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Abstract Background Health advocacy is considered to be a core competence for physicians, but it remains unclear how the health advocacy role, despite being described in overarching competency frameworks, is operationalized in undergraduate medical education (UME). This study aimed to identify how health advocacy is conceptualized and taught in undergraduate medical curricula. Methods We performed a qualitative analysis of curriculum documents from all eight medical schools in the Netherlands, all of which offered competency-based UME. Thematic analysis was used to code all the documents and generate themes on health advocacy conceptualization and teaching. To categorize the emerging themes, we used the framework of Van Melle et al. for evaluating the implementation of competency-based medical educational programs. Results Health advocacy was mostly conceptualized in mission statements about social responsibility of future physicians, related to prevention and promoting health. We found key concepts of health advocacy to be taught mainly in public health and social medicine courses in the bachelor stage and in community-based clerkships in the master stage. Specific knowledge, skills and attitudes related to health advocacy were taught mostly in distinct longitudinal learning pathways in three curricula. Conclusion Health advocacy is conceptualized mostly as related to social responsibility for future physicians. Its teaching is mostly embedded in public health and social medicine courses and community-based settings. A wider implementation is warranted, extending its teaching to the full width of medical teaching, with longitudinal learning pathways providing a promising route for more integrative health advocacy teaching.

Abstract Background Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice remains limited. We previously showed that residents more often prefer paternalistic decision making than their supervisors. Because both the views of residents on the decision-making process in medical consultations and the reasons for their ‘paternalism preference’ are unknown, this study explored residents’ views on the decision-making process in medical encounters and the factors affecting it. Methods We interviewed 12 residents from various specialties at a large Dutch teaching hospital in 2019–2020, exploring how they involved patients in decisions. All participating residents provided written informed consent. Data analysis occurred concurrently with data collection in an iterative process informing adaptations to the interview topic guide when deemed necessary. Constant comparative analysis was used to develop themes. We ceased data collection when information sufficiency was achieved. Results Participants described how active engagement of patients in discussing options and decision making was influenced by contextual factors (patient characteristics, logistical factors such as available time, and supervisors’ recommendations) and by limitations in their medical and shared decision-making knowledge. The residents’ decision-making behavior appeared strongly affected by their conviction that they are responsible for arriving at the correct diagnosis and providing the best evidence-based treatment. They described shared decision making as the process of patients consenting with physician-recommended treatment or patients choosing their preferred option when no best evidence-based option was available. Conclusions Residents’ decision making appears to be affected by contextual factors, their medical knowledge, their knowledge about SDM, and by their beliefs and convictions about their professional responsibilities as a doctor, ensuring that patients receive the best possible evidence-based treatment. They confuse SDM with acquiring informed consent with the physician’s treatment recommendations and with letting patients decide which treatment they prefer in case no evidence based guideline recommendation is available. Teaching SDM to residents should not only include skills training, but also target residents’ perceptions and convictions regarding their role in the decision-making process in consultations.

Abstract Background Medical curricula are increasingly internationalized, with international students being mixed with domestic students in small group learning. Small group learning is known to foster competency learning in undergraduate medical education, specifically Communication, Collaboration, Leadership, and Professionalism. However, it is unclear what happens with the learning of competencies when international students are introduced in small groups. This study explores if students in international small groups master the competencies Collaboration, Leadership and Professionalism at the same level as students in domestic groups in an undergraduate medical curriculum. Method In total, 1215 Students of three academic year cohorts participated in the study. They were divided into four learning communities (LCs), per year cohort, in which tutor groups were the main instructional format. The tutorials of two learning communities were taught in English, with a mix of international and Dutch students. The tutorials of the other two learning communities were taught in Dutch with almost all domestic students. Trained tutors assessed three competencies (Collaboration, Leadership, Professionalism) twice per semester, as ‘Not-on-track’, ‘On-track’, or ‘Fast-on-track’. By using Chi-square tests, we compared students’ competencies performance twice per semester between the four LCs in the first two undergraduate years. Results The passing rate (‘On-track’ plus ‘Fast-on-track’) for the minimum level of competencies did not differ between the mixed and domestic groups. However, students in the mixed groups received more excellent performance evaluations (‘Fast-on-track’) than the students in the homogenous groups of Dutch students. This higher performance was true for both international and Dutch students of the mixed groups. Prior knowledge, age, gender, and nationality did not explain this phenomenon. The effect could also not be explained by a bias of the tutors. Conclusion When students are educated in mixed groups of international and Dutch students, they can obtain the same basic competency levels, no matter what mix of students is made. However, students in the mixed international groups outperformed the students in the homogenous Dutch groups in achieving excellent performance scores. Future research should explore if these findings can be explained from differences in motivation, perceived grading or social network interactions.

Abstract Background To describe the supply, distribution, and characteristics of international medical graduates (IMGs) in family medicine who provide patient care in the U.S. Methods A cross-sectional study design, using descriptive statistics on combined data from the Educational Commission for Foreign Medical Graduates and the American Medical Association, including medical school attended, country of medical school, and citizenship when entering medical school. Results In total, 118,817 physicians in family medicine were identified, with IMGs representing 23.8% (n = 28,227) of the U.S. patient care workforce. Of all 9579 residents in family medicine, 36.0% (n = 3452) are IMGS. In total, 35.9% of IMGs attended medical school in the Caribbean (n = 10,136); 19.9% in South-Central Asia (n = 5607) and 9.1% in South-Eastern Asia (n = 2565). The most common countries of medical school training were Dominica, Mexico, and Sint Maarten. Of all IMGs in family medicine who attended medical school in the Caribbean, 74.5% were U.S. citizens. In total, 40.5% of all IMGs in family medicine held U.S. citizenship at entry to medical school. IMGs comprise almost 40% of the family medicine workforce in Florida, New Jersey and New York. Conclusions IMGs play an important role in the U.S. family medicine workforce. Many IMGs are U.S. citizens who studied abroad and then returned to the U.S. for graduate training. Given the shortage of family physicians, and the large number of IMGs in graduate training programs, IMGs will continue to play a role in the U.S. physician workforce for some time to come. Many factors, including the supply of residency training positions, could eventually restrict the number of IMGs entering the U.S., including those contributing to family practice.

Background Novel virus outbreaks, such as the COVID-19 pandemic, may increase psychological distress among frontline workers. Psychological distress may lead to reduced performance, reduced employability or even burnout. In the present study, we assessed experienced psychological distress during the COVID-19 pandemic from a self-determination theory perspective. Methods This mixed-methods study, with repeated measures, used surveys (quantitative data) combined with audio diaries (qualitative data) to assess work-related COVID-19 experiences, psychological need satisfaction and frustration, and psychological distress over time. Forty-six participants (nurses, junior doctors, and consultants) completed 259 surveys and shared 60 audio diaries. Surveys and audio diaries were analysed separately. Results Quantitative results indicated that perceived psychological distress during COVID-19 was higher than pre-COVID-19 and fluctuated over time. Need frustration, specifically autonomy and competence, was positively associated with psychological distress, while need satisfaction, especially relatedness, was negatively associated with psychological distress. In the qualitative, thematic analysis, we observed that especially organisational logistics (rostering, work-life balance, and internal communication) frustrated autonomy, and unfamiliarity with COVID-19 frustrated competence. Despite many need frustrating experiences, a strong connection with colleagues and patients were important sources of relatedness support (i.e. need satisfaction) that seemed to mitigate psychological distress. Conclusion The COVID-19 pandemic resulted in an increase of psychological distress among frontline workers. Both need frustration and need satisfaction explained unique variance of psychological distress, but seemed to originate from different sources. Challenging times require healthcare organisations to better support their professionals by tailored formal and informal support. We propose to address both indirect (e.g. organisation) and direct (e.g. colleagues) elements of the clinical and social environment in order to reduce need frustration and enhance need satisfaction.

Abstract Background Migration of health professionals has been a cause for global concern, in particular migration from African countries with a high disease burden and already fragile health systems. An estimated one fifth of African-born physicians are working in high-income countries. Lack of good data makes it difficult to determine what constitutes “African” physicians, as most studies do not distinguish between their country of citizenship and country of training. Thus, the real extent of migration from African countries to the United States (US) remains unclear. This paper quantifies where African migrant physicians come from, where they were educated, and how these trends have changed over time. Methods We combined data from the Educational Commission for Foreign Medical Graduates with the 2005 and 2015 American Medical Association Physician Masterfiles. Using a repeated cross-sectional study design, we reviewed the available data, including medical school attended, country of medical school, and citizenship when entering medical school. Results The outflow of African-educated physicians to the US has increased over the past 10 years, from 10 684 in 2005 to 13 584 in 2015 (27.1% increase). This represents 5.9% of all international medical graduates in the US workforce in 2015. The number of African-educated physicians who graduated from medical schools in sub-Saharan countries was 2014 in 2005 and 8150 in 2015 (304.6% increase). We found four distinct categorizations of African-trained physicians migrating to the US: (1) citizens from an African country who attended medical school in their own country (86.2%, n = 11,697); (2) citizens from an African country who attended medical school in another African country (2.3%, n = 317); (3) US citizens who attended medical school in an African country (4.0%, n = 537); (4) citizens from a country outside Africa, and other than the United States, who attended medical school in an African country (7.5%, n = 1013). Overall, six schools in Africa provided half of all African-educated physicians. Conclusions The number of African-educated physicians in the US has increased over the past 10 years. We have distinguished four migration patterns, based on citizenship and country of medical school. The majority of African graduates come to the US from relatively few countries, and from a limited number of medical schools. A proportion are not citizens of the country where they attended medical school, highlighting the internationalization of medical education.

Objectives To study the frequency of observed cases of disciplinary law complaints concerning transgressive behaviour in Dutch healthcare by analysing disciplinary cases handled in Dutch disciplinary law.Design Retrospective review of complaints in the Dutch disciplinary law tribunals from the period 1 January 2015 to 1 January 2020.Setting Dutch healthcare.Method Descriptive retrospective study. All judgements at regional disciplinary tribunals in the first instance from the period 1 January 2015 to 1 January 2020 concerning transgressive behaviour were investigated. The following was studied: year of judgement, number and nature of complaints, type of complainants, profession of defendant.Results Over the study period, 139 complaints about transgressive behaviour were handled, 90 of which involved sexual behaviour. 66/139 complaints were submitted by patients themselves (47.5%). Most complaints were directed against physicians (44.6%; n=62), followed by nurses (30.2%; n=42), psychologists (11.5%; n=16) and physiotherapists (7.9%; n=11). 80.6% of the complaints were directed against a male healthcare professional (OR 4.25; 95% CI 1.7590 to 10.2685; p=0.0013). 104/139 of the complaints originated from an outpatient work setting and about half of the complaints originated from mental healthcare. Of the 90 disciplinary cases in which the complaint was related to sexually transgressive behaviour, 83.3% (n=75) were ruled to be substantiated (5 of which partially) with a measure imposed in all cases: 6 formal warnings (8%), 11 reprimands (14.7%), 10 denials (partial suspension) (13.3%), 26 temporary suspensions (34.7%) and 22 cancellations of the licence to practice (29.3%).Conclusion This study describes jurisprudence of disciplinary cases about transgressive behaviour of healthcare professionals in the Netherlands. The results of this study can be used to monitor trends in observed cases of transgressive behaviour.

BACKGROUND:Migration of physicians has been a cause for global concern. In China, reforms of the higher education and healthcare systems have led to a shortage of postgraduate training positions relative to the number of medical graduates. Medical graduates opt for non-clinical roles or move abroad to pursue further training and practice opportunities. The impact of this physician migration is not known. This study quantifies where Chinese migrant physicians to the U.S. were educated, where they went to practice, and how these trends have changed over time. METHODS:We combined data on physician characteristics from the 2008 and 2017 American Medical Association Physician Masterfiles with demographic information from the Educational Commission for Foreign Medical Graduates. Using a repeated cross-sectional approach, we reviewed the available data, including citizenship at entry to medical school, medical school attended, practice specialty, and practice location. RESULTS:The number of Chinese-educated physicians (CEPs) to the United States (US) has increased over the past 10 years, from 3,878 in 2008 to 5,355 in 2017 (+38.1%). The majority held Chinese citizenship at entry to medical school (98.4% vs 97.1%) with the remainder being citizens of other East Asian nations. Of the Chinese citizens identified in 2008, 913 (19.3%) attended medical school outside of China; in 2017, 376 (6.7%) attended medical school outside of China, representing a decrease of 58.8%. Overall, in 2017, four Chinese medical schools provided 32.1% of all Chinese-educated physicians in the US. Over 50% of the CEPs were practicing in Internal Medicine, Anatomic/ Clinical Pathology, Anesthesiology, Family Medicine or Neurology. Compared with all IMGs, CEPs are more likely to be Anatomic/ Clinical Pathologists and Anesthesiologists. CEPs were concentrated in several states, including New York, California and Massachusetts. In 2017, a lower proportion of CEPs in the US healthcare workforce were in residency training, compared to 2008 (13.2% vs 22.8%). CONCLUSIONS:Unlike trends from some other South Asian countries, the number of CEPs in the US has increased over the past 10 years. Migration trends may vary depending on citizenship and country of medical school training. The majority of Chinese-educated graduates come to the US from relatively few medical schools. Fewer CEPs currently in residency training might indicate lower success rates in securing GME training in the US.