How isolation of key information and allowing clarifying questions may improve information quality and diagnostic accuracy at case handover in paediatrics.

Handover between colleagues is a complex task. The problem is that handovers are often inadequate because they are not structured according to theoretically grounded guidelines. Based on the cognitive load theory, we suggest that allowing a clarifying dialogue and thereby optimizing germane cognitive load enhances the information quality and diagnostic accuracy at handover, but may prolong handover duration. We also expect that mentioning key information first and thus decreasing intrinsic cognitive load improves information quality and diagnostic accuracy. We developed two representative paediatric cases for presentation in a factorial 2 × 2 design. Sixth-year medical students (N = 80) were randomly assigned to one of four groups that differed with regard to how the case histories were delivered to them (chronological order versus key information mentioned first) and direction of information exchange (unidirectional versus a clarifying dialogue). The receivers of the handover were asked to write a report of the cases and suggest the best diagnosis. Dependent variables were information quality of the written report (Information score), quality of the diagnosis (Diagnostic accuracy score) and the time it took to deliver the written handover case report (Handover report duration). Seen through the lens of cognitive load theory, allowing a clarifying dialogue at handover, and thus optimizing the germane cognitive load, significantly increased the Information score (p < 0.0005), Diagnostic accuracy score (< 0.05) and Handover report duration (p < 0.001).

Advancing quality culture in health professions education: experiences and perspectives of educational leaders.

The concept of quality culture has gained increased attention in health professions education, drawing on insights that quality management processes and positive work-related attitudes of staff in synergy lead to continuous improvement. However, the directions that guide institutions from quality culture theory to educational practice have been missing so far. A prospective qualitative case study of three health professions education programmes was conducted to explore how a quality culture can be enhanced according to the experiences and perspectives of educational leaders. The data collection was structured by an appreciative inquiry approach, supported with vignette-based interviews. A total of 25 participants (a selection of course coordinators, bachelor coordinators and directors of education) reflected on quality culture themes to learn about the best of what is (Discover), envision positive future developments (Dream), identify actions to reach the desired future (Design), and determine how to support and sustain improvement actions (Destiny) within their own educational setting. The results are presented as themes subsumed under these four phases. The experiences and perspectives of educational leaders reveal that peer learning in teams and communities, attention to professional development, and embedding support- and innovation networks, are at the heart of quality culture enhancement. An emphasis on human resources, (inter)relations and contextual awareness of leaders stood out as quality culture catalysts. Educational leaders are therefore encouraged to especially fuel their networking, communication, coalition building, and reflection competencies.

How do clinicians become teachers? A communities of practice perspective.

There is widespread acceptance that clinical educators should be trained to teach, but faculty development for clinicians is undermined by poor attendance and inadequate learning transfer. As a result there has been growing interest in situating teacher development initiatives in clinical workplaces. The relationship between becoming a teacher and clinical workplace contexts is under theorised. In response, this qualitative research set out to explore how clinicians become teachers in relation to clinical communities and institutions. Using communities of practice (CoP) as a conceptual framework this research employed the sensitising concepts of regimes of competence and vertical (managerial) and horizontal (professional) planes of accountability to elucidate structural influences on teacher development. Fourteen hospital physicians completed developmental timelines and underwent semi-structured interviews, exploring their development as teachers. Despite having very different developmental pathways, participants' descriptions of their teacher identities and practice that were remarkably congruent. Two types of CoP occupied the horizontal plane of accountability i.e. clinical teams (Firms) and communities of junior doctors (Fraternities). Participants reproduced teacher identities and practice that were congruent with CoPs' regimes of competence in order to gain recognition and legitimacy. Participants also constructed their teacher identities in relation to institutions in the vertical plane of accountability (i.e. hospitals and medical schools). Institutions that valued teaching supported the development of teacher identities along institutionally defined lines. Where teaching was less valued, clinicians adapted their teacher identities and practices to suit institutional norms. Becoming a clinical educator entails continually negotiating one's identity and practice between two potentially conflicting planes of accountability. Clinical CoPs are largely conservative and reproductive of teaching practice whereas accountability to institutions is potentially disruptive of teacher identity and practice.

Understanding the effects of time on collaborative learning processes in problem based learning: a mixed methods study.

Little is known how time influences collaborative learning groups in medical education. Therefore a thorough exploration of the development of learning processes over time was undertaken in an undergraduate PBL curriculum over 18 months. A mixed-methods triangulation design was used. First, the quantitative study measured how various learning processes developed within and over three periods in the first 1,5 study years of an undergraduate curriculum. Next, a qualitative study using semi-structured individual interviews focused on detailed development of group processes driving collaborative learning during one period in seven tutorial groups. The hierarchic multilevel analyses of the quantitative data showed that a varying combination of group processes developed within and over the three observed periods. The qualitative study illustrated development in psychological safety, interdependence, potency, group learning behaviour, social and task cohesion. Two new processes emerged: 'transactive memory' and 'convergence in mental models'. The results indicate that groups are dynamic social systems with numerous contextual influences. Future research should thus include time as an important influence on collaborative learning. Practical implications are discussed.

Visualising the invisible: a network approach to reveal the informal social side of student learning.

World-wide, universities in health sciences have transformed their curriculum to include collaborative learning and facilitate the students' learning process. Interaction has been acknowledged to be the synergistic element in this learning context. However, students spend the majority of their time outside their classroom and interaction does not stop outside the classroom. Therefore we studied how informal social interaction influences student learning. Moreover, to explore what really matters in the students learning process, a model was tested how the generally known important constructs-prior performance, motivation and social integration-relate to informal social interaction and student learning. 301 undergraduate medical students participated in this cross-sectional quantitative study. Informal social interaction was assessed using self-reported surveys following the network approach. Students' individual motivation, social integration and prior performance were assessed by the Academic Motivation Scale, the College Adaption Questionnaire and students' GPA respectively. A factual knowledge test represented student' learning. All social networks were positively associated with student learning significantly: friendships (ß = 0.11), providing information to other students (ß = 0.16), receiving information from other students (ß = 0.25). Structural equation modelling revealed a model in which social networks increased student learning (r = 0.43), followed by prior performance (r = 0.31). In contrast to prior literature, students' academic motivation and social integration were not associated with students' learning. Students' informal social interaction is strongly associated with students' learning. These findings underline the need to change our focus from the formal context (classroom) to the informal context to optimize student learning and deliver modern medics.

Intensive care medicine trainees' perception of professionalism: a qualitative study.

The Competency-Based Training program in Intensive Care Medicine in Europe identified 12 competency domains. Professionalism was given a prominence equal to technical ability. However, little information pertaining to fellows' views on professionalism is available. A nationwide qualitative study was performed. The moderator asked participants to clarify the terms professionalism and professional behaviour, and to explore the questions "How do you learn the mentioned aspects?" and "What ways of learning do you find useful or superfluous?". Qualitative data analysis software (MAXQDA2007) facilitated analysis using an inductive coding approach. Thirty-five fellows across eight groups participated. The themes most frequently addressed were communication, keeping distance and boundaries, medical knowledge and expertise, respect, teamwork, leadership and organisation and management. Medical knowledge, expertise and technical skills seem to become more tacit when training progresses. Topics can be categorised into themes of workplace-based learning, by gathering practical experience, by following examples and receiving feedback on action, including learning from own and others' mistakes. Formal teaching courses (e.g. communication) and scheduled sessions addressing professionalism aspects were also valued. The emerging themes considered most relevant for intensivists were adequate communication skills and keeping boundaries with patients and relatives. Professionalism is mainly learned 'on the job' from role models in the intensive care unit. Formal teaching courses and sessions addressing professionalism aspects were nevertheless valued, and learning from own and others' mistakes was considered especially useful. Self-reflection as a starting point for learning professionalism was stressed.

A framework of teaching competencies across the medical education continuum.

BACKGROUND: The quality of teachers in higher education is subject of increasing attention, as exemplified by the development and implementation of guidelines for teacher qualifications at Universities in The Netherlands. AIM: Because medical education takes a special position in higher education the Council of Deans of Medical Schools in The Netherlands installed a national task force to explore a method to weigh criteria for teacher qualifications of medical teachers. METHODS: A framework was developed covering competencies of teachers throughout the medical education continuum and including medicine, dentistry and veterinary medicine. RESULTS: The framework distinguishes 3 dimensions: (a) six domains of teaching (development - organization - execution - coaching - assessment - evaluation); (b) three levels in the organization at which teachers perform (micro, meso and macro level) and (c) competencies as integration of knowledge, skills and attitude and described as behaviour in specific context. The current framework is the result of several cycles of descriptions, feedback from the field and adaptations. It is meant as a guideline, leaving room for local detailing. CONCLUSION: The framework provides a common language that may be used not only by teachers and teacher trainers, but also by quality assurance committees, human resource managers and institutional boards.

Clinical supervisors' perceived needs for teaching communication skills in clinical practice.

BACKGROUND: Lack of faculty training is often cited as the main obstacle to post-graduate teaching in communication skills. AIMS: To explore clinical supervisors' needs and perceptions regarding their role as communication skills trainers. METHODS: Four focus group discussions were conducted with clinical supervisors from two in-patient and one out-patient medical services from the Geneva University Hospitals. Focus groups were audio taped, transcribed verbatim and analyzed in a thematic way using Maxqda software for qualitative data analysis. RESULTS: Clinical supervisors said that they frequently addressed communication issues with residents but tended to intervene as rescuers, clinicians or coaches rather than as formal instructors. They felt their own training did not prepare them to teach communication skills. Other barriers to teach communication skills include lack of time, competing demands, lack of interest and experience on the part of residents, and lack of institutional priority given to communication issues. Respondents expressed a desire for experiential and reflective training in a work-based setting and emphasised the need for a non-judgmental learning atmosphere. CONCLUSIONS: Results suggest that organisational priorities, culture and climate strongly influence the degree to which clinical supervisors may feel comfortable to teach communication skills to residents. Attention must be given to these contextual factors in the development of an effective communication skills teaching program for clinical supervisors.

Patients' representations of their end-stage renal disease: relation with mortality.

BACKGROUND: Self-regulation theory explains how patients' illness perceptions influence self-management behaviour (e.g. via adherence to treatment). Following these assumptions, we explored whether illness perceptions of ESRD-patients are related to mortality rates. METHODS: Illness perceptions of 182 patients participating in the NECOSAD-2 study in the period between December 2004 and June 2005 were assessed. Cox proportional hazard models were used to estimate whether subsequent all-cause mortality could be attributed to illness perception dimensions. RESULTS: One-third of the participants had died at the end of the follow-up. Mortality rates were higher among patients who believed that their treatment was less effective in controlling their disease (perceived treatment control; RR = 0.71, P = 0.028). This effect remained stable after adjusting for sociodemographic and clinical variables (RR = 0.65, P = 0.015). CONCLUSIONS: If we consider risk factors for mortality, we tend to rely on clinical parameters rather than on patients' representations of their illness. Nevertheless, results from the current exploration may suggest that addressing patients' personal beliefs regarding the effectiveness of treatment can provide a powerful tool for predicting and perhaps even enhancing survival.

The development of shared cognition in paediatric residents analysing a patient video versus a paper patient case.

In a previous study, we established that compared to a written case, a video case enhances observable cognitive processes in the verbal interaction in a postgraduate problem-based learning format. In a new study we examined non-observable cognitive processes using a stimulated recall procedure alongside a reanalysis of the data from the first study. We examined the development of shared cognition as reflected in collaborative concept link formation, an approach to connecting a series of concepts related to a particular topic. Eleven paediatric residents were randomly allocated to two groups. After both analysing the same written case vignette, one group watched a video of the case in the vignette and the other group read a written description of the video. Both groups then reanalysed the vignette. After the group sessions, time-logged transcripts were made of the verbal interaction in both groups and all residents individually took part in a stimulated recall procedure. Causal reasoning concept links were labelled as individual or collaborative depending on whether they originated from individual residents or were directly elicited by verbal utterances from others. The video led to a significantly increased frequency ratio (after intervention: before intervention) of collaborative concept links but did not affect the frequency of individual concept links. This novel process approach to chronological registration of concept link formation offered additional evidence that shared cognition by means of co-elaboration of concept formation is stimulated by the use of patient video recordings in small group learning.

Comparison of text and video cases in a postgraduate problem-based learning format.

OBJECTIVE: To investigate whether adding a brief video case instead of an equivalent written text improves the cognitive and metacognitive processes (data exploration, theory building, theory evaluation and metareasoning) of residents in problem-based learning. SUBJECTS: Paediatric residents. SETTING: Department of Paediatrics, Arhus University Hospital, Skejby, Denmark. METHODS: Eleven residents were each assigned to 1 of 2 groups. Both groups analysed an identical vignette of a patient case. Immediately after this, 1 group watched a 2.5-minute video recording and the other group read a description of the same video recording. The groups then reanalysed the case. Thinking processes were tapped by recording and analysing the verbal group interaction. The frequencies of clause categories were calculated and compared using chi-square tests. RESULTS: The verbal interaction showed statistically significant improvements in data exploration, theory building and theory evaluation after the video case. CONCLUSIONS: The greater improvement in clause frequency after the video case compared with the equivalent text suggests an improvement in data exploration, theory building and theory evaluation. The use of patient video recordings may be a valuable supplement to postgraduate paediatric training, particularly pertaining to movement disorders.

[Severe diarrhoea with invasive intestinal spirochaetosis]. / Ernstige diarree met invasieve intestinale spirochetose.

A 38-year-old heterosexual male presented with a 6 to 7 week history of severe diarrhoea but no other complaints. In routine faecal cultures and routine parasitological investigations no pathogenic micro-organisms were observed. Colonoscopy revealed a normal mucosa. Multiple biopsies were obtained. The histological diagnosis was invasive intestinal spirochaetosis. The immunostain for Borrelia burgdorferi cross-reacted with the spirochetes of the intestinal spirochaetosis. After two weeks of incubation under strict anaerobic conditions a spirochaete was cultured from a biopsy of the sigmoid mucosa. The 16SrDNA sequence was consistent with Brachyspira aalborgi. The HIV and syphilis results were negative. The patient was treated first with metronidazole and then by clindamycin. The diarrhoea subsided after the second course of treatment and the cause was presumed to have been the invasive intestinal spirochaetosis. Intestinal spirochaetosis is usually found coincidentally at histological examination of colon biopsies. There is no general consensus that intestinal spirochaetosis is the cause of the diarrhoea. There is however an association between the presence of symptoms and the invasivity of spirochaetes, morphological colon epithelial changes and evidence of immune response. The literature reports patients who improve symptomatically without specific treatment. Treatment may be given to patients with severe symptoms.

Providing physicians with feedback on how they supervise students during patient contacts.

In this descriptive study an instrument is presented that has been developed to provide physicians with feedback about their strengths and weaknesses in facilitating student learning during patient contacts. The instrument is strongly theory based, i.e. it is based on current general theories of context-bound learning environments, and forms of facilitation promoting transfer of knowledge to actual professional practice. In addition, it has been developed in cooperation with physicians supervising students during patient contacts. The authors have shown how physicians can be provided with individualized feedback on their performance in supervising students during patient contacts.

Profiles of effective tutors in problem-based learning: scaffolding student learning.

OBJECTIVES: Research on tutoring in problem-based learning has not focused so far on the variation in tutoring and how this variation can be interpreted by conceptions about effective tutoring. DESIGN: This study focuses on the profiles of tutors generated by means of an instrument, the so-called Tutor Intervention Profile (TIP), and tries to determine which profiles are more or less effective. The TIP contains four dimensions of tutor behaviour: (1) elaboration; (2) directing the learning process; (3) integration of knowledge; and (4) stimulating interaction and individual accountability. SETTING: The medical school of the University of Maastricht, The Netherlands. SUBJECTS: Sixty-seven tutors who run 67 tutorial groups across three units (courses) in the academic year 1996-97. RESULTS: It appeared that high, average and low performing tutors differ in their performance on each of the four dimensions of the TIP. Several different profiles of tutor performance could be distinguished, which were more or less effective. One group of tutors demonstrated a tutor intervention profile that was characterized as relying more on the use of expert knowledge, whereas another group of tutors was characterized as relying more on their abilities to stimulate the learning process in the tutorial group. The tutor intervention profile that was perceived by students as most effective showed high scores on each of the four dimensions, as expected. Notably, a tutor stressing the learning process in the tutorial group was perceived as more effective than a tutor stressing content (expert tutor). This is especially true for a relatively poor scoring tutor. CONCLUSIONS: The results of this study are consistent with research on human tutoring and research on tutoring in problem-based learning.

Tutor intervention profile: reliability and validity.

An instrument has been developed to provide tutors with feedback about their performance in problem-based tutorial groups. This questionnaire consists of 33 statements reflecting the behaviour of the tutor in the tutorial group when students analyse the case and generate learning issues and the behaviour of the tutor when students report back to the tutorial group about their self-study. The statements are grouped on theoretical dimensions found in the literature about co-operative learning and problem-based learning. This study focuses on the validity and the reliability of this instrument. Confirmatory factor analysis showed that a four-factor model showed a weak fit, whereas each separate factor fitted the data reasonably well. The four factors are: (1) elaboration; (2) directing the learning process; (3) integration of knowledge and (4) stimulating interaction and individual accountability. These factors were strongly correlated with the overall judgement of the tutor at the end of the unit, so the concurrent validity of this instrument was high. Generalizability studies indicated that the rating scales provide reliable information with a sample size of student responses falling within the range of real tutorial group sizes. The results of this study show that the instrument for providing tutors with feedback is valid and reliable. This questionnaire can be used in staff development activities and also provides needs assessment for faculty development.

Vascular reactivity during combined ultrafiltration-haemodialysis: influence of dialysate sodium.

BACKGROUND: It is well known that vascular reactivity is impaired during combined ultrafiltration-haemodialysis as compared to isolated ultrafiltration and haemofiltration, which might be related to differences in plasma osmolality. Therefore vascular reactivity was studied during combined ultrafiltration-haemodialysis in relation to sodium-related differences in plasma osmolality/tonicity. METHODS: With each patient serving as his or her own control, nine stable dialysis patients (23-71 years) were studied during 2 h of combined ultrafiltration-haemodialysis (bicarbonate; UF rate 1.0 l/h)) at two different dialysate sodium concentrations: 134 and 144 mmol/l. Before dialysis as well as every 20 min during dialysis, blood pressure (Dinamap), heart rate (ECG), and forearm vascular resistance and venous tone (strain-gauge plethysmography) were measured. Relative blood volume was monitored continuously by an optical reflection method (Haemoguard 2000), while before and after dialysis blood was obtained for the estimation of plasma prostaglandin E2. RESULTS: High-sodium dialysis resulted in a significantly higher post-dialysis plasma sodium concentration (139. 9 vs 135.0 mmol/l; P<0.01) while the decrease in relative blood volume was significantly smaller as compared to low-sodium dialysis (-8.4 vs -18.4%; P<0.01). There were no significant differences in the different haemodynamic parameters between the two treatment modalities. Both high- and low-sodium dialysis were associated with a significant increase in forearm vascular resistance while venous tone remained unchanged. Although there was no significant difference in plasma PGE2 between the two treatment modalities, PGE2 increased significantly only during low-sodium dialysis. We found no relationship between changes in PGE2 and vascular reactivity. CONCLUSIONS: We conclude that vascular reactivity during combined ultrafiltration-haemodialysis is not directly influenced by sodium-related changes in plasma tonicity. Although not directly studied, the reported improved haemodynamic stability with high-sodium dialysis is probably only mediated through a better preservation of plasma volume. Finally, an increase in plasma PGE2 as observed during low-sodium dialysis does not lead to a decrease in vascular tone.

A prospective study of the natural history of idiopathic non-proteinuric hematuria.

In a prospective study of idiopathic glomerulonephritis we determined the natural history of 49 adult patients (12 primary IgA nephropathy, 13 thin GBM nephropathy, 20 normal renal tissue and 4 miscellaneous nephropathies) who presented with idiopathic non-proteinuric non-azotemic hematuria of at least six months duration, in the absence of hypertension and with a negative urological work-up. The median follow-up was 11 years with a range of 8 to 14 years. At the end of the follow-up, renal function had remained stable in all subsets except for those with miscellaneous disease. Hematuria was still present in all patients with thin GBM nephropathy, in all but two patients with IgA nephropathy who went into immunopathological remission, in three out of four miscellaneous nephropathies, and in seven out of 20 patients with normal renal tissue. Of the latter patients five had a history suggestive of urolithiasis at follow-up, which was in the absence of hypercalciuria and hyperuricosuria. Seven thin GBM patients, five IgA nephropathy patients and three miscellaneous nephropathies developed hypertension; the incidence of hypertension in each subset was significantly higher than in patients with normal renal tissue. This study shows that in young adults with idiopathic chronic non-proteinuric hematuria of four years duration, renal biopsy will give a definite diagnosis in 86% of the patients, and that those patients with so-called minor glomerular diseases are at high risk for hypertension. Those patients with normal renal tissue have a high incidence of urolithiasis and should have a urological follow-up.

Approaches to learning in a problem-based medical programme: a developmental study.

In this study we investigate how the introductory phase of the problem-based medical programme in Maastricht affects the study methods of students. On the first day of the academic year, 142 men and women medical students completed the Short Inventory of Study Approaches and again at the end of the introductory period. The study indicates that these study methods are fostered by training in problem-based learning given during the introductory period.