A Training Game for Students Considering Family Medicine: an Educational Project Report.

The Groningen Institute Model for Management in Care Services aims to prepare medical students for their complex tasks as family physicians, based on the CanMEDS framework. Although initially developed for pharmacy students, the present paper reports on the eight-year experience with GIMMICS for family physician students at the Vrije Universiteit Brussel. The Groningen Institute Model for Management in Care Services is a training game that simulates real-life situations in a structured and supervised setting. It offers students the possibility to practice clinical, practical, and communicational skills. Students install and manage their group practices, hold consultations with simulated patients, participate in several assignments and collaborate with pharmacy students. Feedback sessions showed that the training game is well-received by the students. A self-assessment questionnaire comprised of 23 questions on significant aspects of the seven CanMEDS roles showed significantly higher scores at the end of the game for 17 questions (p<0.05, Wilcoxon signed-rank test ). GIMMICS is a valuable linking pin between the different learning methods in medical education and clinical practice, helping students to improve themselves in the CanMEDS roles. However, simulation-based medical education requires significant time and resource investment.

Cost-effectiveness of screening for active cases of tuberculosis in Flanders, Belgium.

OBJECTIVE: To assess the cost-effectiveness of the tuberculosis screening activities currently funded by the Flemish government in Flanders, Belgium. METHODS: After estimating the expenses for 2013-2014 of each of nine screening components - which include high-risk groups, contacts and people who are seeking tuberculosis consultation at a centre for respiratory health care - and the associated costs per active case of tuberculosis identified between 2007 and 2014, we compared the cost-effectiveness of each component. The applied perspective was that of the Flemish government. FINDINGS: The three most cost-effective activities appeared to be the follow-up of asylum seekers who were found to have abnormal X-rays in initial screening at the Immigration Office, systematic screening in prisons and contact investigation. The mean costs of these activities were 5564 (95% uncertainty interval, UI: 3791-8160), 11 603 (95% UI: 9010-14 909) and 13 941 (95% UI: 10 723-18 201) euros (€) per detected active case, respectively. The periodic or supplementary initial screening of asylum seekers and the screening of new immigrants from high-incidence countries - which had corresponding costs of €51 813 (95% UI: 34 855-76 847), €126 236 (95% UI: 41 984-347 822) and €418 359 (95% UI: 74 975-1 686 588) - appeared much less cost-effective. Between 2007 and 2014, no active tuberculosis cases were detected during screening in the juvenile detention centres. CONCLUSION: In Flanders, tuberculosis screening in juvenile detention centres and among new immigrants and the periodic or supplementary initial screening of asylum seekers appear to be relatively expensive ways of detecting people with active tuberculosis.

Influence of methylphenidate treatment assumptions on cognitive function in healthy young adults in a double-blind, placebo-controlled trial.

BACKGROUND: Increasing numbers of students use stimulants such as methylphenidate (MPH) to improve their study capacity, making them prone to subsequent prolonged drug abuse. This study explored the cognitive effects of MPH in students who either assumed they received MPH or assumed they received a placebo. METHODS: In a double-blind, randomized, placebo-controlled trial with a between-subjects design, 21 students were subjected to partial sleep deprivation, receiving no more than 4 hours sleep the night before they were tested. In the morning, they were given either a placebo or 20 mg of MPH. They then performed free recall verbal tests and Go/No-Go tasks repeatedly, their moods were evaluated using Profile of Mood States and their tiredness was assessed using a visual analog scale, with evaluation of vigilance. RESULTS: No significant differences were found between those subjects who received MPH and those who received a placebo. However, significant differences were found between subjects who assumed they had received MPH or had no opinion, and those who assumed they had received a placebo. At three minutes, one hour, and one day after memorizing ten lists of 20 words, those who assumed they had received MPH recalled 54%, 58%, and 54% of the words, respectively, whereas those who assumed they had received placebo only recalled 35%, 37%, and 34%. CONCLUSION: Healthy, partially sleep-deprived young students who assume they have received 20 mg of MPH experience a substantial placebo effect that improves consolidation of information into long-term memory. This is independent of any pharmacologic effects of MPH, which had no significant effects on verbal memory in this study. This information may be used to dissuade students from taking stimulants such as MPH during examination periods, thus avoiding subsequent abuse and addiction.

Patient health information materials in waiting rooms of family physicians: do patients care?

BACKGROUND: Patient health information materials (PHIMs), such as leaflets and posters are widely used by family physicians to reinforce or illustrate information, and to remind people of information received previously. This facilitates improved health-related knowledge and self-management by patients. OBJECTIVE: This study assesses the use of PHIMs by patient. It also addresses their perception of the quality and the impact of PHIMs on the interaction with their physician, along with changes in health-related knowledge and self-management. METHODS: QUESTIONNAIRE SURVEY AMONG PATIENTS OF FAMILY PRACTICES OF ONE TOWN IN BELGIUM, ASSESSING: (1) the extent to which patients read PHIMs in waiting rooms (leaflets and posters) and take them home, (2) the patients' perception of the impact of PHIMs on interaction with their physician, their change in health-related knowledge and self-management, and (3) the patients judgment of the quality of PHIMs. RESULTS: We included 903 questionnaires taken from ten practices. Ninety-four percent of respondents stated they read PHIMs (leaflets), 45% took the leaflets home, and 78% indicated they understood the content of the leaflets. Nineteen percent of respondents reportedly discussed the content of the leaflets with their physician and 26% indicated that leaflets allowed them to ask fewer questions of their physician. Thirty-four percent indicated that leaflets had previously helped them to improve their health-related knowledge and self-management. Forty-two percent reportedly discussed the content of the leaflets with others. Patient characteristics are of significant influence on the perceived impact of PHIMS in physician interaction, health-related knowledge, and self-management. CONCLUSION: This study suggests that patients value health information materials in the waiting rooms of family physicians and that they perceive such materials as being helpful in improving patient-physician interaction, health-related knowledge, and self-management.

'More shades of grey in my answers': an interview study revisiting attitude erosion during clerkships.

CONTEXT: Small declines in patient-centred attitudes during medical education have caused great concern. Although some of the self-report scales applied have solid psychometric foundations, validity evidence for the interpretation of attitude erosion during clerkships remains weak. OBJECTIVES: We sought to address this gap in a qualitative study of the relationships between scores on four commonly used attitude scales and participants' experiences and reflections. Our aim was to gain a better understanding of the score changes from the participants' perspectives. METHODS: We conducted semi-structured interviews with 15 junior doctors from a cohort (n = 37) that had previously shown a small decline in patient-centred attitudes during clerkships, measured on four self-report scales. In the interviews, we explored interviewees' experiences of their development of patient-centredness and subsequently discussed their scale scores, particularly for those items that contributed to a rise or decline in scores. We analysed the data using a process of constant comparison among personal experiences, scale scores and participants' explanations of score changes, applying the coding techniques of grounded theory. RESULTS: The analysis revealed important response distortions that might be responsible for small declines in scores during clerkships separately from changes in attitudes. The drastic alterations to the participants' frame of reference, attributable to the transition to clinical practice, represented the most prominent cause of distortion. More nuanced, context-specific, patient-centred reasoning resulted in more neutral responses after clerkships, paradoxically causing a decline in scores. In addition to response distortions, the interviews revealed shortcomings in content validity such as an 'extreme' construct of patient-centredness. CONCLUSIONS: This study calls into question the validity of the interpretation of attitude erosion during clerkships. The findings suggest that small declines in scores on self-report attitude scales are related to a recalibration of trainees' understandings of patient-centredness as they grow more clinically experienced. The evolved construct of patient-centredness and the way attitudes are measured require special attention in the development of future instruments.

Patient-centredness from education to practice: the 'lived' impact of communication skills training.

BACKGROUND: Although communication skills training (CST) enhances patient-centred skills and attitudes, the literature indicates a problematic transfer of these from education into practice. AIM: We explored 'lived' experiences of medical students and doctors to gain a better understanding of the impact of CST on patient-centredness in the transition to real practice. METHODS: From a phenomenological perspective, we conducted 15 interviews and 11 focus groups with 4-9 participants/group (n = 67) at two universities and carried out constant comparative analysis. RESULTS: The gap between education and practice is the central phenomenon. Although CST raises students' communication awareness and self-efficacy in an 'ideal' context, this paradoxically seems to jeopardize their ability to bridge the gulf. In addition, CST does not come to grips with students' attitudes. However, CST appears to be successful in equipping students with long-lasting 'handles'. Yet students need more support to mould the provided 'ideal' models into their own unique style of context-specific patient-centred behaviour. This implies: raising students' awareness of own attitudes and communication styles, offering a more realistic training ground, integrating CST with clinical experience and translating the primary-care-rooted concept of patient-centredness into various specialization contexts. CONCLUSION: CST could raise its impact by supporting students' recycling processes towards a personal style of context-sensitive patient-centredness.

Medical students trained in communication skills show a decline in patient-centred attitudes: an observational study comparing two cohorts during clinical clerkships.

OBJECTIVE: Literature indicates a decline in patient-centredness in medical students, especially during clinical clerkships. We examined the impact of preclinical communication skills training (CST) on students' development of patient-centred attitudes and attitudes toward CST during clerkships. METHODS: We prospectively compared two cohorts before and after clerkships: one cohort (n=48) had not received CST, whereas the other (n=37) had received a five-year CST. We assessed the impact using five validated questionnaires. RESULTS: Communication trained students slightly but significantly declined in patient-centred attitudes (3/4 scales) and attitudes toward CST during clerkships, whereas the scores of the untrained students remained stable (5/5 scales). Both cohorts did not differ in attitudes before clerkships. In the trained cohort, males mostly showed a sharper decline than females. In the total group (n=85), females demonstrated higher attitude scores toward CST, and in 1/4 scales measuring patient-centred attitudes. CONCLUSION: This cohort study suggests that CST might make students more vulnerable to decline in attitude scores during clerkships. PRACTICE IMPLICATIONS: These remarkable findings, contrary to what educators would expect to result from their efforts, challenge medical education to address the new questions that are raised about the validity of the questionnaires, the impact of CST and the learning processes involved in the development of patient-centredness.

Help, I'm losing patient-centredness! Experiences of medical students and their teachers.

OBJECTIVES: Despite all educational efforts, the literature shows an ongoing decline in patient-centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient-centredness in order to gain a better understanding of the factors that determine its development. METHODS: We conducted 11 focus groups on the subject of learning and teaching about patient-centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the 'sensitising concepts' provided by the Attitude-Social Influence-Self-Efficacy (ASE) model. RESULTS: Although students express positive attitudes towards patient-centredness and acquire patient-centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today's challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient-centred skills. However, when students lack self-efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non-patient-centred role models and are overwhelmed by powerful experiences, they lose their patient-centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self-awareness and self-care are important qualities of the central phenomenon of the 'doctor-as-person', which is identified as a missing concept in the ASE model. The student-supervisor relationship is found to be key to learning patient-centredness and has several functions: it facilitates the direct transmission of patient-centred skills, knowledge and attitudes; it provides social support of students' patient-centred behaviour; it provides support of the 'student-as-person'; it mirrors patient-centredness by being student-centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student-centred education and guidance be offered, self-awareness be fostered and more opportunities to encounter patients be created, including more time in general practice. CONCLUSIONS: Supportive student-doctor relationships, student-centred education and guidance that addresses the needs of the doctor-as-person are central to the development of patient-centredness. Medical education requires patient-centred, self-caring and self-aware role models.

Individualised training to improve teaching competence of general practitioner trainers: a randomised controlled trial.

INTRODUCTION: In Flanders an important part of training to become a general practitioner (GP) is undertaken within a general practice. This requires a GP trainer to know how to facilitate learning processes. This paper reports a study focused on the research question: Does short but individualised training of GP trainers contribute to their teaching competence? METHOD: A total of 47 GP trainers were randomly divided into 2 groups of a pretest/post-test control group design. After a multiple-station teaching assessment test (MSTAT), the experimental group received a short but individualised training to improve teaching competence while the control group were given no specific programme regarding teaching competence. One year later, all participants were invited to sit the post-test. RESULTS: In all, 61 GP trainers participated in the pretest and 51 in the post-test; 44 GP trainers participated in both tests. Despite the large attrition, the internal validity of the experiment was preserved. Beginners gained a median score of 2.04 (on a scale of 0-5) on the first MSTAT. In the post-test, the experimental group (median = 3.12) scored significantly better on the entire test (Mann-Whitney U = 166.5, P < 0.05) compared with the control group (median = 2.84). However, the GP trainers in the control group also appeared to have made progress. CONCLUSION: General practitioners who start as GP trainers have insufficient teaching competence to guarantee good coaching of students. A personal programme leads to progress in teaching competence; however, it would seem that more time and support are necessary to allow GP trainers to gain full teaching competence. The fact that the control group made progress as well suggests that the test had an important learning effect.