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Context: Learning outcomes for residency training are defined in competency frameworks such as the CanMEDS framework, which ultimately aim to better prepare residents for their future tasks. Although residents' training relies heavily on learning through participation in the workplace under the supervision of a specialist, it remains unclear how the CanMEDS framework informs practice-based learning and daily interactions between residents and supervisors., Objectives: This study aimed to explore how the CanMEDS framework informs residents' practice-based training and interactions with supervisors., Methods: Constructivist grounded theory guided iterative data collection and analyses. Data were collected by direct observations of residents and supervisors, combined with formal and field interviews. We progressively arrived at an explanatory theory by coding and interpreting the data, building provisional theories and through continuous conversations. Data analysis drew on sensitising insights from communities of practice theory, which provided this study with a social learning perspective., Results: CanMEDS roles occurred in an integrated fashion and usually remained implicit during interactions. The language of CanMEDS was not adopted in clinical practice, which seemed to impede explicit learning interactions. The CanMEDS framework seemed only one of many factors of influence in practice-based training: patient records and other documents were highly influential in daily activities and did not always correspond with CanMEDS roles. Additionally, the position of residents seemed too peripheral to allow them to learn certain aspects of the Health Advocate and Leader roles., Conclusions: The CanMEDS framework did not really guide supervisors' and residents' practice or interactions. It was not explicitly used as a common language in which to talk about resident performance and roles. Therefore, the extent to which CanMEDS actually helps improve residents' learning trajectories and conversations between residents and supervisors about residents' progress remains questionable. This study highlights the fact that the reification of competency frameworks into the complexity of practice-based learning is not a straightforward exercise., (© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Background: Job satisfaction is essential for physicians' well-being and patient care. The work ethic of long days and hard work that has been advocated for decades is acknowledged as a threat for physicians' job satisfaction, well-being, and patient safety. Our aim was to determine the actual and preferred job size of physicians and to investigate how these and the differences between them influence physicians' job satisfaction., Method: Data were retrieved from a larger, longitudinal study among physicians starting medical training at Groningen University in 1982/83/92/93 (N = 597). Data from 506 participants (85%) were available for this study. We used regression analysis to investigate the influence of job size on physicians' job satisfaction (13 aspects) and ANOVA to examine differences in job satisfaction between physicians wishing to retain, reduce or increase job size., Results: The majority of the respondents (57%) had an actual job size less than 1.0 FTE. More than 80% of all respondents preferred not to work full-time in the future. Respondents' average actual and preferred job sizes were .85 FTE and .81 FTE, respectively. On average, respondents who wished to work less (35% of respondents) preferred a job size reduction of 0.18 FTE and those who wished to work more (12%) preferred an increase in job size of 0.16 FTE. Job size influenced satisfaction with balance work-private hours most (β = -.351). Physicians who preferred larger job sizes were - compared to the other groups of physicians - least satisfied with professional accomplishments., Conclusions: A considerable group of physicians reported a gap between actual and preferred job size. Realizing physicians' preferences as to job size will hardly affect total workforce, but may greatly benefit individual physicians as well as their patients and society. Therefore, it seems time for a shift in work ethic.

Many different medical school selection processes are used worldwide. In this paper, we examine the effect of (1) participation, and (2) selection in a voluntary selection process on study performance. We included data from two cohorts of medical students admitted to Erasmus MC, Rotterdam and VUmc, Amsterdam, The Netherlands and compared them to previously published data from Groningen medical school, The Netherlands. All included students were admitted based on either (1) a top pre-university grade point average, or (2) a voluntary selection process, or (3) weighted lottery. We distinguished between lottery-admitted students who had participated in the voluntary selection process and had been rejected, and lottery-admitted students who had not participated. Knowledge test scores, study progress, and professionalism scores were examined using ANCOVA modelling, logistic regression, and Bonferroni post hoc multiple-comparison tests, controlling for gender and cohort. For written test grades, results showed a participation effect at Groningen medical school and Erasmus MC (p < 0.001), and a selection effect at VUmc (p < 0.05). For obtained course credits, results showed a participation effect at all universities (p < 0.01) and a selection effect at Groningen medical school (p < 0.005). At Groningen medical school, a participation effect seemed apparent in on time first-year completion (p < 0.05). Earlier reported selection and participation effects in professionalism scores at Groningen medical school were not apparent at VUmc. Top pre-university students performed well on all outcome measures. For both the participation effect and the selection effect, results differed between universities. Institutional differences in curricula and in the design of the selection process seem to mediate relations between the different admissions processes and performance. Further research is needed for a deeper understanding of the influence of institutional differences on selection outcomes.

Situational Judgement Tests (SJTs) are increasingly implemented in medical school admissions. In this paper, we investigate the effects of vocational interests, previous academic experience, gender and age on SJT performance. The SJT was part of the selection process for the Bachelor's degree programme in Medicine at University of Groningen, the Netherlands. All applicants for the academic year 2015-2016 were included and had to choose between learning communities Global Health (n = 126), Sustainable Care (n = 149), Intramural Care (n = 225), or Molecular Medicine (n = 116). This choice was used as a proxy for vocational interest. In addition, all graduate-entry applicants for academic year 2015-2016 (n = 213) were included to examine the effect of previous academic experience on performance. We used MANCOVA analyses with Bonferroni post hoc multiple comparisons tests for applicant performance on a six-scenario SJT. The MANCOVA analyses showed that for all scenarios, the independent variables were significantly related to performance (Pillai's Trace: 0.02-0.47, p < .01). Vocational interest was related to performance on three scenarios (p < .01). Graduate-entry applicants outperformed all other groups on three scenarios (p < .01) and at least one other group on the other three scenarios (p < .01). Female applicants outperformed male applicants on three scenarios (p < .01) and age was positively related to performance on two scenarios (p < .05). A good fit between applicants' vocational interests and SJT scenario was related to better performance, as was previous academic experience. Gender and age were related to performance on SJT scenarios in different settings. Especially the first effect might be helpful in selecting appropriate candidates for areas of health care in which more professionals are needed.

Introduction: Residents benefit from regular, high quality feedback on all CanMEDS roles during their training. However, feedback mostly concerns Medical Expert, leaving the other roles behind. A feedback system was developed to guide supervisors in providing feedback on CanMEDS roles. We analyzed whether feedback was provided on the intended roles and explored differences in quality of written feedback., Methods: In the feedback system, CanMEDS roles were assigned to five authentic situations: Patient Encounter, Morning Report, On-call, CAT, and Oral Presentation. Quality of feedback was operationalized as specificity and inclusion of strengths and improvement points. Differences in specificity between roles were tested with Mann-Whitney U tests with a Bonferroni correction (α = 0.003)., Results: Supervisors (n = 126) provided residents (n = 120) with feedback (591 times). Feedback was provided on the intended roles, most frequently on Scholar (78%) and Communicator (71%); least on Manager (47%), and Collaborator (56%). Strengths (78%) were mentioned more frequently than improvement points (52%), which were lacking in 40% of the feedback on Manager, Professional, and Collaborator. Feedback on Scholar was more frequently (p = 0.000) and on Reflective Professional was less frequently (p = 0.003) specific., Discussion and Conclusion: Assigning roles to authentic situations guides supervisors in providing feedback on different CanMEDS roles. We recommend additional supervisor training on how to observe and evaluate the roles.

The CanMEDS framework has been widely adopted in residency education and feedback processes are guided by it. It is, however, only one of many influences on what is actually discussed in feedback. The sociohistorical culture of medicine and individual supervisors' contexts, experiences and beliefs are also influential. Our aim was to find how CanMEDS roles are constructed in feedback in a postgraduate curriculum-in-action. We applied a set of discourse analytic tools to written feedback from 591 feedback forms from 7 hospitals, including 3150 feedback comments in which 126 supervisors provided feedback to 120 residents after observing their performance in authentic settings. The role of Collaborator was constructed in two different ways: a cooperative discourse of equality with other workers and patients; and a discourse, which gave residents positions of power-delegating, asserting and 'taking a firm stance'. Efficiency-being fast and to the point emerged as an important attribute of physicians. Patients were seldom part of the discourses and, when they were, they were constructed as objects of communication and collaboration rather than partners. Although some of the discourses are in line with what might be expected, others were in striking contrast to the spirit of CanMEDS. This study's findings suggest that it takes more than a competency framework, evaluation instruments, and supervisor training to change the culture of workplaces. The impact on residents of training in such demanding, efficiency-focused clinical environments is an important topic for future research.

Background: The importance of medical education research in Saudi Arabia has been acknowledged increasingly and a lot of concepts used have been derived from the Western world. The question arises, however, whether Western concepts and questionnaires are transferable to societies with different cultures. The aim of this study was to investigate the instrument structure and the reliability of the Arabic version of the Zuckerman-Kuhlman Personality Questionnaire-medium (ZKPQ-m)., Methods: Three statistical methods with decreased amount of strictness were used to analyse our data: Confirmatory Factor Analysis, Procrustes rotation and Principal Component Analysis., Results: Our outcomes did not confirm the original instrument structure. Instead, we found four interpretable components: Emotional Instability, Impulse-seeking, Activeness and Self-Control. However, the amount of explained variance was not very high and the internal consistencies ranged from unsatisfactory to only moderate. The data showed a high percentage of respondents agreeing with more than three items of the Infrequency scale, which may be attributable to the collectivistic culture in Saudi Arabia., Conclusion: We did not succeed in replicating the ZKPQ structure in the Arabic context. Social desirability, a common characteristic in collectivistic cultures, may have reduced the replicability of the internal structure of the ZKPQ-m. Different methods to measure concepts in collectivistic cultures may help to get round social desirability.

Objectives: This study was conducted to: (i) analyse whether students admitted to one medical school based on top pre-university grades, a voluntary multifaceted selection process, or lottery, respectively, differed in study performance; (ii) examine whether students who were accepted in the multifaceted selection process outperformed their rejected peers, and (iii) analyse whether participation in the multifaceted selection procedure was related to performance., Methods: We examined knowledge test and professionalism scores, study progress and dropout in three cohorts of medical students admitted to the University of Groningen, the Netherlands in 2009, 2010 and 2011 (n = 1055). We divided the lottery-admitted group into, respectively, students who had not participated and students who had been rejected in the multifaceted selection process. We used ancova modelling, logistic regression and Bonferroni post hoc multiple-comparison tests and controlled for gender and cohort., Results: The top pre-university grade group achieved higher knowledge test scores and more Year 1 course credits than all other groups (p < 0.05). This group received the highest possible professionalism score more often than the lottery-admitted group that had not participated in the multifaceted selection process (p < 0.05). The group of students accepted in the multifaceted selection process obtained higher written test scores than the lottery-admitted group that had not participated (p < 0.05) and achieved the highest possible professionalism score more often than both lottery-admitted groups. The lottery-admitted group that had not participated in the multifaceted selection process earned fewer Year 1 and 2 course credits than all other groups (p < 0.05). Dropout rates differed among the groups (p < 0.05), but correction for multiple comparisons rendered all pairwise differences non-significant., Conclusions: A top pre-university grade point average was the best predictor of performance. For so-called non-academic performance, the multifaceted selection process was efficient in identifying applicants with suitable skills. Participation in the multifaceted selection procedure seems to be predictive of higher performance. Further research is needed to assess whether our results are generalisable to other medical schools., (© 2014 John Wiley & Sons Ltd.)

In this longitudinal study, we investigated the relationship between physicians' prior achievements (before, during and after medical school) and job satisfaction, and tested the two lines of reasoning that prior achievements influence job satisfaction positively or negatively, respectively. The participants were graduates who started their medical training in 1982 (n = 147), 1983 (n = 154), 1992 (n = 143) and 1993 (n = 153). We operationalised job satisfaction as satisfaction (on a 10-point scale) with 13 cognitive, affective and instrumental aspects of the participants' jobs. The measures of achievement before, during and after medical school included pre-university grade point average, study progress and a residency position in the specialty of first choice, respectively. We included the effect of curriculum type (problem-based learning versus traditional), gender and years of experience as moderator variables. Higher achievers before and during medical school were more satisfied about their income (β = .152, p < .01 and β = .149, p < .05), but less satisfied with their opportunities for personal development (β = -.159, p < .05). High achievers after medical school were more satisfied with professional accomplishments (β = .095, p < .05), with appreciation from support personnel (β = .154, p < .01) and from patients (β = .120, p < .05). Effect sizes were small. Prior achievements influenced job satisfaction. The direction of the influences depended on the job satisfaction aspect in question, which indicates that it is important to distinguish between aspects of job satisfaction. To optimize job satisfaction of high achievers, it is important for graduates to obtain their preferred specialty. Furthermore, it is vital to provide them with enough opportunities for further development.

Background: Internationally, postgraduate medical education (PGME) has shifted to competency-based training. To evaluate the effects of this shift on the outcomes of PGME appropriate instruments are needed., Aim: To provide an inventory of tasks specialists perform in practice, which can be used as an instrument to evaluate the outcomes of PGME across disciplines., Methods: Following methodology from job analysis in human resource management, we used document analyses, observations, interviews and questionnaires. Two thousand seven hundred and twenty eight specialists were then asked to indicate how frequently they performed each task in the inventory, and to suggest additional tasks. Face and content validity was evaluated using interviews and the questionnaire. Tasks with similar content were combined in a total of 12 clusters. Internal consistency was evaluated by calculating Cronbach's alpha. Construct validity was determined by examining predefined differences in task performance between medical, surgical and supportive disciplines., Results: Seven hundred and six specialists (36%) returned the questionnaire. The resulting inventory of 91 tasks showed adequate face and content validity. Internal consistency of clusters of tasks was adequate. Significant differences in task performance between medical, surgical and supportive disciplines indicated construct validity., Conclusion: We established a comprehensive, generic and valid inventory of tasks of specialists which appears to be applicable across medical, surgical and supportive disciplines.

Background: Career advice is an important instrument to help students with the proper specialty selection. The study aims (1) to explore the views of newly graduated doctors in Saudi Arabia about their experience with the current status of career support system during medical training and (2) to identify cross-cultural similarities and differences., Methods: A cross-sectional design study was conducted using a questionnaire to elicit the responses of participants from newly qualified doctors concerning the availability and significance of career advice. SPSS (version 11.0; Chicago, IL) was used to analyze the data and statistical tests, such as chi-square and unpaired t tests, were used to analyze the observations., Results: A response rate of 94.7% was obtained. Among this group, 102 were males and 78 were females. Only 53% did receive career advice. The majority of men felt that career advice during medical studies was inadequate, while women were less negative (69% versus 32%; p = 0.0001). Furthermore, men were more disappointed about the possibilities for career advice after graduating than women (34% versus 13%, p = 0.0001)., Conclusions: The results show that only half of newly graduated doctors had received any career advice during medical training. As the health care system cannot afford the potential waste of time and resources for doctors, career guidance should begin in undergraduate training so that the process of thinking about their future career starts longtime before they make their career choice.

Background: Research on the correlation between personality and students' specialty choice is helpful in their career counselling process and in predicting the future distribution of the specialties in a country., Aims: This study is the first of its kind in the Arab world. The research questions were: (1) What is the influence of gender on the personality profiles of medical students? (2) What are the personality profiles of students categorized according to their preferred specialist choices? (3) What are the preferred career choices of students categorized according to the stage of their medical education?, Method: A cross-sectional study was performed at King Khalid University Medical School including 590 students during the academic year 2010-2011. A long version of the Zuckerman-Kuhlman personality questionnaire measuring five personality factors was used. Students were also asked for their specialty interests. Students were asked by means of a written questionnaire., Results: Study response was 92.5%. Surgery was the single most popular specialty amongst both male and female students. Males had significantly higher scores on the 'impulsive sensation seeking' scale and students preferring a surgery specialty had the highest score on the 'impulsive sensation seeking', 'neuroticism-anxiety', 'aggression-hostility' and 'sociability' scales. Hospital-based, surgical and primary care specialties became more popular as students progressed through their undergraduate years., Conclusions: Different personality types have distinct preferences in medical students' choice of careers. Personality and specialty choice research can enhance career counselling of medical students and fresh graduates. This also has implications for predicting the specialty distribution of the future health careers.

Background: The exploration of specialty choices by medical students is a hot debate as it affects several important determinants of health care delivery. This study was carried out to determine variation in specialty preferences during medical school training and the perceptions that affect students' specialty choice., Methods: A cross-sectional questionnaire-based study was performed on 590 students with a 93.22% response rate and covered queries on demography, specialty choices, and perceptions influencing specialty choices. Class-wise analysis of specialty choices was carried out., Results: The most preferred specialty expressed by male students was surgery, followed by internal medicine and orthopedics, while most preferred by female students were surgery, followed by pediatrics and ophthalmology. Male students' emphasized factors like less competitive field, shortage of specialists, and diversity of patients while the prestige of specialty and teaching opportunities had a greater impact on female students., Conclusions: Surgery, internal medicine, pediatrics, orthopedics, and ophthalmology were the most preferred specialty choices. Gender preference was observed to affect choices of few specialties such as orthopedics and obstetrics/gynecology. Perceptions which have an impact on specialty selection of male and female students may reflect a different tempo of growing up in men and women.

Minimal invasive techniques are rapidly becoming standard surgical techniques for many surgical procedures. To develop the skills necessary to apply these techniques, box trainers and/or inanimate models may be used, but these trainers lack the possibility of inherent objective classification of results. In the past decade, virtual reality (VR) trainers were introduced for training minimal invasive techniques. Minimally invasive surgery (MIS) is, by nature, very suitable for this type of training. The specific psychomotor skills and eye-hand coordination needed for MIS can be mastered largely using VR simulation techniques. It is also possible to transfer skills learned on a simulator to real operations, resulting in error reduction and shortening of procedural operating time. The authors aim to enlighten the process of gaining acceptance in the Netherlands for novel training techniques. The Dutch Societies of Surgery, Obstetrics and Gynecology, and Urology each developed individual training curricula for MIS using simulation techniques, to be implemented in daily practice. The ultimate goal is to improve patient safety. The authors outline the opinions of actors involved, such as different simulators, surgical trainees, surgeons, surgical societies, hospital boards, government, and the public. The actual implementation of nationwide training curricula for MIS is, however, a challenging step.

Background: To improve clinical performance assessment, checklist data should be immediately available to students to offer them detailed feedback and be stored in a database for quality assurance purposes., Aim: To introduce the digital pen as clinical performance assessment tool, report examiner satisfaction and explore the utility of generated checklist data for quality assurance purposes., Methods: The digital pen technology transmits examiners' handwritten assessments to a database and exports PDF-files to students' mailboxes. Descriptive statistical analysis of examiner satisfaction and the generated checklist data was performed., Results: The examiners were satisfied with the digital pen. Valuable data were obtained to improve objective structured clinical examination stations and rating criteria, identify training needs for future students and provide examiners with feedback on their rating skills., Conclusion: The digital pen technology is a practical device for sending completed checklists to students and providing valuable data for quality assurance purposes.

Background: The transition from preclinical to clinical training is perceived as stressful with a high workload being the main difficulty. To ease this transition, we implemented a dual learning year, where just-in-time skills training and clerkships alternated., Aims: To examine the effect of the dual learning year on students' stress and perceptions of workload and skills level, and to compare these data with a baseline measurement from a curriculum in which skills training was provided in advance of clerkships., Method: During the first Master year, students completed four rotations in which 5 weeks of skills training and 5-week clerkships alternated. In the second clerkship week of each rotation, students (n = 476) completed questionnaires measuring their experienced workload, perceived skills level and stress. Analysis of variance was used for trend analysis and to determine differences with the baseline measurement (n = 83)., Results: During the dual learning year, 'experienced workload' decreased (F(1,471) = 9.408, p < 0.01), 'perceived skills level' increased (F(1,471) = 94.202, p < 0.001) and stress decreased (F(1,471) = 3.309, p < 0.10). 'Experienced workload' was lower (F(5,553) = 7.599, p < 0.001) and 'perceived skills level' was comparable to the baseline measurement., Conclusions: Compared to the baseline measurement and the results of earlier studies on transition difficulties, alternating just-in-time skills training and clerkships seem to ease the transition from preclinical to clinical training.

This study describes strategies used by Dutch HIV nurse consultants to promote adherence to antiretroviral therapy (ART) and the assumptions on which these strategies were based. The study used a descriptive qualitative design with individual and focus group interviews. Individual semi-structured interviews (n = 23) focusing on adherence-supporting procedures and case-based focus groups (3 groups with 5-7 participants each) focusing on adherence strategies were held with HIV nurse consultants (n = 19). The strategies described were mainly based on experience. Theoretical principles were rarely discussed and participants seldom referred to the literature. Adherence-promoting strategies were identified for two phases: (a) before beginning ART and (b) during follow-up care while on ART. Strategies that were not used in one specific phase were categorized under "all phases." Data yielded useful ideas for the care of HIV-infected patients, and findings can be applied to the development and use of adherence-promoting strategies., (Copyright © 2010 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.)

Objective: In the Netherlands HIV nursing consultants have participated in HIV-care since 1985; their profession has changed with developments in HIV-treatment over time. The study goal was to gather information about their role in HIV-care and to provide an useful example to other (HIV-)care settings over the world., Methods: Interviews were held with HIV nursing consultants from all AIDS treatment centres. Descriptive analyses and statistical tests to detect differences between centres categorized by care model (parallel/unstructured/alternating), were performed., Results: 58% centres perform substitution of care. HIV nursing consultants see almost all patients at least once a year and see all patients when treatment is started/altered. The frequency of consultations for HIV-patients in stable condition varies, 2-4 times a year. Substitution leads to a slight, non-significant decrease in number of consultations. Adherence support is provided at the start of and during treatment. Regular patient discussions are common. All respondents are acquainted with the guidelines. Detailed knowledge of the adherence issues is limited: 58.3% had read the adherence chapter., Conclusion: Substitution of care model is an appropriate and effective method for the management of HIV-infected patients., Practice Implications: Further development of and research into this new role of HIV nurse consultants is appropriate., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Recently, many medical schools' curricula have been revised so that they represent vertically integrated (VI) curricula. Important changes include: the provision of earlier clinical experience; longer clerkships, and the fostering of increasing levels of responsibility. One of the aims of vertical integration is to facilitate the transition to postgraduate training. The purpose of the present study is to determine whether a VI curriculum at medical school affects the transition to postgraduate training in a positive way., Methods: We carried out a questionnaire study among graduates of six medical schools in the Netherlands, who had followed either a VI or a non-VI curriculum. Items in the questionnaire focused on preparedness for work and postgraduate training, the time and number of applications required to be admitted to residency, and the process of making career choices., Results: In comparison with those who have followed non-VI programmes, graduates of VI curricula appear to make definitive career choices earlier, need less time and fewer applications to obtain residency positions and feel more prepared for work and postgraduate training., Conclusions: The curriculum at medical school affects the transition to postgraduate training. Additional research is required to determine which components of the curriculum cause this effect and to specify under which conditions this effect occurs.

Objective: To examine how the job satisfaction of a cohort Dutch physicians developed between 2000 and 2009., Design: Longitudinal., Method: In 2000 and 2009 physicians who had begun studying medicine in 1982 and 1983 at the University of Groningen were interviewed over the telephone about different variables of job satisfaction. We analysed differences between each year and between male and female physicians. Additionally, clusters of job satisfaction variables were examined., Results: We traced 292 of the 333 graduates. A total of 275 physicians (140 men, 135 women) agreed to an interview (response rate 92%). Between 2000 and 2009, average job satisfaction remained stable or even increased slightly. No differences in levels of job satisfaction were found between male and female physicians. Satisfaction on variables representing direct control such as relationships with patients and colleagues was high. It was lower on variables on which physicians have only minor influence such as organizational and administrative aspects., Conclusion: We could not confirm the fear that exists both inside and outside the Netherlands that job satisfaction among physicians is declining.

Background: Recently, many medical curricula have been changed into vertically integrated programmes. One of the aims of vertical integration is to facilitate the transition from theoretical to clinical education and from medical school to postgraduate training., Aims: The aim of this study was to determine whether a vertically integrated curriculum affects the transition from medical school to postgraduate training., Method: We carried out a survey study among graduates of two cohorts of the Utrecht Medical School, who followed either the traditional or the innovative, vertically integrated, curriculum. Topics of the questionnaire were: (a) activities since medical school, (b) required amount of time and number of applications to get admitted to residency, (c) the process of making career choices., Results: Graduates from the vertically integrated curriculum had made their definite career choice earlier compared to those who followed a traditional programme. Graduates of the new curriculum also needed less time and fewer applications to obtain a residency position., Conclusions: A vertically integrated curriculum at medical school positively affects the transition to postgraduate training. Additional research, among a larger population, is required to determine which components of the curriculum cause this effect and to specify under which conditions these effect occurs.

Medicine is a science and evidence-based profession. Therefore, medical education and training should offer optimal conditions to help students to become a medical expert. However, in order to become a 'good doctor' the development of additional skills should also be stimulated. By including subjects like philosophy of science, medical history and sociology, the link between literature and medicine, and other 'unrelated and irrelevant' academic subjects, medical education programmes can stimulate that future doctors will broaden their mind. This will contribute to their professional performance.

Background: Patients on long-term highly active antiretroviral therapy (HAART) were studied to determine persistence, drug resistance development, and evolution of HIV-1 proviral DNA., Methods: Peripheral blood mononuclear cells were obtained by large volume blood drawn (500 mL) from 8 clinically successfully treated patients who had received uninterrupted HAART for up to 8.9 years. HIV-1 load was determined by Taqman real-time polymerase chain reaction. Drug resistance mutations were determined by sequencing and ultrasensitive, allele-specific, reverse transcriptase (RT)-polymerase chain reaction., Results: HIV-1 DNA load was significantly higher in aged memory (CD45RO CD57) when compared with memory (CD45RO CD57) and naive (CD27 CD45RO) CD4 T cells after HAART. Sequencing revealed no major drug resistance mutations in protease in all patients and appearance of resistance mutations in RT in just 1 patient. In 1 of 5 patients with undetectable viremia during treatment, RT M184 substitutions were detected. Phylogenetic analysis showed short genetic distances between patient sequences., Conclusions: During long-term HAART, HIV-1 is able to persist in terminally differentiated CD4 T cells as proviral DNA. Viral evolution was restricted, and in 80% of the patients with undetectable viremia, no sign of viral replication could be detected.

In order to explore and clarify the underlying processes which lead to (non)-adherence behavior in patients treated with highly active antiretroviral therapy (HAART), a qualitative study was conducted. Thirty-seven in-depth interviews were held with 30 Caucasian HIV-positive patients. Additional data were collected by diaries kept by some participants. The analysis took place in a cyclic process; selection of themes was alternated with input of new material. Adherence to HAART is mainly influenced by the experience of being HIV positive. Acceptance or non-acceptance of HIV leads to one of two basic stances toward adherence: "being determined to be adherent" or "medication is subordinate to other priorities in life". This stance determines the commitment to therapy and influences how patients cope with adherence. Patients who are determined to be adherent find solutions to adherence problems. Patients who are not determined to be adherent solve problems only if the solution does not compromise important aspects of their lives. Insight is provided into the manner in which prevalent themes; "start of HAART", "attitude toward medication", "HAART in daily life", "contextual factors", "health and HAART" and "being informed", influence adherence behavior. Before starting HAART the focus should be on helping the patient to accept HIV as a part of life. The findings need to be taken into account in adherence-promoting interventions.

In the Netherlands, most universities use a lottery system, weighted by average examination grades, to admit students to medical school. However, the political climate for pre-entry selection procedures is changing rapidly. A study by the University Medical Center Rotterdam revealed that pre-entry selection reduces the medical school drop-out rate during the first years of medical training. This is an important observation. It is plausible that students selected by pre-entry selection are more motivated than students selected by a lottery system. However, it is unknown whether these students will also display better professional behaviour and skills in their future careers. Further research is required to determine which of the cognitive and non-cognitive characteristics relevant for predicting students' success in their future careers should be included in the assessment to optimize the selection procedure.

It remains uncertain whether full T cell reconstitution can be established in HIV-infected children and adults with long-term sustained virological control by highly active antiretroviral therapy (HAART). In this study, we comprehensively analyzed various phenotypical markers of CD4 T cell recovery. In addition to measuring T cell activation and proliferation markers, CD4 T cell generation and aging of the CD4 T cell compartment were assessed by measuring TCR excision circles and the fraction of CD31-expressing naive CD4 T cells. In all children and in adults with relatively high CD4 T cell counts at start of therapy (>200 cells/microl), total CD4 T cell numbers normalized within 1 year of therapy. After long-term HAART (4.4-9.6 years), naive CD4 T cell counts had normalized in both groups. Although in adults with low baseline CD4 T cell counts (<200 cells/microl) total CD4 T cell numbers normalized eventually after at least 7 years of HAART, naive CD4 T cell counts had still not recovered. TCR excision circle data showed that thymic T cell production contributed to naive T cell recovery at all ages. The fraction of CD31-expressing naive CD4 T cells was found to be normal, suggesting that the CD4 T cell repertoire was diverse after long-term HAART. Hence, under sustained viral suppression during long-term HAART, the T cell compartment has the potential to fully recover by generating new naive T cells both in children and in adults with high baseline CD4 T cells counts. Irrespective of baseline CD4 T cell counts, reconstitution occurred without a significant effect on T cell aging as reflected by markers for replicative history.

Context: Sexual harassment of medical students has been the focus of many international studies. Prevalence rates from 18% to over 60% have been reported. However, a Dutch study at Nijmegen Medical School found the prevalence rate to be lower (13.3% in the total group; 20% among female students only)., Objectives: We aimed to identify whether Nijmegen constitutes a positive sample of Dutch medical schools or whether incidents of sexual harassment are less prevalent in the Netherlands than elsewhere, and to establish if and how these experiences impact the professional lives of students., Methods: Students received a semi-structured questionnaire containing questions about their experiences of sexual harassment during clerkships. The questions referred to students' reactions to any incidents, the possible consequences for their wellbeing or professional functioning and the way cases of sexual harassment were handled., Results: The prevalence of sexual harassment was significantly higher in Utrecht than in Nijmegen. In both studies rates were relatively low compared with international data. Nevertheless, 1 in 3-5 Dutch female medical students had experienced unwelcome sexual attention from patients, colleagues or supervisors. Three of 10 students who had experienced such an incident stated that it had a negative impact on their functioning afterwards., Conclusions: Prevalence rates of sexual harassment in medical schools in the Netherlands are low compared with international rates. However, the number of women students who experience sexual harassment is still 1 in 3-5. The occurrence of and ways to deal with these incidents should be important topics in the training of medical students and supervisors.

Background: Early clinical experience is being introduced in innovative, vertically integrated undergraduate medical curricula. While in many cases, this early clinical experience is limited to the presence of patients during lectures, in Utrecht students gain 'hands on' experience of daily clinical practice during 6-week clerkships. We studied students' and teachers' opinions of these full clerkships in the third year of a medical course., Methods: All 238 clinical teachers and 89 students involved in the 2003/2004 third year clerkships of the new Utrecht medical curriculum were asked to fill in a 16-item questionnaire about background knowledge, clinical skills, communication skills, and readiness for clerkships. Answers were given on a 5-point Likert scale. Response was 61%., Results: Both students and clinical teachers answered all statements positively (score > 3.00), although some statements were awarded higher scores by students than teachers. In conclusion, students and teachers appear to appreciate clerkships early in the curriculum., Conclusions: Less background knowledge and a lower age than is usual for the more traditional (later) clerkships do not appear to hinder successful completion of an early clerkship. Indeed, early clerkships have several advantages, such as early observation of the future profession, increased motivation for further study, contextual learning, and improvement of clinical skills.

Purpose: To objectively assess changes in body fat distribution in a subgroup of antiretroviral therapy-naïve participants in a randomized comparative trial of regimens including a nucleoside analogue backbone of didanosine with either lamivudine or stavudine., Method: Whole body dual-energy X-ray absorptiometry (DEXA) scans were performed at baseline and weeks 48 and 96 of therapy in all 19 patients from one of the sites participating in the Antiretroviral Regimen Evaluation Study (ARES). Patients had been randomized to receive nelfinavir/didanosine/stavudine (n = 8), nevirapine/didanosine/lamivudine (n = 7), or ritonavir-boosted saquinavir/didanosine/lamivudine (n = 4)., Results: In an intent-to-treat analysis, patients allocated to didanosine plus stavudine-containing treatment after 96 weeks had lost a median of 1,825 g (-26%) of total limb fat, as compared to a median gain of 1,639 (48%) and 403 (6%) g in those randomized to the didanosine/lamivudine plus nevirapine or saquinavir-containing regimens, respectively. These changes in limb fat were statistically significantly different when comparing patients allocated to stavudine-containing treatment with both of the other two treatment arms combined (p = .01)., Conclusion: This study suggests that didanosine/lamivudine, when combined with either nevirapine or ritonavir-boosted saquinavir over 96 weeks of therapy, is possibly not associated with limb fat atrophy, in contrast to when treatment contained didanosine, stavudine, and nelfinavir combined.

Objective: To investigate the mechanism explaining the persistence of human immunodeficiency virus (HIV) type 1 variants with multiple protease inhibitor (PI)-resistance mutations in the absence of PI therapy., Methods: Longitudinal genotypic analyses were performed on sequential samples obtained from 2 HIV-1-infected patients who had stopped PI therapy for 4 years. Replication capacity (RC) was determined using recombinant viruses. Subsequently, the effect that changing individual protease mutations back to wild type has on RC was analyzed., Results: We observed prolonged persistence (up to 4 years) of viruses with multiple protease mutations after PI therapy was stopped, despite the fact that the RC of the viruses was severely reduced. Forcing the virus to evolve toward wild type by changing individual protease mutations to wild type was unsuccessful, because all variants displayed a decreased RC in comparison with that of their predecessors., Conclusions: We propose compensatory fixation as a mechanism for the in vivo persistence of variants with multiple PI-resistance mutations in the absence of PI therapy. Viruses with multiple PI mutations have (partially) compensated for the initial loss in RC. Therefore, reversion of a single mutation causes a (further) reduction in RC and, as a consequence, the route to wild type is blocked.

Purpose: The aim of the study was to investigate whether drug resistance occurs earlier in seminal than in blood plasma with the use of such HAART regimens, of which only the two NRTIs achieve therapeutic concentrations in seminal plasma., Method: Seminal and blood plasma of 12 patients, for 48-96 weeks on suppressive first-line therapy with saquinavir/ritonavir/didanosine/lamivudine, nelfinavir/didanosine/stavudine, or efavirenz/lamivudine/zidovudine were prospectively evaluated for HIV-1-RNA resistance mutations and drug concentrations., Results: Saquinavir, nelfinavir, and efavirenz blood plasma concentrations were in the therapeutic range. Nelfinavir and efavirenz seminal plasma concentrations were below the limit of quantification. In only 2 of 9 seminal plasma samples, from 1 of 6 patients, the saquinavir concentration was above the minimum therapeutic level. The seminal plasma HIV-1-RNA concentration remained undetectable in all patients up to 96 weeks, and therefore drug resistance could not be demonstrated. Thus, despite suboptimal local drug concentrations, no virological failure occurred in seminal plasma after prolonged first-line HAART., Conclusion: This finding supports the hypothesis that the source of HIV in semen is a spillover from the blood/extraluminal tissue and that therefore seminal plasma drug levels may not be critical for viral suppression within the lumen of the male genital tract.

Recently the authors developed and implemented a new approach to clinical reasoning education called clinical reasoning theater (CRT). The purpose of CRT is to demonstrate the process of clinical reasoning to students through the conversation of a doctor with his or her patient. With students as the audience, the doctor's clinical reasoning skills are modeled in CRT when he or she thinks aloud during conversations with the patient, which makes clear why he or she asks particular questions. In CRT the interaction between doctor and patient is analyzed in such a way that the repeated cycles of questions and answers are revealed to the students. CRT's format and the activities of the three "actors,"(the doctor, the patient, and the audience of students) are described. Two "acts" are repeatedly performed. The first act (the communication between the doctor and the patient) deals with the history taking, physical examination, etc. The second act, the time-out period, is the most important component of CRT. In this act, the doctor explains his or her reflections and discusses suggestions from the audience for additional questions. The preliminary results of students' evaluations of the relevance of CRT reveal that they appreciate CRT. Further, the CRT format offers instructors with previous experience as lecturers only sufficient tools to apply the new approach successfully.