Impact of an online learning by concordance program on reflection.

BACKGROUND: Learning by concordance (LbC) is a recent approach that introduces learners to the complexity and uncertainty of clinical practice. Some data on LbC suggest that it stimulates reflection in future clinicians. We developed an online LbC training program on electrocardiogram (ECG) interpretation in general practice at the University of Strasbourg, France, and conducted an exploratory qualitative study to document the impact of this ECG learning-by-concordance training program on reflection in participants. METHODS: We created 18 clinical vignettes on ECG interpretation based on a review of the literature on frequent and serious cardiovascular diseases that can be identified using an ECG in general practice. The training program was delivered online to postgraduate general practice students in two faculties of medicine. We conducted a qualitative study based on thematic analysis of two focus groups and six individual interviews. Inductive and deductive coding were performed. The five major components of reflection in the Nguyen model were used in the deductive coding: (i) thoughts and actions, (ii) attentive, critical, exploratory, and iterative processes (ACEI), (iii) underlying conceptual frame, (iv) change and (v) self. RESULTS: Two focus groups and six individual interviews were conducted. The qualitative analysis indicated 203 codes in the focus groups and 206 codes in the individual interviews, which were divided into five groups based on the components of reflection in the Nguyen model: (i) the self; (ii) attentive, critical, exploratory, and iterative interactions with (iii) one's thoughts and actions; and (iv) a view on both the change itself and (v) the underlying conceptual frame. Inductive coding revealed interesting insights into the impact of the identity of the panel members, the absence of a scoring system and the question of uncertainty in ECG reading. CONCLUSIONS: This study supports the claim that the use of LbC in the context of ECG interpretation could foster reflection in future general practitioners. We discuss future research avenues on instructional design of LbC and reflection.

Should we add patients in concordance of judgment learning tool panels? - An analysis between patients and primary care physicians.

INTRODUCTION: The Concordance of Judgment Learning Tool (CJLT) has been developed for distance asynchronous learning of professionalism in health sciences education. The learning of professionalism is induced by a student's comparison of their own responses with those of the panel members. Whilst CJLT programs typically include same profession experts in their panels, we believe that they could also include patients. Accordingly, we conducted a study aimed at comparing CJLT response patterns between two groups of primary care physicians (PCPs) and patients. METHODS: We conducted a mixed prospective study of responses to a CJLT program based on a group of PCPs and a group of patients: an analysis of the response patterns of the two groups and a qualitative analysis of justifications. RESULTS: A total of 110 participants were included in the study: 70 patients and 40 PCPs. We found a significant difference in response patterns between the PCP and patient groups for nine of the fifteen questions (60%). The qualitative analysis of justifications between groups allowed us to comprehend patients' views on the professionalism of PCPs. CONCLUSIONS: Including patients in CJLT panels can enrich the feedback offered to students in these online training programs.

Does burnout affect clinical reasoning? An observational study among residents in general practice.

BACKGROUND: Burnout results from excessive demands at work. Caregivers suffering from burnout show a state of emotional exhaustion, leading them to distance themselves from their patients and to become less efficient in their work. While some studies have shown a negative impact of burnout on physicians' clinical reasoning, others have failed to demonstrate any such impacts. To better understand the link between clinical reasoning and burnout, we carried out a study looking for an association between burnout and clinical reasoning in a population of general practice residents. METHODS: We conducted a cross-sectional observational study among residents in general practice in 2017 and 2019. Clinical reasoning performance was assessed using a script concordance test (SCT). The Maslach Burnout Inventory for Human Services Survey (MBI-HSS) was used to determine burnout status in both original standards of Maslach's burnout inventory manual (conventional approach) and when individuals reported high emotional exhaustion in combination with high depersonalization or low personal accomplishment compared to a norm group ("emotional exhaustion +1" approach). RESULTS: One hundred ninety-nine residents were included. The participants' mean SCT score was 76.44% (95% CI: 75.77-77.10). In the conventional approach, 126 residents (63.31%) had no burnout, 37 (18.59%) had mild burnout, 23 (11.56%) had moderate burnout, and 13 (6.53%) had severe burnout. In the "exhaustion + 1" approach, 38 residents had a burnout status (19.10%). We found no significant correlation between burnout status and SCT scores either for conventional or "exhaustion + 1" approaches. CONCLUSIONS: Our data seem to indicate that burnout status has no significant impact on clinical reasoning. However, one speculation is that SCT mostly examines the clinical reasoning process's analytical dimension, whereas emotions are conventionally associated with the intuitive dimension. We think future research might aim to explore the impact of burnout on intuitive clinical reasoning processes.

Treatment of nocturnal leg cramps by primary care patients over the age of 60.

Background: Approximately one out of two individuals over the age of 60 suffers from nocturnal leg cramps. These often have an important impact on the person's quality of life. Different drug and non-drug treatments are proposed to treat these cramps, but none to date have been shown to be both safe and effective. The objective of this study was to describe the drug and non-drug treatments used by primary care patients suffering from cramps. Methods: We used data collected as part of two cross-sectional surveys of patients aged 60 years and older attending general practices in the French region of Alsace. We asked the participants suffering from cramps if they were currently using a treatment for their cramps. We distinguished potentially harmful from unharmful treatments. Results: Overall, 632 patients suffering from cramps were included in our study. Only 133 patients (19.5%) were taking a treatment for cramps. 82 patients used one or several of 17 different drug treatments. 58 patients used one or several of 13 different types of non-drug treatments. Potentially harmful treatments, mostly Quinine made up 16,7% (n = 25) of all treatments used for cramps. Conclusions: This study sheds light on the great diversity of therapeutic practices for cramps in outpatient care. Many of the treatments reported by patients have not previously been described in the medical literature. We recommend GPs to ask their patients about the treatments they take for cramps in order to make sure that they are safe.

How do general practice residents use social networking sites in asynchronous distance learning?

BACKGROUND: Blended learning environments - involving both face-to-face and remote interactions - make it easier to adapt learning programs to constraints such as residents' location and low teacher-student ratio. Social networking sites (SNS) such as Facebook®, while not originally intended to be used as learning environments, may be adapted for the distance-learning part of training programs. The purpose of our study was to explore the use of SNS for asynchronous distance learning in a blended learning environment as well as its influence on learners' face-to-face interactions. METHODS: We conducted a qualitative study and carried out semi-structured interviews. We performed purposeful sampling for maximal variation to include eight general practice residents in 2(nd) and 3(rd) year training. A thematic analysis was performed. RESULTS: The social integration of SNS facilitates the engagement of users in their learning tasks. This may also stimulate students' interactions and group cohesion when members meet up in person. CONCLUSIONS: Most of the general practice residents who work in the blended learning environment we studied had a positive appraisal on their use of SNS. In particular, we report a positive impact on their engagement in learning and their participation in discussions during face-to-face instruction. Further studies are needed in order to evaluate the effectiveness of SNS in blended learning environments and the appropriation of SNS by teachers.

Acute low back pain management in primary care: a simulated patient approach.

BACKGROUND: Recent medical guidelines for acute low back pain (aLBP) are unevenly followed. Based on financial criteria or associated with a desirability bias, studies incompletely describe the actual management provided by general practitioners (GPs) in terms of diagnosis, treatment and prevention of progression towards chronicity. OBJECTIVE: To compare actual practices of French GPs for aLBP management with clinical guidelines. METHODS: A young simulated patient (SP) consulted, using a single scenario of aLBP, in 30 primary care practices in the Paris region. RESULTS: Heterogeneous data were collected according to the grid items: during the questioning, 29 GPs (97%) asked for age and 1 GP (3%) for pregnancy; during the clinical examination, 21 GPs (70%) asked for spinal stiffness and 3 GPs (10%) for cauda equina syndrome. Non-steroidal anti-inflammatory drugs were prescribed by 27 GPs (90%). Imaging (2 GPs or 7%) and physiotherapy (3 GPs or 10%) was rarely prescribed. A sick leave was prescribed by 22 GPs (73%). Twenty-seven GPs (90%) reassured the patient. CONCLUSION: aLBP management was in line with international guidelines in terms of clinical examination, physiotherapy and imaging prescriptions and some risk factors for chronicity were taken into account. However, patient questioning was brief, and drug and sick leave prescriptions did not meet international guidelines. The SP approach seems to be a useful tool for assessing actual GP practices.