Shared decision-making performance of general practice residents: an observational study combining observer, resident, and patient perspectives.

BACKGROUND: Shared decision making (SDM) is considered fundamental to person-centred care. However, applying SDM may be a challenge for residents in general practice, since it is a complex competence that requires the integration of knowledge and skills from several competency domains. OBJECTIVE: To support learning of SDM during medical residency, we aimed to gain insight in Dutch residents' observed and perceived SDM performance in general practice. METHODS: We evaluated residents' SDM performance from an observer, resident, and patient perspective. Consultations of first- and third-year residents were recorded. Trained observers used the validated Observing Patient Involvement (OPTION5) scale to assess observed SDM performance of residents in 98 actual recorded consultations. Perceived SDM performance was evaluated by residents and patients completing validated SDM questionnaires, supplemented with questions about (the context of) the consultation and perceived relevance of SDM immediately after the consultation. The data were analysed using descriptive statistics (mean, SD, minimums, and maximums) and explorative bivariate analyses. RESULTS: The residents' observed mean SDM performance was 19.1 (range, 0-100, SD = 10.9), mean resident self-reported SDM performance was 56.9 (range, 0-100, SD = 18.5), and mean patient-reported SDM performance was 73.3 (range, 0-100, SD = 26.8). We found a significant and positive correlation between observed SDM performance and residents' perceived relevance of SDM for the consultation (t = 4.571, P ≤ 0.001) and the duration of the consultation (r = 0.390, P ≤ 0.001). CONCLUSIONS: This study showed that there is room for increasing awareness of the potential incongruence between observed and perceived SDM performance during medical residency, in order to facilitate the implementation of SDM in clinical practice.

THE PROBLEM: Shared decision making is an important process in which healthcare professional and patient work together to reach a decision on how to solve a health problem. This decision should include patients' needs and what matters most to them. We investigated if consultations between general practitioners in training (i.e. residents) and their patients demonstrate shared decision making. The research methods: We asked the residents and patients to respond to questions on their experience of shared decision making right after the consultation. We recorded 98 consultations of residents with their patients. Two researchers rated to what extent residents demonstrated shared decision-making behaviours during these consultations. THE RESULTS: The patients reported more shared decision making than the residents (patients: 73 versus residents: 57 on a 0­100 scale). The researchers observed low levels of SDM during the consultations (19 on a 0­100 scale). Our conclusion: Residents should be aware that shared decision making does not yet frequently occur in practice. To improve the extent to which residents share decisions with their patients in general practice, residents should learn why, when, and how to involve patients in decision making during consultations.

[Quality of discharge summary for patients with limited life expectancy]. / Communicatie rondom ontslag van terminale patiënten.

The written discharge summary is the main vector of communication and serves as a critical method of patient information transfer between hospitalist and primary care provider. It is a shown challenge to timely delivery and completeness of a discharge letter, especially when it involves patients in palliative care or with a limited life expectancy. Despite the implementation of standardized letters and guidelines. Personalized interactive information transfer of hospital discharge summary between hospitalist and primary care provider should include a written as well as the strong consideration of an oral transmission. This should ensure continuity of care and limit deficiencies in content and availability of critical medical information. Joint responsibility of continuous care instead of simply a transfer.

Identifying residents' educational needs to optimising postgraduate medical education about shared decision-making.

OBJECTIVE: To investigate how to optimise resident engagement during workplace learning of shared decision-making (SDM) by understanding their educational needs. METHODS: A qualitative multicentre study was conducted using video-stimulated interviews with 17 residents in General Practice. Video recordings of residents' recent clinical encounters were used to facilitate reflection on their educational needs. RESULTS: Data analysis resulted in five themes regarding residents' educational needs for learning SDM: acquiring knowledge and skills needed to perform SDM; practising SDM; reflection and feedback; longitudinal and integrated training; and awareness and motivation for performing SDM. CONCLUSION: Residents expressed a need for continuous attention to be paid to SDM during postgraduate medical education. That would help them engage in two parallel learning processes: acquiring the knowledge and skills necessary to perform SDM, and practising SDM in the clinical workplace. Alignment between the educational curriculum, workplace learning and resident learning activities is essential to operationalise SDM attitude, knowledge and skills into clinical performance. PRACTICE IMPLICATIONS: The identified educational needs provide ingredients for fostering the development of SDM proficiency. The findings suggest that residents and clinical supervisors need parallel training to bridge the gap between education and clinical practice when learning SDM.

Chances for learning intraprofessional collaboration between residents in hospitals.

CONTEXT: Intraprofessional collaboration (intraPC) between primary care (PC) doctors and medical specialists (MSs) is becoming increasingly important. Patient safety issues are often related to intraPC. In order to equip doctors well for their task of providing good quality and continuity of care, intraPC needs explicit attention, starting in postgraduate training. Worldwide, PC residents undertake a hospital placement during their postgraduate training, where they work in proximity with MS residents. This placement offers the opportunity to learn intraPC. It is yet unknown whether and how residents learn intraPC and what barriers to and opportunities for exist in learning intraPC during hospital placements. METHODS: We performed an ethnographic non-participatory observational study in three emergency departments and three geriatric departments of five hospitals in the Netherlands. This was followed by 42 in-depth interviews with the observed residents and supervisors. The observations were used to feed the questions for the in-depth interviews. We analysed the interviews iteratively following the data collection using template analysis. RESULTS: Hospital wards are rich in opportunities for learning intraPC. These opportunities, however, are seldom exploited for various reasons: intraPC receives limited attention when formulating placement goals, so purposeful learning of intraPC hardly takes place; residents lack awareness of the learning of intraPC; MS residents are not accustomed to searching for expertise from PC residents; PC residents adapt to the MS role and they contribute very little of their PC knowledge, and power dynamics in the hospital department negatively influence the learning of intraPC. Therefore, improvements in mindset, professional identity and power dynamics are crucial to facilitate and promote intraPC. CONCLUSIONS: Intraprofessional collaboration is not learned spontaneously during hospital placements. To benefit from the abundant opportunities to learn intraPC, adjustments to the set-up of these placements are necessary. Learning intraPC is promoted when there is a collaborative culture, hierarchy is limited, and there is dedicated time for intraPC and support from the supervisor.

Differences between GP perception of delivered empathy and patient-perceived empathy: a cross-sectional study in primary care.

BACKGROUND: Empathy has positive effects on a range of healthcare outcomes. It is therefore an important skill for a GP. However, the correlation between GP perception of delivered empathy and patient perception of GP empathic communication during consultations is still unclear. AIM: To investigate the correlation between GP perception of delivered empathy and patient-perceived empathy. DESIGN AND SETTING: Cross-sectional study in primary care in the Netherlands, between December 2016 and February 2017. METHOD: GPs and their patients were asked to fill in an empathy questionnaire directly after a consultation. Patient perception of received empathy during the consultation was measured through the Dutch version of the Consultation and Relational Empathy (CARE) questionnaire. GP perception of delivered empathy during the consultation was measured with an adapted version of the CARE questionnaire. RESULTS: The authors obtained questionnaires from 147 consultations by 34 different GPs in 16 primary care practices. A total of 143 consultations were eligible for inclusion in the analysis. Mean patient-perceived empathy score was significantly higher than mean GPs' empathy score (42.1, range 20.0 to 50.0 and 31.6, range 24.0 to 41.0, respectively, P<0.0001). Furthermore, a low correlation (r = 0.06) was found between GP empathy score and patient-perceived empathy score. CONCLUSION: GPs rate the delivered empathy during consultations consistently and significantly lower than their patients experience empathy during consultations. Moreover, GPs' impressions of the empathy delivered during the consultation do not predict the actual amount of empathy perceived by their patients. Patients experience a great deal of empathy during their clinical encounter. GPs' self-reports on empathy delivered gives an inaccurate reflection, and underestimates patient-perceived empathy.

[More sensitive approach to question of sexual orientation]. / Genuanceerde aanpak bij vragen naar seksuele oriëntatie.

Doctors encounter lesbian, gay and bisexual (LGB) patients. Most LGBs are physically and mentally healthy, but LGBs also have unique healthcare needs, that is mental health issues, sexually-transmitted diseases including HIV infection, substance use, and avoidance of healthcare. Sexual minority stress due to stigmatisation, rejection, internalised homophobia, bullying and violence is a causal issue. Optimising care for LGBs involves knowing patients' sexual orientation by asking them. As sexual orientation comprises the domains of sexual identity, sexual attraction and sexual behaviour, all should be addressed appropriately as these domains together or separately determine the impact on health. Sexual identity correlates closely, but not completely, with sexual behaviour. Individuals may engage in same-sex sexual behaviour, but not identify themselves as lesbian, gay or bisexual. Patients are willing to answer questions about their sexual orientation. Doctors should take the initiative to discuss sexual orientation and avoid making heteronormative assumptions. The uptake of LGB-related issues in guidelines and educational programmes may improve doctors' awareness.

Should we assess clinical performance in single patient encounters or consistent behaviors of clinical performance over a series of encounters? A qualitative exploration of narrative trainee profiles.

BACKGROUND: A variety of tools have been developed to assess performance which typically use a single clinical encounter as a source for making competency inferences. This strategy may miss consistent behaviors. We therefore explored experienced clinical supervisors' perceptions of behavioral patterns that potentially exist in postgraduate general practice trainees expressed as narrative profiles to aid the grading of clinical performance. METHODS: We conducted semistructured interviews with clinical supervisors who had frequently observed clinical performance in trainees. Supervisors were asked to describe which behavioral patterns they had discerned in excellent and underperforming trainees, during different stages of training, in their careers as clinical supervisor. We analyzed the interviews using a grounded theory approach. RESULTS: The analysis resulted in a conceptual framework that distinguishes between desirable and undesirable narrative profiles. The framework consists of two dimensions: doctor-patient interaction and medical expertise. Personal values appear to be a moderating factor. CONCLUSIONS: According to experienced clinical supervisors, consistent behaviors do exist in GP trainees when observing clinical performance over time. The conceptual framework has to be validated by further observational studies to assess its potential for making robust and fair assessments of clinical performance and monitor the development of consultation performance over time.

How do trained raters take context factors into account when assessing GP trainee communication performance? An exploratory, qualitative study.

Communication assessment in real-life consultations is a complex task. Generic assessment instruments help but may also have disadvantages. The generic nature of the skills being assessed does not provide indications for context-specific behaviour required in practice situations; context influences are mostly taken into account implicitly. Our research questions are: 1. What factors do trained raters observe when rating workplace communication? 2. How do they take context factors into account when rating communication performance with a generic rating instrument? Nineteen general practitioners (GPs), trained in communication assessment with a generic rating instrument (the MAAS-Global), participated in a think-aloud protocol reflecting concurrent thought processes while assessing videotaped real-life consultations. They were subsequently interviewed to answer questions explicitly asking them to comment on the influence of predefined contextual factors on the assessment process. Results from both data sources were analysed. We used a grounded theory approach to untangle the influence of context factors on GP communication and on communication assessment. Both from the think-aloud procedure and from the interviews we identified various context factors influencing communication, which were categorised into doctor-related (17), patient-related (13), consultation-related (18), and education-related factors (18). Participants had different views and practices on how to incorporate context factors into the GP(-trainee) communication assessment. Raters acknowledge that context factors may affect communication in GP consultations, but struggle with how to take contextual influences into account when assessing communication performance in an educational context. To assess practice situations, raters need extra guidance on how to handle specific contextual factors.

Gendered specialities during medical education: a literature review.

The careers of male and female physicians indicate gender differences, whereas in medical education a feminization is occurring. Our review aims to specify gender-related speciality preferences during medical education. A literature search on gender differences in medical students' speciality preferences was conducted in PubMed, Eric, Embase and Social Abstracts, and reference lists from January 2000 to June 2013. Study quality was assessed by critical appraisal. Our search yielded 741 hits and included 14, mostly cross-sectional, studies originating from various countries. No cohort studies were found. Throughout medical education, surgery is predominantly preferred by men and gynaecology, paediatrics and general practice by women. Internal medicine was pursued by both genders. The extent of gender-specific speciality preferences seemed related to the male-to-female ratio in the study population. When a population contained more male students gynaecology seemed even more preferred by women, while in a more feminine population, men more highly preferred surgery. Internationally, throughout medical education, gender-related speciality preferences are apparent. The extent might be influenced by the male-to-female ratio of a study population. Further research of the role of gender in career considerations of medical students on the future workforce is necessary.

The effect of gender medicine education in GP training: a prospective cohort study.

The purpose of this study is to compare the change in general practitioner (GP) trainees' gender awareness following a modular gender medicine programme or a mainstream gender medicine programme. In 2007, a prospective study was conducted in three cohorts of in total 207 GP trainees who entered GP training in the Netherlands. The outcome measure was the Nijmegen Gender Awareness in Medicine Scale and a 16-item gender knowledge questionnaire. Two gender medicine teaching methods were compared: a modular approach (n = 75) versus a mainstream approach (n = 72). Both strategies were compared with a control cohort (n = 60). Statistical analysis included analysis of variance and t-tests. The overall response rates for the modular, mainstream and control cohort were 78, 72 and 82 %, respectively. There was a significant difference in change in gender knowledge scores between the modular cohort compared with the mainstream and control cohort (p = 0.049). There were no statistical differences between the cohorts on gender sensitivity and gender role ideology. At entry and end, female GP trainees demonstrated significantly higher gender awareness than male GP trainees. A modular teaching method is not a more favourable educational method to teach gender medicine in GP training. Female GP trainees are more gender aware, but male GP trainees are not unaware of gender-related issues.

Chlamydia prevalence in the general population: is there a sex difference? a systematic review.

BACKGROUND: The focus of Chlamydia trachomatis screening and testing lies more on women than on men. The study aim was to establish by systematic review the prevalence of urogenital Chlamydia trachomatis infection in men and women in the general population. METHODS: Electronic databases and reference lists were searched from 2000 to 2013 using the key words "Chlamydia trachomatis", "population-based study" and "disease prevalence". Reference lists were checked. Studies were included in the analysis if Chlamydia trachomatis prevalence was reported for both men and women in a population-based study. Prevalence rates for men and women were described as well as highest prevalence rate by age and sex. The difference in prevalence between the sexes in each study was calculated. RESULTS: Twenty-five studies met the inclusion criteria and quality assessment for the review. In nine of the twenty-five studies there was a statistically significant sex difference in the chlamydia prevalence. In all nine studies the prevalence of chlamydia was higher in women than in men. The prevalence for women varied from 1.1% to 10.6% and for men from 0.1% to 12.1%. The average chlamydia prevalence is highly variable between countries. The highest prevalence of chlamydia occurred predominantly in younger age groups (< 25 years). The absence of symptoms in population-based urogenital chlamydia infection is common in men and women (mean 88.5% versus 68.3%). CONCLUSIONS: The urogenital chlamydia trachomatis prevalence in the general population is more similar than dissimilar for men and women. A modest sex difference is apparent. The prevalence rates can be used to inform chlamydia screening strategies in general practice.

Expert consensus on gender criteria for assessment in medical communication education.

OBJECTIVE: The aim of this study is to develop gender criteria that can be included in communication skills assessment in medical education. METHODS: A three-round Delphi study was conducted. The invited 59 participants were experts in the field of gender medicine education (n = 28) and doctor-patient communication (n = 31). Each Delphi round comprised a questionnaire, an analysis, and a feedback report. In the first round, gender experts explored gender themes in doctor-patient communication from which initial gender criteria were defined. The second and third rounds were used to validate the importance and feasibility of gender criteria. Consensus was defined as a 75% panel agreement and a mean of 4 or higher on a 5-point Likert scale. RESULTS: Four gender criteria achieved consensus after the third round. The importance of including the gender criteria in communication skills assessment was rated consistently higher than its feasibility. Gender criteria relating to the patients' perspective, to gathering information and to gender and power were considered the most important. CONCLUSION: Using a Delphi study, we have developed gender criteria for inclusion in communication skills assessment to promote good communication between doctors and patients. PRACTICE IMPLICATIONS: Gender influences medical communication. Incorporating gender in communication skills assessment may be useful to improve the teaching and learning of communication skills.

Attention to gender in communication skills assessment instruments in medical education: a review.

CONTEXT: Gender is increasingly regarded as an important factor in doctor-patient communication education. This review aims to assess if and how gender is addressed by current assessment instruments for communication skills in medical education. METHODS: In 2009 at Radboud University Nijmegen Medical Centre, an online search was conducted in the bibliographic databases PubMed, PsycINFO and ERIC for references about communication skills assessment instruments designed to be completed by trained faculty staff and used in medical education. The search strategy used the following search terms: 'consultation skills'; 'doctor-patient communication'; 'physician-patient relations'; 'medical education'; 'instruments'; 'measurement', and 'assessment'. Papers published between January 1999 and June 2009 were included. The assessment instruments identified were analysed for gender-specific content. RESULTS: The search yielded 21 communication skills assessment instruments. Only two of the 17 checklists obtained explicitly considered gender as a communication-related issue. Only six of 21 manuals considered gender in any way and none gave specific details to explain which aspects of communication behaviour should be assessed with regard to gender. CONCLUSIONS: Very few communication assessment instruments in medical education focus on gender. Nevertheless, interest exists in using gender in communication skills assessment. The criteria for and purpose of assessing gender in communication skills in medical education are yet to be clarified.

Incorporating and evaluating an integrated gender-specific medicine curriculum: a survey study in Dutch GP training.

BACKGROUND: We recently set standards for gender-specific medicine training as an integrated part of the GP training curriculum. This paper describes the programme and evaluation of this training. METHODS: The programme is designed for GP registrars throughout the 3-year GP training. The modules emphasize interaction, application, and clinically integrated learning and teaching methods in peer groups. In 2005 - 2008, after completion of each tutorial, GP registrars were asked to fill in a questionnaire on a 5-point Likert scale to assess the programme's methods and content. GP registrars were also asked to identify two learning points related to the programme. RESULTS: The teaching programme consists of five 3-hour modules that include gender themes related to and frequently seen by GPs such as in doctor-patient communication and cardiovascular disease. GP registrars evaluated the training course positively. The written learning points suggest that GP registrars have increased their awareness of why attention to gender-specific information is relevant. CONCLUSION: In summary, gender-specific medicine training has been successfully integrated into an existing GP training curriculum. The modules and teaching methods are transferable to other training institutes for postgraduate training. The evaluation of the teaching programme shows a positive impact on GP registrars' gender awareness.