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Assisted dying practices, which include euthanasia and physician-assisted suicide (PAS), have expanded significantly around the world over the past 20 years. Euthanasia refers to the act of intentionally ending the life of a patient by a health care practitioner through medical means at that patient's explicit request while PAS involves the provision or prescribing of drugs by a health care practitioner for a patient to end their own life. The growing global aging population accompanied by higher levels of chronic disease and protracted illnesses have sharpened the focus on end of life issues and societal and legislative debates continue to address related moral and ethical complexities. Assisted dying practices are now legal in 18 jurisdictions, increasing the number of people with access to euthanasia and/or physician-assisted suicide (PAS) to over 200 million. New legislation is being crafted or considered in Portugal, Spain and 16 US states. Germany has recently overturned a ban on assisted dying services and New Zealand will put legalization of euthanasia to a vote in 2020. Assisted dying practice characteristics differ and there is also considerable variation in the terminology and labels used for assisted dying, which can add to the confusion and controversy around the practices. Frequency of use also varies greatly by jurisdiction, though a consistent increase has been seen in European countries including Belgium, the Netherlands and Switzerland as well as some jurisdictions with long-standing physician assisted dying laws, such as Oregon and Washington. All assisted dying legislation includes substantive and procedural requirements, such as minimum age, waiting period, health condition, physician consultation and reporting procedure, however, some are extensive and detailed while others are more limited. As access to assisted dying expands in new and existing jurisdictions, research must also expand to diligently examine the impact on patients, specifically among vulnerable populations, as well as on health care practitioners, health care systems and communities. This article will provide a thorough investigation, or 'status quaestionis' of the terminology, evolution and current legislative picture of assisted dying practices around the globe and contribute to the ongoing ethical, regulatory and practice debate, which have become increasingly important considerations for medical practice, end-of-life care and public health.

Objectives: To describe and compare euthanasia and physician-assisted suicide (EAS) practice in Flanders, Belgium (BE), the Netherlands (NL) and Switzerland (CH)., Methods: Mortality follow-back surveys among attending physicians of a random sample of death certificates., Results: We studied 349 EAS deaths in BE (4.6% of all deaths), 851 in NL (4.6% of all deaths) and 65 in CH (1.4% of all deaths). People who died by EAS were mostly aged 65 or older (BE: 81%, NL: 77% and CH: 71%) and were mostly diagnosed with cancer (BE: 57% and NL: 66%). Home was the most common place of death in NL (79%), while in BE and CH, more variation was found regarding to place of death. The decision to perform EAS was more frequently discussed with a colleague physician in BE (93%) and NL (90%) than in CH (60%)., Conclusions: EAS practice characteristics vary considerably in the studied countries with legal EAS. In addition to the legal context, cultural factors as well as the manner in which legislation is implemented play a role in how EAS legislation translates into practice.

Background: Medical schools aim to contribute to a pool of doctors who are ready for a future practice that will be ever-changing requiring collaboration skills and lifelong learning. They adapt their curricula and selection procedures to fulfil this responsibility. This study aims to determine whether two different selection procedures in one medical school, both matching the key characteristics of the subsequent curricula (one traditional, knowledge-based, and one recently designed for self directed learning and focusing on practice), select students with different personality traits as a side-effect. This perspective was chosen as personality has been related to the CanMeds competencies, innovation capacities, medical school performance and medical professional success., Methods: A total of 621 students admitted through the new or the traditional selection procedure were invited to complete a Big Five Inventory questionnaire at the start of their Bachelor's programme. Using ANCOVA, we compared Big Five traits of students admitted through the new selection procedure (n = 196) and the traditional selection procedure (n = 425)., Results: The group of students admitted through the procedure matching the newly designed curriculum had a lower mean score on neuroticism (p < .01) and higher mean scores on conscientiousness, extraversion, agreeableness and openness (p < .001) than the other group., Conclusions: The findings of the current study indicate that the medical school population is influenced in terms of personality traits as a side-effect of a changing selection procedure. We recommend studying this mechanism and its implications further and using it more consciously in selection procedure design., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Fosfomycin susceptibility testing is complicated and prone to error. Before using fosfomycin widely in patients with serious infections, acquisition of WT distribution data and reliable susceptibility testing methods are crucial. In this study, the performance of five methods for fosfomycin testing in the routine laboratory against the reference method was evaluated., Methods: Ten laboratories collected up to 100 ESBL-producing isolates each (80 Escherichia coli and 20 Klebsiella pneumoniae). Isolates were tested using Etest, MIC test strip (MTS), Vitek2, Phoenix and disc diffusion. Agar dilution was performed as the reference method in a central laboratory. Epidemiological cut-off values (ECOFFs) were determined for each species and susceptibility and error rates were calculated., Results: In total, 775 E. coli and 201 K. pneumoniae isolates were tested by agar dilution. The ECOFF was 2 mg/L for E. coli and 64 mg/L for K. pneumoniae. Susceptibility rates based on the EUCAST breakpoint of ≤32 mg/L were 95.9% for E. coli and 87.6% for K. pneumoniae. Despite high categorical agreement rates for all methods, notably in E. coli, none of the alternative antimicrobial susceptibility testing methods performed satisfactorily. Due to poor detection of resistant isolates, very high error rates of 23.3% (Etest), 18.5% (MTS), 18.8% (Vitek2), 12.5% (Phoenix) and 12.9% (disc diffusion) for E. coli and 22.7% (Etest and MTS), 16.0% (Vitek2) and 12% (Phoenix) for K. pneumoniae were found. None of the methods adequately differentiated between WT and non-WT populations., Conclusions: Overall, it was concluded that none of the test methods is suitable as an alternative to agar dilution in the routine laboratory.

In medical school selection, non-cognitive performance in particular correlates with performance in clinical practice. It is arguable, therefore, that selection should focus on non-cognitive aspects despite the predictive value of prior cognitive performance for early medical school performance. The aim of this study at Radboud University Medical Center, the Netherlands, is to determine the effects of admitting students through an autonomous non-cognitive procedure on early medical school performance. We compared their performance to the performance of students selected through an autonomous cognitive selection procedure, enrolling in the Bachelor's curriculum simultaneously. 574 students (2013 and 2014 cohorts), admitted through non-cognitive selection (based on portfolio, CASPer and MMI, n = 135) or cognitive selection (curriculum sample selection, n = 439) were included in the study. We compared dropout rates, course credits and grades, using logistic and linear regression. The dropout rate was the highest in the non-cognitive selection group (p < 0.001). Students admitted through non-cognitive selection more often obtained the highest grade for the nursing attachment (p = 0.02) and had a higher mean grade for the practical clinical course in year 3 (p = .04). No differences in course grades were found. The results indicate that students perform best on the elements of the curriculum that are represented most strongly in the selection procedure they had participated in. We recommend the use of curriculum sample procedures, resembling the early medical school curriculum,-whether it has a more cognitive or a more non-cognitive focus-, to select the students who are likely to be successful in the subsequent curriculum.

Context: Despite evidence for the predictive value of both pre-admission characteristics and past performance at medical school, their relative contribution to predicting medical school performance has not been thoroughly investigated., Objectives: This study was designed to determine the relative importance of pre-admission characteristics and past performance in medical school in predicting student performance in pre-clinical and clinical training., Methods: This longitudinal prospective study followed six cohorts of students admitted to a Dutch, 6-year, undergraduate medical course during 2002-2007 (n = 2357). Four prediction models were developed using multivariate logistic regression analysis. Main outcome measures were 'Year 1 course completion within 1 year' (models 1a, 1b), 'Pre-clinical course completion within 4 years' (model 2) and 'Achievement of at least three of five clerkship grades of ≥ 8.0' (model 3). Pre-admission characteristics (models 1a, 1b, 2, 3) and past performance at medical school (models 1b, 2, 3) were included as predictor variables., Results: In model 1a - including pre-admission characteristics only - the strongest predictor for Year 1 course completion was pre-university grade point average (GPA). Success factors were 'selected by admission testing' and 'age > 21 years'; risk factors were 'Surinamese/Antillean background', 'foreign pre-university degree', 'doctor parent' and male gender. In model 1b, number of attempts and GPA at 4 months were the strongest predictors for Year 1 course completion, and male gender remained a risk factor. Year 1 GPA was the strongest predictor for pre-clinical course completion, whereas being male or aged 19-21 years were risk factors. Pre-clinical course GPA positively predicted clinical performance, whereas being non-Dutch or a first-generation university student were important risk factors for lower clinical grades. Nagelkerke's R(2) ranged from 0.16 to 0.62., Conclusions: This study not only confirms the importance of past performance as a predictor of future performance in pre-clinical training, but also reveals the importance of a student's background as a predictor in clinical training. These findings have important practical implications for selection and support during medical school., (© 2015 John Wiley & Sons Ltd.)

In this longitudinal study, we investigated the relationship between physicians' prior achievements (before, during and after medical school) and job satisfaction, and tested the two lines of reasoning that prior achievements influence job satisfaction positively or negatively, respectively. The participants were graduates who started their medical training in 1982 (n = 147), 1983 (n = 154), 1992 (n = 143) and 1993 (n = 153). We operationalised job satisfaction as satisfaction (on a 10-point scale) with 13 cognitive, affective and instrumental aspects of the participants' jobs. The measures of achievement before, during and after medical school included pre-university grade point average, study progress and a residency position in the specialty of first choice, respectively. We included the effect of curriculum type (problem-based learning versus traditional), gender and years of experience as moderator variables. Higher achievers before and during medical school were more satisfied about their income (β = .152, p < .01 and β = .149, p < .05), but less satisfied with their opportunities for personal development (β = -.159, p < .05). High achievers after medical school were more satisfied with professional accomplishments (β = .095, p < .05), with appreciation from support personnel (β = .154, p < .01) and from patients (β = .120, p < .05). Effect sizes were small. Prior achievements influenced job satisfaction. The direction of the influences depended on the job satisfaction aspect in question, which indicates that it is important to distinguish between aspects of job satisfaction. To optimize job satisfaction of high achievers, it is important for graduates to obtain their preferred specialty. Furthermore, it is vital to provide them with enough opportunities for further development.

Context: Cultural differences between countries may entail differences in feedback processes., Aims: By replicating a Dutch study in Indonesia, we analysed whether differences in processes influenced the perceived instructiveness of feedback., Methods: Over a two-week period, Indonesian students (n = 215) recorded feedback moments during clerkships, noting who provided the feedback, whether the feedback was based on observations, who initiated the feedback, and its perceived instructiveness. Data were compared with the earlier Dutch study and analysed with χ(2) tests, t-tests and multilevel techniques. Cultural differences were explored using Hofstede's Model, with Indonesia and the Netherlands differing on "power distance" and "individualism.", Results: Perceived instructiveness of feedback did not differ significantly between both countries. However, significant differences were found in feedback provider, observation and initiative. Indonesian students perceived feedback as more instructive if provided by specialists and initiated jointly by the supervisor and student (βresidents = -0.201, p < 0.001 and βjoint = 0.193, p = 0.001). Dutch students appreciated feedback more when it was based on observation., Conclusions: We obtained empirical evidence that one model of feedback does not necessarily translate to another culture. Further research is necessary to unravel other possible influences of culture in implementing feedback procedures in different countries.

Objectives: Traditional student feedback questionnaires are imperfect course evaluation tools, largely because they generate low response rates and are susceptible to response bias. Preliminary research suggests that prediction-based methods of course evaluation - in which students estimate their peers' opinions rather than provide their own personal opinions - require significantly fewer respondents to achieve comparable results and are less subject to biasing influences. This international study seeks further support for the validity of these findings by investigating: (i) the performance of the prediction-based method, and (ii) its potential for bias., Methods: Participants (210 Year 1 undergraduate medical students at McGill University, Montreal, Quebec, Canada, and 371 Year 1 and 385 Year 3 undergraduate medical students at the University Medical Center Groningen [UMCG], University of Groningen, Groningen, the Netherlands) were randomly assigned to complete course evaluations using either the prediction-based or the traditional opinion-based method. The numbers of respondents required to achieve stable outcomes were determined using an iterative process. Differences between the methods regarding the number of respondents required were analysed using t-tests. Differences in evaluation outcomes between the methods and between groups of students stratified by four potentially biasing variables (gender, estimated general level of achievement, expected test result, satisfaction after examination completion) were analysed using multivariate analysis of variance (manova)., Results: Overall response rates in the three student cohorts ranged from 70% to 94%. The prediction-based method required significantly fewer respondents than the opinion-based method (averages of 26-28 and 67-79 respondents, respectively) across all samples (p < 0.001), whereas the outcomes achieved were fairly similar. Bias was found in four of 12 opinion-based condition comparisons (three sites, four variables), and in only one comparison in the prediction-based condition., Conclusions: Our study supports previous findings that prediction-based methods require significantly fewer respondents to achieve results comparable with those obtained through traditional course evaluation methods. Moreover, our findings support the hypothesis that prediction-based responses are less subject to bias than traditional opinion-based responses. These findings lend credence to prediction-based as an accurate and efficient method of course evaluation., (© Blackwell Publishing Ltd 2013.)

Context: Research from numerous medical schools has shown that students from ethnic minorities underperform compared with those from the ethnic majority. However, little is known about why this underperformance occurs and whether there are performance differences among ethnic minority groups., Objectives: This study aimed to investigate underperformance across ethnic minority groups in undergraduate pre-clinical and clinical training., Methods: A longitudinal prospective cohort study of progress on a 6-year undergraduate medical course was conducted in a Dutch medical school. Participants included 1661 Dutch and 696 non-Dutch students who entered the course over a consecutive 6-year period (2002-2007). Main outcome measures were performance in Year 1 and in the pre-clinical and clinical courses. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch students, adjusted for age, gender, pre-university grade point average (pu-GPA), additional socio-demographic variables (first-generation immigrant, urban background, first-generation university student, first language, medical doctor as parent) and previous performance at medical school., Results: Compared with Dutch students, Surinamese and Antillean students specifically underperformed in the Year 1 course (pass rate: 37% versus 64%; adjusted OR 0.40, 95% CI 0.27-0.60) and the pre-clinical course (pass rate: 19% versus 41%; adjusted OR 0.57, 95% CI 0.35-0.93). On the clinical course all non-Dutch subgroups were less likely than Dutch students to receive a grade of ≥ 8.0 (at least three of five grades: 54-77% versus 88%; adjusted ORs: 0.17-0.45)., Conclusions: Strong ethnic disparities exist in medical school performance even after adjusting for age, gender, pu-GPA and socio-demographic variables. More subjective grading cannot be ruled out as a cause of lower grades in clinical training, but other possible explanations should be studied further to mitigate the disparities., (© Blackwell Publishing Ltd 2012.)

Contamination of retail chicken meat by Extended Spectrum Beta-Lactamase (ESBL) producing bacteria likely contributes to the increasing incidence of infections with these bacteria in humans. This study aimed to compare the prevalence and load of ESBL positive isolates between organic and conventional retail chicken meat samples, and to compare the distribution of ESBL genes, strain genotypes and co-resistance. In 2010, 98 raw chicken breasts (n=60 conventional; n=38 organic) were collected from 12 local stores in the Netherlands. Prevalence of ESBL producing micro-organisms was 100% on conventional and 84% on organic samples (p<0.001). Median loads of ESBL producing micro-organisms were 80 (range <20-1360) in conventional, and <20 (range 0-260) CFU/25 g in organic samples (p=0.001). The distribution of ESBL genes in conventional samples and organic samples was 42% versus 56%, respectively (N.S.), for CTX-M-1, 20% versus 42% (N.S.) for TEM-52, and 23% versus 3% (p<0.001) for SHV-12. CTX-M-2 (7%), SHV-2 (5%) and TEM-20 (3%) were exclusively found in conventional samples. Co-resistance rates of ESBL positive isolates were not different between conventional and organic samples (co-trimoxazole 56%, ciprofloxacin 14%, and tobramycin 2%), except for tetracycline, 73% and 46%, respectively, p<0.001). Six of 14 conventional meat samples harbored 4 MLST types also reported in humans and 5 of 10 organic samples harbored 3 MLST types also reported in humans (2 ST10, 2 ST23, ST354). In conclusion, the majority of organic chicken meat samples were also contaminated with ESBL producing E. coli, and the ESBL genes and strain types were largely the same as in conventional meat samples., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Background: The Netherlands and Belgium legalized euthanasia in 2002., Aim: In this study we describe and compare cases of reported euthanasia and physician-assisted suicide in the first 5 years of legislation., Design/setting/participants: The databases of the cases reported in Belgium and the Netherlands were made available by the review committees. We compared characteristics of all cases reported between September 2002-December 2007., Results: In the Netherlands 10,319 cases were reported, in Belgium 1917. Gender and age distributions were similar in both countries. Most patients suffered from cancer (83-87%), but patients more often suffered from diseases of the nervous system in Belgium (8.3% vs. 3.9%). In the Netherlands, reported euthanasia more often occurred at home compared with Belgium (81% vs. 42%), where it occurred more often in hospital (52% vs. 9%). In the Netherlands, all cases were based on the oral request of a competent patient. In Belgium, 2.1% of the reported cases was based on an advance directive., Conclusions: We conclude that countries debating legislation must realise that the rules and procedures for euthanasia they would agree upon and the way they are codified or not into law may influence the practice that develops once the legislation is effected or what part of that practice is reported.

Intestinal carriage of extended-spectrum beta-lactamase (ESBL) -producing bacteria in food-producing animals and contamination of retail meat may contribute to increased incidences of infections with ESBL-producing bacteria in humans. Therefore, distribution of ESBL genes, plasmids and strain genotypes in Escherichia coli obtained from poultry and retail chicken meat in the Netherlands was determined and defined as 'poultry-associated' (PA). Subsequently, the proportion of E. coli isolates with PA ESBL genes, plasmids and strains was quantified in a representative sample of clinical isolates. The E. coli were derived from 98 retail chicken meat samples, a prevalence survey among poultry, and 516 human clinical samples from 31 laboratories collected during a 3-month period in 2009. Isolates were analysed using an ESBL-specific microarray, sequencing of ESBL genes, PCR-based replicon typing of plasmids, plasmid multi-locus sequence typing (pMLST) and strain genotyping (MLST). Six ESBL genes were defined as PA (bla(CTX-M-1) , bla(CTX-M-2) , bla(SHV-2) , bla(SHV-12) , bla(TEM-20) , bla(TEM-52) ): 35% of the human isolates contained PA ESBL genes and 19% contained PA ESBL genes located on IncI1 plasmids that were genetically indistinguishable from those obtained from poultry (meat). Of these ESBL genes, 86% were bla(CTX-M-1) and bla(TEM-52) genes, which were also the predominant genes in poultry (78%) and retail chicken meat (75%). Of the retail meat samples, 94% contained ESBL-producing isolates of which 39% belonged to E. coli genotypes also present in human samples. These findings are suggestive for transmission of ESBL genes, plasmids and E. coli isolates from poultry to humans, most likely through the food chain., (2011 The Authors. Clinical Microbiology and Infection; 2011 European Society of Clinical Microbiology and Infectious Diseases.)

Context: teaching students in reflection calls for specific teacher competencies. We developed and validated a rating scale focusing on Student perceptions of their Teachers' competencies to Encourage Reflective Learning in small Groups (STERLinG)., Methods: we applied an iterative procedure to reduce an initial list of 241 items pertaining to teacher competencies to 47 items. Subsequently, we validated the instrument in two successive studies. In the first study, we invited 679 medical and speech and language therapy students to assess the teachers of their professional development groups with the STERLinG. Principal components analysis (PCA) with varimax rotation was used to investigate the internal structure of the instrument. In the second study, which involved 791 medical, dental, and speech and language therapy students, we performed a confirmatory factor analysis using the oblique multiple group (OMG) method to verify the original structure., Results: in Study 1, 463 students (68%) completed the STERLinG. The PCA yielded three components: Supporting self-insight; Creating a safe environment, and Encouraging self-regulation. The final 36-item instrument explained 44.3% of the variance and displayed high reliability with α-values of 0.95 for the scale, and 0.91, 0.86 and 0.86 for the respective subscales. In Study 2, 501 students (63%) completed the STERLinG. The OMG confirmed the original structure of the STERLinG and explained 53.0% of the total variance with high α-values of 0.96 for the scale, and 0.94, 0.90 and 0.90 for the respective subscales., Conclusions: the STERLinG is a practical and valid tool for gathering student perceptions of their teachers' competencies to facilitate reflective learning in small groups considering its stable structure, the correspondence of the STERLinG structure with educational theories and the coverage of important domains of reflection. In addition, our study may provide a theoretical framework for the practice of and research into reflective learning.

Background: The transition from preclinical to clinical training is perceived as stressful with a high workload being the main difficulty. To ease this transition, we implemented a dual learning year, where just-in-time skills training and clerkships alternated., Aims: To examine the effect of the dual learning year on students' stress and perceptions of workload and skills level, and to compare these data with a baseline measurement from a curriculum in which skills training was provided in advance of clerkships., Method: During the first Master year, students completed four rotations in which 5 weeks of skills training and 5-week clerkships alternated. In the second clerkship week of each rotation, students (n = 476) completed questionnaires measuring their experienced workload, perceived skills level and stress. Analysis of variance was used for trend analysis and to determine differences with the baseline measurement (n = 83)., Results: During the dual learning year, 'experienced workload' decreased (F(1,471) = 9.408, p < 0.01), 'perceived skills level' increased (F(1,471) = 94.202, p < 0.001) and stress decreased (F(1,471) = 3.309, p < 0.10). 'Experienced workload' was lower (F(5,553) = 7.599, p < 0.001) and 'perceived skills level' was comparable to the baseline measurement., Conclusions: Compared to the baseline measurement and the results of earlier studies on transition difficulties, alternating just-in-time skills training and clerkships seem to ease the transition from preclinical to clinical training.

Background: Considering the growing amount of medical knowledge and the focus of medical education on acquiring competences, using open-book tests seems inevitable. A possible disadvantage of these tests is that students underestimate test preparation., Aims: We examined whether students who used a deep learning approach needed less open-book test time, and how students performed on open-book questions asked in a closed-book setting., Method: Second- (N = 491) and third-year students (N = 325) prepared half of the subject matter to be tested closed-book and half to be tested open-book. In agreement with the Board of Examiners, some questions in the closed-book test concerned open-book subject matter, and vice versa. Data were gathered about test time, deep learning and preparation time. Repeated measurement analysis, t-tests and partial correlations were used to analyse the data., Results: We found a negative relationship between deep learning and open-book test time for second-year students. Students scored the lowest on closed-book questions about open-book subject matter., Conclusions: Reduction of the available test time might force students to prepare longer and deeper for open-book tests. Further research is needed to identify variables that influence open-book test time and to determine how restrictive this time should be.

During in-training assessment students are frequently assessed over a longer period of time and therefore it can be expected that their performance will improve. We studied whether there really is a measurable performance improvement when students are assessed over an extended period of time and how this improvement affects the reliability of the overall judgement. In-training assessment results were obtained from 104 students on rotation at our university hospital or at one of the six affiliated hospitals. Generalisability theory was used in combination with multilevel analysis to obtain reliability coefficients and to estimate the number of assessments needed for reliable overall judgement, both including and excluding performance improvement. Students' clinical performance ratings improved significantly from a mean of 7.6 at the start to a mean of 7.8 at the end of their clerkship. When taking performance improvement into account, reliability coefficients were higher. The number of assessments needed to achieve a reliability of 0.80 or higher decreased from 17 to 11. Therefore, when studying reliability of in-training assessment, performance improvement should be considered.

In Belgium and the Netherlands, consultation of a second independent physician by the attending physician is mandatory in euthanasia cases. In both countries, specialized consultation services have been established to provide physicians trained for that purpose. This retrospective study describes and compares the quality of consultation of both services based on surveys of attending physicians and those providing the consultation (consultants). While Dutch consultants discussed certain subjects, for example, alternative curative or palliative treatment more often with the attending physician than Belgian consultants, both usually discussed those subjects considered necessary for a quality consultation and were independent from patient and attending physician. Over 90% of attending physicians in both countries evaluated the consultant's knowledge of palliative care, patient's disease, and judicial procedure, and their communication skills, as sufficient. Consultation with specialized consultation services seems to promote quality of euthanasia consultations.

The aging of the European population will lead to a rapid increase in dementia cases in the coming decades, posing challenges for the organization and provision of end-of-life care. Studying the place of death of patients with dementia, and what determines it, is relevant in this context. Using death certificates, the deaths of people aged 65 and older whose underlying cause of death was a dementia-related disease was studied in Belgium, the Netherlands, England, Scotland, and Wales. Between 50% (Wales) and 92% (Netherlands) of patients with dementia died in a nursing home and between 3% (Netherlands) and 46% (Wales) in hospital. Home death was rare (3-5%) except in Belgium (11%). Multivariate analysis showed that place of death was related to age, sex, available hospital and nursing home beds, and country of residence. Although availability of hospital and nursing home beds partially explained the variation between countries, considerable variation remained even after controlling for that, plus age, sex, and social support. Place of death from dementia differed significantly between the countries studied. In all countries, a majority of patients with dementia died in a long-term care facility. The provision of appropriate long-term care facilities with appropriate staffing could be the primary policy instrument that could help patients with dementia avoid dying in the hospital and ensure quality of end-of-life care in Europe.

Background: A well-known problem with student surveys is a too low response rate. Experiences with predicting electoral outcomes, which required much smaller sample sizes, inspired us to adopt a similar approach to course evaluation. We expected that having respondents estimate the average opinions of their peers required fewer respondents for comparable outcomes than giving own opinions., Methods: Two course evaluation studies were performed among successive first-year medical students (N = 380 and 450, respectively). Study 1: Half the cohort gave opinions on nine questions, while the other half predicted the average outcomes. A prize was offered for the three best predictions (motivational remedy). Study 2: Half the cohort gave opinions, a quarter made predictions without a prize and a quarter made predictions with previous year's results as prior knowledge (cognitive remedy). The numbers of respondents required for stable outcomes were determined following an iterative process. Differences between numbers of respondents required and between average scores were analysed with ANOVA., Results: In both studies, the prediction conditions required significantly fewer respondents (p < 0.001) for comparable outcomes. The informed prediction condition required the fewest respondents (N < 20)., Conclusion: Problems with response rates can be reduced by asking respondents to predict evaluation outcomes rather than giving opinions.

Place of death is an important societal indicator of end-of-life quality for the terminally ill. Using death certificate data, we examined metropolitan/non-metropolitan variation in place of death of patients with life-limiting conditions in Belgium, The Netherlands and England. Metropolitan patients were less likely to die at home and, in England, less likely to die in care homes, than non-metropolitan terminally ill. We found a lesser degree of social support and lower availability of care home beds as partial explanations of the metropolitan/non-metropolitan discrepancy. These findings warrant specific approaches to end-of-life care in metropolitan areas.

The potential richness of the feedback for learners and teachers is one of the educational advantages of progress tests (PTs). Every test administration yields information on a student's knowledge level in each sub-domain of the test (cross-sectional information), and it adds a next point to the corresponding knowledge growth curve (longitudinal information). Traditional paper-based feedback has severe limitations and requires considerable effort from the learners to give meaning to the data. We reasoned that the PT data should be flexibly accessible in all pathways and with any available comparison data, according to the personal interest of the learner. For that purpose, a web-based tool (Progress test Feedback, the ProF system) was developed. This article presents the principles and features of the generated feedback and shows how it can be used. In addition to enhancement of the feedback, the ProF database of longitudinal PT-data also provides new opportunities for research on knowledge growth, and these are currently being explored.

Background: Social comparison theory is relevant for learning in general. In a clinical context, we examined four hypotheses concerning: preferred other to compare with, preferred direction of comparison, response to social comparison and influence of personal social comparison orientation (SCO)., Aim: To investigate the relevance of social comparison for clinical workplace learning., Method: Students (n = 437) from nine different hospitals completed two questionnaires measuring their SCO and the direction of and response to their comparisons. t-tests were used to analyse the data., Results: Students substantially did compare. They preferred to compare with peer students more than with residents or staff, and with peers doing better more than with peers doing worse. Their response to social comparison was more often stimulating for learning than discouraging. Students high in SCO reported a stronger stimulating and discouraging response to their comparisons than students low in SCO., Conclusion: Social comparison does play a role in clinical workplace learning. The mainly stimulating response to social comparison indicates a positive learning influence. The preferred comparison with peers emphasizes the role of peers in the learning process. Further research should focus on student comparison behaviour and on situations that strengthen the positive effects of social comparison and reduce the negative or obstructing ones.

Background: The Netherlands, Belgium, and Luxembourg have adopted laws decriminalizing euthanasia under strict conditions of prudent practice. These laws stipulate, among other things, that the attending physician should consult an independent colleague to judge whether the substantive criteria of due care have been met. In this context initiatives were taken in the Netherlands and Belgium to establish specialized services providing such consultants: Support and Consultation for Euthanasia in the Netherlands (SCEN) and Life End Information Forum (LEIF) in Belgium. The aim of this study is to describe and compare these initiatives., Methods: We studied and compared relevant documents concerning the Dutch and Belgian consultation service (e.g. articles of bye-laws, inventories of activities, training books, consultation protocols)., Results: In both countries, the consultation services are delivered by trained physicians who can be consulted in cases of a request for euthanasia and who offer support and information to attending physicians. The context in which the two organisations were founded, as well as the way they are organised and regulated, is different in each country. By providing information on all end-of-life care matters, the Belgian LEIF seems to have a broader consultation role than the Dutch SCEN. SCEN on the other hand has a longer history, is more regulated and organised on a larger scale and receives more government funding than LEIF. The number of training hours for physicians is equal. However, SCEN-training puts more emphasis on the consultation report, whereas LEIF-training primarily emphasizes the ethical framework of end-of-life decisions., Conclusion: In case of a request for euthanasia, in the Netherlands as well as in Belgium similar consultation services by independent qualified physicians have been developed. In countries where legalising physician-assisted death is being contemplated, the development of such a consultation provision could also be considered in order to safeguard the practice of euthanasia (as it can provide safeguards to adequate performance of euthanasia and assisted suicide).

Context: Students' perceptions of their learning environment are of great importance to their learning process. In this study we assessed the time allocated by students to clerkship activities and the relationship between students' allocations of time and their perceptions of the quality of their clinical learning environment., Methods: Participants were 133 undergraduate students from eight hospitals taking part in four clerkship rotations. All students recorded the time they spent on eight clerkship activities over 2 weeks and completed the Postgraduate Hospital Educational Environment Measure (PHEEM). Partial correlation analyses were undertaken to examine the relationship between the amount of time students spent on each activity and their PHEEM scores., Results: Students spent nearly 8 hours a day on clerkship activities. Most time was spent on observing doctors (40%), followed by participating in consultations without direct supervision (12%). The time students spent on observing doctors (r = 0.206, P < 0.05) and in consultations without direct supervision (r = 0.211, P < 0.05) was significantly related to the students' PHEEM scores. There was a significant relationship at the P < 0.10 level between the time spent on directly supervised activities and students' PHEEM scores (r = 0.165, P < 0.10)., Conclusions: The results suggest that the time spent on activities involving direct patient contact is positively related to students' perceptions of the quality of their learning environment. None of the activities were significantly negatively related to the students' perceptions of their clinical learning environment. Future research should examine the optimal time allocations required to enhance the perceived quality of the clinical learning environment.

Background: The validation of educational instruments, in particular the employment of factor analysis, can be improved in many instances., Aims: To demonstrate the superiority of a sophisticated method of factor analysis, implying an integration of recommendations described in the factor analysis literature, over often employed limited applications of factor analysis. We demonstrate the essential steps, focusing on the Postgraduate Hospital Educational Environment Measure (PHEEM)., Method: The PHEEM was completed by 279 clerks. We performed Principal Component Analysis (PCA) with varimax rotation. A combination of three psychometric criteria was applied: scree plot, eigenvalues >1.5 and a minimum percentage of additionally explained variance of approximately 5%. Furthermore, four interpretability criteria were used. Confirmatory factor analysis was performed to verify the original scale structure., Results: Our method yielded three interpretable and practically useful dimensions: learning content and coaching, beneficial affective climate and external regulation. Additionally, combining several criteria reduced the risk of overfactoring and underfactoring. Furthermore, the resulting dimensions corresponded with three learning functions essential to high-quality learning, thus strengthening our findings. Confirmatory factor analysis disproved the original scale structure., Conclusions: Our sophisticated approach yielded several advantages over methods applied in previous validation studies. Therefore, we recommend this method in validation studies to achieve best practice.

Objectives: To describe and compare current legal procedures for notifying, controlling and evaluating (NCE-procedures) euthanasia in Belgium and the Netherlands, and to discuss the implications for a safe and controllable euthanasia practice., Methods: We systematically studied and compared official documents relating to the Belgian and the Dutch NCE-procedures for euthanasia., Results: In both countries, physicians are required to notify their cases to a review Committee, stimulating them to safeguard the quality of their euthanasia practice and to make societal control over the practice of euthanasia possible. However, the procedures in both countries differ. The main differences are that the Dutch notification and control procedures are more elaborate and transparent than the Belgian, and that the Belgian procedures are primarily anonymous, whereas the Dutch are not. Societal evaluation is made in both countries through the Committees' summary reports to Parliament., Conclusions: Transparent procedures like the Dutch may better facilitate societal control. Informing physicians about the law and the due care requirements for euthanasia, and systematic feedback about their medical actions are both pivotal to achieving efficient societal control and engendering the level of care needed when performing such far-reaching medical acts.

Objectives: We aimed to study the effects of active-learning curricula on graduation rates of students and on the length of time needed to graduate., Methods: Graduation rates for 10 generations of students enrolling in the eight Dutch medical schools between 1989 and 1998 were analysed. In addition, time needed to graduate was recorded. Three of the eight schools had curricula emphasising active learning, small-group instruction and limited numbers of lectures; the other five had conventional curricula to varying degrees., Results: Overall, the active-learning curricula graduated on average 8% more students per year, and these students graduated on average 5 months earlier than their colleagues from conventional curricula., Conclusions: Four hypotheses potentially explaining the effect of active learning on graduation rate and study duration were considered: (i) active-learning curricula promote the social and academic integration of students; (ii) active-learning curricula attract brighter students; (iii) active-learning curricula retain more poor students, and (iv) the active engagement of students with their study required by active-learning curricula induces better academic performance and, hence, lower dropout rates. The first three hypotheses had to be rejected. It was concluded that the better-learning hypothesis provides the most parsimonious account for the data.

Background: Several authors assume that the supervisor's role, observation of behaviour and students' active participation are important factors in the instructiveness of feedback., Aim: This study aims to provide empirical evidence for these expectations., Methods: For two weeks, 142 clerks from eight hospitals recorded for each individual feedback event: who provided the feedback, whether the feedback was based on observation of behaviour, who initiated the feedback moment and the perceived instructiveness of the feedback. Data were analysed with multilevel techniques., Results: The perceived instructiveness of feedback provided by specialists and residents did not differ significantly. However, both were perceived to be more instructive than feedback from nursing and paramedical staff (beta(specialists) = 0.862, p < 0.01; beta(residents) = 0.853, p < 0.01). Feedback on behaviour that had been directly observed was reported to be more instructive than feedback on behaviour that had not been observed (beta(observed) = 0.314, p < 0.001). Feedback which stemmed from student initiative or a joint initiative was experienced to be more instructive than feedback which ensued from the supervisor's initiative (beta(student) = 0.441, p < 0.01; beta(joint) = 0.392, p < 0.01)., Conclusions: The expectations concerning the influence of observation and student initiative on the instructiveness of feedback were confirmed in this empirical study. Expected differences in instructiveness between feedback from specialists and residents were not confirmed.

In the Netherlands, most universities use a lottery system, weighted by average examination grades, to admit students to medical school. However, the political climate for pre-entry selection procedures is changing rapidly. A study by the University Medical Center Rotterdam revealed that pre-entry selection reduces the medical school drop-out rate during the first years of medical training. This is an important observation. It is plausible that students selected by pre-entry selection are more motivated than students selected by a lottery system. However, it is unknown whether these students will also display better professional behaviour and skills in their future careers. Further research is required to determine which of the cognitive and non-cognitive characteristics relevant for predicting students' success in their future careers should be included in the assessment to optimize the selection procedure.

Today's health sciences educational programmes have to deal with a growing and changing amount of knowledge. It is becoming increasingly important for students to be able to use and manage knowledge. We suggest incorporating open-book tests in assessment programmes to meet these changes. This view on the use of open-book tests is discussed and the influence on test quality is examined. To cope with the growing amount of medical knowledge, we have divided the body of knowledge into core knowledge, which students must know without need for references, and backup knowledge, which students need to understand and use properly with the help of references if so desired. As a result, all tests consist of a subtest for reproduction and understanding of core knowledge (a closed-book test) and a subtest for the ability to understand and manage backup knowledge (an open-book test). Statistical data from 14 such double-subtest exams for first and second-year students were analyzed for two cohorts (N = 435 and N = 449) with multilevel analysis, in accordance with generalizability theory. The reliability of the open and closed-book sections of the separate tests varied between 0.712 and 0.850. The open-book items reduce reliability somewhat. The estimated disattenuated correlation was 0.960 and 0.937 for cohorts 1 and 2 respectively. It is concluded that the use of open-book items with closed-book items slightly decreases test reliability but the overall index is acceptable. In addition, open and closed-book sections are strongly positively related. Therefore, open-book tests could be helpful in complementing today's assessment programmes.

Context: Many students experience a tough transition from pre-clinical to clinical training and previous studies suggest that this may constrict students' progress. However, clear empirical evidence of this is lacking. The aim of this study was to determine: whether the perceived difficulty of transition influences student performance during the first 2 weeks of clerkships; whether it influences students' overall performance in their first clerkship, and the degree to which the difficulty of transition is influenced by students' pre-clinical knowledge and skills levels., Methods: Clerks (n = 83) from a university hospital and eight affiliated hospitals completed a questionnaire measuring the perceived difficulty of the transition period. Data collected included student scores on pre-clinical knowledge and skills, their performance during the second week of the first clerkship, and their overall performance in the first clerkship. Univariate and multivariate multiple regression analyses were used to analyse the data., Results: The perceived difficulty of transition was neither predictive of student performance during the transition period (adjusted R(2) = 11.8%, P = NS), nor of their overall clerkship performance (adjusted R(2) = 8.6%, P = NS). Students' pre-clinical knowledge and skills played a minor role in the perceived difficulty of the transition period., Conclusions: The negative effect of the transition period on student progress suggested in the literature was not found in this study. A possible explanation for the limited influence of students' knowledge and skills on performance during the transition period is that the workload in this period causes a cognitive overload, interfering with students' abilities to apply their pre-clinical knowledge and skills.

Background: To cope with a lack of doctors and in anticipation of the Bachelor-Master structure for Medicine, several Dutch universities offer graduate entry programmes for students with degrees in areas related to Medicine. The graduate entry programme is a four-year programme: after a transition period of one year students enroll in the fourth year of the regular six-year training programme., Aim: The research questions in this study were (1) whether and when graduate entry students' knowledge reached a level comparable to that of regular medical students and (2) whether there were differences in knowledge levels between graduate entry students with a university or HBO (college) degree., Methods: The progress test results of ninety graduate entry students who were enrolled in the transitional programme between 2002 and 2004 were compared to those of regular third-year students., Results: Initially, graduate entry students scored significantly lower on the progress tests, but differences disappeared within a year. No differences were found between graduate entry students with a university or HBO degree., Conclusions: The results of this study indicate that the increase in knowledge after a one-year transitional period is sufficient to enroll students with related degrees in the fourth year of the regular medical training programme.

Objective: To determine the effectiveness of single-point benchmarking and longitudinal benchmarking for inter-school educational evaluation., Methods: We carried out a mixed, longitudinal, cross-sectional study using data from 24 annual measurement moments (4 tests x 6 year groups) over 4 years for 4 annual progress tests assessing the graduation-level knowledge of all students from 3 co-operating medical schools. Participants included undergraduate medical students (about 5000) from 3 medical schools. The main outcome measures involved between-school comparisons of progress test results based on different benchmarking methods., Results: Variations in relative school performance across different tests and year groups indicate instability and low reliability of single-point benchmarking, which is subject to distortions as a result of school-test and year group-test interaction effects. Deviations of school means from the overall mean follow an irregular, noisy pattern obscuring systematic between-school differences. The longitudinal benchmarking method results in suppression of noise and revelation of systematic differences. The pattern of a school's cumulative deviations per year group gives a credible reflection of the relative performance of year groups., Conclusions: Even with highly comparable curricula, single-point benchmarking can result in distortion of the results of comparisons. If longitudinal data are available, the information contained in a school's cumulative deviations from the overall mean can be used. In such a case, the mean test score across schools is a useful benchmark for cross-institutional comparison.

Objective: To determine whether items of progress tests used for inter-curriculum comparison favour students from the medical school where the items were produced (i.e. whether the origin bias of test items is a potential confounder in comparisons between curricula)., Methods: We investigated scores of students from different schools on subtests consisting of progress test items constructed by authors from the different schools. In a cross-institutional collaboration between 3 medical schools, progress tests are jointly constructed and simultaneously administered to all students at the 3 schools. Test score data for 6 consecutive progress tests were investigated. Participants consisted of approximately 5000 undergraduate medical students from 3 medical schools. The main outcome measure was the difference between the scores on subtests of items constructed by authors from 2 of the collaborating schools (subtest difference score)., Results: The subtest difference scores showed that students obtained better results on items produced at their own schools. This effect was more pronounced in Years 2-5 of the curriculum than in Year 1, and diminished in Year 6., Conclusions: Progress test items were subject to origin bias. As a consequence, all participating schools should contribute equal numbers of test items if tests are to be used for valid and fair inter-curriculum comparisons.

The practice of assessment is governed by an interesting paradox. On the one hand good assessment requires substantial resources which may exceed the capacity of a single institution and we have reason to doubt the quality of our in-house examinations. On the other hand, our parsimonity with regard to our resources makes us reluctant to pool efforts and share our test material. This paper reports on an initiative to share test material across different medical schools. Three medical schools in The Netherlands have successfully set up a partnership for a specific testing method: progress testing. At present, these three schools collaboratively produce high-quality test items. The jointly produced progress tests are administered concurrently by these three schools and one other school, which buys the test. The steps taken in establishing this partnership are described and results are presented to illustrate the unique sort of information that is obtained by cross-institutional assessment. In addition, plans to improve test content and procedure and to expand the partnership are outlined. Eventually, the collaboration may even extend to other test formats. This article is intended to give evidence of the feasibility and exciting potential of between school collaboration in test development and test administration. Our experiences have demonstrated that such collaboration has excellent potential to combine economic benefit with educational advantages, which exceed what is achievable by individual schools.

Background: It is known that children with previously diagnosed heart defects die suddenly. The causes of death are often unknown., Objective: The aim of the study was to identify all infants and children within the Netherlands with previously diagnosed heart disease who had a sudden unexpected death (SUD), and to identify the possible cause of death., Design: Retrospective, cross-sectional study., Patients and Setting: All children (<19 years) with a previously diagnosed heart defect and SUD between January 1990 and June 2001 in seven out of eight tertiary centres in the Netherlands were identified using the hospital databases. We excluded patients receiving compassionate care. Diagnoses, clinical status and circumstances of death were sought from case notes and post mortem reports. Deaths were classified as of cardiac or non-cardiac origin., Results: We identified 150 cases of SUD (89 male) at a median age of 2.3 years (range 18 days-18.9 years); 49/150 patients (33%) were

Objective: To analyse the career development of two cohorts of medical graduates from the University of Groningen, the Netherlands., Design: Structured interviews., Method: For all 333 graduates who commenced undergraduate medical training in 1982 and 1983, data were collected for the period 1993-2000 with respect to resident training, income, job load, job satisfaction and scientific research. Gender differences were analysed for all of the variables. This was done by means of structured interviews as well as a strategic search in Medline and the on-line public catalogue of the University of Groningen., Results: In the year 2000, 73% of the graduates had enrolled in resident training, 8% had not succeeded in finding a place. The wish to work part-time had increased strongly over the years. In general, job satisfaction was reasonable. In total 31% of the cohort had published one or more English articles or written a thesis. Gender differences were found for job load and publications., Conclusions: Ten years after graduation, medical careers had become established. Men had not succeeded in fulfilling their wishes to work part-time. Women were disadvantaged with respect to their scientific career.

Objective: To determine the working experience and desires of doctors, who started their medical training approximately 10 years ago., Design: Telephone inquiry., Setting: University of Groningen, the Netherlands., Method: In the summer of 1993, 98% of medical graduates who started their training at the University of Groningen in 1982 of 1983 were questioned about working experience and wishes for the future., Results: Over 70% worked as medical assistants in hospitals; most of them were not (yet) in training. Almost all male subjects and 4 out of 5 female subjects worked full time. Half of them wished to keep a full time job (two-thirds of the men, one-third of the women)., Conclusion: When all working desires would be fulfilled, the future work time per doctor would be 86%. There is a great need for specialist training places.

Smoking habits and attitudes towards smoking of medical students (n = 725), house officers (n = 126) and consultants (n = 236) of the University Hospital of Groningen were studied, in 1989 by means of a World Health Organization (WHO) questionnaire. Overall response rate was 84%. Twenty seven percent of the medical students are current smokers, 28% of the house officers and 34% of the consultants. There is a remarkable difference among medical specialists i.e: smoking prevalence is highest among psychiatrists and lowest among paediatricians. The prevalence of smoking in medical students and house officers is lower than in the Dutch population. Smoking habits of the consultants are similar to those of the general population. About 75% of the doctors reported having no experience with smoking cessation programmes. Doctors report a need for more skills and knowledge on smoking cessation programmes.

Smoking habits and attitudes towards smoking of medical students (n = 725), house officers (n = 126) and consultants (n = 236) of the University Hospital of Groningen were studied in 1989 using a WHO questionnaire. Overall response was 84%. Twenty-seven percent of the medical students, 28% of the house officers and 34% of the consultants are current smokers. The prevalence of smoking in medical students and house officers is lower than that in the Dutch population. Smoking habits of consultants are similar to the general population. The prevalence of smoking Dutch physicians which was 56% in 1983 is decreasing rapidly. Doctors report they want more information about smoking cessation programs.