Teaching geriatrics using an innovative, individual-centered educational game: students and educators win. A proof-of-concept study.

Given the increasingly aging population, nearly every doctor will encounter elderly adults who present with multiple complex comorbidities that can challenge even experienced physicians. This may explain why many medical students do not have a positive attitude toward elderly adults and find the complexity of their problems overwhelming. It was hypothesized that a recently developed medical school geriatrics course, based on the game GeriatriX and designed specifically to address the complexities associated with decision-making in geriatrics, can have a positive effect on attitudes toward geriatrics and on perceived knowledge of geriatrics. The effects of this game-based course were evaluated as a proof of concept. The assessment was based on the Aging Semantic Differential (ASD) and a validated self-perceived knowledge scale of geriatric topics. The usability of (and satisfaction with) GeriatriX was also assessed using a 5-point Likert scale. After completion of the course, the ASD changed significantly in the geriatrics course group (n = 29; P = .02) but not in a control group that took a neuroscience course (n = 24; P = .30). Moreover, the geriatrics course group had a significant increase in self-perceived knowledge for 12 of the 18 topics (P = .002), whereas in the control group self-perceived knowledge increased significantly for one topic only (sensory impairment) (P = .04). Finally, the geriatrics students reported enjoying GeriatriX. This proof-of-concept study clearly supports the hypothesis that a 4-week course using a modern educational approach such as GeriatriX can improve students' self-perceived knowledge of geriatrics and their attitudes toward elderly adults.

Influence on birthing positions affects women's sense of control in second stage of labour.

OBJECTIVE: to explore whether choices in birthing positions contributes to women's sense of control during birth. DESIGN: survey using a self-report questionnaire. Multiple regression analyses were used to investigate which factors associated with choices in birthing positions affected women's sense of control. SETTING: midwifery practices in the Netherlands. PARTICIPANTS: 1030 women with a physiological pregnancy and birth from 54 midwifery practices. FINDINGS: in the total group of women (n=1030) significant predictors for sense of control were: influence on birthing positions (self or self together with others), attendance of antenatal classes, feelings towards birth in pregnancy and pain in second stage of labour. For women who preferred other than supine birthing positions (n=204) significant predictors were: influence on birthing positions (self or self together with others), feelings towards birth in pregnancy, pain in second stage of labour and having a home birth. For these women, influence on birthing positions in combination with others had a greater effect on their sense of control than having an influence on their birthing positions just by themselves. KEY CONCLUSIONS: women felt more in control during birth if they experienced an influence on birthing positions. For women preferring other than supine positions, home birth and shared decision-making had added value. IMPLICATIONS FOR PRACTICE: midwives can play an important role in supporting women in their use of different birthing positions and help them find the positions they feel most comfortable in. Thus, contributing to women's positive experience of birth.

Prevention of coronary heart disease and osteoporosis in women aged 45 to 49 years: a challenging role for general practitioners.

OBJECTIVE: Part of the risks for coronary heart disease (CHD) and osteoporosis in women are established by their lifestyle in the premenopausal period. Therefore, we assessed the risk of women aged 45 to 49 years for CHD and osteoporosis and its relation with socioeconomic status (SES) and access to general practitioners (GPs) to provide clues for prevention. METHODS: The health interview data used for this study originated from the second Dutch National Survey of General Practice, a study with a response rate of 64.5%. We studied SES, risk factors for CHD and osteoporosis, and access to GPs in women aged 45 to 49 years. RESULTS: The data of 571 women aged 45 to 49 years were included. A total of 39% had an increased risk for developing CHD in the next 10 years, and 3% had a high risk. A total of 22% had an increased risk for osteoporosis. We found a significant relation between SES and unhealthy lifestyle. An unhealthy lifestyle led to an increased or high risk for CHD, and a high osteoporosis risk. We did not find a significant relation between SES and GP consultation frequency. CONCLUSIONS: Special attention is required for women with the lowest SES because they have an unhealthier lifestyle than do women with middle or the highest SES. The group of women at higher risk for CHD and osteoporosis consulted their GP with the same frequency as did women at lower risk. The Dutch GP seems to be in an ideal position to play a role in the prevention of CHD and osteoporosis in premenopausal women because access to GPs is not influenced by SES.

Incorporating and evaluating an integrated gender-specific medicine curriculum: a survey study in Dutch GP training.

BACKGROUND: We recently set standards for gender-specific medicine training as an integrated part of the GP training curriculum. This paper describes the programme and evaluation of this training. METHODS: The programme is designed for GP registrars throughout the 3-year GP training. The modules emphasize interaction, application, and clinically integrated learning and teaching methods in peer groups. In 2005 - 2008, after completion of each tutorial, GP registrars were asked to fill in a questionnaire on a 5-point Likert scale to assess the programme's methods and content. GP registrars were also asked to identify two learning points related to the programme. RESULTS: The teaching programme consists of five 3-hour modules that include gender themes related to and frequently seen by GPs such as in doctor-patient communication and cardiovascular disease. GP registrars evaluated the training course positively. The written learning points suggest that GP registrars have increased their awareness of why attention to gender-specific information is relevant. CONCLUSION: In summary, gender-specific medicine training has been successfully integrated into an existing GP training curriculum. The modules and teaching methods are transferable to other training institutes for postgraduate training. The evaluation of the teaching programme shows a positive impact on GP registrars' gender awareness.

From gender bias to gender awareness in medical education.

Gender is an essential determinant of health and illness. Gender awareness in doctors contributes to equity and equality in health and aims towards better health for men and women. Nevertheless, gender has largely been ignored in medicine. First, it is stated that medicine was 'gender blind' by not considering gender whenever relevant. Secondly, medicine is said to be 'male biased' because the largest body of knowledge on health and illness is about men and their health. Thirdly, gender role ideology negatively influences treatment and health outcomes. Finally, gender inequality has been overlooked as a determinant of health and illness. The uptake of gender issues in medical education brings about specific challenges for several reasons. For instance, the political-ideological connotations of gender issues create resistance especially in traditionalists in medical schools. Secondly, it is necessary to clarify which gender issues must be integrated in which domains. Also, some are interdisciplinary issues and as such more difficult to integrate. Finally, schools need assistance with implementation. The integration of psychosocial issues along with biomedical ones in clinical cases, the dissemination of literature and education material, staff education, and efforts towards structural embedding of gender in curricula are determining factors for successful implementation. Gender equity is not a spontaneous process. Medical education provides specific opportunities that may contribute to transformation for medical schools educate future doctors for future patients in future settings. Consequently, future benefits legitimize the integration of gender as a qualitative investment in medical education.

Does equal education generate equal attitudes? Gender differences in medical students' attitudes toward the ideal physician.

BACKGROUND: Developing a patient-centered attitude is an important objective of medical education. Gender differences in students' patient-centered attitudes are also reported. PURPOSES: Our study aims to measure (a) do gender differences and age differences exist in 1st- and 6th-year students' attitudes toward the ideal physician? and (b) what happens to gender differences in attitudes as students pass the medical curriculum? METHODS: In 2004, attitudes of 1st-year and 6th-year medical students of the Radboud University Nijmegen Medical Centre are measured with the Ideal Physician Scale. Scores between groups are compared with t tests and univariate analysis of variance tests. RESULTS: Although both male and female students' attitudes become more care-oriented as they pass through the curriculum, gender differences are still apparent. CONCLUSIONS: Medical education does not differentially influence male and female students. Nevertheless, existing gender differences are reproduced. Equal education does not lead to equal attitudes.

Increased awareness of intimate partner abuse after training: a randomised controlled trial.

BACKGROUND: Intimate partner abuse is very common among female patients in family practice. In general, doctors overlook the possibility of partner abuse. AIM: To investigate whether awareness of intimate partner abuse, as well as active questioning, increase after attending focus group and training, or focus group only. DESIGN OF STUDY: Randomised controlled trial in a stratified sample. SETTING: Family practices in Rotterdam and surrounding areas. METHOD: A full-training group (n = 23), a group attending focus group discussions alone (n = 14), and a control group (n = 17) were formed. Data were collected with incident reporting of every female patient (aged >18 years) that was suspected of, or presented, partner abuse during a period of 6 months. The primary outcome measure was the number of reported patients; the secondary outcome measure was the number of patients with whom the GP had non-obvious reasons to suspect/discuss abuse. RESULTS: Comparison of the full-training group (n = 87 patients) versus the control group (n = 14 patients) resulted in a rate ratio of 4.54 (95% confidence interval [CI] = 2.55 to 8.09, P <0.001); the focus group only group (n = 30 cases) versus control group: rate ratio of 2.2 (95% CI = 1.14 to 4.26, P = 0.019); full-training versus the focus group only group: rate ratio of 2.19 (95% CI = 1.36 to 3.52, P = 0.001). Comparison of the fulltraining group with the untrained groups for awareness of partner abuse in case of non-obvious signs resulted in: odds ratio 5.92 (95% CI = 2.25 to 15.62, P <0.01) all corrected for sex, district, practice setting, working part/full-time, experience, and age of the doctor. CONCLUSIONS: Training was the most significant determinant to improve awareness and identification of intimate partner abuse. Active questioning increased, especially where there were non-obvious signs. The focus group on its own doubled the awareness of partner abuse.

Intrauterine contraception: the role of general practitioners in four Dutch general practices.

The intrauterine device (IUD) use in the Netherlands and the United States is limited to a small group of women, though the risk of infection and pregnancy is small. Therefore, it was of interest to investigate the characteristics of women who choose an IUD as contraceptive method and the influence of general practitioners concerning IUD insertion. The aim of this retrospective cohort study was to assess differences between general practices and to investigate the characteristics of IUD users. Also, we wished to study changes in IUD use with time. Patients were selected from four academic general practices belonging to the continuous morbidity registration project in Nijmegen, the Netherlands. The population under study included 461 women registered in the academic practices with a code for insertion of a new IUD in the period from 1981 to 2001. More than half of the women were between 25 and 34 years old at the time of insertion. Almost one quarter were nulliparous, one quarter unmarried and the distribution of socioeconomic status was the same as the entire practice population. General practitioners have clear preferences for certain types of IUD and, in particular, for not inserting an IUD in nulliparous women. In conclusion, married or cohabiting women, around 30 years of age, with children, are in the majority in receiving an IUD as contraception. General practitioners clearly follow their own opinions about inserting IUD in nulliparous women. Currently, general practitioners are prescribing more Multiload Cu 375 IUDs and levonorgestrel-releasing IUDs.

Substandard factors in perinatal care in The Netherlands: a regional audit of perinatal deaths.

BACKGROUND: To determine: 1) whether substandard factors were present in cases of perinatal death, and to what extent another course of action might have resulted in a better outcome, and 2) whether there were differences in the frequency of substandard factors by level of care, particularly between midwives and gynecologists/obstetricians and between home and hospital births. METHODS: Population-based perinatal audit, with explicit evidence-based audit criteria. SETTING: The northern part of the province of South-Holland in The Netherlands. All levels of perinatal care (primary, secondary and tertiary care, and home and hospital births) were included. CASES: Three hundred and forty-two cases of perinatal mortality (24 weeks of pregnancy--28 days after birth). MAIN OUTCOME MEASURES: Scores by a Dutch and a European audit panel. Score 0: no substandard factors identified; score 1, 2 or 3: one or more substandard factors identified, which were unlikely (1), possibly (2) or probably (3) related to the perinatal death. RESULTS: In 25% of the perinatal deaths (95% Confidence Interval: 20-30%) a substandard factor was identified that according to the Dutch panel was possibly or probably related to the perinatal death. These were mainly maternal/social factors (10% of all perinatal deaths; most frequent substandard factor: smoking during pregnancy), and antenatal care factors (10% of all perinatal deaths; most frequent substandard factor: detection of intra-uterine growth retardation). We did not find statistically significant differences in scores between midwives and gynecologists/obstetricians or between home and hospital births. The European panel identified more substandard factors, but these were again equally distributed by level of care. CONCLUSIONS: Perinatal deaths might be partly preventable in The Netherlands. There is no evidence that the frequency of substandard factors is related to specific aspects of the perinatal care system in The Netherlands.