Measuring health insurance literacy in the Netherlands - First results of the HILM-NL questionnaire.

BACKGROUND: There are several indications that citizens in the Netherlands struggle to make critical, well-considered decisions about which insurance policy best fits their needs and preferences. This can lead to citizens being sub-optimally insured, facing unexpected costs or suffering inadequate coverage. This study aims to examine how health insurance literacy (HIL) is distributed among citizens in the Netherlands; and to find out whether there are certain groups who have more difficulty choosing and using a health insurance policy. METHODS: We measured health insurance literacy using the HILM-NL questionnaire, the validated Dutch version of the original health insurance literacy measure (HILM). In February 2020, the HILM-NL was sent to 1,500 members of the Nivel Dutch Health Care Consumer Panel. The response rate was 54% (806). RESULTS: There is a wide variation in HIL among citizens in the Netherlands. The average total HILM-NL score is 55.14 (on a range of 21-84). The level of education and the household net income are significantly related to HIL. CONCLUSIONS: Citizens who completed less education or earn a lower income are relatively more likely to have difficulty choosing a health insurance policy or using policy benefits to pay for health services once enrolled. It is important to support these vulnerable groups properly in their choice and use of a health insurance policy.

The Importance of Choosing a Health Insurance Policy and the Ability to Comprehend That Choice for Citizens in the Netherlands.

BACKGROUND: In a health insurance system based on managed competition, such as in the Netherlands, it is important that all citizens can make well-informed decisions on which policy fits their needs and preferences best. However, partly due to the large variety of health insurance policies, there are indications that a significant group of citizens do not make rational decisions when choosing a policy. OBJECTIVE: This study aimed to provide more insight into (1) how important it is for citizens in the Netherlands to choose a health insurance policy and (2) how easy it is for them to comprehend the information they receive. METHODS: Data were collected by sending a survey to members of the Nivel Dutch Health Care Consumer Panel in February 2017. The response rate was 44% (N = 659). KEY RESULTS: Our results indicate that citizens in the Netherlands acknowledge the importance of choosing a health insurance policy, but they also point out that it is difficult to comprehend health insurance information. CONCLUSION: Our findings suggest that a section of the citizens do not have the appropriate skills to decide which insurance policy best fits their needs and preferences. Having better insight into their level of health insurance literacy is an important step in the process of evaluating the extent to which citizens can fulfill their role in the health insurance system. Our results suggest that it is important to better tailor information on health insurances to the specific needs and skills of the individual. By doing this, citizens will be better supported in making well-informed decisions regarding health insurance policies, which should have a positive effect on the functioning of the Dutch health insurance system. [HLRP: Health Literacy Research and Practice. 2021;5(4):e287-e294.] Plain Language Summary: The number of health insurance policy options to choose from is extensive in the Netherlands. This study explored to what extent citizens in the Netherlands find it important to choose a health insurance policy, and to what extent they comprehend the information they receive. The data were collected in 2017 using the Nivel Dutch Health Care Consumer Panel.

Development of Comprehensible Prescription Label Instructions: A Study Protocol for a Mixed-Methods Approach.

INTRODUCTION: Patients receive information about their medication from different sources, including prescription labels. These labels are physically attached to each package dispensed to patients and contain the most important instructions on how to use the medication correctly. However, many patients experience difficulties in understanding and applying the instructions on these labels correctly, especially patients with limited health literacy. The aim of this study is to investigate the comprehensibility of prescription label instructions among patients with adequate and limited health literacy skills, and to implement improvements in primary health care. METHODS: We used a mixed-methods approach, which consisted of four phases. Phase 1 (desk research) was divided into a systematic literature review on the comprehensibility of prescription label instructions (1a) and a content analysis of the textual elements in Dutch prescription label instructions (1b). In phase 2 (patient studies), semi-structured interviews were conducted to investigate the comprehensibility of seven prescription labels among patients with different health literacy skills (2a), and a quantitative study in which the comprehensibility of six optimized prescription labels was compared among patients with different health literacy skills (2b). Patient studies were conducted in eight Dutch pharmacies. In phase 3 optimized prescription label instructions were implemented in national medication databases which has been supported by a guideline (3a), and education of pharmacy workers (3b). Phase 4 consists of evaluating the optimized prescription label instructions by experiences from patients and pharmacists. ANTICIPATED RESULTS: This mixed-methods approach will result in scientific publications of the individual studies, and a guideline on how to compose comprehensible prescription label instructions to be put on medication packages. Optimized prescription label instructions will be implemented in national medication databases. DISCUSSION: This protocol describes a mixed-method research to compose and implement comprehensible prescription label instructions and will lead to knowledge about the comprehensibility of textual elements in these labels, with specific attention for patients with limited health literacy. Implementation of optimized prescription label instructions will lead to a better understanding of them, which may contribute to improved medication adherence. A limitation is that non-textual aspects of prescription labels are not investigated.

Recognizing and Addressing Limited PHarmaceutical literacy: Development of the RALPH interview guide.

BACKGROUND: In the context of medication use, pharmaceutical literacy skills are crucial for appropriate and safe use of medication. Recognition of patients with inadequate pharmaceutical literacy in daily pharmacy practice is difficult. No instrument is yet available to support pharmacists herein. The aim of this study was therefore to develop an interview guide for pharmacists to Recognize and Address Limited PHarmaceutical literacy (RALPH). METHODS: The RALPH interview guide was constructed in three phases: (1) development including a literature search, expert group discussion, and feasibility test with 15 patients; (2) pilot-test with 421 patients throughout 30 community pharmacies, and (3) final test with 508 patients to optimize the interview guide. RESULTS: The development phase resulted in a first interview guide comprising 15 questions: seven in the functional domain (understanding instructions), four in the communicative domain (finding and understanding medication information) and four in the critical domain (critically analyzing medication information). This version was pilot-tested in 30 pharmacies, with 147 patients during medication reviews and another 274 patients were interviewed while waiting to collect their medication. This test phase led to removal of questions that proved difficult to interpret and to rephrasing some questions. The second version including 11 questions was tested by 109 pharmacists trainees with 508 patients, resulting in the final RALPH interview guide comprising 10 questions, all directly linked to the patient's own medication: three in the functional, three in the communicative and four in the critical domain. Besides instructions on how to use the interview guide, recommendations are provided for pharmacists on how to support patients with limited pharmaceutical literacy skills. CONCLUSIONS: The practice-based RALPH interview guide supports pharmacists in recognizing patients with limited pharmaceutical literacy. With this insight, pharmacists can tailor their medication counseling to patients' pharmaceutical literacy level to better support patients in their medication use.

Health literacy and primary health care use of ethnic minorities in the Netherlands.

BACKGROUND: In the Netherlands, ethnic minority populations visit their general practitioner (GP) more often than the indigenous population. An explanation for this association is lacking. Recently, health literacy is suggested as a possible explaining mechanism. Internationally, associations between health literacy and health care use, and between ethnicity and health literacy have been studied separately, but, so far, have not been linked to each other. In the Netherlands, some expectations have been expressed with regard to supposed low health literacy of ethnic minority groups, however, no empirical study has been done so far. The objectives of this study are therefore to acquire insight into the level of health literacy of ethnic minorities in the Netherlands and to examine whether the relationship between ethnicity and health care use can be (partly) explained by health literacy. METHODS: A questionnaire was sent to a sample of 2.116 members of the Dutch Health Care Consumer Panel (response rate 46%, 89 respondents of non-western origin). Health literacy was measured with the Health Literacy Questionnaire (HLQ) which covers nine different domains. The health literacy levels of ethnic minority groups were compared to the indigenous population. A negative binomial regression model was used to estimate the association between ethnicity and GP visits. To examine whether health literacy is an explaining factor in this association, health literacy and interaction terms of health literacy and ethnicity were added into the model. RESULTS: Differences in levels of health literacy were only found between the Turkish population and the indigenous Dutch population. This study also found an association between ethnicity and GP visits. Ethnic minorities visit their GP 33% more often than the indigenous population. Three domains of the HLQ (the ability to navigate the health care system, the ability to find information and to read and understand health information) partly explained the association between ethnicity and GP visits. CONCLUSIONS: In general, there are no differences in health literacy between most of the ethnic minority groups in the Netherlands and the indigenous Dutch population. Only the Turkish population scored significantly lower on several health literacy domains. Some domains of health literacy do explain the association between ethnicity and higher frequency of GP visits. Further research is recommended to understand the pathways through which health literacy impacts health care use.

What role does health literacy play in patients' involvement in medical decision-making?

Patients vary in their preferences towards involvement in medical decision-making. Previous research, however, gives no clear explanation for this observed variation in their involvement. One possible explanation might be health literacy. Health literacy refers to personal characteristics and social resources needed for people to access, understand and use information to make decisions about their health. This study aimed to examine the relationship between health literacy and self-reported patient involvement. With respect to health literacy, we focused on those competences relevant for medical decision-making. We hypothesized that people with higher health literacy report that they are more involved in medical decision-making. A structured questionnaire was sent to members of the Dutch Health Care Consumer Panel in May 2015 (response 46%, N = 974). Health literacy was measured using five scales of the Health Literacy Questionnaire. A regression model was used to estimate the relationship between health literacy and self-reported involvement. In general, our results did not show a relationship between health literacy and self-reported involvement. We did find a positive significant association between the health literacy scale appraisal of health information and self-reported involvement. Our hypothesis was partly confirmed. The results from this study suggest that higher order competences, that is to say critical health literacy, in particular, are important in reporting involvement in medical decision-making. Future research is recommended to unravel further the relationship between health literacy and patient involvement in order to gain insight into whether health literacy might be an asset to enhance patient participation in medical decision-making.

Determinants of the intention to use e-Health by community dwelling older people.

BACKGROUND: In the future, an increasing number of elderly people will be asked to accept care delivered through the Internet. For example, health-care professionals can provide treatment or support via telecare. But do elderly people intend to use such so-called e-Health applications? The objective of this study is to gain insight into the intention of older people, i.e. the elderly of the future, to use e-Health applications. Using elements of the Unified Theory of Acceptance and Use of Technology (UTAUT), we hypothesized that their intention is related to the belief that e-Health will help (performance expectancy), the perceived ease of use (effort expectancy), the beliefs of important others (social influence), and the self-efficacy concerning Internet usage. METHODS: A pre-structured questionnaire was completed by 1014 people aged between 57 and 77 (response 67%). The hypothesized relationships were tested using nested linear regression analyses. RESULTS: If offered an e-Health application in the future, 63.1% of the respondents would definitely or probably use it. In general, people with a lower level of education had less intention of using e-Health. The majority of respondents perceived e-Health as easy to use (60.8%) and easy to learn (68.4%), items that constitute the scale for effort expectancy. Items in the performance expectancy scale generally scored lower: 45.8% perceived e-Health as useful and 38.2% perceived it as a pleasant way to interact. The tested model showed that expected performance and effort were highly related to intention to use e-Health. In addition, self-efficacy was related to intention to use while social influence was not. CONCLUSIONS: Acceptance of e-Health can be increased by informing people about the potential benefits of e-Health and letting them practice with the application. Special attention should be paid to people with less education and people who have not used the Internet before.

The Net Promoter Score--an asset to patient experience surveys?

BACKGROUND: In the search for more straightforward ways of summarizing patient experiences and satisfaction, there is growing interest in the Net Promoter Score (NPS): How likely is it that you would recommend our company to a friend or colleague? OBJECTIVE: To assess what the NPS adds to patient experience surveys. The NPS was tested against three other constructs already used in current surveys to summarize patient experiences and satisfaction: global ratings, recommendation questions and overall scores calculated from patient experiences. To establish whether the NPS is a valid measure for summarizing patient experiences, its association with these experiences should be assessed. METHODS: Associations between the NPS and the three other constructs were assessed and their distributions were compared. Also, the association between the NPS and patient experiences was assessed. Data were used from patient surveys of inpatient hospital care (N = 6018) and outpatient hospital care (N = 10 902) in six Dutch hospitals. RESULTS: Analyses showed that the NPS was moderately to strongly correlated with the other three constructs. However, their distributions proved distinctly different. Furthermore, the patient experiences from the surveys showed weaker associations with the NPS than with the global rating and the overall score. CONCLUSIONS: Because of the limited extent to which the NPS reflects the survey results, it seems less valid as a summary of patient experiences than a global rating, the existing recommendation question or an overall score calculated from patient experiences. In short, it is still unclear what the NPS specifically adds to patient experience surveys.

Patient experiences of inpatient hospital care: a department matter and a hospital matter.

OBJECTIVE: To examine the added value of measuring and possibly presenting patient experiences at the department level, in addition to the hospital level, and to explore the possibility that patient experiences differ according to the 'type' of hospital department. DESIGN: Secondary analysis of data from a widely used survey on patient experiences of Dutch inpatient hospital care [Consumer Quality Index (CQI) Inpatient Hospital Care]. SETTING: Inpatient hospital care experience survey of patients of 78 Dutch hospitals. PARTICIPANTS: A total of 15 171 randomly selected inpatients from 78 Dutch hospitals, who had at least one night of hospitalization between October 2006 and October 2007. MAIN OUTCOME MEASURES: Explained variance in patient experiences at the department level, compared with the explained variance at the hospital level. Significant differences in patient experiences between types of departments, expressed in regression coefficients. Patient experiences were measured using validated quality indicators, calculated from specific survey items. RESULTS: Adding the department level to the analyses of patient experiences is statistically worthwhile for a number of quality indicators of the CQI Inpatient Hospital Care, and will enable the presentation of more detailed results within hospitals. Furthermore, the results indicated that there are some systematic differences in patient experiences between specific types of hospital departments across hospitals. However, the proportion of variance in experiences explained by both department and hospital is limited (max. 14%). CONCLUSIONS: Analyses of quality information on patient experiences of inpatient hospital care should not only take the hospital level, but also at the more specific department level into account.

Are patients' preferences regarding the place of treatment heard and addressed at the point of referral: an exploratory study based on observations of GP-patient consultations.

BACKGROUND: Today, in several north-western European countries, patients are encouraged to choose, actively, a healthcare provider. However, patients often visit the provider that is recommended by their general practitioner (GP). The introduction of patient choice requires GPs to support patients to be involved, actively, in the choice of a healthcare provider. We aim to investigate whether policy on patient choice is reflected in practice, i.e. what the role of the patient is in their choices of healthcare providers at the point of referral and to what extent GPs' and patients' healthcare paths influence the role that patients play in the referral decision. METHODS: In 2007-2008, we videotaped Dutch GP-patient consultations. For this study, we selected, at random, 72 videotaped consultations between 72 patients and 39 GPs in which the patient was referred to a healthcare provider. These were analysed using an observation protocol developed by the researchers. RESULTS: The majority of the patients had little or no input into the choice of a healthcare provider at the point of referral by their GP. Their GPs did not support them in actively choosing a provider and the patients often agreed with the provider that the GP proposed. Patients who were referred for diagnostic purposes seem to have had even less input into their choice of a provider than patients who were referred for treatment. CONCLUSIONS: We found that the GP chooses a healthcare provider on behalf of the patient in most consultations, even though policy on patient choice expects from patients that they choose, actively, a provider. On the one hand, this could indicate that the policy needs adjustments. On the other hand, adjustments may be needed to practice. For instance, GPs could help patients to make an active choice of provider. However, certain patients prefer to let their GP decide as their agent. Even then, GPs need to know patients' preferences, because in a principal-agent relationship, it is necessary that the agent is fully informed about the principal's preferences.

Overall scores as an alternative to global ratings in patient experience surveys; a comparison of four methods.

BACKGROUND: Global ratings of healthcare by patients are a popular way of summarizing patients' experiences. Summary scores can be used for comparing healthcare provider performance and provider rankings. As an alternative, overall scores from actual patient experiences can be constructed as summary scores. This paper addresses the statistical and practical characteristics of overall scores as an alternative to a global rating in summarizing patient survey results. METHODS: Data from a 2010 patient experience survey for approximately 12,000 nursing home residents (7.5% of all Dutch nursing home residents at the time) from 464 nursing homes in the Netherlands (25% of the Dutch nursing homes) was used. Data was collected through specifically designed standardized interview surveys. The respondents' scores for 15 established quality indicators (or composites) for nursing home care were used to calculate overall scores for each nursing home, using four different strategies. The characteristics of the overall scores were compared against each other and with the respondents' global rating. RESULTS: The individual indicators showed stronger associations with each of the four overall strategies than with the global ratings. Furthermore, the dispersion of the overall scores across nursing homes was greater. Differences between overall scores appeared limited. CONCLUSIONS: Overall scores proved more valid than global ratings as a summary of the indicator scores, and also showed more pronounced differences between nursing homes. Because of the limited statistical differences between the strategies, and for practical reasons, a straightforward averaging of quality indicator scores may be preferred as an overall score.

Comparing the outcome of two different procedures to handle complaints from a patient's perspective.

AIM OF THE STUDY: To assess differences in patient satisfaction between a complaints procedure designed towards the needs of complainants (referred to here as the 'Committee') and a procedure that primarily aims at improving the professional quality of health care (referred to here as the 'Board'). METHOD: Patients' experiences and satisfaction were assessed through a questionnaire completed by 80 patients complaining to a Board and 335 to a complaints Committee. Only complainants with a complaint that was judged to be founded or partially founded were included. RESULTS: Only half of the complainants reported being satisfied with the procedure they underwent. After controlling for differences in respondent characteristics, satisfaction with the Board was higher than with the Committee. The level of variance explained, however, was low (3%). The majority of respondents reported favourably on procedural aspects, for example, the impartiality of the procedure, and empathy demonstrated for their situation. Only a minority of complainants in both procedures believed that changes would be made as a result of their complaint. DISCUSSION: The absence, in the eyes of most complainants, of tangible results of filing a complaint in both rather formal procedures may serve as an explanation for both the low level of overall satisfaction and the fact that the procedure which was developed specifically for patients did not perform better. To resolve the problem of low satisfaction with complaints handling, procedures should be developed that offer a basic degree of procedural safety. But this procedural safety should not stand in the way of what complainants really want: changes for the better.

Improving cancer patient care: development of a generic cancer consumer quality index questionnaire for cancer patients.

BACKGROUND: To develop a Consumer Quality Index (CQI) Cancer Care questionnaire for measuring experiences with hospital care of patients with different types of cancer. METHODS: We derived quality aspects from focus group discussions, existing questionnaires and literature. We developed an experience questionnaire and sent it to 1,498 Dutch cancer patients. Another questionnaire measuring the importance of the quality aspects was sent to 600 cancer patients. Data were psychometrically analysed. RESULTS: The response to the experience questionnaire was 50 percent. Psychometric analysis revealed 12 reliable scales. Patients rated rapid and adequate referral, rapid start of the treatment after diagnosis, enough information and confidence in the healthcare professionals as most important themes. Hospitals received high scores for skills and cooperation of healthcare professionals and a patient-centered approach by doctors; and low scores for psychosocial guidance and information at completion of the treatment. CONCLUSIONS: The CQI Cancer Care questionnaire is a valuable tool for the evaluation of the quality of cancer care from the patient's perspective. Large scale implementation is necessary to determine the discriminatory powers of the questionnaire and may enable healthcare providers to improve the quality of cancer care. Preliminary results indicate that hospitals could improve their psychosocial guidance and information provision.

Free choice of healthcare providers in the Netherlands is both a goal in itself and a precondition: modelling the policy assumptions underlying the promotion of patient choice through documentary analysis and interviews.

BACKGROUND: In the Netherlands in 2006, a health insurance system reform took place in which regulated competition between insurers and providers is key. In this context, the government placed greater emphasis on patients being able to choose health insurers and providers as a precondition for competition. Patient choice became an instrument instead of solely a goal in itself. In the current study, we investigated the concept of 'patient choice' of healthcare providers, as postulated in the supporting documentation for this reform, because we wanted to try to understand the assumptions policy makers had regarding patient choice of healthcare providers. METHODS: We searched policy documents for assumptions made by policy makers about patient choice of healthcare providers that underlie the health insurance system reform. Additionally, we held interviews with people who were involved in or closely followed the reform. RESULTS: Our study shows that the government paid much more attention to the instrumental goal of patient choice. Patients are assumed to be able to choose a provider rationally if a number of conditions are satisfied, e.g. the availability of enough comparative information. To help ensure those conditions were met, the Dutch government and other parties implemented a variety of supporting instruments. CONCLUSIONS: Various instruments have been put in place to ensure that patients can act as consumers on the healthcare market. Much less attention has been paid to the willingness and ability of patients to choose, i.e. choice as a value. There was also relatively little attention paid to the consequences on equity of outcomes if some patient groups are less inclined or able to choose actively.

Determinants of patient choice of healthcare providers: a scoping review.

BACKGROUND: In several northwest European countries, a demand-driven healthcare system has been implemented that stresses the importance of patient healthcare provider choice. In this study, we are conducting a scoping review aiming to map out what is known about the determinants of patient choice of a wide range of healthcare providers. As far as we know, not many studies are currently available that attempt to draw a general picture of how patients choose a healthcare provider and of the status of research on this subject. This study is therefore a valuable contribution to the growing amount of literature about patient choice. METHODS: We carried out a specific type of literature review known as a scoping review. Scoping reviews try to examine the breadth of knowledge that is available about a particular topic and therefore do not make selections or apply quality constraints. Firstly, we defined our research questions and searched the literature in Embase, Medline and PubMed. Secondly, we selected the literature, and finally we analysed and summarized the information. RESULTS: Our review shows that patients' choices are determined by a complex interplay between patient and provider characteristics. A variety of patient characteristics determines whether patients make choices, are willing and able to choose, and how they choose. Patients take account of a variety of structural, process and outcome characteristics of providers, differing in the relative importance they attach to these characteristics. CONCLUSIONS: There is no such thing as the typical patient: different patients make different choices in different situations. Comparative information seems to have a relatively limited influence on the choices made by many patients and patients base their decisions on a variety of provider characteristics instead of solely on outcome characteristics. The assumptions made in health policy about patient choice may therefore be an oversimplification of reality. Several knowledge gaps were identified that need follow-up research.

Different patient subgroup, different ranking? Which quality indicators do patients find important when choosing a hospital for hip- or knee arthroplasty?

BACKGROUND: Patients are increasingly expected to become active, critical consumers in healthcare. They can use comparative healthcare information presented on websites to make informed choices for healthcare providers. However, the use of this information has been limited so far. An obstacle can be that the information is not perceived as relevant by patients. Presenting only the most important quality indicators might improve the usefulness of this information. The aim of this study was to explore which quality indicators different subgroups of patients find important when choosing a hospital for total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: In this explorative, cross-sectional study, questionnaires were distributed to 265 patients who underwent or had to undergo THA/TKA. Participants were asked to rank the importance of three types of quality indicators: patient experience indicators, clinical performance indicators, and indicators about hospital services. We used random effects regression analyses to assess the relative importance of the indicators in different subgroups of patients. RESULTS: 110 patients (response rate 41.5%) who underwent or had to undergo THA/TKA participated. Conduct of doctors, the presence of procedures to prevent adverse effects of thrombosis and information about the specialist area of orthopaedists were the most important patient experience indicator, clinical performance indicator and indicator about hospital services, respectively. We found a few differences between patient subgroups in the importance attached to the quality indicators. CONCLUSIONS: This study provides a first insight into which quality indicators patients find important when choosing a hospital for THA/TKA, and shows that subgroups of patients differ in the value they attach to these indicators. More extended research is needed to establish the indicators that should at least be presented in succinct overviews of comparative healthcare information for patients choosing a hospital for THA/TKA.

The Dutch consumer quality index: an example of stakeholder involvement in indicator development.

BACKGROUND: Like in several other Western countries, in the Dutch health care system regulated competition has been introduced. In order to make this work, comparable information is required about the performance of health care providers in terms of effectiveness, safety and patient experiences. Without further coordination, external actors will all try to force health care providers to be transparent. For health care providers this might result in a situation in which they have to deliver data for several sets of indicators, defined by different actors. Therefore, in the Netherlands an effort is made to define national sets of performance indicators and related measuring instruments. In this article, the following questions are addressed, using patient experiences as an example:- When and how are stakeholders involved in the development of indicators and instruments that measure the patients' experiences with health care providers?- Does this involvement lead to indicators and instruments that match stakeholders' information needs? DISCUSSION: The Dutch experiences show that it is possible to implement national indicator sets and to reach consensus about what needs to be measured. Preliminary evaluations show that for health care providers and health insurers the benefits of standardization outweigh the possible loss of tailor-made information. However, it has also become clear that particular attention should be given to the participation of patient/consumer organisations. SUMMARY: Stakeholder involvement is complex and time-consuming. However, it is the only way to balance the information needs of all the parties that ask for and benefit from transparency, without frustrating the health care system.

The influence of a vertically integrated curriculum on the transition to postgraduate training.

BACKGROUND: Recently, many medical curricula have been changed into vertically integrated programmes. One of the aims of vertical integration is to facilitate the transition from theoretical to clinical education and from medical school to postgraduate training. AIMS: The aim of this study was to determine whether a vertically integrated curriculum affects the transition from medical school to postgraduate training. METHOD: We carried out a survey study among graduates of two cohorts of the Utrecht Medical School, who followed either the traditional or the innovative, vertically integrated, curriculum. Topics of the questionnaire were: (a) activities since medical school, (b) required amount of time and number of applications to get admitted to residency, (c) the process of making career choices. RESULTS: Graduates from the vertically integrated curriculum had made their definite career choice earlier compared to those who followed a traditional programme. Graduates of the new curriculum also needed less time and fewer applications to obtain a residency position. CONCLUSIONS: A vertically integrated curriculum at medical school positively affects the transition to postgraduate training. Additional research, among a larger population, is required to determine which components of the curriculum cause this effect and to specify under which conditions these effect occurs.

Sexual harassment during clinical clerkships in Dutch medical schools.

CONTEXT: Sexual harassment of medical students has been the focus of many international studies. Prevalence rates from 18% to over 60% have been reported. However, a Dutch study at Nijmegen Medical School found the prevalence rate to be lower (13.3% in the total group; 20% among female students only). OBJECTIVES: We aimed to identify whether Nijmegen constitutes a positive sample of Dutch medical schools or whether incidents of sexual harassment are less prevalent in the Netherlands than elsewhere, and to establish if and how these experiences impact the professional lives of students. METHODS: Students received a semi-structured questionnaire containing questions about their experiences of sexual harassment during clerkships. The questions referred to students' reactions to any incidents, the possible consequences for their wellbeing or professional functioning and the way cases of sexual harassment were handled. RESULTS: The prevalence of sexual harassment was significantly higher in Utrecht than in Nijmegen. In both studies rates were relatively low compared with international data. Nevertheless, 1 in 3-5 Dutch female medical students had experienced unwelcome sexual attention from patients, colleagues or supervisors. Three of 10 students who had experienced such an incident stated that it had a negative impact on their functioning afterwards. CONCLUSIONS: Prevalence rates of sexual harassment in medical schools in the Netherlands are low compared with international rates. However, the number of women students who experience sexual harassment is still 1 in 3-5. The occurrence of and ways to deal with these incidents should be important topics in the training of medical students and supervisors.

Senior medical students' appraisal of CanMEDS competencies.

CONTEXT: In 2003 the Dutch Central College of Medical Specialties presented guidelines for the modernisation of all medical specialty training programmes in the Netherlands. These guidelines are based to a large extent on the CanMEDS (Canadian Medical Education Directives for Specialists) 2000 model, which defines 7 roles for medical specialists. This model was adjusted to the Dutch situation. The roles were converted to 7 fields of competency: Medical Performance; Communication; Collaboration; Knowledge and Science; Community Performance; Management, and Professionalism. OBJECTIVE: As changes in postgraduate training will probably be most effective if future trainees recognise their value, we set out to determine how senior medical students rated these fields of competency in terms of their importance. METHODS: We carried out a study at University Medical Centre (UMC) Utrecht, the Netherlands, in which 80 Year 6 medical students answered a questionnaire in which they rated the importance of each of 28 key competencies within the 7 competency fields. RESULTS: Although all key competencies were regarded as important (averages > or = 3.8), Professionalism and Communication scored highest on the student ratings. Management was assessed as least important. CONCLUSIONS: It is interesting that medical students acknowledged the importance of competencies other than those involving medical expertise and performance. It confirms the opinion that educating doctors is currently viewed as much more than providing theoretical and clinical knowledge and skills. The CanMEDS framework is appreciated by Dutch medical students. The fact that all competencies are seen as important adds to their face validity and therefore to their usefulness as a basis for postgraduate training.