Addressing the hidden curriculum in the clinical workplace: A practical tool for trainees and faculty.

INTRODUCTION: The hidden curriculum, commonly described in negative terms, is considered highly influential in medical education, especially in the clinical workplace. Structured approaches to address it are limited in number and scope. METHODS AND RESULTS: This paper presents a practical, value-neutral method called REVIEW (Reflecting & Evaluating Values Implicit in Education in the Workplace), to facilitate reflection and discussion on the hidden curriculum by faculty members and trainees. REVIEW approaches the hidden curriculum as a reflection of the professional microculture of a clinical team. This microculture results from collective problem solving and mutual negotiation when facing different, often conflicting, demands and interests, and their underlying values in daily clinical practice. Using this nonjudgmental conceptual framework, REVIEW employs a series of 50 culture statements that must be prioritized using Q-sort methodology, reflecting how the culture in a particular clinical context (e.g. ward or department) is perceived by faculty members and trainees. This procedure can be done individually or in groups. Most important is the resulting team discussion after the exercise - a discussion about perceptions of actual team culture and the culture desired by the team. DISCUSSION AND CONCLUSIONS: Our early experiences suggest that REVIEW can be a useful tool for addressing the hidden curriculum.

[Active career management needed for female doctors]. / Actiever carrièrebeleid nodig voor vrouwelijke artsen.

For more than 15 years two-thirds of medical students have been women. Despite this, they represent a minority (16-25 %) of professors in academic medicine. There is still a major gender gap to the disadvantage of women in leading positions in academia, with women earning only 80% of the salary of their male counterparts and fewer opportunities for scientific grants. Recent studies have shown that career ambition among men and women in medicine is comparable. However, successful women more often doubt their own achievements than men do. This is known as the 'imposter phenomenon' and acts as a barrier to career progression. Female leadership should be more actively promoted and encouraged to establish the diversity and creativity that we need in our current healthcare system.

Characterizing physicians' information needs at the point of care.

Physicians have many information needs that arise at the point of care yet go unmet for a variety of reasons, including uncertainty about which information resources to select. In this study, we aimed to identify the various types of physician information needs and how these needs relate to physicians' use of the database PubMed and the evidence summary tool UpToDate. We conducted semi-structured interviews with physicians (Stanford University, United States; n = 13; and University Medical Center Utrecht, the Netherlands; n = 9), eliciting participants' descriptions of their information needs and related use of PubMed and/or UpToDate. Using thematic analysis, we identified six information needs: refreshing, confirming, logistics, teaching, idea generating and personal learning. Participants from both institutions similarly described their information needs and selection of resources. The identification of these six information needs and their relation to PubMed and UpToDate expands upon previously identified physician information needs and may be useful to medical educators designing evidence-based practice training for physicians.

Educational interventions to improve the meaningful use of Electronic Health Records: a review of the literature: BEME Guide No. 29.

BACKGROUND: Electronic health records (EHRs) are increasingly available and this was expected to reduce healthcare costs and medical errors. This promise has not been realized because healthcare professionals are unable to use EHRs in a manner that contributes to significant improvements in care, i.e. meaningful. Policymakers now acknowledge that training healthcare professionals in meaningful use is essential for successful EHR implementation. To help educators and policymakers design evidence based educational interventions (i.e. interventions that involve educational activities but no practical lessons) and training (i.e. interventions that involve practical components), we summarized all evidence regarding the efficacy of different educational interventions to improve meaningful use of EHRs. METHODS: We used a predefined search filter to search eight databases for studies that considered an educational intervention to promote meaningful use of EHRs by healthcare professionals. RESULTS: Seven of the 4507 reviewed articles met the in- and exclusion criteria. CONCLUSIONS: These studies suggest that a combination of classroom training, computer-based training and feedback is most effective to improve meaningful use. In addition, the training should be tailored to the needs of the trainees and they should be able to practice in their own time. However, the evidence is very limited and we recommend that governments, hospitals and other policymakers invest more in the development of evidence based educational interventions to improve meaningful use of EHRs.

Mentoring portfolio use in undergraduate and postgraduate medical education.

AIM: Mentoring is widely acknowledged as being crucial for portfolio learning. The aim of this study is to examine how mentoring portfolio use has been implemented in undergraduate and postgraduate settings. METHOD: The results of interviews with six key persons involved in setting up portfolio use in medical education programmes were used to develop a questionnaire, which was administered to 30 coordinators of undergraduate and postgraduate portfolio programmes in the Netherlands and Flanders. RESULTS: The interviews yielded four main aspects of the portfolio mentoring process--educational aims, individual meetings, small group sessions and mentor characteristics. Based on the questionnaire data, 16 undergraduate and 14 postgraduate programmes were described. Providing feedback and stimulating reflection were the main objectives of the mentoring process. Individual meetings were the favourite method for mentoring (26 programmes). Small group sessions to support the use of portfolios were held in 16 programmes, mostly in the undergraduate setting. In general, portfolio mentors were clinically qualified academic staff trained for their mentoring tasks. CONCLUSION: This study provides a variety of practical insights into implementing mentoring processes in portfolio programmes.

Maternal hypoglycemia during pregnancy in type 1 diabetes: maternal and fetal consequences.

There is strong evidence that the avoidance of hyperglycemia is essential inoptimizing pregnancy outcome in type 1 diabetes. The price to pay is a striking increase in severe hypoglycemia (SH), defined as episodes requiring help from another person. During type 1 diabetic pregnancy, occurrence rates of SH up to 15 times higher as in the intensively treated group of the Diabetes Control and Complications Trial (DCCT) are reported. Blood glucose (BG) treatment targets differ considerably between clinics; some authors advocate lower limits as low as 3.3 mmol/l. Improved glycemic control and/or recurrent hypoglycemia (i.e. BG <3.9 mmol/l) may result in impairment of glucose counterregulatory responses. Also, glucose counterregulation may be altered by pregnancy itself. Short-acting insulin analogs may help reduce hypoglycemia with preservation of good glycemic control, but their use during pregnancy has yet to be proven safe.Several clinical studies did not establish an association between maternal hypoglycemia and diabetic embryopathy. However, animal studies clearly indicate that hypoglycemia is potentially teratogenic during organogenesis. Increased rates of macrosomia continue to be observed despite near normal HbA(1c) levels. This may, at least in part, be the result of rebound hyperglycemia elicited by hypoglycemia. Exposure to hypoglycemia in utero may have long-term effects on offspring including neuropsychological defects. It is yet unclear to what extent the benefits of tight glycemic control balance with the increased risk of (severe) hypoglycemia during type 1 diabetic pregnancy. Efforts must be made to avoid low BG, i.e. <3.9 mmol/l, when tightening glycemic control.

Risk indicators predictive for severe hypoglycemia during the first trimester of type 1 diabetic pregnancy.

OBJECTIVES: To investigate the frequency of severe hypoglycemia (SH) and hypoglycemic coma during the first trimester of type 1 diabetic pregnancy and in the 4 months before gestation and to identify risk indicators predicting first trimester SH in a nonselected nationwide cohort of pregnant women with type 1 diabetes. RESEARCH DESIGN AND METHODS: We conducted a longitudinal cohort survey in 278 pregnant type 1 diabetic women using questionnaires at inclusion and at 17 weeks of gestation, addressing the frequencies of SH (i.e., external help required) and hypoglycemic coma, general characteristics, hypoglycemia awareness, blood glucose symptom threshold, and the Hypoglycemia Fear Survey. RESULTS: The occurrence of SH (including hypoglycemic coma) rose from 0.9 +/- 2.4 episodes per 4 months before gestation to 2.6 +/- 6.3 episodes during the first trimester (P < 0.001), including an increase in episodes of coma from 0.3 +/- 1.3 to 0.7 +/- 3.7 (P=0.03). The proportion of women affected by SH rose from 25 to 41% (P < 0.001). First-trimester SH was independently related to a history of SH before gestation (odds ratio [95%CI]: 9.2 [3.9-21.7]), a 10 years' longer diabetes duration (1.6 [1.0-2.4]), an HbA1c level < or = 6.5% (2.5 [1.3-5.0]), and a 0.1 unit/kg higher daily insulin dose (5.4 [1.5-18.9]), adjusted for a decreased symptom threshold. CONCLUSIONS: In type 1 diabetic pregnancy, the risk of SH is increased already before pregnancy and rises further during the first trimester. A history of SH before gestation, longer duration of diabetes, an HbA1c level < or = 6.5%, and a higher total daily insulin dose were risk indicators predictive for SH during the first trimester. Further research should aim to elucidate how the benefits of strict glycemic control balance with the markedly increased risk of SH early in pregnancy.

The sulfonylurea glyburide induces impairment of glucagon and growth hormone responses during mild insulin-induced hypoglycemia.

OBJECTIVE: The sulfonylurea (SU) glyburide may cause severe and prolonged episodes of hypoglycemia. We aimed at investigating the impact of glyburide on glucose counterregulatory hormones during stepwise hypoglycemic clamp studies. RESEARCH DESIGN AND METHODS: We performed stepwise hypoglycemic clamp studies in 16 healthy volunteers (7 women and 9 men aged 44 +/- 10 years). We investigated counterregulatory hormonal and symptom responses at arterialized venous plasma glucose levels (PG) of 3.8, 3.2, and 2.6 mmol/l, comparing 10 mg glyburide orally and placebo in a double-blind, randomized crossover fashion. RESULTS: The increase in plasma glucagon with time from PG = 3.8 onward was smaller for glyburide than for placebo (P = 0.014). Plasma glucagon area under the curve (AUC)(60-180) was lower after glyburide than after placebo (1,774 +/- 715 vs. 2,161 +/- 856 pmol. l(-1). min, P = 0.014). From PG = 3.8 onward, plasma growth hormone (GH) levels with placebo were nearly two times (1.9 [95% CI 1.2-2.9]) as high as with glyburide (P = 0.011). AUC(60-180) for GH was lower after glyburide than after placebo (geometric mean [range] 665 [356-1,275] and 1,058 [392-1,818] mU. l(-1). min, respectively; P = 0.04). No significant differences were observed for plasma cortisol, epinephrine and norepinephrine, or incremental symptom scores. CONCLUSIONS: The SU glyburide induces multiple defects in glucose counterregulatory hormonal responses, notably decreases in both glucagon and GH release.