The reliability of the College of Intensive Care Medicine of Australia and New Zealand "Hot Case" examination.

BACKGROUND: High stakes examinations used to credential trainees for independent specialist practice should be evaluated periodically to ensure defensible decisions are made. This study aims to quantify the College of Intensive Care Medicine of Australia and New Zealand (CICM) Hot Case reliability coefficient and evaluate contributions to variance from candidates, cases and examiners. METHODS: This retrospective, de-identified analysis of CICM examination data used descriptive statistics and generalisability theory to evaluate the reliability of the Hot Case examination component. Decision studies were used to project generalisability coefficients for alternate examination designs. RESULTS: Examination results from 2019 to 2022 included 592 Hot Cases, totalling 1184 individual examiner scores. The mean examiner Hot Case score was 5.17 (standard deviation 1.65). The correlation between candidates' two Hot Case scores was low (0.30). The overall reliability coefficient for the Hot Case component consisting of two cases observed by two separate pairs of examiners was 0.42. Sources of variance included candidate proficiency (25%), case difficulty and case specificity (63.4%), examiner stringency (3.5%) and other error (8.2%). To achieve a reliability coefficient of > 0.8 a candidate would need to perform 11 Hot Cases observed by two examiners. CONCLUSION: The reliability coefficient for the Hot Case component of the CICM second part examination is below the generally accepted value for a high stakes examination. Modifications to case selection and introduction of a clear scoring rubric to mitigate the effects of variation in case difficulty may be helpful. Increasing the number of cases and overall assessment time appears to be the best way to increase the overall reliability. Further research is required to assess the combined reliability of the Hot Case and viva components.

Child participation during outpatient consultations: a mixed methods study.

Although children wish to be included in their own healthcare, they recognize a gap between their right to be heard and their ability to become involved. Despite adaptation of medical consultation styles which suit a more patient-centered approach, data on the current state of child participation in clinical encounters are missing. We aimed to assess actual child participation in a Dutch pediatric clinic. Children aged 4-18 years visiting a pediatric outpatient clinic for consultation after general practitioner's referral were included. Sixteen consultations of six pediatricians were recorded and transcribed verbatim. Quantitative measurement included word count and speech turn; conversation analysis with qualitative appraisal provided data on participatory behavior. Quantitative child participation equaled parent participation in turns (28% vs 29%, respectively), but remained limited in words (relative contribution 11% for child, 23% for parent and 66% for pediatrician). Children spoke on average six words per speech turn. Child age correlated positively with participation in words (p = 0.022, r = 0.566) and turns (p = < 0.001, r = 0.746). Children were mostly involved during social history taking, introduction, and physical examination but did not actively speak during the decision-making process. Children took an active role by instigating talks. Qualitative facilitators included appropriate language and verbal or non-verbal child allocated turns. Adults involved children by asking them questions and verifying their opinions or plans with the child. Teenagers participated most during the entire consultation, while younger children were more likely to lose their focus by the end of the conversation. CONCLUSION: Despite increased turn taking, children's verbal participation remains low in pediatric consultations. If pediatricians and parents maintain a triadic conversation style throughout every stage of the medical encounter, child participation may increase. WHAT IS KNOWN: • Verbal child participation varies between 4 and 17%, measured in turns, words, speech time, or utterances. • Child participation is limited to social talk, laughter, and providing medical information. WHAT IS NEW: • Child speech turns equal parental speech turns (28%), but average relative word count remains low (11%). • Three percent of the children's turns are defined a "contributing in decision making, giving their opinion or give consent," which equals three turns per consultation.

Observational study on the timing and method of interruption by hospital consultants during the opening statement in outpatient consultations.

OBJECTIVE: To analyse verbal interruptions by Dutch hospital consultants during the patient's opening statement in medical encounters. DESIGN: Cross-sectional descriptive study. SETTING: Isala teaching hospital in Zwolle, the Netherlands. PARTICIPANTS: 94 consultations by 27 consultants, video recorded in 2018 and 2019. MAIN OUTCOME MEASURES: Physicians' verbal interruptions during patients' opening statements, rate of completion of patients' opening statements, time to first interruption and the effect of gender, age and physician specialty on the rate and type of physicians' verbal interruptions. RESULTS: Patients were interrupted a median of 9 times per minute during their opening statement, the median time to the first interruption was 6.5 s. Most interruptions (67%) were backchannels (such as 'hm hm' or 'go on'), considered to be encouraging the patient to continue. In 52 consultations (55%), patients could not finish their opening statement due to a floor changing interruption by the consultant. The median time to such an interruption was 31.4 s, on average 20 s shorter than a finished opening statement (p=0.004). Female consultants used more backchannels (median 9, IQR 5-12) than male consultants (median 7, IQR 2-11, p=0.028). CONCLUSIONS: Hospital-based consultants use various ways to interrupt patients during their opening statements. Most of these interruptions are encouraging backchannels. Still, consultants change the conversational floor in more than half of their patients during their opening statements after a median of 31 s.

Simulation-based bronchoscopy training: Randomized trial comparing worked example to video introduction.

INTRODUCTION: Learning the complex skill of bronchoscopy involves the integration of cognitive domains and motor skills. The development of simulators has opened up new possibilities in bronchoscopy training. This study aimed at evaluating how effective the modeling example methodology is in training this skill and assessed its effect on cognitive load in learning. METHODS: Forty-seven medical students participating in a simulator-based bronchoscopy training program were randomly allocated to a control group, receiving a video lesson, and the modeling example group. They were evaluated by the simulator's metrics at different time points: pre-, posttest, and 15 days and 12 months after training. Cognitive load was assessed with the modified Paas scale. RESULTS: Simulation-based training was effective for both groups, based on simulator metrics (p < .05). The modeling example group outperformed the control group in all measures at posttest and after 15 days (p < .001). After 12 months, there was a decline in skill in both groups, but the modeling example group performed better (p < .001). Simulation-based training reduced cognitive load, more strongly so in the modeling example group (p < .001). CONCLUSION: The modeling example group showed substantial benefits over the control group, both in reducing the cognitive load in learning and in retaining knowledge and skill after 15 days and 12 months.

Child participation in triadic medical consultations: A scoping review and summary of promotive interventions.

OBJECTIVES: To promote patient centered care, children with health issues should be supported to participate in consultations with health care professionals. We aimed to summarize, in a scoping review, the evidence on child participation in triadic encounters and its promotive interventions. METHODS: Two researchers systematically searched four major databases, and included studies on child participation in medical consultations. A synthesis of quantitative and qualitative data was made. RESULTS: Of 1678 retrieved records, 39 papers were included: 22 quantitative, 14 qualitative and 3 mixed-methods studies. Child participation, measured by utterances, turns or speech time, ranged between 4% and 14%. Participation increased with age. Equidistant seating arrangements, child-directed gaze and finding the appropriate tone of voice by the physician promoted child participation. Despite all facilitative efforts of doctors and parents, such as social talk, eHealth tools or consultation education, no increase in child participation was observed over the last 50 years. CONCLUSIONS: Children continue to participate only marginally in medical consultations, despite their desire to be involved in various aspects of the clinical encounter and their right to have their voice heard. PRACTICE IMPLICATIONS: Health care professionals should provide more opportunities for children to participate in triadic medical encounters and create an inclusive environment.

A framework to improve quality of hospital-based physiotherapy: a design-based research study.

BACKGROUND: A quality framework for hospital-based physiotherapy is lacking. This study aims to design a framework, building on the currently available literature, to improve the quality of hospital-based physiotherapy. METHODS: A multidisciplinary panel of six representatives of hospital-based physiotherapy and their key stakeholders (patients, medical specialists, hospital management and professional association) was set up. We used brainwriting to sample ideas and the 'decision-matrix' to select the best ideas. RESULTS: The first round of brainwriting with an online panel of six experienced participants yielded consensus on seven possible methods for quality improvement of hospital-based physiotherapy [1]: continuing education [2] ,feedback on patient reported experience measures and patient reported outcome measures [3] ,a quality portfolio [4] ,peer observation and feedback [5] ,360 degree feedback [6] ,a management information system, and [7] intervision with intercollegiate evaluation. Placing these methods in a decision matrix against four criteria (measurability, acceptability, impact, accessibility) resulted in a slight preference for a management information system, with almost equal preference for five other methods immediately thereafter. The least preference was given to a 360-degree feedback. CONCLUSIONS: In the design of a framework for improving the quality of hospital-based physiotherapy, all seven suggested methods were perceived as relevant but differed in terms of advantages and disadvantages. This suggests that, within the framework, a mixture of these methods may be desirable to even out respective advantages and disadvantages.

Endoscopy training in the Netherlands: a national survey among gastroenterology residents.

Background and study aims Training in endoscopy is a key objective of gastroenterology residency. There is currently no standardized or systematic training approach. This study evaluated and compared the current status of gastrointestinal endoscopy training programs in all teaching hospitals in the Netherlands from a resident perspective. Materials and methods A national online survey with open and closed questions on gastrointestinal endoscopy training was administered to all gastroenterology residents (N = 180) in the eight educational regions in the Netherlands. Results One hundred residents who had already started endoscopy training were included in the analyses. Sixty-five residents (65 %) were satisfied with their endoscopy training program. Participation in a preclinical endoscopy course was mandatory in seven of eight educational regions. Residents from the region without a mandatory endoscopy training course were significantly less likely to be satisfied with their endoscopy training program (32 %, P  = .011). Criteria used to determine the level of supervision differed greatly between teaching hospitals (e. g. assessed endoscopy competence, predefined period of time or number of procedures). Only 26 residents (26 %) reported uniformity in teaching methods and styles between different supervising gastroenterologists in their teaching hospital. Conclusions Although most gastroenterology residents were satisfied with the endoscopy training program and endoscopy supervision in their teaching hospital, this study identified considerable local and regional variability. Future studies should be conducted to evaluate the trainers' perspective and trainers' behavior during endoscopy training sessions, which might eventually lead to the development of best practices regarding endoscopy training, including standardization of training programs and supervision methods.

[Feedback in medical education - separate coaching for improvement from summative assessment]. / Feedback in de medische opleiding.

A supervisor's feedback can change a medical learner's behaviour consistently if the learner views the supervisor as a credible role model. A learner's trust in the supervisor is a prerequisite for feedback to contribute to effective learning. In current educational practice, coaching for improvement and summative assessment are frequently mixed, which leads medical learners to experience workplace based assessments as tests and makes them unresponsive to formative feedback. Carefully separating coaching for improvement from summative assessment is required to allow the learner to accept and apply the feedback given by the supervisor. Supervisors should focus their attention to providing formative feedback, not to documenting it. The R2C2 model (rapport - receptivity - content - coaching) is a useful tool to effectively provide constructive formative feedback.

Patient coaching: What do patients want? A mixed methods study in waiting rooms of outpatient clinics.

INTRODUCTION: Effective communication in specialist consultations is difficult for some patients. These patients could benefit from support from a coach who accompanies them to and during medical specialist consultations to improve communication in the consultation room. This study aims to investigate patients' perspective on interest in support from a patient coach, what kind of support they would like to receive and what characterizes an ideal patient coach. METHODS: We applied a mixed method design to obtain a realistic understanding of patients' perspectives on a patient coach. Patients in the waiting rooms of outpatient clinics were asked to fill out a short questionnaire which included questions about demographic characteristics, perceived efficacy in patient-provider interaction and patients' interest in support from a patient coach. Subsequently, patients interested in a patient coach were asked to participate in a semi-structured interview. The quantitative data were examined using univariate analysis and the qualitative interview data were analysed using content analysis. RESULTS: The survey was completed by 154 patients and eight of them were interviewed. Perceived efficacy in patient-physician interactions was the only variable that showed a significant difference between patients with and without an interest in support from a patient coach. The interviews revealed that a bad communication experience was the main reason for having an interest in support from a patient coach. Before the consultation, a patient coach should take the time to get to know the patient, build trust, and help the patient create an agenda, so take the patient seriously and recognize the patient as a whole person. During the consultation, a patient coach should support the patient by intervening and mediating when necessary to elicit the patient's agenda. After the consultation, a patient coach should be able to explain and discuss medical information and treatment consequences. An ideal patient coach should have medical knowledge, a strong personality and good communication skills. CONCLUSION: Especially patients who had a bad communication experience in a specialist consultation would like support from a patient coach. The kind of support they valued most was intervening and mediating during the consultation. To build the necessary trust, patient coaches should take time to get to know the patient and take the patient seriously. Medical knowledge, good communication skills and a strong personality were considered prerequisites for patient coaches to be capable to intervene in specialist consultations.

Hypoallergenicity assessment of an extensively hydrolyzed whey-protein formula in cow's milk allergic infants.

BACKGROUND: Extensively hydrolyzed formulas are recommended for the dietary management of infants with cow's milk allergy (CMA). OBJECTIVES: Hypoallergenicity, growth, and gastrointestinal (GI) tolerability of a new extensively hydrolyzed whey-protein formula (eHWF) in CMA children were assessed. METHODS: In this prospective, randomized, international, multi-center study (Trial NL3889), 34 children with confirmed CMA (74% IgE-mediated) underwent a double-blind, placebo-controlled food challenge (DBPCFC) with an eHWF developed with non-porcine enzymes, supplemented with prebiotic short-chain galacto- and long-chain fructo-oligosaccharides (0.8 g/L, ratio 9:1), arachidonic acid (0.35/100 g), and docosahexaenoic acid (0.35/100 g). If tolerant to the eHWF, children participated in a 7-day open food challenge with this eHWF. Anthropometrics and GI tolerability were assessed in an optional 16-weeks follow-up. RESULTS: Of the 34 children who started the DBPCFC with the eHWF, 25 subjects (19 boys, mean age: 61 weeks, 18 with IgE-mediated CMA) completed the DBPCFC and 7-day open challenge without major protocol deviations and tested negative at both challenges. One child experienced a late moderate eczematous allergic reaction in the optional follow-up period, indicating the need for close monitoring of subjects starting new formula. Weight and length gain followed the World Health Organization growth curves. Changes in frequency and consistency of stools upon test formula intake were transient. CONCLUSIONS: The newly developed eHWF is a suitable option in CMA treatment as all subjects tolerated the product. This result is in line with the international criteria for hypoallergenicity (American Academy of Pediatrics) that state that more than 90% of CMA children must tolerate the formula. Use of the formula is also associated with normal growth curves and GI tolerability. TRIAL REGISTRATION: Trial NL3889, https://www.trialregister.nl/trial/3889.

[Development and validation of a uniform QUality Instrument for ClerKship (QUICK)]. / Hoe meet je de kwaliteit van een coschap?

OBJECTIVE: Because both clerks and medical faculty quality management workers expressed the need for it, we aimed to develop a compact, valid and uniform instrument to assess the quality of Dutch clinical clerkships across all medical faculties in the Netherlands. METHOD: We divided all 249 items from existing published and unpublished clerkship quality instruments into the three essential learning environment domains: content, atmosphere and organisation. In a 3-stage Delphi procedure, the 45 most relevant items from this list were selected that comprehensively covered the three domains. All clinical clerks in the country's northeastern educational region were invited to evaluate their last clerkship using this draft instrument. We used half of these data for item reduction and the other half to validate the final instrument, the QUality Instrument for ClerKships (QUICK). RESULTS: After the Delphi procedure and further item reduction, the QUICK comprises 15 items, 5 in each domain. The internal consistency of the QUICK and each of the three domains was satisfactory (Cronbach's α 0.88, 0.73, 0.84 and 0.67, respectively). The variance of the draft instrument domain scores were explained for >80% by item variance of the final QUICK. A panel of educational experts and medical faculty quality management workers evaluated QUICK's face validity as good. CONCLUSION: The QUICK is a concise and valid instrument to assess the quality of Dutch clinical clerkships. Its repeated use in a quality cycle can contribute to monitoring and ongoing development of the quality of this key phase in the medical education curriculum.

[Observing a resident doing a consultation with a patient: goal determines form]. / Hoe observeer je een aios die een consult doet?

Observation of residents by supervisors is a highly recommended, but underused educational tool in postgraduate medical education. Observation can be performed indirectly (using video recordings of residents performing clinical tasks) or directly (supervisor is present when the resident performs the task). The choice of the observation method depends on aim and context of the observation. In general practice, patients tend to involve the supervisor when the resident performs the consultation. They value such participatory direct observation because they know the supervisor and appreciate their input. For specific residents' learning aims (e.g. consultation efficiency), it may be more useful if the supervisor takes a "fly on the wall" approach. Supervisors wishing to take a "fly on the wall" approach to direct observation need to inform the patient about their role and position themselves outside the patient's field of view. Indirect observation by reviewing video-recorded consultations is an alternative for this purpose.

Shared decision-making in the Netherlands: Progress is made, but not for all. Time to become inclusive to patients.

Dutch initiatives targeting shared decision-making (SDM) are still growing, supported by the government, the Federation of Patients' Organisations, professional bodies and healthcare insurers. The large majority of patients prefers the SDM model. The Dutch are working hard to realise improvement in the application of SDM in daily clinical practice, resulting in glimpses of success with objectified improvement on observed behavior. Nevertheless, the culture shift is still ongoing. Large-scale uptake of SDM behavior is still a challenge. We haven't yet fully reached the patients' needs, given disappointing research data on patients' experiences and professional behavior. In all Dutch implementation projects, early adopters, believers or higher-educated persons have been overrepresented, while patients with limited health literacy have been underrepresented. This is a huge problem as 25% of the Dutch adult population have limited health literacy. To further enhance SDM there are issues to be addressed: We need to make physicians conscious about their limited application of SDM in daily practice, especially regarding preference and decision talk. We need to reward clinicians for the extra work that comes with SDM. We need to be inclusive to patients with limited health literacy, who are less often actually involved in decision-making and at the same time more likely to regret their chosen treatment compared to patients with higher health literacy.

Quality aspects of hospital-based physiotherapy from the perspective of key stakeholders: a qualitative study.

BACKGROUND: For the design of a robust quality system for hospital-based physiotherapy, it is important to know what key stakeholders consider quality to be. OBJECTIVE: To explore key stakeholders' views on quality of hospital-based physiotherapy. METHODS: We conducted 53 semi-structured interviews with 62 representatives of five key stakeholder groups of hospital-based physiotherapy: medical specialists, hospital managers, boards of directors, multidisciplinary colleagues and patients. Audio recordings of these interviews were transcribed verbatim and analysed with thematic analysis. RESULTS: According to the interviewees, quality of hospital-based physiotherapy is characterised by: (1) a human approach, (2) context-specific and up-to-date applicable knowledge and expertise, (3) providing the right care in the right place at the right time, (4) a proactive departmental policy in which added value for the hospital is transparent, (5) professional development and innovation based on a vision on science and developments in healthcare, (6) easy access and awareness of one's own and others' position within the interdisciplinary cooperation and (7) ensuring a continuum of care with the inclusion of preclinical and postclinical care of patients. CONCLUSIONS: Important quality aspects in the perspective of all stakeholders were an expertise that matches the specific pathology of the patient, the hospital-based physiotherapist being a part of the care team, and the support and supervision of all patients concerning physical functioning during the hospitalisation period. Whereas patients mainly mentioned the personal qualities of the physiotherapist, the other stakeholders mainly focused on professional and organisational factors. The results of this study offer opportunities for hospital-based physiotherapy to improve the quality of provided care seen from the perspective of key stakeholders.

Effectiveness of Individual Feedback and Coaching on Shared Decision-making Consultations in Oncology Care: Protocol for a Randomized Clinical Trial.

BACKGROUND: Shared decision-making (SDM) is particularly important in oncology as many treatments involve serious side effects, and treatment decisions involve a trade-off between benefits and risks. However, the implementation of SDM in oncology care is challenging, and clinicians state that it is difficult to apply SDM in their actual workplace. Training clinicians is known to be an effective means of improving SDM but is considered time consuming. OBJECTIVE: This study aims to address the effectiveness of an individual SDM training program using the concept of deliberate practice. METHODS: This multicenter, single-blinded randomized clinical trial will be performed at 12 Dutch hospitals. Clinicians involved in decisions with oncology patients will be invited to participate in the study and allocated to the control or intervention group. All clinicians will record 3 decision-making processes with 3 different oncology patients. Clinicians in the intervention group will receive the following SDM intervention: completing e-learning, reflecting on feedback reports, performing a self-assessment and defining 1 to 3 personal learning questions, and participating in face-to-face coaching. Clinicians in the control group will not receive the SDM intervention until the end of the study. The primary outcome will be the extent to which clinicians involve their patients in the decision-making process, as scored using the Observing Patient Involvement-5 instrument. As secondary outcomes, patients will rate their perceived involvement in decision-making, and the duration of the consultations will be registered. All participating clinicians and their patients will receive information about the study and complete an informed consent form beforehand. RESULTS: This trial was retrospectively registered on August 03, 2021. Approval for the study was obtained from the ethical review board (medical research ethics committee Delft and Leiden, the Netherlands [N20.170]). Recruitment and data collection procedures are ongoing and are expected to be completed by July 2022; we plan to complete data analyses by December 2022. As of February 2022, a total of 12 hospitals have been recruited to participate in the study, and 30 clinicians have started the SDM training program. CONCLUSIONS: This theory-based and blended approach will increase our knowledge of effective and feasible training methods for clinicians in the field of SDM. The intervention will be tailored to the context of individual clinicians and will target the knowledge, attitude, and skills of clinicians. The patients will also be involved in the design and implementation of the study. TRIAL REGISTRATION: Netherlands Trial Registry NL9647; https://www.trialregister.nl/trial/9647. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35543.

Patients' preferred and perceived decision-making roles, and observed patient involvement in videotaped encounters with medical specialists.

OBJECTIVE: To assess how patients prefer and perceive medical decision making, which factors are associated with their preferred and perceived decision-making roles, and whether observed involvement reflects patients' perceived role. METHODS: We asked 781 patients visiting a medical specialist from 18 different disciplines to indicate their preferred and perceived decision-making roles. Patient involvement in videotaped consultations was assessed with the OPTION5 instrument. RESULTS: Most patients preferred and perceived decision making as shared (SDM; 58% and 43%, respectively), followed by paternalistic (26% and 38%), and informative (16% and 15%). A large minority (n = 103, 21%) of patients preferring shared or informative decision making (n = 482) experienced paternalistic decision making. Mean (SD) OPTION5 scores were highest in consultations which patients perceived as informative (26.0 (19.7)), followed by shared (19.1 (17.2)) and lowest in paternalistic decision making (11.8 (13.4) p < 0.001). CONCLUSIONS: Most patients want to be involved in decision making. Patients perceive that the physician makes the decision more often than they prefer, and perceive more involvement in the decision than objective assessment by an independent researcher shows. PRACTICE IMPLICATIONS: A clearer understanding of patients' medical decision-making experiences is needed to optimize physician SDM training programmes and patient awareness campaigns.

Shared decision making, patient-centered communication and patient satisfaction - A cross-sectional analysis.

OBJECTIVES: The integration of shared decision making (SDM) and patient-centered communication (PCC) is needed to actively involve patients in decision making. This study examined the relationship between shared decision making and patient-centered communication. METHODS: In 82 videotaped hospital outpatient consultations by 41 medical specialists from 18 disciplines, we assessed the extent of shared decision making by the OPTION5 score and patient-centered communication by the Four Habits Coding Scheme (4HCS), and analyzed the occurrence of a high versus low degree (above or below median) of SDM and/or PCC, and its relation to patient satisfaction scores. RESULTS: In comparison to earlier studies, we observed comparable 4HCS scores and relatively low OPTION5 scores. The correlation between the two was weak (r = 0.29, p = 0.009). In 38% of consultations, we observed a combination of high SDM and low PCC scores or vice versa. The combination of a high SDM and high PCC, which was observed in 23% of consultations, was associated with significantly higher patient satisfaction scores. CONCLUSION: Shared decision making and patient-centered communication are not synonymous and do not always co-exist. PRACTICE IMPLICATIONS: The value of integrated training of shared decision making and patient-centered communication should be further explored.

Association between allergen component sensitisation and clinical allergic disease in children.

BACKGROUND: Allergen component sensitisation testing is becoming increasingly important in the diagnosis of peanut allergy. The aim of the present study was to evaluate the relationship between sensitisation and symptoms of allergic disease in children by testing a large panel of inhalants, food allergens, and allergen components. METHODS: For 287 children visiting our laboratory for allergy testing, symptoms of allergic disease were recorded by standardised validated questionnaires. Specific IgE to 11 whole allergens was assessed by ImmunoCAP, and to 112 allergen components by ISAC ImmunoCAP assay. We used latent class analysis (LCA) to distinguish clinical phenotypes. RESULTS: Inhalant and food allergen sensitisation was common, irrespective of the children's allergic symptom type. Less than 10% of the variance in symptom scores was explained by variations in the number of allergens (components) that the child was sensitised to. In LCA, 135 children (50.2%) had mild allergy, with few symptoms and sensitisation to no or few allergens, 74 children (27.5%) had more symptoms and sensitisation to inhalant allergens (respiratory allergy) and 60 children (22.3%) showed polysensitisation to a median of six allergens and had more severe symptoms of different organ systems. Adding allergen component test results to LCA failed to result in identifiable classes of allergic disease in children. CONCLUSIONS: In this group of children with allergic symptoms, referred for allergy testing by their physician, broad screening for allergen component sensitisation did not contribute to distinguishing phenotypes of allergic disease.

Why do medical residents prefer paternalistic decision making? An interview study.

BACKGROUND: Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice remains limited. We previously showed that residents more often prefer paternalistic decision making than their supervisors. Because both the views of residents on the decision-making process in medical consultations and the reasons for their 'paternalism preference' are unknown, this study explored residents' views on the decision-making process in medical encounters and the factors affecting it. METHODS: We interviewed 12 residents from various specialties at a large Dutch teaching hospital in 2019-2020, exploring how they involved patients in decisions. All participating residents provided written informed consent. Data analysis occurred concurrently with data collection in an iterative process informing adaptations to the interview topic guide when deemed necessary. Constant comparative analysis was used to develop themes. We ceased data collection when information sufficiency was achieved. RESULTS: Participants described how active engagement of patients in discussing options and decision making was influenced by contextual factors (patient characteristics, logistical factors such as available time, and supervisors' recommendations) and by limitations in their medical and shared decision-making knowledge. The residents' decision-making behavior appeared strongly affected by their conviction that they are responsible for arriving at the correct diagnosis and providing the best evidence-based treatment. They described shared decision making as the process of patients consenting with physician-recommended treatment or patients choosing their preferred option when no best evidence-based option was available. CONCLUSIONS: Residents' decision making appears to be affected by contextual factors, their medical knowledge, their knowledge about SDM, and by their beliefs and convictions about their professional responsibilities as a doctor, ensuring that patients receive the best possible evidence-based treatment. They confuse SDM with acquiring informed consent with the physician's treatment recommendations and with letting patients decide which treatment they prefer in case no evidence based guideline recommendation is available. Teaching SDM to residents should not only include skills training, but also target residents' perceptions and convictions regarding their role in the decision-making process in consultations.