Unprofessional behaviour of GP residents leading to a dismissal dispute: characteristics and outcomes of those who appeal.

BACKGROUND: Recognition of poor performance in General Practice trainees is important because underperformance compromises patients' health and safety. However, in General Practice, research on persistent underperformance while in training and its ultimate consequences is almost completely lacking. We aim to explore the unprofessional behaviours of residents in General Practice who were dismissed from training and who litigated against dismissal. METHODS: We performed a structured analysis using open-source data from all General Practice cases before the Conciliation Board of the Royal Dutch Medical Association between 2011 and 2020. Anonymised law cases about residents from all Dutch GP training programmes were analysed in terms of the quantitative and qualitative aspects related to performance. RESULTS: Between 2011 and 2020, 24 residents who were dismissed from training challenged their programme director's decision. Dismissed residents performed poorly in several competencies, including communication, medical expertise and most prominently, professionalism. Over 90% of dismissed residents failed on professionalism. Most lacked self-awareness and/or failed to profit from feedback. Approximately 80% failed on communication, and about 60% on medical expertise as well. A large majority (more than 80%) of dismissed residents had previously participated in some form of remediation. CONCLUSIONS: Deficiencies in both professionalism and communication were the most prevalent findings among the dismissed General Practice residents. These two deficiencies overlapped considerably. Dismissed residents who challenged their programme director's decision were considered to lack self-awareness, which requires introspection and the appreciation of feedback from others.

'You are not alone.' An exploratory study on open-topic, guided collaborative reflection sessions during the General Practice placement.

BACKGROUND: To support professional development of medical students faced with challenges of the clinical phase, collaborative reflection sessions (CRSs) are used to share and reflect on workplace experiences. Facilitation of CRSs seems essential to optimise learning and to provide important skills for lifelong learning as a professional. However, little is known about which workplace experiences students share in CRSs without advance guidance on specific topics, and how reflecting on these experiences contributes to students' professional development. Therefore, we explored which workplace experiences students shared, what they learned from reflection on these experiences, and how they perceived the value of CRSs. METHODS: We conducted an exploratory study among medical students (N = 99) during their General Practice placement. Students were invited to openly share workplace experiences, without pre-imposed instruction. A thematic analysis was performed on shared experiences and student learning gains. Students' perceptions of CRSs were analysed using descriptive statistics. RESULTS: All 99 students volunteered to fill out the questionnaire. We found four themes relating to students' shared experiences: interactions with patients, complex patient care, diagnostic or therapeutic considerations, and dealing with collegial issues. Regarding students' learning gains, we found 6 themes: learning from others or learning from sharing with others, learning about learning, communication skills, self-regulation, determination of position within the healthcare team, and importance of good documentation. Students indicated that they learned from reflection on their own and peer's workplace experiences. Students valued the CRSs as a safe environment in which to share workplace experiences and helpful for their professional development. CONCLUSIONS: In the challenging General Practice placement, open-topic, guided CRSs provide a helpful and valued learning environment relevant to professional development and offer opportunities for vicarious learning among peers. CRSs may also be a valuable tool to incorporate into other placements.

Reflection on medical errors: A thematic analysis.

BACKGROUND: As there is a need to prepare doctors to minimize errors, we wanted to determine how doctors go about reflecting upon their medical errors. METHODS: We conducted a thematic analysis of the published reflection reports of 12 Dutch doctors about the errors they had made. Three questions guided our analysis: What triggers doctors to become aware of their errors? What topics do they reflect upon to explain what happened? What lessons do doctors learn after reflecting on their error? RESULTS: We found that the triggers which made doctors aware of their errors were mostly death and/or a complication. This suggests that the trigger to recognize that something might be wrong came too late. The 12 doctors cited 20 topics' themes that explained the error and 16 lessons-learnt themes. The majority of the topics and lessons learnt were related more to the doctors' inner worlds (personal features) than to the outer world (environment). CONCLUSION: To minimize errors, doctors should be trained to become earlier and in time aware of distracting and misleading features that might interfere with their clinical reasoning. This training should focus on reflection in action and on discovering more about doctors' personal inner world to identify vulnerabilities.

"What kind of doctor do you want to become?": Clinical supervisors' perceptions of their roles in the professional identity formation of General Practice residents.

PURPOSE: Supporting the development of a professional identity is a primary objective in postgraduate education. Few empirical studies have explored professional identity formation (PIF) in residency, and little is known about supervisors' perceptions of their roles in residents' PIF. In this study, we sought to understand how supervisors perceive their roles in the PIF of General Practice (GP) residents. MATERIALS AND METHODS: Guided by principles of qualitative description, we conducted eight focus groups with 55 supervisors at four General Practice training institutes across the Netherlands. Informed by a conceptual framework of PIF, we performed a thematic analysis of focus group transcripts. RESULTS: Three themes related to how GP supervisors described their roles in supporting residents' PIF: supervising with the desired goal of GP training in mind; role modeling and mentoring as key strategies to achieve that goal; and the value of developing bonds of trust to support the process. CONCLUSIONS: To our knowledge, this study is the first to explore PIF in GP training from the perspective of clinical supervisors. The identified themes mirror the components of the therapeutic alliance between doctors and patients from a supervisor's perspective and highlight the pivotal roles of the supervisor in a resident's PIF.

General practitioners' everyday clinical decision-making on psychosocial problems of children and youth in the Netherlands.

BACKGROUND: Psychosocial problems in children and youth are common and may negatively impact their lives and the lives of their families. Since general practitioners (GPs) play a crucial role in detecting and intervening in such problems, it is clinically necessary to improve our insight into their clinical decision-making (CDM). The objective of this study was to explore which mechanisms underlie GPs' everyday CDM and their options for management or referral. MATERIAL AND METHODS: This was a mixed methods study in which qualitative (interview substudy) and quantitative (online survey substudy) data were collected from GPs. Using a question framework and vignettes representative of clinical practice, GPs' CDM was explored. GPs were selected by means of an academic research network and purposive sampling. Data collection continued in constant comparison between both substudies. Using grounded theory, data from both substudies were triangulated into a flowchart consisting of mechanisms and management/referral options. RESULTS: CDM-mechanisms were divided into three groups. GP-related mechanisms were GPs' primary approach of the problem (somatically or psychosocially) and their self-assessed competence to solve the problem based on interest in and knowledge about youth mental health care. Mechanisms related to the child and its social context included GPs' assessment whether there was psychiatric (co)morbidity, their sense of self-limitedness of the problem and assessed complexity of the problem. Whether GPs' had existing collaboration agreements with youth care providers and how they experienced their collaboration were collaboration-related mechanisms. CONCLUSION: The current study contributes to a relatively unexplored research area by revealing GP's in-depth thought processes regarding their CDM. However, existing research in this area supports the identified CDM mechanisms. Future initiatives should focus on validating CDM mechanisms in a larger population. If confirmed, mechanisms could be integrated into GP training and may offer guidelines for regulating proper access to mental health care services.

[Contraception: article for education and training]. / Anticonceptie.

Successful contraception is essential and the stable number of abortions illustrate the success of contraception policies in The Netherlands. This article considers relevant issues based on the latest NHG Contraception Standard. The patient takes centre stage in the selection of contraceptive and tailor made care is imperative. There are a number of alternative contraceptives each with their own functionality and merits. An important distinction is the use of hormones; the latter in view of the growing awareness of women of the alleged pros or cons of hormones. Important criteria for the choice of contraceptive methods are stage of life, reliability, ease of use, influence on the menstruation cycle, and foremost the personal preference of the woman in question. There are both absolute and relative contra-indications for a number of contraception methods as tabulated in the article.

Unprofessional behaviour of GP residents and its remediation: a qualitative study among supervisors and faculty.

BACKGROUND: Lapses in professionalism have profound negative effects on patients, health professionals, and society. The connection between unprofessional behaviour during training and later practice requires timely identification and remediation. However, appropriate language to describe unprofessional behaviour and its remediation during residency is lacking. Therefore, this exploratory study aims to investigate which behaviours of GP residents are considered unprofessional according to supervisors and faculty, and how remediation is applied. METHODS: We conducted eight semi-structured focus group interviews with 55 broadly selected supervisors from four Dutch GP training institutes. In addition, we conducted individual semi-structured interviews with eight designated professionalism faculty members. Interview recordings were transcribed verbatim. Data were coded in two consecutive steps: preliminary inductive coding was followed by secondary deductive coding using the descriptors from the recently developed 'Four I's' model for describing unprofessional behaviours as sensitising concepts. RESULTS: Despite the differences in participants' professional positions, we identified a shared conceptualisation in pinpointing and assessing unprofessional behaviour. Both groups described multiple unprofessional behaviours, which could be successfully mapped to the descriptors and categories of the Four I's model. Behaviours in the categories 'Involvement' and 'Interaction' were assessed as mild and received informal, pedagogical feedback. Behaviours in the categories 'Introspection' and 'Integrity', were seen as very alarming and received strict remediation. We identified two new groups of behaviours; 'Nervous exhaustion complaints' and 'Nine-to-five mentality', needing to be added to the Four I's model. The diagnostic phase of unprofessional behaviour usually started with the supervisor getting a 'sense of alarm', which was described as either a 'gut feeling', 'a loss of enthusiasm for teaching' or 'fuss surrounding the resident'. This sense of alarm triggered the remediation phase. However, the diagnostic and remediation phases did not appear consecutive or distinct, but rather intertwined. CONCLUSIONS: The processes of identification and remediation of unprofessional behaviour in residents appeared to be intertwined. Identification of behaviours related to lack of introspection or integrity were perceived as the most important to remediate. The results of this research provide supervisors and faculty with an appropriate language to describe unprofessional behaviours among residents, which can facilitate timely identification and remediation.

Perception of social media behaviour among medical students, residents and medical specialists.

INTRODUCTION: Behaviour is visible in real-life events, but also on social media. While some national medical organizations have published social media guidelines, the number of studies on professional social media use in medical education is limited. This study aims to explore social media use among medical students, residents and medical specialists. METHODS: An anonymous, online survey was sent to 3844 medical students at two Dutch medical schools, 828 residents and 426 medical specialists. Quantitative, descriptive data analysis regarding demographic data, yes/no questions and Likert scale questions were performed using SPSS. Qualitative data analysis was performed iteratively, independently by two researchers applying the principles of constant comparison, open and axial coding until consensus was reached. RESULTS: Overall response rate was 24.8%. Facebook was most popular among medical students and residents; LinkedIn was most popular among medical specialists. Personal pictures and/or information about themselves on social media that were perceived as unprofessional were reported by 31.3% of students, 19.7% of residents and 4.1% of medical specialists. Information and pictures related to alcohol abuse, partying, clinical work or of a sexually suggestive character were considered inappropriate. Addressing colleagues about their unprofessional posts was perceived to be mainly dependent on the nature and hierarchy of the interprofessional relation. DISCUSSION: There is a widespread perception that the presence of unprofessional information on social media among the participants and their colleagues is a common occurrence. Medical educators should create awareness of the risks of unprofessional (online) behaviour among healthcare professionals, as well as the necessity and ways of addressing colleagues in case of such lapses.

Patient complaints in general practice seen through the lens of professionalism: a retrospective observational study.

BACKGROUND: Professionalism is a key competence for physicians. Patient complaints provide a unique insight into patient expectations regarding professionalism. Research exploring the exact nature of patient complaints in general practice, especially focused on professionalism, is limited. AIM: To characterise patient complaints in primary care and to explore in more detail which issues with professionalism exist. DESIGN & SETTING: A retrospective observational study in which all unsolicited patient complaints to a representative out-of-hours general practice (OOH GP) service provider in The Netherlands were analysed over a 10-year period (2009-2019). METHOD: Complaints were coded for general characteristics and thematically categorised using the CanMEDS Physician Competency Framework (CanMEDS) as sensitising concepts. Complaints categorised as professionalism were subdivided using open coding. RESULTS: Out of 746 996 patient consultations (telephone, face-to-face, and home visits) 484 (0.065%) resulted in eligible complaint letters. The majority consisted of two or more complaints, resulting in 833 different complaints. Most complaints concerned GPs (80%); a minority (19%) assistants. Thirty-five per cent concerned perceived professionalism lapses of physicians. A rich diversity in the wording of professionalism lapses was found, where ' not being taken seriously ' was mentioned most often. Forty-five per cent related to medical expertise, such as missed diagnoses or unsuccessful clinical treatment. Nineteen per cent related to management problems, especially waiting times and access to care. Communication issues were only explicitly mentioned in 1% of the complaints. CONCLUSION: Most unsolicited patient complaints were related to clinical problems. A third, however, concerned professionalism issues. Not being taken seriously was the most frequent mentioned theme within the professionalism category.

Unravelling sexual care in chronically ill patients: the perspective of GP practice nurses; Health Service Research.

BACKGROUND: Assessment of sexual health is important in chronically ill patients, as many experience sexual dysfunction (SD). The general practice nurse (GPN) can play a crucial part in addressing SD. OBJECTIVE: The aim of this cross-sectional study was to examine to which extent GPNs discuss SD with chronically ill patients and what barriers may refrained them from discussing SD. Furthermore, we examined which factors had an association with a higher frequency of discussing SD. METHODS: A cross-sectional survey using a 48-item questionnaire was send to 637 GPNs across the Netherlands. RESULTS: In total, 407 GPNs returned the questionnaire (response rate 63.9%) of which 337 completed the survey. Two hundred and twenty-one responding GPNs (65.6%) found it important to discuss SD. More than half of the GPNS (n = 179, 53.3%) never discussed SD during a first consultation, 60 GPNs (18%) never discussed SD during follow-up consultations. The three most important barriers for discussing SD were insufficient training (54.7%), 'reasons related to language and ethnicity' (47.5%) and 'reasons related to culture and religion' (45.8%). More than half of the GPNs thought that they had not enough knowledge to discuss SD (n = 176, 54.8%). A protocol on addressing SD would significantly increase discussing during SD. CONCLUSIONS: This study indicates that GPNs do not discuss SD with chronically ill patients routinely. Insufficient knowledge, training and reasons related to cultural diversity were identified as most important reasons for this practice pattern. Implementation of training in combination with guidelines on SD in the general practice could improve on the discussing of sexual health with chronic patients.

[Touch in the time of corona]. / Aanraken in tijden van corona.

No more shaking hands and keeping your distance to flatten the corona epidemic. The forced distance between doctor and patient in times of corona makes us realize the value of touch in healthcare. The temporary austerity of contacts offers a scope for reflection on the small things that make the difference between care and healing.

Shared decision making seen through the lens of professional identity formation.

The finding in the article by Driever et al.; "Shared decision,making: Physicians' preferred role, usual role and their perception of its key components" of lower preferred and practiced SDM role in residents in favour of a paternalistic role, compared to their more seasoned colleagues deserves more in depth, qualitative research. Because our residents are tomorrows doctors, I would strongly encourage the authors of this insightful article to consider research focused on residents as the next step in their research on SDM and to see this future research through a 'medical-education-PIF-lens'. The multi-level professionalism framework, designed as a framework for reflection and development in medical education might be of help is this future research.

[Health is more than just a number]. / Gezondheid is geen getal.

It has not gone unnoticed: the multidisciplinary guideline 'Cardiovascular Risk Management' has been revised. The various discussions around this guideline, however, appear to reduce it to a cholesterol guideline. Indeed, the target value for LDL (low-density lipoprotein) cholesterol of 1.8 mmol/L in patients under the age of 70 with cardiovascular disease will demand a lot from patients and their general practitioners. Therefore, personally, I have reservations about this guideline. Luckily, the guideline does contain a 'get-out clause' in the form of the sentence "the absolute risk reduction must be weighed against possible disadvantages of daily medication use, the chance of side effects and possible costs", which leaves the door open for pragmatic patient management. One can but hope that these recommended standards stay out of the hands of Pharisees and teachers and are not elevated to becoming mandatory requirements. After all, health is more than just a number, it is a story.

A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity.

The relatively new term "Professional Identity Formation" (PIF) complements behavior-based and attitude-based perspectives on professionalism. Unprofessional behavior and its remediation should also be addressed from this perspective. However, a framework is needed to guide discussion and remediation of unprofessional behavior, which can encompass behavior-based, attitude-based, and identity-based perspectives on professionalism. To this end, the authors propose a multi-level professionalism framework which describes, apart from professional behavior, more levels which influence professional performance: environment, competencies, beliefs, values, identity, and mission. The different levels can provide tools for educators to address and discuss unprofessional behavior with their students in a comprehensive way. By reflecting on all the different levels of the framework, educators guard themselves against narrowing the discussion to either professional behavior or professional identity. The multi-level professionalism framework can help educators and students to gain a better understanding of the root of unprofessional behavior, and of remediation strategies that would be appropriate. For despite the recent emphasis on PIF, unprofessional behavior and its remediation will remain important issues in medical education.

Sleep-Related Painful Erections Following Sexual Intercourse.

Sleep-related painful erections (SRPE) is a rare disorder characterized by recurrent painful nocturnal erections during REM sleep in the absence of pain during daytime erections. Approximately 35 cases of SRPE have been reported in the literature, none of them associated with preceding sexual intercourse. We add the report of a 40-year-old patient with a 6-year history of SRPE which only, but always, occurred after sexual intercourse with ejaculation in the evening before. As a result, the frequency of intercourse diminished, causing relationship problems. A non-pharmacological solution was found in shifting the time of sexual intercourse. The patient refused any proposed pharmacological treatment, because of "not wanting to be a patient at his age."

Causes and characteristics of medical student referrals to a professional behaviour board.

OBJECTIVES: To describe the nature of unprofessional behaviour displayed by medical students, as well as the characteristics of students referred to the professional behaviour board. METHODS: A descriptive mixed methods approach was taken, in which qualitative data on unprofessional behaviour, as well as quantitative data on the demographics of referred students were collected during the study period between June 1, 2009 and January 1, 2014. In order to compare the referred students with the total student population, data on gender, nationality and phase in the curriculum of the total student population, collected from the student administration desk, were also used. RESULTS: In the study period, a total of 107 referrals were reported, concerning 93 different students (3% of the total student population). Sixty-five of the 107 referrals (61%) concerned male students. Thirty referrals (28%) concerned non-Dutch students. Most referrals (71%) occurred during clinical rotations. The referrals were equally distributed over three professional behaviour domains: dealing with oneself, dealing with others, and dealing with tasks/work. 'Withdrawn behaviour' was reported 17 times, 'insufficient Dutch language proficiency' 14 times, 'impertinent emails' 9 times and 'placing privacy-sensitive photos on the internet' 3 times. CONCLUSIONS: Although only a minority of students are referred to a professional behaviour board, this study shows that student characteristics such as gender and nationality may correlate to a higher incidence of unprofessional behaviour. Further explanatory and exploratory research is needed to unravel this relationship, and to study the influence of curriculum reforms on these relationships, respectively.