Innovating the practice of medical speciality training.

Educational innovations are being introduced into medical speciality training. But how do people who participate in medical speciality training (residents, consultants, programme directors) deal with these innovations? And what effects do educational innovations have according to these people?By addressing these questions, this thesis contributes to the knowledge about the challenging process of innovating medical speciality training.

Cultural diversity: blind spot in medical curriculum documents, a document analysis.

BACKGROUND: Cultural diversity among patients presents specific challenges to physicians. Therefore, cultural diversity training is needed in medical education. In cases where strategic curriculum documents form the basis of medical training it is expected that the topic of cultural diversity is included in these documents, especially if these have been recently updated. The aim of this study was to assess the current formal status of cultural diversity training in the Netherlands, which is a multi-ethnic country with recently updated medical curriculum documents. METHODS: In February and March 2013, a document analysis was performed of strategic curriculum documents for undergraduate and postgraduate medical education in the Netherlands. All text phrases that referred to cultural diversity were extracted from these documents. Subsequently, these phrases were sorted into objectives, training methods or evaluation tools to assess how they contributed to adequate curriculum design. RESULTS: Of a total of 52 documents, 33 documents contained phrases with information about cultural diversity training. Cultural diversity aspects were more prominently described in the curriculum documents for undergraduate education than in those for postgraduate education. The most specific information about cultural diversity was found in the blueprint for undergraduate medical education. In the postgraduate curriculum documents, attention to cultural diversity differed among specialties and was mainly superficial. CONCLUSIONS: Cultural diversity is an underrepresented topic in the Dutch documents that form the basis for actual medical training, although the documents have been updated recently. Attention to the topic is thus unwarranted. This situation does not fit the demand of a multi-ethnic society for doctors with cultural diversity competences. Multi-ethnic countries should be critical on the content of the bases for their medical educational curricula.

Perceived effects of innovations in postgraduate medical education: a Q study focusing on workplace-based assessment.

PURPOSE: Anticipating users' perceptions of the effects an innovation will have in daily practice prior to implementation may lead to a more optimal innovation process. In this study, the authors aimed to identify the kinds of perceptions that exist concerning the effects of workplace-based assessment (WBA), an innovation that is widely used in medical education, among its users. METHOD: In 2012, the authors used Q methodology to ascertain the principal user perceptions of effects of WBA in practice. Participating obstetrics-gynecology residents and attending physicians (including residency program directors) at six hospitals in the Netherlands performed individual Q sorts to rank 36 statements concerning WBA and WBA tools according to their level of agreement. The authors conducted by-person factor analysis to uncover patterns in the rankings of the statements. They used the statistical results and participant comments about their sorts to interpret and describe distinct perceptions. RESULTS: The analysis of 65 Q sorts (completed by 22 residents and 43 attendings) identified five distinct user perceptions regarding the effects of WBA in practice, which the authors labeled enthusiasm, compliance, effort, neutrality, and skepticism. These perceptions were characterized by differences in views on three main issues: the intended goals of the innovation, its applicability (ease of applying it to practice), and its actual impact. CONCLUSIONS: User perceptions of the effects of innovations in medical education can be typified and should be anticipated. This study's insights into five principal user perceptions can support the design and implementation of innovations in medical education.

The CanMEDS framework: relevant but not quite the whole story.

BACKGROUND: Despite acknowledgement that the Canadian Medical Educational Directives for Specialists (CanMEDS) framework covers the relevant competencies of physicians, many educators and medical professionals struggle to translate the CanMEDS roles into comprehensive training programmes for specific specialties. AIM: To gain insight into the applicability of the CanMEDS framework to guide the design of educational programmes for specific specialties by exploring stakeholders' perceptions of specialty specific competencies and examining differences between those competencies and the CanMEDS framework. METHODS: This case study is a sequel to a study among ObsGyn specialists. It explores the perspectives of patients, midwives, nurses, general practitioners, and hospital boards on gynaecological competencies and compares these with the CanMEDS framework. RESULTS: Clinical expertise, reflective practice, collaboration, a holistic view, and involvement in practice management were perceived to be important competencies for gynaecological practice. Although all the competencies were covered by the CanMEDS framework, there were some mismatches between stakeholders' perceptions of the importance of some competencies and their position in the framework. CONCLUSION: The CanMEDS framework appears to offer relevant building blocks for specialty specific postgraduate training, which should be combined with the results of an exploration of specialty specific competencies to arrive at a postgraduate curriculum that is in alignment with professional practice.

The transition to hospital consultant: Denmark and the Netherlands compared on preparedness for practice, perceived intensity and contextual factors.

INTRODUCTION: Danish and Dutch new consultants' perceptions regarding the transition to consultant were compared to gain insight into this period, particularly the influence of contextual factors concerning the organisation of specialty training and health care therein. Preparation for medical and generic competencies, perceived intensity and burnout were compared. Additionally, effects of differences in working conditions and cultural dimensions were explored. METHODS: All consultants registered in the Netherlands in 2007-2009 (n = 2643) and Denmark in 2007-2010 (n = 1336) received in June 2010 and April 2011, respectively, a survey about their preparation for medical and generic competencies, perceived intensity and burnout. Power analysis resulted in required sample sizes of 542. Descriptive statistics and independent t-tests were used for analysis. RESULTS: Data were available of 792 new consultants in the Netherlands and 677 Danish new consultants. Compared to their Dutch counterparts, Danish consultants perceived specialty training and the transition less intensely, reported higher levels of preparation for generic competencies and scored lower on burnout. CONCLUSIONS: The importance of contextual aspects in the transition is underscored and shows that Denmark appears to succeed better in aligning training with practice. Regulations regarding working hours and progressive independence of trainees appear to facilitate the transition.

The transition to hospital consultant and the influence of preparedness, social support, and perception: A structural equation modelling approach.

BACKGROUND: Insight into the transition from specialist registrar to hospital consultant is needed to better align specialty training with starting as a consultant and to facilitate this transition. AIMS: This study investigates whether preparedness regarding medical and generic competencies, perceived intensity, and social support are associated with burnout among new consultants. METHOD: A population-based study among all 2643 new consultants in the Netherlands (all specialties) was conducted in June 2010. A questionnaire covering preparedness for practice, intensity of the transition, social support, and burnout was used. Structural equation modelling was used for statistical analysis. RESULTS: Data from a third of the population were available (32% n = 840) (43% male/57% female). Preparation in generic competencies received lower ratings than in medical competencies. A total of 10% met the criteria for burnout and 18% scored high on the emotional exhaustion subscale. Perceived lack of preparation in generic competencies correlated with burnout (r = 0.15, p < 0.001). No such relation was found for medical competencies. Furthermore, social support protected against burnout. CONCLUSIONS: These findings illustrate the relevance of generic competencies for new hospital consultants. Furthermore, social support facilitates this intense and stressful stage within the medical career.

New consultants mastering the role of on-call supervisor: a longitudinal qualitative study.

CONTEXT: The supervision of specialty registrars during on-call shifts is essential to ensure the quality of both health care and medical education, but has been identified as a major novelty and stressor for new consultants in the transition from specialty training. There is a paucity of research on how consultants deal with their new supervisory roles and which factors influence this process. These issues are addressed in a prospective study designed to gather insights that can inform measures to ensure the provision of high-quality supervision and specialty training. METHODS: A longitudinal qualitative study was performed in the Netherlands. Semi-structured interviews were conducted with new consultants. The study was guided by an interpretative phenomenological approach until saturation was reached. At 3-month intervals between July 2011 and March 2012, eight novice consultants in internal medicine were interviewed three times each about their supervisory role while on call. Interviews focused on their preparation for the role in training, the actions they took to master the role, and their progression over time. RESULTS: Three interrelated domains of relevant factors emerged from the data: preparedness; personal characteristics, and contextual characteristics. Preparedness referred to the extent to which new consultants were prepared by training to take full responsibility for registrars' actions while supervising them from a distance. Personal characteristics, such as coping strategies and views on supervision, guided consultants' development as supervisors. Essential to this process were contextual characteristics, especially those concerning the extent to which the consultant knew the registrar, was familiar with departmental procedures, and had access to support from colleagues. CONCLUSIONS: New consultants should be prepared for their supervisory role by training and by being given a proper introduction to their workplace. The former requires progressive independence and exposure to supervisory tasks during specialty training; the latter requires an induction programme to enable new consultants to familiarise themselves with the departmental environment and the registrars they will be supervising.

Exploration of perceived effects of innovations in postgraduate medical education.

CONTEXT: Many studies have examined how educational innovations in postgraduate medical education (PGME) impact on teaching and learning, but little is known about effects in the clinical workplace outside the strictly education-related domain. Insights into the full scope of effects may facilitate the implementation and acceptance of innovations because expectations can be made more realistic, and difficulties and pitfalls anticipated. Using workplace-based assessment (WBA) as a reference case, this study aimed to determine which types of effect are perceived by users of innovations in PGME. METHODS: Focusing on WBA as a recent instance of innovation in PGME, we conducted semi-structured interviews to explore perceptions of the effects of WBA in a purposive sample of Dutch trainees and (lead) consultants in surgical and non-surgical specialties. Interviews conducted in 2011 with 17 participants were analysed thematically using template analysis. To support the exploration of effects outside the domain of education, the study design was informed by theory on the diffusion of innovations. RESULTS: Six domains of effects of WBA were identified: sentiments (affinity with the innovation and emotions); dealing with the innovation; specialty training; teaching and learning; workload and tasks, and patient care. Users' affinity with WBA partly determined its effects on teaching and learning. Organisational support and the match between the innovation and routine practice were considered important to minimise additional workload and ensure that WBA was used for relevant rather than easily assessable training activities. Dealing with WBA stimulated attention for specialty training and placed specialty training on the agenda of clinical departments. CONCLUSIONS: These outcomes are in line with theoretical notions regarding innovations in general and may be helpful in the implementation of other innovations in PGME. Given the substantial effects of innovations outside the strictly education-related domain, individuals designing and implementing innovations should consider all potential effects, including those identified in this study.

Clarifying students' feedback-seeking behaviour in clinical clerkships.

CONTEXT: Why and how do students seek feedback on their performance in the clinical workplace and which factors influence this? These questions have remained largely unanswered in research into workplace learning during clinical clerkships. Research on feedback has focused mainly on feedback providers. Whether and how feedback recipients actively seek feedback are under-examined issues. Research in organisational psychology has proposed a mechanism whereby feedback seeking is influenced by motives and goal orientation mediated by the perceived costs and benefits of feedback. Building on a recently published model of resident doctors' feedback-seeking behaviour, we conducted a qualitative study to explore students' feedback-seeking behaviours in the clinical workplace. METHODS: Between April and June 2011, we conducted semi-structured face-to-face interviews with veterinary medicine students in Years 5 and 6 about their feedback-seeking behaviour during clinical clerkships. In the interviews, 14 students were asked about their goals and motives for seeking feedback, the characteristics of their feedback-seeking behaviour and factors influencing that behaviour. Using template analysis, we coded the interview transcripts and iteratively reduced and displayed the data until agreement on the final template was reached. RESULTS: The students described personal and interpersonal factors to explain their reasons for seeking feedback. The factors related to intentions and the characteristics of the feedback provider, and the relationship between the feedback seeker and provider. Motives relating to image and ego, particularly when students thought that feedback might have a positive effect on image and ego, influenced feedback-seeking behaviour and could induce specific behaviours related to students' orientation towards particular sources of feedback, their orientation towards particular topics for and timing of feedback, and the frequency and method of feedback-seeking behaviour. CONCLUSIONS: This study shows that during clinical clerkships, students actively seek feedback according to personal and interpersonal factors. Perceived costs and benefits influenced this active feedback-seeking behaviour. These results may contribute towards the optimising and developing of meaningful educational opportunities during clerkships.

How lead consultants approach educational change in postgraduate medical education.

CONTEXT: Consultants in charge of postgraduate medical education (PGME) in hospital departments ('lead consultants') are responsible for the implementation of educational change. Although difficulties in innovating in medical education are described in the literature, little is known about how lead consultants approach educational change. OBJECTIVES: This study was conducted to explore lead consultants' approaches to educational change in specialty training and factors influencing these approaches. METHODS: From an interpretative constructivist perspective, we conducted a qualitative exploratory study using semi-structured interviews with a purposive sample of 16 lead consultants in the Netherlands between August 2010 and February 2011. The study design was based on the research questions and notions from corporate business and social psychology about the roles of change managers. Interview transcripts were analysed thematically using template analysis. RESULTS: The lead consultants described change processes with different stages, including cause, development of content, and the execution and evaluation of change, and used individual change strategies consisting of elements such as ideas, intentions and behaviour. Communication is necessary to the forming of a strategy and the implementation of change, but the nature of communication is influenced by the strategy in use. Lead consultants differed in their degree of awareness of the strategies they used. Factors influencing approaches to change were: knowledge, ideas and beliefs about change; level of reflection; task interpretation; personal style, and department culture. CONCLUSIONS: Most lead consultants showed limited awareness of their own approaches to change. This can lead them to adopt a rigid approach, whereas the ability to adapt strategies to circumstances is considered important to effective change management. Interventions and research should be aimed at enhancing the awareness of lead consultants of approaches to change in PGME.

The curriculum for the doctor of the future: messages from the clinician's perspective.

BACKGROUND: Medical curricula should focus on the future of health care. Contemporary competency frameworks for curriculum design such as Canadian Medical Education Directions for Specialists (CanMEDS), ACGME and Tomorrow's Doctors share this vision by stressing generic competencies. AIM: The objective of this study was to investigate how well a contemporary competency framework fits in with clinicians' perspectives on future health care. METHODS: Using a strategic planning approach, a semi-structured open-ended questionnaire on the future of their profession was sent to 102 Dutch gynecologists. Through inductive analysis, a future perspective and its needed competencies were identified and compared to the CanMEDS framework. RESULTS: The 62 responses showed content validity for the CanMEDS roles. Additionally, two roles were identified: advanced technology user and entrepreneur. Within the role Communicator, the focus will change through more active patient participation. The roles Collaborator and Manager are predicted to change in focus because of an increase of complex interdisciplinary teamwork and leadership roles. CONCLUSION: By studying the Dutch gynecologists' perspective of the future in a strategic planning approach, two additional roles and focus areas within a contemporary competency framework were identified. The perspective of clinicians on future health care provides valuable messages on how to design future-proof curricula.