Developing a competency framework for training with simulations in healthcare: a qualitative study.

BACKGROUND: Simulation is a technique used to create an experience without going through the real event. Competency-based medical education focuses on outcomes and ensures professionals have the necessary knowledge, skills, and attitudes. The purpose of this study was to develop a set of competencies for the instructors providing basic and advanced levels of simulation-based training in healthcare. METHODS: We conducted a qualitative study in three steps, with each next step building on and influenced by the previous one. First, we conducted a literature review, then a consensus development panel, and finally a three-step Delphi process. The participants were experts in the fields of healthcare, education, and simulations. RESULTS: The six main competencies identified for the instructor providing simulation-based training at the basic level in healthcare include knowledge of simulation training, education/training development, education/training performance, human factors, ethics in simulation, and assessment. An instructor providing simulation-based training at an advanced level in healthcare should also possess the following five competencies: policies and procedures, organisation and coordination, research, quality improvement, and crisis management. CONCLUSION: The identified competencies can serve as a valuable resource for simulation educators and organisations involved in simulation education, to plan curriculum and implement a continuous train-the-trainers programme.

FAMILY PHYSICIAN OPINIONS ON ELECTRONIC TOOLS AND CARDIOVASCULAR DISEASE PREVENTION GUIDELINE AVAILABILITY, USAGE AND ADHERENCE IN CROATIA.

Family physicians are burdened with a great number of guidelines considering different conditions they treat. We analyzed opinions of family physicians on electronic tools which help managing chronic conditions and their influence on patient care by cardiovascular disease (CVD) prevention guideline availability, usage and adherence. A descriptive study was performed on a convenient sample of 417 (response rate 56.0%) Croatian family physicians. Data on physician characteristics and availability, usage and adherence to CVD prevention guidelines were analyzed. The χ2-test was used for comparisons. Significance was defined as p<0.05. Family physicians who used additional electronic tools in Electronic Health Record software on more than 80% of their patients had CVD prevention guidelines more available (p<0.01) and used them more frequently (p<0.01). A group who used electronic tools on more than 80% of their patients had CVD prevention guidelines available to them frequently and used them on more than 60% of their patients, also strictly adhering to the guidelines (p<0.01). Physicians who used CVD prevention guidelines on more than 60% of their patients spent more time doing patient education (p=0.036). Using electronic tools helps Croatian family physicians in terms of availability, usage and adherence to the guidelines and quality improvement.

Awareness and use of evidence-based medicine information among patients in Croatia: a nation-wide cross-sectional study.

AIM: To determine the use of evidence-based medicine (EBM) information and the level of awareness and knowledge of EBM among patients in Croatia. METHODS: A cross-sectional study was conducted among 987 patients in 10 family medicine practices in Croatia. Patients from both urban (n=496) and rural (n=482) areas were surveyed. A 27-item questionnaire was used to collect data about sources that patients searched for medical information, patient awareness and use of Cochrane systematic reviews and other EBM resources, and their demographic characteristics. RESULTS: Half of the patients searched for medical information from sources other than physician. Internet was the most common place they searched for information. Very few patients indicated using EBM sources for medical information; one fifth of patients heard of EBM and 4% of the patients heard of the Cochrane Collaboration. Patients considered physician's opinion as the most reliable source of medical information. A logistic regression model showed that educational level and urban vs rural residence were the predictors of awareness about EBM and systematic reviews (P<0.001 for both). CONCLUSION: Our finding that patients consider a physician's opinion to be the most reliable source of health-related information could be used for promotion of high-quality health information among patients. More effort should be devoted to the education of patients in rural areas and those with less formal education. New avenues for knowledge translation and dissemination of high-quality health information among patients are necessary.

Putting Functional Gastrointestinal Disorders within the Spectrum of Inflammatory Disorders Can Improve Classification and Diagnostics of These Disorders.

The spectrum, intensity, and overlap of symptoms between functional gastrointestinal disorders (FGIDs) and other gastrointestinal disorders characterize patients with FGIDs, who are incredibly different in their backgrounds. An additional challenge with regard to the diagnosis of FGID and the applicability of a given treatment is the ongoing expansion of the risk factors believed to be connected to these disorders. Many cytokines and inflammatory cells have been found to cause the continuous existence of a low level of inflammation, which is thought to be a basic pathophysiological process. The idea of the gut-brain axis has been created to offer a basic framework for the complex interactions that occur between the nervous system and the intestinal functions, including the involvement of gut bacteria. In this review paper, we intend to promote the hypothesis that FGIDs should be seen through the perspective of the network of the neuroendocrine, immunological, metabolic, and microbiome pathways. This hypothesis arises from an increased understanding of chronic inflammation as a systemic disorder, that is omnipresent in chronic health conditions. A better understanding of inflammation's role in the pathogenesis of FGIDs can be achieved by clustering markers of inflammation with data indicating symptoms, comorbidities, and psycho-social factors. Finding subclasses among related entities of FGIDs may reduce patient heterogeneity and help clarify the pathophysiology of this disease to allow for better treatment.

Risk factors for fatal outcome in patients with opioid dependence treated with methadone in a family medicine setting in Croatia.

AIM: To determine the risk factors for fatal outcome in patients with opioid dependence treated with methadone at the primary care level. METHODS: A group of 287 patients with opioid dependence was monitored prospectively from 1995 to 2007. At the beginning of the study, we collected the data on patient baseline characteristics, treatment characteristics, and living environment. At the annual check-up, we collected the data on daily methadone dose, method of methadone therapy administration, and family physician's assessment of the patient's drug use status. RESULTS: Out of 287 patients, 8% died. Logistic regression analysis showed that the predictors of fatal outcome were continuation of drug use during previous therapeutic attempts (odds ratio [OR], 19.402; 95% confidence interval [CI], 1.659-226.873), maintenance therapy as the planned treatment modality (OR, 3.738; 95% CI, 1.045-13.370), living in an unstable relationship (OR, 9.275; 95% CI, 2.207-38.984), and loss of continuity of care (OR, 12.643; 95% CI, 3.001-53.253). CONCLUSION: The patients presenting these risk factors require special attention. It is important for family physicians to insist on compliance with the treatment protocol and intervene when they lose contact with the patient to prevent the fatal outcome.

Transitioning from face-to-face to distance education. Part 1: A cross-sectional study in the former Yugoslavia during COVID-19.

BACKGROUND: The countries of the former Yugoslavia have health and education systems with the same tradition but these have changed over the years. Little is known about how family medicine teaching transitioned from face-to-face to distance education during the COVID-19 pandemic. OBJECTIVES: to investigate student/teacher experience in transitioning from face-to-face to distance education. METHODS: A cross-sectional, online survey was conducted among 21 medical schools of the former Yugoslavia between December 2021 and March 2022. Under/postgraduate teachers and students who taught/studied family medicine during the academic year 2020/2021 were invited to participate. Of 31 questions for students and 35 for teachers, all but nine open questions were analysed using descriptive statistics. RESULTS: Seventeen of 21 medical schools contributed data involving 117 participants representing all countries of the former Yugoslavia. At the beginning of the pandemic, 30%, 26% and 15% of teachers, students and trainees, respectively, received formal preparation in distance education. Of these, 92% of teachers and 58% of students/trainees felt they were not adequately prepared. Synchronous teaching was the main method used, with a third using hybrid methods. All participants were least confident about online assessment. More than 75% of respondents agreed that lectures could be kept online, not patient consultations or practical skills' classes. CONCLUSION: Teachers used various old and new methods to provide learning opportunities despite COVID-19 constraints. Effective technology-based strategies are essential to ensure assessment integrity and enhance the learning environment.

Despite limited preparedness, teachers and students/trainees transitioned to distance education.Students/trainees believed synchronous delivery of lectures and small group work can be conducted online but not practical skills' classes.Online assessments and practical work with patients were considered the most challenging aspects of distance education.

Transitioning from face-to-face to distance education. Part 2: A qualitative study in the former Yugoslavia during COVID-19.

BACKGROUND: Similar to other countries, Departments of Family Medicine in the former Yugoslavia had to transition from face-to-face to distance education during COVID-19. OBJECTIVES: To elucidate obstacles and facilitators of the transition from face-to-face to distance education. METHODS: A cross-sectional, multicentre, qualitative study design was used to analyse nine open-ended questions from an online survey using inductive thematic analysis. The questionnaire was distributed to 21 medical schools, inviting them to involve at least two teachers/students/trainees. Data were collected between December 2021 and March 2022. RESULTS: In 17 medical schools, 23 students, 54 trainees and 40 teachers participated. The following themes were identified: facilitators and barriers of transition, innovations for enhancing distance education, convenience of distance education, classical teaching for better communication, the future of distance education, reaching learning outcomes and experience of online assessment. Innovations referred mainly to new online technologies for interactive education and communication. Distance education allowed for greater flexibility in scheduling and self-directed learning; however, participants felt that classical education allowed better communication and practical learning. Teachers believed knowledge-related learning outcomes could be achieved through distance education but not teaching clinical skills. Participants anticipated a future where a combination of teaching methods is used. CONCLUSION: The transition to distance education was made possible thanks to its flexible scheduling, innovative tools and possibility of self-directed learning. However, face-to-face education was considered preferable for fostering interpersonal relations and teaching clinical skills. Educators should strive to strike a balance between innovative approaches and the preservation of personal experiences.

Participants found that distance education offers many possibilities, mainly self-directed, flexible learning.Participants felt that face-to-face education remains invaluable since it facilitates communication and the development of practical skills.A balance between new technologies and personal encounters was believed to be best.

[Primary health care and family medicine--possibilities for treatment of opiate addicts]. / Mogucnosti u lijecenju ovisnika o opijatima u primarnoj zdravstvenoj zastiti i obiteljskoj medicini.

The global trend of promoting management and treatment of drug addicts in family physician offices is the result of the success of opioid agonist therapy. Studies have shown favorable results by shifting treatment into the hands of family physician. This process contributes to general health care of drug addicts and their health by linking different areas of health care, thereby providing comprehensive protection. Shifting treatment of addiction to family physician offices contributes to the elimination of treatment isolation and stigmatization, while further benefits are lower barriers to employment, increase in patient privacy and opportunity to provide health care. The aim of this study was to provide a concise overview of the knowledge from new clinical research over the past ten years on heroin addiction treatment in primary care. New research dealing with the approach to treating addicts indicates a direct link between receiving primary health care with a reduced likelihood of using heroin; furthermore, the main concerns of drug addicts for treatment are availability of more therapeutic programs, better functioning of existing programs, and improved staff relations towards them; final results and outcomes achieved by office and hospital treatment of drug addicts are similar and confirm the positive linear relationship between treatment duration and outcome. Studies comparing therapies show a positive effect of the adaptive methadone treatment maintenance model on the psychosocial factors; equal efficiency of treatment regardless of initiation with buprenorphine or with methadone; and equal effectiveness of levo-alpha-acetylmethadol treatment compared with methadone and diacetylmorphine as a good alternative for addiction therapy with previously unsatisfactory results. New studies on buprenorphine show equal effectiveness and cost of detoxification whether guided by a family physician or at the hospital; non-supervised therapy does not significantly influence the outcome, but is significantly cheaper; long-term therapy with buprenorphine in the doctor's office shows mild retention.

Safety Culture and the Positive Association of Being a Primary Care Training Practice during COVID-19: The Results of the Multi-Country European PRICOV-19 Study.

The day-to-day work of primary care (PC) was substantially changed by the COVID-19 pandemic. Teaching practices needed to adapt both clinical work and teaching in a way that enabled the teaching process to continue, while maintaining safe and high-quality care. Our study aims to investigate the effect of being a training practice on a number of different outcomes related to the safety culture of PC practices. PRICOV-19 is a multi-country cross-sectional study that researches how PC practices were organized in 38 countries during the pandemic. Data was collected from November 2020 to December 2021. We categorized practices into training and non-training and selected outcomes relating to safety culture: safe practice management, community outreach, professional well-being and adherence to protocols. Mixed-effects regression models were built to analyze the effect of being a training practice for each of the outcomes, while controlling for relevant confounders. Of the participating practices, 2886 (56%) were non-training practices and 2272 (44%) were training practices. Being a training practice was significantly associated with a lower risk for adverse mental health events (OR: 0.83; CI: 0.70-0.99), a higher number of safety measures related to patient flow (Beta: 0.17; CI: 0.07-0.28), a higher number of safety incidents reported (RR: 1.12; CI: 1.06-1.19) and more protected time for meetings (Beta: 0.08; CI: 0.01-0.15). No significant associations were found for outreach initiatives, availability of triage information, use of a phone protocol or infection prevention measures and equipment availability. Training practices were found to have a stronger safety culture than non-training practices. These results have important policy implications, since involving more PC practices in education may be an effective way to improve quality and safety in general practice.

Medical Students' Perspective and Knowledge of Asymptomatic Hyperuricemia and Gout Management: A Cross-Sectional Study.

The prevalence and incidence of gout doubled from 1990 to 2017. Therefore, we can expect that a number of doctors have come across a patient with gout in their daily practice. Hence, we wanted to investigate how familiar our medical students, as future medical professionals, are with gout. This cross-sectional survey included Medical Studies students from the two largest universities in Croatia: the University of Split School of Medicine, and the University of Zagreb School of Medicine, and included a total of 221 fifth or sixth year medical students. Most students gave correct answers to questions about treatment approach and non-pharmacological interventions in asymptomatic hyperuricemia (>80%). Less than 3% of all students agreed they knew enough about care for patients with asymptomatic hyperuricemia, whereas almost 15% thought they were well familiar with care for gout patients. Less than 8% of students considered their school education adequate on both topics, and less than 2% were aware of the existence of EULAR guidelines. Physicians lacking in the latest knowledge on the pathophysiology of gout, the influence of lifestyle, and genetic factors limits their ability to properly manage gout. With increasing prevalence, gout should be more represented in medical students' education.

Illness perception and cardiovascular risk factors in patients with type 2 diabetes: cross-sectional questionnaire study.

AIM. To investigate illness perception in patients with type 2 diabetes mellitus and its association with the degree of control over relevant cardiovascular risk factors. METHODS. A cross-sectional questionnaire-based study was performed from June 2007 to March 2008. A stratified random sample of 46 Croatian general practitioners was asked to select, using systematic sampling, the first 6 patients with type 2 diabetes mellitus aged > or =18 years who visited them for consultation during the study period. Data on 250 patients included patient illness perception assessment (Brief Illness Perception Questionnaire, IPQ), cardiovascular risk factors, and socio-demographic data. RESULTS. The patients' mean age was 63.0+/-10.9 years and mean duration of diabetes was 9.3+/-7.8 years. The patients' illness perception assessment on an 11-point (0 to 10) scale showed the highest median scores (interquartile range): 10 (8 to 10) for "timeline" and 8 (7 to 9) for "treatment control," followed by 7 (5 to 8) for "personal control," 7 (5 to 9) for "understanding," 5 (3 to 7) for "consequences," 6 (4 to 7) for "concern," and 5 (2 to 7) for "emotional response." The lowest score was 3 (1 to 5) for "identity." Multivariate logistic regression showed that the Brief IPQ item "concern" (P<0.001) was a significant predictor of body mass index; "personal control" (P<0.001) and "concern" (P=0.048) were significant predictors of fasting blood glucose; "treatment control" (P=0.009) was a significant predictor of total cholesterol; and "understanding" (P=0.010) was a significant predictor of blood pressure. CONCLUSION. As patients' beliefs seem to be associated with the degree of control over cardiovascular risk factors, they should be included in routine clinical assessments.

Partial adoption of 'minimal core curriculum' in undergraduate teaching of family medicine: A cross-sectional study among Central and South-Eastern European medical schools.

BACKGROUND: In 2011, Tandeter et al. published a list of 15 themes, based on a Delphi survey among representatives of the European Academy of Teachers in General Practice and Family Medicine (EURACT), and suggested this be the 'minimal core curriculum' (MCC) for undergraduate education in family medicine. OBJECTIVES: To determine: (1) if medical schools in the former Yugoslavia region are familiar with the MCC; and (2) to what degree it is being taught to medical students. METHODS: In July 2015, a questionnaire was distributed to 19 medical schools in the former Yugoslavia region. A copy of the description of the curriculum for GP/FM was requested from participants. Two researchers conducted content analysis of the curricula according to the 15 predefined MCC themes, independently. RESULTS: Thirteen (68%) medical schools responded. Of these, 10 (77%) stated that they were familiar with the MCC. Not a single institution encompassed all 15 MCC themes. The number of themes included by individual medical schools ranged from 6/15 (40%) to 13/15 (87%).The following themes were covered by 12 of 13 (92%) medical schools: Introduction to GP/FM; communication skills; prevention and health promotion; and management of chronic diseases. The three themes most poorly covered were: consulting skills (5/13), management of diseases at an early, undifferentiated stage (2/13) and decision-making based on prevalence and incidence (1/13). CONCLUSION: Despite familiarity with EURACT's MCC among medical schools in the former Yugoslavia region, significant variation in curricula content exists, and no curriculum covered all MCC themes.

What can we Learn from each other about Undergraduate Medical Education in General Practice/Family Medicine?

INTRODUCTION: There is a dearth of published literature on the organisation of family medicine/general practice undergraduate teaching in the former Yugoslavia. METHODS: A semi-structured questionnaire was sent to the addresses of 19 medical schools in the region. Questions covered the structure of Departments of Family Medicine (DFM), organisation of teaching, assessment of students and their involvement in departmental activities. RESULTS: Thirteen medical schools responded, of which twelve have a formal DFM. Few DFM have full-time staff, with most relying upon external collaborators. Nine of 13 medical schools have family doctors teaching other subjects, covering an average of 2.4 years of the medical curriculum (range: 1-5). The total number of hours dedicated to teaching ranged from 30 - 420 (Md 180). Practice-based teaching prevails, which is conducted both in city and rural practices in over half of the respondent schools. Written exams are conducted at all but two medical schools, with the written grade contributing between 30 and 75 percent (Md=40%) of the total score. Nine medical schools have a formal method of practical skills assessment, five of which use Objective Structured Clinical Examinations. Student participation is actively sought at all but three medical schools, mainly through research. CONCLUSION: Most medical schools of the former Yugoslavia recognise the importance of family medicine in undergraduate education, although considerable variations exist in the organisation of teaching. Where DFM do not exist, we hope our study will provide evidence to support their establishment and the employment of more GPs by medical schools.

Is burnout in family physicians in Croatia related to interpersonal quality of care?

The impact of physician burnout on the quality of patient care is unclear. This cross-sectional study aimed to investigate the prevalence of burnout in family physicians in Croatia and its association with physician and practice characteristics, and patient enablement as a consultation outcome measure. Hundred and twenty-five out of 350 family physicians responded to our invitation to participate in the study. They were asked to collect data from 50 consecutive consultations with their adult patients who had to provide information on patient enablement (Patient Enablement Instrument). Physicians themselves provided their demographic and professional data, including workload, job satisfaction, consultation length, and burnout [Maslach Burnout Inventory-Human Services Survey (MBI-HSS)]. MBI-HSS scores were analysed in three dimensions: emotional exhaustion (EE), depersonalisation (DP), and personal accomplishment (PA). Of the responding physicians, 42.4% scored high for EE burnout, 16.0% for DP, and 15.2% for PA. Multiple regression analysis showed that low job satisfaction and more patients per day predicted high EE scores. Low job satisfaction, working more years at a current workplace, and younger age predicted high DP scores. Lack of engagement in education and academic work, shorter consultations, and working more years at current workplace predicted low PA scores, respectively (P<0.05 for each). Burnout is common among family physicians in Croatia yet burnout in our physicians was not associated with patient enablement, suggesting that it did not affect the quality of interpersonal care. Job satisfaction, participation in educational or academic activities and sufficient consultation time seem to reduce the likelihood of burnout.