to consider in the design of interventions: participatory design, work process involvement, personalised education and role models. We conducted three group discussions with in total eighteen participants. We formulated three design principles specific for learning PSCC in postgraduate training programmes: (1) The importance of interaction, being able to engage in a learning dialogue. (2) Facilitate that the learning dialogue concerns collaboration. (3) Create a workplace that facilitates engagement in a learning dialogue. In the last design principle we distinguished five subcategories: intervention emphasises the urge for PSCC and is based on daily practice, the presence of role models, the work context creates time for learning PSCC, learning PSCC is formalised in curricula and the presence of a safe learning environment. CONCLUSION: This article describes design principles for interventions in postgraduate training programmes with the aim to learn PSCC. Interaction is key in learning PSCC. This interaction should concern collaborative issues. Furthermore, it is essential to include the workplace in the intervention and make adjacent changes in the workplace when implementing interventions. The knowledge gathered in this study can be used to design interventions for learning PSCC. Evaluation of these interventions is needed to acquire more knowledge and adjust design principles when necessary.

Competencies to promote collaboration between primary and secondary care doctors: an integrative review.

BACKGROUND: In a society where ageing of the population and the increasing prevalence of long-term conditions are major issues, collaboration between primary and secondary care is essential to provide continuous, patient-centred care. Doctors play an essential role at the primary-secondary care interface in realising 'seamless' care. Therefore, they should possess collaborative competencies. However, knowledge about these collaborative competencies is scarce. In this review we explore what competencies doctors need to promote collaboration between doctors at the primary-secondary care interface. METHODS: We conducted an integrative literature review. After a systematic search 44 articles were included in the review. They were analysed using a thematic analysis approach. RESULTS: We identified six themes regarding collaborative competencies: 'patient-centred care: a common concern', 'roles and responsibilities', 'mutual knowledge and understanding', 'collaborative attitude and respect', 'communication' and 'leadership'. In every theme we specified components of knowledge, skills and attitudes as found in the reviewed literature. The results show that doctors play an important role, not only in the way they collaborate in individual patient care, but also in how they help shaping organisational preconditions for collaboration. CONCLUSIONS: This review provides an integrative view on competencies necessary for collaborative practice at the primary-secondary care interface. They are part of several domains, showing the complexity of collaboration. The information gathered in this review can support doctors to enhance and learn collaboration in daily practice and can be used in educational programmes in all stages of medical education.

Agile and adaptive governance in crisis response: Lessons from the COVID-19 pandemic.

Countries around the world have had to respond to the COVID-19 outbreak with limited information and confronting many uncertainties. Their ability to be agile and adaptive has been stressed, particularly in regard to the timing of policy measures, the level of decision centralization, the autonomy of decisions and the balance between change and stability. In this contribution we use our observations of responses to COVID-19 to reflect on agility and adaptive governance and provide tools to evaluate it after the dust has settled. Whereas agility relates mainly to the speed of response within given structures, adaptivity implies system-level changes throughout government. Existing institutional structures and tools can enable adaptivity and agility, which can be complimentary approaches. However, agility sometimes conflicts with adaptability. Our analysis points to the paradoxical nature of adaptive governance. Indeed, successful adaptive governance calls for both decision speed and sound analysis, for both centralized and decentralized decision-making, for both innovation and bureaucracy, and both science and politics.

Learning intraprofessional collaboration by participating in a consultation programme: what and how did primary and secondary care trainees learn?

BACKGROUND: A growing number of patients require overview and management in both primary and secondary care. This situation requires that primary and secondary care professionals have well developed collaborative skills. While knowledge about interprofessional collaboration and education is rising, little is known about intraprofessional collaboration and education between physicians of various disciplines. This study examines a newly developed consultation programme for trainees in general practice and internal medicine to acquire intraprofessional collaboration skills. METHODS: Focus groups were conducted with trainees and their supervisors and mentors to explore what and how the trainees learned by participating in the consultation programme. RESULTS: Trainees reported that they gained knowledge about and skills in collaboration and consultation they could not have gained otherwise. Furthermore, the programme gave the opportunity to gain other competencies relevant for becoming the medical expert trainees they are expected to be. Learning outcomes were comparable to those described in interprofessional education literature. Interaction, by meeting each other and by discussing cases with mentors or supervisors, appeared to be a key factor in the learning process. Meetings, discussing preconceptions and enthusiasm of the mentors and supervisors facilitated the learning. Technical problems and lack of information hampered the learning. These influencing factors are important for future development of intraprofessional learning programmes. CONCLUSIONS: Participants in an innovative consultation programme for GP- and IM-trainees reported that they acquired consultation and collaboration skills they could not have gained otherwise. Interaction appeared to be an important factor in the learning process. The findings of this study can inform developers of intraprofessional education programmes between primary and secondary care trainees.

Competencies for collaboration between general practitioners and medical specialists: a qualitative study of the patient perspective.

OBJECTIVES: To explore the patient view of competencies essential for doctors to provide good collaboration at the primary-secondary care interface. DESIGN: We used a qualitative research approach. Focus groups with patients were conducted to explore their opinions of doctors' competencies to provide good collaboration between primary and secondary care doctors. Transcripts were analysed using thematic analysis. SETTING: Dutch primary-secondary care interface. PARTICIPANTS: Sixteen participants took part in five focus groups. Patients treated in both primary and secondary care, defined as having a minimum of two contacts with their general practitioner and two contacts with a medical specialty in the last 6 months, were included. Psychiatric patients and children were excluded from this study. RESULTS: Three groups of competencies were identified: (1) relationship building, both with patients and with other doctors; (2) transparent collaborating: be able to provide clarity on the process of collaboration and on roles and responsibilities of those involved and (3) reflective practising: to be willing to acknowledge mistakes, give and receive feedback and act as a lifelong learner. CONCLUSIONS: This focus group study enhances our understanding of the patient perspective on doctors' collaborative competencies at the primary-secondary care interface. With this information, doctors can improve their collaborative skills to a level that would meet their patients' needs. Patients expect doctors to be able to build relationships and act as reflective practitioners. Including patients in the collaborative process by giving them a role that is appropriate to their abilities and by making collaboration more explicit could help to improve collaboration between general practitioners and medical specialists.

Anakinra injection site reaction on FDG PET/CT.

Adult-onset Still's disease (AOSD) is a rare inflammatory disorder of unknown etiology, mainly characterized by fever, arthritis, skin rash, and raised ferritin concentration. FDG PET/CT scan of a 29-year-old woman with AOSD showed extensive lymphadenopathy, hypermetabolic splenomegaly, and increased bone marrow uptake consistent with AOSD activity. In addition, large dense lesions with high FDG uptake in the subcutaneous fat in the thighs corresponding to injection sites were seen. She had been treated with prednisone and daily subcutaneous injection of 100 mg anakinra before the scan indicating the subcutaneous lesions as injection site reactions to anakinra.