How to use polarity thinkingTM to manage tensions between accountability and learner agency when using a multipurpose portfolio?

Portfolios are often implemented to target multiple purposes, e.g. assessment, accountability and/or self-regulated learning. However, in educational practice, it appears to be difficult to combine different purposes in one portfolio, as interdependencies between the purposes can cause tensions. This paper explored directions to manage tensions that are inextricably linked to multipurpose portfolio use. We used a systems thinking methodology, that was based on the polarity thinkingTM framework. This framework provides a step-by-step approach to chart a polarity map® that can help to balance the tensions present in specific settings. We followed the steps of the framework to chart a polarity map for multipurpose portfolio use. Based on literature and our prior research, we selected one overarching polarity: accountability and learner agency. This polarity seems responsible for multiple tensions related to multipurpose portfolio use. We formulated values (potential benefits) and fears (tensions that can arise) of the two poles of this polarity. Then, we organised a session with stakeholders who work with the portfolio of the Dutch General Practice speciality programme. Together we formulated action steps and early warnings that can help to balance accountability and learner agency during multipurpose portfolio use. In addition to previous recommendations concerning portfolio use, we advocate that it is important to create a shared frame of reference between all involved with the multipurpose portfolio. During this process, the acknowledgement and discussion of tensions related to multipurpose portfolio use are vital.

Peer assessment in medical communication skills training in programmatic assessment: A qualitative study examining faculty and student perceptions.

INTRODUCTION: Current literature recommends assessment of communication skills in medical education combining different settings and multiple observers. There is still a gap in understanding about whether and how peers assessment facilitates learning in communication skills training. METHODS: We designed a qualitative study using focus group interviews and thematic analysis, in a medical course in the Netherlands. We aimed to explore medical students' and teachers' experiences, perceptions, and perspectives about challenges and facilitating factors in PACST (Peer assessment in medical communication skills training). RESULTS: Most of the participants reported that peer feedback was a valuable experience when learning communication skills. The major challenges for the quality and credibility of PACST reported by the participants are the question whether peer feedback is critical enough for learning and the difficulty of actually engaging students in the assessment process. CONCLUSION: Teachers reviewing students' peer assessments may improve the quality and their credibility and the reviewed assessments can best be used for learning purposes. We suggest to pay sufficient attention to teachers' roles in PACST, ensuring a safe and trustworthy environment and additionally helping students to internalize the value of being vulnerable during the evaluation process.

How is self-regulated learning documented in e-portfolios of trainees? A content analysis.

BACKGROUND: It is assumed that portfolios contribute to self-regulated learning (SRL). Presence of these SRL processes within the documentation kept in portfolios is presupposed in common educational practices, such as the assessment of reflective entries. However, questions can be asked considering the presence of SRL within portfolios. The aim of this study was to gain insight into the documentation of SRL processes within the electronic (e)-portfolio content of medical trainees. SRL consists of numerous processes, for this study the focus was on self-assessment via reflection and feedback, goal-setting and planning, and monitoring, as these are the processes that health professions education research mentions to be supported by portfolios. METHODS: A database containing 1022 anonymous e-portfolios from General Practitioner trainees was used to provide descriptive statistics of the various available e-portfolio forms. This was followed by a quantitative content analysis of 90 e-portfolios, for which, a codebook was constructed to rate the documentation of the included SRL processes. RESULTS: The numbers of forms in the e-portfolios varied to a great extent. Content analysis showed a limited documentation of reflective entries, and available entries mainly described events and experiences without explanations and context. Feedback was generally limited to comments on what went well and lacked specificity, context and suggestions for future action. Learning goals and plans were short of specificity, but did contain challenging topics and different goals were compatible with each other. 75% of the e-portfolios showed (limited) signs of monitoring. CONCLUSIONS: The e-portfolio content showed limited documentation of SRL processes. As documentation of SRL requires time and asks for a high level of introspection and writing skills, one cannot expect documentation of SRL processes to appear in e-portfolio content without efforts.

Validity, reliability and discriminative capacity of an electronic quality of life instrument (Pelican) for childhood asthma in the Netherlands.

PURPOSE: To assess psychometric properties of the Pelican instrument, an online Dutch self-administered Quality of Life instrument for childhood asthma for scientific and clinical use. METHODS: A cohort study was done in two asthma populations and healthy children. One asthma population had assessment at start, 4 and 8 weeks. The other asthma population and healthy children had one assessment. All children were aged 6-12 years. Children completed the Pelican instrument, Paediatric Asthma Quality of Life Questionnaire, feeling thermometer and Childhood Asthma Control Test. Lung function and fraction exhaled nitric oxide were measured. Parents completed Functional Status II, Asthma Control Questionnaire, Childhood Asthma Control Test questionnaires and symptom diaries. We assessed interpretability, structural validity, internal consistency, reliability, construct and discriminative validity of the Pelican instrument. RESULTS: Eighty-five asthmatic (mean age 8.5 years) and 49 healthy children (mean age 8.4 years) participated. The Pelican instrument has 5 domains with 21 items after factor analysis. Internal consistency was 0.89 (CI 0.85-0.92), domain reliability showed Cronbach's α's from 0.64 to 0.76 and item-to-scale correlations from 0.61 to 0.81. Test-retest reliability was confirmed ICC = 0.88 (CI 0.79-0.93). Construct validity was demonstrated by significant moderate correlations with other relevant asthma outcomes like PAQLQ (r = -0.59, p < 0.01). Discriminative capacity between controlled or uncontrolled asthma (t = 3.20, p < 0.01, Δ = 0.64) and asthma versus healthy subjects (t = 6.31, p < 0.01, Δ = 0.94) was found. CONCLUSIONS: The psychometric properties of the Pelican instrument were acceptable in Dutch paediatric asthma patients between 6 and 12 years old.

Current clinical guideline definitions of airflow obstruction and COPD overdiagnosis in primary care.

The aim of the present study was to establish the agreement between two recommended definitions of airflow obstruction in symptomatic adults referred for spirometry by their general practitioner, and investigate how rates of airflow obstruction change when pre-bronchodilator instead of post-bronchodilator spirometry is performed. The diagnostic spirometric results of 14,056 adults with respiratory obstruction were analysed. Differences in interpretation between a fixed 0.70 forced expiratory volume in one second (FEV(1))/forced vital capacity (FVC) cut-off point and a sex- and age-specific lower limit of normal cut-off point for this ratio were investigated. Of the subjects, 53% were female and 69% were current or ex-smokers. The mean post-bronchodilator FEV(1)/FVC was 0.73 in males and 0.78 in females. The sensitivity of the fixed relative to the lower limit of normal cut-off point definition was 97.9%, with a specificity of 91.2%, positive predictive value of 72.0% and negative predictive value of 99.5%. For the subgroup of current or ex-smokers aged > or =50 yrs, these values were 100, 82.0, 69.2 and 100%, respectively. The proportion of false positive diagnoses using the fixed cut-off point increased with age. The positive predictive value of pre-bronchodilator airflow obstruction was 74.7% among current or ex-smokers aged > or =50 yrs. The current clinical guideline-recommended fixed 0.70 forced expiratory volume in one second/forced vital capacity cut-off point leads to substantial overdiagnosis of obstruction in middle-aged and elderly patients in primary care. Using pre-bronchodilator spirometry leads to a high rate of false positive interpretations of obstruction in primary care.

Occupational health and general practice: from opportunities lost to opportunities capitalised?

BACKGROUND AND AIM: Western populations are in the middle of the epidemiological transition of chronic diseases. Care of patients with chronic disease is directed at optimising life expectancy and quality of life. Daily and social functioning, including paid work are part of the treatment objectives. Yet, advice for and support in work related coping with chronic diseases, and collaboration with occupational health are not--yet--part of routine curative medical care procedures. This is also the case in general practice, where most patients with chronic conditions are treated. This 'blind spot' signals a generic lost opportunity in optimizing the care of patients with chronic disease. This paper analyses from empirical data the importance of integrating work-related advice and support in general practice and explores potential evidence of the benefits this provides for patients: the opportunities that can be capitalised through better interaction between occupational physicians (OP) and general practitioners (GP). METHODS: The paper is based on a review of three sources: (i) Epidemiology of chronic diseases: the Nijmegen Continuous Morbidity Registration; (ii) The relevant guidelines of the Dutch College of General Practitioners; (iii) Studies of work-related implications of asthma and COPD management of GPs of the Nijmegen centre of Evidence-Based Practice. RESULTS: Chronic diseases like cardiovascular disease, diabetes mellitus, COPD and asthma dominate general practice and lead annually to a large number of consultations. Although a majority of patients are 65 years or older--in particular for the first three diseases--GPs also care for a substantial number of under-65 years old. General practice guidelines for these disorders advocate care directed at normal functioning but do not systematically address functioning in the working place. Analysis of work-related functioning in case of chronic respiratory diseases, however, highlight that work-related factors and circumstances play an important role in patients' coping strategies. Patients tend to ignore negative effects of their workplace on their physical condition and as a consequence suffer undue limitations. Despite these work related risks, COPD patients who were in paid employement perceived higher quality of life than COPD patients who were disabled for work, but had similar disease severity (airway obstruction). Interestingly, a programme of patients' self-management of asthma resulted, in comparison to GP-supervised usual care in a substantial and lasting reduction of asthma related absence from work and other social-daily activities. CONCLUSIONS AND DISCUSSION: All consultations with employees with a chronic (respiratory) disease can be considered as opportunities to supervise work-related implications of the disease. Patients value their ability to work but frequently apply inefficient coping through ignoring the implications of their circumstances for their disease. A more efficient coping can probably be achieved through a more active involvement of patients in managing their own disease. Guidelines--like the Dutch College of General Practitioners'--have developed into a sophisticated and generally respected system of guidance of patient care. Explicit emphasis of management in relation to the workplace may present a logical opportunity to capitalise on.

Factors associated with asthma control.

The aim of this study was to evaluate which factors are associated with asthma control experienced by asthma patients. In a cross-sectional study patients aged 16-60 years with mild to moderate asthma were selected. The influence of the following factors on asthma control was studied in a multivariate model: age, gender, socioeconomic status, smoking, perceived hyperresponsiveness (PHR, responding with asthma symptoms to one or more triggers), allergy (Phadiatop), long-acting bronchodilating agents, and inhaled corticosteroids. Asthma control was measured by means of the Asthma Control Questionnaire (ACQ) as developed by Juniper. Forced expiratory volume in 1 second (FEV1) was measured by means of a portable spirometer. In this study with 311 patients, mean ACQ score was 1.39 (range 0-4.43). A stepwise backward linear regression analysis showed that low socioeconomic status (beta 0.425; p=0.001), current smoking (beta 0.555; p<0.001), high dose of inhaled corticosteroids (beta 0.364; p=0.04) and perceived hyperresponsiveness for increasing number of different triggers (PHR for 1 trigger beta 0.833; p=0.03; 2 triggers beta 0.810; p=0.03; 3 triggers beta 0.995; p=0.01; 4 triggers beta 1.131; p=0.002; 5 triggers beta 1.182; p=0.002) are independent predictors for poorer asthma control. Beside treatment with medication, stopping smoking and avoidance of triggers are factors, which may have a high impact on asthma control.

Self-management of asthma in general practice, asthma control and quality of life: a randomised controlled trial.

BACKGROUND: A study was undertaken to determine the effectiveness of asthma self-management in general practice. METHODS: Nineteen general practices were randomly allocated to usual care (UC) or self-management (SM). Asthma patients were included after confirmation of the GP diagnosis. Follow up was 2 years. Patients kept diary cards and visited the lung function laboratory every 6 months. Outcomes were number of successfully treated weeks, limited activity days, asthma specific quality of life, forced expiratory volume in 1 second (FEV(1)), FEV(1) reversibility, concentration of histamine provoking a fall in FEV(1) of 20% or more (PC(20) histamine), and amount of inhaled steroids. RESULTS: A total of 214 patients were included in the study (104 UC/110 SM; one third of the total asthma population in general practice); 62% were female. The mean percentage of successfully treated weeks per patient in the UC group was 72% (74/103 weeks) compared with 78% (81/105 weeks) in the SM group (p=0.003). The mean number of limited activity days was 1.2 (95% CI 0.5 to 1.9) in the SM group and 3.9 (95% CI 2.5 to 5.4) in the UC group. The estimated increase in asthma quality of life score was 0.10 points per visit in the UC group and 0.21 points per visit in the SM group (p=0.055). FEV(1), FEV(1) reversibility, and PC(20) histamine did not change. There was a saving of 217 puffs of inhaled steroid per patient in favour of the SM group (p<0.05). CONCLUSION: Self-management lowers the burden of illness as perceived by patients with asthma and is at least as effective as the treatment usually provided in Dutch primary care. Self-management is a safe basis for intermittent treatment with inhaled corticosteroids.

Present and future management of asthma and COPD: proceedings from WONCA 1998.

On 15 June 1998, a workshop on asthma and chronic obstructive pulmonary disease (COPD) was held at the WONCA conference in Dublin. Based on the current guidelines for diagnosis and treatment of asthma and COPD, new developments and present and future research projects were discussed. Based on these guidelines and the research findings, new developments were positioned. The final conclusion of this workshop was that there is a need to continue exchanging ideas at an international level. So an initiative to start a Scientific Group of Primary Care Research within the European Respiratory Society has been taken.

Self-treatment of asthma: possibilities and perspectives from the practitioner's point of view.

OBJECTIVES: Self-management of asthma is becoming more and more widespread. The implementation of this treatment strategy requires changes in the role and attitude of the GP. These changes may be hindered by obstacles both expected and experienced. As self-treatment of asthma is more common in the UK, comparison between UK and Dutch GPs provides a good opportunity to identify possible obstacles in general practice to the implementation of self-treatment of asthma with inhaled corticosteroids. METHODS: We carried out a qualitative descriptive study with self-administered questionnaires and interviews. Questionnaires were sent to 500 randomly selected Dutch GPs. Interviews were held with 20 Dutch and 25 British GPs in order to acquire more in-depth information. The outcome measures were attitude towards, knowledge regarding and experiences with self-treatment of asthma; organizational requirements; and expectations of consequences of self-treatment in general practice. RESULTS: The Dutch and British GPs investigated have a positive attitude towards self-treatment of asthma. Though knowledge about self-treatment is present among a majority of the GPs, self-treatment by patients is not yet as common in The Netherlands as it is in the UK. Nineteen per cent of the Dutch GPs had experience with a written peak-flow-based self-treatment plan related to the usage of inhaled steroids. According to our findings, present expected obstacles are probably mainly of the organizational kind, such as the availability of time, money and materials. CONCLUSIONS: There is a positive attitude towards the implementation of self-treatment plans in general practice, but problems relating to certain identified obstacles need to be addressed. There is a need to define which patients might profit from self-treatment, and further proof of both the clinical effectiveness and the cost-effectiveness of self-treatment needs to be acquired.