How learning style affects evidence-based medicine:a survey study

BACKGROUND: Learning styles determine how people manage new information. Evidence-based medicine (EBM) involves the management of information in clinical practice. As a consequence, the way in which a person uses EBM can be related to his or her learning style. In order to tailor EBM education to the individual learner, this study aims to determine whether there is a relationship between an individual's learning style and EBM competence (knowledge/skills, attitude, behaviour). METHODS: In 2008, we conducted a survey among 140 novice GP trainees in order to assess their EBM competence and learning styles (Accommodator, Diverger, Assimilator, Converger, or mixed learning style). RESULTS: The trainees' EBM knowledge/skills (scale 0-15; mean 6.8; 95%CI 6.4-7.2) were adequate and their attitudes towards EBM (scale 0-100; mean 63; 95%CI 61.3-64.3) were positive. We found no relationship between their knowledge/skills or attitudes and their learning styles (p = 0.21; p = 0.19). Of the trainees, 40% used guidelines to answer clinical questions and 55% agreed that the use of guidelines is the most appropriate way of applying EBM in general practice. Trainees preferred using evidence from summaries to using evidence from single studies. There were no differences in medical decision-making or in EBM use (p = 0.59) for the various learning styles. However, we did find a link between having an Accommodating or Converging learning style and making greater use of intuition. Moreover, trainees with different learning styles expressed different ideas about the optimal use of EBM in primary care. CONCLUSIONS: We found that EBM knowledge/skills and EBM attitudes did not differ with respect to the learning styles of GP trainees. However, we did find differences relating to the use of intuition and the trainees' ideas regarding the use of evidence in decision-making

Abnormal vaginal bleeding in women of reproductive age: a descriptive study of initial management in general practice

<p>Abstract</p> <p>Background</p> <p>Abnormal vaginal bleeding (AVB) in women of reproductive age is a common reason for consulting a general practitioner. Nevertheless, how general practitioners (GPs) choose to initially manage AVB is largely unknown, as is the prevalence of underlying pathology of AVB in primary care.</p> <p>Methods</p> <p>To investigate the initial diagnostic procedures and treatment for AVB used in general practice, we performed a descriptive study based on computerised medical records. New consultations for AVB in 2000 and 2001 were selected. Patient characteristics, diagnostic procedures and treatment were analysed.</p> <p>Results</p> <p>In total, 270 new consultations were included. The majority of patients (75%) consulted the GP for AVB only once. GPs performed diagnostic procedures in 54% of all consultations. Overall, additional diagnostic procedures revealed abnormalities in 11% of women. However, the diagnostic procedures implemented by the GPs varied widely per bleeding type and contraceptive use. Anaemia was found in 36% of 45 women tested. Uterine fibroids were found in 41% of 27 women examined by ultrasound. Medication was prescribed in 34% of all consultations. A gynaecological referral was registered in 4% of all contacts.</p> <p>Conclusion</p> <p>Initially, GPs tend to follow a policy of expectant management in women of reproductive age with AVB. However, when additional diagnostic procedures were performed, anaemia and uterine fibroids were found in a considerable number of women.</p

Wordt de patiënt er beter van? : Over huisartsopleiding, kwaliteit, evidence-based medicine en nog het een en ander

De patiënt van nu mag ervan uitgaan dat de huisarts een gedegen, academische opleiding achter de rug heeft. Een opleiding die zich voortdurend aanpast aan en vooruitloopt op de veranderingen in het beroep, zoals het werken in grotere samenwerkingsverbanden, en in de maatschappij (bijvoorbeeld de vergrijzing). Alle facetten van de huisartsopleiding nemen hiertoe deel aan een continu kwaliteitsproces. Niet alleen moet de kwaliteit van het opleidingsinstituut als organisatie optimaal zijn, maar ook dat van de opleidingspraktijken en de stage-instellingen, van de daar werkzame opleiders, de docenten van het opleidingsinstituut en van het cursorisch onderwijs. Dit alles gericht op het 'product': een competente huisarts. Een proces dat nooit 'af' is en dat wordt ondersteund door wetenschappelijk onderzoek om waar mogelijk en nodig evidence based de opleiding te verbeteren. Margrethe Wieringa-de Waard zoekt naar aanleiding hiervan in haar oratie antwoorden op de vragen: wat merkt de patiënt hiervan, hoe evidence based is de opleiding zelf, en voldoet het aloude model van opleiding nog wel of is het tijd voor een nieuwe aanpak

What Are the Barriers to Residents' Practicing Evidence-Based Medicine? A Systematic Review.

Purpose Insufficient time and lack of skills are important barriers to the practice of evidence-based medicine (EBM). Residents could have additional barriers because their practice can be strongly influenced by the educational system and clinical supervisors. The purpose of this study, therefore, was to systematically appraise and summarize the literature on the barriers that residents experience in the application of EBM in daily practice. Method The authors searched MEDLINE, EMBASE, the Cochrane Library, CINAHL, and ERIC for publications preceding January 2008. Additionally, they manually screened the abstracts of relevant conferences (Association for Medical Education in Europe, Society of General Internal Medicine, Society of Medical Decision Making, Ottawa, and Evidence-Based Health Care Teachers & Developers) from January 2001 until January 2008. The search was extended by contacting experts in the field. Original studies on barriers to applying EBM in daily practice were included. Methodological quality was assessed and results were extracted by two reviewers using prespecified forms. Results The search resulted in 511 titles, 84 abstracts, and 3 studies suggested by experts, of which 9 were included in this review. The quality of the included studies was high. The most frequently mentioned barriers for residents were limited available time (28%-85%), attitude, and knowledge and skills. In four studies, specific barriers related to the position of residents, such as influences from staff members, lack of experience in EBM, and low possibilities to change conditions, were described. Conclusions Residents experience specific barriers to practice EBM. These barriers should be recognized and integrated into EBM training programs for resident

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

Observations of evidence-based medicine in general practice

No objective measures are available for assessing the practice of evidence-based medicine (EBM) in general practitioner (GP) trainees, as there is no description of the EBM behaviour that is expected from trainees. As a first step to do so, we aimed to identify which expressions of EBM (defined as the integration of evidence, clinical experience and patient situation) can be observed in daily GP practice. Secondly, we aimed to identify which considerations GPs had regarding EBM but did not share with the patient during consultations. We performed a qualitative study, in which GPs were observed during and interviewed after clinical consultations, with a focus on expressions and considerations related to EBM during clinical decision-making. We observed 147 consultations by 34 GPs (17 trainers and 17 trainees). EBM behaviour was rarely visible in GPs' decision-making. When interviewing the GPs, we found that aspects of EBM that played a role in decision-making were not discussed with the patient. Explicit consideration of all aspects of EBM would make EBM measurable and GPs more aware of the foundations of their decisions. EBM behaviour is difficult to observe during GP consultations and therefore cannot be assessed through observations alon

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

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

Management of miscarriage:A randomized controlled trial of expectant management versus surgical evacuation

Background: In many countries, surgical uterine evacuation is the standard treatment for women with a miscarriage, but expectant management has been advocated as an alternative. The choice between the two options cannot be based on published evidence alone, because randomized clinical trials are scarce while generalizability of findings to patients with a strong preference for either management options in unclear. Methods: In a randomized controlled trial, the complications and efficacy of either expectant or surgical management for miscarriages were compared, and the results in patients who refused randomization and were managed according to their own preference were studied. In total, 122 patients were randomized and 305 were managed according to their choice. Results: No differences were found in the number of emergency curettages and complications between expectant and surgical management. Efficacy at 6 weeks was 30/64 (47%) in women allocated to expectant management, and 55/58 (95%) in women allocated to surgical evacuation. After 7 days, 37% of expectantly managed women had a spontaneous complete miscarriage. After 6 weeks, intention-to-treat analysis including cross-overs showed similar effectiveness (92% versus 100%). Results in the preference groups were comparable with those in the randomized groups. Conclusion: In our experience a waiting period of 7 days after diagnosis may prevent 37% of surgical procedures.</p

Opening the black box: the patient mix of GP trainees

The variety of health problems (patient mix) that medical trainees encounter is presumed to be sufficient to master the required competencies. To describe the patient mix of GP trainees, to study differences in patient mix between first-year and third-year GP trainees, and to investigate differences in exposure to sex-specific diseases between male and female trainees. Prospective cohort study in Dutch primary care. During a 6-month period, aggregated data about International Classification of Primary Care diagnosis codes, and data on the sex and age of all contacts were collected from the electronic patient record (EPR) system. Seventy-three trainees participated in this study. The mean coding percentage was 86% and the mean number of face-to-face consultations per trimester was 450.0 in the first year and 485.4 in the third year, indicating greater variance in the number of patient contacts among third-year trainees. Diseases seen most frequently were: musculoskeletal (mean per trimester = 89.2 in the first year/91.0 in the third year), respiratory (98.2/92.7) and skin diseases (89.5/96.0). Least often seen were diseases of the blood and blood-forming organs (5.3/7.2), male genital disorders (6.1/7.1), and social problems (4.3/4.2). The mean number of chronic diseases seen per trimester was 48.0 for first-year trainees and 62.4 for third-year trainees. Female trainees saw an average of 39.8 female conditions per trimester--twice as many as male trainees (mean = 21.3). Considerable variation exists trainees in the number of patient contacts. Differences in patient mix between first- and third-year trainees seem at least partly related to year-specific learning objectives. The use of an EPR-derived educational instrument provides insight into the trainees' patient mix at both the group and the individual level. This offers opportunities for GP trainers, trainees, and curriculum designers to optimise learning when exposure may be lo