Crew Resource Management Training for Surgical Teams, A Fragmented Landscape.

OBJECTIVE: Medical Crew Resource Management (CRM) training courses are designed to increase patient safety by reducing the effects of human errors. These training courses are most popular in surgery and a wide range of medical CRM training courses for surgical teams is now available. However, the effects of these CRM training courses on patient outcomes are inconclusive. Although surgical teams feel the need to be trained in team collaboration skills, they are often puzzled about what criteria to apply when choosing a medical CRM training course. This study aimed to compare CRM training courses on didactic components and simulation-exercises to explore if these courses are interchangeable. METHODS: In this qualitative study, semi-structured interviews were conducted among 10 main CRM training providers of surgical teams in the Netherlands. RESULTS: Although a large variety was found in the content of CRM training courses, the most substantial differences were found in the simulation-exercises. Nine out of 10 trainers stated that standard simulation-exercises would be a step forward to ensure quality in CRM trainings. According to the trainers, the implementation of medical CRM can reduce human errors and as a result, preventable patient complications. They suggested a quality standard for CRM trainers in the medical field to ensure the quality of medical team training as a way to reach this. CONCLUSIONS: Medical CRM training courses are diverse and noninterchangeable. Trainers expect that if CRM becomes part of surgical training and is embedded in operating theatre culture, it could be of great value for patients and professionals.

Development of competence in volumetric image interpretation in radiology residents.

BACKGROUND: During residency, radiology residents learn to interpret volumetric radiological images. The development of their competence for volumetric image interpretation, as opposed to 2D image reading, is not completely understood. The purpose of the present study was to investigate how competence for volumetric image interpretation develops in radiology residents and how this compares with competence development for 2D image interpretation, by studying resident scores on image-based items in digital radiology tests. METHODS: We reviewed resident scores on volumetric and 2D image-based test items in 9 consecutive semi-annual digital radiology tests that were carried out from November 2013 to April 2018. We assessed percentage-correct sum scores for all test items about volumetric images and for all test items about 2D images in each test as well as for all residents across the 9 tests (i.e. 4.5 years of test materials). We used a paired t-test to analyze whether scores differed between volumetric and 2D image-based test items in individual residents in postgraduate year (PGY) 0-5, subdivided in 10 half-year phases (PGY 0-0.5, 0.5-1.0, 1.0-1.5 et cetera). RESULTS: The percentage-correct scores on volumetric and 2D image-based items showed a comparable trend of development, increasing in the first half of residency and flattening off in the second half. Chance-corrected scores were generally lower in volumetric than in 2D items (on average 1-5% points). In PGY 1.5-4.5, this score difference was statistically significant (p-values ranging from 0.02 to < 0.001), with the largest difference found in PGY 2.5 (mean: 5% points; 95% CI: -7.3 - -3.4). At the end of training in PGY 5, there was no statistically significant score difference between both item types. CONCLUSIONS: The development of competence in volumetric image interpretation fits a similar curvilinear growth curve during radiology residency as 2D image interpretation competence in digital radiology tests. Although residents performed significantly lower on volumetric than 2D items in PGY 1.5-4.5, we consider the magnitude of this difference as relatively small for our educational setting and we suggest that throughout radiology training there are no relevant differences in the development of both types of competences, as investigated by digital radiology tests.

Fourteen years of progress testing in radiology residency training: experiences from The Netherlands.

OBJECTIVES: To describe the development of the Dutch Radiology Progress Test (DRPT) for knowledge testing in radiology residency training in The Netherlands from its start in 2003 up to 2016. METHODS: We reviewed all DRPTs conducted since 2003. We assessed key changes and events in the test throughout the years, as well as resident participation and dispensation for the DRPT, test reliability and discriminative power of test items. RESULTS: The DRPT has been conducted semi-annually since 2003, except for 2015 when one digital DRPT failed. Key changes in these years were improvements in test analysis and feedback, test digitalization (2013) and inclusion of test items on nuclear medicine (2016). From 2003 to 2016, resident dispensation rates increased (Pearson's correlation coefficient 0.74, P-value <0.01) to maximally 16 %. Cronbach´s alpha for test reliability varied between 0.83 and 0.93. The percentage of DRPT test items with negative item-rest-correlations, indicating relatively poor discriminative power, varied between 4 % and 11 %. CONCLUSIONS: Progress testing has proven feasible and sustainable in Dutch radiology residency training, keeping up with innovations in the radiological profession. Test reliability and discriminative power of test items have remained fair over the years, while resident dispensation rates have increased. KEY POINTS: • Progress testing allows for monitoring knowledge development from novice to senior trainee. • In postgraduate medical training, progress testing is used infrequently. • Progress testing is feasible and sustainable in radiology residency training.

Variations in assessment and certification in postgraduate anaesthesia training: a European survey.

BACKGROUND: Postgraduate specialty training has traditionally been based on a time- and rotation-based model, but competency-based models are emerging. Because anaesthesia training evolves differently across Europe, variations in assessment and certification processes are expected, but the extent of similarities and differences is unknown. The aim of this study was to compare anaesthesia training programmes in Europe, focusing on assessment and certification processes. METHODS: We performed an online survey among national representatives of the Union of European Medical Specialists/European Board of Anaesthesiology. RESULTS: All 36 countries participated. Duration of training had a median of 5 yr (range 2.75-7). Mean number of different assessment tools was 7.45 (range 4-13), with more tools being used in competency-based programmes [mean 9.1 (sd 2.97) vs 7.0 (sd 1.97); P=0.03]. Most countries had a nationally uniform certification process. Based on a qualitative analysis of the survey findings, a categorization of countries emerged, reflecting the approach to assessment and certification. We observed two main streams of countries with an underlying knowledge or procedural focus within a time- and rotation-based apprenticeship model. These main streams are evolving, to different extents, towards a third orientation, competency-based training. CONCLUSIONS: Assessment and certification processes in European anaesthesia training are diverse. In many countries, a time-based apprenticeship model is evolving towards a competency-based certification process. This diversity precludes comparison of competence of graduating anaesthetists across Europe.

How visual search relates to visual diagnostic performance: a narrative systematic review of eye-tracking research in radiology.

Eye tracking research has been conducted for decades to gain understanding of visual diagnosis such as in radiology. For educational purposes, it is important to identify visual search patterns that are related to high perceptual performance and to identify effective teaching strategies. This review of eye-tracking literature in the radiology domain aims to identify visual search patterns associated with high perceptual performance. Databases PubMed, EMBASE, ERIC, PsycINFO, Scopus and Web of Science were searched using 'visual perception' OR 'eye tracking' AND 'radiology' and synonyms. Two authors independently screened search results and included eye tracking studies concerning visual skills in radiology published between January 1, 1994 and July 31, 2015. Two authors independently assessed study quality with the Medical Education Research Study Quality Instrument, and extracted study data with respect to design, participant and task characteristics, and variables. A thematic analysis was conducted to extract and arrange study results, and a textual narrative synthesis was applied for data integration and interpretation. The search resulted in 22 relevant full-text articles. Thematic analysis resulted in six themes that informed the relation between visual search and level of expertise: (1) time on task, (2) eye movement characteristics of experts, (3) differences in visual attention, (4) visual search patterns, (5) search patterns in cross sectional stack imaging, and (6) teaching visual search strategies. Expert search was found to be characterized by a global-focal search pattern, which represents an initial global impression, followed by a detailed, focal search-to-find mode. Specific task-related search patterns, like drilling through CT scans and systematic search in chest X-rays, were found to be related to high expert levels. One study investigated teaching of visual search strategies, and did not find a significant effect on perceptual performance. Eye tracking literature in radiology indicates several search patterns are related to high levels of expertise, but teaching novices to search as an expert may not be effective. Experimental research is needed to find out which search strategies can improve image perception in learners.

The don't know option in progress testing.

Formula scoring (FS) is the use of a don't know option (DKO) with subtraction of points for wrong answers. Its effect on construct validity and reliability of progress test scores, is subject of discussion. Choosing a DKO may not only be affected by knowledge level, but also by risk taking tendency, and may thus introduce construct-irrelevant variance into the knowledge measurement. On the other hand, FS may result in more reliable test scores. To evaluate the impact of FS on construct validity and reliability of progress test scores, a progress test for radiology residents was divided into two tests of 100 parallel items (A and B). Each test had a FS and a number-right (NR) version, A-FS, B-FS, A-NR, and B-NR. Participants (337) were randomly divided into two groups. One group took test A-FS followed by B-NR, and the second group test B-FS followed by A-NR. Evidence for impaired construct validity was sought in a hierarchical regression analysis by investigating how much of the participants' FS-score variance was explained by the DKO-score, compared to the contribution of the knowledge level (NR-score), while controlling for Group, Gender, and Training length. Cronbach's alpha was used to estimate NR and FS-score reliability per year group. NR score was found to explain 27 % of the variance of FS [F(1,332) = 219.2, p < 0.0005], DKO-score, and the interaction of DKO and Gender were found to explain 8 % [F(2,330) = 41.5, p < 0.0005], and the interaction of DKO and NR 1.6 % [F(1,329) = 16.6, p < 0.0005], supporting our hypothesis that FS introduces construct-irrelevant variance into the knowledge measurement. However, NR-scores showed considerably lower reliabilities than FS-scores (mean year-test group Cronbach's alphas were 0.62 and 0.74, respectively). Decisions about FS with progress tests should be a careful trade-off between systematic and random measurement error.

Interpretation of radiological images: towards a framework of knowledge and skills.

The knowledge and skills that are required for radiological image interpretation are not well documented, even though medical imaging is gaining importance. This study aims to develop a comprehensive framework of knowledge and skills, required for two-dimensional and multiplanar image interpretation in radiology. A mixed-method study approach was applied. First, a literature search was performed to identify knowledge and skills that are important for image interpretation. Three databases, PubMed, PsycINFO and Embase, were searched for studies using synonyms of image interpretation skills or visual expertise combined with synonyms of radiology. Empirical or review studies concerning knowledge and skills for medical image interpretation were included and relevant knowledge and skill items were extracted. Second, a preliminary framework was built and discussed with nine selective experts in individual semi-structured interviews. The expert team consisted of four radiologists, one radiology resident, two education scientists, one cognitive psychologist and one neuropsychologist. The framework was optimised based on the experts comments. Finally, the framework was applied to empirical data, derived from verbal protocols of ten clerks interpreting two-dimensional and multiplanar radiological images. In consensus meetings adjustments were made to resolve discrepancies of the framework with the verbal protocol data. We designed a framework with three main components of image interpretation: perception, analysis and synthesis. The literature study provided four knowledge and twelve skill items. As a result of the expert interviews, one skill item was added and formulations of existing items were adjusted. The think-aloud experiment showed that all knowledge items and three of the skill items were applied within all three main components of the image interpretation process. The remaining framework items were apparent only within one of the main components. After combining two knowledge items, we finally identified three knowledge items and thirteen skills, essential for image interpretation by trainees. The framework can serve as a guideline for education and assessment of two- and three-dimensional image interpretation. Further validation of the framework in larger study groups with different levels of expertise is needed.

Key factors in work engagement and job motivation of teaching faculty at a university medical centre.

This study reports about teacher motivation and work engagement in a Dutch University Medical Centre (UMC). We examined factors affecting the motivation for teaching in a UMC, the engagement of UMC Utrecht teaching faculty in their work, and their engagement in teaching compared with engagement in patient care and research. Based on a pilot study within various departments at the UMCU, a survey on teaching motivation and work engagement was developed and sent to over 600 UMCU teachers. About 50 % responded. Work engagement was measured by the Utrecht Work Engagement Scale, included in this survey. From a list of 22 pre-defined items, 5 were marked as most motivating: teaching about my own speciality, noticeable appreciation for teaching by my direct superior, teaching small groups, feedback on my teaching performance, and freedom to determine what I teach. Feedback on my teaching performance showed the strongest predictive value for teaching engagement. Engagement scores were relatively favourable, but engagement with patient care was higher than with research and teaching. Task combinations appear to decrease teaching engagement. Our results match with self-determination theory and the job demands-resources model, and challenge the policy to combine teaching with research and patient care.

[Art observation in the medical curriculum: a literature review]. / Kunstobservatie in het medisch curriculum: een literatuuronderzoek.

OBJECTIVE: To investigate the effect of art observation on the visual diagnostic skills of medical students. DESIGN: Systematic literature review. METHOD: We searched for relevant articles in PubMed, Embase, and the Cochrane Library, and screened the references of these articles through Web of Science for additional literature. Subsequently, data from all included articles were extracted and critically appraised. RESULTS: In total, we retrieved 7 relevant articles, each of which reported positive effects of art observation on the visual diagnostic skills of the participants. These effects included improved general or detailed observation, and increased recognition of patterns and emotions. CONCLUSION: Based on the available literature, art observation seems to have a positive effect on the visual diagnostic skills of medical students. However, the evidence is rather poor due to methodological limitations of the individual studies. It is therefore premature to conclude that art observation should be embedded in the medical curricula. Additional randomised studies are necessary to confirm the added value of this teaching method.

An argument-based approach to the validation of UHTRUST: can we measure how recent graduates can be trusted with unfamiliar tasks?

There is a need for valid methods to assess the readiness for clinical practice of medical graduates. This study evaluates the validity of Utrecht Hamburg Trainee Responsibility for Unfamiliar Situations Test (UHTRUST), an authentic simulation procedure to assess whether medical trainees are ready to be entrusted with unfamiliar clinical tasks near the highest level of Miller's pyramid. This assessment, in which candidates were judged by clinicians, nurses and standardized patients, addresses the question: can this trainee be trusted with unfamiliar clinical tasks? The aim of this paper is to provide a validity argument for this assessment procedure. We collected data from various sources during preparation and administration of a UHTRUST-assessment. In total, 60 candidates (30 from the Netherlands and 30 from Germany) participated. To provide a validity argument for the UHTRUST-assessment, we followed Kane's argument-based approach for validation. All available data were used to design a coherent and plausible argument. Considerable data was collected during the development of the assessment procedure. In addition, a generalizability study was conducted to evaluate the reliability of the scores given by assessors and to determine the proportion of variance accounted by candidates and assessors. It was found that most of Kane's validity assumptions were defendable with accurate and often parallel lines of backing. UHTRUST can be used to compare the readiness for clinical practice of medical graduates. Further exploration of the procedures for entrustment decisions is recommended.

How motivation affects academic performance: a structural equation modelling analysis.

Few studies in medical education have studied effect of quality of motivation on performance. Self-Determination Theory based on quality of motivation differentiates between Autonomous Motivation (AM) that originates within an individual and Controlled Motivation (CM) that originates from external sources. To determine whether Relative Autonomous Motivation (RAM, a measure of the balance between AM and CM) affects academic performance through good study strategy and higher study effort and compare this model between subgroups: males and females; students selected via two different systems namely qualitative and weighted lottery selection. Data on motivation, study strategy and effort was collected from 383 medical students of VU University Medical Center Amsterdam and their academic performance results were obtained from the student administration. Structural Equation Modelling analysis technique was used to test a hypothesized model in which high RAM would positively affect Good Study Strategy (GSS) and study effort, which in turn would positively affect academic performance in the form of grade point averages. This model fit well with the data, Chi square = 1.095, df = 3, p = 0.778, RMSEA model fit = 0.000. This model also fitted well for all tested subgroups of students. Differences were found in the strength of relationships between the variables for the different subgroups as expected. In conclusion, RAM positively correlated with academic performance through deep strategy towards study and higher study effort. This model seems valid in medical education in subgroups such as males, females, students selected by qualitative and weighted lottery selection.

Motivation as an independent and a dependent variable in medical education: a review of the literature.

BACKGROUND: Motivation in learning behaviour and education is well-researched in general education, but less in medical education. AIM: To answer two research questions, 'How has the literature studied motivation as either an independent or dependent variable? How is motivation useful in predicting and understanding processes and outcomes in medical education?' in the light of the Self-determination Theory (SDT) of motivation. METHODS: A literature search performed using the PubMed, PsycINFO and ERIC databases resulted in 460 articles. The inclusion criteria were empirical research, specific measurement of motivation and qualitative research studies which had well-designed methodology. Only studies related to medical students/school were included. RESULTS: Findings of 56 articles were included in the review. Motivation as an independent variable appears to affect learning and study behaviour, academic performance, choice of medicine and specialty within medicine and intention to continue medical study. Motivation as a dependent variable appears to be affected by age, gender, ethnicity, socioeconomic status, personality, year of medical curriculum and teacher and peer support, all of which cannot be manipulated by medical educators. Motivation is also affected by factors that can be influenced, among which are, autonomy, competence and relatedness, which have been described as the basic psychological needs important for intrinsic motivation according to SDT. CONCLUSION: Motivation is an independent variable in medical education influencing important outcomes and is also a dependent variable influenced by autonomy, competence and relatedness. This review finds some evidence in support of the validity of SDT in medical education.

How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE guide No. 59.

Self-determination Theory (SDT), designed by Edward Deci and Richard Ryan, serves among the current major motivational theories in psychology. SDT research has been conducted in many areas, among which are education and health care, but its applications in medical education are rare. The potential of SDT to help understand processes in medical education justifies this Guide. SDT is explained in seven principles, one of which is the distinction of three innate psychological needs of human beings: for competence, for autonomy and for relatedness. Further, SDT elaborates how humans tend to internalise regulation of behaviour that initially has been external, in order to develop autonomous, self-determined behaviour. Implications of SDT for medical education are discussed with reference to preparation and selection, curriculum structure, classroom teaching, assessments and examinations, self-directed learning, clinical teaching, students as teachers and researchers, continuing professional development, faculty development and stress among trainees.

Twelve tips to stimulate intrinsic motivation in students through autonomy-supportive classroom teaching derived from self-determination theory.

BACKGROUND: Self-determination theory (SDT) of motivations distinguishes between intrinsic and extrinsic motivations. Intrinsic motivation is observed when one engages in an activity out of genuine interest and is truly self-determined. Intrinsic motivation is the desired type of motivation for study as it is associated with deep learning, better performance and positive well-being in comparison to extrinsic motivation. It is dependent on the fulfilment of three basic psychological needs described by SDT. These are the needs for autonomy, competence and relatedness. According to SDT, autonomy-supportive teaching is important, because it makes students feel autonomous and competent in their learning and also supported (relatedness) by their teachers. AIM: The concept of autonomy-supportive teaching is relevant to medical education, but less known. Through this article, we aim to make this concept understood and practically used by medical teachers. METHODS: We used SDT literature as a basis to formulate these 12 tips. RESULTS: We present 12 practical tips derived from SDT, for teachers in health professions, on how to engage in autonomy-supportive teaching behaviours in order to stimulate intrinsic motivation in their students. CONCLUSION: These tips demonstrate that it is not difficult to engage in autonomy-supportive teaching behaviour. It can be learned through practice and self-reflection on teaching practices.

[The interest shown by medical students and recently qualified doctors in a career in psychiatry]. / De belangstelling voor het beroep van psychiater bij studenten geneeskunde en basisartsen.

BACKGROUND: In view of the current shortage of psychiatrists in the Netherlands it is important to find out what attracts medical students and recently qualified doctors to a career in psychiatry. AIM: To discover what aspects of psychiatry are of interest to medical students and recently qualified doctors and to determine what interest profile is suited to the practice of psychiatry. METHOD: Medical students and recently qualified doctors from the Free University medical school in Amsterdam and from Utrecht University medical school completed a questionnaire which investigated why certain specialisms, including psychiatry, were chosen as future careers, and which also examined the appeal of 47 aspects of a career in medicine. RESULTS: About 30% of the students expressed an interest in becoming psychiatrist. The interest was slightly greater among first-year students but decreased in the course of their medical training. About 6% of recently qualified doctors actually work in psychiatry and a larger percentage want to become psychiatrist in five years' time. The interest profile of persons interested in psychiatry differs from that of persons not interested in psychiatry and is different for men and women. CONCLUSION: The interest of students in a career in psychiatry decreases in the course of their medical training. This is in keeping with the general decrease in interest in any other career in medicine and probably reflects the current increasing focus on only one single medical specialism. The interest profile of persons interested in a career in psychiatry lies more in the communicative and psychosocial sphere and is focused in relationships that develop during long-term treatment rather than on medical-technical aspects. After qualifying as doctors, women with an interest in psychiatry often develop an interest in improvisation, diagnostics and pharmacotherapy.

[Career goals and choice of profession among recently graduated physicians]. / Carrièrewensen en beroepskeuze van recent afgestudeerde artsen.

OBJECTIVE: To obtain insight into the career choice of recently graduated physicians and the factors that influence this choice. DESIGN: Descriptive. METHOD: Questionnaires were sent to 1091 physicians who graduated from the VU University in Amsterdam or the University Utrecht between 1 July 1999 and 30 June 2002. Graduates were asked to provide the following information: current occupation, number of days that they have worked in current occupation, 5-year career goals, prerequisites for obtaining a residency, time spent on patient care and research, and the extent to which certain factors have influenced their career choice. Respondents were subdivided into three groups: clinical specialists, general practitioners, and public or occupational health professionals. RESULTS: The response was 70%, and approximately half of the respondents were engaged in additional resident training: 68% in a clinical specialty, 23% in general practice, 9% in public or occupational health, and 2% in another occupation. Most of the respondents worked full-time but would prefer to work less in the future. Full-time availability was the most important prerequisite for a clinical residency. Work experience after graduation was also considered important to obtain a residency in general practice or public or occupational health. Among clinical and general practitioner residents, the most important factor influencing career choice was interest in the specific field. For public and occupational health residents, the most important factor was working within office hours, particularly for female respondents. CONCLUSION: Various factors influence career choice in recently graduated physicians, and these factors are specialty-dependent. Graduates are interested in the possibility of working part-time in their present occupation and in the near future.

Progress testing with short answer questions.

The concept of progress testing was developed in the 1970s. Significant features of progress tests are that the content is not linked to any specific course or unit, and that it reflects the final objectives of the curriculum as a whole. The questions are taken from a broad domain and cover a range of disciplines. Furthermore, the test is taken repeatedly over a period of time, to monitor students' progress. Known progress tests all use closed format questions. In 2002-2003 the University Medical Center Utrecht initiated a progress test with short answer questions. The test consists of 40 cases, each with a clinical and a basic science short-answer key feature question. This differs from other progress tests that use close format items, but also in the philosophy of mastery level testing and in the deliberate linking of basic science concepts to clinical case vignettes. The first four executions of the test show high internal consistencies (Cronbach's alpha 0.85 to 0.87) and satisfactory item parameters. The effort of marking answers is reasonable, the effort of writing case vignettes with short-answer items is less than writing MC-items if similar test reliabilities are to be achieved.

Students' conceptions of the medical profession; an interview study.

Students' beliefs and attitudes towards the medical profession have been studied in relation to career choices, but most research has been restricted to either predetermined aspects or to a limited number of specialties. This study aimed at getting unprompted insight in the students' perceptions of their future profession in dimensions that may be determinants of study success and career choice. Undergraduate and graduated medical students were interviewed and asked to characterize the medical profession in general and four contrasting specialties in particular. Grounded Theory methodology was used to analyse the data. Participants were medical students at the start of their training (n = 16), during clerkships (n = 10) and after graduation (n = 37). Beginning students perceive the medical profession in limited dimensions: the activities of a physician, their relationship to patients and the physician's knowledge, skills and personality. They do not see many differences between specialties, in contrast with students with clinical experience and graduate students. Undergraduate students' perception is focussed more on social aspects of the profession compared to graduates.

Factors predictive of successful learning in postgraduate medical education.

PURPOSE: To establish which personal and contextual factors are predictive of successful outcomes in postgraduate medical education. METHOD: We performed a follow-up study of 118 doctors on a postgraduate occupational health training programme on the management of mental health problems. The following personal and contextual variables were measured as potential predictors of outcome: gender; age; years of experience as a doctor; university of graduation; learning style (Kolb); present employer (occupational health service), and educational format (problem-based or lecture-based). The main outcome measures were: scores on knowledge tests consisting of true/false and open answer questions, and performance in practice based on self-report and performance indicators. To determine the effect of potential predictive factors univariate analyses of variance and repeated measurement analysis of variance was applied. RESULTS: The mean scores of knowledge (P < 0.001) and performance (P = 0.001) of the participants increased after the educational programme. After multivariate analysis female gender was positively related to accruements in both knowledge and performance (both P < 0.05), independently of the influence of other factors. Accommodator learning style showed a relation with knowledge increase (P = 0.05), but had no influence on performance (P = 0.79). The problem-based educational format yielded a better performance outcome (P = 0.05), but had no influence on knowledge tests (P = 0.31). CONCLUSION: Gender and learning style were found to be related to an increase in knowledge. Gender was also found to be related to improvement in performance after a postgraduate medical education programme. We found no interactions with course design (i.e. problem-based or non problem-based learning formats), but further research could reveal other cues, suggesting practical consequences of student characteristics for course design in postgraduate training.

Factors Associated with the Nature, Timing and Stability of the Specialty Career Choices of Recently Graduated Doctors in European Countries, a Literature Review.

The aim of this study was to identify factors that are associated with the choice of a spe-cialty, the moment of the definitive choice, and the stability of the choice over time. The focus was on recently graduated doctors in European countries. A review of the literature from October 1994 to October 2004 was conducted. Most of the identified studies were of good quality. Enthusiasm, self-appraisal of skills, human interest and domestic circumstances were the main factors associated with the choice for medical specialization. Female doctors paid a great deal of attention to reasonable working hours and part-time jobs. They were also less certain about their career choice, and made this choice later than men. Most doctors with a preference for general practice at the time of qualification as a medical doctor achieved their aim. Women, who preferred a clinical specialization, had less opportunity than men to achieve their career satisfactorily.