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.

How does portfolio use support self-regulated learning during general practitioner specialty training? A qualitative focus group study.

OBJECTIVES: Portfolios are used to support self-regulated learning (SRL), but the research literature is still inconclusive on their effectiveness. This study explored experiences with portfolio use among different stakeholders, to answer the research question: How does portfolio use support SRL during general practitioner (GP) specialty training? DESIGN: We used a qualitative research design, based on phenomenology. SETTING: Three of the eight training institutes of Dutch GP specialty training participated in this study. PARTICIPANTS: The three stakeholder groups that use the portfolio were included in nine homogenous focus groups: trainees (n=16), supervisors (n=16) and faculty (n=17). All participants had at least 6-month experience with portfolio use. RESULTS: Three themes were identified: SRL with(out) the portfolio, stakeholder dynamics and ambiguities. Respondents were doubtful about the learning benefits of portfolio use, as most trainees used their portfolio to 'check off' what was considered required. Stakeholder dynamics contributed to checking off behaviour in two ways. First, trainees experienced documenting learning activities to be superfluous, since the close relationship with their supervisor already supported SRL sufficiently. Second, faculty often (unintentionally) took portfolio ownership away from trainees, as they instructed trainees to deliver portfolio content that was valuable for assessment. Without ownership, trainees struggled to use the portfolio for SRL. Besides, ambiguities related to portfolio use amplified checking off behaviour. CONCLUSIONS: Portfolio use did not support SRL in our setting. The multipurpose use of the portfolio (for the support of SRL and assessment) was identified as the primary obstacle. Underlying is a conflict that is often present in current medical curricula: agency versus accountability. If the support of SRL is considered a valuable and attainable purpose of portfolio use, it is important to realise that deliberate attention for this purpose is required during the design, guidance, assessment and evaluation of the portfolio.

Supervisory dyads' communication and alignment regarding the use of workplace-based observations: a qualitative study in general practice residency.

BACKGROUND: In medical residency, performance observations are considered an important strategy to monitor competence development, provide feedback and warrant patient safety. The aim of this study was to gain insight into whether and how supervisor-resident dyads build a working repertoire regarding the use of observations, and how they discuss and align goals and approaches to observation in particular. METHODS: We used a qualitative, social constructivist approach to explore if and how supervisory dyads work towards alignment of goals and preferred approaches to performance observations. We conducted semi-structured interviews with supervisor-resident dyads, performing a template analysis of the data thus obtained. RESULTS: The supervisory dyads did not frequently communicate about the use of observations, except at the start of training and unless they were triggered by internal or external factors. Their working repertoire regarding the use of observations seemed to be primarily driven by patient safety goals and institutional assessment requirements rather than by providing developmental feedback. Although intended as formative, the institutional test was perceived as summative by supervisors and residents, and led to teaching to the test rather than educating for purposes of competence development. CONCLUSIONS: To unlock the full educational potential of performance observations, and to foster the development of an educational alliance, it is essential that supervisory dyads and the training institute communicate clearly about these observations and the role of assessment practices of- and for learning, in order to align their goals and respective approaches.

Supervisors' intention to observe clinical task performance: an exploratory study using the theory of planned behaviour during postgraduate medical training.

BACKGROUND: Direct observation of clinical task performance plays a pivotal role in competency-based medical education. Although formal guidelines require supervisors to engage in direct observations, research demonstrates that trainees are infrequently observed. Supervisors may not only experience practical and socio-cultural barriers to direct observations in healthcare settings, they may also question usefulness or have low perceived self-efficacy in performing direct observations. A better understanding of how these multiple factors interact to influence supervisors' intention to perform direct observations may help us to more effectively implement the aforementioned guidelines and increase the frequency of direct observations. METHODS: We conducted an exploratory quantitative study, using the Theory of Planned Behaviour (TPB) as our theoretical framework. In applying the TPB, we transfer a psychological theory to medical education to get insight in the influence of cognitive and emotional processes on intentions to use direct observations in workplace based learning and assessment. We developed an instrument to investigate supervisors intention to perform direct observations. The relationships between the TPB measures of our questionnaire were explored by computing bivariate correlations using Pearson's R tests. Hierarchical regression analysis was performed in order to assess the impact of the respective TPB measures as predictors on the intention to perform direct observations. RESULTS: In our study 82 GP supervisors completed our TPB questionnaire. We found that supervisors had a positive attitude towards direct observations. Our TPB model explained 45% of the variance in supervisors' intentions to perform them. Normative beliefs and past behaviour were significant determinants of this intention. CONCLUSION: Our study suggests that supervisors use their past experiences to form intentions to perform direct observations in a careful, thoughtful manner and, in doing so, also take the preferences of the learner and other stakeholders potentially engaged in direct observations into consideration. These findings have potential implications for research into work-based assessments and the development of training interventions to foster a shared mental model on the use of direct observations.

Stakeholder perspectives on workplace-based performance assessment: towards a better understanding of assessor behaviour.

Workplace-Based Assessment (WBA) plays a pivotal role in present-day competency-based medical curricula. Validity in WBA mainly depends on how stakeholders (e.g. clinical supervisors and learners) use the assessments-rather than on the intrinsic qualities of instruments and methods. Current research on assessment in clinical contexts seems to imply that variable behaviours during performance assessment of both assessors and learners may well reflect their respective beliefs and perspectives towards WBA. We therefore performed a Q methodological study to explore perspectives underlying stakeholders' behaviours in WBA in a postgraduate medical training program. Five different perspectives on performance assessment were extracted: Agency, Mutuality, Objectivity, Adaptivity and Accountability. These perspectives reflect both differences and similarities in stakeholder perceptions and preferences regarding the utility of WBA. In comparing and contrasting the various perspectives, we identified two key areas of disagreement, specifically 'the locus of regulation of learning' (i.e., self-regulated versus externally regulated learning) and 'the extent to which assessment should be standardised' (i.e., tailored versus standardised assessment). Differing perspectives may variously affect stakeholders' acceptance, use-and, consequently, the effectiveness-of assessment programmes. Continuous interaction between all stakeholders is essential to monitor, adapt and improve assessment practices and to stimulate the development of a shared mental model. Better understanding of underlying stakeholder perspectives could be an important step in bridging the gap between psychometric and socio-constructivist approaches in WBA.

Psychometric characteristics of health-related quality-of-life questionnaires in oropharyngeal dysphagia.

Dysphagia can have severe consequences for the patient's health, influencing health-related quality of life (HRQoL). Sound psychometric properties of HRQoL questionnaires are a precondition for assessing the impact of dysphagia, the focus of this study, resulting in recommendations for the appropriate use of these questionnaires in both clinical practice and research contexts. We performed a systematic review starting with a search for and retrieval of all full-text articles on the development of HRQoL questionnaires related to oropharyngeal dysphagia and/or their psychometric validation from the electronic databases PubMed and Embase published up to June 2011. Psychometric properties were judged according to quality criteria proposed for health status questionnaires. Eight questionnaires were included in this study. Four are aimed solely at HRQoL in oropharyngeal dysphagia: the deglutition handicap index (DHI), dysphagia handicap index (DHI'), M.D. Anderson Dysphagia Inventory (MDADI), and SWAL-QOL, while the EDGQ, EORTC QLQ-STO 22, EORTC QLQ-OG 25 and EORTC QLQ-H&N35 focus on other primary diseases resulting in dysphagia. The psychometric properties of the DHI, DHI', MDADI, and SWAL-QOL were evaluated. For appropriate applicability of HRQoL questionnaires, strong scores on the psychometric criteria face validity, criterion validity, and interpretability are prerequisites. The SWAL-QOL has the strongest ratings for these criteria, while the DHI' is the most easy to apply given its 25 items and the use of a uniform scoring format. For optimal use of HRQoL questionnaires in diverse settings, it is necessary to combine psychometric and utility approaches.

Psychometric evaluation of the OM8-30 questionnaire in Dutch children with otitis media.

The Dutch translation of the OM8-30 questionnaire, originally developed in the UK on a large clinical sample, has been applied for validation in an ENT sample, with the aim of assessing otitis media impact and identifying treatment needs in children suffering from chronic otitis media (OM) and/or upper respiratory tract infections (URTI). Caregivers of 246 children completed the OM8-30 and also the generic Strengths and Difficulties Questionnaire (SDQ), prior to otolaryngologist consultation. Factor analysis confirmed the hypothesized six-factor structure, accounting for 55.5% of the variance. The internal consistency was satisfactory to good for all of the physical and developmental facets (alpha-values > or = 0.68). The correlation matrix with the SDQ scales and total difficulties score showed significant relationships for almost all of the OM8-30 developmental facets and sub-aggregate (Ps < 0.01), supporting the concurrent validity of the OM8-30 as a measure of impact in otitis media. This first examination of the Dutch OM8-30 shows that the psychometric characteristics are sufficiently good for the assessment of disease impact, and that this can be subdivided into impact on physical health and on developmental aspects. Recommendations for further research include the study of confounders such as hearing, age and previous operations so that these can be adjusted out, and the determination of which subgroup of children may benefit from tympanostomy tubes.

Response-shift bias and parent-reported quality of life in children with otitis media.

OBJECTIVES: To validate the 6-item quality-of-life survey (OM-6) and to investigate response-shift bias regarding children with otitis media. SETTING: Otorhinolaryngology department of a university hospital that serves the southernmost part of the Netherlands. PATIENTS: Seventy-seven children (age range, 12-38 months) experiencing persistent otitis media with effusion and scheduled for placement of tympanostomy tubes. SURVEY: The OM-6 measures health-related quality of life in 6 domains: physical suffering, hearing loss, speech impairment, emotional distress, activity limitations, and caregiver concerns. INTERVENTION: Parents completed the OM-6 before surgery (pretest) and 6 weeks after surgery (posttest). At the posttest, parents also completed a retrospective version of the pretest (retrospective pretest). RESULTS: For most items, the test-retest reliability was good (R>0.8). The internal consistency of the OM-6 was satisfactory (alpha =.79). The construct validity, determined by correlating the ear-related global quality-of-life measure and the OM-6 summary score, was fair (R = -0.77, P<.01). Prospective change in quality of life on the OM-6 ranged from moderate (standardized response mean >/=0.5) to large (standardized response mean >/=0.8). Response-shift bias was present at the group level (t = -3.3, P<.01). Retrospective change was significant for hearing loss (z = -3.3, P<.05) and ear-related global quality of life (z = -3.6, P<.05). CONCLUSIONS: The validity of the OM-6 has been proved in a Dutch population. The data suggest that parents underestimate the seriousness of hearing loss and overestimate the quality of life of their child before surgery, indicating a response shift. Treatment results could lead parents to realize that the situation before surgery had been worse than they thought.