An Interprofessional Faculty Development Program for Workplace-Based Learning.

Background: Most faculty development programs in health professions education, pivotal in cultivating competent and effective teachers, focus on systematic, planned and formal learning opportunities. A large part of clinical teaching however, encompasses ad-hoc, informal and interprofessional workplace-based learning whereby individuals learn as part of everyday work activities. To fully harness the educational potential embedded in daily healthcare practices, prioritizing interprofessional faculty development for workplace-based learning is crucial. Approach: Utilizing the 'ADDIE' instructional design framework we developed, implemented and evaluated an interprofessional faculty development program for workplace-based learning. This program, encompassing seven formal training sessions each with a different theme and five individual workplace-based assignments, aimed to support clinical teachers in recognizing and optimizing informal learning. Outcomes: The pilot program (n = 10) and first two regular courses (n = 13 each) were evaluated using questionnaires containing Likert scale items and open textboxes for narrative comments. The quality and relevance of the program to the clinical work-place were highly appreciated. Additional valued elements included practical knowledge provided and tools for informal workplace-based teaching, the interprofessional aspect of the program and the workplace-based assignments. Since its development, the program has undergone minor revisions twice and has now become a successful interprofessional workplace-based alternative to existing faculty development programs. Reflection: This faculty development program addresses the specific needs of healthcare professionals teaching in clinical settings. It stands out by prioritizing informal learning, fostering collaboration, and supporting integration of formal training into daily practice, ensuring practical application of learned knowledge and skills. Furthermore, it emphasizes interprofessional teaching and learning, enhancing workplace environments.

Clinical supervision under pressure: a qualitative study amongst health care professionals working on the ICU during COVID-19.

PURPOSE: The unprecedented influx of patients in 2020 with COVID-19 to intensive care units (ICU) required redeployment of healthcare professionals without adequate previous ICU-training. In these extraordinary circumstances, pivotal elements of effective clinical supervision emerged. This study sets out to explore the nature, aspects and key features of supervision under highly demanding circumstances among certified and redeployed health-care professionals on COVID-19 ICUs. MATERIALS AND METHODS: A prospective qualitative, single center, semi-structured interview study among healthcare professionals at COVID-19 ICUs at University Medical Center Utrecht, the Netherlands between July and December 2020. Interview data were analyzed using an inductive coding style. RESULTS: A total of 13 certified and 13 redeployed health'hcare professionals, including physicians, nurses, and operation room technicians participated. Seven themes were identified as essential for both certified (supervisors) and redeployed (trainees) personnel: an open attitude, observing boundaries, gauging coworkers' capacities, being available, providing feedback, continuity in care and teams, and combining supervision with workload. CONCLUSIONS: This study provides seven recommendations for both supervisors and trainees to help optimize clinical supervision. They align with the known five factors determining entrustment and supervision (trainee, supervisor, task, context, and relationship). To ensure good clinical supervision, be it either during normal circumstances or under pressure, efforts should primarily focus on factors that are within a supervisor or trainee's span of control. MESH: Clinical supervision, interprofessional, COVID-19, Intensive Care.

The logic behind entrustable professional activity frameworks: A scoping review of the literature.

INTRODUCTION: Entrustable professional activities (EPAs), discrete profession-specific tasks requiring integration of multiple competencies, are increasingly used to help define and inform curricula of specialty training programmes. Although guidelines exist to help guide the developmental process, deciding what logic to use to draft a preliminary EPA framework poses a crucial but often difficult first step. The logic of an EPA framework can be defined as the perspective used by its developers to break down the practice of a profession into units of professional work. This study aimed to map dominant logics and their rationales across postgraduate medical education and fellowship programmes. METHODS: A scoping review using systematic searches within five electronic databases (Medline, Embase, Google Scholar, Scopus and Web of Science) was performed. Dominant logics of included papers were identified using inductive coding and iterative analysis. RESULTS: In total, 42 studies were included. Most studies were conducted in the United States (n = 22; 52%), Canada (n = 6; 14%) and the Netherlands (n = 4; 10%). Across the reported range of specialties, family medicine (n = 4; 10%), internal medicine (n = 4; 10%), paediatrics (n = 3; 7%) and psychiatry (n = 3; 7%) were the most common. Three dominant logics could be identified, namely, 'service provision', 'procedures' and/or 'disease or patient categories'. The majority of papers (n = 37; 88%) used two or more logics when developing EPA frameworks (median = 3, range = 1-4). Disease or patient groups and service provision were the most common logics used (39% and 37%, respectively). CONCLUSIONS: Most programmes used a combination of logics when trying to capture the essential tasks of a profession in EPAs. For each of the three dominant logics, the authors arrived at a definition and identified benefits, limitations and examples. These findings may potentially inform best practice guidelines for EPA development.

Supervision, Interprofessional Collaboration, and Patient Safety in Intensive Care Units during the COVID-19 Pandemic.

Background: To meet coronavirus disease (COVID-19) demands in the spring of 2020, many intensive care (IC) units (ICUs) required help of redeployed personnel working outside their regular scope of practice, causing an expansion and change of staffing ratios. Objective: How did this composite alternative ICU workforce experience supervision, interprofessional collaboration, and quality and safety of care under the unprecedented clinical circumstances at the height of the first pandemic wave as lived experiences uniquely captured during the first peak of the pandemic? Methods: An international, cross-sectional survey was conducted among physicians, nurses, and allied personnel deployed or redeployed to ICUs in Utrecht, New York, and Dublin from April to May of 2020. Data were analyzed separately for the three sites. Quantitative data were treated for descriptive statistics; qualitative data were analyzed thematically and combined for general interpretations. Results: On the basis of 234, 83, and 34 responses (response rates of 68%, 48%, and 41% in Utrecht, New York, and Dublin, respectively), we found that the amount of supervision and the quality and safety of care were perceived as being lower than usual but still acceptable. The working atmosphere was overwhelmingly felt to be collaborative and supportive. Where IC-certified nurse-to-patient ratios had decreased most (Utrecht), nurses voiced criticism about supervision and quality of care. Continuity within the work environment, team composition, and informal ("curbside") consultations were critical mediators of success. Conclusion: In the exceptional circumstances encountered during the COVID-19 pandemic, many ICUs were managed by a composite workforce of IC-certified and redeployed personnel. Although supervision is critical for safe care, supervisory roles were not clearly related to the amount of prior ICU experience. Vital for satisfaction with the quality of care was the span of control for those who assumed supervisory roles (i.e., the ratio of certified to noncertified personnel). Stable teams that matched less experienced personnel with more experienced personnel; a strong, interprofessional, collaborative atmosphere; a robust culture of informal consultation; and judicious, more flexible use of rules and regulations proved to be essential.

An EPA for better Bedside Teaching.

BACKGROUND: Bedside teaching (BST), a time-honoured tradition of clinical teaching which integrates theoretical knowledge and clinical practice, has declined steeply over the last decade. Moreover, many clinician teachers today are not specifically trained in and/or comfortable in delivering effective BST. Resucitating this valuable educational format may require a new approach to preparing teachers and setting the stage for effective BST. Framing BST as an entrustable professional activity (EPA) for teachers may be one strategy to enhance its application and quality. METHODS: We aimed to redefine, describe essential features and effective practices for high-quality BST, based on clinical teacher participant perspectives through a focus group discussion and open-ended questionnaires via e-mail, supplemented by insights from literature. RESULTS: Based on data collected, we generated a definition of BST and a list of suggested strategies to optimise BST, for example, preparation, safe learning environment, flexible teaching and patient's benefits. A structured EPA description was created based on this definition. CONCLUSION: Effective BST requires skilled clinical teachers who are comfortable and confident in this mode of teaching; framing BST as a teaching EPA could guide faculty development and clinical teacher certification.

Blended learning for postgraduates; an interactive experience.

BACKGROUND: Blended learning has the potential to stimulate effective learning and to facilitate high quality education. For postgraduate health professionals, blended learning is relatively new. For this group we developed, implemented and evaluated two blended learning modules in a master program on quality and safety in patient care. Aiming for a better preparation compared to traditional textbook homework, the course provided not only web lectures and reading, but also interactive assignments and collaborative learning. Additional goal was saving time for the teachers resulting in a potential cost savings. METHOD: The experiences of 21 postgraduate health professionals were evaluated with two voluntary and anonymous questionnaires beginning of 2017 with a special focus on the added value of online interaction, underexposed in previous research. RESULTS: This evaluation shows that online modules are regarded as being an effective preparation for face-to-face meetings for postgraduate health professionals. Added value of social interactive online preparation was perceived from collaborating and interacting with each other. Both the interaction between the students, and the e-moderator and teachers were well received. CONCLUSIONS: Based on the results of this study, we suggest that blended learning may indeed increase the level of education and stimulate effective learning for postgraduate health care professionals. The professionals experienced added value of social interactive online preparation from collaborating and interacting with each other. We consider better aligning of the online and face-to-face components as one of the highest priorities.

Defensive medicine among neurosurgeons in the Netherlands: a national survey.

OBJECTIVE: In defensive medicine, practice is motivated by legal rather than medical reasons. Previous studies have analyzed the correlation between perceived medico-legal risk and defensive behavior among neurosurgeons in the United States, Canada, and South Africa, but not yet in Europe. The aim of this study is to explore perceived liability burdens and self-reported defensive behaviors among neurosurgeons in the Netherlands and compare their practices with their non-European counterparts. METHODS: A survey was sent to 136 neurosurgeons. The survey included questions from several domains: surgeon characteristics, patient demographics, type of practice, surgeon liability profile, policy coverage, defensive practices, and perception of the liability environment. Survey responses were analyzed and summarized. RESULTS: Forty-five neurosurgeons filled out the questionnaire (response rate of 33.1%). Almost half (n = 20) reported paying less than 5% of their income to annual malpractice premiums. Nearly all respondents view their insurance premiums as a minor or no burden (n = 42) and are confident that in their coverage is sufficient (n = 41). Most neurosurgeons (n = 38) do not see patients as "potential lawsuits". CONCLUSIONS: Relative to their American peers, Dutch neurosurgeons view their insurance premiums as less burdensome, their patients as a smaller legal threat, and their practice as less risky in general. They are sued less often and engage in fewer defensive behaviors than their non-European counterparts. The medico-legal climate in the Netherlands may contribute to this difference.

Bridging generation gaps in medical education: a "light bulb moment" at the Association for Medical Education in Europe annual conference in Barcelona.

Generation gaps have been described before and so have ways to deal with them. But they were mainly focused on the teachers. We would like to bridge these generation gaps, not only by creating awareness but also by learning from each other. This leads to better equipped doctors across all generations and promotes lifelong learning instantaneously.

Long-term compliance with lipid-lowering medication after genetic screening for familial hypercholesterolemia.

BACKGROUND: Familial hypercholesterolemia is a common lipid disorder that predisposes to premature cardiovascular disease. Lipid-lowering treatment of affected individuals is widely advocated, and maximum benefit can be obtained if medication is started early. A screening program for familial hypercholesterolemia is ongoing in the Netherlands since 1994. To assess the extent of treatment and therapy compliance, patients were followed up for 2 years after the diagnosis was established. METHODS: Data were obtained by questionnaire. The 747 patients with familial hypercholesterolemia participating in the study were from the general community, and 62.4% were not receiving cholesterol-lowering medication. RESULTS: The overall percentage of treated patients had risen from 37.6% at screening to 92.5% 1 year later and then decreased to 85.9% 2 years after screening. During follow-up, 6.4% of patients discontinued their medication and 12.0% of untreated patients never started medication for various reasons, but in the majority of cases as advised by their own physicians. The mean reduction in low-density lipoprotein cholesterol levels in previously untreated patients was 30.1% (from 219 to 153 mg/dL [5.7 to 4.0 mmol/L]). For those already receiving treatment, an additional reduction of 10.3% (from 195 to 175 mg/dL [5.0 to 4.5 mmol/L]) was obtained. CONCLUSIONS: Most patients were receiving treatment 2 years after identification and had a positive attitude toward the screening program. However, the reduction of cholesterol levels still did not meet the internationally accepted goals of treatment. This underscores the fact that additional education is required to improve the treatment of individuals with familial hypercholesterolemia.

Consumption of tall oil-derived phytosterols in a chocolate matrix significantly decreases plasma total and low-density lipoprotein-cholesterol levels.

In a randomized, double-blind, placebo-controlled trial we evaluated the effect of dietary chocolates enriched with a wood-based phytosterol-phytostanol mixture, containing 18 % (w/w) sitostanol, compared with placebo dietary chocolates in seventy subjects with primary hypercholesterolaemia (total cholesterol levels below 8 mmol/l). For 4 weeks, participants consumed three servings of the phytosterol-enriched chocolate/d that provided 1.8 g unesterified phytosterols/d or a placebo chocolate in conjunction with a low-fat, low-cholesterol diet. Plasma total and LDL-cholesterol levels were statistically significantly reduced by 6.4 % (-0.44 mmol/l) and 10.3 % (-0.49 mmol/l), respectively, after 4 weeks of phytosterol-enriched-chocolate treatment. Plasma HDL-cholesterol and triacylglycerol levels were not affected. Consumption of phytosterol-enriched chocolates significantly increased plasma lathosterol concentration (+20.7 %), reflecting an increased endogenous cholesterol synthesis in response to phytosterol-induced decreased intestinal cholesterol absorption. Furthermore, the chocolates enriched with phytosterols significantly increased both plasma sitosterol (+95.8 %) and campesterol (+64.1 %) levels, compared with the placebo chocolate group. However, the absolute values of plasma sitosterol and campesterol remained within the normal range, that is, below 10 mg/l. The chocolates with phytosterols were palatable and induced no clinical or biochemical side effects. These findings indicate that dietary chocolate enriched with tall oil-derived phytosterols (1.8 g/d) is effective in lowering blood total and LDL-cholesterol levels in subjects with mild hypercholesterolaemia and thus may be helpful in reducing the risk of CHD in these individuals.

Declaring war on undertreatment: rationale for an aggressive approach to lowering cholesterol.

Few things are better understood within the medical community than the relationship between elevated total and low-density lipoprotein cholesterol (LDL-C) levels, cardiovascular disease and death. There is consensus in the treatment guidelines of numerous national and international bodies that cholesterol levels in at-risk patients should be reduced to target levels that have been shown in population studies to be associated with low rates of coronary heart disease (CHD). However, dyslipidaemia continues to be underdiagnosed and undertreated. The 'landmark' statin trials have demonstrated unequivocally that effective lipid-lowering therapy significantly decreases CHD morbidity and mortality. Furthermore, these benefits of lipid-lowering therapy are not limited to middle-aged men, but extend across a broad range of patient populations. Recent trial data suggest that lowering LDL-C to target levels is possible in a substantial proportion of patients when statins are administered aggressively and results in a greater reduction in the risk of major coronary events. This reduction in events is seen in patients with stable coronary disease as well as those treated immediately after an acute coronary syndrome. Although strong clinical and angiographic evidence shows that intensive treatment prevents morbidity and saves lives, indications are that clinicians are still waiting too long to treat dyslipidaemia and when treatment is initiated it is often at inadequate dosages. Undertreatment of dyslipidaemia is an issue that the healthcare community can no longer ignore.

Association between increased arterial-wall thickness and impairment in ABCA1-driven cholesterol efflux: an observational study.

BACKGROUND: Decreased concentrations of HDL cholesterol are associated with increased cardiovascular risk. These concentrations are directly related to cholesterol efflux from cells-the first step and a key process in reverse cholesterol transport. Cholesterol efflux is mediated by the ATP-binding cassette A1 transporter (ABCA1), the rate-limiting step in the production of HDL. We aimed to assess the relation between cholesterol efflux, HDL concentrations, and arterial-wall changes in individuals with impaired ABCA1 function. METHODS: We investigated 30 individuals from families with ABCA1 mutations, and 110 controls matched for age, sex, and ethnic origin. We measured concentrations of HDL cholesterol in plasma and intima-media thickness of the carotid arteries by B-mode ultrasonography in all participants. We also measured cholesterol efflux from skin fibroblasts in nine individuals with ABCA1 mutations and in ten controls. FINDINGS: Individuals with ABCA1 mutations had lower amounts of cholesterol efflux, lower HDL cholesterol concentrations, and greater intima-media thicknesses than controls. An intima-media thickness at the upper limit of normal (0.80 mm) was reached by age 55 years in the ABCA1 heterozygotes, and at age 80 years in unaffected controls (p<0.0001). Additionally, strong positive correlations were seen between HDL cholesterol concentrations and cholesterol efflux (r=0.90, p=0.001), and negative correlations between apolipoprotein-AI-mediated (r=-0.61, p=0.030) and HDL-particle-mediated (r=-0.60, p=0.018) efflux and intima-media thickness in the ABCA1 mutation carriers. INTERPRETATION: These results show a direct relation between ABCA1-mediated cellular cholesterol efflux and arterial-wall thickness, and therefore suggest that increasing efflux could inhibit atherosclerosis progression before the manifestation of symptomatic cardiovascular disease.