How does guided group reflection work to support professional identity formation in postgraduate medical education: A scoping review.

PURPOSE: In postgraduate medical education, guided group reflection is often applied to support professional identity formation. However, little is known about how guided group reflection is shaped and how it works. Our scoping review synthesizes existing evidence about various approaches for guided group reflection, their aims, components and potential working mechanisms. METHODS: We conducted a scoping review using JBI (Joanna Briggs Institute) guidelines for conducting scoping reviews. We searched PubMed, PsycINFO, EMBASE and ERIC databases for all research articles published in English or Dutch in an iterative team approach. The articles were extracted and summarized quantitatively and qualitatively. RESULTS: We included 71 papers (45 primary research papers and 26 non-empirical papers including program descriptions, theoretical concepts and personal experiences). We identified a diversity of approaches for guided group reflection (e.g. Balint groups, supervised collaborative reflection and exchange of experiences), applied in a variety of didactic formats and aims. We distilled potential working mechanisms relating to engagement in reflection, group learning and the supervisor's role. CONCLUSIONS: There are significant knowledge gaps about the aims and underlying mechanisms of guided group reflection. Future systematic research on these topics is needed to understand the effectiveness of educational methods, that can help facilitate learning conditions to best shape professional identity formation (PIF) in educational curricula.

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.

How does portfolio use support self-regulated learning during general practitioner specialty training? A qualitative focus group study.

OBJECTIVES: Portfolios are used to support self-regulated learning (SRL), but the research literature is still inconclusive on their effectiveness. This study explored experiences with portfolio use among different stakeholders, to answer the research question: How does portfolio use support SRL during general practitioner (GP) specialty training? DESIGN: We used a qualitative research design, based on phenomenology. SETTING: Three of the eight training institutes of Dutch GP specialty training participated in this study. PARTICIPANTS: The three stakeholder groups that use the portfolio were included in nine homogenous focus groups: trainees (n=16), supervisors (n=16) and faculty (n=17). All participants had at least 6-month experience with portfolio use. RESULTS: Three themes were identified: SRL with(out) the portfolio, stakeholder dynamics and ambiguities. Respondents were doubtful about the learning benefits of portfolio use, as most trainees used their portfolio to 'check off' what was considered required. Stakeholder dynamics contributed to checking off behaviour in two ways. First, trainees experienced documenting learning activities to be superfluous, since the close relationship with their supervisor already supported SRL sufficiently. Second, faculty often (unintentionally) took portfolio ownership away from trainees, as they instructed trainees to deliver portfolio content that was valuable for assessment. Without ownership, trainees struggled to use the portfolio for SRL. Besides, ambiguities related to portfolio use amplified checking off behaviour. CONCLUSIONS: Portfolio use did not support SRL in our setting. The multipurpose use of the portfolio (for the support of SRL and assessment) was identified as the primary obstacle. Underlying is a conflict that is often present in current medical curricula: agency versus accountability. If the support of SRL is considered a valuable and attainable purpose of portfolio use, it is important to realise that deliberate attention for this purpose is required during the design, guidance, assessment and evaluation of the portfolio.

Identifying characteristics of a skilled communicator in the clinical encounter.

BACKGROUND: In medical communication research, there has been a shift from 'communication skills' towards 'skilled communication', the latter implying the development of flexibility and creativity to tailor communication to authentic clinical situations. However, a lack of consensus currently exists what skilled communication entails. This study therefore aims to identify characteristics of a skilled communicator, hereby contributing to theory building in communication research and informing medical training. METHOD: In 2020, six nominal group technique (NGT) sessions were conducted in the context of the general practitioner (GP) training programme engaging 34 stakeholders (i.e. GPs, GP residents, faculty members and researchers) based on their experience and expertise in doctor-patient communication. Participants in each NGT session rank-ordered a 'Top 7' of characteristics of a skilled communicator. The output of the NGT sessions was analysed using mixed methods, including descriptive statistics and thematic content analysis during an iterative process. RESULTS: Rankings of the six sessions consisted of 191 items in total, which were organised into 41 clusters. Thematic content analysis of the identified 41 clusters revealed nine themes describing characteristics of a skilled communicator: (A) being sensitive and adapting to the patient; (B) being proficient in applying interpersonal communication; (C) self-awareness, learning ability and reflective capacity; (D) being genuinely interested; (E) being proficient in applying patient-centred communication; (F) goal-oriented communication; (G) being authentic; (H) active listening; and (I) collaborating with the patient. CONCLUSIONS: We conceptualise a skilled communication approach based on the identified characteristics in the present study to support learning in medical training. In a conceptual model, two parallel processes are key in developing adaptive expertise in communication: (1) being sensitive and adapting communication to the patient and (2) monitoring communication performance in terms of self-awareness and reflective capacity. The identified characteristics and the conceptual model provide a base to develop a learner-centred programme, facilitating repeated practice and reflection. Further research should investigate how learners can be optimally supported in becoming skilled communicators during workplace learning.

How does portfolio use affect self-regulated learning in clinical workplace learning: What works, for whom, and in what contexts?

INTRODUCTION: Portfolio use to support self-regulated learning (SRL) during clinical workplace learning is widespread, but much is still unknown regarding its effectiveness. This review aimed to gain insight in the extent to which portfolio use supports SRL and under what circumstances. METHODS: A realist review was conducted in two phases. First, stakeholder interviews and a scoping search were used to formulate a program theory that explains how portfolio use could support SRL. Second, an in-depth literature search was conducted. The included papers were coded to extract context-mechanism-outcome configurations (CMOs). These were synthesized to answer the research question. RESULTS: Sixteen papers were included (four fulfilled all qualitative rigor criteria). Two primary portfolio mechanisms were established: documenting as a moment of contemplation (learners analyze experiences while writing portfolio reports) and documentation as a reminder of past events (previous portfolio reports aid recall). These mechanisms may explain the positive relationship between portfolio use and self-assessment, reflection, and feedback. However, other SRL outcomes were only supported to a limited extent: formulation of learning objectives and plans, and monitoring. The partial support of the program theory can be explained by interference of contextual factors (e.g., system of assessment) and portfolio-related mechanisms (e.g., mentoring). DISCUSSION: Portfolio research is falling short both theoretically-in defining and conceptualizing SRL-and methodologically. Nevertheless, this review indicates that portfolio use has potential to support SRL. However, the working mechanisms of portfolio use are easily disrupted. These disruptions seem to relate to tensions between different portfolio purposes, which may undermine learners' motivation.

Identifying residents' educational needs to optimising postgraduate medical education about shared decision-making.

OBJECTIVE: To investigate how to optimise resident engagement during workplace learning of shared decision-making (SDM) by understanding their educational needs. METHODS: A qualitative multicentre study was conducted using video-stimulated interviews with 17 residents in General Practice. Video recordings of residents' recent clinical encounters were used to facilitate reflection on their educational needs. RESULTS: Data analysis resulted in five themes regarding residents' educational needs for learning SDM: acquiring knowledge and skills needed to perform SDM; practising SDM; reflection and feedback; longitudinal and integrated training; and awareness and motivation for performing SDM. CONCLUSION: Residents expressed a need for continuous attention to be paid to SDM during postgraduate medical education. That would help them engage in two parallel learning processes: acquiring the knowledge and skills necessary to perform SDM, and practising SDM in the clinical workplace. Alignment between the educational curriculum, workplace learning and resident learning activities is essential to operationalise SDM attitude, knowledge and skills into clinical performance. PRACTICE IMPLICATIONS: The identified educational needs provide ingredients for fostering the development of SDM proficiency. The findings suggest that residents and clinical supervisors need parallel training to bridge the gap between education and clinical practice when learning SDM.

Supervisory dyads' communication and alignment regarding the use of workplace-based observations: a qualitative study in general practice residency.

BACKGROUND: In medical residency, performance observations are considered an important strategy to monitor competence development, provide feedback and warrant patient safety. The aim of this study was to gain insight into whether and how supervisor-resident dyads build a working repertoire regarding the use of observations, and how they discuss and align goals and approaches to observation in particular. METHODS: We used a qualitative, social constructivist approach to explore if and how supervisory dyads work towards alignment of goals and preferred approaches to performance observations. We conducted semi-structured interviews with supervisor-resident dyads, performing a template analysis of the data thus obtained. RESULTS: The supervisory dyads did not frequently communicate about the use of observations, except at the start of training and unless they were triggered by internal or external factors. Their working repertoire regarding the use of observations seemed to be primarily driven by patient safety goals and institutional assessment requirements rather than by providing developmental feedback. Although intended as formative, the institutional test was perceived as summative by supervisors and residents, and led to teaching to the test rather than educating for purposes of competence development. CONCLUSIONS: To unlock the full educational potential of performance observations, and to foster the development of an educational alliance, it is essential that supervisory dyads and the training institute communicate clearly about these observations and the role of assessment practices of- and for learning, in order to align their goals and respective approaches.

Exploring typologies of consultation performance using authentic clinical experiences to support learning and assessment in postgraduate medical training.

OBJECTIVE: To validate and refine typologies of consultation performance from previous research to identify learning needs associated with each typology. METHODS: We performed a qualitative study in a General Practice Specialty Training programme, using a two-stage design. First, we selected four exemplars from 80 videotaped consultations of 7 first-year and 6 third-year trainees that reflected the four typologies. We subsequently held individual interviews with clinical supervisors (N = 20) who observed these consultations to identify recurrent trainee behaviours. RESULTS: The 'doctor-patient interaction' dimension from previous research was specified to encompass relationship-building, exploring, structuring, and shared decision-making competencies. Medical expertise was a moderating factor. The attitude and consultation behaviours included in the typologies were validated and we formulated directions for learning based on learning needs identified per typology. CONCLUSION: Supervisors have a shared frame of reference for the behaviours reflecting proficient consultation performance. Serving as a developmental road map, all learning needs emphasised contextual adaptation, calling for an improved balance between patient-centred relationship building and application of medical expertise. PRACTICE IMPLICATIONS: By providing rich and tailored feedback on consultation performance, the refined typologies - albeit subject to additional refinement in future research - may promote the monitoring of individual competence development over time.

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.

Supervisors' intention to observe clinical task performance: an exploratory study using the theory of planned behaviour during postgraduate medical training.

BACKGROUND: Direct observation of clinical task performance plays a pivotal role in competency-based medical education. Although formal guidelines require supervisors to engage in direct observations, research demonstrates that trainees are infrequently observed. Supervisors may not only experience practical and socio-cultural barriers to direct observations in healthcare settings, they may also question usefulness or have low perceived self-efficacy in performing direct observations. A better understanding of how these multiple factors interact to influence supervisors' intention to perform direct observations may help us to more effectively implement the aforementioned guidelines and increase the frequency of direct observations. METHODS: We conducted an exploratory quantitative study, using the Theory of Planned Behaviour (TPB) as our theoretical framework. In applying the TPB, we transfer a psychological theory to medical education to get insight in the influence of cognitive and emotional processes on intentions to use direct observations in workplace based learning and assessment. We developed an instrument to investigate supervisors intention to perform direct observations. The relationships between the TPB measures of our questionnaire were explored by computing bivariate correlations using Pearson's R tests. Hierarchical regression analysis was performed in order to assess the impact of the respective TPB measures as predictors on the intention to perform direct observations. RESULTS: In our study 82 GP supervisors completed our TPB questionnaire. We found that supervisors had a positive attitude towards direct observations. Our TPB model explained 45% of the variance in supervisors' intentions to perform them. Normative beliefs and past behaviour were significant determinants of this intention. CONCLUSION: Our study suggests that supervisors use their past experiences to form intentions to perform direct observations in a careful, thoughtful manner and, in doing so, also take the preferences of the learner and other stakeholders potentially engaged in direct observations into consideration. These findings have potential implications for research into work-based assessments and the development of training interventions to foster a shared mental model on the use of direct observations.

How doctors recognise that their patients are worried: A qualitative study of patient cues.

OBJECTIVES: Recognising patient cues indicating worry is essential for successful reassurance. To obtain more insight into the variety and nature of patient cues that may arise in practice, this study explores doctors' reflections on patient cues they recognise during consultations. METHODS: We performed a qualitative study during which GPs participated in stimulated recall interviews, using their own video-recorded consultations to enhance reflection. First, we reanalysed an existing dataset of 15 interviews during which GPs elaborated on the doctor-patient interaction. Additionally, 12 GPs were interviewed specifically about recognising patients' cues. RESULTS: GPs described four categories of patient cues that indicate worry. GPs recognised worry based on non-verbal cues such as visible bodily reactions, and verbal cues that can be further categorised by type of worry (e.g. about serious disease). Moreover, GPs described behavioural cues, e.g. the patient bringing a list of symptoms. Lastly, GPs recognise worry based on prior knowledge about the patient. CONCLUSIONS: GPs reflections have given insight into a wide variety of non-verbal -, verbal -, behavioural- and foreknowledge-based cues. PRACTICE IMPLICATIONS: The identified cues can guide other clinicians in recognising worries and inform medical communication training and future research on the effectiveness of recognising cues and patient reassurance.

Stakeholder perspectives on workplace-based performance assessment: towards a better understanding of assessor behaviour.

Workplace-Based Assessment (WBA) plays a pivotal role in present-day competency-based medical curricula. Validity in WBA mainly depends on how stakeholders (e.g. clinical supervisors and learners) use the assessments-rather than on the intrinsic qualities of instruments and methods. Current research on assessment in clinical contexts seems to imply that variable behaviours during performance assessment of both assessors and learners may well reflect their respective beliefs and perspectives towards WBA. We therefore performed a Q methodological study to explore perspectives underlying stakeholders' behaviours in WBA in a postgraduate medical training program. Five different perspectives on performance assessment were extracted: Agency, Mutuality, Objectivity, Adaptivity and Accountability. These perspectives reflect both differences and similarities in stakeholder perceptions and preferences regarding the utility of WBA. In comparing and contrasting the various perspectives, we identified two key areas of disagreement, specifically 'the locus of regulation of learning' (i.e., self-regulated versus externally regulated learning) and 'the extent to which assessment should be standardised' (i.e., tailored versus standardised assessment). Differing perspectives may variously affect stakeholders' acceptance, use-and, consequently, the effectiveness-of assessment programmes. Continuous interaction between all stakeholders is essential to monitor, adapt and improve assessment practices and to stimulate the development of a shared mental model. Better understanding of underlying stakeholder perspectives could be an important step in bridging the gap between psychometric and socio-constructivist approaches in WBA.

Should we assess clinical performance in single patient encounters or consistent behaviors of clinical performance over a series of encounters? A qualitative exploration of narrative trainee profiles.

BACKGROUND: A variety of tools have been developed to assess performance which typically use a single clinical encounter as a source for making competency inferences. This strategy may miss consistent behaviors. We therefore explored experienced clinical supervisors' perceptions of behavioral patterns that potentially exist in postgraduate general practice trainees expressed as narrative profiles to aid the grading of clinical performance. METHODS: We conducted semistructured interviews with clinical supervisors who had frequently observed clinical performance in trainees. Supervisors were asked to describe which behavioral patterns they had discerned in excellent and underperforming trainees, during different stages of training, in their careers as clinical supervisor. We analyzed the interviews using a grounded theory approach. RESULTS: The analysis resulted in a conceptual framework that distinguishes between desirable and undesirable narrative profiles. The framework consists of two dimensions: doctor-patient interaction and medical expertise. Personal values appear to be a moderating factor. CONCLUSIONS: According to experienced clinical supervisors, consistent behaviors do exist in GP trainees when observing clinical performance over time. The conceptual framework has to be validated by further observational studies to assess its potential for making robust and fair assessments of clinical performance and monitor the development of consultation performance over time.

Psychometric characteristics of health-related quality-of-life questionnaires in oropharyngeal dysphagia.

Dysphagia can have severe consequences for the patient's health, influencing health-related quality of life (HRQoL). Sound psychometric properties of HRQoL questionnaires are a precondition for assessing the impact of dysphagia, the focus of this study, resulting in recommendations for the appropriate use of these questionnaires in both clinical practice and research contexts. We performed a systematic review starting with a search for and retrieval of all full-text articles on the development of HRQoL questionnaires related to oropharyngeal dysphagia and/or their psychometric validation from the electronic databases PubMed and Embase published up to June 2011. Psychometric properties were judged according to quality criteria proposed for health status questionnaires. Eight questionnaires were included in this study. Four are aimed solely at HRQoL in oropharyngeal dysphagia: the deglutition handicap index (DHI), dysphagia handicap index (DHI'), M.D. Anderson Dysphagia Inventory (MDADI), and SWAL-QOL, while the EDGQ, EORTC QLQ-STO 22, EORTC QLQ-OG 25 and EORTC QLQ-H&N35 focus on other primary diseases resulting in dysphagia. The psychometric properties of the DHI, DHI', MDADI, and SWAL-QOL were evaluated. For appropriate applicability of HRQoL questionnaires, strong scores on the psychometric criteria face validity, criterion validity, and interpretability are prerequisites. The SWAL-QOL has the strongest ratings for these criteria, while the DHI' is the most easy to apply given its 25 items and the use of a uniform scoring format. For optimal use of HRQoL questionnaires in diverse settings, it is necessary to combine psychometric and utility approaches.

Psychometric evaluation of the OM8-30 questionnaire in Dutch children with otitis media.

The Dutch translation of the OM8-30 questionnaire, originally developed in the UK on a large clinical sample, has been applied for validation in an ENT sample, with the aim of assessing otitis media impact and identifying treatment needs in children suffering from chronic otitis media (OM) and/or upper respiratory tract infections (URTI). Caregivers of 246 children completed the OM8-30 and also the generic Strengths and Difficulties Questionnaire (SDQ), prior to otolaryngologist consultation. Factor analysis confirmed the hypothesized six-factor structure, accounting for 55.5% of the variance. The internal consistency was satisfactory to good for all of the physical and developmental facets (alpha-values > or = 0.68). The correlation matrix with the SDQ scales and total difficulties score showed significant relationships for almost all of the OM8-30 developmental facets and sub-aggregate (Ps < 0.01), supporting the concurrent validity of the OM8-30 as a measure of impact in otitis media. This first examination of the Dutch OM8-30 shows that the psychometric characteristics are sufficiently good for the assessment of disease impact, and that this can be subdivided into impact on physical health and on developmental aspects. Recommendations for further research include the study of confounders such as hearing, age and previous operations so that these can be adjusted out, and the determination of which subgroup of children may benefit from tympanostomy tubes.

Level of psychosocial adaptation in young school children with otitis media.

OBJECTIVE: Assessment of the level of psychosocial adaptation in Dutch young school children with persistent and/or recurrent otitis media compared to a U.S. community sample. The goal of this study was to determine the presence of behavioural effects related to a history of hearing loss resulting from recurrent or persistent otitis media. METHODS: Caregivers of 160 children, age range 4-7 years, suffering from either upper respiratory tract infections (URTI) and/or otitis media with effusion (OME), completed the generic Strengths and Difficulties Questionnaire (SDQ) and impact supplement before consulting the ENT physician. RESULTS: In the ENT sample significant differences were found for the SDQ subscales hyperactivity-inattention and emotional symptoms, as well as for the total difficulties score and impact rating, compared to the U.S. community sample (p<.0005). Classification of severity (low, medium, high difficulties) for SDQ symptom scores, according to U.S. normative scoring bands, showed significantly more children in higher severity bands for SDQ total difficulties (p<.0005), emotional symptoms (p<.005), hyperactivity-inattention (p<.001) and prosocial behaviour (p<.005). This is expressed in a larger percentage of scores in the high difficulties (>90% of scores) than in the medium difficulties (80-90% of scores) band for most ENT SDQ scores, except for SDQ prosocial behaviour (18.1%) and total difficulties (17.5%). CONCLUSION: The level of psychosocial adaptation seems to be compromised in the Dutch ENT sample for both internalising (emotional symptoms) and externalising (hyperactivity-inattention) behaviour dimensions, which indirectly supports the cumulative effects of a disease history with chronic otitis media, resulting in poorer attention skills and fewer social interactions present. The classification of SDQ symptom severity, indicates that any behavioural effect of otitis media and resulting hearing loss is within the borderline score range, asking for vigilance regarding possible developmental and educational sequelae during childhood.

First psychometric evaluation of a disease-specific questionnaire for children's behavior related to otitis media with effusion.

The major goal of the present study is a psychometric analysis of two age-specific questionnaires for the assessment of Otitis Media with Effusion-specific behavior in young children, intended for use in case-finding. In total, 172 children ages 12 to 24 mo. and 121 children ages 24 to 48 mo. were available initially. Caregivers completed the questionnaires on two occasions before tympanostomy tube insertion and once 6 wk. later. Factor analysis of a matrix for 30 items yielded four factors for the younger age group and six factors for a 33-item matrix for the older age group, showing more differentiation of factors in terms of developmental specificity for behavior related to Otitis Media with Effusion. The total internal consistency was .82, and each factor measured different aspects of disease-specific behavior (alpha < or = 0.25) in both questionnaires. Sensitivity to change seemed promising and was significant for the age group 12 to 24 mo. Research with revised questionnaires is recommended, in an ongoing validation process, to create optimal developmental conditions for children with chronic or persistent Otitis Media with Effusion.

Response-shift bias and parent-reported quality of life in children with otitis media.

OBJECTIVES: To validate the 6-item quality-of-life survey (OM-6) and to investigate response-shift bias regarding children with otitis media. SETTING: Otorhinolaryngology department of a university hospital that serves the southernmost part of the Netherlands. PATIENTS: Seventy-seven children (age range, 12-38 months) experiencing persistent otitis media with effusion and scheduled for placement of tympanostomy tubes. SURVEY: The OM-6 measures health-related quality of life in 6 domains: physical suffering, hearing loss, speech impairment, emotional distress, activity limitations, and caregiver concerns. INTERVENTION: Parents completed the OM-6 before surgery (pretest) and 6 weeks after surgery (posttest). At the posttest, parents also completed a retrospective version of the pretest (retrospective pretest). RESULTS: For most items, the test-retest reliability was good (R>0.8). The internal consistency of the OM-6 was satisfactory (alpha =.79). The construct validity, determined by correlating the ear-related global quality-of-life measure and the OM-6 summary score, was fair (R = -0.77, P<.01). Prospective change in quality of life on the OM-6 ranged from moderate (standardized response mean >/=0.5) to large (standardized response mean >/=0.8). Response-shift bias was present at the group level (t = -3.3, P<.01). Retrospective change was significant for hearing loss (z = -3.3, P<.05) and ear-related global quality of life (z = -3.6, P<.05). CONCLUSIONS: The validity of the OM-6 has been proved in a Dutch population. The data suggest that parents underestimate the seriousness of hearing loss and overestimate the quality of life of their child before surgery, indicating a response shift. Treatment results could lead parents to realize that the situation before surgery had been worse than they thought.