Early Bird or Night Owl: Insights into Dutch Students' Study Patterns using the Medical Faculty's E-learning Registrations.

Phenomenon: Educational activities for students are typically arranged without consideration of their preferences or peak performance hours. Students might prefer to study at different times based on their chronotype, aiming to optimize their performance. While face-to-face activities during the academic schedule do not offer flexibility and cannot reflect students' natural learning rhythm, asynchronous e-learning facilitates studying at one's preferred time. Given their ubiquitous accessibility, students can use e-learning resources according to their individual needs and preferences. E-learning usage data hence serves as a valuable proxy for certain study behaviors, presenting research opportunities to explore students' study patterns. This retrospective study aims to investigate when and for how long undergraduate students used medical e-learning modules. Approach: We performed a cross-sectional analysis of e-learning usage at one medical faculty in the Netherlands. We used data from 562 undergraduate multimedia e-learning modules for pre-clinical students, covering various medical topics over a span of two academic years (2018/19 and 2019/20). We employed educational data mining approaches to process the data and subsequently identified patterns in access times and durations. Findings: We obtained data from 70,805 e-learning sessions with 116,569 module visits and 1,495,342 page views. On average, students used e-learning for 16.8 min daily and stopped using a module after 10.2 min, but access patterns varied widely. E-learning was used seven days a week with an hourly access pattern during business hours on weekdays. Across all other times, there was a smooth increase or decrease in e-learning usage. During the week, more students started e-learning sessions in the morning (34.5% vs. 19.1%) while fewer students started in the afternoon (42.6% vs. 50.8%) and the evening (19.4% vs. 27.0%). We identified 'early bird' and 'night owl' user groups that show distinct study patterns. Insights: This retrospective educational data mining study reveals new insights into the study patterns of a complete student cohort during and outside lecture hours. These findings underline the value of 24/7 accessible study material. In addition, our findings may serve as a guide for researchers and educationalists seeking to develop more individualized educational programs.

How clinical teaching teams deal with educational change: 'we just do it'.

BACKGROUND: In postgraduate medical education, program directors are in the lead of educational change within clinical teaching teams. As change is part of a social process, it is important to not only focus on the program director but take their other team members into account. The purpose of this study is to provide an in-depth insight into how clinical teaching teams manage and organize curriculum change processes, and implement curriculum change in daily practice. METHODS: An explorative qualitative semi-structured interview study was conducted between October 2016 and March 2017. A total of six clinical teaching teams (n = 6) participated in this study, i.e. one program director, one clinical staff member, and one trainee from each clinical teaching team (n = 18). Data were analysed and structured by means of thematic analysis. RESULTS: The analysis yielded to five factors that positively impact change: shared commitment, reinvention, ownership, supportive structure and open culture. Factors that negatively impact change were: resistance, behaviour change, balance between different tasks, lack of involvement, lack of consensus, and unsafe culture and hierarchy. Overall, no clear change strategy could be recognized. CONCLUSIONS: Insight was gathered in factors facilitating and hindering the implementation of change. It seems particularly important for clinical teaching teams to be able to create a sense of ownership among all team members by making a proposed change valuable for their local context as well as to be capable of working together as a team. Cultural factors seem to be particularly relevant in a team's ability to accomplish this.

Improving the training of the future gynaecologist: development of a European curriculum in Obstetrics and Gynaecology (EBCOG-PACT).

The European Board & College of Obstetrics and Gynaecology has initiated improvement of the European standards of training in Obstetrics and Gynaecology through the project called 'EBCOG-PACT'. In this project, a pan-European curriculum for postgraduate training in Obstetrics and Gynaecology has been developed. The curriculum is societally responsive, and based on the latest medical educational methodology. It consists of the description of outcomes of training for the common Core Curriculum and Electives, the General competencies and soft skills to be trained, and strategies for training of obstetrical skills, gynaecological skills, ultrasound skills and bio-psychosocial and communicative skills. Also, the curriculum provides strategies for assessment through entrustment, a model for portfolio as well as strategies for faculty development and quality management of training. The implementation of the European curriculum in Obstetrics and Gynaecology will provide opportunities for national scientific and professional societies and ministries of health or education to consider modernisation of national or local OBGYN training programs.

[Integral obstetrics impeded by history? Midwives and gynaecologists through the ages]. / Integrale verloskunde gehinderd door het verleden?

There is a long and complicated history concerning the interprofessional collaboration between midwives and gynaecologists, which is still evident in current practice. Yet, in the analysis of collaborative problems, history and its lessons are often overlooked. Consequently, less effective solutions to problems may be found, because the root cause of a problem is not addressed. In this historical perspective we show how policies of the respective professions have often focused on self-preservation and competition, rather than on effective collaboration. We also highlight how the independent midwives lost and regained authorisation, status and income. Finally, using a theoretical model for interprofessional collaboration, we reflect on where history impedes the development of integral obstetrics. The focus must be averted away from professional self-interest and power struggles, but this proves to be a complex exercise.

How do medical specialists value their own intercultural communication behaviour? A reflective practice study.

BACKGROUND: Intercultural communication behaviour of doctors with patients requires specific intercultural communication skills, which do not seem structurally implemented in medical education. It is unclear what motivates doctors to apply intercultural communication skills. We investigated how purposefully medical specialists think they practise intercultural communication and how they reflect on their own communication behaviour. METHODS: Using reflective practice, 17 medical specialists independently watched two fragments of videotapes of their own outpatient consultations: one with a native patient and one with a non-native patient. They were asked to reflect on their own communication and on challenges they experience in intercultural communication. The interviews were open coded and analysed using thematic network analysis. RESULTS: The participants experienced only little differences in their communication with native and non-native patients. They mainly mentioned generic communication skills, such as listening and checking if the patient understood. Many participants experienced their communication with non-native patients positively. The participants mentioned critical incidences of intercultural communication: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere. CONCLUSION: Despite extensive experience in intercultural communication, the participants of this study noticed hardly any differences between their own communication behaviour with native and non-native patients. This could mean that they are unaware that consultations with non-native patients might cause them to communicate differently than with native patients. The reason for this could be that medical specialists lack the skills to reflect on the process of the communication. The participants focused on their generic communication skills rather than on specific intercultural communication skills, which could either indicate their lack of awareness, or demonstrate that practicing generic communication is more important than applying specific intercultural communication. They mentioned well-known critical incidences of ICC: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere. Nevertheless, they showed a remarkably enthusiastic attitude overall was noteworthy. A strategy to make doctors more aware of their intercultural communication behaviour could be a combination of experiential learning and ICC training, for example a module with reflective practice.

[CanMEDS 2015: better doctors?]. / CanMEDS 2015: nog betere dokters?

Recently, the CanMEDS model, which forms the basis for competency-based learning in both undergraduate and postgraduate training, has been renewed by the introduction of CanMEDS 2015. The most prominent change is the emphasis on leadership skills, which is also reflected by the name change for the role of 'manager' to 'leader'. The addition of milestones provides clearly defined targets for learning and assessment, which facilitates the monitoring of the progression in competence. Furthermore, CanMEDS 2015 strongly focusses on the overall coherence of the separate competencies. CanMEDS, designed as a model that helps to train young doctors to become good doctors, also helps us - the trainers - to become better doctors ourselves.

Quality specifications in postgraduate medical e-learning: an integrative literature review leading to a postgraduate medical e-learning model.

BACKGROUND: E-learning is driving major shifts in medical education. Prioritizing learning theories and quality models improves the success of e-learning programs. Although many e-learning quality standards are available, few are focused on postgraduate medical education. METHODS: We conducted an integrative review of the current postgraduate medical e-learning literature to identify quality specifications. The literature was thematically organized into a working model. RESULTS: Unique quality specifications (n = 72) were consolidated and re-organized into a six-domain model that we called the Postgraduate Medical E-learning Model (Postgraduate ME Model). This model was partially based on the ISO-19796 standard, and drew on cognitive load multimedia principles. The domains of the model are preparation, software design and system specifications, communication, content, assessment, and maintenance. CONCLUSION: This review clarified the current state of postgraduate medical e-learning standards and specifications. It also synthesized these specifications into a single working model. To validate our findings, the next-steps include testing the Postgraduate ME Model in controlled e-learning settings.

[Drawn towards a career in elderly care medicine, but not till after medical school. Elderly care medicine as a career choice]. / Gegrepen door de ouderengeneeskunde, maar niet tijdens de studie geneeskunde! Keuze voor de opleiding tot specialist ouderengeneeskunde.

In order to develop strategies for raising the interest of medical students in a career in elderly care medicine (a specialty in The Netherlands) we should start by gaining more insight into the process influencing career choices among medical students and graduates. In this qualitative study we conducted three focus group discussions with trainees in elderly care medicine and two focus group discussions with obstetrics and gynaecology trainees. We found that all trainees made their career choice after clinical exposure in the field. The elderly care medicine trainees did not make their choice until after graduation, working in temporary employment in a nursing home. The obstetrics and gynaecology trainees made their specialty choice during medical school after their clerkship. Almost all focus group participants had a very negative perception during medical school about geriatrics and elderly care medicine. Once they were employed in a nursing home they changed their minds. They came to realize the work was more interesting, more difficult, more intensive and more meaningful than they had initially thought.

The art of medical education.

Is the art of medical education just making sure to provide sufficient up to date medical knowledge and a lot of clinical experience? It is much more. The art of medical education is about a teaching program that is designed to serve the community of the near future. The program is the result of a thorough evaluation of societal needs and is capable of influencing the properties of future care. New care professionals who are trained in the program will -become instrumental in solving complex problems in health systems. The art of medical education is about the change of traditional ideas of how to cope with these health systems. This change will raise anger and resistance. Effective change management is essential to survive attacks from laggards and to maintain enthusiasm to invest in the health care of the future. Educationalist science provides several important insights that help us find the optimal shape of the program. Good role models and a learning environment that is an example of the intended professional and organisational behaviour, learning by doing, simulation programs, educational tools like e-learning systems, a good assessment and feedback system, and a portfolio to prove and discuss professional progress are all pivotal components of the ideal program. To achieve mastery within the art of medical education, a quality improvement program will be the crown of the process. Medical education is a multifaceted process and so the quality improvement should be. The art of medical education is a great challenge. The health care of your future deserves it.

The assessment of professional competence: building blocks for theory development.

This article presents lessons learnt from experiences with assessment of professional competence. Based on Miller's pyramid, a distinction is made between established assessment technology for assessing 'knows', 'knowing how' and 'showing how' and more recent developments in the assessment of (clinical) performance at the 'does' level. Some general lessons are derived from research of and experiences with the established assessment technology. Here, many paradoxes are revealed and empirical outcomes are often counterintuitive. Instruments for assessing the 'does' level are classified and described, and additional general lessons for this area of performance assessment are derived. These lessons can also be read as general principles of assessment (programmes) and may provide theoretical building blocks to underpin appropriate and state-of-the-art assessment practices.

Validation and implementation of surgical simulators: a critical review of present, past, and future.

BACKGROUND: In the past 20 years the surgical simulator market has seen substantial growth. Simulators are useful for teaching surgical skills effectively and with minimal harm and discomfort to patients. Before a simulator can be integrated into an educational program, it is recommended that its validity be determined. This study aims to provide a critical review of the literature and the main experiences and efforts relating to the validation of simulators during the last two decades. METHODS: Subjective and objective validity studies between 1980 and 2008 were identified by searches in Pubmed, Cochrane, and Web of Science. RESULTS: Although several papers have described definitions of various subjective types of validity, the literature does not offer any general guidelines concerning methods, settings, and data interpretation. Objective validation studies on endourological simulators were mainly characterized by a large variety of methods and parameters used to assess validity and in the definition and identification of expert and novice levels of performance. CONCLUSION: Validity research is hampered by a paucity of widely accepted definitions and measurement methods of validity. It would be helpful to those considering the use of simulators in training programs if there were consensus on guidelines for validating surgical simulators and the development of training programs. Before undertaking a study to validate a simulator, researchers would be well advised to conduct a training needs analysis (TNA) to evaluate the existing need for training and to determine program requirements in a training program design (TPD), methods that are also used by designers of military simulation programs. Development and validation of training models should be based on a multidisciplinary approach involving specialists (teachers), residents (learners), educationalists (teaching the teachers), and industrial designers (providers of teaching facilities). In addition to technical skills, attention should be paid to contextual, interpersonal, and task-related factors.

Progress testing in postgraduate medical education.

BACKGROUND: The role of knowledge in postgraduate medical education has often been discussed. However, recent insights from cognitive psychology and the study of deliberate practice recognize that expert problem solving requires a well-organized knowledge database. This implies that postgraduate assessment should include knowledge testing. Longitudinal assessment, like progress testing, seems a promising approach for postgraduate progress knowledge assessment. AIMS: To evaluate the validity and reliability of a national progress test in postgraduate Obstetrics and Gynaecology training. METHODS: Data of 10 years of postgraduate progress testing were analyzed on reliability with Cronbach's alpha and on construct validity using one-way ANOVA with a post hoc Scheffe test. RESULTS: Average reliability with true-false questions was 0.50, which is moderate at best. After the introduction of multiple-choice questions average reliability improved to 0.65. Construct validity or discriminative power could only be demonstrated with some certainty between training year 1 and training year 2 and higher training years. CONCLUSION: Validity and reliability of the current progress test in postgraduate Obstetrics and Gynaecology training is unsatisfactory. Suggestions for improvement of both test construct and test content are provided.

The influence of context on residents' evaluations: effects of priming on clinical judgment and affect.

Different lines of research have suggested that context is important in acting and learning in the clinical workplace. It is not clear how contextual information influences residents' constructions of the situations in which they participate. The category accessibility paradigm from social psychology appears to offer an interesting perspective for studying this topic. We explored the effect of activating medically irrelevant mental concepts in one context, so-called 'priming', on residents' interpretations as reflected in their judgments in another, work-related context. Obstetric-gynecologic residents participated in two unrelated-tasks experiments. In the first experiment residents were asked to indicate affect about a change in a routine procedure after performing an ostensibly unrelated 'priming' task which activated the concept of either ineffective coping or effective coping. The second experiment concerned residents' patient management decisions in a menorrhagia case after 'priming' with either action or holding off. Contextually activated mental concepts lead to divergent affective and cognitive evaluations in a subsequent medical context. Residents are not aware of this effect. The strength of the effect varies with residents' level of experience. Context influences residents' constructions of a work-related situation by activating mental concepts which in turn affect how residents experience situations. Level of experience appears to play a mediating role in this process.

[Plea for more attention to the importance of gender during medical training]. / Pleidooi voor artsenopleiding met aandacht voor gender.

Gender is an important factor in disease and health. Male and female patients with the same disease may present with different complaints. This is especially true in cardiology. Basic medical training should specifically address this topic. Moreover, the gender of the physician is an important factor in patient care. Physicians are unaware of the influence of their gender on their performance. Reflective practice is an essential educational tool in modern specialist training. As medical specialist training in The Netherlands is being modernized at present, this may be the perfect time for physicians to become aware of their gender and its impact on their performance. This will improve medical care for both male and female patients by male and female doctors.

Attending doctors' perspectives on how residents learn.

CONTEXT: Graduate medical education is currently facing major educational reforms. There is a lack of empirical evidence in the literature about the learning processes of residents in the clinical workplace. This qualitative study uses a 'grounded theory' approach to continue the development of a theoretical framework of learning in the clinical workplace by adding the perspective of attending doctors. METHODS: A total of 21 Dutch attending doctors involved in the training of residents in obstetrics and gynaecology participated in 1 of 3 focus group sessions. They discussed their perceptions of how residents learn and what factors influence residents' learning. A grounded theory approach was used to analyse the transcribed discussions. RESULTS: Three related themes emerged. The first concerned the central role of participation in work-related activities: according to attending doctors, residents learn by tackling the everyday challenges of clinical work. The second involved the ways in which attending doctors influence what residents learn from work-related activities. The final theme focused on attending doctors' views of the essential characteristics of residents and their development during residency. CONCLUSIONS: Attending doctors' perspectives complement current insights derived from similar research among residents and from related literature. As part of an ongoing effort to further develop understanding of how residents learn, this study adds several ways in which attending doctors strive to combine guidance in both patient care and resident training. Furthermore, attending doctors' perspectives draw attention to other aspects of learning in the clinical workplace, such as the role of confidence and the balance between supervision and independence.

How residents learn: qualitative evidence for the pivotal role of clinical activities.

OBJECTIVES: Medical councils worldwide have outlined new standards for postgraduate medical education. This means that residency programmes will have to integrate modern educational views into the clinical workplace. Postgraduate medical education is often characterised as a process of learning from experience. However, empirical evidence regarding the learning processes of residents in the clinical workplace is lacking. This qualitative study sought insight into the intricate process of how residents learn in the clinical workplace. METHODS: We carried out a qualitative study using focus groups. A grounded theory approach was used to analyse the transcribed tape recordings. A total of 51 obstetrics and gynaecology residents from teaching hospitals and affiliated general hospitals participated in 7 focus group discussions. Participants discussed how they learn and what factors influence their learning. RESULTS: An underlying theoretical framework emerged from the data, which clarified what happens when residents learn by doing in the clinical workplace. This framework shows that work-related activities are the starting point for learning. The subsequent processes of 'interpretation' and 'construction of meaning' lead to refinement and expansion of residents' knowledge and skills. Interaction plays an important role in the learning process. This is in line with both cognitivist and sociocultural views on learning. CONCLUSIONS: The presented theoretical framework of residents' learning provides much needed empirical evidence for the actual learning processes of residents in the clinical workplace. The insights it offers can be used to exploit the full educational potential of the clinical workplace.

[The basic biomedical subjects are now less important in the training of medical doctors]. / Biomedische basisvakken zijn voor de artsopleiding tegenwoordig minder belangrijk.

Medical doctors that neglect the roles of communicator, team worker, organizer and professional can be expected to perform inadequately. The content of the training of medical doctors should be reconsidered. A selection should be made of the biomedical sciences that are required during the training for later medical practice. Thus, these basic sciences should, in part, make way for social sciences to ensure the development of team skills.

Psychometric properties of an instrument to measure the clinical learning environment.

OBJECTIVES: The clinical learning environment is an influential factor in work-based learning. Evaluation of this environment gives insight into the educational functioning of clinical departments. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an evaluation tool consisting of a validated questionnaire with 3 subscales. In this paper we further investigate the psychometric properties of the PHEEM. We set out to validate the 3 subscales and test the reliability of the PHEEM for both clerks (clinical medical students) and registrars (specialists in training). METHODS: Clerks and registrars from different hospitals and specialties filled out the PHEEM. To investigate the construct validity of the 3 subscales, we used an exploratory factor analysis followed by varimax rotation, and a cluster analysis known as Mokken scale analysis. We estimated the reliability of the questionnaire by means of variance components according to generalisability theory. RESULTS: A total of 256 clerks and 339 registrars filled out the questionnaire. The exploratory factor analysis plus varimax rotation suggested a 1-dimensional scale. The Mokken scale analysis confirmed this result. The reliability analysis showed a reliable outcome for 1 department with 14 clerks or 11 registrars. For multiple departments 3 respondents combined with 10 departments provide a reliable outcome for both groups. DISCUSSION: The PHEEM is a questionnaire measuring 1 dimension instead of the hypothesised 3 dimensions. The sample size required to achieve a reliable outcome is feasible. The instrument can be used to evaluate both single and multiple departments for both clerks and registrars.

Hormone replacement therapy in women treated for gynaecological malignancy.

Can we prescribe hormone replacement therapy (HRT) safely for women, with postmenopausal complaints who were treated for a gynaecological malignancy? Only three retrospective studies have investigated this issue in endometrial cancer patients. No recurrences or deaths occurred in these treated groups. However, the physician introduced bias through the selection of favourable groups. At present, combined estrogen and progestogen therapy is probably not contra-indicated in endometrial cancer stage I and probably also not in stage II, although so far there is only circumstantial evidence. Squamous cell cancers of the cervix, vulva, and vagina are unlikely to be influenced by HRT. In the only study available of women with ovarian cancer, < or = 50 years, estrogen replacement therapy did not have a negative influence on (disease-free) survival. According to the data currently available, no evidence exists that HRT adversely influences survival and overall survival after treatment for ovarian cancer. In general, adenocarcinomas of the cervix and leiomyosarcomas of the uterus may be managed such as the adenocarcinomas of the uterus. During the last 25 years, HRT has been shown to substantially reduce the risk of cardiovascular diseases, osteoporotic fractures and colon carcinoma. On the other hand there is a significant increase of the risk in breast cancer with prolonged use of > 5 years. Re-evaluation of the current view that HRT should no be given to women treated for a gynaecological malignancy is strongly warranted after evaluating the advantages and the disadvantages of HRT use in each individual patient. Long-term HRT in women treated for a gynaecological cancer must be based on the medical history of the individual patient (and her family).