What are the characteristics of excellent physicians and residents in the clinical workplace? A systematic review.

OBJECTIVES: In order to recognise and facilitate the development of excellent medical doctors (physicians and residents), it is important to first identify the characteristics of excellence. Failure to recognising excellence causes loss of talent, loss of role models and it lowers work ethos. This causes less than excellent patient care and lack of commitment to improve the healthcare system. DESIGN: Systematic review performed according to the Association for Medical Education in Europe guideline. INFORMATION SOURCES: We searched Medline, Embase, Psycinfo, ERIC and CINAHL until 14 March 2022. ELIGIBILITY CRITERIA: We included original studies describing characteristics of excellent medical doctors, using a broad approach as to what is considered excellence. Assuming that excellence will be viewed differently depending on the interplay, and that different perspectives (peers, supervisors and patients) will add to a complete picture of the excellent medical doctor, we did not limit this review to a specific perspective. DATA EXTRACTION AND SYNTHESIS: Data extraction and quality assessment were performed independently by two researchers. We used the Quality Assessment Tool for Different Designs for quality assessment. RESULTS: Eleven articles were eligible and described the characteristics from different perspectives: (1) physicians on physicians, (2) physicians on residents, (3) patients on physicians and (4) mixed group (diverse sample of participants on physicians). The included studies showed a wide range of characteristics, which could be grouped into competencies (communication, professionalism and knowledge), motivation (directed to learning and to patient care) and personality (flexibility, empathy). CONCLUSIONS: In order to define excellence of medical doctors three clusters seem important: competence, motivation and personality. This is in line with Renzulli’s model of gifted behaviour. Our work adds to this model by specifying the content of these clusters, and as such provides a basis for definition and recognition of medical excellence

Somatically ill persons’ self-nominated quality of life domains: review of the literature and guidelines for future studies

OBJECTIVE: To review which domains somatically ill persons nominate as constituting their QoL. Specific objective is to examine whether the method of enquiry affect these domains. METHODS: We conducted two literature searches in the databases PubMed/Medline, CINAHL and Psychinfo for qualitative studies examining patients' self-defined QoL domains using (1) SEIQoL and (2) study-specific questions. For each database, two researchers independently assessed the eligibility of the retrieved abstracts and three researchers subsequently classified all QoL domains. RESULTS: Thirty-six eligible papers were identified: 27 studies using the SEIQoL, and nine presenting data derived from study-specific questions. The influence of the method of enquiry on patients' self-nominated QoL domains appears limited: most domains were presented in both types of studies, albeit with different frequencies. CONCLUSIONS: This review provides a comprehensive overview of somatically ill persons' self-nominated QoL domains. However, limitations inherent to reviewing qualitative studies (e.g., the varying level of abstraction of patients' self-defined QoL domains), limitations of the included studies and limitations inherent to the review process, hinder cross-study comparisons. Therefore, we provide guidelines to address shortcomings of qualitative reports amenable to improvement and to stimulate further improvement of conducting and reporting qualitative research aimed at exploring respondents' self-nominated QoL domains

SUGAR-DIP trial: Oral medication strategy versus insulin for diabetes in pregnancy, study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial

Introduction In women with gestational diabetes mellitus (GDM) requiring pharmacotherapy, insulin was the established first-line treatment. More recently, oral glucose lowering drugs (OGLDs) have gained popularity as a patient-friendly, less expensive and safe alternative. Monotherapy with metformin or glibenclamide (glyburide) is incorporated in several international guidelines. In women who do not reach sufficient glucose control with OGLD monotherapy, usually insulin is added, either with or without continuation of OGLDs. No reliable data from clinical trials, however, are available on the effectiveness of a treatment strategy using all three agents, metformin, glibenclamide and insulin, in a stepwise approach, compared with insulin-only therapy for improving pregnancy outcomes. In this trial, we aim to assess the clinical effectiveness, cost-effectiveness and patient experience of a stepwise combined OGLD treatment protocol, compared with conventional insulin-based therapy for GDM. Methods The SUGAR-DIP trial is an open-label, multicentre randomised controlled non-inferiority trial. Participants are women with GDM who do not reach target glycaemic control with modification of diet, between 16 and 34 weeks of gestation. Participants will be randomised to either treatment with OGLDs, starting with metformin and supplemented as needed with glibenclamide, or randomised to treatment with insulin. In women who do not reach target glycaemic control with combined metformin and glibenclamide, glibenclamide will be substituted with insulin, while continuing metformin. The primary outcome will be the incidence of large-for-gestational-age infants (birth weight >90th percentile). Secondary outcome measures are maternal diabetes-related endpoints, obstetric complications, neonatal complications and cost-effectiveness analysis. Outcomes will be analysed according to the intention-to-treat principle. Ethics and dissemination The study protocol was approved by the Ethics Committee of the Utrecht University Medical Centre. Approval by the boards of management for all participating hospitals will be obtained. Trial results will be submitted for publication in peer-reviewed journals

Exploring differences in patient mix in a cohort of GP trainees and their trainers

Background During specialty training for general practice, trainees acquire the required competencies through work-based learning. Previous small-scale and older studies suggest that the patient mix of general practitioner (GP) trainees differs from that of their trainers: trainees are exposed to more minor illnesses, and fewer chronic diseases and severe conditions, which may influence the development of their competency. Research question What are the differences in the patient mix between trainees and trainers? Methods 49 first- and 24 third-year trainees and their trainers (n=114) were included in the study. International Classification of Primary Care (ICPC) contact and diagnosis codes were extracted from electronic patient records over 6 months. Results Trainers had double the number of face-to-face consultations, and treble the number of telephone consultations compared with trainees. The trainees' patient mix consisted of significantly more patients with eye diseases, ear diseases, respiratory diseases, skin diseases and minor illnesses compared with their trainers. Trainers encountered significantly more patients with circulatory diseases, psychiatric diseases, metabolic diseases, male genital conditions, social problems, and chronic and oncological diseases. Female trainers and trainees encountered almost twice the number of female conditions compared with their male counterparts, while for male conditions, the opposite was found. Discussion Considerable differences between the patient mix of trainers and trainees were found. Specialty trainers and teachers must be aware of areas of low exposure. Trainers should ensure trainees handle more chronic, complex, psychosocial and circulatory condition

Assessment of motivational interviewing: a qualitative study of response process validity, content validity and feasibility of the motivational interviewing target scheme (MITS) in general practice

Abstract Background The Motivational Interviewing target Scheme (MITS) is an instrument to assess competency in Motivational Interviewing (MI) and can be used to assess MI in long and brief consultations. In this qualitative study we examined two sources of the Unified Model of Validity, the current standard of assessment validation, in the context of General Practice. We collected evidence concerning response process validity and content validity of the MITS in general practice. Furthermore, we investigated its feasibility. Methods Assessing consultations of General Practitioners and GP-trainees (GPs), the assessors systematically noted down their considerations concerning the scoring process and the content of the MITS in a semi-structured questionnaire. Sampling of the GPs was based on maximum variation and data saturation was used as a stopping criterion. An inductive approach was used to analyse the data. In response to scoring problems the score options were adjusted and all consultations were assessed using the original and the adjusted score options. Results Twenty seven assessments were needed to reach data saturation. In most consultations, the health behaviour was not the reason for encounter but was discussed on top of discussing physical problems. The topic that was most discussed in the consultations was smoking cigarettes. The adjusted score options increased the response process validity; they were more in agreement with theoretical constructs and the observed quality of MI in the consultations. Concerning content validity, we found that the MITS represents the broad spectrum and the current understanding of MI. Furthermore, the MITS proved to be feasible to assess MI in brief consultations in general practice. Conclusions Based on the collected evidence the MITS seems a promising instrument to measure MI interviewing in brief consultations. The evidence gathered in this study lays the foundation for research into other aspects of validation

An application of structural equation modeling to detect response shifts and true change in quality of life data from cancer patients undergoing invasive surgery

The objective is to show how structural equation modeling can be used to detect reconceptualization, reprioritization, and recalibration response shifts in quality of life data from cancer patients undergoing invasive surgery. A consecutive series of 170 newly diagnosed cancer patients, heterogeneous to cancer site, were included. Patients were administered the SF-36 and a short version of the multidimensional fatigue inventory prior to surgery, and 3 months following surgery. Indications of response shift effects were found for five SF-36 scales: reconceptualization of 'general health', reprioritization of 'social functioning', and recalibration of 'role-physical', 'bodily pain', and 'vitality'. Accounting for these response shifts, we found deteriorated physical health, deteriorated general fitness, and improved mental health. The sizes of the response shift effects on observed change were only small. Yet, accounting for the recalibration response shifts did change the estimate of true change in physical health from medium to large. The structural equation modeling approach was found to be useful in detecting response shift effects. The extent to which the procedure is guided by subjective decisions is discusse

Formal definitions of measurement bias and explanation bias clarify measurement and conceptual perspectives on response shift

Objective: Response shift is generally associated with a change in the meaning of test scores, impeding the comparison of repeated measurements. Still, different researchers have different views of response shift. From a measurement perspective, response shift can be considered as bias in the measurement of change, whereas from a more conceptual perspective, it can be considered as bias in the explanation of change. We propose definitions to accommodate both interpretations of response shift. Study Design and Setting: Formal definitions of measurement bias and explanation bias serve to define response shift in measurement and conceptual perspectives. Examples from the field of health-related quality of life research illustrate the definitions. Results: Definitions of response shifts as special cases of either measurement bias or explanation bias clarify different interpretations of response shift and lead to different research methods. Different structural equation models are suggested to investigate biases and response shifts in each of the two perspectives. Conclusion: It is important to distinguish between measurement and conceptual perspectives as they involve different ideas about response shift. Definitions from both perspectives help to resolve conceptual and methodological confusion around response shift and to further its research. (C) 2009 Elsevier Inc. All rights reserve

Which barriers affect morbidity registration performance of GP trainees and trainers?

Diagnosis coding percentages in the specialty training of general practitioners (GPs) are generally high, but not perfect, indicating barriers against coding still exist, possibly influencing the validity of data based on electronic patient records (EPRs). To study the relationship between barriers to coding diagnoses with the International Classification of Primary Care (ICPC) of GP trainees and trainers and their self-reported and actual coding performance. A questionnaire was developed, and returned by 71 (of 73, 97%) GP trainees and 103 (of 108, 95%) GP trainers, affiliated to the GP Specialty Training of the Academic Medical Center, University of Amsterdam. Their barriers to ICPC coding and self-reported coding performance were compared with EPR-derived data extractions that were collected during one year. Mean coding percentages were 88.3 (SD=11.5) and 82.3% (SD=19.0) (trainees/trainers). Most participants reported always registering ICPC codes for consultations and home visits, specifically in those situations pre-specified in the questionnaire. Telephone consultations, repeat prescriptions and administrative actions were coded less frequently. Most participants never or rarely experienced coding barriers, an exception being 'insufficient refinement of the ICPC system'. Most motivation and ICPC-related barriers correlated with self-reported and actual coding performance. Regression analyses showed that 'ICPC coding is unpleasant to use' predicted both trainees' and trainers' coding percentages. The trainers' coding percentage was also predicted by 'no personal gain from ICPC' and 'coding is difficult'. The mean coding percentages we found were high, but could further be improved by increasing GPs' motivation and by making ICPC coding more user-friendly. EPR-derived data seem biased by non-coded telephone consultations onl

Who determines the patient mix of GP trainees? The role of the receptionist

During their specialty training, Dutch GP trainees work at a GP under the supervision of a GP trainer. Research suggests that the patient mix of GP trainees differs from that of their trainers. Receptionists assign patients to either the trainee or the trainer, thereby influencing the patient mix of the trainees. The decision to which doctor to assign is complex and depends on the latitude the receptionists have. Their considerations when assigning patients are unknown. To study receptionists' assigning behaviour. This was a questionnaire survey. To design the questionnaire, topics about assigning behaviour were identified in a focus group. The resulting questionnaire was sent to 478 GP training practices in the Netherlands. Response rate was 68%. Of the receptionists, 95% asked for the reason for the consultation at least 'sometimes'. Most (86.3%) of the receptionists considered the patient mix of trainees and trainers to be similar. Almost all receptionists (97%) reported 'often' or 'always' assigning 'every possible problem' to the trainee and a similar picture arose regarding specific subpopulations. However, the receptionists reported that they assigned complex and new patients to the trainers more often than to trainees. With some exceptions, receptionists try to assign trainees a varied patient mi