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BACKGROUND: The shortage of general practitioners (GPs) is a worsening problem in many countries and poses a threat to the services provided by primary care and by extension for the entire healthcare system. Issues with GP workforce recruitment and retention can be reasons for this shortage. OBJECTIVES: To describe GP trainees and newly qualified GPs experiences and perceptions on how their training and early experiences of work influence their career intentions in primary care in Estonia. METHODS: A qualitative study with GP trainees (n = 12) and newly qualified GPs (n = 13) using semi-structured group interviews (n = 6) was conducted. Interviews were conducted from October until November 2020. Data were analysed using thematic analysis with NVivo Software. RESULTS: Although early-career GPs in Estonia envision their future roles as GP practice owners with patient list, this is often postponed due to various reasons. Early-career GPs expressed a sense of unpreparedness to fill all the roles of GPs' and found the process of establishing a GP practice and taking on a patient lists very complicated. They value work-life balance and prefer workplaces, which offer flexible working conditions. CONCLUSION: Potential strategies were identified to enhance the willingness of early-career GPs to continue their career as GP practice owners with patient list: improving the GP training program by placing more emphasis on managing skills and making the process of establishing GP practice and taking on a patient list less bureaucratic and more accessible.

This study highlights the career intentions of GP trainees and newly qualified GPs in Estonia.Participants of this study perceive the many different roles of being a GP as very challenging.Understanding early-career GPs ideas about the future work environments can be helpful in shaping future workforce strategies.

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BACKGROUND: Peer-assisted learning (PAL) - where students take up a teaching role at an early stage of their training-is widely used in medical curricula. Many qualitative studies have investigated the perceptions and benefits of PAL, but no studies have longitudinally explored how peer teachers experienced their development. This could allow for a better understanding of PAL. In this study, we explored the perceived impact of being a peer teacher on the development of personal and professional competencies as a medical student. METHODS: We longitudinally conducted semi-structured interviews with peer teachers, during their 2-year teaching period in the skills lab at the University of Antwerp and applied descriptive thematic analysis. RESULTS: In total we gathered 47 interviews in 13 peer teachers (9 female, 4 male,. 1-7 interviews each). Peer teachers reported an increase in self-confidence, which gradually transformed into self-efficacy in clinical and teaching skills., Participants told us to be inspired by the previous generation of peer teachers. Their motivation shifted from personal benefits to benefiting others while becoming a role model themselves. The peer teachers illustrated how they developed maturity by integrating different CanMEDS roles. They grew in reflection, changed/transformed an initial mark-driven study drive into more patient-centered ambitions, and started developing a personal style. CONCLUSIONS: Our study suggests that being a peer teacher leads to more self-efficacy, in clinical and teaching skills, to become a role model with as motivation to benefit others and to grow towards a good doctor maturity. Although the task is to teach peers, this opportunity nurtures the practice and integration of various CanMEDS roles, not only that of scholar but also communicator, collaborator and leader, thereby positively influencing their personal and professional development and their identity as a doctor (professional role).

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BACKGROUND: The clinical learning environment is important in GP specialty training and impacts professional development. Uniquely for GP trainees, about half of their training periods occur in a hospital environment, which is not their final workplace. There is still little understanding of how hospital-based training influences GP's professional development. OBJECTIVES: To seek the views of GP trainees on how their hospital experience contributes to their professional development as a GP. METHODS: This international and qualitative study seeks the views of GP trainees from Belgium, Ireland, Lithuania, and Slovenia. Semi-structured interviews were performed in the original languages. A joint thematic analysis in the English language resulted in key categories and themes. RESULTS: From the four themes identified, GP trainees were found to experience additional challenges on top of the service provision/education tensions, which are common to all hospital trainees. Despite these, the hospital rotation component of GP training is valued by trainees. A strong finding of our study is the need to ensure that learning from the hospital placements is placed firmly in the context of general practice, e.g. GP placements prior or parallel with the hospital placements, educational activities resourced by GPs during their hospital experience, encouraging hospital teachers to have greater awareness of the educational needs of GPs, including an awareness of their training curriculum. CONCLUSION: This novel study highlights how hospital placements for GP trainees could be enhanced. Further study could be broadened to recently qualified GPs, which may uncover new areas of interest.

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BACKGROUND: The General Practice (GP) postgraduate program exists for 80% out of workplace learning. The quality of the clinical learning environment (CLE) has a direct effect on the quality of training and the professional development of GP trainees. METHODOLOGY: Participatory research was used to involve all stakeholders in the development process of a 360° evaluation tool that should improve the average quality of GP training practices, guide GP trainees towards the best training practices and detect and remediate GP trainers of lower quality. RESULTS: TOEKAN (Tool for Communication and Evaluation of Quality Standards) was developed, which consists of a 72-item questionnaire for GP trainees and GP trainers and an 18-item questionnaire for those who coach and remediate GP trainers. The outcomes of the TOEKAN questionnaires are visualized in an online dashboard. DISCUSSION: TOEKAN is the first 360° evaluation tool for CLE in GP education. All stakeholders will complete the survey on a regular basis and have access to the results. By creating intrinsic and extrinsic motivation as well as mediation measures, the quality of CLE will improve. Continuous monitoring of the use and outcomes of TOEKAN will allow to critically review and improve this new evaluation tool as well as support the broader implementation.

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BACKGROUND: In view of the exponential use of the CanMEDS framework along with the lack of rigorous evidence about its applicability in workplace-based medical trainings, further exploring is necessary before accepting the framework as accurate and reliable competency outcomes for postgraduate medical trainings. Therefore, this study investigated whether the CanMEDS key competencies could be used, first, as outcome measures for assessing trainees' competence in the workplace, and second, as consistent outcome measures across different training settings and phases in a postgraduate General Practitioner's (GP) Training. METHODS: In a three-round web-based Delphi study, a panel of experts (n = 25-43) was asked to rate on a 5-point Likert scale whether the CanMEDS key competencies were feasible for workplace-based assessment, and whether they could be consistently assessed across different training settings and phases. Comments on each CanMEDS key competency were encouraged. Descriptive statistics of the ratings were calculated, while content analysis was used to analyse panellists' comments. RESULTS: Out of twenty-seven CanMEDS key competencies, consensus was not reached on six competencies for feasibility of assessment in the workplace, and on eleven for consistency of assessment across training settings and phases. Regarding feasibility, three out of four key competencies under the role "Leader", one out of two competencies under the role "Health Advocate", one out of four competencies under the role "Scholar", and one out of four competencies under the role "Professional" were deemed as not feasible for assessment in a workplace setting. Regarding consistency, consensus was not achieved for one out of five competencies under "Medical Expert", two out of five competencies under "Communicator",one out of three competencies under "Collaborator", one out of two under "Health Advocate", one out of four competencies under "Scholar", one out of four competencies under "Professional". No competency under the role "Leader" was deemed to be consistently assessed across training settings and phases. CONCLUSIONS: The findings indicate a mismatch between the initial intent of the CanMEDS framework and its applicability in the context of workplace-based assessment. Although the CanMEDS framework could offer starting points, further contextualization of the framework is required before implementing in workplace-based postgraduate medical trainings.

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BACKGROUND: Indigenous populations are represented among the poor and disadvantaged in rural areas. High rates of infectious diseases are observed in indigenous child populations, and fever as a general symptom is common. OBJECTIVE: We aim to improve the skills of healers in rural indigenous areas in the South of Ecuador for managing children with fevers. METHOD: We performed participatory action research (PAR) for this study with 65 healers. RESULTS: The PAR focused on the following four phases: (1) 'observation,' eight focus groups were used. (2) 'planning' phase was developed, and with culturally reflective peer group sessions, a culturally adapted flowchart was constructed titled "Management of children with fever." In phase (3): 'action', the healers were trained to manage children with fever. Phase (4): 'evaluation', 50% of the healers used the flowchart. CONCLUSIONS: Explicit recognition of the need for traditional healers and health professionals in indigenous communities to work together to improve health indicators such as infant mortality exists. Additionally, strengthening the transfer system in rural areas is based on knowledge and cooperation between the community and the biomedical system.

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The PinPoint Case Platform (PPCP) offers independent online case-based CME. To align with personal learning needs, a functionality of needs assessments ("QuickScan") was developed, directing users to follow personalised case journeys. A randomised study was conducted, comparing its effectiveness, time efficiency and user experience with a format of non-individualised case-based learning. Forty-two residents in urology from five European countries were randomly assigned to follow non-individualised case-based learning (control group) or a needs assessment plus personalised case journeys on different topics in prostate cancer. After performing a pre- and post-assessment, both groups showed a similar increase in test scores (Mann-Whitney U = 247; p = .113), but the time needed for completing the learning exercise was significantly lower in the group with the personalised approach (median: 45 vs 90 minutes; Mann-Whitney U = 97.5; p = .0141). The quality of the two learning methods was similarly well received by both groups. In conclusion, learners who followed personalised case journeys learned similarly effective but more time efficient than non-individualised case-based learners. Future studies should determine if these findings can be extrapolated to board-certified physicians following CME activities.

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INTRODUCTION: Maternal mortality is a health problem in developing countries and is the result of several factors such as sociodemographic and economic inequalities and difficulties in accessing the health services. In addition, training strategies in obstetric emergencies targeting the non-medical personnel such as traditional midwives are scarce. The focus of this study is to develop learning and communication bridges on the management of obstetric emergencies and on policies of patients' referral to the biomedical health system in rural areas. METHODOLOGY: A Participant Action Research (PAR) study with a mixed methods approach was set up to elaborate culturally adapted flowcharts. The project lasted approximately 3,5 years, from September 2016 to January 2021. RESULTS: The study was conducted with 94 traditional midwives from southern Ecuador and is divided into 4 phases, namely: 1) Exploration: focus groups and interviews were conducted to document the management of obstetric emergencies through the presentation of "clinical case" scenarios in three important topics, namely: pre-eclampsia, shoulder dystocia and postpartum hemorrhage, 2) Planning: a number of reflective sessions were conducted between the researchers and the healers/midwives to elaborate flowcharts. 3) Action: the training was conducted in rooms dedicated to proficiency in the aforementioned topics and using the flowcharts, 4) Evaluation: 90% of the participants reported having used the flowcharts during the first year after the training. The most frequently used flowchart was that of pre-eclampsia for the recognition of warning signs during pregnancy control. CONCLUSION: This study documents common practices of pregnancy and delivery management by traditional midwives. Furthermore, cultural flowcharts were developed for and together with midwives to improve the clinical response to obstetric emergencies. The preliminary evaluation was favorable; the most frequently used flowchart concerned preeclampsia. In this process, establishing a partnership was crucial for successful intercultural collaboration.

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BACKGROUND: In Europe, hospital training is integrated in the postgraduate curriculum of General Practitioners (GPs) according to the European Directives. However, little is known about the specific learning objectives of GP trainees during this training. OBJECTIVES: This exploratory study investigated GP trainees' expected learning objectives for their hospital training and the factors influencing the learning process. METHODS: Semi-structured interviews were conducted in three focus groups consisting of first-year GP trainees before their hospital training. Data were coded thematically and analysed in NVivo. RESULTS: A total of 22 Belgian GP trainees (55% females, average age of 26.2 years) were interviewed. Three major themes emerged: learning objectives, factors influencing learning and organisational aspects. GP trainees mainly wanted to improve their knowledge of common conditions by conducting consultations and follow certain patients' hospitalisation trajectory. Emergency medicine or internal medicine was the preferred specialty. Other GP trainees wanted to learn more about some specific conditions. Conversely, an overloaded work schedule was dreaded to hinder effective learning. Regular meetings and supervision from their hospital trainer were deemed crucial to strengthen GP trainees' learning trajectory. CONCLUSION: GP trainees wanted to learn more about both common conditions and some specific conditions. Their previous year in a GP setting strengthened their confidence and facilitated purposeful learning. Relieving GP trainees from administrative tasks when working as supplementary doctors could strike a better balance between the continuity of the clinical department and their personal learning objectives.

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BACKGROUND: This study investigates the impact of Peer-Assisted Learning (PAL) in clinical skills on peer teachers' academic scores and competencies; however, controversy remains on this topic, and concrete evidence on its impact lacking. METHODS: We performed a mixed methods study combining a retrospective cohort study with a modified Delphi survey. Peer teachers and Skills Lab faculty members participated in this study. A validated questionnaire, the CanMEDS Competency Based Inventory (CCBI), and group interviews were used to assess the outcomes of PAL. Our results were also triangulated with literature data. RESULTS: In 3 consecutive cohorts of medical students (n = 311), 78 participated in PAL. Peer teachers obtained higher scores from the start of the study, at different timepoints in medical school, and on their final scores compared to all other students. Interestingly their progress followed the same path and magnitude as other well-performing students. However, based on our findings from a modified Delphi survey (CCBI interviews) and a literature review, we found further supporting evidence for a positive impact of PAL on the competencies of physical skills (medical expert), teamwork and leadership (collaborator), lifelong learning (scholar), and for admitting uncertainty/limits (professional) within the CanMEDS roles. CONCLUSIONS: We conclude that higher achieving students are more likely to volunteer for a peer tutoring program; however this does not significantly augment their academic scores as compared to above well-performing non-teaching fellow students. Importantly, our modified Delphi survey indicated which CanMEDS roles were positively impacted by PAL: medical expert, collaborator, scholar and professional.

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BACKGROUND: COVID-19 has changed General Practice (GP) education as well as GP clinical activities. These changes have had an impact on the well-being of medical trainees and the role of GP plays in the society. We have therefore aimed to investigate the impact that COVID-19 has had on GP trainees and trainers in four domains: education, workload, practice organization and the role of GP in society. DESIGN: a cross-sectional study design was used. METHODS: The Interuniversity Centre for the Education of General Practitioners sent an online survey with close-ended and open-ended questions to all GP trainees and trainers in Flanders, active in the period March - September 2020. Descriptive statistics were performed to analyze the quantitative data and thematic analysis for the qualitative data. RESULTS: 216 (response 25%) GP trainees and 311 (response 26%) trainers participated. GP trainees (63%, N = 136) and trainers (76%, N = 236) reported new learning opportunities since the COVID-19 pandemic. The introduction of telehealth consulting and changing guidelines required new communication and organizational skills. Most of the GP trainees (75%, n = 162) and trainers (71%, n = 221) experienced more stress at work and an overload of administrative work. The unfamiliarity with a new infectious disease and the fact that COVID-19 care compromised general GP clinical activities, created insecurity among GP trainers and trainees. Moreover, GP trainees felt that general GP activities were insufficiently covered during the COVID-19 pandemic for their training in GP. GP trainers and trainees experienced mutual support, and secondary support came from other direct colleagues. Measures such as reducing the writing of medical certificates and financial support for administrative and (para) medical support can help to reprioritize the core of GP care. COVID-19 has enhanced the use of digital learning over peer-to-peer learning and lectures. However, GP trainees and trainers preferred blended learning educational activities. CONCLUSIONS: COVID-19 has created learning opportunities such as telehealth consulting and a flexible organization structure. To ensure quality GP education during the pandemic and beyond, regular GP care should remain the core activity of GP trainees and trainers and a balance between all different learning methods should be found.

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General Practice/Family Medicine (GP/FM) is a key discipline within primary health care and so by extension for the whole health care system. An essential condition for effective GP/FM care is a work force that is highly qualified. As society is changing rapidly, a revision of the GP/FM definition is ongoing, in addition to a recent movement of identifying related core values. In this paper, we want to give an overview on how these new paths and perspectives are currently reflected in GP/FM teaching and training. We selected four core values that fit in with possible future visions: person-centered care, continuity of care, cooperation in care, and community-oriented care. By a narrative review, we observed that GP/FM education toward core values is often built around overarching topics. Teaching and learning take place in specific contexts, most of all through placements within communities, primary care settings, or hospital wards. Mixed teaching- and training methods are used combining knowledge, skills, and attitude. Furthermore, collaboration with other health professionals and peers is stressed, in addition to the importance of role models, a holistic focus and the involvement of patients. Since these core values are important within GP/FM and rather few studies on the educational aspects and learning tools were found we advocate encouraging each other more to share good practices, certainly the innovative ones specifically related to GP/FM.

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CONSTRUCT: The authors aimed to investigate the utility of the comparative judgment method for assessing students' written self-reflections. BACKGROUND: Medical practitioners' reflective skills are increasingly considered important and therefore included in the medical education curriculum. However, assessing students' reflective skills using rubrics does not appear to guarantee adequate inter-rater reliabilities. Recently, comparative judgment was introduced as a new method to evaluate performance assessments. This study investigates the merits and limitations of the comparative judgment method for assessing students' written self-reflections. More specifically, it examines the reliability in relation to the time spent assessing, the correlation between the scores obtained using the two methods (rubrics and comparative judgment), and, raters' perceptions of the comparative judgment method. APPROACH: Twenty-two self-reflections, that had previously been scored using a rubric, were assessed by a group of eight raters using comparative judgment. Two hundred comparisons were completed and a rank order was calculated. Raters' impressions were investigated using a focus group. FINDINGS: Using comparative judgment, each self-reflection needed to be compared seven times with another self-reflection to reach a scale separation reliability of .55. The inter-rater reliability of rating (ICC, (1, k)) using rubrics was .56. The time investment required for these reliability levels in both methods was around 24 minutes. The Kendall's tau rank correlation indicated a strong correlation between the scores obtained via both methods. Raters reported that making comparisons made them evaluate the quality of self-reflections in a more nuanced way. Time investment was, however, considered heavy, especially for the first comparisons. Although raters appreciated that they did not have to assign a grade to each self-reflection, the fact that the method does not automatically lead to a grade or feedback was considered a downside. CONCLUSIONS: First evidence was provided for the comparative judgment method as an alternative to using rubrics for assessing students' written self-reflections. Before comparative judgment can be implemented for summative assessment, more research is needed on the time investment required to ensure no contradictory feedback is given back to students. Moreover, as the comparative judgment method requires an additional standard setting exercise to obtain grades, more research is warranted on the merits and limitations of this method when a pass/fail approach is used.

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BACKGROUND: The new paradigm of intercultural policies focuses on rethinking the common public culture. In Ecuador, the "Buen Vivir" plan seeks to incorporate the ancestral medical knowledge, experience and beliefs of traditional healers into the formal health services. This study explores views on the formal health system from the perspective of the healers belonging to the Kichwa and Shuar ethnicities in the South of Ecuador. METHODS: A qualitative study with a phenomenological approach was performed. Focus groups were conducted in three locations in Southern Ecuador. Shuar, Kichwa and Mestizo ethnic groups were included in the research. RESULTS: Eleven focus groups with a total of 110 participants belonging to the Shuar, Kichwa and Mestizo ethnic groups participated in the study. Six themes were created through analysis: 1) conflicts with health professionals, 2) acceptance of traditional healers, 3) respect, 4) work as a team, 5) environment and patient care, and 6) salary and recognition. CONCLUSION: This study indicated the perceived barriers compromising respectful collaboration between health staff and traditional healers from an indigenous perspective. Power inequalities and a historically unidirectional relationship and, in addition, differences in health beliefs, seem to create misunderstandings regarding each other's approach when faced with health and disease. However, insight in these barriers can create opportunities towards collaboration, which will have a positive effect on patient confidence in one or both systems and support continuity between traditional healers and the formal health system.

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BACKGROUNDS: An intercultural society facilitates equitable and respectful interrelations. Knowing and understanding each other's sociocultural and linguitic contexts is a prerequisite for an intercultural society. This study explores the concepts of health and illness among healers of indigenous ethnicities in Southern Ecuador. METHODS: A qualitative observational study with eleven focus groups was conducted in three locations in Southern Ecuador; a total of 110 participants the Shuar, Kichwa and Mestizo ethnic groups were included. A phenomenological and hermeneutic analysis was conducted. RESULTS: Fourteen main subtopics around of two predefined themes, i.e., "Health" and "Illness" were identified: 1) four bodies, 2) religiosity, 3) health as a good diet, 4) health as god's blessing or a gift, 5) health as balance/ harmony, 6) health as community and social welfare, 7) health as potentiality or a skill, 8) health as peacefulness, 9) heath as individual will, 10) illness as an imbalance, 11) illness as bad energy, 12) illness as a bad diet, 13) illness as suffering or worry, and 14) illness from God, Nature and People illness. By analysing all the topics' and subtopics' narratives, a health and illness definition was developed. The principal evidence for this new framework is the presence of interculturality as a horizontal axis in health. The indigenous perspective of health and illness focus on a balance between 4 bodies: the physical, spiritual, social and mental bodies. Additionally, "good health" is obtained through of the good diet and balanced/harmony. CONCLUSION: Indigenous healers in Southern Ecuador have views on health and illness that differ from the Western biomedical model of care. These different views must be recognized and valued in order to build an intercultural (health) system that empowers both ancestral and modern medical knowledge and healing.

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BACKGROUND: Research shows that few general practitioners perform intra- and periarticular infiltrations. Lack of good training strategies to teach these skills would be an important reason for this observation. In this study, we investigated and compared three different training strategies for infiltrations of the glenohumeral joint, subacromial space, lateral epicondyle, carpal tunnel and knee joint. METHODS: Trainees in general practice were randomized into three teaching groups: a theoretical lecture (n = 18), or a theoretical lecture with training on anatomical models (n = 19) or with a training on cadavers (n = 11). The study period was 3 months. Before and after the training, the self-efficacy (questionnaire) and skills (Objective Structured Clinical Examination or OSCE, test on anatomical models) were evaluated. The self-efficacy was assessed again 3 months later. A Kruskal-Wallis test was used to compare the results before versus after training and between groups (p < 0.05). RESULTS: All three training strategies had a significantly positive effect on the self-efficacy concerning knowledge and skills. This benefit remained 3 months after training. However, some participants still felt uncomfortable to perform infiltrations. Best scores for self-efficacy concerning skills and best scores on the OSCE were observed after training on cadavers, followed by training on anatomical models. CONCLUSIONS: Based on this study we suggest the combination of a theoretical lecture with a training on cadavers to teach infiltration techniques. To achieve an optimal long-term effect, additional refresher trainings may be necessary.

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High-quality training is a prerequisite to teaching future general practitioners. To inspire and guide all countries to implement General Practice (GP) specialist education and training and bring it to the highest standards, we aimed, within the European context, to produce a collaborative document entitled 'Educational Requirements for GP Specialty Training'. Through an iterative process existing documents from the European Academy of Teachers in GP and Family Medicine (EURACT) and the World Organization of Family Medicine Doctors (WONCA) were collated. Other reports, grey literature about specialty GP training and requirements for trainees, trainers and training institutions were included. State-of-the-art GP specialty training 'core' competences, characteristics and essential features of GP are described. General principles and specified tools for training and assessment are summarised. Recommendations on the duration and place(s) of training and selection of trainees are provided. Trainers should be accredited teachers and quality training institutions are essential. New insights, existing gaps and issues for debate have highlighted areas for further research. This document was produced in the specific context of Europe but its general principles are relevant to GP training in all countries.

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Around 30% of individuals will develop herpes zoster (HZ), caused by the varicella zoster virus (VZV), during their life. While several risk factors for HZ, such as immunosuppressive therapy, are well known, the genetic and molecular components that determine the risk of otherwise healthy individuals to develop HZ are still poorly understood. We created a computational model for the Human Leukocyte Antigen (HLA-A, -B, and -C) presentation capacity of peptides derived from the VZV Immediate Early 62 (IE62) protein. This model could then be applied to a HZ cohort with known HLA molecules. We found that HLA-A molecules with poor VZV IE62 presentation capabilities were more common in a cohort of 50 individuals with a history of HZ compared to a nationwide control group, which equated to a HZ risk increase of 60%. This tendency was most pronounced for cases of HZ at a young age, where other risk factors are less prevalent. These findings provide new molecular insights into the development of HZ and reveal a genetic predisposition in those individuals most at risk to develop HZ.

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BACKGROUND: Portfolios are used as tools to coach and assess students in the workplace. This study sought to evaluate the content validity of portfolios as reflected in their capacity to adequately assess achieved competences of medical students during clerkships. METHODS: We reviewed 120 workplace portfolios at three medical universities (Belgium and the Netherlands). To validate their content, we developed a Validity Inventory for Portfolio Assessment (VIPA) based on the CanMEDS roles. Two raters evaluated each portfolio and indicated for each VIPA item whether the portfolio provided sufficient information to enable satisfactory assessment of the item. We ran a descriptive analysis on the validation data and computed Cohen's Kappa to investigate interrater agreement. RESULTS: The portfolios adequately covered the items pertaining to the communicator (90%) and professional (87%) roles. Coverage of the medical expert, collaborator, scholar and manager roles ranged between 75% and 85%. The health advocate role, covering 59%, was clearly less well represented. This role also exhibited little interrater agreement (Kappa < 0.4). CONCLUSIONS: This study lends further credence to the evidence that portfolios can indeed adequately assess the different CanMEDS roles during clerkships, the health advocate role, which was less well represented in the portfolio content, excepted.

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