Learning patient-centredness with simulated/standardized patients: A realist review: BEME Guide No. 68.

BACKGROUND: Given the positive outcomes of patient-centred care on health outcomes, future doctors should learn how to deliver patient-centred care. The literature describes a wide variety of educational interventions with standardized patients (SPs) that focus on learning patient-centredness. However, it is unclear which mechanisms are responsible for learning patient-centredness when applying educational interventions with SPs. OBJECTIVE: This study aims to clarify how healthcare learners and professionals learn patient-centredness through interventions involving SPs in different healthcare educational contexts. METHODS: A realist approach was used to focus on what works, for whom, in what circumstances, in what respect and why. Databases were searched through 2019. Nineteen papers were included for analysis. Through inductive and deductive coding, CIC'MO configurations were identified to build partial program theories. These CIC'MOs describe how Interventions with SPs change the Context (C→C') such that Mechanisms (M) are triggered that are expected to foster patient-centredness as Outcome. RESULTS: Interventions with SPs create three contexts which are 'a safe learning environment,' 'reflective practice,' and 'enabling people to learn together.' These contexts trigger the following seven mechanisms: feeling confident, feeling a sense of comfort, feeling safe, self-reflection, awareness, comparing & contrasting perspectives, combining and broadening perspectives. A tentative final program theory with mechanisms belonging to three main learning components (cognitive, regulative metacognitive and affective) is proposed: Interventions with SPs create a safe learning environment (C') in which learners gain feelings of confidence, comfort and safety (affective M). This safe learning environment enables two other mutual related contexts in which learners learn together (C'), through comparing & contrasting, combining and broadening their perspectives (cognitive M) and in which reflective practice (C') facilitates self-reflection and awareness (metacognitive M) in order to learn patient-centeredness. CONCLUSION: These insights offer educators ways to deliberately use interventions with SPs that trigger the described mechanisms for learning patient-centredness.

Factors determining development of researchers within a research network on cancer diagnosis in primary care (CanTest): an interview study.

OBJECTIVES: Developing connections with other researchers in a network, learning informally through these connections and using them to reach goals, is expected to increase research capacity and strengthen performance. So far, this has not been empirically demonstrated. We assessed what and how network collaboration adds to development of researchers. DESIGN: Exploratory qualitative study using semistructured online interviews, analysed by inductive and deductive methods. For the deductive analysis, an existing value creation framework to study informal learning in networks was used and adjusted to our context. SETTING: The CanTest Collaborative-an international team of primary care cancer researchers working on early detection and diagnosis of cancer. PARTICIPANTS: Sixteen primary care cancer researchers. RESULTS: Connections with other researchers in an international network created diverse value cycles, where most outcomes were in the potential value cycle, acquiring knowledge, skills, social capital, resources and ideas. Not all potential value will be applied but many interviewees described realised as well as transformational value. In our context, the transformational value from the framework appeared to be related to other perspectives on the research process. Advancement of the network depends on opportunities, timing, role models and connections between different perspectives. CONCLUSIONS: Focus on the factors that are relevant for network advancement will support researchers in early detection and diagnosis of cancer research patients who participate in an international network and bring sustainable change in this domain. When, subsequently, researchers in the CanTest network bring about more realised and transformational learning outcomes, this will contribute to capacity development.

Fostering patient-centredness by following patients outside the clinical setting: an interview study.

BACKGROUND: Patient-centredness is considered a core competency for health professionals. To support faculty in designing courses focused on patient-centredness, an understanding of how educational interventions lead to patient-centredness is required. This study aims to show how learning mechanisms, which potentially contribute to patient-centredness, are triggered. METHODS: Thirty-five third-year medical students at the UMC Utrecht followed four different patients for two years. The intervention took place in an out-of-hospital setting. Students visited patients in their home circumstances and accompanied them to clinical events. Twelve students were interviewed. The realist approach was used to construct configurations which relate components of the intervention to the context and learning mechanisms. RESULTS: Following patients in their home circumstances for a prolonged period supported the development of meaningful relationships between students and patients and provided continuity. In the context of a meaningful relationship and continuity, mechanisms contributing to learning patient-centredness were triggered. The most important learning mechanisms found in this study were: reflecting, contextualising disease in a real persons' life, broadening perspectives and engaging with the patients. CONCLUSIONS: Learning mechanisms are triggered by continuity and by meaningful student-patient relationships. These can be enhanced by an out-of-hospital setting and longitudinal contact. Thus, a relationship between students and patients is an important enabler for the development of patient-centredness.

Learning from patients about patient-centredness: A realist review: BEME Guide No. 60.

Background: Patient-centred work is an essential part of contemporary medicine. Literature shows that educational interventions contribute to developing patient-centredness, but there is a lack of insight into the associated learning processes.Objective: Through reviewing articles about educational interventions involving patients, we aspire to develop a program theory that describes the processes through which the educational interventions are expected to result in change. The processes will clarify contextual elements (called contexts) and mechanisms connected to learning patient-centredness.Methods: In our realist review, an initial, rough program theory was generated during the scoping phase, we searched for relevant articles in PubMed, PsycINFO, ERIC, CINAHL and Embase for all years before and through 2016. We included observational studies, case reports, interviews, and experimental studies in which the participants were students, residents, doctors, nurses or dentists. The relevance and rigour of the studies were taken into account during analysis. With deductive as well as inductive coding, we extended the rough program theory.Results: In our review, we classified five different contexts which affect how upcoming professionals learn patient-centredness. These aspects are influenced through components in the intervention(s) related to the learner, the teacher, and the patient. We placed the mechanisms together in four clusters - comparing and combining as well as broadening perspectives, developing narratives and engagement with patients, self-actualisation, and socialisation - to show how the development of (dimensions of) patient-centredness occurs. Three partial-program-theories (that together constituting a whole program theory) were developed, which show how different components of interventions within certain contexts will evoke mechanisms that contribute to patient-centredness.Translation into daily practice: These theories may help us better understand how the roles of patients, learners and teachers interact with contexts such as the kind of knowledge that is considered legitimate or insight in the whole illness trajectory. Our partial program theories open up potential areas for future research and interventions that may benefit learners, teachers, and patients.

The Feasibility of Longitudinal Patient Contacts in a Large Medical School.

PROBLEM: Longitudinal patient contacts are being implemented worldwide as a way to enhance a patient-centered orientation among medical students. In large medical schools, longitudinal integrated clerkships may not be feasible, so other ways must be sought to expose students to prolonged contact with patients. INTERVENTION: Medical students were attached to a family practice and assigned a panel of 4 patients to follow over the 3 years of their clinical training. Their role was that of companion on the patient's medical journey. The program consisted of several encounters, joining the patient in the medical setting for significant events, and written assignments. This intervention was piloted with 35 students. We describe our experiences from the 1st pilot year of this program. CONTEXT: The intervention was performed with 3rd-year students-of a 6-year curriculum-at a large medical school in the Netherlands. OUTCOME: Finding enough patients per practice was feasible. On the whole, students fulfilled the program's expectations regarding frequency of patient encounters and assignments. The most frequent problems encountered by the students were uncertainty about their role and setting boundaries in their contact with the patients. They needed more preceptor supervision and coaching than they received. LESSONS LEARNED: For junior students, close and structured supervision led by the faculty is necessary to help them navigate and learn from a panel of patients. Students need guidance about what role they should take on and on how to manage both their own and their patient's expectations. Guided reflection is necessary to help students give meaning to their experiences with patients.

[Physician, disclose thyself! Self-disclosure as an educational tool]. / Dokter, laat meer van uzelf zien!

Supervisor self-disclosure is essential for both personal and professional development of the next generation of doctors. We highlight the importance of self-disclosure and urge doctors in a supervising role to embed self-disclosure in their supervisory activities. Effective supervision of residents and interns encompasses many elements. Self-disclosure positively contributes to a safe teaching environment as well as a nurturing supervisor-trainee relationship. Self-disclosure can be used in many supervisory settings to benefit the development of residents and interns. It is of the utmost importance that self-disclosure should be used consciously and at suitable moments. Tools to achieve optimal self-disclosure are provided.

Talking matters: abused women's views on disclosure of partner abuse to the family doctor and its role in handling the abuse situation.

OBJECTIVE: We aimed to explore what women valued most in disclosing partner abuse to their doctor and whether disclosure played a role in handling their abuse situation. METHODS: A qualitative method was used to understand abused women's views and experiences with disclosure to their family doctor. Thirty-six women were interviewed within 4 weeks after disclosure to their family doctor. RESULTS: Most women went to see the doctor for some medical complaint, and only three women planned to disclose the abuse. Twenty-five women valued most their doctor's communicative approach with empathy or empowering and nine women valued most the instrumental approach. Eight women of the latter group wanted this combined with a communicative approach. After disclosure to the family doctor, a group of women (n=20) perceived a real change in their possibilities to handle their situation. They appeared to be in a position we named: 'in transition', a state in which they started or continued a process of change. Another group of women (n=13) appeared to be in a 'locked-up' position, a state without any prospect on change, feeling out of control and fearing the abuser. Three women reacted reserved towards change. CONCLUSION: A communicative approach, providing empathy and empowerment, is important to women in disclosing partner abuse. More than half of the women perceived possibilities for a change. PRACTICE IMPLICATIONS: Talking about abuse is an important step in a woman's process of change. Doctors should acknowledge the advantage of their position as a professional confidant and ask women about abuse.

Utilisation of health care by women who have suffered abuse: a descriptive study on medical records in family practice.

BACKGROUND: Female patients, abused by their partner, are heavy users of medical services. To date, valid indicators of partner abuse of women are lacking. AIM: To outline the healthcare utilisation in family practice of women who have suffered abuse, and compare this to the average female population in family practice. DESIGN OF STUDY: As part of a primary study on the role of family doctors in recognising and managing partner abuse a retrospective study was performed. Anonymised data from the electronic medical records of women who have suffered abuse were collected over the period January 2001-July 2004. These data were compared to those from the average female population of the Second Dutch National Survey in General Practice 2001 (DNSGP-2). SETTING: Family practices in Rotterdam and surrounding areas in 2004. METHOD: The numbers of consultations and prescriptions for pain medication, tranquillisers and antidepressants of women who have suffered abuse (n = 92) were compared to those of the female population of the DNSGP-2 (n = 210 071). The presented health problems and referrals of the studied group were examined. RESULTS: Pain, in all its manifestations, appeared to be the most frequently presented health problem. Compared to the female population of the DNSGP-2, in all age categories, women who have suffered abuse consult their family doctor almost twice as often and receive three to seven times more pain medication. CONCLUSION: A doubled consultation frequency, chronic pain and an excessively high number of prescriptions for pain medication are characteristics of healthcare utilisation of women have been abused in this study. These findings contribute to the development of the concept of the 'symptomatic' female patient.

"I am not frustrated anymore". Family doctors' evaluation of a comprehensive training on partner abuse.

OBJECTIVE: The aim of this study was to discover the ways in which a training program on intimate partner abuse affected a doctor's daily practice. METHODS: Eighteen family doctors who participated in a training program on partner abuse were interviewed. RESULTS: The interviewees evaluated the training program to be useful in raising their awareness and suspect criteria on partner abuse. Any questions and frustrations they had concerning the subject were resolved. They felt more confident and equipped to discuss and aid abused patients after the training. CONCLUSION: In order to improve doctors' awareness of partner abuse in daily practice, they must need first realize the scale of the problem and then become more comfortable in their own attitude and finally more confident in their ability to aid these patients. PRACTICE IMPLICATIONS: Training on partner abuse should be specifically tailored to change awareness, attitudes and consultation skills.

Discussing partner abuse: does doctor's gender really matter?

BACKGROUND: There are conflicting findings on the influence of gender on responding to partner abuse. OBJECTIVES: We aimed to explore gender differences in family doctors' views, attitudes, experiences and practices regarding intimate partner abuse against women. METHODS: We used the focus-group method with a stratified, randomized sample of family physicians. Three male and three female groups took part. Two independent researchers analysed the transcripts of the discussions. RESULTS: There were differences between male and female groups in discussing partner abuse, although similarities were also noted. Major contrasts in opinions were seen in (i) the role of sexuality: part of the male family doctors stated that denial of sexual relationships by a spouse was a contributing and eliciting factor to male aggression, whereas female doctors emphasized unanimously the humiliation of sexual coercion and the danger of opposing. (ii) Children as witnesses: this issue was discussed in female groups only, (iii) female doctors talked about emotional involvement with patients and male doctors about keeping distance, (iv) female doctors viewed leaving an abusive partner as a process whilst male doctors saw no progress, (v) experiences with abused patients: female doctors remembered more actual cases and (vi) practices in managing partner abuse differed between men and women. CONCLUSION: These remarkable gender-related differences among doctors might affect care for abused women. Doctors should be aware of gender-related views, attitudes and practices that can be harmful to their patients.

Increased awareness of intimate partner abuse after training: a randomised controlled trial.

BACKGROUND: Intimate partner abuse is very common among female patients in family practice. In general, doctors overlook the possibility of partner abuse. AIM: To investigate whether awareness of intimate partner abuse, as well as active questioning, increase after attending focus group and training, or focus group only. DESIGN OF STUDY: Randomised controlled trial in a stratified sample. SETTING: Family practices in Rotterdam and surrounding areas. METHOD: A full-training group (n = 23), a group attending focus group discussions alone (n = 14), and a control group (n = 17) were formed. Data were collected with incident reporting of every female patient (aged >18 years) that was suspected of, or presented, partner abuse during a period of 6 months. The primary outcome measure was the number of reported patients; the secondary outcome measure was the number of patients with whom the GP had non-obvious reasons to suspect/discuss abuse. RESULTS: Comparison of the full-training group (n = 87 patients) versus the control group (n = 14 patients) resulted in a rate ratio of 4.54 (95% confidence interval [CI] = 2.55 to 8.09, P <0.001); the focus group only group (n = 30 cases) versus control group: rate ratio of 2.2 (95% CI = 1.14 to 4.26, P = 0.019); full-training versus the focus group only group: rate ratio of 2.19 (95% CI = 1.36 to 3.52, P = 0.001). Comparison of the fulltraining group with the untrained groups for awareness of partner abuse in case of non-obvious signs resulted in: odds ratio 5.92 (95% CI = 2.25 to 15.62, P <0.01) all corrected for sex, district, practice setting, working part/full-time, experience, and age of the doctor. CONCLUSIONS: Training was the most significant determinant to improve awareness and identification of intimate partner abuse. Active questioning increased, especially where there were non-obvious signs. The focus group on its own doubled the awareness of partner abuse.

Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study.

BACKGROUND: Post-traumatic stress disorder (PTSD) is the only psychiatric condition that requires a specific event to have occurred for its diagnosis. AIMS: To gather evidence from the adult general population on whether life events (e.g. divorce, unemployment) generate as many symptoms of post-traumatic stress as traumatic events (e.g. accidents, abuse). METHOD: Data on demographic characteristics and history of stressful events were collected through a written questionnaire sent to a random sample of 2997 adults. Respondents also filled out a PTSD symptom checklist, keeping in mind their worst event. Mean PTSD scores were compared, controlling for differences between the two groups. Differences in item scores and in the distribution of the total PTSD scores were analysed. RESULTS: Of the 1498 respondents, 832 were eligible for inclusion in our analysis. For events from the past 30 years the PTSD scores were higher after life events than after traumatic events; for earlier events the scores were the same for both types of events. These findings could not be explained by differences in demographics, history of stressful events, individual item scores, or the distribution of the total PTSD scores. CONCLUSIONS: Life events can generate at least as many PTSD symptoms as traumatic events. Our findings call for further studies on the specificity of traumatic events as a cause of PTSD.

Traumatic events in a general practice population: the patient's perspective.

OBJECTIVES: The aim of the present study was to describe the patient's perspective on the GP's care after violent events: which role is the GP assigned; and how is the care appreciated. Events studied were serious accidents, burglary, robbery, physical and sexual abuse, disasters and war. METHOD: A postal questionnaire was sent to a random sample of 2997 patients (> or =20 years) from the practice population of 32 GPs (67 500 patients). RESULTS: The response was 50%. Forty-two per cent of the respondents had experienced one or more events. Twenty-eight per cent of the victims desired some kind of professional help; more than half of them desired that care from their GP, three-quarters actually seeking it. Most frequently sought care was sympathy, "a number of good talks", and care for physical complaints. Overall, contentment with the GP's contribution was high; patients especially appreciate sympathy and support, as well as initiative on the GP's part in commencing and pursuing care. Of those who felt no need for professional help, 88% found that they could cope with the traumatic event well enough, with or without the help of family and friends. For those who did not seek help, although they did desire it, the main reasons were that they considered their problems insufficiently medical or felt that their GP lacked the time. In the case of physical and sexual abuse, feelings of guilt and issues of patient confidentiality played a role for some patients. CONCLUSIONS: The number of events experienced by our respondents is lower than in previous studies for burglary, robbery, physical and sexual abuse (adults and children); the occurrence of accidents is similar. The majority of the people who experience traumatic events cope with them well enough without professional help. For those seeking help, the GP plays an important role. Care could be improved as follows: the GP should make it clear to patients that he/she can play a role in caring for them in the aftermath of a traumatic event and stress the confidential nature of the consultation. On the whole, GPs should be more supportive and attentive when being consulted about this topic; also patients would like their doctors to be more active in raising the subject, as well as in initiating follow-up.