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Introduction: Although the Dutch and the Canadian postgraduate Obstetrics and Gynecology (OBGYN) medical education systems are similar in their foundations [programmatic assessment, competency based, involving CanMED roles and EPAs (entrustable professional activities)] and comparable in healthcare outcome, their program structures and assessment methods considerably differ., Materials and Methods: We compared both countries' postgraduate educational blueprints and used an auto-ethnographic method to gain insight in the effects of training program structure and assessment methods on how trainees work. The research questions for this study are as follows: what are the differences in program structure and assessment program in Obstetrics and Gynecology postgraduate medical education in the Netherlands and Canada? And how does this impact the advancement to higher competency for the postgraduate trainee?, Results: We found four main differences. The first two differences are the duration of training and the number of EPAs defined in the curricula. However, the most significant difference is the way EPAs are entrusted. In Canada, supervision is given regardless of EPA competence, whereas in the Netherlands, being competent means being entrusted, resulting in meaningful and practical independence in the workplace. Another difference is that Canadian OBGYN trainees have to pass a summative written and oral exit examination. This difference in the assessment program is largely explained by cultural and legal aspects of postgraduate training, leading to differences in licensing practice., Discussion: Despite the fact that programmatic assessment is the foundation for assessment in medical education in both Canada and the Netherlands, the significance of entrustment differs. Trainees struggle to differentiate between formative and summative assessments. The trainees experience both formative and summative forms of assessment as a judgement of their competence and progress. Based on this auto-ethnographic study, the potential for further harmonization of the OBGYN PGME in Canada and the Netherlands remains limited., 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 © 2024 Paternotte, Dijksterhuis, Goverde, Ezzat and Scheele.)

Objective: Gaining insight into contextual factors and mechanisms supporting or hindering autonomy supportive consultation and into outcomes of such consultations., Methods: We conducted a systematic review using the realist synthesis procedure according to RAMESES guideline. A search was performed in PubMed, Embase, PsycINFO and Cinahl from inception to March 2019 using the search terms: 'autonomy' AND 'support' AND 'consultation' OR 'communication' AND 'intervention'. The review process including paper selection, quality assessment, full text reading for data-extraction was conducted by two researchers independently., Results: Of 2792 articles, 18 met our inclusion criteria. Contextual factors influencing an autonomy supportive consultation were: work organization and the attitude of professionals. An overarching supporting mechanism for AS was relationship building. In addition, each phase of the decision-making process seems to need supporting mechanisms fulfilling patients 'specific psychological needs in that phase. The outcome of AS is higher levels of patient well-being., Conclusion: Autonomy supportive consultation works under various contexts coupled with mechanisms that give rise to favourable-outcomes, of which relationship building, taking time and exploring patients' needs seem the most important., Practice Implications: The results of our review facilitate professionals to reflect on their autonomy supportive consultation skills, which could improve their autonomy supportive behaviour., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: As competency-based education has gained currency in postgraduate medical education, it is acknowledged that trainees, having individual learning curves, acquire the desired competencies at different paces. To accommodate their different learning needs, time-variable curricula have been introduced making training no longer time-bound. This paradigm has many consequences and will, predictably, impact the organization of teaching hospitals. The purpose of this study was to determine the effects of time-variable postgraduate education on the organization of teaching hospital departments., Methods: We undertook exploratory case studies into the effects of time-variable training on teaching departments' organization. We held semi-structured interviews with clinical teachers and managers from various hospital departments., Results: The analysis yielded six effects: (1) time-variable training requires flexible and individual planning, (2) learners must be active and engaged, (3) accelerated learning sometimes comes at the expense of clinical expertise, (4) fast-track training for gifted learners jeopardizes the continuity of care, (5) time-variable training demands more of supervisors, and hence, they need protected time for supervision, and (6) hospital boards should support time-variable training., Conclusions: Implementing time-variable education affects various levels within healthcare organizations, including stakeholders not directly involved in medical education. These effects must be considered when implementing time-variable curricula.

Background: Evaluating the quality of postgraduate medical education (PGME) programs through accreditation is common practice worldwide. Accreditation is shaped by educational quality and quality management. An appropriate accreditation design is important, as it may drive improvements in training. Moreover, accreditors determine whether a PGME program passes the assessment, which may have major consequences, such as starting, continuing or discontinuing PGME. However, there is limited evidence for the benefits of different choices in accreditation design. Therefore, this study aims to explain how changing views on educational quality and quality management have impacted the design of the PGME accreditation system in the Netherlands., Methods: To determine the historical development of the Dutch PGME accreditation system, we conducted a document analysis of accreditation documents spanning the past 50 years and a vision document outlining the future system. A template analysis technique was used to identify the main elements of the system., Results: Four themes in the Dutch PGME accreditation system were identified: (1) objectives of accreditation, (2) PGME quality domains, (3) quality management approaches and (4) actors' responsibilities. Major shifts have taken place regarding decentralization, residency performance and physician practice outcomes, and quality improvement. Decentralization of the responsibilities of the accreditor was absent in 1966, but this has been slowly changing since 1999. In the future system, there will be nearly a maximum degree of decentralization. A focus on outcomes and quality improvement has been introduced in the current system. The number of formal documents striving for quality assurance has increased enormously over the past 50 years, which has led to increased bureaucracy. The future system needs to decrease the number of standards to focus on measurable outcomes and to strive for quality improvement., Conclusion: The challenge for accreditors is to find the right balance between trusting and controlling medical professionals. Their choices will be reflected in the accreditation design. The four themes could enhance international comparisons and encourage better choices in the design of accreditation systems.

Objectives: To explore patients' preferences and experiences regarding intercultural communication which could influence the development of intercultural patient-centred communication training., Methods: This qualitative study is based on interviews with non-native patients. Thirty non-native patients were interviewed between September and December 2015 about their preferences and experiences regarding communication with a native Dutch doctor. Fourteen interviews were established with an interpreter. The semi-structured interviews took place in Amsterdam. They were focused on generic and intercultural communication skills of doctors. Relevant fragments were coded by two researchers and analysed by the research team by means of thematic network analysis. Informed consent and ethical approval was obtained beforehand., Results: All patients preferred a doctor with a professional patient-centred attitude regardless of the doctor's background. Patients mentioned mainly generic communication aspects, such as listening, as important skills and seemed to be aware of their own responsibility in participating in a consultation. Being treated as a unique person and not as a disease was also frequently mentioned. Unfamiliarity with the Dutch healthcare system influenced the experienced communication negatively. However, a language barrier was considered the most important problem, which would become less pressing once a doctor-patient relation was established., Conclusions: Remarkably, patients in this study had no preference regarding the ethnic background of the doctor. Generic communication was experienced as important as specific intercultural communication, which underlines the marginal distinction between these two. A close link between intercultural communication and patient-centred communication was reflected in the expressed preference 'to be treated as a person'.

Introduction: Intercultural communication (ICC) between doctors and patients is often associated with misunderstandings and dissatisfaction. To develop ICC-specific medical education, it is important to find out which ICC skills medical specialists currently apply in daily clinical consultations., Methods: Doctor-patient consultations of Dutch doctors with non-Dutch patients were videotaped in a multi-ethnic hospital in the Netherlands. The consultations were analyzed using the validated MAAS-Global assessment list in combination with factors influencing ICC, as described in the literature., Results: In total, 39 videotaped consultations were analyzed. The doctors proved to be capable of practising many communication skills, such as listening and empathic communication behaviour. Other skills were not practised, such as being culturally aware and checking the patient's language ability., Conclusion: We showed that doctors did practice some but not all the relevant ICC skills and that the ICC style of the doctors was mainly biomedically centred. Furthermore, we discussed the possible overlap between intercultural and patient-centred communication. Implications for practice could be to implement the relevant ICC skills in the existing communication training or develop a communication training with a patient-centred approach including ICC skills., Competing Interests: Conflict of interestE. Paternotte, F. Scheele, M.C. Seeleman, L. Bank, A.J.J.A. Scherpbier and S. van Dulmen declare that they have no competing interest, no financial competing interests and no non-financial competing interests.The study was performed according to Dutch privacy legislation. Approval of the Dutch medical-education ethics board was obtained for this observational study (NVMO-ERB 355). Beforehand, all participating doctors and patients were informed about the aim and the procedure of the study. All participants signed an informed consent form before the recording of the consultation was started.

Importance: Increasing health care expenditures are taxing the sustainability of the health care system. Physicians should be prepared to deliver high-value, cost-conscious care., Objective: To understand the circumstances in which the delivery of high-value, cost-conscious care is learned, with a goal of informing development of effective educational interventions., Data Sources: PubMed, EMBASE, ERIC, and Cochrane databases were searched from inception until September 5, 2015, to identify learners and cost-related topics., Study Selection: Studies were included on the basis of topic relevance, implementation of intervention, evaluation of intervention, educational components in intervention, and appropriate target group. There was no restriction on study design., Data Extraction and Synthesis: Data extraction was guided by a merged and modified version of a Best Evidence in Medical Education abstraction form and a Cochrane data coding sheet. Articles were analyzed using the realist review method, a narrative review technique that focuses on understanding the underlying mechanisms in interventions. Recurrent patterns were identified in the data through thematic analyses. Resulting themes were discussed within the research team until consensus was reached., Main Outcomes and Measures: Main outcomes were factors that promote education in delivering high-value, cost-conscious care., Findings: The initial search identified 2650 articles; 79 met the inclusion criteria, of which 14 were randomized clinical trials. The majority of the studies were conducted in North America (78.5%) using a pre-post interventional design (58.2%; at least 1619 participants); they focused on practicing physicians (36.7%; at least 3448 participants), resident physicians (6.3%; n = 516), and medical students (15.2%; n = 275). Among the 14 randomized clinical trials, 12 addressed knowledge transmission, 7 reflective practice, and 1 supportive environment; 10 (71%) concluded that the intervention was effective. The data analysis suggested that 3 factors aid successful learning: (1) effective transmission of knowledge, related, for example, to general health economics and prices of health services, to scientific evidence regarding guidelines and the benefits and harms of health care, and to patient preferences and personal values (67 articles); (2) facilitation of reflective practice, such as providing feedback or asking reflective questions regarding decisions related to laboratory ordering or prescribing to give trainees insight into their past and current behavior (56 articles); and (3) creation of a supportive environment in which the organization of the health care system, the presence of role models of delivering high-value, cost-conscious care, and a culture of high-value, cost-conscious care reinforce the desired training goals (27 articles)., Conclusions and Relevance: Research on educating physicians to deliver high-value, cost-conscious care suggests that learning by practicing physicians, resident physicians, and medical students is promoted by combining specific knowledge transmission, reflective practice, and a supportive environment. These factors should be considered when educational interventions are being developed.

Objective: To assess the rate of complications of surgical interventions delayed more than 24 h after delivery in women suspected of placental remnants., Methods: A retrospective review was performed to analyse complications of delayed surgical interventions. Women were identified from the operation database and their medical records were reviewed to determine the rate of immediate and long-term complications, including reproductive outcome., Result: A total of 127 women were evaluated. The median interval between delivery and surgery was 42 days. Immediate complications were registered in 22.0% and re-interventions in 16.5%. Placental remnants were histologically confirmed in 63.8%. Intrauterine adhesions (IUAs), only of the severe type, were recorded in 20.5%, although a minority of women was hysteroscopically revised. The difference between women treated by dilatation and curettage (D&C) and hysteroscopy was not statistically significant. Similar reproductive outcomes were encountered in women treated by D&C and hysteroscopy and in women with and without IUAs, although the samples were small., Conclusion: Identification of placental remnants remains difficult while delayed interventions are associated with significant immediate and long-term complications. The impact on reproductive performance remains unclear. Further research is necessary to examine treatment options in relation to complications and reproductive outcome.

Objective: Due to migration, doctors see patients from different ethnic backgrounds. This causes challenges for the communication. To develop training programs for doctors in intercultural communication (ICC), it is important to know which barriers and facilitators determine the quality of ICC. This study aimed to provide an overview of the literature and to explore how ICC works., Methods: A systematic search was performed to find literature published before October 2012. The search terms used were cultural, communication, healthcare worker. A realist synthesis allowed us to use an explanatory focus to understand the interplay of communication., Results: In total, 145 articles met the inclusion criteria. We found ICC challenges due to language, cultural and social differences, and doctors' assumptions. The mechanisms were described as factors influencing the process of ICC and divided into objectives, core skills and specific skills. The results were synthesized in a framework for the development of training., Conclusion: The quality of ICC is influenced by the context and by the mechanisms. These mechanisms translate into practical points for training, which seem to have similarities with patient-centered communication., Practice Implications: Training for improving ICC can be developed as an extension of the existing training for patient-centered communication., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Cultural diversity among patients presents specific challenges to physicians. Therefore, cultural diversity training is needed in medical education. In cases where strategic curriculum documents form the basis of medical training it is expected that the topic of cultural diversity is included in these documents, especially if these have been recently updated. The aim of this study was to assess the current formal status of cultural diversity training in the Netherlands, which is a multi-ethnic country with recently updated medical curriculum documents., Methods: In February and March 2013, a document analysis was performed of strategic curriculum documents for undergraduate and postgraduate medical education in the Netherlands. All text phrases that referred to cultural diversity were extracted from these documents. Subsequently, these phrases were sorted into objectives, training methods or evaluation tools to assess how they contributed to adequate curriculum design., Results: Of a total of 52 documents, 33 documents contained phrases with information about cultural diversity training. Cultural diversity aspects were more prominently described in the curriculum documents for undergraduate education than in those for postgraduate education. The most specific information about cultural diversity was found in the blueprint for undergraduate medical education. In the postgraduate curriculum documents, attention to cultural diversity differed among specialties and was mainly superficial., Conclusions: Cultural diversity is an underrepresented topic in the Dutch documents that form the basis for actual medical training, although the documents have been updated recently. Attention to the topic is thus unwarranted. This situation does not fit the demand of a multi-ethnic society for doctors with cultural diversity competences. Multi-ethnic countries should be critical on the content of the bases for their medical educational curricula.

The major challenge of vascular tissue engineering is to develop a small calibre vascular graft with a high patency rate. In native vessels, the thrombosis is prevented by the endothelium located at the luminal site of the vessel. The aim of this study was to develop a resistant endothelial lining on the inner surface of vascular graft using a polyelectrolyte multilayers (PEM) film. Umbilical arteries were de-endothelialized, coated with 3.5 bilayers of poly(styrene sulfonate) (PSS)/poly(allylamine hydrochloride) (PAH) and then cellularized with endothelial cells. The grafts were cultured for a week in static condition and preconditioned by exposure to a shear stress of at 1 Pa for three hours before implantation on the rabbit carotid site. Histological and confocal microscopy in vitro investigations showed that PEMs films improve cell adhesion and retention on the luminal surface after shear stress preconditioning. In vivo Doppler data showed that graft preconditioning is a crucial factor for graft patency. Indeed, preconditioned grafts remained over the whole experimental period, whereas unpreconditioned grafts were obstructed after only one week of implantation. These results open the route toward the development of a new generation of vascular substitutes having a long term patency.

A microstructured composite material made of collagen hydrogel (matrix) and silk fibroin microfibers (randomly oriented reinforcing fibers) is investigated in order to conjugate the mechanical resistance of fibroin with the suitable biological performance of collagen to design new scaffolds for vascular tissue engineering. Results show that fibroin microfibers and collagen fibrils have suitable interfacial adhesion, and the scaffold exhibits improved mechanical properties if compared with a pure collagen hydrogel. Furthermore, the overall biological performance is improved., (Copyright © 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

The lack of blood donations and the threat of infections from blood and blood products have led to extensive research into the development of blood substitutes. The latest generation of hemoglobin based oxygen carriers (HBOC) has been shown to induce side effects like hypertension, vasoconstriction, inflammation and oxidative stress. HBOC are able to restore volemia and transport oxygen after a hemorrhagic shock, the reperfusion leading to the restoration of the blood flow in vessels. We propose an innovative approach, more closely emulating clinical situations, to assess the impact of HBOC perfusion on endothelial cells (EC) in vitro. Through this approach we quantified levels of oxidative stress, vasoactive factors and inflammation. EC were cultivated under a laminar flow to reproduce the return of shear stress (SS) during the reperfusion. We showed that heme oxygenase I transcription correlated with changes in oxidatively modified heme and methemoglobin; all were lower under SS. SS induced increased nitric oxide production, which may have implications for the mechanism of in vivo vasoconstriction and hypertension. E-selectin changes under SS were greater than those of ICAM-1. Our results demonstrate how it is essential to include SS in assays attempting to understand the potential vascular side effects of HBOC perfusion.

Located in temperate, maritime climate with frequent rainfall, crop protection in Belgian orchards is dominated by fungicides. Though, the importance of arthropod pests should not be underestimated. Pcfruit, the former Research station of Gorsem, has been maintaining a warning system for fruit pests in Belgium since 1944. Therefore, various pests and beneficial's and their life cycle stages have been monitored in Gorsem and in different observation posts across Belgium, being part of a monitoring network. Although up to 3000 arthropod species are present in pome fruit orchards, about 25% can be considered as harmful and another 25% as beneficial. Out of those species, around 100 harmful and 50 beneficial organisms are omnipresent. The list of monitored species is extended yearly for upcoming or difficult to control organisms. Integrated pest management was introduced in the eighties, with the accent on using selective pesticides and saving beneficial organisms. A shift in pesticide use affected the importance of secondary pests, together with recent exceptional climatic conditions. Following many years of monitoring insects and mites and editing warning bulletins in our station, a ranking of the economical importance of different pest species is presented.