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Background: Clinician-teachers, physicians with educational responsibilities in either classroom or clinical setting, are assumed to add value by virtue of their dual role. The clinical responsibilities are often prioritised over the educational tasks. How and under which circumstances clinician-teachers are able to perform their educational role and create added value for different stakeholders is currently unclear., Objectives: To identify for whom, how and under which circumstances educational activities executed by CTs by virtue of their dual role add value to others., Scope: CTs activities linking the system of education and clinical practice beyond direct patient interactions and purposefully executed., Methods: A realist review was conducted. Databases were searched in two stages: a narrow conventional search, followed by a comprehensive artificial intelligence-aided search. Studies concerning clinician-teachers' dual role were included. Realist analysis was applied to identify in which contexts resource mechanisms triggered reasoning mechanisms, which led to specific outcomes for different stakeholders., Results: Sixty-six studies were included. In contexts where clinician-teachers' dual role was formally recognised and valued, clinician-teachers benefitted from the credibility and legitimacy bestowed on them, making the transfer of domain-specific knowledge more impactful. In contexts where sociocultural differences between both systems existed, CTs were able to mediate and adjust recommendations aligned with stakeholders' perceived relevance. Also, contexts organised to support both roles made resource mechanisms more impactful. Clinician-teachers added value to students' clinical competency and learning environment, and to educational organisations' curricular innovation. In their clinical workspace, clinician-teachers added value by enhancing colleague physicians' teaching expertise, implementing educational innovations and recruiting students for scarce specialisms., Conclusion: Clinician-teachers add value to students, colleague physicians and the clinical and educational contexts at large. Domain-specific knowledge of both systems was important to gain credibility and achieve added value. Openness, formal recognition and allocated time for both roles in educational and clinical contexts towards the dual role are important to strengthen the impact of the dual role., (© 2024 The Author(s). Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Current guidance suggests oral antibiotics can be considered for children with acute otitis media (AOM) and ear discharge, but there is an absence of evidence regarding the relative effectiveness of antibiotic-corticosteroid eardrops., Aim: To establish whether antibiotic-corticosteroid eardrops are non-inferior to oral antibiotics in children with AOM and ear discharge., Design and Setting: Open randomized controlled non-inferiority trial set in Dutch primary care., Methods: Children were randomized to hydrocortisone-bacitracin-colistin eardrops (five drops, three times per day in the discharging ear(s)) or amoxicillin suspension (50 mg per kilogram of body weight per day, divided over three doses administered orally) for 7 days. The primary outcome was the proportion of children with resolution of ear pain and fever at day 3., Results: Between December 2017 and March 2023, 58 of the planned 350 children were recruited due to slow accrual for various reasons. Children assigned to eardrops (n = 26) had lower resolution rates of ear pain and fever at 3 days compared to those receiving oral antibiotics (n = 31): 42% vs 65%; adjusted risk difference 20.3%, 95% confidence interval -5.3% to 41.9%), longer parent-reported ear discharge (6 vs 3 days; P = .04), and slightly higher mean ear pain scores (Likert scale 0-6) over days 1-3 (2.1 vs 1.4, P = .02), but received fewer oral antibiotic courses in 3months (11 for 25 children vs 33 for 30 children), and had less GI upset and rash (12% vs 32% and 8% vs 16%, respectively)., Conclusion: Early termination stopped us from determining non-inferiority of antibiotic-corticosteroid eardrops. Our limited data, requiring confirmation, suggest that oral antibiotics may be more effective than antibiotic-corticosteroid eardrops in resolving symptoms and shortening the duration of ear discharge., (© The Author(s) 2024. Published by Oxford University Press.)

The Medical Specialties council of the Royal Dutch medical association (CGS) has published an innovative perspective on the future landscape of specialisms in medicine. The proposal introduces generalism as the standard of training and professional practice, which represents a fundamental change from the current system. The envisioned new structure would consist of a number of broad core specialisms, emphasizing generalist knowledge and skills, and additional subspecialties for highly complex care. This is expected to enhance healthcare efficiency and improve patient treatment. The plan meets changing healthcare needs and accommodates the preference of young doctors regarding their residency training and careers.The CGS wants to further explore the new perspective with all parties involved.

Introduction: Ear pain is the most prominent symptom of childhood acute otitis media (AOM). To control the pain and reduce reliance on antibiotics, evidence of effectiveness for alternative interventions is urgently needed. This trial aims to investigate whether analgesic ear drops added to usual care provide superior ear pain relief over usual care alone in children presenting to primary care with AOM., Methods and Analysis: This is a pragmatic, two-arm, individually randomised, open, superiority trial with cost-effectiveness analysis and nested mixed-methods process evaluation in general practices in the Netherlands. We aim to recruit 300 children aged 1-6 years with a general practitioner (GP) diagnosis of AOM and ear pain. Children will be randomly allocated (ratio 1:1) to either (1) lidocaine hydrochloride 5 mg/g ear drops (Otalgan) one to two drops up to six times daily for a maximum of 7 days in addition to usual care (oral analgesics, with/without antibiotics); or (2) usual care. Parents will complete a symptom diary for 4 weeks as well as generic and disease-specific quality of life questionnaires at baseline and 4 weeks. The primary outcome is the parent-reported ear pain score (0-10) over the first 3 days. Secondary outcomes include proportion of children consuming antibiotics, oral analgesic use and overall symptom burden in the first 7 days; number of days with ear pain, number of GP reconsultations and subsequent antibiotic prescribing, adverse events, complications of AOM and cost-effectiveness during 4-week follow-up; generic and disease-specific quality of life at 4 weeks; parents' and GPs' views and experiences with treatment acceptability, usability and satisfaction., Ethics and Dissemination: The Medical Research Ethics Committee Utrecht, the Netherlands, has approved the protocol (21-447/G-D). All parents/guardians of participants will provide written informed consent. Study results will be submitted for publication in peer-reviewed medical journals and presented at relevant (inter)national scientific meetings., Trial Registration: The Netherlands Trial Register: NL9500; date of registration: 28 May 2021. At the time of publication of the study protocol paper, we were unable to make any amendments to the trial registration record in the Netherlands Trial Register. The addition of a data sharing plan was required to adhere to the International Committee of Medical Journal Editors guidelines. The trial was therefore reregistered in ClinicalTrials.gov (NCT05651633; date of registration: 15 December 2022). This second registration is for modification purposes only and the Netherlands Trial Register record (NL9500) should be regarded as the primary trial registration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objective: To develop and validate a symptom-based prediction rule for early recognition of acute coronary syndrome (ACS) in patients with acute chest discomfort who call out-of-hours services for primary care (OHS-PC)., Design: Cross-sectional study. A diagnostic prediction rule was developed with multivariable regression analyses. All models were validated with internal-external cross validation within seven OHS-PC locations. Both age and sex were analysed as statistical interaction terms, applying for age non-linear effects., Setting: Seven OHS-PC in the Netherlands., Participants: 2192 patients who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2017. Backed up recordings of telephone triage conversations were analysed., Primary and Secondary Outcomes Measures: Diagnosis of ACS retrieved from the patient's medical records in general practice, including hospital specialists discharge letters. Performance of the prediction rules was calculated with the c-statistic and the final model was chosen based on net benefit analyses., Results: Among the 2192 patients who called the OHS-PC with acute chest discomfort, 8.3% females and 15.3% males had an ACS. The final diagnostic model included seven predictors (sex, age, acute onset of chest pain lasting less than 12 hours, a pressing/heavy character of the pain, radiation of the pain, sweating and calling at night). It had an adjusted c-statistic of 0.77 (95% CI 0.74 to 0.79) with good calibration., Conclusion: The final prediction model for ACS has good discrimination and calibration and shows promise for replacing the existing telephone triage rules for patients with acute chest discomfort in general practice and OHS-PC., Trial Registration Number: NTR7331., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

It is often thought that acute ear discharge as a presenting symptom of acute otitis media (AOM) means that the infection is petering out. However, children with AOM presenting with ear discharge due to a spontaneous perforation of the eardrum (AOMd) have a poorer prognosis (i.e. higher rates of ear pain and/or fever at 3-7 days) than those without ear discharge. In this article we emphasize the importance of physical examination and early treatment of children and adults who present with acute ear discharge.

Background: Around 15%-20% of children with acute otitis media present with ear discharge due to a spontaneous tear or perforation of the eardrum (AOMd). Current guidance recommends clinicians to consider oral antibiotics as first-line treatment in this condition. The opening in the eardrum however should allow topical antibiotics to enter the middle ear directly. Local administration of antibiotics does not expose children to systemic side effects and may put less selective resistance pressure on bacteria. Evidence on the effectiveness of this approach in children with AOMd is lacking., Methods and Analysis: A primary care-based, open, individually randomised, controlled, non-inferiority trial. The trial aims to recruit 350 children aged 6 months to 12 years with AOMd and ear pain and/or fever. Participants will be randomised to 7 days of hydrocortisone-bacitracin-colistin eardrops five drops three times daily or amoxicillin oral suspension 50 mg/kg body weight per day, divided over three doses. Parents will keep a daily diary of AOM symptoms, adverse events and complications for 2 weeks. In addition, they will record AOM recurrences, healthcare utilisation and societal costs for 3 months. The primary outcome is the proportion of children without ear pain and fever at day 3. Secondary outcomes include ear pain and fever intensity/severity; days with ear discharge; eardrum perforation at 2 weeks; adverse events during first 2 weeks; costs; and cost effectiveness at 2 weeks and 3 months. The primary analyses will be intention-to-treat and per-protocol analyses will be conducted as well., Ethics and Dissemination: The medical research ethics committee Utrecht, The Netherlands has given ethical approval (17-400/G-M). Parents/guardians of participants will provide written informed consent. Study results will be submitted for publication in peer-reviewed medical journals and presented at relevant (inter)national scientific meetings., Trial Registration Number: The Netherlands National Trial Register; NTR6723. Date of registration: 27 November 2017., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Presentation and antibiotic prescribing for common infectious disease episodes decreased substantially during the first COVID-19 pandemic wave in Dutch general practice. We set out to determine the course of these variables during the first pandemic year. We conducted a retrospective observational cohort study using routine health care data from the Julius General Practitioners' Network. All patients registered in the pre-pandemic year ( n = 425,129) and/or during the first pandemic year ( n = 432,122) were included. Relative risks for the number of infectious disease episodes (respiratory tract/ear, urinary tract, gastrointestinal, and skin), in total and those treated with antibiotics, and proportions of episodes treated with antibiotics (prescription rates) were calculated. Compared to the pre-pandemic year, primary care presentation for common infections remained lower during the full first pandemic year (RR, 0.77; CI, 0.76-0.78), mainly attributed to a sustained decline in respiratory tract/ear and gastrointestinal infection episodes. Presentation for urinary tract and skin infection episodes declined during the first wave, but returned to pre-pandemic levels during the second and start of the third wave. Antibiotic prescription rates were lower during the full first pandemic year (24%) as compared to the pre-pandemic year (28%), mainly attributed to a 10% lower prescription rate for respiratory tract/ear infections; the latter was not accompanied by an increase in complications. The decline in primary care presentation for common infections during the full first COVID-19 pandemic year, together with lower prescription rates for respiratory tract/ear infections, resulted in a substantial reduction in antibiotic prescribing in Dutch primary care.

Introduction: Workplace-based learning conversations can be a good opportunity for supervisors and trainees to learn from each other. When both professionals discuss their specific knowledge openly with each other, learning conversations may be a useful educational tool, for instance for learning how to apply evidence-based medicine (EBM) in the workplace. We do, however, need a better understanding of how the exchange of knowledge provides opportunities for such bidirectional learning. The aim of this study was therefore to analyse how trainees and supervisors currently handle bidirectional learning opportunities by describing in detail how supervisors respond to knowledge expressed by trainees during a learning conversation., Method: We video-recorded learning conversations between supervisors and trainees in general practice (GP). Within these learning conversations, EBM discussions on medical topics were selected and transcribed. We then identified, analysed using Conversation Analysis (CA) and categorised each expression of knowledge by the trainee and the supervisor's subsequent response., Results: We found that when a trainee expresses knowledge during the learning conversation, supervisors either (a) refute the expressed knowledge, (b) immediately suggest an alternative or (c) pose (additional) questions. These responses have consequences for the learning opportunities of both trainee and supervisor: it is only when supervisors pose further questions that trainees are encouraged to elaborate on their knowledge, leading to a bidirectional learning opportunity., Discussion: Improving EBM learning opportunities for both supervisors and trainees requires more than simply instructing trainees to express knowledge-based-for instance-on recent evidence more often. Inflexible institutional roles related to historical claims of supervisors' epistemic authority hamper bidirectional learning. Posing open questions during learning conversations enhances the flexibility of institutional roles while also creating bidirectional learning opportunities., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Recent reports have highlighted the impact of the COVID-19 pandemic on the incidence of infectious disease illnesses and antibiotic use. This study investigates the effect of the pandemic on childhood incidence of otitis media (OM) and associated antibiotic prescribing in a large primary care-based cohort in the Netherlands., Material and Methods: Retrospective observational cohort study using routine health care data from the Julius General Practitioners' Network (JGPN). All children aged 0-12 registered in 62 practices before the COVID-19 pandemic (1 March 2019 - 29 February 2020) and/or during the pandemic (1 March 2020 - 28 February 2021) were included. Data on acute otitis media (AOM), otitis media with effusion (OME), ear discharge episodes and associated antibiotic prescriptions were extracted. Incidence rates per 1,000 child years (IR), incidence rate ratios (IRR) and incidence rate differences (IRD) were compared between the two study periods., Results: OM episodes declined considerably during the COVID-19 pandemic: IR pre-COVID-19 vs COVID-19 for AOM 73.7 vs 27.1 [IRR 0.37]; for OME 9.6 vs 4.1 [IRR 0.43]; and for ear discharge 12.6 vs 5.8 [IRR 0.46]. The absolute number of AOM episodes in which oral antibiotics were prescribed declined accordingly (IRD pre-COVID-19 vs COVID-19: -22.4 per 1,000 child years), but the proportion of AOM episodes with antibiotic prescription was similar in both periods (47% vs 46%, respectively)., Discussion: GP consultation for AOM, OME and ear discharge declined by 63%, 57% and 54% respectively in the Netherlands during the COVID-19 pandemic. Similar antibiotic prescription rates before and during the pandemic indicate that the case-mix presenting to primary care did not considerably change. Our data therefore suggest a true decline as a consequence of infection control measures introduced during the pandemic., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Hullegie, Schilder, Marchisio, de Sévaux, van der Velden, van de Pol, Boeijen, Platteel, Torretta, Damoiseaux and Venekamp.)

Vulvovaginitis is a common problem in the GP's practice. Causes are bacterial vaginosis (BV), Candida infection and sexually transmitted infections (STIs). Only if empirical treatment fails, a vaginal swab is sent in for culture and BV detection. However, without culture essential, bacterial pathogens may escape diagnosis. Many molecular BV assays have recently appeared on the marketplace, all quite differing in price and targets. However, for years, the Nugent score has been the gold standard for BV detection. We analysed retrospectively 10 years of microbiology results of vulvovaginal swabs, focusing on less frequently reported bacterial pathogens, and assessed the characteristics of BV diagnostics. Vulvovaginal swabs sent in between 2010 and 2020 from > 11,000 GP patients with vulvovaginitis associated symptoms, but negative STI tests, were analysed. First cultures and repeat cultures after at least 6 months were included in four age groups: < 12, 12-17, 18-51 and > 51 years. Candida species and BV were most frequently found, with the highest prevalence in premenopausal women. Haemophilus influenzae, beta-haemolytic streptococci, Streptococcus pneumoniae and Staphylococcus aureus were isolated in 5.6% of all cultures, with the highest percentages in children and postmenopausal women. If empirical treatment of vulvovaginitis fails, bacterial culture should be performed to detect all potentially pathogenic microorganisms to obtain a higher rate of successful diagnosis and treatment, avoiding unnecessary antimicrobial use and costs. For BV detection, molecular testing may seem attractive, but Nugent scoring still remains the low-cost gold standard. We recommend incorporating the above in the appropriate guidelines., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Phenomenon: Supervisors and trainees can learn skills related to evidence-based medicine from each other in the workplace by collaborating and interacting, in this way benefiting from each other's strengths. This study explores supervisors' perceptions of how they currently learn evidence-based medicine by engaging in learning conversations with their trainee. Approach: Semi-structured, video-stimulated elicitation interviews were held with twenty-two Dutch and Belgian supervisors in general practice. Supervisors were shown fragments of their video-recorded learning conversations, allowing them to reflect. Recorded interviews were analyzed using a grounded theory-based approach. Findings: Supervisors did not immediately perceive workplace learning conversations as an opportunity to learn evidence-based medicine from their trainee. They mostly saw these conversations as a learning opportunity for trainees and a chance to maintain the quality of care within their practice. Nevertheless, during the interviews, supervisors did acknowledge that learning conversations help them to gain up-to-date knowledge and search skills or more awareness of their own knowledge or gaps in their knowledge. Not identified as a learning outcome was how to apply evidence-based medicine within a clinical practice by combining evidence with clinical expertise and the patient's preferences. Insights: Supervisors acknowledge that they learn elements of the three aspects of evidence-based medicine by having learning conversations with their trainee, but they currently see this as secondary to the trainee's learning process. Emphasizing opportunities for bidirectional learning could improve learning of evidence-based medicine during workplace learning conversations.

Background: Although primarily considered a childhood disease, acute otitis media (AOM) also occurs in adults. Data on the burden of this condition in adults are, however, scarce., Objective: To explore the primary care incidence and current management of AOM in adults., Methods: All patients aged 15 and older included in the routine health care database of the Julius General Practitioners' Network were followed from 2015 to 2018 (contributing to a total of 1 261 575 person-years). We extracted data on AOM episodes, AOM-related consultations, comorbidities, and antibiotic and analgesic prescriptions., Results: Five thousand three hundred and fifty-eight patients experienced one or more AOM episodes (total number of AOM episodes: 6667; mean 1.2 per patient). The overall AOM incidence was 5.3/1000 person-years and was fairly stable over the study period. Incidence was particularly high in atopic patients (7.3/1000 person-years) and declined with age (from 7.1 in patients 15-39 years of age to 2.7/1000 person-years in those aged 64 years and older). Oral antibiotics, predominantly amoxicillin, were prescribed in 46%, and topical antibiotics in 21% of all episodes., Conclusion: Over the past years, the incidence of AOM in adults in primary care has been stable. Oral antibiotic prescription rates resemble those in children with AOM, whereas a remarkably high topical antibiotic prescription rate was observed. Future prognostic research should inform on the need and feasibility of prospective studies into the best management strategy in this condition., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To identify clinical variables that are associated with the diagnosis acute coronary syndrome (ACS) in women and men with chest discomfort who contact out-of-hours primary care (OHS-PC) by telephone, and to explore whether there are indications whether these variables differ among women and men., Design: Cross-sectional study in which we compared patient and call characteristics of triage call recordings between women with and without ACS, and men with and without ACS., Setting: Nine OHS-PC in the Netherlands., Participants: 993 women and 802 men who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2016., Primary Outcome Measure: Diagnosis of ACS retrieved from the patient's medical record in general practice, including hospital specialists' discharge letters., Results: Among 1795 patients (mean age 58.8 (SD 19.5) years, 55.3% women), 15.0% of men and 8.6% of women had an ACS. In both sexes, retrosternal chest pain was associated with ACS (women with ACS vs without 62.3% vs 40.3%, p=0.002; men with ACS vs without 52.5% vs 39.7%, p=0.032; gender interaction, p=0.323), as was pressing/heavy/tightening pain (women 78.6% vs 61.5%, p=0.011; men 82.1% vs 57.4%, p=<0.001; gender interaction, p=0.368) and radiation to the arm (women 75.6% vs 45.9%, p<0.001; men 56.0% vs 34.8%, p<0.001; gender interaction, p=0.339). Results indicate that only in women were severe pain (65.4% vs 38.1%, p=0.006; gender interaction p=0.007) and radiation to jaw (50.0% vs 22.9%, p=0.007; gender interaction p=0.015) associated with ACS.Ambulances were dispatched equally in women (72.9%) and men with ACS (70.0%)., Conclusion: Our results indicate there were more similarities than differences in symptoms associated with the diagnosis ACS for women and men. Important exceptions were pain severity and radiation of pain in women. Whether these differences have an impact on predicting ACS needs to be further investigated with multivariable analyses., Trial Registration Number: NTR7331., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Acute otitis media (AOM) is among the most common paediatric conditions managed in primary care. Most recent estimates of the cost of AOM date from a decade ago and lack a full societal perspective. We therefore explored the societal cost of childhood AOM in the Netherlands within the setting of a trial comparing the effectiveness of an intervention aimed at educating general practitioners (GPs) about pain management in AOM compared to usual care., Methods: Economic analysis alongside a cluster randomised controlled trial conducted between February 2015 and May 2018 in 37 practices (94 GPs). In total, 224 children with AOM were included of which 223 (99%) completed the trial (intervention: n = 94; control: n = 129). The cost of AOM due to health care costs, patient and family costs, and productivity losses by parent caregivers were retrieved from study diaries and primary care electronic health records, during 28-day follow-up. We calculated mean cost (€ and $) per AOM episode per patient with standard deviations (SD, in €) regardless of study group assignment because there was no clinical effect of the trial intervention. In sensitivity analysis, we calculated cost in the intervention and usual care group, after exclusion of extreme outliers., Results: Mean total AOM cost per patient were €565.93 or $638.78 (SD €1071.01); nearly 90% of these costs were due to productivity losses experienced by parents. After exclusion of outliers, AOM cost was €526.70 or $594.50 (SD €987.96) and similar in the intervention and usual care groups: €516.10 or $582.53 (SD €949.69) and €534.55 or $603.36 (SD €920.55) respectively., Conclusions: At €566 or $639 per episode, societal cost of AOM is higher than previously known and mainly driven by productivity losses by children's parents. Considering its high incidence, AOM poses a significant economic burden that extends beyond direct medical costs., Trial Registration: Netherlands Trial Register no. NTR4920: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4920 .

This work aims to understand intra- and interprofessional networks of general practitioners (GPs) and ear, nose, and throat specialists (ENT specialists), and in what manner supervisors in these specialties involve interns in their professional network to help them learn intra- and interprofessional collaboration. An egocentric social network approach was used to collect and analyze quantitative as well as qualitative data. For this, semi-structured interviews were held with ten GP and ten ENT specialists. GPs had significantly more interprofessional contacts than ENT specialists ( p < .01), with no significant difference in the network sizes of both professions ( p = .37). All supervisors involved interns in their (ego)network actively as well as more passively. They actively discussed how collaboration with other professionals evolved, or passively assumed that an intern would learn from observing the supervisors' network interactions. Many supervisors considered the interns' initiative essential in deciding to involve an intern in their network. Although the workplace of GPs differed notably from hospital settings where ENT specialists work, the network sizes of both were comparable. Clerkships at the general practice seemed to provide more opportunities to learn interprofessional collaboration, for example with the medical nurse. Supervisors in both specialties could involve interns more actively in their intra- and interprofessional network while interns could take more initiative to learn collaboration from their supervisors' network.

In 2020, the COVID-19 pandemic brought dramatic changes in the delivery of primary health care across the world, presumably changing the number of consultations for infectious diseases and antibiotic use. We aimed to assess the impact of the pandemic on infections and antibiotic prescribing in Dutch primary care. All patients included in the routine health care database of the Julius General Practitioners' Network were followed from March through May 2019 ( n = 389,708) and March through May 2020 ( n = 405,688). We extracted data on consultations for respiratory/ear, urinary tract, gastrointestinal and skin infections using the International Classification of Primary Care (ICPC) codes. These consultations were combined in disease episodes and linked to antibiotic prescriptions. The numbers of infectious disease episodes (total and those treated with antibiotics), complications, and antibiotic prescription rates (i.e., proportion of episodes treated with antibiotics) were calculated and compared between the study periods in 2019 and 2020. Fewer episodes were observed during the pandemic months than in the same months in 2019 for both the four infectious disease entities and complications such as pneumonia, mastoiditis and pyelonephritis. The largest decline was seen for gastrointestinal infections (relative risk (RR), 0.54; confidence interval (CI), 0.51 to 0.58) and skin infections (RR, 0.71; CI, 0.67 to 0.75). The number of episodes treated with antibiotics declined as well, with the largest decrease seen for respiratory/ear infections (RR, 0.54; CI, 0.52 to 0.58). The antibiotic prescription rate for respiratory/ear infections declined from 21% to 13% (difference -8.0% (CI, -8.8 to -7.2)), yet the prescription rates for other infectious disease entities remained similar or increased slightly. The decreases in primary care infectious disease episodes and antibiotic use were most pronounced in weeks 15-19, mid-COVID-19 wave, after an initial peak in respiratory/ear infection presentation in week 11, the first week of lock-down. In conclusion, our findings indicate that the COVID-19 pandemic has had profound effects on the presentation of infectious disease episodes and antibiotic use in primary care in the Netherlands. Consequently, the number of infectious disease episodes treated with antibiotics decreased. We found no evidence of an increase in complications.

Dutch general practitioners (GPs) and medical specialists (MSs) create collaborative patient care agreements (CPCAs) to improve intraprofessional collaboration. We set out to identify contradictions between the activity systems of primary and secondary care that could result in expansive learning and new ways of working collaboratively. We analysed nineteen semi-structured interviews using activity theory (AT) as a theoretical framework and using these two activity systems as the units of analysis. There were contradictions within and between the activity systems related, for example, to different understandings of 'care' in generalist and specialist settings. GPs and MSs were able to identify contradictions and learn expansively when they iteratively co-created CPCAs in groups. They found it much harder to tackle contradictions, however, when they disseminated these tools within their respective professional communities, leaving unresolved contradictions and missed opportunities for collaboration. This research shows the educational benefits of taking collective responsibility for improving collaborative patient care.

Background: To be able to practice evidence-based medicine (EBM) when making decisions for individual patients, it is important to learn how to combine the best available evidence with the patient's preferences and the physician's clinical expertise. In general practice training, these skills can be learned at the workplace using learning conversations: meetings between the supervising general practitioner (GP) and GP trainee to discuss medical practice, selected topics or professional performance. This study aimed to give insight into the perceptions of GP trainees on their EBM learning processes during learning conversations., Methods: We held semi-structured video-stimulated elicitation interviews (n = 22) with GP trainees affiliated to GP training institutes in the Netherlands and Belgium. GP trainees were shown fragments of their learning conversations, enabling reflection during the interview. Taking an inductive approach, interview recordings were transcribed verbatim and analysed with NVivo software., Results: GP trainees perceived learning conversations as useful for learning and discussing EBM. Multiple EBM learning activities were identified, such as discussing evidence together, relating evidence to cases in daily practice and discussing the supervisor's experience and the specific local context in the light of what the evidence recommends. However, for learning to occur, trainees need and expect specific behaviour, both from their supervisors and themselves. Supervisors should supply well-substantiated answers that are applicable in practice and give the trainee confirmation. In turn, the trainee needs to prepare well in order to ask focused, in-depth questions. A safe space allowing equal and open discussion between trainee and supervisor is perceived as an essential context for optimal EBM learning., Conclusions: Our findings show that trainees find learning conversations useful for EBM learning in general practice. To bring EBM learning to its full potential, attention should be paid to optimising the behavioural and contextual factors found relevant to enhancing EBM learning.

Background: Evidence-based medicine (EBM) in general practice involves applying a complex combination of best-available evidence, the patient's preferences and the general practitioner's (GP) clinical expertise in decision-making. GPs and GP trainees learn how to apply EBM informally by observing each other's consultations, as well as through more deliberative forms of workplace-based learning. This study aims to gain insight into workplace-based EBM learning by investigating the extent to which GP supervisors and trainees recognise each other's EBM behaviour through observation, and by identifying aspects that influence their recognition., Methods: We conducted a qualitative multicentre study based on video-stimulated recall interviews (VSI) of paired GP supervisors and GP trainees affiliated with GP training institutes in Belgium and the Netherlands. The GP pairs (n = 22) were shown fragments of their own and their partner's consultations and were asked to elucidate their own EBM considerations and the ones they recognised in their partner's actions. The interview recordings were transcribed verbatim and analysed with NVivo. By comparing pairs who recognised each other's considerations well with those who did not, we developed a model describing the aspects that influence the observer's recognition of an actor's EBM behaviour., Results: Overall, there was moderate similarity between an actor's EBM behaviour and the observer's recognition of it. Aspects that negatively influence recognition are often observer-related. Observers tend to be judgemental, give unsolicited comments on how they would act themselves and are more concerned with the trainee-supervisor relationship than objective observation. There was less recognition when actors used implicit reasoning, such as mindlines (internalised, collectively reinforced tacit guidelines). Pair-related aspects also played a role: previous discussion of a specific topic or EBM decision-making generally enhanced recognition. Consultation-specific aspects played only a marginal role., Conclusions: GP trainees and supervisors do not fully recognise EBM behaviour through observing each other's consultations. To improve recognition of EBM behaviour and thus benefit from informal observational learning, observers need to be aware of automatic judgements that they make. Creating explicit learning moments in which EBM decision-making is discussed, can improve shared knowledge and can also be useful to unveil tacit knowledge derived from mindlines.

Purpose: Clinician-scientists are said to be well placed to connect research and practice, but their broker role has been underexplored. This review sought to gain an understanding of the broker role of clinician-scientists., Method: The authors conducted a realist review to describe context-mechanism-outcome (CMO) configurations associated with the broker role of clinician-scientists. CINAHL, PubMed, PsycINFO, Web of Science, and Embase were searched between May and August 2017. Data were analyzed qualitatively; data synthesis focused on assembling CMO configurations., Results: Of an initial 2,241 articles, 9 were included in the final review. Included papers show that clinician-scientists, in their broker role, achieve 2 organizational-level outcomes: an increased volume of clinically relevant, research, and increased evidence application to improve care. They also achieve the individual-level outcome of professional development as a researcher, clinician, and broker. Multidimensional skills and management support are necessary context factors. Mechanisms that contribute to outcomes include balancing economic and scientific interests and performing boundary-crossing activities. Four CMO configurations by which clinician-scientists achieve outcomes in brokering a connection between research and practice were identified. Useful program theories for explaining these are boundary crossing, social network, communities of practice, and diffusion of innovation theory., Conclusions: The mechanisms found may provide insight for interventions aiming to support clinician-scientists in their broker role. The authors expect that if more attention is paid to learning multidimensional skills and management support for the broker role is strengthened, stronger links between research and practice could be forged.

Background: For unclarified reasons, parents tend to be cautious about administering analgesics to their children, potentially leading to suboptimal management of AOM symptoms. We aim to understand parents' views and expectations of pain management in acute otitis media (AOM) in children., Methods: Qualitative study alongside a cluster-randomised controlled trial (PIM-POM study) aimed at optimising pain management in childhood AOM. We purposefully sampled 14 parents of children diagnosed with AOM by their GP, who were recruited to the trial between November 2017 and May 2018. Semi-structured interviews were held at home in the first two weeks after trial enrollment. Interviews were audio-recorded, transcribed and analyzed thematically., Results: Parents experienced difficulties in recognising earache and other symptoms of an ear infection. They consulted the GP for a diagnosis, for reassurance and for management advice. Parents shared that, prior to consultation, they had insufficient knowledge of the benefits of correctly dosed pain medication at regularly scheduled intervals. Parents valued the GP's advice on pain management, and were happy to accept pain medication as standalone therapy, provided that the GP explained why antibiotics would not be needed. Parents' views and expectations of pain management in AOM were shaped by previous experiences of AOM within their family; those with a positive experience of pain medication are more likely to use it in subsequent AOM episodes., Conclusions: Parents of children with AOM consult the GP to help cope with uncertainties in recognising symptoms of AOM, and to receive management advice. It is important that GPs are aware of parents' lack of understanding of the role of pain medication in managing AOM, and that they address this during the consultation., Trial Registration: Netherlands Trial Register, identifier NTR4920 (registration date: 19 December 2014).

Purpose: Annual influenza immunization in medical risk groups is recommended in many countries. Recent evidence suggests that repeated inactivated influenza vaccine (IIV) immunization throughout childhood may impair long-term immunity against influenza. We assessed whether prior immunization altered the effect of IIV in children with preexisting medical conditions on primary care-diagnosed respiratory illness (RI) episodes during the influenza season., Methods: Electronic records of IIV-immunized children who met the criteria for annual IIV immunization according to Dutch guidelines were extracted from a primary care database from 2004 to 2015. For each year, we collected information on IIV immunization status, primary care-attended RI episodes (including influenza-like illness, acute RI, and asthma exacerbation), and potential confounders. Generalized estimating equations were used to model the association between prior IIV and occurrence of at least one RI episode during the influenza season, with "current year immunized but without IIV history" as reference group., Results: A total of 4,183 children (follow-up duration: 11,493 child-years) were IIV immunized at least once. Adjusted estimates showed lower odds for RI in current year-immunized children with prior IIV compared with those without (odds ratio [OR] = 0.61; 95% CI, 0.47-0.78 for "current year immunized and one IIV in previous 2 years"; OR = 0.85; 95% CI, 0.68-1.07 for "current year immunized and ≥2 IIVs in previous 3 years, including prior year")., Conclusion: Repeated IIV immunization in children with preexisting medical conditions has no negative impact on, and may even increase, long-term protection against RI episodes diagnosed during the influenza season in primary care., (© 2019 Annals of Family Medicine, Inc.)

Purpose of Review: One in two children treated with tympanostomy tubes, experience episodes of otorrhea whilst their tubes are in place. In this review, we present the results of the most recent publications on prevention and treatment of tympanostomy tube otorrhea (TTO)., Recent Findings: Recent systematic reviews on water precautions for children with tympanostomy tubes support the American Academy of Otolaryngology - Head and Neck Surgery guideline recommendation against such preventive measures as there is no evidence that it protects against TTO. Studies on tympanostomy tube design and material suggest that silicone tubes have a lower TTO risk and that biofilms appear to be mainly located in the perpendicular junction of the T-tubes and the round rims of the Paparella-type tubes. Another study shows that the biofilm-component DNAB-II protein is present in otorrhea of half of children with TTO. Targeting this protein could lead to a collapse of the biofilm structure and as such a potential new treatment for chronic TTO. New systematic reviews show that antibiotic eardrops are the most effective first-line treatment of acute TTO and suggest that an antibiotic-corticosteroid combination is more effective than antibiotic only. Although in many countries, quinolone eardrops are the preferred choice because of being non-ototoxic, one study found a higher risk of persistent perforation after tube extrusion in children treated with quinolone eardrops as compared with children treated with aminoglycoside eardrops., Summary: Recent evidence confirms that water precautions for children with tympanostomy tubes are not effective in preventing TTO. Antibiotic-corticosteroid eardrops are the most effective treatment of acute TTO.

Background: Whilst current guidelines highlight the importance of pain management for children with acute otitis media (AOM), there is evidence to suggest that this is not implemented in everyday practice. We have developed a primary care-based multifaceted educational intervention to optimise pain management in children with AOM, and we trial its clinical and cost effectiveness., Methods: This cluster randomised controlled trial aims to recruit 250 children aged 6 months to 10 years presenting with AOM to general practitioners (GPs) in 30 primary care centres (PCCs) across the Netherlands. GPs in the PCCs allocated to the intervention group receive a blended GP educational programme (online and face-to-face training). The intervention asks GPs to proactively discuss pain management with parents using an information leaflet, and to prescribe paracetamol and ibuprofen according to current guidelines. GPs in both groups complete an online module illustrating various otoscopic images to standardise AOM diagnosis. GPs in the PCCs allocated to the control group do not receive any further training and provide 'care as usual'. During the 4-week follow-up, parents complete a symptom diary. The primary outcome is the difference in parent-reported mean earache scores over the first 3 days. Secondary outcomes include both number of days with earache and fever, GP re-consultations for AOM, antibiotic prescriptions, and costs. Analysis will be by intention-to-treat., Discussion: The optimal use of analgesics through the multifaceted intervention may provide symptom relief and thereby reduce re-consultations and antibiotic prescriptions in children with AOM., Trial Registration: Netherlands Trial Register, NTR4920 . Registered on 19 December 2014.

Objective: This population-based cohort study assesses the impact of switching from a 7-valent pneumococcal conjugate vaccine (PCV) to a 10-valent PCV on outpatient antibiotic use in Dutch infants, and whether geographical vaccination coverage modifies this association., Setting and Participants: We extracted 2006-2013 anonymised antibiotic purchase data of 255 154 Dutch infants aged below 2 years from Achmea Health, a health insurance fund covering 28% of the national population., Design and Main Outcome Measure: Changes in monthly antibiotic use from 2006-2011 (PCV7) to 2011-2013 (PCV10) were estimated using time-series analysis accounting for seasonality and autocorrelation. Interaction terms for vaccination coverage (categorised into seven groups) and period were added to the model to test whether this association was vaccination coverage-dependent., Results: 275 337 antibiotic courses were used by 119 078 infants (461 352 person-years). PCV10 introduction was associated with a modest 1.6% overall reduction in antibiotic use (purchase rate ratio: 0.98, 95% CI: 0.98 to 0.99). Our model showed a significant difference in time trend in antibiotic use after PCV10 introduction (p = 0.0084) with an increase in prescriptions in the PCV7 period (slope: 0.0023/month, 95% CI: -0.0001 to 0.0047) versus a decline in the PCV10 period (slope: -0.0089/month, 95% CI: -0.0150 to -0.0029). There was no evidence that PCV vaccination coverage affected this association, but since the largest rate ratios were observed in municipalities with the lowest vaccine coverage and had very wide accompanying CIs, our study might have insufficient power to detect such an association., Conclusions: Switching from PCV7 to PCV10 was associated with a modest decline in outpatient antibiotic use in Dutch infants., Competing Interests: Competing interests: ACF is an employee of Seqirus Netherlands B.V., Amsterdam, The Netherlands. Seqirus was not involved in any aspect of the submitted work. EAMS reports independent research grants from GlaxoSmithKline and Pfizer. AWH is chair of a large (around 600 employees) research and teaching institute within our University Medical Center. The Institute performs both investigator-driven and industry-driven research projects with a number of pharmaceutical and diagnostic companies. In addition, some of the members of staff receive unrestricted grants for research projects from a number of companies. It is the institute’s explicit policy to work with several companies and not to focus on one or two industrial partners. AWH received no personal payment from any industrial partner. AMS and the evidENT team at University College London have been supported by a NIHR Research Professorship award with the remit to develop a UK infrastructure and programme of clinical trials in ENT Hearing and Balance. The other authors have indicated they have no potential conflicts of interest to disclose., (© Author(s) (or their employer(s)) [2018]. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Clinical practice guidelines focusing on judicious use of antibiotics for childhood acute otitis media (AOM) have been introduced in many countries around the world., Objective: To systematically review the effects of these guidelines on the prescription of antibiotics and analgesics for children with AOM., Methods: Systematic searches of PubMed, Embase and Cochrane Library from inception to 6 June 2017 using broad search terms. Studies specifically aimed at evaluating the effects of introduction of national AOM practice guidelines on type of antibiotic and/or analgesic prescriptions were included, irrespective of design, setting or language. The Risk Of Bias In Non-randomized Studies of Interventions tool was used to assess risk of bias., Results: Of 411 unique records retrieved, seven studies conducted in six different countries (France, Italy, Spain, Sweden, UK and USA (twice)) compared data before and after guideline introduction. All studies had an observational design, using longitudinal data of children aged under 15 years (n=200-4.6 million) from either routine care, insurance databases or electronic surveys. Risk of bias of all studies was judged serious to critical.Of the five studies reporting on antibiotic prescription rates, three showed a decline of 5%-12% up to 3 years after guideline introduction and two found no or negligible effect. In one US study, the initial 9% decline decreased to 5% after 4-6 years. The recommended first choice antibiotic was prescribed more frequently (9%-58% increase) after guideline introduction in four out of five studies reporting on this outcome. Analgesic prescription rates for AOM were reported in one US study and increased from 14% to 24% after guideline introduction., Conclusion: Based upon what is published, the effects of introduction of national clinical practice guidelines on antibiotic and analgesic prescribing for children with AOM seem modest at the most., Registration: PROSPERO: CRD42016050976., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Aim: To compare quality of care provided by nurse practitioners (NP) with care provided by general practitioners (GP) for children with respiratory tract infections (RTI) in the Netherlands., Background: Nurse practitioners increasingly manage acute conditions in general practice, with opportunities for more protocolled care. Studies on quality of NPs' care for children with RTIs are limited to the US healthcare system and do not take into account baseline differences in illness severity., Design: Retrospective observational cohort study., Methods: Data were extracted from electronic healthcare records of children 0-6 years presenting with RTI between January-December 2013. Primary outcomes were antibiotic prescriptions and early return visits. Generalized estimating equations were used to correct for potential confounders., Results: A total of 899 RTI consultations were assessed (168 seen by NP; 731 by GP). Baseline characteristics differed between these groups. Overall antibiotic prescription and early return visit rates were 21% and 24%, respectively. Adjusted odds ratio for antibiotic prescription after NP vs. GP delivered care was 1.40 (95% confidence interval 0.89-2.22) and for early return visits 1.53 (95% confidence interval 1.01-2.31). Important confounder for antibiotic prescription was illness severity. Presence of wheezing was a confounder for return visits. Complication and referral rates did not differ., Conclusion: Antibiotic prescription, complication and referral rates for paediatric RTI consultations did not differ significantly between NP and GP consultations, after correction for potential confounders. General practitioners, however, see more severely ill children and have a lower return visit rate. A randomised controlled study is needed to determine whether NP care quality is truly noninferior., (© 2018 John Wiley & Sons Ltd.)

Background and Objectives: For Evidence Based Medicine (EBM) learning journal clubs are recommended, but these are not common practice. How participants discuss and learn about applying evidence in other group meetings is unknown. We examined different types of group meetings and explored the use of, and discussions about, clinical research evidence., Methods: A mixed-methods study design was adopted. After distribution and analysis of a questionnaire about types of group meetings, interviews were conducted to better understand the most frequently occurring type., Results: GPs have different types of meetings, but the most common group meetings where evidence wass discussed were so called quality circles, i.e. pharmacotherapy audit meetings in which GPs discuss drug prescription figures or preferred treatment together with pharmacists. Interviews showed that the source of evidence used mostly are the recommendations in the national GP guidelines. The underlying evidence or new research did not play an important role in the discussions., Conclusions: Quality circles seem to be more goal-oriented than learning oriented. Learning discussions about controversies in clinical research or about the integration of evidence, patient values and clinical expertise occurred infrequently. To harvest the potential value of group meetings for EBM learning, quality circles in their present design are not optimal.

The introduction of the CanMEDS method to qualify training and ongoing education for healthcare providers in terms of competencies has provided a clear framework for medical schools' curricula. Different roles are outlined, and one of these is health advocacy. Physicians are accountable to society to use their knowledge and expertise to improve health. Even before the introduction of CanMEDS, physicians took responsibility for improving health by tackling issues in society that negatively affected the health of many; one obvious example is the provision of clean water and sewage systems to prevent epidemics of infectious diseases such as cholera. The role of the health advocate is now addressed within medical education in graduate and postgraduate medical training curricula. If they are to be really effective, trainers should provide proper role models on how to be a health advocate; even though each doctor does not have to become a politician to change the world, all doctors should look further than the individual patient in their surgery.