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Objective: To compare postpartum hemorrhage (PPH) patient outcomes before and after an in situ instructional design based PPH simulation attended by obstetrics and gynecology (OBGYN) residents. Methods: This uncontrolled before-and-after study was conducted in Recife, Brazil including all 1388 women delivering from June to August 2012 and all 1357 delivering from June to August 2013. The 36 OBGYN residents were divided into13 teams of two or three participants and were trained through ID based PPH simulation training with the following eight steps: (1) prior knowledge activation, (2) video demonstration, (3) dual-coding PPH protocol discussion-an image association during the training, (4) training scenario # 1, (5) debriefing, (6) training scenario # 2 with immediate feedback, (7) training scenario # 3, and (8) debriefing with self-assessment. The training scenarios had an increasing level of complexity. The main goal of the training was the adequate management of PPH and situational awareness improvement-the ability to anticipate, recognize, and intercept unfolding error chains. The primary patient outcomes rates used for the before and after comparison were therapeutic uterotonics use within 24 h of birth and blood transfusion. Secondary outcomes were therapeutic oxytocin mean dosage IU within 24 h of birth, postpartum Hb

Objectives To assess the stakeholders' perceptions on the competency of entry-level pharmacists and the use of written licensure examination as the primary assessment for licensure decisions on entry-level pharmacists who have completed the Pharmacy Internship Program 1 1Abbreviations that may not be standard in the field: PIP: pharmacists' internship program. (PIP) in developing countries. Method A cross-sectional survey was conducted among stakeholders in which they completed a web-based 21-item pre-tested questionnaire to determine their views regarding the competency outcomes and assessment program for entry-level pharmacist. Results The stakeholders rated the entry-level pharmacists to possess all competencies except research skills. Stakeholders suggested improvement of the program by defining the competency framework and training preceptors. However, stakeholders disagree on using written examination as the primary assessment for licensure decision and suggested the incorporation of other performance-based assessments like preceptor's assessment reports. Conclusion Stakeholders are uncertain on entry-level pharmacists in developing countries possessing adequate research competencies and think their assessment program for licensure need more than written examination to assess all required competencies.

Item does not contain fulltext 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.

Background: Although simulation training is increasingly used to meet modern technology and patient safety demands, its successful integration within surgical curricula is still rare. The Dutch Urological Practical Skills (D-UPS) curriculum provides modular simulation-based training of technical and non-technical basic urological skills in the local hospital setting. This study aims to assess the educational impact of implementing the D-UPS curriculum in the Netherlands and to provide focus points for improvement of the D-UPS curriculum according to the participants. Methods: Educational impact was assessed by means of qualitative individual module-specific feedback and a quantitative cross-sectional survey among residents and supervisors. Twenty out of 26 Dutch teaching hospitals participated. The survey focussed on practical aspects, the D-UPS curriculum in general, and the impact of the D-UPS curriculum on the development of technical and non-technical skills. Results: A considerable survey response of 95 % for residents and 76 % for supervisors was obtained. Modules were attended by junior and senior residents, supervised by a urologist, and peer teaching was used. Ninety percent of supervisors versus 67 % of residents judged the D-UPS curriculum as an important addition to current residency training (p = 0.007). Participants’ aggregated general judgement of the modules showed a substantial percentage favorable score (M ± SE: 57 ± 4 %). The impact of training on, e.g., knowledge of materials/equipment and ability to anticipate on complications was high, especially for junior residents (77 ± 5 and 71 ± 7 %, respectively). Focus points for improvement of the D-UPS curriculum according to the participants include adaptation of the training level to residents’ level of experience and focus on logistics. Conclusion: The simulation-based D-UPS curriculum has a high educational impact. Residents and supervisors consider the curriculum to be an important addition to current residency training. Focus points for improvement of the D-UPS curriculum according to the participants include increased attention to logistics and integration of a spiral learning approach.

The current shift towards competency-based residency training has increased the need for objective assessment of skills. In this study, we developed and validated an assessment tool that measures technical and non-technical competency in transurethral resection of bladder tumour (TURBT). The ‘Test Objective Competency’ (TOCO)–TURBT tool was designed by means of cognitive task analysis (CTA), which included expert consensus. The tool consists of 51 items, divided into 3 phases: preparatory (n = 15), procedural (n = 21), and completion (n = 15). For validation of the TOCO–TURBT tool, 2 TURBT procedures were performed and videotaped by 25 urologists and 51 residents in a simulated setting. The participants’ degree of competence was assessed by a panel of eight independent expert urologists using the TOCO–TURBT tool. Each procedure was assessed by two raters. Feasibility, acceptability and content validity were evaluated by means of a quantitative cross-sectional survey. Regression analyses were performed to assess the strength of the relation between experience and test scores (construct validity). Reliability was analysed by generalizability theory. The majority of assessors and urologists indicated the TOCO–TURBT tool to be a valid assessment of competency and would support the implementation of the TOCO–TURBT assessment as a certification method for residents. Construct validity was clearly established for all outcome measures of the procedural phase (all r > 0.5, p

Objective intrapartum referrals are high-risk situations. To ensure patient safety, care professionals need to have a shared understanding of a labouring woman's situation. We aimed to gain insight into similarities and differences between midwives and obstetricians in the assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting in the Netherlands. Design factorial survey. Setting in the Netherlands, the main caregivers for women with low risks of pathology are primary-care midwives working in the locality. Approximately half of all women start labour under supervision of primary-care midwives. Roughly 40% of these women are referred to a hospital during labour, where obstetricians take over responsibility. In 2013, the reason for referral for 5161 women (14.1% of all referrals during labour) was a prolonged first stage of labour. Participants respondents consisted of primary-care midwives ( N =69), obstetricians ( N =47) and hospital based midwives, known as clinical midwives ( N =31). Measurements each respondent assessed seven hypothetical vignettes. The assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting based on this indication were used as outcome measures, rated on a 7-point Likert scale (1=very unlikely to 7=very likely). Data were analysed using a linear multilevel model with a two-level hierarchy. Findings compared to primary-care midwives, obstetricians were more likely to define a prolonged first stage of labour when progress in cervical dilation was slow (b: 1.11; 95% CI: 0.66 – 1.57). The attributes parity, progress, intensity of uterine contractions and the woman's state of mind, were used by all three groups in the decision to refer a woman to clinical setting based on a prolonged first stage of labour. Key conclusion and implications for practice we found relevant interprofessional differences and similarities in the assessment of a prolonged first stage of labour and consequent referral. Further interprofessional alignment of clinical assessments, for instance through interprofessional discussions and a review of professional guidelines, might help to improve collaborative care.

To investigate the value of the physical Simbla Transurethral Resection of a Bladder Tumor (TURBT) simulator as an educational tool within urological residency training, by means of a training needs analysis (TNA) and assessment of its feasibility, acceptability, and face, content, and construct validity.To analyze the training needs for TURBT, procedural steps and pitfalls were identified and the TNA was completed during an expert consensus meeting. Participants (n = 76) were divided into three groups based on their experience in TURBT: novices, intermediates, and experts. Participants performed two standardized TURBT procedures on the simulator. Face validity and content validity, as well as feasibility and acceptability, were assessed with a quantitative survey. Construct validity was assessed by comparing the performance of novices, intermediates, and experts on resection time, quality of tumor resection, and overall performance.Of the 21 procedural steps and 17 pitfalls defined in TNA, 13 steps and 8 pitfalls were covered by the Simbla. Participants rated the Simbla's overall realism (face validity) with a score of 8 of 10 (range 6-9). The simulator was judged to be most useful (content validity) for learning eye-hand coordination: score 8 (6-10). All aspects regarding realism and usefulness were rated above the acceptability threshold of 6/10. Intermediates (100%) and experts (96%) considered the Simbla to be a useful educational tool within the urological curriculum. Resection time was longer for novices than for experts (p 0.05; construct validity). In addition, the overall performance of novices was rated lower compared with intermediates and experts, and novices showed more irradical resections and bladder perforations (all p 0.05).The Simbla TURBT simulator is a valid, feasible, and acceptable educational tool for training procedural skills and may be implemented in the urological curriculum to complement learning in clinical practice. TNA is valuable in defining training objectives and evaluating the educational value of a simulator.

Item does not contain fulltext OBJECTIVE: To compare learning outcomes of postpartum hemorrhage simulation training based on either instructional design guidelines or best practice. METHODS: A pretest-post-test non-equivalent groups study was conducted among obstetrics and gynecology residents in Recife, Brazil, from June 8 to August 30, 2013. The instructional design group included 13 teams, whereas the best practice group included seven teams. A standardized task checklist was used for scenario analysis and the proportion of correctly executed tasks compared (post-test minus pretest). RESULTS: The instructional design group scored higher than the best practice group for total number of tasks completed (median difference 0.46 vs 0.17; P

Item does not contain fulltext PURPOSE: This study aims to provide an overview of type and frequency of musculoskeletal complaints among urologists. In addition, the urologists' knowledge about ergonomic conditions during minimally invasive urology was assessed, and they were asked how they would prefer to gain knowledge about this topic. MATERIALS AND METHODS: An online and hard copy version questionnaire was administered to urologists from different countries, mainly from Europe, performing endourology and laparoscopy. RESULTS: Of the 285 respondents, 245 (86.0%) urologists experienced musculoskeletal complaints in the past 12 months and 62.1% were considered to be work related. Most common areas for chronic complaints were neck, back, and shoulders. Almost 50% of the urologists experienced chronic musculoskeletal complaints, for which endourology (odds ratio [OR] 3.06; 95% confidence interval [CI] 1.37-6.80) and laparoscopy (OR 1.70; 95% CI 1.27-2.28) were significant risk factors. One third of the urologists considered their knowledge about ergonomics minimal, and 8% stated that they had no knowledge about these topics. Fifty percent of the respondents preferred to integrate information about ergonomic rules into hands-on training of urologic skills. CONCLUSION: High prevalence of experienced musculoskeletal complaints was found among urologists predominantly related to endourology and laparoscopy. Urologists indicate that they have a lack of knowledge about ergonomics in the operating room. Hence, we recommend integration of ergonomics in hands-on training programs early in the residency curriculum to gain knowledge and awareness and hopefully to offer possibilities to prevent these complaints in the future.

Item does not contain fulltext BACKGROUND: In 2011, the European Basic Laparoscopic Urological Skills (E-BLUS) examination was introduced as a pilot for the examination of final-year urologic residents. OBJECTIVE: In this study, we aimed to answer the following research questions: What level of laparoscopic skills do final-year residents in urology have in Europe, and do the participants of the E-BLUS pass the examination according to the validated criteria? DESIGN, SETTING, AND PARTICIPANTS: Participants of the examination were final-year urology residents from different European countries taking part in the European Urology Residents Education Program in 2011 and 2012. SURGICAL PROCEDURE: The E-BLUS exam consists of five tasks validated for the training of basic urologic laparoscopic skills. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Performances of the tasks were recorded on DVD and analysed by an objective rater. Time and number of errors made in tasks 1-4 were noted. Furthermore, all expert laparoscopic urologists were asked to score participants on a global rating scale (1-5) based on three items: depth perception, bimanual dexterity, and efficiency. Participants were asked to complete a questionnaire on prior training and laparoscopic experience. RESULTS AND LIMITATIONS: Seventy DVD recordings were analysed. Most participants did not pass the time criteria on task 4 (90%), task 2 (85.7%), task 1 (74.3%), and task 5 (71.4%). Task 3 was passed by 84.3%. The overall quality score was passed by 64%. When combining time and quality, only three participants (4.2%) passed the examination according to the validated criteria. According to the questionnaire, 61% did not have the opportunity to train in laparoscopic skills. CONCLUSIONS: The results of the E-BLUS examination show that the level of basic laparoscopic skills among European residents is low. Although quality of performance is good, most residents do not pass the validated time criteria. Regular laparoscopic training or a dedicated fellowship should improve the laparoscopic level of residents in urology.

The influence of problem-based learning (PBL) and open-book tests on long-term knowledge retention is unclear and subject of discussion. Hypotheses were that PBL as well as open-book tests positively affect long-term knowledge retention. Four progress test results of fifth and sixth-year medical students (n = 1,648) of three medical schools were analyzed. Two schools had PBL driven curricula, and the third one had a traditional curriculum (TC). One of the PBL schools (PBLob) used a combination of open-book (assessing backup knowledge) and closed-book tests (assessing core knowledge); the other two schools (TC and PBLcb) only used closed-book tests. The items of the progress tests were divided into core and backup knowledge. T tests (with Bonferroni correction) were used to analyze differences between curricula. PBL students performed significantly better than TC students on core knowledge (average effect size (av ES) = 0.37-0.74) and PBL students tested with open-book tests scored somewhat higher than PBL students tested without such tests (av ES = 0.23-0.30). Concerning backup knowledge, no differences were found between the scores of the three curricula. Students of the two PBL curricula showed a substantially better long-term knowledge retention than TC students. PBLob students performed somewhat better on core knowledge than PBLcb students. These outcomes suggest that a problem-based instructional approach in particular can stimulate long-term knowledge retention. Distinguishing knowledge into core and backup knowledge and using open-book tests alongside closed-book tests could enhance long-term core knowledge retention.

Background: Earlier studies suggested national culture to be a potential barrier to curriculum reform in medical schools. In particular, Hofstede’s cultural dimension ‘uncertainty avoidance’ had a significant negative relationship with the implementation rate of integrated curricula.Aims: However, some schools succeeded to adopt curriculum changes despite their country’s strong uncertainty avoidance. This raised the question: ‘How did those schools overcome the barrier of uncertainty avoidance?’Method: Austria offered the combination of a high uncertainty avoidance score and integrated curricula in all its medical schools. Twenty-seven key change agents in four medical universities were interviewed and transcripts analysed using thematic cross-case analysis.Results: Initially, strict national laws and limited autonomy of schools inhibited innovation and fostered an ‘excuse culture’: ‘It’s not our fault. It is the ministry’s’. A new law increasing university autonomy stimulated reforms. However, just this law would have been insufficient as many faculty still sought to avoid change. A strong need for change, supportive and continuous leadership, and visionary change agents were also deemed essential. Conclusions: In societies with strong uncertainty avoidance strict legislation may enforce resistance to curriculum change. In those countries opposition by faculty can be overcome if national legislation encourages change, provided additional internal factors support the change process.

Background Progress testing (PT) is used in Western countries to evaluate students’ level of functional knowledge, and to enhance meaning-oriented and self-directed learning. However, the use of PT has not been investigated in East Asia, where reproduction-oriented and teacher-centered learning styles prevail. Here, we explored the applicability of PT by focusing on student perceptions. Methods Twenty-four students from Years 2, 3, and 5 at Jichi Medical University in Japan attended a pilot PT session preceded by a brief introduction of its concept and procedures. Variations in obtained test scores were analyzed by year, and student perceptions of PT were explored using focus groups. Results Formula scores (mean ± standard deviation) in Years 2, 3, and 5 were 12.63 ± 3.53, 35.88 ± 14.53, and 71.00 ± 18.31, respectively. Qualitative descriptive analysis of focus group data showed that students disfavored testing of medical knowledge without tangible goals, but instead favored repetitive assessment of knowledge that had been learned and was tested on a unit basis in the past in order to achieve deep learning. Further, students of all school years considered that post-test explanatory lectures by teachers were necessary. Conclusions East Asian students’ perceptions indicated that, in addition to their intensive memorization within narrow test domains compartmentalized by end-of-unit tests, the concept of PT was suitable for repetitive memorization, as it helped them to integrate their knowledge and to increase their understanding. Post-test explanatory lectures might lessen their dislike of the intangible goals of PT, but at the expense of delaying the development of self-directed learning. Key issues for the optimization of PT in East Asia may include administration of PT after completed end-of-unit tests and a gradual change in feedback methodology over school years from test-oriented post-test lectures to the provision of literature references only, as a means of enhancing test self-review and self-directed learning. Electronic supplementary material The online version of this article (doi:10.1186/s12909-016-0766-2) contains supplementary material, which is available to authorized users.

Item does not contain fulltext AIM: There is growing pressure from the government and the public to define proficiency standards for surgical skills. Aim of this study was to estimate the reliability of the Program for Laparoscopic Urological Skills (PLUS) assessment and to set a certification standard for second-year urological residents. METHODS: Fifty participants were assessed on performance time and performance quality to investigate the reliability of the PLUS assessment. Generalisability coefficient of 0.8, on a scale of 0 to 1.0, was considered to indicate good reliability for assessment purposes. Pass/fail standards were based on laparoscopic experience: Novices, intermediates, and experts (>100 procedures). The pass/fail standards were investigated for the PLUS performances of 33 second-year urological residents. RESULTS: Fifteen novices, twenty-three intermediates and twelve experts were included. An inter-trial reliability of >0.80 was reached with two trials for each task. Inter-rater reliability of the quality measurements was 0.79 for two judges. Pass/fail scores were determined for the novice/intermediate boundary and the intermediate/expert boundary. Pass rates for second-year residents were 63.64% and 9.09%, respectively. CONCLUSION: The PLUS assessment is reliable for setting a certification standard for second-year urological residents that serves as a starting point for residents to proceed to the next level of laparoscopic competency.

Item does not contain fulltext Although other web-based approaches to assessment of professional behaviour have been studied, no publications studying the potential advantages of a web-based instrument versus a classic, paper-based method have been published to date. This study has two research goals: it focuses on the quantity and quality of comments provided by students and their peers (two researchers independently scoring comments as correct and incorrect in relation to five commonly used feedback rules (and resulting in an aggregated score of the five scores) on the one, and on the feasibility, acceptability and perceived usefulness of the two approaches on the other hand (using a survey). The amount of feedback was significantly higher in the web-based group than in the paper based group for all three categories (dealing with work, others and oneself). Regarding the quality of feedback, the aggregated score for each of the three categories was not significantly different between the two groups, neither for the interim, nor for the final assessment. Some, not statistically significant, but nevertheless noteworthy trends were nevertheless noted. Feedback in the web-based group was more often unrelated to observed behaviour for several categories for both the interim and final assessment. Furthermore, most comments relating to the category 'Dealing with oneself' consisted of descriptions of a student's attendance, thereby neglecting other aspects of personal functioning. The survey identified significant differences between the groups for all questionnaire items regarding feasibility, acceptability and perceived usefulness in favour of the paper-based form. The use of a web-based instrument for professional behaviour assessment yielded a significantly higher number of comments compared to the traditional paper-based assessment. Unfortunately, the quality of the feedback obtained by the web-based instrument as measured by several generally accepted feedback criteria did not parallel this increase. 01 maart 2012

Item does not contain fulltext There has been increasing use and significance of progress testing in medical education. It is used in many ways and with several formats to reflect the variety of curricula and assessment purposes. These developments have occurred alongside a recognised sensitivity for error variance inherent in multiple choice tests from which challenges to its validity and reliability have arisen. This Guide presents a generic, systemic framework to help identify and explore improvements in the quality and defensibility of progress test data. The framework draws on the combined experience of the Dutch consortium, an individual medical school in the United Kingdom, and the bulk of the progress test literature to date. It embeds progress testing as a quality-controlled assessment tool for improving learning, teaching and the demonstration of educational standards. The paper describes strengths, highlights constraints and explores issues for improvement. These may assist in the establishment of potential or new progress testing in medical education programmes. They can also guide the evaluation and improvement of existing programmes.

Background It is often assumed that the way teachers approach their teaching is determined by the way they think about learning. This study explores how teachers of an undergraduate medical programme (UMP) think about learning, how they approach teaching and whether their conceptions of learning relate to their teaching approaches. Methods Quantitative data of academic teachers involved in the undergraduate programme in medicine were collected and analysed. We used a questionnaire designed to measure teachers'' conceptions of their own learning (COL) and of student learning as well as teachers'' approaches to teaching (AT). Results Teachers of the medical undergraduate programme hold a variety of COL, of how students learn and their AT. No significant correlations were found between teachers'' conceptions of learning and their AT. Conclusions Although UMP teachers'' ideas on learning and teaching are very diverse, some of their conceptions are interrelated. Teachers'' ideas on their own learning is sometimes -- but not always -- related to how they think about student learning. But most importantly, the way UMP teachers think about learning is not automatically converted into the way they approach teaching.

Purpose Clinical teaching's importance in the medical curriculum has led to increased interest in its evaluation. Instruments for evaluating clinical teaching must be theory based, reliable, and valid. The Maastricht Clinical Teaching Questionnaire (MCTQ), based on the theoretical constructs of cognitive apprenticeship, elicits evaluations of individual clinical teachers' performance at the workplace. The authors investigated its construct validity and reliability, and they used the underlying factors to test a causal model representing effective clinical teaching. Method Between March 2007 and December 2008, the authors asked students who had completed clerkship rotations in different departments of two teaching hospitals to use the MCTQ to evaluate their clinical teachers. To establish construct validity, the authors performed a confirmatory factor analysis of the evaluation data, and they estimated reliability by calculating the generalizability coefficient and standard error measurement. Finally, to test a model of the factors, they fitted a structural linear model to the data. Results Confirmatory factor analysis yielded a five-factor model which fit the data well. Generalizability studies indicated that 7 to 10 student ratings can produce reliable ratings of individual teachers. The hypothesized structural linear model underlined the central roles played by modeling and coaching (mediated by articulation). Conclusions The MCTQ is a valid and reliable evaluation instrument, thereby demonstrating the usefulness of the cognitive apprenticeship concept for clinical teaching during clerkships. Furthermore, a valuable model of clinical teaching emerged, highlighting modeling, coaching, and stimulating students' articulation and exploration as crucial to effective teaching at the clinical workplace.

In the complex practice of today's blended learning, educators need to be able to evaluate both online and face-to-face communication in order to get the full picture of what is going on in blended learning scenarios. The aim of this study was to investigate the reliability and feasibility of a practical instrument for analysing face-to-face communication that is in alignment with tools for analysing online communication. We examined whether an existing coding scheme for online communication could be modified to evaluate face-to-face communication. We investigated the reliability, validity and usability of a modified version of the Transcript Analysis Tool (TAT) in analysing communication among students during small-group sessions comprising presentations by students and discussion. The modified TAT proved to be effective in obtaining a detailed description of students' participation in the communication and of the focus of the communication. Evaluation was more efficient when direct video analysis was used than when a transcript of the same video was analysed. Direct analysis took about 2 h for 20 min of video recording and had an inter-rater reliability of kappa = 0.56. The modified TAT appears to be an effective and efficient instrument to analyse face-to-face communication in small group sessions. Its combined use with an evaluation instrument for online learning may create a powerful evaluation instrument for blended learning. Further studies are needed to establish the value of such an instrument.

Background: Medical students increasingly participate in rotations in primary care settings, such as general practices. Although general practices can differ markedly from hospital settings, research on the instructional quality of general practice rotations is relatively scarce. Aim: We conducted a study to identify which aspects make a significant contribution to the instructional quality of general practice clerkships, as perceived by students. Method: After completing their general practice attachment, 155 fifth-year medical students filled out an evaluation questionnaire. Exploratory factor analysis and reliability analysis identified clusters of correlated independent variables. Subsequent regression analysis revealed the relations between the reduced set of independent variables and the dependent variable 'Instructional quality'. Results: Both the quality of supervision and the size and diversity of the patient mix substantially affected students' experienced instructional quality. Opportunities and facilities to perform independently were correlated with instructional quality, but did not affect the instructiveness directly. Conclusions: Supervision, patient mix and independence are crucial factors for learning in general practice. This is consistent with findings in hospital settings. The perceived quality of instruction hinges on supervision, which is not only the variable most strongly related to instructional quality, but which also affects both the patient mix and students' independence.

Introduction The emphasis on the importance of professionalism in a recent CoBaTrICE-IT paper was impressive. However, insight into the elements of professionalism as perceived relevant for intensivists from the fellows’ view, and how these are taught and learned, is limited. Objectives and methods A nationwide study was performed in 2007–2008. All ICM fellows (n = 90) were sent a questionnaire containing the following questions regarding training in professionalism (7-point Likert scale (1 = very inadequate, 7 = very adequate)): which are the elements perceived to be important in intensivists’’ daily practice (38 items, cat. I)? Which methods of learning and teaching are recognised (16 items, cat. II)? Which methods of teaching and learning are considered especially useful (16 items, cat. III)? Finally, the perceived quantity and quality of formal and informal learning methods, as well as the responsible organisational body was studied. Data were analysed using SPSS 15.0. Results Response was 75.5 % (n = 68), mean age 34 years. Regarding Elements, scores on virtually all items were high. The factor ‘striving for excellence’ explained half the variance. Two other aspects, ‘Teamwork’ and ‘Dealing with ethical dilemmas’, were identified. Regarding Methods, three dimensions, ‘formal curriculum’’, ‘private and academic experiences’ and ‘role modelling’, proved important. The factor ‘formal curriculum’ explained most of the variance. Regarding Usefulness the same factors, now mainly explained by the factor Private and academic experiences, emerged with variance. In both categories the items ‘observations in daily practice’ and ‘watching television programmes like ER and House’ were the highest- and lowest-scoring items (5.99 and 5.81, and 2.69 and 2.49, respectively). Mean scores regarding the quantity of formal and informal teaching were 4.06 and 4.58 (range 1.841 and 1.519). For the quality of teaching, the figures were 4.22 and 4.52 (range 1.659 and 1.560, respectively). 54 suggestions for improvement of teaching were documented. The need for some form of formal teaching of professionalism aspects as well as for feedback was most frequently mentioned (n = 19 and 16). The local training centres are considered and should remain pivotal for teaching professionalism issues (n = 17 and 28). Conclusions Almost all elements of professionalism were considered relevant to intensivists’ daily practice. Although formal teaching methods regarding professionalism aspects are easily recognised in daily practice, learning by personal experiences and informal ways quantitatively plays a more important, and more valued role. Qualitative comments, nevertheless, stress the need for providing and receiving (solicited and unsolicited) feedback, thereby requesting expansion of formal teaching methods. The local training centres (should continue to) play a major role in teaching professionalism, although an additional role for the (inter)national intensive care organisations remains.

OBJECTIVETo assess the construct validity of the URO MentorTM (Simbionix Corp., Cleveland, OH, USA) virtual reality training model for several variables of skills training in cysto-urethroscopy, addressing two research questions: (i) Does training on the URO Mentor significantly improve novices' performance in terms of time, trauma, areas inspected and Global Rating Scale (GRS) score?; (ii) is discrimination between different levels of expertise possible using the URO Mentor?METHODSThirty experts and 50 novices performed seven tasks on the URO Mentor during one training session. The first, fourth and seventh tasks were 'test tasks' to evaluate participants' performance. The simulator recorded procedure time and trauma; a supervisor scored which areas were inspected and gave scores on the GRS. A two-way analysis of variance with repeated-measures test was used to analyse experts' and novices' performances, with P RESULTSNovices' performances showed a significant improvement with large ES in time (linear trend of learning curve P CONCLUSIONSTraining on the URO Mentor appears to result in a medium to large improvement of novices' performances for time, trauma, areas inspected and GRS scores. Moreover, discrimination between different levels of expertise is possible using this simulator.

Study Type – Therapy (RCT) Level of Evidence 1b OBJECTIVE To assess whether real-time cysto-urethroscopy (CUS) performance improves by simulator-based training (criterion or predictive validity), addressing the research question ‘Does practical skills training on the URO Mentor (UM, Simbionix USA Corp., Cleveland, OH, USA) virtual-reality simulator improve the performance of flexible CUS in patients’. SUBJECTS AND METHODS Participants (71 interns from Catharina Hospital Eindhoven, CHE, and 29 from University Medical Centre Groningen, UMCG) were randomized to carry out CUS in a patient after training on the UM (UM-trained, 50) or without training on UM (control, 50). The assessment of real-time performance consisted of scoring on a Global Rating Scale (GRS) by supervisors unaware of training status. Data were analysed using stepwise multiple linear regression. The effect size (ES) indication for correlations was used to interpret the magnitude of a standard regression coefficient (β); an ES of 0.10, 0.30 and 0.50 were considered small, moderate and large, respectively. The study was approved by the Medical Review Ethics Committees of the participating hospitals. RESULTS Overall, the group that received training performed significantly better than the controls (P ≤ 0.003, β range 0.30–0.47). There was no effect of training for participants with a specific preference for a surgical speciality in two of five GRS scores. Participants from CHE obtained higher GRS 3 scores than those from UMCG. Significantly more UMCG trainees indicated having had stress than those from CHE (P

In this paper, staff members’ perceptions about the organisational culture are measured. The questions addressed are: what are their opinions about the current and preferred organisational culture? Are there differences between the current and preferred situation? Do the perceptions differ per department? The Organisational Culture Assessment Instrument was sent to staff involved in 18 different departments within Dutch universities of applied science. The results demonstrated that both a flexibility‐ and control‐oriented culture were moderately experienced in practice. In addition, significant differences were found between the current and preferred situation as well as a significant variation over departments for the current situation. Staff members in general, prefer a flexibility‐oriented culture to a control‐oriented culture. These findings imply that the organisational culture in many departments is not yet fully in line with the staff members’ preferences.

Derkx HP, Rethans JJ, Maiburg HJS, Winkens RAG, Muijtjens AM, Van Rooij HG, Knottnerus JA. Kwaliteit van telefonische triage op huisartsenposten in Nederland. Communicatieve vaardigheden en verslaglegging. Huisarts Wet 2009;52(9):455-61.

We designed an e-learning model to promote critical thinking about basic science topics in online communities of students during work placements in higher education. To determine the effectiveness and efficiency of the model we explored the online discussions in two case studies. We evaluated the quantity of the interactions by looking at quantitative data of the discussion 'threads' and we evaluated the quality of the discussion by content analysis of the individual messages. Both the procedural facilitation of the discussion and the instrument for content analysis were based on Garrison's 'Practical Inquiry model of Cognitive Presence'. Furthermore, we explored the experiences of the students and moderators by interviewing them and we organised their perceptions using the framework of an activity system. On the basis of the quantitative and qualitative data we conclude that the e-learning model was successful in establishing a dialogue among a group of students and an expert during work placements at different locations. The 'Practical Inquiry model' was useful in facilitating a sustained on-topic discourse involving critical thinking. Although the amount of critical thinking was moderate, the results suggest ways to increase integration and resolution activities in the online discussions.

Aim: Aim of this study is to elucidate which standard setting method is optimal to prevent incompetent students to pass and competent students to fail a dental Objective Structured Clinical Examination (OSCE). Material and methods: An OSCE with 14 test stations was used to assess the performance of 119 third year dental students in a training group practice. To establish the pass/fail standard per station, three standard setting methods were applied: the Angoff I method, the modified Angoff II with reality check and the Borderline Regression (BR) method. For the final decision about passing or failing the complete OSCE, three methods were compared: total compensatory (TC), a partial compensatory (PC) within clusters of competence and a non-compensatory (NC) model. The reliability of the pass/fail standard of the three methods was indicated by the root mean square error (RMSE). As a criterion measure, a sample of the students (n = 89) was rated in the clinic by their instructors and accordingly these students were divided into two groups: competent and incompetent students. The students' clinical rating (considered for this study as 'true qualification') was compared with the pass-fail classification resulting from the OSCE. Undeserved passing of an incompetent student was considered as more damaging than failing a competent student. Results: The BR method showed more acceptable results than the two Angoff methods. In terms of pass rate the BR method showed the highest pass rates: for the TC model the Angoff method I and II and the BR showed pass rates of 86.6%, 86.6% and 97.5% respectively. For the PC model the pass rates were 30.3%, 34.5% and 61.3%, and for the NC model the pass rates were 0.8%, 1.7% and 7.6%. The BR method showed lower RMSEs (higher reliability): for the TC model the RMSEs were 1.3%, 1.0% and 0.3% for the Angoff I, Angoff II and BR method respectively, and for the PC model the RMSE of the clusters of competence range was 2.0—3.7% for Angoffs I; 1.8—2.2% for Angoff II and 0.6—0.7% for the BR method. In terms of incorrect decisions, the BR method had a higher loss due to incorrect decisions for the TC model than for the PC model which is in accordance with the results of other studies in medical education. Conclusions: Therefore we conclude that the BR method in a PC model provides defensible pass/fail standards and seems to be the optimal choice for OSCEs in health education.

Interest in the areas of food animals (FA) and veterinary public health (VPH) appears to be declining among prospective students of veterinary medicine. To address the expected shortage of veterinarians in these areas, the Utrecht Faculty of Veterinary Medicine has developed an admissions procedure to select undergraduates whose aptitude and interests are suited to these areas. A study using expert meetings, open interviews, and document analysis identified personal characteristics that distinguished veterinarians working in the areas of FA and VPH from their colleagues who specialized in companion animals (CA) and equine medicine (E). The outcomes were used to create a written selection tool. We validated this tool in a study among undergraduate veterinary students in their final (sixth) year before graduation. The applicability of the tool was verified in a study among first-year students who had opted to pursue either FA/VPH or CA/E. The tool revealed statistically significant differences with acceptable effect sizes between the two student groups. Because the written selection tool did not cover all of the differences between the veterinarians who specialized in FA/VPH and those who specialized in CA/E, we developed a prestructured panel interview and added it to the questionnaire. The evaluation of the written component showed that it was suitable for selecting those students who were most likely to succeed in the FA/VPH track.

OBJECTIVE To determine the effectiveness of single-point benchmarking and longitudinal benchmarking for inter-school educational evaluation. METHODS We carried out a mixed, longitudinal, cross-sectional study using data from 24 annual measurement moments (4 tests x 6 year groups) over 4 years for 4 annual progress tests assessing the graduation-level knowledge of all students from 3 co-operating medical schools. Participants included undergraduate medical students (about 5000) from 3 medical schools. The main outcome measures involved between-school comparisons of progress test results based on different benchmarking methods. RESULTS Variations in relative school performance across different tests and year groups indicate instability and low reliability of single-point benchmarking, which is subject to distortions as a result of school-test and year group-test interaction effects. Deviations of school means from the overall mean follow an irregular, noisy pattern obscuring systematic between-school differences. The longitudinal benchmarking method results in suppression of noise and revelation of systematic differences. The pattern of a school's cumulative deviations per year group gives a credible reflection of the relative performance of year groups. CONCLUSIONS Even with highly comparable curricula, single-point benchmarking can result in distortion of the results of comparisons. If longitudinal data are available, the information contained in a school's cumulative deviations from the overall mean can be used. In such a case, the mean test score across schools is a useful benchmark for cross-institutional comparison.

OBJECTIVE To determine the differential effects of a paper-based versus a web-based portfolio in terms of portfolio quality, user-friendliness and student motivation. METHODS An experimental design was used to compare Year 1 medical students' reflective portfolios. The portfolios differed in presentation medium only (i.e. web-based versus paper-based). Content analysis, a student questionnaire and mentor interviews were used to evaluate portfolio quality, user-friendliness and student motivation. A total of 92 portfolios were scored independently by 2 raters using a portfolio quality-rating instrument. RESULTS Portfolio structure, quality of reflection and quality of evidence showed no significant effects of presentation medium. Multi-level analysis showed a significant effect for student motivation: web-based portfolios scored 0.39 more than paper-based portfolios (P < 0.05; effect size 0.76). The mentors reported no differences in portfolio quality, except that there were more visuals in web-based portfolios. Students spent significantly more time preparing the web-based than the paper-based portfolios (15.4 hours versus 12.2 hours; t = 2.1, P < 0.05; effect size 0.46). The 2 student groups did not differ significantly in terms of their satisfaction with the portfolio. The mentors perceived the web-based portfolios as more user-friendly. CONCLUSIONS The web-based portfolios were found to enhance students' motivation, were more user-friendly for mentors, and delivered the same content quality compared with paper-based portfolios. This suggests that web-based presentation may promote acceptance of portfolios by students and teachers alike.

Summary Objectives: To determine whether self-directed learning about (electronic) patient records during a PBL (problem-based learning) block, dealing with the content of disciplines concerned with the diagnosis and therapy of diseases of the abdomen, increased the knowledge of the students with respect to the patient records. Methods: At the beginning and at the end of the tenweek block the same questionnaire was offered to the students (180). Cohen’s d for effect size was used to determine the increase in knowledge. Results: For those students that answered the questionnaire twice (53), a Cohen’s d of 0.94 was obtained. Conclusions: The knowledge of the students concerning the advantages and limitations of (electronic) patient records increased significantly. The corresponding effect size was large.

Contains fulltext : 155120.PDF (Publisher’s version ) (Open Access) General practitioners (GPs) are increasingly called upon to identify patients at risk for hereditary cancers, and their genetic competencies need to be enhanced. This article gives an overview of a research project on how to build effective educational modules on genetics, assessed by randomized controlled trials (RCTs), reflecting the prioritized educational needs of primary care physicians. It also reports on an ongoing study to investigate long-term increase in genetic consultation skills (1-year follow-up) and interest in and satisfaction with a supportive website on genetics among GPs. Three oncogenetics modules were developed: an online Continuing Professional Development (G-eCPD) module, a live genetic CPD module, and a "GP and genetics" website (huisartsengenetica.nl) providing further genetics information applicable in daily practice. Three assessments to evaluate the effectiveness (1-year follow-up) of the oncogenetic modules were designed: 1.An online questionnaire on self-reported genetic competencies and changes in referral behaviour, 2.Referral rates from GPs to clinical genetics centres and 3.Satisfaction questionnaire and visitor count analytics of supportive genetics website. The setting was Primary care in the Netherlands and three groups of study participants were included in the reported studies:. Assessment 1. 168 GPs responded to an email invitation and were randomly assigned to an intervention or control group, evaluating the G-eCPD module (n = 80) or the live module (n = 88). Assessment 2. Referral rates by GPs were requested from the clinical genetics centres, in the northern and southern parts of the Netherlands (Amsterdam and Maastricht), for the two years before (2010 [n = 2510] and 2011 [n = 2940]) and the year after (2012 [n = 2875]) launch of the oncogenetics CPD modules and the website. Assessment 3. Participants of the website evaluation were all recruited online. When they visited the website during the month of February 2013, a pop-up invitation came up. Of the 1350 unique visitors that month, only 38 completed the online questionnaire. Main outcomes measure showed long-term (self-reported) genetic consultation skills (i.e. increased genetics awareness and referrals to clinical genetics centres) among GPs who participated in the oncogenetic training course, and interest in and satisfaction with the supportive website. 42 GPs (52%) who previously participated in the G-eCPD evaluation study and 50 GPs (57%) who participated in the live training programme responded to the online questionnaire on long-term effects of educational outcome. Previous RCTs showed that the genetics CPD modules achieved sustained improvement of oncogenetic knowledge and consultation skills (3-months follow-up). Participants of these RCTs reported being more aware of genetic problems long term; this was reported by 29 GPs (69%) and 46 GPs (92%) participating in the G-eCPD and live module evaluation studies, respectively (Chisquare test, p

The portfolio is becoming increasingly accepted as a valuable tool for learning and assessment. The validity of portfolio assessment, however, may suffer from bias due to irrelevant qualities, such as lay-out and writing style. We examined the possible effects of such qualities in a portfolio programme aimed at stimulating Year 1 medical students to reflect on their professional and personal development. In later curricular years, this portfolio is also used to judge clinical competence. We developed an instrument, the Portfolio Analysis Scoring Inventory, to examine the impact of form and content aspects on portfolio assessment. The Inventory consists of 15 items derived from interviews with experienced mentors, the literature, and the criteria for reflective competence used in the regular portfolio assessment procedure. Forty portfolios, selected from 231 portfolios for which ratings from the regular assessment procedure were available, were rated by 2 researchers, independently, using the Inventory. Regression analysis was used to estimate the correlation between the ratings from the regular assessment and those resulting from the Inventory items. Inter-rater agreement ranged from 0.46 to 0.87. The strongest predictor of the variance in the regular ratings was 'quality of reflection' (R 0.80; R2 66%). No further items accounted for a significant proportion of variance. Irrelevant items, such as writing style and lay-out, had negligible effects. The absence of an impact of irrelevant criteria appears to support the validity of the portfolio assessment procedure. Further studies should examine the portfolio's validity for the assessment of clinical competence.

Morning reports offer opportunities for intensive work-based learning. In this controlled study, we measured learning processes and outcomes with the report of paediatric emergency room patients. Twelve specialists and 12 residents were randomised into four groups and discussed the same two paediatric cases. The groups differed in their presentation modality (verbal only vs. verbal + text) and the use of buzz groups (with vs. without). The verbal interactions were analysed for clinical reasoning processes. Perceptions of learning and judgment of learning were reported in a questionnaire. Diagnostic accuracy was assessed by a 20-item multiple-choice test. Combined bimodal presentation and buzz groups increased the odds ratio of clinical reasoning to occur in the discussion of cases by a factor of 1.90 (p = 0.013), indicating superior reasoning for buzz groups working with bimodal materials. For specialists, a positive effect of bimodal presentation was found on perceptions of learning (p

The practice of assessment is governed by an interesting paradox. On the one hand good assessment requires substantial resources which may exceed the capacity of a single institution and we have reason to doubt the quality of our in-house examinations. On the other hand, our parsimonity with regard to our resources makes us reluctant to pool efforts and share our test material. This paper reports on an initiative to share test material across different medical schools. Three medical schools in The Netherlands have successfully set up a partnership for a specific testing method: progress testing. At present, these three schools collaboratively produce high-quality test items. The jointly produced progress tests are administered concurrently by these three schools and one other school, which buys the test. The steps taken in establishing this partnership are described and results are presented to illustrate the unique sort of information that is obtained by cross-institutional assessment. In addition, plans to improve test content and procedure and to expand the partnership are outlined. Eventually, the collaboration may even extend to other test formats. This article is intended to give evidence of the feasibility and exciting potential of between school collaboration in test development and test administration. Our experiences have demonstrated that such collaboration has excellent potential to combine economic benefit with educational advantages, which exceed what is achievable by individual schools.

Contains fulltext : 170678.pdf (Publisher’s version ) (Open Access) BACKGROUND: Teachers' conceptions of learning and teaching are partly unconscious. However, they are critical for the delivery of education and affect students' learning outcomes. Lasting changes in teaching behaviour can only be realized if conceptions of teachers have been changed accordingly. Previously we constructed a questionnaire named COLT to measure conceptions. In the present study, we investigated if different teacher profiles could be assessed which are based on the teachers' conceptions. These teacher profiles might have implications for individual teachers, for faculty development activities and for institutes. Our research questions were: (1) Can we identify teacher profiles based on the COLT? (2) If so, how are these teacher profiles associated with other teacher characteristics? METHODS: The COLT questionnaire was sent electronically to all teachers in the first three years of the undergraduate curriculum of Medicine in two medical schools in the Netherlands with student-centred education. The COLT (18 items, 5 point Likert scales) comprises three scales: 'teacher centredness', 'appreciation of active learning' and 'orientation to professional practice'. We also collected personal information about the participants and their occupational characteristics. Teacher profiles were studied using a K-means cluster analysis and calculating Chi squares. RESULTS: The response rate was 49.4% (N = 319/646). A five-cluster solution fitted the data best, resulting in five teacher profiles based on their conceptions as measured by the COLT. We named the teacher profiles: Transmitters (most traditional), Organizers, Intermediates, Facilitators and Conceptual Change Agents (most modern). The teacher profiles differed from each other in personal and occupational characteristics. CONCLUSIONS: Based on teachers' conceptions of learning and teaching, five teacher profiles were found in student-centred education. We offered suggestions how insight into these teacher profiles might be useful for individual teachers, for faculty development activities and for institutes and departments, especially if involved in a curriculum reform towards student-centred education.

The Job Demands-Resources model (JD-R model) was used as the theoretical basis of a tailormade questionnaire to measure the psychosocial work environment and personal resources of recently graduated veterinary professionals. According to the JD-R model, two broad categories of work characteristics that determine employee wellbeing can be distinguished: job demands and job resources. Recently, the JD-R model has been expanded by integrating personal resource measures into the model. Three semistructured group interviews with veterinarians active in different work domains were conducted to identify relevant job demands, job resources and personal resources. These demands and resources were organised in themes (constructs). For measurement purposes, a set of questions ('a priori scale') was selected from the literature for each theme. The full set of a priori scales was included in a questionnaire that was administered to 1760 veterinary professionals. Exploratory factor analysis and reliability analysis were conducted to arrive at the final set of validated scales (final scales). 860 veterinarians (73 per cent females) participated. The final set of scales consisted of seven job demands scales (32 items), nine job resources scales (41 items), and six personal resources scales (26 items) which were considered to represent the most relevant potential predictors of work-related wellbeing in this occupational group. The procedure resulted in a tailormade questionnaire: the Veterinary Job Demands and Resources Questionnaire (Vet-DRQ). The use of valid theory and validated scales enhances opportunities for comparative national and international research.

Contains fulltext : 136897.pdf (Publisher’s version ) (Open Access) Medical professionals are increasingly expected to deliver genetic services in daily patient care. However, genetics education is considered to be suboptimal and in urgent need of revision and innovation. We designed a Genetics e-learning Continuing Professional Development (CPD) module aimed at improving general practitioners' (GPs') knowledge about oncogenetics, and we conducted a randomized controlled trial to evaluate the outcomes at the first two levels of the Kirkpatrick framework (satisfaction, learning and behavior). Between September 2011 and March 2012, a parallel-group, pre- and post-retention (6-month follow-up) controlled group intervention trial was conducted, with repeated measurements using validated questionnaires. Eighty Dutch GP volunteers were randomly assigned to the intervention or the control group. Satisfaction with the module was high, with the three item's scores in the range 4.1-4.3 (5-point scale) and a global score of 7.9 (10-point scale). Knowledge gains post test and at retention test were 0.055 (P

Contains fulltext : 137892.pdf (Publisher’s version ) (Open Access) PURPOSE: General practitioners are increasingly called upon to deliver genetic services and could play a key role in translating potentially life-saving advancements in oncogenetic technologies to patient care. If general practitioners are to make an effective contribution in this area, their genetics competencies need to be upgraded. The aim of this study was to investigate whether oncogenetics training for general practitioners improves their genetic consultation skills. METHODS: In this pragmatic, blinded, randomized controlled trial, the intervention consisted of a 4-h training (December 2011 and April 2012), covering oncogenetic consultation skills (family history, familial risk assessment, and efficient referral), attitude (medical ethical issues), and clinical knowledge required in primary-care consultations. Outcomes were measured using observation checklists by unannounced standardized patients and self-reported questionnaires. RESULTS: Of 88 randomized general practitioners who initially agreed to participate, 56 completed all measurements. Key consultation skills significantly and substantially improved; regression coefficients after intervention were equivalent to 0.34 and 0.28 at 3-month follow-up, indicating a moderate effect size. Satisfaction and perceived applicability of newly learned skills were highly scored. CONCLUSION: The general practitioner-specific training proved to be a feasible, satisfactory, and clinically applicable method to improve oncogenetics consultation skills and could be used as an educational framework to inform future training activities with the ultimate aim of improving medical care.

Background: Modern postgraduate training in medical microbiology requires more objective tools to monitor knowledge during the training than interviews by responsible educational supervisors. Aim: Evaluation of the feasibility and validity of a progress test (PT) to enable formative assessment of the knowledge development in a postgraduate training in medical microbiology. Methods: Data consisted of the scores of all trainees attending the annual PTs in the 5-year postgraduate Medical Microbiology training in the Netherlands from 2005 until 2010. Knowledge development as measured by the PT was analysed per PT by one-way ANOVA over year groups. In addition a longitudinal analysis (repeated measures ANOVA) was applied to the scores of the subgroup of trainees who participated in a four year sequence of PTs. Results: Up until the fourth training year residents who were further advanced in their training, in general scored significantly higher than trainees of lower years (one-way ANOVA, p

Objective: Asynchronous electrical activation of the left ventricle (LV), induced by ventricular pacing (VP), reduces mechanical load in early- and enhances it in late-activated regions. Consequently, chronic VP leads to asymmetric hypertrophy. We investigated whether such locally induced myocardial hypertrophy also occurs in the presence of pressure overload hypertrophy (POH). Methods: POH was induced by aortic banding in puppies. At age 9 months, seven dogs were paced at the right ventricular (RV) apex at physiological heart rate for 6 months (POH-pace group), while four POH dogs served as POH-control group. Changes in volume of the LV cavity and the total LV wall and of five LV wall sectors were measured by means of 2D-echocardiography and X-ray marker detection. Results: During the last 6 months of the protocol the volume of the five LV wall sectors increased in the POH-control group, ranging from 27±9 to 30±5% (mean±S.D.). In POH-pace animals sector wall volume in the four sectors at intermediate to long distance from the pacing site increased to a similar extent (ranging from 31±16 to 35±17%), but wall volume in the early-activated apical septum increased significantly less (17±21%). In these hearts myocyte diameter was significantly smaller in the apical septum than in the lateral LV wall. The regional difference in wall volume changes (19±21%) was significantly smaller in the POH-pace group than in chronically paced, non-hypertrophic, canine hearts in a previous study from our laboratory (43±14%). Conclusions: In hypertrophying hearts chronic pacing at the RV apex suppresses the development of hypertrophy in the early-activated apical septum but does not cause additional hypertrophy in late-activated regions, as is the case in non-hypertrophic hearts. The latter suggests that the local growth response is reduced in hypertrophying hearts.

Purpose. To compare four standard-setting procedures for an objective structure clinical examination (OSCE). Methods. A 12-station OSCE was administered to 84 students in each of the final (fourth-) year medical classes of 1996 and 1997 at Dalhousie University Faculty of Medicine. Four standard-setting procedures (Angoff, borderline, relative, and holistic) were applied to the data to establish a cutoff score for a pass/fail decision. Results. The procedures yielded highly inconsistent results. The Angoff and borderline procedures gave similar results; however, the relative and holistic methods gave widely divergent results. The Angoff procedure yielded results reliable enough to use in decision making for a high-stakes examination, but would have required more judges or more stations. Conclusions. The Angoff and borderline procedures provide reasonable and defensible approaches to standard setting and are practical to apply by non-psychometricians in medical schools. Further investigation of the other procedures is needed. Acad. Med. 2000;75:267‐271.

Cardiac tagging permits non-invasive study of myocardial motion with high accuracy. Unfortunately, tagging contrast is impaired at later heart phases due to longitudinal relaxation. Histogram modification is presented as a method for improving contrast in later, faded images of a tagging series by altering these images such that their intensity histograms approximate the shape of the first, unfaded image of the series. This technique greatly improves the contrast and facilitates automatic detection of tags. Furthermore, a method is described for automatically tracking tag positions in short-axis images of the left ventricle modulated with a tagging grid. The method differs from previously reported methods in that, in one single filtering process in the Fourier domain, both the grid crossings as well as the grid centers are detected, and thus increased sampling resolution is obtained. The method was validated by applying a mathematical model of left ventricular motion to tagged images of the thigh muscle. The average discrepancy between theoretically predicted and automatically detected tag positions was 0.04 +/- 0.17 mm (mean +/- SD).

Motion and deformation of the cardiac wall may be measured by following the positions of implanted radiopaque markers in three dimensions, using two x-ray cameras simultaneously. Regularly, calibration of the position measurement system is obtained by registration of the images of a calibration object, containing 10-20 radiopaque markers at known positions. Unfortunately, an accidental change of the position of a camera after calibration requires complete recalibration. Alternatively, redundant information in the measured image positions of stereo pairs can be used for calibration. Thus, a separate calibration procedure can be avoided. In the current study a model is developed that describes the geometry of the camera setup by five dimensionless parameters. Maximum Likelihood (ML) estimates of these parameters were obtained in an error analysis. It is shown that the ML estimates can be found by application of a nonlinear least squares procedure. Compared to the standard unweighted least squares procedure, the ML method resulted in more accurate estimates without noticeable bias. The accuracy of the ML method was investigated in relation to the object aperture. The reconstruction problem appeared well conditioned as long as the object aperture is larger than 0.1 rad. The angle between the two viewing directions appeared to be the parameter that was most likely to cause major inaccuracies in the reconstruction of the 3-D positions of the markers. Hence, attempts to improve the robustness of the method should primarily focus on reduction of the error in this parameter.

Norm-referenced pass/fail decisions are quite common in achievement testing in health sciences education. The use of relative standards has the advantage of correcting for variations in test-difficulty. However, relative standards also show some serious drawbacks, and the use of an absolute and fixed standard is regularly preferred. The current study investigates the consequences of the use of an absolute instead of a relative standard. The performance of the developed standard setting procedure was investigated by using actual progress test scores obtained at the Maastricht medical school in an episode of eight years. When the absolute instead of the relative standard was used 6% of the decisions changed: 2.6% of the outcomes changed from fail to pass, and 3.4% from pass to fail. The failure rate, which was approximately constant when using the relative standard, varied from 2% to 47% for different tests when an absolute standard was used. It is concluded that an absolute standard is precarious because of the variations in difficulty of tests.

Motion and deformation of an object may be quantified by following attached markers in video or cine frame sequences. When recording cardiac motion by video (256 x 256 pixels, 50 Hz), generally no more than approximately 20 markers can be followed due to difficulties in proper identification of marker images. In the present study we developed the lower rank (LR) tracking method which can automatically follow considerably more than 20 markers. The performance of the method was evaluated in computer simulations of naturally moving myocardial markers observed in a sequence of 60 video frames. White noise was added to the marker coordinates. Realistic loss of data due to detection failure was simulated by deleting a generated marker image when the distance to another marker image was below a given minimum value. In a test, realistic values were substituted for the noise level sigma (0.5 pixel) and the minimum marker distance dm (4 pixels). For numbers of markers ranging from 50 to 100, 95-90% of the detected marker images was correctly tracked. Less than 0.7% was part of a false track, i.e. a track containing images of different markers. Under less favourable conditions (sigma = 1 pixel; dm = 8 pixels) the method was robust: for 75 markers with 40% of the marker images missing, still 70% of the detected images was correctly tracked, while the fraction in false tracks did not increase. The LR tracking method appears reliable for automatic tracking of large amounts of moving markers in a sequence of video or cine frames.

Background: The Dutch postgraduate medical training has been revised to focus on seven competencies. The role as manager is one of these competencies. Recent studies show that this competency receives little attention during the residency training. In an earlier study, we discovered that residents perceived their competency as managers to be moderate. Aim: In this study, we investigated how medical specialists perceived the managerial competencies of medical residents and their need for management education. Methods: In September 2010, a 46-item questionnaire was designed which examined medical specialists' perceptions of the competency and needs of residents in the field of medical management. Two hundred ninety-eight specialists were invited via email to participate. Results: Hundred twenty-nine specialists (43.3%) responded to our survey. They rated the residents' competencies in contract negotiating skills, knowledge of the healthcare system, and specialist department poorly. They felt that residents were competent in updating their medical knowledge. Ninety-four percent reported a need for training in management among residents. Preferred topics were time management and healthcare organization. The preferred training method was a workshop given during residency by an extramural expert. Conclusion: Dutch medical specialists perceive the management competencies of residents in some areas to be inadequate. They feel that training in medical management during residency is necessary.

Objective Visual expertise relies on perceptive as well as cognitive processes. At present, knowledge of these processes when diagnosing clinical cases mainly stems from studies with still pictures. Patient video cases constitute a dynamic and authentic, diagnostic challenge that may simulate seeing and diagnosing a patient in person. This study investigates visual attention and the concomitant cognitive processes of clinicians diagnosing authentic pediatric video cases. Methods A total of 43 clinicians with varying levels of expertise took part in this cross-sectional study. They diagnosed four brief video recordings of children: two with seizures and two with disorders imitating seizures. We used eye tracking to investigate time looking at relevant areas in the video cases and a concurrent think-aloud procedure to explore the associated clinical reasoning processes. Results More experienced clinicians were more accurate in visual diagnosis and spent more of their time looking at relevant areas. At the same time, they explored data less, yet they built and evaluated more diagnostic hypotheses. Interpretation This study adds a new perspective on medical expertise. More experienced clinicians (experts) focus better on relevant areas allowing them to explore data less and at the same time to build and evaluate more diagnostic hypotheses. The combination of effective visual search and the ability to effectively monitor for and evaluate different diagnostic options seems to characterize the experts in visual domains. (Less)

Item does not contain fulltext PURPOSE: Studies that compare the effects of problem-based and conventional medical curricula on student performance generally show no significant differences. However, curriculum comparison studies are at best quasi-experimental, so they are prone to forms of selection bias. The purpose of this study was to reanalyze data from such comparisons by controlling for two potential biases: differential student attrition and differential exposure. METHOD: The authors reanalyzed 104 previously published comparisons involving a single, problem-based medical school in the Netherlands (Maastricht University's medical school), using student attrition and study duration data from this school and the schools with which it was compared. The authors removed bias by reequalizing the comparison groups in terms of attrition and study duration. RESULTS: The uncorrected data showed no differences between problem-based and conventional curricula: Mean effect sizes as expressed by Cohen d were 0.02 for medical knowledge and 0.07 for diagnostic reasoning. However, the reanalysis demonstrated medium-level effect sizes favoring the problem-based curriculum. After corrections for attrition and study duration, the mean effect size for knowledge acquisition was 0.31 and for diagnostic reasoning was 0.51. CONCLUSIONS: Effects of the Maastricht problem-based curriculum were masked by differential attrition and differential exposure in the original studies. Because this school has been involved in many studies included in influential literature reviews published in the past 20 years, the authors' findings have implications for the assessment of the value of problem-based learning put forward by these reviews. 01 april 2012

Background Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions. Methods The aim of this paper was to provide a more comprehensive overview of medical error in hospitals using a combination of different information sources. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. The main outcome measures were distribution of incidents over the thirteen categories of the ICPS classifier “Incident type”, described as odds ratios (OR) and proportional similarity indices (PSI). Results A total of 1012 incidents resulted in 1282 classified items. Large differences between data from IRS and patient complaints (PSI = 0.32) and from IRS and retrospective chart review (PSI = 0.31) were mainly attributable to behaviour (OR = 6.08), clinical administration (OR = 5.14), clinical process (OR = 6.73) and resources (OR = 2.06). Conclusions IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety.