Reflection on medical errors: A thematic analysis.

BACKGROUND: As there is a need to prepare doctors to minimize errors, we wanted to determine how doctors go about reflecting upon their medical errors. METHODS: We conducted a thematic analysis of the published reflection reports of 12 Dutch doctors about the errors they had made. Three questions guided our analysis: What triggers doctors to become aware of their errors? What topics do they reflect upon to explain what happened? What lessons do doctors learn after reflecting on their error? RESULTS: We found that the triggers which made doctors aware of their errors were mostly death and/or a complication. This suggests that the trigger to recognize that something might be wrong came too late. The 12 doctors cited 20 topics' themes that explained the error and 16 lessons-learnt themes. The majority of the topics and lessons learnt were related more to the doctors' inner worlds (personal features) than to the outer world (environment). CONCLUSION: To minimize errors, doctors should be trained to become earlier and in time aware of distracting and misleading features that might interfere with their clinical reasoning. This training should focus on reflection in action and on discovering more about doctors' personal inner world to identify vulnerabilities.

How learning style affects evidence-based medicine: a survey study.

BACKGROUND: Learning styles determine how people manage new information. Evidence-based medicine (EBM) involves the management of information in clinical practice. As a consequence, the way in which a person uses EBM can be related to his or her learning style. In order to tailor EBM education to the individual learner, this study aims to determine whether there is a relationship between an individual's learning style and EBM competence (knowledge/skills, attitude, behaviour). METHODS: In 2008, we conducted a survey among 140 novice GP trainees in order to assess their EBM competence and learning styles (Accommodator, Diverger, Assimilator, Converger, or mixed learning style). RESULTS: The trainees' EBM knowledge/skills (scale 0-15; mean 6.8; 95%CI 6.4-7.2) were adequate and their attitudes towards EBM (scale 0-100; mean 63; 95%CI 61.3-64.3) were positive. We found no relationship between their knowledge/skills or attitudes and their learning styles (p = 0.21; p = 0.19). Of the trainees, 40% used guidelines to answer clinical questions and 55% agreed that the use of guidelines is the most appropriate way of applying EBM in general practice. Trainees preferred using evidence from summaries to using evidence from single studies. There were no differences in medical decision-making or in EBM use (p = 0.59) for the various learning styles. However, we did find a link between having an Accommodating or Converging learning style and making greater use of intuition. Moreover, trainees with different learning styles expressed different ideas about the optimal use of EBM in primary care. CONCLUSIONS: We found that EBM knowledge/skills and EBM attitudes did not differ with respect to the learning styles of GP trainees. However, we did find differences relating to the use of intuition and the trainees' ideas regarding the use of evidence in decision-making.

The death of a patient: a model for reflection in GP training.

BACKGROUND: The Dutch government has chosen a policy of strengthening palliative care in order to enable patients to die at home according to their preference. In order to facilitate this care by GPs, we wanted to know how to support them in their training. Therefore we examined the ways in which the death of a patient influences the doctor both at a professional and at a personal level. METHODS: Based on a qualitative study, we developed a model for reflection for GP trainees on the meaning of the death of patients and its influence on the GP.The qualitative study was done in 2007 and is based on open in-depth interviews and a focus group. We recruited 18 participants who were highly professional GPs and experienced in talking about the death of patients. We invited GPs from a list of experienced GPs, who in addition are also second-opinion GPs for euthanasia (SCEN-physicians) and from a pool of GP trainers, our intention being to include GPs holding a variety of world views. Interviews were audio-taped and transcribed verbatim. A grounded theory approach was used to analyze the results. Themes were first identified independently by three researchers, then after discussion these three sets were rearranged to one list of themes and their mutual relation were determined. A model for the interaction of the GP at professional and at a personal level was formulated. RESULTS: Forty three themes emerged from the interviews and focus group. These themes fell into three groups: professional values and experiences, personal values and experiences, and the opinions of the GPs as to what constitutes a good death. We constructed a model of the doctor-patient relationship on the basis of these findings. This model enables GP trainees identifying the unique character of the doctor-patient relationship as well as its reciprocity when the two were confronted by the patient's impending death. CONCLUSIONS: In dealing with the approaching death of a patient the unique interaction between patient and doctor and the cumulative experiences of doctors with their patients brings about a shift in the GP's own values. The professional development of GP trainees may be facilitated by reflection on the interaction of their own values and beliefs.

Job satisfaction among general practitioners: a systematic literature review.

OBJECTIVE: In recent years, the incidence of being overworked and burnt out has increased among general practitioners (GPs). One of the factors that influences the development of burnout is the job satisfaction that physicians experience. Therefore, we conducted a literature review to answer the question: what factors influence the job satisfaction experienced by GPs? METHODS: We used two methods to retrieve citations. We searched four literature databases for citations from 1990 until July 2006, and we checked the reference lists of relevant articles. The inclusion criteria were: GPs had to be the subjects of the study, the study had to describe empirical research, the study had to focus on job satisfaction, and the number of subjects had to be greater than 30. RESULTS: We found 24 relevant citations. Factors increasing job satisfaction which were mentioned more than twice were: diversity of work, relations and contact with colleagues, and being involved in teaching medical students. Factors decreasing job satisfaction were: low income, too many working hours, administrative burdens, heavy workload, lack of time, and lack of recognition. CONCLUSION: Aspects of job satisfaction concerning the content of the profession seem to increase job satisfaction, and aspects concerning employment conditions seem to decrease job satisfaction.

Effect of an evidence-based answering service on GPs and their patients: a pilot study.

OBJECTIVES: For general practitioners (GPs), an important obstacle to practising evidence-based medicine is lack of time. An evidence-based answering service was developed that took over searching and appraisal of medical evidence from the GPs. GPs sent in questions, and the informationist formulated the answers. Our objectives were to find out if such an evidence-based answering service was feasible, including assessing the effect of the answers on GPs and their patients, as reported by the GPs. METHODS: After attending a workshop on building well-formulated questions from daily practice, the GPs sent in questions to the informationist. The literature was searched, the relevant information was appraised, and the answers to the questions were formulated. With a questionnaire, the effect of the answers on the GP and the patient was assessed, as well as the perceived barriers to implementing the answers. RESULTS: From 26 GPs, 61 questions were received. For 12% of questions, information was found with the highest evidence level, while for 36%, no information was found. However, for 89% of the questions for which no information could be found, the answer 'no information found' did have an effect on the GP concerned. In total, 81% of all the answers had an effect on the GP, and, according to the GP, 52% had an effect on the patient. Few barriers to implementing the evidence were perceived. Most of the answers were found in Pubmed/Medline, the Cochrane Library and Embase. CONCLUSIONS: This study indicates that an evidence-based answering service can have an impact on GPs and their patients. Librarians can provide an evidence-based answering service for GPs and their patients. The evidence-based answering service for GPs in this study had an impact on 81% of the GPs and on 52% of their patients. Although for one-third of the questions no evidence-based answer was found, this message in itself had an impact on 89% of the GPs. An informationist as mediator between medical information and doctors can save doctors' time.