Designing a Workplace-Based Learning Environment for Learning Health Promotion: A Design-Based Research.

Introduction: The healthcare landscape has a growing emphasis on health promotion (HP), which makes HP important in the training of future physicians. This study employed design-based research to develop a clerkship focused on HP and to outline design principles for shaping workplace learning environments to promote HP learning. Methods: We evaluated a nursing-home clerkship designed at Radboud University Medical Center in the Netherlands, and refined it over three rounds. Data collection involved individual and group interviews with students and supervisors, as well as observations during clerkship-related meetings and activities. These interactions also facilitated the exchange of perspectives between participants and generation of new design ideas, fostering co-creation of the clerkship design. Data were analyzed through iterative thematic inquiry to inform new design choices and develop design principles. Results: Evolved clerkship designs included an app for capturing practice experiences to discuss in relation to students' professional roles, loosening the strict assessment structure, and collaborative creation of a practice assignment about 'Positive Health'. We constructed four design principles, including: to question and discuss students' professional identity, provide concrete and meaningful assignments, aim for a peer-learner role for supervisors, and foster co-creation of the workplace learning environment. Discussion: Our design principles support the design of workplace-based learning for HP, a subject that is novel within healthcare practice. We find that co-creation of workplace-based learning, which requires embracing uncertainty, is pivotal in this context, for students, practitioners, and educational institutions.

Shared decision-making performance of general practice residents: an observational study combining observer, resident, and patient perspectives.

BACKGROUND: Shared decision making (SDM) is considered fundamental to person-centred care. However, applying SDM may be a challenge for residents in general practice, since it is a complex competence that requires the integration of knowledge and skills from several competency domains. OBJECTIVE: To support learning of SDM during medical residency, we aimed to gain insight in Dutch residents' observed and perceived SDM performance in general practice. METHODS: We evaluated residents' SDM performance from an observer, resident, and patient perspective. Consultations of first- and third-year residents were recorded. Trained observers used the validated Observing Patient Involvement (OPTION5) scale to assess observed SDM performance of residents in 98 actual recorded consultations. Perceived SDM performance was evaluated by residents and patients completing validated SDM questionnaires, supplemented with questions about (the context of) the consultation and perceived relevance of SDM immediately after the consultation. The data were analysed using descriptive statistics (mean, SD, minimums, and maximums) and explorative bivariate analyses. RESULTS: The residents' observed mean SDM performance was 19.1 (range, 0-100, SD = 10.9), mean resident self-reported SDM performance was 56.9 (range, 0-100, SD = 18.5), and mean patient-reported SDM performance was 73.3 (range, 0-100, SD = 26.8). We found a significant and positive correlation between observed SDM performance and residents' perceived relevance of SDM for the consultation (t = 4.571, P ≤ 0.001) and the duration of the consultation (r = 0.390, P ≤ 0.001). CONCLUSIONS: This study showed that there is room for increasing awareness of the potential incongruence between observed and perceived SDM performance during medical residency, in order to facilitate the implementation of SDM in clinical practice.

THE PROBLEM: Shared decision making is an important process in which healthcare professional and patient work together to reach a decision on how to solve a health problem. This decision should include patients' needs and what matters most to them. We investigated if consultations between general practitioners in training (i.e. residents) and their patients demonstrate shared decision making. The research methods: We asked the residents and patients to respond to questions on their experience of shared decision making right after the consultation. We recorded 98 consultations of residents with their patients. Two researchers rated to what extent residents demonstrated shared decision-making behaviours during these consultations. THE RESULTS: The patients reported more shared decision making than the residents (patients: 73 versus residents: 57 on a 0­100 scale). The researchers observed low levels of SDM during the consultations (19 on a 0­100 scale). Our conclusion: Residents should be aware that shared decision making does not yet frequently occur in practice. To improve the extent to which residents share decisions with their patients in general practice, residents should learn why, when, and how to involve patients in decision making during consultations.

Workplace-based learning about health promotion in individual patient care: a scoping review.

OBJECTIVE: To outline current knowledge regarding workplace-based learning about health promotion in individual patient care. DESIGN: Scoping review. DATA SOURCES: PubMed, ERIC, CINAHL and Web of Science from January 2000 to August 2023. ELIGIBILITY CRITERIA: We included articles about learning (activities) for healthcare professionals (in training), about health promotion in individual patient care and in the context of workplace-based learning. DATA EXTRACTION AND SYNTHESIS: The studies were evaluated using a charting template and were analysed thematically using a template based on Designable Elements of Learning Environments model. RESULTS: From 7159 studies, we included 31 that described evaluations of workplace-based learning about health promotion, around a variety of health promotion topics, for different health professions. In the articles, health promotion was operationalised as knowledge, skills or attitudes related to specific lifestyle factors or more broadly, with concepts such as health literacy, advocacy and social determinants of health. We assembled an overview of spatial and instrumental, social, epistemic and temporal elements of learning environments in which health promotion is learnt. CONCLUSIONS: The studies included in our analysis varied greatly in their approach to health promotion topics and the evaluation of learning outcomes. Our findings suggest the importance of providing opportunities for health profession learners to engage in authentic practice situations and address potential challenges they may experience translating related theory into practice. Additionally, our results highlight the need for conscious and articulated integration of health promotion in curricula and assessment structures. We recommend the exploration of opportunities for health profession students, professionals and patients to learn about health promotion together. Additionally, we see potential in using participatory research methods to study future health promotion learning. STUDY REGISTRATION: Open Science Framework, https://doi.org/10.17605/OSF.IO/6QPTV.

The influence of a digital clinical reasoning test on medical student learning behavior during clinical clerkships.

Recently, a new digital clinical reasoning test (DCRT) was developed to evaluate students' clinical-reasoning skills. Although an assessment tool may be soundly constructed, it may still prove inadequate in practice by failing to function as intended. Therefore, more insight is needed into the effects of the DCRT in practice. Individual semi-structured interviews and template analysis were used to collect and process qualitative data. The template, based on the interview guide, contained six themes: (1) DCRT itself, (2) test debriefing, (3) reflection, (4) practice/workplace, (5) DCRT versus practice and (6) 'other'. Thirteen students were interviewed. The DCRT encourages students to engage more in formal education, self-study and workplace learning during their clerkships, particularly for those who received insufficient results. Although the faculty emphasizes the different purposes of the DCRT (assessment of/as/for learning), most students perceive the DCRT as an assessment of learning. This affects their motivation and the role they assign to it in their learning process. Although students appreciate the debriefing and reflection report for improvement, they struggle to fill the identified knowledge gaps due to the timing of receiving their results. Some students are supported by the DCRT in exhibiting lifelong learning behavior. This study has identified several ways in which the DCRT influences students' learning practices in a way that can benefit their clinical-reasoning skills. Additionally, it stresses the importance of ensuring the alignment of theoretical principles with real-world practice, both in the development and utilization of assessment tools and their content. Further research is needed to investigate the long-term impact of the DCRT on young physicians' working practice.

Effect of interprofessional and intraprofessional clinical collaboration on patient related outcomes in multimorbid older patients - a retrospective cohort study on the Intensive Collaboration Ward.

BACKGROUND: The management and care of older patients with multiple health problems is demanding and complex. Interprofessional and intraprofessional collaboration has the potential to improve both the efficiency and the quality of care for these patients. However, it has proven difficult to demonstrate the efficacy of this approach in terms of objective patient-related outcomes. Recently, a care model with interprofessional and intraprofessional care was started, the Intensive Collaboration Ward (ICW). This ward combines interprofessional care and intraprofessional care for older patients with multiple health problems. The aim of this study was to evaluate the effects of ICW care in older patients with multiple health problems. METHODS: This retrospective cohort study evaluated the effects on patients outcomes. This was done by comparing patients of the new model, the ICW (ICW group), to a historical cohort of comparable patients who would have been eligible for the ICW (control group). Outcomes were medical consultations, allied health professional consultations, radiological procedures, waiting time for radiological procedures, change in primary treating specialty, length of hospital stay, readmission rate, and mortality rate. Linear and logistic regression analyses were performed, adjusted for baseline differences. RESULTS: The ICW group required significantly fewer medical consultations than the control group. Calls to specialists from the emergency room decreased significantly, but there was no change in in-person consultations on the ER. 51% of control patients had ≥ 1 in-hospital consultation compared to 21% of ICW patients (p < 0.05). Patients in the ICW group received significantly more consultations with allied health professionals and more often had a change in primary treating specialty. CONCLUSIONS: Interprofessional and intraprofessional clinical collaboration on the ICW reduced in-hospital consultations and increased allied health professionals' consultations. This approach may decrease fragmentation of care and provide more integrated, efficient and patient centered care. This may improve the overall care of older patients with multiple health problems.

A Qualitative Study on How Entrustable Professional Activities Support Medical Students in Their Transitions across Clerkships.

Introduction: Medical students regularly transition between clerkships. These transitions can lead to discontinuity in their development because of the need to adapt to a new environment. The use of entrustable professional activities (EPAs) might facilitate less disruptive transitions across clerkships, as they could provide support at the start of a clerkship. This study aims to shed light on how an EPA-based curriculum contributes to medical students' learning processes during transitions. Methods: The authors used a constructivist rapid ethnographic design. They conducted observations and interviews with 11 medical students in their Pediatrics clerkship; six of them were in clerkships not utilizing EPAs, and five were using EPAs. Data collection was followed by template analysis such that all data were coded with a template that was continually updated until the authors all agreed upon a definitive template. Results: Four themes proved important when considering the impact of EPAs during transitions between clerkships: transitions as a learning opportunity, building relationships in context, taking leadership in the landscape of practice and feedback-seeking behavior. Discussion: EPAs smooth clerkship transitions, as they establish continuity in the student's development and facilitate navigating discontinuity in transitions. Students build skills and confidence in order to grow and work with increasing independence within the clerkships. Transitions offer important learning opportunities for students, which can be fully exploited by using EPA guidance.

An Innovative Undergraduate Medical Curriculum Using Entrustable Professional Activities.

The need to educate medical professionals in changing medical organizations has led to a revision of the Radboudumc's undergraduate medical curriculum. Entrustable professional activities (EPAs) were used as a learning tool to support participation and encourage feedback-seeking behavior, in order to offer students the best opportunities for growth. This paper describes the development of the Radboudumc's EPA-based Master's curriculum and how EPAs can facilitate continuity in learning in the clerkships. Four guiding principles were used to create a curriculum that offers possibilities for the students' development: (1) working with EPAs, (2) establishing entrustment, (3) providing continuity in learning, and (4) organizing smooth transitions. The new curriculum was designed with the implementation of EPAs and an e-portfolio, based on these 4 principles. The authors found that the revised curriculum corresponds to daily practice in clerkships. Students used their e-portfolios throughout all clerkships, which stimulates feedback-seeking behavior. Moreover, EPAs promote continuity in learning while rotating clerkships every 1 to 2 months. This might encourage curriculum developers to use EPAs when aiming for greater continuity in the development of students. Future research needs to focus on the effect of EPAs on transitions across clerkships in order to further improve the undergraduate medical curriculum.

Effects of a shared decision making intervention for older adults with multiple chronic conditions: the DICO study.

BACKGROUND: To evaluate the effects of a shared decision making (SDM) intervention for older adults with multiple chronic conditions (MCCs). METHODS: A pragmatic trial evaluated the effects of the SDMMCC intervention, existing of SDM training for nine geriatricians in two hospitals and a preparatory tool for patients. A prospective pre-intervention post-intervention multi-center clinical study was conducted in which an usual care group of older patients with MCC and their informal caregivers was included before the implementation of the intervention and a new cohort of patients and informal caregivers after the implementation of the intervention. SDM was observed using the OPTIONMCC during video-recorded consultations. Patient- and caregivers reported outcomes regarding their role in SDM, involvement, perceived SDM and decisional conflict were measured. The differences between groups regarding the level of observed SDM (OPTIONMCC) were analyzed with a mixed model analysis. Dichotomous patient-reported outcomes were analyzed with a logistic mixed model. RESULTS: From two outpatient geriatric clinics 216 patients with MCCs participated. The mean age was 77.3 years, and 56.3% of patients were female. No significant difference was found in the overall level of SDM as measured with the OPTIONMCC or in patient-reported outcomes. However, at item level the items discussing 'goals', 'options', and 'decision making' significantly improved after the intervention. The items discussing 'partnership' and 'evaluating the decision-making process' showed a significant decrease. Fifty-two percent of the patients completed the preparatory tool, but the results were only discussed in 12% of the consultations. CONCLUSION: This study provides scope for improvement of SDM in geriatrics. Engaging older adults with MCCs and informal caregivers in the decision making process should be an essential part of SDM training for geriatricians, beyond the SDM steps of explaining options, benefits and harms. More attention should be paid to the integration of preparatory work in the consultation.

Interdisciplinary education affects student learning: a focus group study.

BACKGROUND: In order to best prepare medical students for their increasingly complex future career, interdisciplinary higher education is swiftly gaining popularity. However, the implementation of interdisciplinary learning in medical education is challenging. The present study deepens the understanding of the challenges and opportunities inherent to the implementation of an interdisciplinary course. We elucidated the attitudes and beliefs of students participating in a newly developed interdisciplinary minor, in which students of medicine (MS) and communication and information sciences (CISS) were involved. METHODS: We conducted four semi-structured focus group interviews, of which two were held before, and two were held after the course. Seven MS and six CISS participated voluntarily. A pre-arranged interview guide was used. The interviews were recorded and afterwards systematically analyzed with the 'constant comparative analysis' technique. RESULTS: The focus group interviews revealed three differences in epistemics between students in terms of 1) curriculum content, 2) educational formats and 3) student's competence perceptions. These factors influenced the way students evaluated themselves, each other and the interdisciplinary course. CONCLUSIONS: We conclude that factors that influence interdisciplinary learning are personal epistemics, individual learning preferences, and the synergy that is achieved throughout interdisciplinary learning. Organizing the dialogue among students of different disciplines could make students aware of inequalities, implicated biases and assigned status of different student groups. These empirical results are crucial to tailor interdisciplinary education to each specific discipline and to take interdisciplinary learning to a higher level of maturity.

Combined interprofessional and intraprofessional clinical collaboration reduces length of stay and consultations: a retrospective cohort study on an intensive collaboration ward (ICW).

Patients with multiple health problems are a growing population at high risk of receiving fragmented care, resulting in a poorer quality of care, preventable hospitalisations, and higher costs. Health agencies such as the World Health Organization (WHO) advocate the implementation of interprofessional care, which should lead to better patient care. This retrospective cohort study investigated the effect of combined interprofessional and intraprofessional collaboration on the management of mainly elderly patients with multiple health problems on an Intensive Collaboration Ward (ICW). Patient health outcomes, patient experience, and the cost and value of care were assessed. In total, 200 patients admitted to the ICW were compared with 51 control patients with an indication for the ICW who were admitted to a regular ward because of a shortage of ICW beds. Patients admitted to the ICW had a shorter length of hospital stay than control patients (median 5 vs 7 days, p = .004) and had fewer in-hospital consultations (p = .003). Patient satisfaction did not differ between the ICW and control patients (mean rating (1-10) 8.22 vs 8.75, p = .060). This study indicates that interprofessional and intraprofessional clinical collaboration reduces the length of hospital stay and the number of in-hospital consultations, without affecting patient satisfaction.

Learning clinical reasoning in the workplace: a student perspective.

INTRODUCTION: Clinical reasoning is a core competency for every physician, as well as one of the most complex skills to learn. This study aims to provide insight into the perspective of learners by asking students about their own experiences with learning clinical reasoning throughout the medical Master's curriculum. METHODS: We adopted a constructivist approach to organise three semi-structured focus groups within the Master's curriculum at the medical school of the Radboud University Medical Center in Nijmegen (Netherlands) between August and December 2019. Analysis was performed through template analysis. RESULTS: The study included 18 participants who (1) defined and interpreted clinical reasoning, (2) assessed the teaching methods and (3) discussed how they used their context in order to learn and perform clinical reasoning during their clinical rotations. They referred to a variety of contexts, including the clinical environment and various actors within it (e.g. supervisors, peers and patients). CONCLUSION: With regard to the process by which medical students learn clinical reasoning in practice, this study stresses the importance of integrating context into the clinical reasoning process and the manner in which it is learnt. The full incorporation of the benefits of dialogue with the practice of clinical reasoning will require additional attention to educational interventions that empower students to (1) start conversations with their supervisors; (2) increase their engagement in peer and patient learning; (3) recognise bias and copy patterns in their learning process; and (4) embrace and propagate their role as boundary crossers.

How an EPA-based curriculum supports professional identity formation.

BACKGROUND: Entrustable professional activities (EPAs) are widely used in medical education, and they might be an important incentive to stimulate professional identity formation (PIF) of medical students, by actively encouraging participation in the workplace. The goal of this study was to explore the effects of an EPA-based curriculum on the PIF of medical students in undergraduate curricula. METHODS: In this study at the Radboud University Medical Center in Nijmegen, the Netherlands, the authors interviewed twenty-one medical students in three focus group interviews (November 2019), and conducted a thematic analysis based on both the synthesizing concepts PIF, communities of practice and EPAs, and newly defined themes. RESULTS: Four central themes proved crucial for understanding the influence of EPAs on PIF: creating learning opportunities, managing feedback, dealing with supervision in context and developing confidence. EPAs helped students to create learning opportunities and to choose activities purposefully, and the use of EPAs stimulated their feedback-seeking behavior. The context and way of supervision had a great impact on their development, where some contexts offer better learning opportunities than others. EPAs helped them develop trust and self-confidence, but trust from supervisors hardly appears to result from using EPAs. CONCLUSIONS: An EPA-based curriculum does stimulate PIF in the complex context of working and learning by supporting participation in the workplace and by encouraging feedback-seeking behavior. Striking the right balance between participation, feedback-seeking behavior and choosing learning activities is essential. TRIAL REGISTRATION: This study was approved by the ethics committee of the Netherlands Association of Medical Education (NVMO, case number 2019.5.12).

Identifying Entrustable Professional Activities for Shared Decision Making in Postgraduate Medical Education: A National Delphi Study.

PURPOSE: Although shared decision making (SDM) is considered the preferred approach in medical decision making, it is currently not routinely used in clinical practice. To bridge the transfer gap between SDM training and application, the authors aimed to reach consensus on entrustable professional activities (EPAs) for SDM and associated behavioral indicators as a framework to support self-directed learning during postgraduate medical education. METHOD: Using existing literature on SDM frameworks and competencies; input from an interview study with 17 Dutch experts in SDM, doctor-patient communication, and medical education; and a national SDM expert meeting as a starting point, in 2017, the authors conducted a modified online Delphi study with a multidisciplinary Dutch panel of 32 experts in SDM and medical education. RESULTS: After 3 Delphi rounds, consensus was reached on 4 EPAs-(1) the resident discusses the desirability of SDM with the patient, (2) the resident discusses the options for management with the patient, (3) the resident explores the patient's preferences and deliberations, and (4) the resident takes a well-argued decision together with the patient. Consensus was also reached on 18 associated behavioral indicators. Of the 32 experts, 30 (94%) agreed on this list of SDM EPAs and behavioral indicators. CONCLUSIONS: The authors succeeded in developing EPAs and associated behavioral indicators for SDM for postgraduate medical education to improve the quality of SDM training and the application of SDM in clinical practice. These EPAs are characterized as process EPAs for SDM in contrast with content EPAs related to diverse medical complaints. A next step is the implementation of the SDM EPAs in existing competency-based workplace curricula.

The development of the evidence-based SDMMCC intervention to improve shared decision making in geriatric outpatients: the DICO study.

BACKGROUND: Shared decision making (SDM) contributes to personalized decisions that fit the personal preferences of patients when choosing a treatment for a condition. However, older adults frequently face multiple chronic conditions (MCC). Therefore, implementing SDM requires special features. The aim of this paper is to describe the development of an intervention to improve SDM in older adults with MCC. METHODS: Following the Medical Research Council framework for developing complex interventions, the SDMMCC intervention was developed step-wise. Based on a literature review and empirical research in a co-creation process with end users, we developed training for geriatricians and a preparatory tool for older patients with MCC and informal caregivers. After assessing feasibility, the intervention was implemented in a pilot study (N = 108) in two outpatient geriatric clinics of an academic and a non-academic teaching hospital in Amsterdam, the Netherlands. RESULTS: Key elements of the training for geriatricians include developing skills to involve older adults with MCC and informal caregivers in SDM and following the six-step 'Dynamic model for SDM with frail older patients', as well as learning how to explore personal goals related to quality of life and how to form a partnership with the patient and the informal caregiver. Key elements of the preparatory tool for patients include an explicit invitation to participate in SDM, nomination that the patient's own knowledge is valuable, invitation to form a partnership with the geriatrician, encouragement to share information about daily and social functioning and exploration of possible goals. Furthermore, the invitation of informal caregivers to share their concerns was also a key element. CONCLUSIONS: Through a process of co-creation, both training for geriatricians and a preparatory tool for older adults and their informal caregivers were developed, tailored to the needs of the end users and based on the 'Dynamic model of SDM with frail older patients'.

Educating Dutch General Practitioners in Dementia Advance Care Planning: A Cluster Randomized Controlled Trial.

OBJECTIVES: Advance care planning (ACP) is seldom initiated with people with dementia (PWD) and mainly focuses on medical end-of-life decisions. We studied the effects of an educational intervention for general practitioners (GPs) aimed at initiating and optimizing ACP, with a focus on discussing medical and nonmedical preferences of future care. DESIGN: A single-blinded cluster randomized controlled trial. SETTING AND PARTICIPANTS: In 2016, 38 Dutch GPs (all from different practices) completed the study. They recruited 140 PWD, aged ≥65 years at any stage and with any type of dementia, from their practice. METHODS: Intervention group GPs were trained in ACP, including shared decision-making and role-playing exercises. Control group GPs provided usual care. The primary outcome was ACP initiation: the proportion of PWD that had at least 1 ACP conversation documented in their medical file. Key secondary outcomes were the number of medical (ie, resuscitation, hospital admission) and nonmedical (ie, activities, social contacts) preferences discussed. At the 6-month follow-up, subjects' medical records were analyzed using random effect logistics and linear models with correction for GP clustering. RESULTS: 38 GP clusters (19 intervention; 19 control) included 140 PWD (intervention 73; control 67). Four PWD (2.9%) dropped out on the primary and key secondary outcomes. After 6 months, intervention group GPs initiated ACP with 35 PWD (49.3%), and control group GPs initiated ACP with 9 PWD (13.9%) [odds ratio (OR) 1.99; P = .002]. Intervention group GPs discussed 0.8 more medical [95% confidence interval (CI) 0.3, 1.3; P = .003] and 1.5 more nonmedical (95% CI 0.8, 2.3; P < .001) preferences per person with dementia than control group GPs. CONCLUSIONS AND IMPLICATIONS: Our educational intervention increased ACP initiation, and the number of nonmedical and medical preferences discussed. This intervention has the potential to better align future care of PWD with their preferences but because of the short follow-up, the GPs' long-term adoption remains unknown.

Measuring triadic decision making in older patients with multiple chronic conditions: Observer OPTIONMCC.

OBJECTIVE: To develop a valid and reliable tool to measure triadic decision making between older adults with multiple chronic conditions (MCC), their informal caregivers and geriatricians. METHODS: Video observational study with cross-sectional assessment of interaction during medical consultations between geriatricians (n = 10), patients (n = 108) and informal caregivers (68) by three calibrated raters at the geriatric outpatient department of two Dutch hospitals. The Observer OPTIONMCC instrument was developed, based on the 'Dynamic model of SDM in frail older patients' and the 'Observing Patient Involvement in Decision Making - 5 item scale' (Observer OPTION-5). RESULTS: Factor analysis confirms that it is acceptable to regard the new scale as a single construct. The 7-item single factor solution explained 62.76% of the variability for geriatricians, 61.60% of the variability for patients and 54.32% of the variability for informal caregivers. The inter-rater ICC for the total Observer OPTIONMCC score was .96, .96, and .95 (resp. geriatricians, patients, informal caregivers), with values ranging from .60 to .95 for individual items, showing good levels of agreement. CONCLUSION AND PRACTICE IMPLICATIONS: We conclude that Observer OPTIONMCC is sufficiently valid and reliable to be used for the assessment of triadic SDM in populations of older patients with MCC.

Lessons learned from narrative feedback of students on a geriatric training program.

Geriatrics continues to draw insufficient numbers of medical students today. Currently, little is known regarding how education can motivate students to choose geriatrics. The authors' aim was to examine geriatrics from the students' perspective to identify elements that can be useful in education and improving attitudes toward, interest in, and knowledge about geriatrics. The authors analyzed narrative reflection essays of 36 students and clarified the themes from the essays during focus group sessions. Four overarching themes that influenced students' perspective on geriatrics were identified: professional identity, perception of geriatrics, geriatric-specific problems, and learning environment. Students have an inaccurate image of clinical practice and the medical professional identity, which has a negative impact on their attitude toward, interest in, and knowledge of geriatrics. Furthermore, this study yielded the important role of the hidden curriculum on professional identity, the novelty of geriatric-specific problems to students, and the importance of educational approach and good role models.

[SDM supports better application of EBM in geriatric patients]. / Gezamenlijke besluitvorming zorgt voor een betere toepassing van evidence-based medicine in de geriatrische patiënt.

Evidence based medicine (EBM) is the integration of the best research evidence, clinical expertise and patient values in the decision making process for patient care. However, elderly people are often excluded from participating in scientific studies and they often have multiple morbidities, which complicates the application of EBM. Shared decision making (SDM), a process where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve appropriate treatment can help to shape EBM for this group of patients.In this article, we provide tools for finding relevant literature for the geriatric patient population and for shaping the SDM process to achieve personalized care.

Shared decision making with frail older patients: Proposed teaching framework and practice recommendations.

This study has two aims: The first aim is to identify core competencies for shared decision making (SDM) with frail older persons, and the second is to determine key elements of a teaching framework, based on the authors' recently developed model for SDM with older patients who are frail. To this end the authors conducted a qualitative inquiry among health professionals (n = 53) and older patients who are frail (n = 16). Participants formulated core competencies and educational needs for SDM with older patients who are frail, which were further explored in the literature. This resulted in practice recommendations and a teaching framework with the following key elements: create a knowledge base for all health professionals, offer practical training, facilitate communication, identify discussion partners, engage patients, and collaborate. The authors' teaching framework for SDM with older patients who are frail may be useful for clinicians, educators, and researchers who aim to promote SDM with older patients who are frail.

Expert and patient consensus on a dynamic model for shared decision-making in frail older patients.

OBJECTIVE: Shared decision-making (SDM) is widely recommended as a way to support patients in making healthcare choices. Due to an ageing population, the number of older patients will increase. Existing models for SDM are not sufficient for this patient group, due to their multi-morbidity, the lack of guidelines and evidence applicable to the numerous combinations of diseases. The aim of this study was to gain consensus on a model for SDM in frail older patients with multiple morbidities. METHODS: We used a three-round Delphi study to reach consensus on a model for SDM in older patients with multiple morbidities. The expert panel consisted of 16 patients (round 1), and 59 professionals (rounds 1-3). In round 1, the SDM model was introduced, rounds 2 and 3 were used to validate the importance and feasibility of the SDM model. RESULTS: Consensus for the proposed SDM model as a whole was achieved for both importance (91% panel agreement) and feasibility (76% panel agreement). CONCLUSIONS: SDM in older patients with multiple morbidities is a dynamic process. It requires a continuous counselling dialogue between professional and patient or proxy decision maker. PRACTICE IMPLICATIONS: The developed model for SDM in clinical practice may help professionals to apply SDM in the complex situation of the care for older patients.