Margreet Wieringa-de Waard

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 residents.

Barriers to GPs' use of evidence-based medicine: a systematic review

BACKGROUND GPs report various barriers to the use and practice of evidence-based medicine (EBM). A review of research on these barriers may help solve problems regarding the uptake of evidence in clinical outpatient practice. AIM To determine the barriers encountered by GPs in the practice of EBM and to come up with solutions to the barriers identified. DESIGN A systematic review of the literature. METHOD The following databases were searched: MEDLINE (PubMed), Embase, CINAHL, ERIC, and the Cochrane Library, until February 2011. Primary studies (all methods, all languages) that explore the barriers that GPs encounter in the practice of EBM were included. RESULTS A total of 14 700 articles were identified, of which 22 fulfilled all inclusion criteria. Of the latter, nine concerned qualitative, 12 concerned quantitative, and one concerned both qualitative and quantitative research methods. The barriers described in the articles cover the categories: evidence (including the accompanying EBM steps), the GPs preferences (experience, expertise, education), and the patients preferences. The particular GP setting also has important barriers to the use of EBM. Barriers found in this review, among others, include lack of time, EBM skills, and available evidence; patient-related factors; and the attitude of the GP. CONCLUSION Various barriers are encountered when using EBM in GP practice. Interventions that help GPs to overcome these barriers are needed, both within EBM education and in clinical practice.

The attributes of the clinical trainer as a role model: a systematic review.

Purpose Medical trainees (interns and residents) and their clinical trainers need to be aware of the differences between positive and negative role modeling to ensure that trainees imitate and that trainers demonstrate the professional behavior required to provide high-quality patient care. The authors systematically reviewed the medical and medical education literature to identify the attributes characterizing clinical trainers as positive and negative role models for trainees. Method The authors searched the MEDLINE, EMBASE, ERIC, and PsycINFO databases from their earliest dates until May 2011. They included quantitative and qualitative original studies, published in any language, on role modeling by clinical trainers for trainees in graduate medical education. They assessed the methodological quality of and extracted data from the included studies, using predefined forms. Results Seventeen articles met inclusion criteria. The authors divided attributes of role models into three categories: patient care qualities, teaching qualities, and personal qualities. Positive role models were frequently described as excellent clinicians who were invested in the doctor–patient relationship. They inspired and taught trainees while carrying out other tasks, were patient, and had integrity. These findings confirm the implicit nature of role modeling. Positive role models’ appearance and scientific achievements were among their least important attributes. Negative role models were described as uncaring toward patients, unsupportive of trainees, cynical, and impatient. Conclusions The identified attributes may help trainees recognize which aspects of the clinical trainer’s professional behavior to imitate, by adding the important step of apperception to the process of learning professional competencies through observation.

Management of spontaneous miscarriage in the first trimester: an example of putting informed shared decision making into practice

Editorial by Cahill In many parts of the Western world there is a strong preference among gynaecologists to rely on surgical evacuation for the management of miscarriages in the first trimester. Why so many specialists have adopted surgery as the standard procedure seems determined by custom and habit and rooted in history rather than being an evidence based choice. During the first half of the 20th century the high rate of infections from retained products of conception with ensuing mortality from septicaemia—often complications from criminal attempts to terminate a pregnancy—resulted in the policy of immediate surgical evacuation whenever a diagnosis of inevitable abortion was made.1 Today these complications are rare, and their role in the justification of a universal tendency to perform surgery has therefore expired.2 Expectant management finds its main protagonists in general practice, where the process of spontaneous miscarriage is acknowledged more readily as being a well regulated natural process in human reproduction. Relatively new is the medical approach to spontaneous miscarriages.3 The combination of the antiprogestogen mifepristone and the prostaglandin analogue misoprostol is being used successfully for the termination of pregnancies on a large scale. The use of these substances has also been tried in the management of spontaneous miscarriage. Doctors and patients are confronted with a situation where opinions about the proper management of spontaneous miscarriage differ widely. That the available options are so diverse makes it even more complex. This paper aims to increase the awareness of various management options and explores the available evidence. #### Summary points Surgical evacuation is unnecessary after a complete miscarriage with retained products of conception and should be indicated by clinical rather than ultrasonographical criteria Expectant management is used in general practice on a large scale and is more feasible than surgical evacuation Medical management has no apparent benefits …

A systematic review of the relationship between patient mix and learning in work-based clinical settings. A BEME systematic review: BEME Guide No. 24

Background: Clinical workplace-based learning has been the means to becoming a medical professional for many years. The importance of an adequate patient mix, as defined by the number of patients and the types of medical problems, for an optimal learning process is based on educational theory and recognised by national and international accreditation standards. The relationship between patient mix and learning in work-based curricula as yet remains unclear. Aim: To review research addressing the relationship between patient mix and learning in work-based clinical settings. Method: The search was conducted across Medline, Embase, Web of Science, ERIC and the Cochrane Library from the start date of the database to July 2011. Original quantitative studies on the relationship between patient mix and learning for learners at any level of the formal medical training/career were included. Methodological quality was assessed and two reviewers using pre-specified forms extracted results. Results: A total of 10,420 studies were screened on title and abstract. Of these, 298 articles were included for full-text analysis, which resulted in the inclusion of 22 papers. The quality of the included studies, scored with the Medical Education Research Study Quality Instrument (MERSQI), ranged from 8.0 to 14.5 (of 18 points). A positive relationship was found between patient mix and self-reported outcomes evaluating the progress in competence as experienced by the trainee, such as self-confidence and comfort level. Patient mix was also found to correlate positively with self-reported outcomes evaluating the quality of the learning period, such as self-reported learning benefit, experienced effectiveness of the rotation, or the instructional quality. Variables, such as supervision and learning style, might mediate this relationship. A relationship between patient mix and formal assessment has never been demonstrated. Conclusion: Patient mix is positively related to self-reported learning outcome, most evidently the experienced quality of the learning programme.

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

BackgroundAbnormal 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.MethodsTo 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.ResultsIn 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.ConclusionInitially, 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.

Assessment of the clinical trainer as a role model: a Role Model Apperception Tool (RoMAT).

PurposePositive role modeling by clinical trainers is important for helping trainees learn professional and competent behavior. The authors developed and validated an instrument to assess clinical trainers as role models: the Role Model Apperception Tool (RoMAT).MethodOn the basis of a 2011 systematPurpose Positive role modeling by clinical trainers is important for helping trainees learn professional and competent behavior. The authors developed and validated an instrument to assess clinical trainers as role models: the Role Model Apperception Tool (RoMAT). Method On the basis of a 2011 systematic review of the literature and through consultation with medical education experts and with clinical trainers and trainees, the authors developed 17 attributes characterizing a role model, to be assessed using a Likert scale. In 2012, general practice (GP) trainees, in their first or third year of postgraduate training, who attended a curriculum day at four institutes in different parts of the Netherlands, completed the RoMAT. The authors performed a principal component analysis on the data that were generated, and they tested the instrument’s validity and reliability. Results Of 328 potential GP trainees, 279 (85%) participated. Of these, 202 (72%) were female, and 154 (55%) were first-year trainees. The RoMAT demonstrated both content and convergent validity. Two components were extracted: “Caring Attitude” and “Effectiveness.” Both components had high reliability scores (0.92 and 0.84, respectively). Less experienced trainees scored their trainers significantly higher on the Caring Attitude component. Conclusions The RoMAT proved to be a valid, reliable instrument for assessing clinical trainers’ role-modeling behavior. Both components include an equal number of items addressing personal (Heart), teaching (Head), and clinical (Hands-on) qualities, thus demonstrating that competence in the “3Hs” is a condition for positive role modeling. Educational managers (residency directors) and trainees alike can use the RoMAT.

Measuring evidence-based medicine knowledge and skills. The Dutch Berlin Questionnaire: translation and validation

on the reporting quality of the reviews. What is not reported is considered not to have been done by the authors. Therefore, the tools might be considered too unfair toward mixed-methods reviews. It is possible that mixed-methods reviews are published more frequently in journals that impose a maximum number of words to authors. This is a situation where authors tend to report less methodological aspects of their work and are more fluent on results and discussion sections [9]. Moja et al. [9] found that nearly 50% of published systematic reviews did not specify how the methodological quality of primary studies was evaluated or how it was considered in the interpretation of results, contrary to quantitative Cochrane reviews. Although systematic approaches have been proposed to achieve mixed-methods reviews [1], at present days, there is no specific guideline. The realization of mixed-methods reviews is a methodological challenge in terms of study selection, assessment of quality of different types of primary studies, and synthesis of results [2]. Because the methodological aspects of qualitative studies and quantitative studies can be considerably different, it might be necessary to consider as many critical appraisal tools as there are types of systematic reviews. Our experience emphasizes the need for a consensus on standards for reporting quality of mixed-methods reviews. Without such a consensus, assessing this type of systematic review should be done with caution.

Do GP trainers use feedback in drawing up their Personal Development Plans (PDPs)? Results from a quantitative study

Background: General practice (GP) trainers play a key role GP trainees’ education. To stimulate development of trainer competencies a Personal Development Plan (PDP) can be helpful, especially when feedback is incorporated. Aims: To investigate to what extent GP trainers use feedback in PDPs. Methods: GP trainers were provided with three feedback sources: trainees’ rating scores, trainees’ narrative comments, and self-assessment scores. Trainers were instructed to use these while drawing up PDP goals. With quantitative analyses the extent to feedback sources were used was determined. Results: Of the trainers 93% submitted a PDP. More than 75% of goals were based on provided feedback. Multiple sources addressing the same issue increased feedback use. If two sources pointed in the same direction, feedback was used more often if one of them concerned “narrative comments”. Ratings were lowest for GP-related Expertise and Teaching Skills. Most goals defined concerned these domains. Fewer goals regarded Personal Functioning. Proportion of feedback used concerning Personal functioning was lowest. Conclusions: GP trainers use most feedback and address issues most commented upon. Narrative comments deserve a profound place when eliciting feedback. Research into the quality with which feedback is used in PDP goals should complement these results.

Didactic and technical considerations when developing e-learning and CME

Several usability issues were encountered during the design of a blended e-learning program for a course in evidence-based medicine for general practice trainers. The program was developed in four steps. We focused in this article on step 2 and 3. Step 2 focused on which educational principles to apply, that is, which learning theories, instructional designs and other theories should influence the program. Step 3 focused on the design elements, namely whether to use hypermedia and/or multimedia, and what screen design and which font to use. This article presents the important issues in designing an e-course and provides an impression of the complexity of designing high quality e-learning in particular for continuing medical education (CME).