Nationwide survey of patients' and doctors' perceptions of what is needed in doctor - patient communication in a Southeast Asian context.

BACKGROUND: Asian countries are making efforts to apply the partnership model in doctor-patient communication that has been used effectively in Western countries. However, notable differences between Western and Asian cultures, especially the acceptance of a hierarchical order and little attention to individuality in Asian cultures, could mean that the application of the partnership model in Vietnam requires adaptation. The study aimed to investigate whether communication models used in the Western world are appropriate in Southeast Asia, and to identify key items in doctor-patient communication that should be included in a doctor-patient communication model for training in Vietnam. METHODS: In six provinces, collaborating medical schools collected data from 480 patients using face-to-face surveys with a structured guideline following a consultation session, and from 473 doctors using a cross-sectional survey on how they usually conduct consultation sessions with patients. Data collection tools covered a list of communication skills based on Western models, adapted to fit with local legislation. Using logistic regression, we examined whether doctor patient communication items and other factors were predictors of patient satisfaction. RESULTS: Both patients and doctors considered most elements in the list necessary for good doctor-patient communication. Both also felt that while actual communication was generally good, there was also room for improvement. Furthermore, the doctors had higher expectations than did the patients. Four items in the Western model for doctor-patient communication, all promoting the partnership relation between them, appeared to have lower priority for both patients and doctors in Vietnam. CONCLUSION: The communication model used in the Western world could be applied in Vietnam with minor adaptations. Increasing patients' understanding of their partner role needs to be considered. The implications for medical training in universities are to focus first on the key skills perceived as needing to be strengthened by both doctors and patients. In the longer term, all of these items should be included in the training to prepare for the future.

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.

Prevalence of Diabetic Retinopathy in Urban Slums: The Aditya Jyot Diabetic Retinopathy in Urban Mumbai Slums Study-Report 2.

OBJECTIVES: The aims of the study were to estimate the prevalence of diabetic retinopathy (DR) and enumerate history-based risk factors in the urban slums of Western India. METHODS: The population-based study was conducted in seven wards of Mumbai urban slums, where we screened 6569 subjects of ≥ 40 years age, with a response rate of 98.4%, for type 2 diabetes mellitus (T2DM) based on American Diabetes Association criteria. All subjects with T2DM underwent dilated 30° seven-field stereo-fundus-photography for DR severity grading based on modified Airlie House classification. A multivariate logistic regression model was used to assess the correlation of DR with the history-based risk factors. RESULTS: The prevalence of DR in the general population of Mumbai urban slums was 1.41% (95% CI 0.59-2.23) and in the T2DM population it was 15.37% (95% CI 8.87-21.87). The positive associations with DR were the longer duration of DM (≥ 11 years: OR, 12.77; 95% CI 2.93-55.61) and male gender (OR, 2.05; 95% CI 1.08-3.89); increasing severity of retinopathy was also significantly associated with longer duration of DM (p < 0.001). However, history of hypertension, family history of DM, consanguineous marriage and migration status were not associated with DR in the study population. CONCLUSIONS: The prevalence of DR in the general population and T2DM subjects were 1.41% and 15.37% respectively in Mumbai urban slums. Duration of DM and male gender were significantly associated with DR. The slums in Western India show the trends of urban lifestyle influences similar to the rest of urban India.

Community-based education: The influence of role modeling on career choice and practice location.

INTRODUCTION: Research findings in medical education support the importance of positive role models in enhancing learning and influencing the career path of medical students and graduates. The authors explored the characteristics of positive and negative role models during Community-Based Education and Service (COBES), as well as their effect on trainees' career paths. METHOD: A cross-sectional survey was conducted by means of a questionnaire among medical students to explore the characteristics of positive and negative role models during COBES. Associations between gender, choice of specialty, and practice location were assessed using the chi-square test. All qualitative data analysis was performed using the principles of primary, secondary, and tertiary coding. RESULT: The majority of the students indicated that role modeling during COBES will affect their choice of specialty and practice location with a significant gender difference in terms of practice location (p < 0.005). Qualitative data supported the finding that positive role modeling during COBES may influence graduates willingness to work in rural area. CONCLUSION: The desire and willingness to work in a rural community combined with good communication and excellent interpersonal skills as well as good leadership skills are attributes of good role modeling that could influence medical students' career choice during COBES.

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.

The perceived usefulness of community based education and service (COBES) regarding students' rural workplace choices.

BACKGROUND: Community Based Education and Service (COBES) are those learning activities that make use of the community as a learning environment. COBES exposes students to the public and primary health care needs of rural communities. The purpose of this study was to investigate students' perceived usefulness of COBES and its potential effect on their choice of career specialty and willingness to work in rural areas. METHOD: A mixed method cross sectional study design using semi-structured interviews, questionnaires, and focus group discussions were used for health facility staff, faculty and students and community members. RESULTS: One hundred and seventy questionnaires were administered to students and 134 were returned (78.8% response rate). The majority (59.7%) of students were male. Almost 45% of the students indicated that COBES will have an influence on their choice of career specialty. An almost equal number (44%) said COBES will not have an influence on their choice of career specialty. However, 60.3% of the students perceived that COBES could influence their practice location. More males (64.7%, n = 44) than females (57.8%, n = 26) were likely to indicate that COBES will influence their practice location but the differences were statistically insignificant (p = 0.553). The majority of students, who stated that COBES could influence their practice location, said that COBES may influence them to choose to practice in the rural area and that exposure to different disease conditions among different population groups may influence them in their career choice. Other stakeholders held similar views. Qualitative data supported the finding that COBES could influence medical students' choice of specialty and their practice location. CONCLUSION: Medical students' 'perceptions of the influence of COBES on their choice of career specialty were varied. However, most of the students felt that COBES could influence them to practice in rural locations.

A qualitative interview study on the positive well-being of medical school faculty in their teaching role: job demands, job resources and role interaction.

BACKGROUND: Attention for the well-being of medical school faculty is not only important for the prevention of attrition and burnout, but may also boost performance in their tasks in medical education. Positive well-being can be conceptualized as work engagement and this is associated with increased performance. In this study we explore how demands and resources from different tasks affect work engagement specifically for education. METHODS: Between June and September 2013, we conducted a multisite semi-structured interview study with a diverse group of medical school faculty and used an open-coding strategy within the Work Engagement Model on the transcribed interviews. RESULTS: We interviewed 16 faculty members whose teaching experience ranged from 7 to 38 years and whose professional tasks ranged from being solely an educator to being a physician, researcher, educator and administrator simultaneously. All participants were clear on the perceived demands and resources, although similar aspects of the work environment could be perceived oppositely between participants. Overarching themes were perceptions related to the organization or department, often described as a general and long-term effect and perceptions directly related to a task, often described as a direct and short-term effect on well-being. Furthermore, the demands and resources as resultant of fulfilling multiple tasks were described clearly by participants. CONCLUSIONS: The ambiguous nature of the work environment in terms of demands and resources requires an individualized approach to supporting work engagement. Furthermore, faculty members perceive many resources from fulfilling multiple tasks in relation to their tasks in education. Faculty developers and administrators alike could use these findings to apply the concept of work engagement to their daily support of faculty in medical education.

Effects of a 1 year development programme for recently graduated veterinary professionals on personal and job resources: a combined quantitative and qualitative approach.

BACKGROUND: The early years in professional practice are for many veterinary and medical professionals a period of great challenges and consequently increased stress levels. Personal resources appear to have a positive impact on the course of this transition period. Personal resources are defined as developable systems of positive beliefs about one's self and the world that are generally linked to resilience. They are negatively related to burnout and positively and reciprocally to job resources, work engagement and job performance. With the aim of enhancing personal resources of recently graduated veterinarians, a 1 year multi-modular resources development programme was designed. This study was conducted to analyse: 1. if and how the development programme affected participants' personal resources, and 2. if and how personal resources affected participants' work characteristics and work engagement. RESULTS: Quantitative study: Twenty-five participants and ten non-participants completed an online survey covering personal resources, job resources and work engagement at the start and finish of the programme. Results showed a significant increase of personal resources in participants for self-reported ratings of proactive behaviour (Effect Size=-0.4), self-efficacy (Effect Size=-0.6) and reflective behaviour (Effect Size=-0.6). Results of the control group were not significant, although some moderate effect sizes were found. Qualitative study: Additionally 16 semi-structured interviews with participants of the programme were taken 6 months after finishing the programme. Analysis of the interviews revealed that participants also developed other important personal resources namely self-acceptance, self-esteem, awareness of own influence and responsibility. The reflection process, which took place in the course of the programme, seemed to be a necessary step for the development of the other personal resources. According to participants of the resources development programme, the increase in personal resources also gave rise to an increase in job resources. CONCLUSION: The multi-modular resources development programme seems to support development of participants' personal resources. Because personal resources are beneficial in improving well-being irrespective of where an individual starts working, it is important to give them explicit attention in educational settings.

Making sense of how physician preceptors interact with medical students: discourses of dialogue, good medical practice, and relationship trajectories.

Work based learning and teaching in health care settings are complex and dynamic. Sociocultural theory addresses this complexity by focusing on interaction between learners, teachers, and their environment as learners develop their professional identity. Although social interaction between doctors and students plays a crucial role in this developmental process, socio-cultural research from the perspective of doctors is scarce. We performed discourse analysis on seven general practitioners' audio diaries during a 10-week general practice clerkship to study how they gave shape to their interaction with their students. Examination of 61 diary-entries revealed trajectories of developing relationships. These trajectories were initiated by the way respondents established a point of departure, based on their first impression of the students. It continued through the development of dialogue with their student and through conceptualizations of good medical practice. Such conceptualizations about what was normal in medical and educational practice enabled respondents to recognize qualities in the student and to indirectly determine students' desired learning trajectory. Towards the end, discursive turns in respondents' narratives signaled development within the relationship. This became evident in division of roles and positions in the context of daily practice. Although respondents held power in the relationships, we found that their actions depended strongly on what the students afforded them socially. Our findings address a gap in literature and could further inform theory and practice, for example by finding out how to foster constructive dialogue between doctors and students, or by exploring different discourses among learners and teachers in other contexts.

Measuring potential predictors of burnout and engagement among young veterinary professionals; construction of a customised questionnaire (the Vet-DRQ).

The Job Demands-Resources model (JD-R model) was used as the theoretical basis of a tailormade questionnaire to measure the psychosocial work environment and personal resources of recently graduated veterinary professionals. According to the JD-R model, two broad categories of work characteristics that determine employee wellbeing can be distinguished: job demands and job resources. Recently, the JD-R model has been expanded by integrating personal resource measures into the model. Three semistructured group interviews with veterinarians active in different work domains were conducted to identify relevant job demands, job resources and personal resources. These demands and resources were organised in themes (constructs). For measurement purposes, a set of questions ('a priori scale') was selected from the literature for each theme. The full set of a priori scales was included in a questionnaire that was administered to 1760 veterinary professionals. Exploratory factor analysis and reliability analysis were conducted to arrive at the final set of validated scales (final scales). 860 veterinarians (73 per cent females) participated. The final set of scales consisted of seven job demands scales (32 items), nine job resources scales (41 items), and six personal resources scales (26 items) which were considered to represent the most relevant potential predictors of work-related wellbeing in this occupational group. The procedure resulted in a tailormade questionnaire: the Veterinary Job Demands and Resources Questionnaire (Vet-DRQ). The use of valid theory and validated scales enhances opportunities for comparative national and international research.

Burnout and engagement, and its predictors in young veterinary professionals: the influence of gender.

With the aim to assess levels of burnout and work engagement in junior veterinarians and identify predictors of burnout and work engagement in male and female veterinarians, 1760 veterinarians who had graduated in The Netherlands between 1999 and 2009, received an electronic questionnaire. Veterinarians numbering 860 (73 per cent females) participated. Levels of exhaustion, cynicism and work engagement were significantly lower compared to the norm group (a random sample of the Dutch working population). Male veterinarians were less exhausted and more engaged than female veterinarians. Exhaustion decreased over the years. Job demands positively related to exhaustion were work-home interference and workload. Job resources positively related to work engagement were opportunities for professional development and skills discretion (ie, the ability to use and develop skills on the job. Personal resources explained more of the variance in work engagement of female and male veterinarians (31 per cent and 42 per cent) than of the variance in exhaustion (19 per cent and 21 per cent) and cynicism (19 per cent and 10 per cent). Personal resources positively related to work engagement were self-efficacy and proactive behaviour. Relative importance analysis revealed differences between men and women in the importance of various job demands, job resources and personal resources in explaining burnout and engagement in young veterinary professionals.

Students' perceptions of aspects affecting seminar learning.

BACKGROUND: Many medical and veterinary schools have curricula in which they use seminars of approximately 25 students to achieve their learning goals. There is not much research on seminar learning. AIM: To explore students' views regarding aspects that affect seminar learning. METHODS: Twenty-four second-year students of a 3-year bachelor curriculum participated in semi-structured focus group interviews. The sessions were audio-taped and transcribed. Two researchers independently coded the data using qualitative methods. An iterative process of data reduction resulted in emerging aspects. The participating students were asked to comment on the preliminary results. RESULTS: Course schedule, coherence and alignment of the different educational methods, the amount and type of seminar questions and the amount and clarity of the preparation materials affected seminar learning. Also, the didactic approach and facilitating methods used by the teachers, the group composition, size and atmosphere, the amount of active student participation and interaction and assessment influenced seminar learning according to students. CONCLUSION: Most aspects that affect seminar learning are consistent with aspects affecting small group learning. Course schedule and alignment seem to have a stronger impact on seminar learning.

Patients' appreciation of pre-clinical student performance in primary healthcare centres in Indonesia.

INTRODUCTION: In Indonesia, primary healthcare (PHC) centres are among the eligible institutions to provide 'early clinical experiences' (ECE) for pre-clinical medical students. This study explored whether patients of PHC centres would accept third-year pre-clinical students practicing clinical skills with them. METHODS: Immediately after being seen by a pre-clinical student--supervised by a general physician--76 patients of PHC centres participated in a structured, eight-question interview. Interviews were transcribed verbatim and coded to collate and interpret answers to the questions. RESULTS: Most of the patients were satisfied with the clinical performance of their pre-clinical student. Negative comments regarding some students addressed lack of confidence, being nervous, unable to provide satisfactory explanation and education and failure to speak the local language. Some patients suggested more practice for these students in PHC centres. CONCLUSION: Patients in Indonesian PHC centres generally appreciated health services provided by pre-clinical medical students; no significant objections were recorded. This supports the suitability of these PHC centres to offer ECE for pre-clinical students.

Teaching conceptions and approaches to teaching of medical school faculty: the difference between how medical school teachers think about teaching and how they say that they do teach.

BACKGROUND: It is often assumed that the way teachers approach their teaching is determined by the way they think about learning. This study explores how teachers of an undergraduate medical programme (UMP) think about learning, how they approach teaching and whether their conceptions of learning relate to their teaching approaches. METHODS: Quantitative data of academic teachers involved in the undergraduate programme in medicine were collected and analysed. We used a questionnaire designed to measure teachers' conceptions of their own learning (COL) and of student learning as well as teachers' approaches to teaching (AT). RESULTS: Teachers of the medical undergraduate programme hold a variety of COL, of how students learn and their AT. No significant correlations were found between teachers' conceptions of learning and their AT. CONCLUSIONS: Although UMP teachers' ideas on learning and teaching are very diverse, some of their conceptions are interrelated. Teachers' ideas on their own learning is sometimes - but not always - related to how they think about student learning. But most importantly, the way UMP teachers think about learning is not automatically converted into the way they approach teaching.

Effects of partial substitution of pre-clinical skills training by attachments to primary health care centers: An experimental study.

BACKGROUND: Recent studies indicate that students may encounter problems when they have to apply clinical skills learned in a skills laboratory to patients. To facilitate this transition, it has been advised to include patient contacts early in the pre-clinical curriculum. OBJECTIVE: To compare clinical skills performance and level of preparedness for entering the clerkships between students who were prepared exclusively in a skills laboratory and peers for whom part of their skills training program was substituted by training in a primary health care (PHC) center. METHODS: Pre-clinical students either trained clinical skills exclusively in a skills laboratory while their peers attended a mixed program of laboratory trainings and practice in PHC centers. Students' perception of preparedness for the clerkships was explored through the Preparation for Hospital Practice Questionnaire. Students' clinical skills were assessed by an Objective Structured Clinical Examination (OSCE) and by supervisors in PHC centers. RESULTS: Students following the mixed program felt better prepared for their clerkships than skills lab-trained peers. Students' perceptions were supported by assessments by their supervisors. However, mean OSCE scores of both groups did not differ significantly. CONCLUSION: PHC centers can be involved to better prepare pre-clinical students for their clerkships.

An evidence-based mobile decision support system for subaxial cervical spine injury treatment.

Bringing evidence to practice is a key issue in modern medicine. The key barrier to information searching is time. Clinical decision support systems (CDSS) can improve guideline adherence. Mounting evidence exists that mobile CDSS on handheld computers support physicians in delivering appropriate care to their patients. Subaxial cervical spine injuries account for almost half of spine injuries, and a majority of spinal cord injuries. A valid and reliable classification exists, including evidence-based treatment algorithms. A mobile CDSS on this topic was not yet available. We developed and tested an iPhone application based on the Subaxial Injury Classification (SLIC) and 5 evidence-based treatment algorithms for the surgical approach to subaxial cervical spine injuries. The application can be downloaded for free. Users are cordially invited to provide feedback in order to direct further development and evaluation of CDSS for traumatic lesions of the spinal column.

Comparison of three clinical environments for pre-clinical clinical skills training.

OBJECTIVES: Primary health care (PHC), secondary health care (SHC), and tertiary health care (THC) were compared in search of the most suitable setting for clinical skills training of pre-clinical students. METHODS: The Dundee Ready Educational Environment Measure questionnaire was presented to 300 clerkship students of the Faculty of Medicine at Gadjah Mada University, Indonesia who were attached to PHC, SHC, and THC settings. Students were asked to assess their current attachment for suitability for training of pre-clinical students. Semi-structured interviews were held with 46 clinical supervisors based on the three types of settings. RESULTS: Clerkship students preferred PHC centers over SHC and THC hospitals for clinical skills training of pre-clinical students (p < 0.05). PHC staff felt their centers to be well-equipped to train pre-clinical students, including availability of supervisors' time for teaching, adequate physical facilities and equipment, and suitable patient cases. CONCLUSION: In the developing country context, PHC centers seemed more appropriate for clinical skills training of pre-clinical students than SHC and THC hospitals. However, the skills laboratory must guard that clinical skills are trained and performed in the same way in that facility, in PHC centers and in teaching hospitals.

Exploring the validity and reliability of a questionnaire for evaluating veterinary clinical teachers' supervisory skills during clinical rotations.

BACKGROUND: Feedback to aid teachers in improving their teaching requires validated evaluation instruments. When implementing an evaluation instrument in a different context, it is important to collect validity evidence from multiple sources. AIM: We examined the validity and reliability of the Maastricht Clinical Teaching Questionnaire (MCTQ) as an instrument to evaluate individual clinical teachers during short clinical rotations in veterinary education. METHODS: We examined four sources of validity evidence: (1) Content was examined based on theory of effective learning. (2) Response process was explored in a pilot study. (3) Internal structure was assessed by confirmatory factor analysis using 1086 student evaluations and reliability was examined utilizing generalizability analysis. (4) Relations with other relevant variables were examined by comparing factor scores with other outcomes. RESULTS: Content validity was supported by theory underlying the cognitive apprenticeship model on which the instrument is based. The pilot study resulted in an additional question about supervision time. A five-factor model showed a good fit with the data. Acceptable reliability was achievable with 10-12 questionnaires per teacher. Correlations between the factors and overall teacher judgement were strong. CONCLUSIONS: The MCTQ appears to be a valid and reliable instrument to evaluate clinical teachers' performance during short rotations.

Workplace learning from a socio-cultural perspective: creating developmental space during the general practice clerkship.

Workplace learning in undergraduate medical education has predominantly been studied from a cognitive perspective, despite its complex contextual characteristics, which influence medical students' learning experiences in such a way that explanation in terms of knowledge, skills, attitudes and single determinants of instructiveness is unlikely to suffice. There is also a paucity of research which, from a perspective other than the cognitive or descriptive one, investigates student learning in general practice settings, which are often characterised as powerful learning environments. In this study we took a socio-cultural perspective to clarify how students learn during a general practice clerkship and to construct a conceptual framework that captures this type of learning. Our analysis of group interviews with 44 fifth-year undergraduate medical students about their learning experiences in general practice showed that students needed developmental space to be able to learn and develop their professional identity. This space results from the intertwinement of workplace context, personal and professional interactions and emotions such as feeling respected and self-confident. These forces framed students' participation in patient consultations, conversations with supervisors about consultations and students' observation of supervisors, thereby determining the opportunities afforded to students to mind their learning. These findings resonate with other conceptual frameworks and learning theories. In order to refine our interpretation, we recommend that further research from a socio-cultural perspective should also explore other aspects of workplace learning in medical education.

Workplace learning in general practice: supervision, patient mix and independence emerge from the black box once again.

BACKGROUND: Medical students increasingly participate in rotations in primary care settings, such as general practices. Although general practices can differ markedly from hospital settings, research on the instructional quality of general practice rotations is relatively scarce. AIM: We conducted a study to identify which aspects make a significant contribution to the instructional quality of general practice clerkships, as perceived by students. METHOD: After completing their general practice attachment, 155 fifth-year medical students filled out an evaluation questionnaire. Exploratory factor analysis and reliability analysis identified clusters of correlated independent variables. Subsequent regression analysis revealed the relations between the reduced set of independent variables and the dependent variable 'Instructional quality'. RESULTS: Both the quality of supervision and the size and diversity of the patient mix substantially affected students' experienced instructional quality. Opportunities and facilities to perform independently were correlated with instructional quality, but did not affect the instructiveness directly. CONCLUSIONS: Supervision, patient mix and independence are crucial factors for learning in general practice. This is consistent with findings in hospital settings. The perceived quality of instruction hinges on supervision, which is not only the variable most strongly related to instructional quality, but which also affects both the patient mix and students' independence.