Some residents drop out of specialty training. How important is prior clinical experience? A survey among residents in the Netherlands.

Objectives: The drop-out rate among residents across all medical specialties in the Netherlands approximates 12.7%. This implies a capacity loss in the medical workforce, a waste of educational resources and personal damage to individuals. The aim of our study was to investigate reasons for dropping out of residency and the relationship with medical work experience after medical school and prior to residency, which is common among Dutch graduates. Method: A questionnaire listing 28 reasons for drop-out was developed and tested. The questionnaire was sent in a nationwide survey to all residents who drop out between 1 September 2017 and 1 September 2019. The respondents were asked to indicate on a 5-point Likert scale, how they weighed reasons for drop-out. Factor analysis was applied to identify dominant factors. Results: The response rate was 39% (N=129; 99 females) representing all medical specialties. The factor structure of our measure showed 5 factors; high emotional job demands, lack of professional satisfaction, incompatible lifestyle, tensions in working relationships and disappointing career perspectives. Of the respondents 69 (54%) had prior clinical experience as a physician-not-in-training in the same medical specialty before residency. The factor "lack of professional satisfaction" weighed heavier for respondents without prior experience as a reason for drop-out. Conclusion: Of influence on dropping out of residency is the lack of a clear image of the responsibilities as a physician within the residency of choice, fuelled by limited prior experience after medical school and before residency. One third of dropouts confirmed that prior physician experience within the same specialty could have prevented dropping out or prevented choosing this specialty in the first place.

Physicians' norms and attitudes towards substance use in colleague physicians: A cross-sectional survey in the Netherlands.

INTRODUCTION: Substance use disorders (SUD) in physicians often remain concealed for a long time. Peer monitoring and open discussions with colleagues are essential for identifying SUD. However, physicians often feel uncomfortable discussing substance use with a colleague. We explored physicians' attitudes and norms about substance use (disorders) and their (intended) approach upon a presumption of substance use in a colleague. MATERIALS AND METHODS: An online cross-sectional survey concerning "Addiction in physicians" was administered by the Royal Dutch Medical Association physician panel. Overall, 1685 physicians (47%) responded. Data were analyzed by logistic regression to explore factors associated with taking action upon a substance use presumption. RESULTS: Most physicians agreed that SUD can happen to anyone (67%), is not a sign of weakness (78%) and that it is a disease that can be treated (83%). Substance use in a working context was perceived as unacceptable (alcohol at work: 99%, alcohol during a standby duty: 91%, alcohol in the eight hours before work: 77%, and illicit drugs in the eight hours before work: 97%). Almost all respondents (97%) intend to act upon a substance use presumption in a colleague. Of the 29% who ever had this presumption, 65% took actual action. Actual action was associated with male gender and older age (OR = 1.81; 95% CI = 1.20-2.74 and OR = 1.03; 95% CI = 1.01-1.05, respectively). CONCLUSIONS: About one-third of physicians reported experience with a presumption of substance use in a colleague. Whilst most physicians intend to take action upon such a presumption, two-thirds actually do act upon a presumption. To bridge this intention-behavior gap continued medical education on signs and symptoms of SUD and instructions on how to enter a supportive dialogue with a colleague about personal issues, may enhance physicians' knowledge, confidence, and ethical responsibility to act upon a presumption of substance use or other concerns in a colleague.

The Significance of Experiencing Clinical Responsibilities for Specialty Career Choice.

AIM: Medical trainees make career choices in the final year of medical school or after graduation, if they do not continue with residency directly. Most Dutch medical students are trained in vertically integrated (VI) curricula, with early clinical experience and a gradual increase in clinical responsibilities. Students in such curricula have been reported to make career choices at an earlier stage than graduates from more traditionally designed curricula. Many Dutch graduates build further clinical experience after graduation as physicians-not-in-training (PNITs) before beginning residency. We explored how students make career choices and whether pre-residency clinical responsibilities influence this choice. METHOD: A qualitative study with a phenomenology approach was used. The authors conducted a longitudinal interview study of medical students with two intervals over a 2-year period. The interview questions covered how trainees establish career preferences and which factors affect preference and choice over time. RESULTS: Experiencing clinical responsibility was a key factor for career preference during all interview rounds. Being a PNIT who makes diagnostic and therapeutic decisions, have their own patients and have significant patient care responsibilities creates opportunities to build an image of a future context of employment. Some participants mentioned that their experience of having full responsibility as a PNIT was pivotal in a career preference change. CONCLUSION: Clinical responsibility as a student or a PNIT appears to be important for career preference and choice. The experience of responsibility as a medical doctor forces trainees to reflect on personal needs and to consider which career preference fits best.

Factors affecting senior medical students' career choice.

OBJECTIVES: To gain insight into factors affecting career preference and career choice during the final phase of medical school, above and beyond a model that was presented by Bland and colleagues in 1995 (the "Bland model"). METHODS: A qualitative study was conducted. One-hour semi-structured interviews were conducted with final-year medical students about career preference and the factors influencing preference and choice. The interviews were transcribed and a thematic analysis was applied, to identify patterns and interrelationships in the data and to compare and contrast these with the Bland model. RESULTS: Twenty-four students participated. Three critical sets of factors, not present in the Bland model, emerged from the interviews: (a) factors arising from student-initiated information collection, (b) patient population characteristics of a specialty domain, and (c) the characteristics of teams and colleagues within a specialty. CONCLUSIONS: Students appear to actively match and calibrate perceptions of different specialty characteristics with their current personal needs and expected future needs, and to include cues from self-initiated information collection about a speciality. This agency aligns with Billett's workplace learning theory. Next, specialty patient population features appear to be taken into account; this was not unexpected but not included in the Bland model. Finally, the characteristics of teams and colleagues of a specialty were stressed in the interviews. These three components broaden the applicability of the Bland model--originally created for primary-care careers--to medical specialties in general.

Dynamics of career choice among students in undergraduate medical courses. A BEME systematic review: BEME Guide No. 33.

INTRODUCTION: Due to the lack of a theoretically embedded overview of the recent literature on medical career decision-making, this study provides an outline of these dynamics. Since differences in educational routes to the medical degree likely affect career choice dynamics, this study focuses on medical career decision-making in educational systems with a Western European curriculum structure. METHODS: A systematic search of electronic databases (Medline, Embase) was conducted from January 2008 to November 2014. A panel of seven independent reviewers performed the data extraction, quality assessment and data synthesis using the Bland-Meurer model of medical specialty choice as a reference. RESULTS: Fifty-seven studies met the inclusion criteria for the review. Factors associated with specialty preference or career choice can be classified in five main categories: (1) medical school characteristics (e.g., curriculum structure), (2) student characteristics (e.g., age, personality), (3) student values (e.g., personal preference), (4) career needs to be satisfied (e.g., expected income, status, and work-life balance), and (5) perception of specialty characteristics (e.g., extracurricular or curricular experiences). Especially career needs and perceptions of specialty characteristics are often associated with medical career decision-making. CONCLUSION: Our results support that medical career decisions are formed by a matching of perceptions of specialty characteristics with personal needs. However, the process of medical career decision-making is not yet fully understood. Besides identifying possible predictors, future research should focus on detecting interrelations between hypothesized predictors and identify the determinants and interrelations at the various stages of the medical career decision-making process.

Neutral to positive views on the consequences of nurse prescribing: Results of a national survey among registered nurses, nurse specialists and physicians.

BACKGROUND: Over the last two decades, the number of countries where nurses are legally permitted to prescribe medication has grown considerably. A lack of peer support and/or objections by physicians can act as factors hampering nurse prescribing. Earlier research suggests that physicians are generally less supportive and more concerned about nurse prescribing than nurses are. However, direct comparisons between doctors' and nurses' views are scarce and are often based on small sample sizes. OBJECTIVES: To gain insight into the views of Dutch registered nurses (RNs), nurse specialists (with a master's in Advanced Nursing Practice) and physicians on the consequences of nurse prescribing. DESIGN: Survey study. PARTICIPANTS: Survey questionnaires were sent to national samples of RNs, nurse specialists and physicians. METHODS: The questionnaire addressed, among others, respondents' general views on the consequences of nurse prescribing for the quality of care, the nursing and medical professions, and the relationship between the medical and nursing professions. RESULTS: The net response rate was 66.0% for RNs (n=617), 28.3% for nurse specialists (n=375) and 33.7% for physicians (n=265). It was found that all groups agreed that nurse prescribing benefits nurses' daily practice and the nursing profession. There were few concerns about negative consequences for physicians' practice and the medical profession. Nurse specialists gave significantly (P<0.05) more positive scores on most items than RNs and physicians. We found relatively little difference in views between RNs and physicians. It was only on issues surrounding the quality of care and patient safety that doctors showed more concerns, albeit mild, than RNs and nurse specialists. CONCLUSIONS: RNs, nurse specialists and physicians generally hold neutral to moderately positive views on nurse prescribing. This is beneficial for the implementation and potential success of nurse prescribing in practice, as a lack of peer support and/or objections from physicians can be a hampering factor. However, concerns about the consequences of nurse prescribing for the quality of care and patient safety remain a point for attention, especially among physicians.

[Addicted colleagues: a blind spot amongst physicians?]. / Verslaafde collega's: een blinde vlek binnen de beroepsgroep?

Physician impairment due to substance abuse or dependence is at least as prevalent as amongst non-physicians and is a real challenge. Not only for the impaired physicians themselves, but also for their colleagues, family members and patients. A 68-year-old physician describes her experiences of being an alcoholic as well as a patient with concomitant psychiatric disorders, including the hurdles she had to get over to deal with her disease and remain abstinent. Although colleagues knew what was going on, some of them took no action. The initial treatment by her general practitioner proved compromised. Addressing addiction amongst fellow physicians can be challenging and for this reason the Royal Dutch Medical Association (KNMG) has started the ABS Programme. On prompt and adequate intervention, treatment in specialised facilities has proved to be highly and durably effective. Addicted physicians who have been successfully treated should be monitored and supported, thus enabling their safe return to practice.

A Pain Monitoring Program for nurses: effect on the administration of analgesics.

Both physicians and nurses are responsible for adequate pain management. The aim of this study was to assess pain management behavior of physicians and nurses, and to evaluate the effects of a Pain Monitoring Program for nurses on the extent to which nurses administer analgesics. The Pain Monitoring Program consisted of two components: educating nurses about pain, pain assessment and pain management; and implementing daily pain assessment by means of a numeric rating scale. Several outcomes were distinguished to evaluate the administration of analgesics by nurses: the prescribed analgesics by physicians, the administered analgesics by nurses, and the discrepancy between the ordered and the administered analgesics. The effects of the Pain Monitoring Program on these outcomes were measured in a quasi-experimental design with a non-equivalent control group. In total, 703 patients participated: 358 patients in the control group and 345 in the intervention group. Patients were interviewed twice, i.e. at the beginning and at the end of hospitalization. Results of the control group showed that at the first interview 70% of the patients were prescribed analgesics by physicians and only 74% of those patients were actually administered analgesics by nurses. Consequently, 50% of the patients in pain received analgesics. The administered analgesics was in absolute agreement with the prescribed analgesics in 60% of the patients with routine analgesics and in 85% of the patients with PRN analgesics. The relative difference between ordered and administered routine analgesics was small, namely 15% for opioids and 20% for non-opioids. Similar results of the control group were found for the second interview. In addition, the results showed that the Pain Monitoring Program was effective in improving nurses' administration of analgesics. At the first interview more patients received analgesics that were prescribed on a PRN basis and the doses of administered routine non-opioids including PRN increased. At the time of the second interview, more patients received weak opioids. The Pain Monitoring Program was especially effective in patients with moderate to severe pain. However, the discrepancy between the analgesics ordered by physicians and actually administered by nurses did not change as a result of the Pain Monitoring Program. Based on this study it can be concluded that the use of a simple method such as a numeric rating scale together with pain education for nurses is effective in improving the administration of analgesics by nurses. These are important results because nurses play an essential role in helping patients to cope with their pain. Because the Pain Monitoring Program (PMP) was effective in a heterogeneous population in multiple care settings, the possibility of implementing the PMP in routine nursing practice should be considered.