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Aim: The aim of this report, written for the 40th anniversary issue of Medical Teacher, is to document 20 years of development of the Utrecht undergraduate medical curriculum, as both to exhibit accountability and to inform the community of the process and choices that can be made in long-term curriculum development.Methods: We used the SPICES model, created by Medical Teacher's Editor Ronald Harden and colleagues in 1984.Results: The Utrecht six-year program, now called "CRU+", has many distinct features that were introduced, most of which are well documented. A limited selection includesA new 3+3 years Bachelor-Master structure following the EU Bologna rules leading to MD registration for cohorts of about 300.Horizontally integrated classroom teaching of basic sciences with clinical disciplines predominantly in groups of 12 and limited lectures.Mandatory knowledge retention tests, retesting the clinically relevant core knowledge from block tests of semesters one through four.Vertical integration not only linking clinical experience with background knowledge, but also exemplified by a stepwise increase in health care responsibilities throughout the curriculum.A final year focussing on growth towards the level of a primary responsible physician in a 12-week sub-internship for a limited number of patients and beds, in a chosen specialty. The student is called a semi-physician in the clerkship of this transitional year to residency.Teaching skills training for all medical graduates, an elective teaching rotation and various peer-teaching arrangements throughout the curriculum.Integrated semi-longitudinal clerkships with an assessment focus on entrustment decisions for Entrustable Professional Activities.Conclusion: UMC Utrecht has made a continuous attempt to both develop its medical curriculum and to study and report on its development in the literature, regarding new methods found and insights derived. UMC Utrecht will remain committed to developing training to meet twenty-first century demands of medical graduates.

Context Learning outcomes for residency training are defined in competency frameworks such as the CanMEDS framework, which ultimately aim to better prepare residents for their future tasks. Although residents’ training relies heavily on learning through participation in the workplace under the supervision of a specialist, it remains unclear how the CanMEDS framework informs practice-based learning and daily interactions between residents and supervisors. Objectives This study aimed to explore how the CanMEDS framework informs residents’ practice-based training and interactions with supervisors. Methods Constructivist grounded theory guided iterative data collection and analyses. Data were collected by direct observations of residents and supervisors, combined with formal and field interviews. We progressively arrived at an explanatory theory by coding and interpreting the data, building provisional theories and through continuous conversations. Data analysis drew on sensitising insights from communities of practice theory, which provided this study with a social learning perspective. Results CanMEDS roles occurred in an integrated fashion and usually remained implicit during interactions. The language of CanMEDS was not adopted in clinical practice, which seemed to impede explicit learning interactions. The CanMEDS framework seemed only one of many factors of influence in practice-based training: patient records and other documents were highly influential in daily activities and did not always correspond with CanMEDS roles. Additionally, the position of residents seemed too peripheral to allow them to learn certain aspects of the Health Advocate and Leader roles. Conclusions The CanMEDS framework did not really guide supervisors’ and residents’ practice or interactions. It was not explicitly used as a common language in which to talk about resident performance and roles. Therefore, the extent to which CanMEDS actually helps improve residents’ learning trajectories and conversations between residents and supervisors about residents’ progress remains questionable. This study highlights the fact that the reification of competency frameworks into the complexity of practice-based learning is not a straightforward exercise.

Situational Judgement Tests (SJTs) are increasingly implemented in medical school admissions. In this paper, we investigate the effects of vocational interests, previous academic experience, gender and age on SJT performance. The SJT was part of the selection process for the Bachelor's degree programme in Medicine at University of Groningen, the Netherlands. All applicants for the academic year 2015-2016 were included and had to choose between learning communities Global Health (n = 126), Sustainable Care (n = 149), Intramural Care (n = 225), or Molecular Medicine (n = 116). This choice was used as a proxy for vocational interest. In addition, all graduate-entry applicants for academic year 2015-2016 (n = 213) were included to examine the effect of previous academic experience on performance. We used MANCOVA analyses with Bonferroni post hoc multiple comparisons tests for applicant performance on a six-scenario SJT. The MANCOVA analyses showed that for all scenarios, the independent variables were significantly related to performance (Pillai's Trace: 0.02-0.47, p

Background: The importance of medical education research in Saudi Arabia has been acknowledged increasingly and a lot of concepts used have been derived from the Western world. The question arises, however, whether Western concepts and questionnaires are transferable to societies with different cultures. The aim of this study was to investigate the instrument structure and the reliability of the Arabic version of the Zuckerman-Kuhlman Personality Questionnaire-medium ( ZKPQ-m).Methods: Three statistical methods with decreased amount of strictness were used to analyse our data: Confirmatory Factor Analysis, Procrustes rotation and Principal Component Analysis.Results: Our outcomes did not confirm the original instrument structure. Instead, we found four interpretable components: Emotional Instability, Impulse-seeking, Activeness and Self-Control. However, the amount of explained variance was not very high and the internal consistencies ranged from unsatisfactory to only moderate. The data showed a high percentage of respondents agreeing with more than three items of the Infrequency scale, which may be attributable to the collectivistic culture in Saudi Arabia.Conclusion: We did not succeed in replicating the ZKPQ structure in the Arabic context. Social desirability, a common characteristic in collectivistic cultures, may have reduced the replicability of the internal structure of the ZKPQ-m. Different methods to measure concepts in collectivistic cultures may help to get round social desirability.

Many different medical school selection processes are used worldwide. In this paper, we examine the effect of (1) participation, and (2) selection in a voluntary selection process on study performance. We included data from two cohorts of medical students admitted to Erasmus MC, Rotterdam and VUmc, Amsterdam, The Netherlands and compared them to previously published data from Groningen medical school, The Netherlands. All included students were admitted based on either (1) a top pre-university grade point average, or (2) a voluntary selection process, or (3) weighted lottery. We distinguished between lottery-admitted students who had participated in the voluntary selection process and had been rejected, and lottery-admitted students who had not participated. Knowledge test scores, study progress, and professionalism scores were examined using ANCOVA modelling, logistic regression, and Bonferroni post hoc multiple-comparison tests, controlling for gender and cohort. For written test grades, results showed a participation effect at Groningen medical school and Erasmus MC (p

Background: Job satisfaction is essential for physicians' well-being and patient care. The work ethic of long days and hard work that has been advocated for decades is acknowledged as a threat for physicians' job satisfaction, well-being, and patient safety. Our aim was to determine the actual and preferred job size of physicians and to investigate how these and the differences between them influence physicians' job satisfaction.Method: Data were retrieved from a larger, longitudinal study among physicians starting medical training at Groningen University in 1982/83/92/93 (N = 597). Data from 506 participants (85%) were available for this study. We used regression analysis to investigate the influence of job size on physicians' job satisfaction (13 aspects) and ANOVA to examine differences in job satisfaction between physicians wishing to retain, reduce or increase job size.Results: The majority of the respondents (57%) had an actual job size less than 1.0 FTE. More than 80% of all respondents preferred not to work full-time in the future. Respondents' average actual and preferred job sizes were.85 FTE and .81 FTE, respectively. On average, respondents who wished to work less (35% of respondents) preferred a job size reduction of 0.18 FTE and those who wished to work more (12%) preferred an increase in job size of 0.16 FTE. Job size influenced satisfaction with balance work-private hours most (beta = -.351). Physicians who preferred larger job sizes were - compared to the other groups of physicians - least satisfied with professional accomplishments.Conclusions: A considerable group of physicians reported a gap between actual and preferred job size. Realizing physicians' preferences as to job size will hardly affect total workforce, but may greatly benefit individual physicians as well as their patients and society. Therefore, it seems time for a shift in work ethic.

ObjectivesThis study was conducted to: (i) analyse whether students admitted to one medical school based on top pre-university grades, a voluntary multifaceted selection process, or lottery, respectively, differed in study performance; (ii) examine whether students who were accepted in the multifaceted selection process outperformed their rejected peers, and (iii) analyse whether participation in the multifaceted selection procedure was related to performance.MethodsWe examined knowledge test and professionalism scores, study progress and dropout in three cohorts of medical students admitted to the University of Groningen, the Netherlands in 2009, 2010 and 2011 (n=1055). We divided the lottery-admitted group into, respectively, students who had not participated and students who had been rejected in the multifaceted selection process. We used ancova modelling, logistic regression and Bonferroni post hoc multiple-comparison tests and controlled for gender and cohort.ResultsThe top pre-university grade group achieved higher knowledge test scores and more Year1 course credits than all other groups (pConclusionsA top pre-university grade point average was the best predictor of performance. For so-called non-academic performance, the multifaceted selection process was efficient in identifying applicants with suitable skills. Participation in the multifaceted selection procedure seems to be predictive of higher performance. Further research is needed to assess whether our results are generalisable to other medical schools.

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 (beta = .152, p

Background: Career advice is an important instrument to help students with the proper specialty selection. The study aims (1) to explore the views of newly graduated doctors in Saudi Arabia about their experience with the current status of career support system during medical training and (2) to identify cross-cultural similarities and differences.Methods: A cross-sectional design study was conducted using a questionnaire to elicit the responses of participants from newly qualified doctors concerning the availability and significance of career advice. SPSS (version 11.0; Chicago, IL) was used to analyze the data and statistical tests, such as chi-square and unpaired t tests, were used to analyze the observations.Results: A response rate of 94.7% was obtained. Among this group, 102 were males and 78 were females. Only 53% did receive career advice. The majority of men felt that career advice during medical studies was inadequate, while women were less negative (69% versus 32%; p = 0.0001). Furthermore, men were more disappointed about the possibilities for career advice after graduating than women (34% versus 13%, p = 0.0001).Conclusions: The results show that only half of newly graduated doctors had received any career advice during medical training. As the health care system cannot afford the potential waste of time and resources for doctors, career guidance should begin in undergraduate training so that the process of thinking about their future career starts longtime before they make their career choice.

Introduction: Residents benefit from regular, high quality feedback on all CanMEDS roles during their training. However, feedback mostly concerns Medical Expert, leaving the other roles behind. A feedback system was developed to guide supervisors in providing feedback on CanMEDS roles. We analyzed whether feedback was provided on the intended roles and explored differences in quality of written feedback.Methods: In the feedback system, CanMEDS roles were assigned to five authentic situations: Patient Encounter, Morning Report, On-call, CAT, and Oral Presentation. Quality of feedback was operationalized as specificity and inclusion of strengths and improvement points. Differences in specificity between roles were tested with Mann-Whitney U tests with a Bonferroni correction (=0.003).Results: Supervisors (n=126) provided residents (n=120) with feedback (591 times). Feedback was provided on the intended roles, most frequently on Scholar (78%) and Communicator (71%); least on Manager (47%), and Collaborator (56%). Strengths (78%) were mentioned more frequently than improvement points (52%), which were lacking in 40% of the feedback on Manager, Professional, and Collaborator. Feedback on Scholar was more frequently (p=0.000) and on Reflective Professional was less frequently (p=0.003) specific.Discussion and conclusion: Assigning roles to authentic situations guides supervisors in providing feedback on different CanMEDS roles. We recommend additional supervisor training on how to observe and evaluate the roles.

The extent to which students feel involved in their education positively influences academic achievement. Individual student–faculty meetings can foster student involvement. To be effective, faculty acknowledgement of the benefit of these meetings is a prerequisite. The aim of this study was to explore faculty perceptions of individual student–faculty meetings. In addition we investigated students’ perceptions. As part of the undergraduate programme, mandatory individual intake and follow-up meetings between first-year medical students (n = 425) and senior faculty members (n = 34) have been implemented from 2009 onwards. We administered a questionnaire on faculty perceptions of the benefit and impact of intake meetings. Subsequently, after both meetings had been held, strong and weak points of the mandatory programme were explored using open-ended questions. Students’ perceptions were investigated by open-ended questions as a part of the curriculum evaluation process. Faculty enjoyed the meetings (90 %), perceived the meetings to be beneficial (74 %) and expected a positive effect on student involvement (74 %). Faculty appreciated the opportunity to give advice tailored to students’ personal needs and levels of performance. The students appreciated the meetings and the attention given to their personal situation and study progress. Faculty and student appreciation of the meetings seems to support the assumption that the individual meetings increase students’ social and academic involvement. Further research should focus on the impact of individual student–faculty meetings on students’ learning behaviours.

Background: The exploration of specialty choices by medical students is a hot debate as it affects several important determinants of health care delivery. This study was carried out to determine variation in specialty preferences during medical school training and the perceptions that affect students' specialty choice.Methods: A cross-sectional questionnaire-based study was performed on 590 students with a 93.22% response rate and covered queries on demography, specialty choices, and perceptions influencing specialty choices. Class-wise analysis of specialty choices was carried out.Results: The most preferred specialty expressed by male students was surgery, followed by internal medicine and orthopedics, while most preferred by female students were surgery, followed by pediatrics and ophthalmology. Male students' emphasized factors like less competitive field, shortage of specialists, and diversity of patients while the prestige of specialty and teaching opportunities had a greater impact on female students.Conclusions: Surgery, internal medicine, pediatrics, orthopedics, and ophthalmology were the most preferred specialty choices. Gender preference was observed to affect choices of few specialties such as orthopedics and obstetrics/gynecology. Perceptions which have an impact on specialty selection of male and female students may reflect a different tempo of growing up in men and women.

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 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.

Objective: In the Netherlands HIV nursing consultants have participated in HIV-care since 1985: their profession has changed with developments in HIV-treatment over time. The study goal was to gather information about their role in HIV-care and to provide an useful example to other (HIV-)care settings over the world.Methods: Interviews were held with HIV nursing consultants from all AIDS treatment centres. Descriptive analyses and statistical tests to detect differences between centres categorized by care model (parallel/unstructured/alternating), were performed.Results: 58% centres perform substitution of care. HIV nursing consultants see almost all patients at least once a year and see all patients when treatment is started/altered. The frequency of consultations for HIV-patients in stable condition varies, 2-4 times a year. Substitution leads to a slight, non-significant decrease in number of consultations. Adherence support is provided at the start of and during treatment. Regular patient discussions are common. All respondents are acquainted with the guidelines. Detailed knowledge of the adherence issues is limited: 58.3% had read the adherence chapter.Conclusion: Substitution of care model is an appropriate and effective method for the management of HIV-infected patients.Practice implications: Further development of and research into this new role of HIV nurse consultants is appropriate. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

This study describes strategies used by Dutch HIV nurse consultants to promote adherence to anti retroviral therapy (ART) and the assumptions on which these strategies were based. The study used a descriptive qualitative design with individual and focus group interviews. Individual semi-structured interviews (n = 23) focusing on adherence-supporting procedures and case-based focus groups (3 groups with 5-7 participants each) focusing on adherence strategies were held with HIV nurse consultants (n = 19). The strategies described were mainly based on experience. Theoretical principles were rarely discussed and participants seldom referred to the literature. Adherence-promoting strategies were identified for two phases: (a) before beginning ART and (b) during follow-up care while on ART Strategies that were not used in one specific phase were categorized under "all phases." Data yielded useful ideas for the care of HIV-infected patients, and findings can be applied to the development and use of adherence-promoting strategies. (Journal of the Association of Nurses in AIDS Care, 21, 489-502) Copyright (C) 2010 Association of Nurses in AIDS Care

Patients on long-term highly active antiretroviral therapy (HAART) were studied to determine persistence, drug resistance development, and evolution of HIV-1 proviral DNA.Peripheral blood mononuclear cells were obtained by large volume blood drawn (500 mL) from 8 clinically successfully treated patients who had received uninterrupted HAART for up to 8.9 years. HIV-1 load was determined by Taqman real-time polymerase chain reaction. Drug resistance mutations were determined by sequencing and ultrasensitive, allele-specific, reverse transcriptase (RT)-polymerase chain reaction.HIV-1 DNA load was significantly higher in aged memory (CD45RO CD57) when compared with memory (CD45RO CD57) and naive (CD27 CD45RO) CD4 T cells after HAART. Sequencing revealed no major drug resistance mutations in protease in all patients and appearance of resistance mutations in RT in just 1 patient. In 1 of 5 patients with undetectable viremia during treatment, RT M184 substitutions were detected. Phylogenetic analysis showed short genetic distances between patient sequences.During long-term HAART, HIV-1 is able to persist in terminally differentiated CD4 T cells as proviral DNA. Viral evolution was restricted, and in 80% of the patients with undetectable viremia, no sign of viral replication could be detected.

Alle opleidingen, zowel de basis- als de medisch specialistische vervolgopleidingen, zitten midden in een ingrijpend veranderingsproces. In de basisopleiding zijn nieuwe curricula ontworpen waarin onderwijs gerelateerd aan een ziektegeschiedenis of probleem wordt aangeboden, preklinische en klinische vakken geintegreerd aan bod komen, onderwijs in kleine groepen wordt gegeven, en veel aandacht wordt geschonken aan communicatieve vaardigheden en attitude. Daarnaast zijn competentiegericht opleiden – op dit moment door de ervaringen op middelbare scholen en in het MBO helaas een beetje een beladen term – academische vorming

PURPOSE: To objectively assess changes in body fat distribution in a subgroup of antiretroviral therapy-naïve participants in a randomized comparative trial of regimens including a nucleoside analogue backbone of didanosine with either lamivudine or stavudine. METHOD: Whole body dual-energy X-ray absorptiometry (DEXA) scans were performed at baseline and weeks 48 and 96 of therapy in all 19 patients from one of the sites participating in the Antiretroviral Regimen Evaluation Study (ARES). Patients had been randomized to receive nelfinavir/didanosine/stavudine (n = 8), nevirapine/didanosine/lamivudine (n = 7), or ritonavir-boosted saquinavir/didanosine/lamivudine (n = 4). RESULTS: In an intent-to-treat analysis, patients allocated to didanosine plus stavudine-containing treatment after 96 weeks had lost a median of 1,825 g (-26%) of total limb fat, as compared to a median gain of 1,639 (48%) and 403 (6%) g in those randomized to the didanosine/lamivudine plus nevirapine or saquinavir-containing regimens, respectively. These changes in limb fat were statistically significantly different when comparing patients allocated to stavudine-containing treatment with both of the other two treatment arms combined (p = .01). CONCLUSION: This study suggests that didanosine/lamivudine, when combined with either nevirapine or ritonavir-boosted saquinavir over 96 weeks of therapy, is possibly not associated with limb fat atrophy, in contrast to when treatment contained didanosine, stavudine, and nelfinavir combined

Early clinical experience is being introduced in innovative, vertically integrated undergraduate medical curricula. While in many cases, this early clinical experience is limited to the presence of patients during lectures, in Utrecht students gain 'hands on' experience of daily clinical practice during 6-week clerkships. We studied students' and teachers' opinions of these full clerkships in the third year of a medical course.All 238 clinical teachers and 89 students involved in the 2003/2004 third year clerkships of the new Utrecht medical curriculum were asked to fill in a 16-item questionnaire about background knowledge, clinical skills, communication skills, and readiness for clerkships. Answers were given on a 5-point Likert scale. Response was 61%.Both students and clinical teachers answered all statements positively (score3.00), although some statements were awarded higher scores by students than teachers. In conclusion, students and teachers appear to appreciate clerkships early in the curriculum.Less background knowledge and a lower age than is usual for the more traditional (later) clerkships do not appear to hinder successful completion of an early clerkship. Indeed, early clerkships have several advantages, such as early observation of the future profession, increased motivation for further study, contextual learning, and improvement of clinical skills.

Background: Medical curricula become more and more vertically integrated (VI) to prepare graduates better for clinical practice. VI curricula show early clinical education, integration of biomedical sciences and focus on increasing clinical responsibility levels for trainees. Results of earlier questionnaire-based studies indicate that the type of the curriculum can affect the perceived preparedness for work as perceived by students or supervisors. The aim of the present study is to determine difference in actual performance of graduates from VI and non-VI curricula.Methods: We developed and implemented an authentic performance assessment based on different facets of competence for medical near-graduates in the role of beginning residents on a very busy day. Fifty nine candidates participated: 30 VI (Utrecht, The Netherlands) and 29 non-VI (Hamburg, Germany). Two physicians, one nurse and five standardized patients independently assessed each candidate on different facets of competence. Afterwards, the physicians indicated how much supervision they estimated each candidate would require on nine so called "Entrustable Professional Activities (EPAs)" unrelated to the observed scenarios.Results: Graduates from a VI curriculum received significantly higher scores by the physicians for the facet of competence "active professional development", with features like 'reflection' and 'asking for feedback'. In addition, VI graduates scored better on the EPA "solving a management problem", while the non-VI graduates got higher scores for the EPA "breaking bad news".Conclusions: This study gives an impression of the actual performance of medical graduates from VI and non-VI curricula. Even though not many differences were found, VI graduates got higher scores for features of professional development, which is important for postgraduate training and continuing education.

Contains fulltext : 47519.pdf (Publisher’s version ) (Closed access) BACKGROUND: To improve the dosing frequency and pill burden of antiretroviral therapy, we compared two once-daily dosed regimens to a twice-daily dosed regimen. METHOD: HIV-1-infected, antiretroviral drug-naive adults were randomized to either twice-daily nelfinavir and stavudine and once-daily didanosine (regimen A) or simplified once-daily dosed antiretroviral regimens consisting of nevirapine, didanosine, and lamivudine (regimen B) or saquinavir, ritonavir, didanosine, and lamivudine (regimen C). RESULTS: At 48 weeks of therapy, the proportion of patients with a blood plasma HIV-1 RNA concentration (pVL)

External site visits as part of the process of accreditation are an important aspect of quality control of medical education programmes. In 2011/2012 all medical schools (University Medical Centres, UMCs) in the Netherlands had such a visit. According to the accreditation system of the Netherlands and Flanders, accreditation has to be renewed every 6 years. The preparation of the site visit starts with the writing of a ‘critical reflection’ describing three aspects of the programme: the intended learning outcomes, the teaching and learning environment and the assessment. Furthermore, the critical reflection should present facts and figures about numbers of staff involved, supportive personnel, study results, etc. Due to changes in the accreditation system, the process of quality control of the programme is no longer part of the critical reflection and site visit. In the new system of accreditation the universities can apply for accreditation of the quality control process of all the programmes they offer [1]. Once institutional accreditation has been acquired, the site visits of the individual programmes are limited to the three standards mentioned above. Accreditation is given by the Netherlands and Flanders Accreditation Organization (NVAO) on the basis of the site visit report of an independent and certified visiting organization. As the Deans of the eight UMCs felt that this series of site visits should have additional value for all UMCs, the visiting organization was asked to evaluate all programmes in a separate ‘state of the art’ report. In autumn 2012, the state of the art report was presented [2]. The report contains examples of best practices, a benchmarking of the Dutch programmes with the curricula of medical schools abroad and the committee’s ideas about medical education in the next decades. The authors will elaborate in more detail on the content of the report in one of the forthcoming issues of PME. In general, according to the opinion of the visiting committee, the quality of the medical programmes in the Netherlands is good and the graduates of these programmes meet the international standards of quality for medical doctors. However, although Dutch medical schools are very prominent in the area of research in medical education [3] and are at the frontline of innovation, the visiting committee suggests that a new step forwards should be made. The committee poses the challenging—but also rhetoric—question whether medical education is future-proof. This question fits very well with the growing opinion that both medical (undergraduate and graduate) education and postgraduate medical specialist training should get prepared for the next change. They refer to the recent publications of the Carnegie Foundation for the Advancement of Teaching [4] and The Lancet [5] and make a plea for a more system-based approach to medical education: after the concept of a science-based medical education, followed by the concept of problem-based education, it is now time for a system-based approach. Definitely, educational concepts based on previous approaches with proven effectiveness should be preserved, but the content of the programme needs to change in concurrence with the changes in society and the requirements for good health care in the next decades. Patient safety, multidisciplinary collaboration, health care for elderly people, leadership, efficiency and cost reduction of health care are characteristics of a more system-based approach to medical education. In the Dutch situation with the CanMEDS model as the national guideline for the content of the programmes of medical education, these themes can be implemented within this model [6]. In my opinion, the CanMEDS model offers a good framework for making medical education more future-proof. Interestingly, in the process of implementing the CanMEDS model in postgraduate medical specialist training, the same themes have been identified for the education of the ‘intrinsic’ CanMEDS roles (communicator, organizer, collaborator, scholar, health advocate and professional). In the Netherlands, current experience with the CanMEDS roles in postgraduate training shows that the role of the medical expert is very prominent in the training programmes. The intrinsic roles, however, do not yet receive sufficient attention in the programmes. Last year, in order to help residents and medical specialist programme directors with the implementation of the intrinsic roles, the CanBetter project was started [7]. Just as we teach our students and residents the importance of livelong learning, the content of medical curricula and postgraduate specialist training programmes should continuously reflect the changes in society. In order to keep our programmes future-proof the plea of the visiting committee’s state of the art report inspires us to a livelong improvement of medical education. The year of 2012 has meant a great change for Perspectives on Medical Education, the journal of the Netherlands Association of Medical Education. It was the first volume of the journal to be published in English. When we started the preparations for the change from a Dutch into an English journal, the great challenge was to increase the interest of authors and readers. So far, taking the number of submissions into account, the new format is a success. The number of submitted manuscripts has quadrupled and around 25 % of the first authors originate from countries outside the Netherlands and Flanders. At the same time the percentage of rejected manuscripts has increased to 30 %. In summary, after 1 year of experience with PME, it appears that the new format of the journal really appeals to a greater audience and facilitates the improvement in the quality of the journal. The recent inclusion of PME into the PubMed database will definitely contribute to the growth and strength of the journal. With respect to the Editorial Board some changes will occur in 2013. According to the journal’s history, at present the members of the Editorial Board originate from the Netherlands and Flanders. However, it is our aim to change the Editorial Board gradually into a more international Board. Furthermore, as you can see in the advertisement in this issue of PME, there will be a vacancy for the position of Editor as—after more than two terms of being the Editor—I will be leaving this position in the course of 2013.

Background: To improve clinical performance assessment, checklist data should be immediately available to students to offer them detailed feedback and be stored in a database for quality assurance purposes.Aim: To introduce the digital pen as clinical performance assessment tool, report examiner satisfaction and explore the utility of generated checklist data for quality assurance purposes.Methods: The digital pen technology transmits examiners' handwritten assessments to a database and exports PDF-files to students' mailboxes. Descriptive statistical analysis of examiner satisfaction and the generated checklist data was performed.Results: The examiners were satisfied with the digital pen. Valuable data were obtained to improve objective structured clinical examination stations and rating criteria, identify training needs for future students and provide examiners with feedback on their rating skills.Conclusion: The digital pen technology is a practical device for sending completed checklists to students and providing valuable data for quality assurance purposes.

Recent thymic emigrants can be identified by T cell receptor excision circles (TRECs) formed during T-cell receptor rearrangement. Decreasing numbers of TRECs have been observed with aging and in human immunodeficiency virus (HIV)-1 infected individuals, suggesting for thymic impairment. Here, we show that in healthy individuals, declining thymic output will affect the TREC content only when accompanied by naive T-cell division. The rapid decline in TRECs observed during HIV-1 infection and the increase following HAART are better explained not by thymic impairment, but by changes in peripheral T-cell division rates. Our data indicate that TREC content in healthy individuals is only indirectly related to thymic output, and in HIV-1 infection is mainly affected by immune activation.

Een belangrijk kenmerk van de modernisering van de medisch specialistische vervolgopleidingen is het competentiegericht opleiden. Hiervoor wordt in Nederland het CanMEDS competentiemodel gebruikt.1 Dit model wordt tevens de leidraad in de opleiding tot basisarts. Volgens het nieuwe Raamplan Artsopleiding dat in 2009 verschijnt, zal CanMEDS ook voor de initiele opleidingen richtinggevend zijn. Competenties zijn dus ‘hot’. Maar er is meer dan competenties. Enigszins generaliserend kun je zeggen dat er drie factoren zijn die belangrijk zijn voor een goede opleiding: de student of arts in opleiding tot specialist (aios), de docent of opleider, en de leeromgeving. Ik licht deze factoren kort toe.

The safety profile, tolerability, pharmacodynamics, and pharmacokinetics of four doses of recombinant human granulocyte colony-stimulating factor (filgrastim) were assessed in healthy volunteers in a double-masked, placebo-controlled, parallel-group trial. Healthy subjects received subcutaneous injections of filgrastim 75 microg (n = 8), 150 microg (n = 4), 300 microg (n = 4), 600 microg (n = 8), or placebo (n = 6) daily for 10 consecutive days. Blood samples were drawn daily immediately before the injection and on days 1 and 10 serially throughout the day. Increased absolute neutrophil counts (ANCs) were seen within 90 minutes of drug administration in subjects in all dose groups, peaking approximately 12 hours after administration. This increase was dose related in subjects in the three lower dose groups. The time to peak ANC on day 10 was approximately 9 hours, with a daily ANC profile in all four dose groups that was similar to the profile on day 1. In all dose groups, ANCs were near baseline within 48 hours of discontinuation of filgrastim. Mild, reversible thrombocytopenia was reported in 4 of 10 subjects in the highest dose group. Two subjects in the filgrastim 600-microg group were withdrawn for adverse events. Filgrastim had a good safety profile and caused dose-related increases in ANC when administered to healthy volunteers for up to 10 days.

OBJECTIVE: Amphotericin B deoxycholate initial therapy and fluconazole maintenance therapy is the treatment of choice for AIDS-associated cryptococcal meningitis. However, the administration of amphotericin B is associated with considerable toxicity. A potential strategy for reducing the toxicity and increasing the therapeutic index of amphotericin B is the use of lipid formulations of this drug. DESIGN AND METHODS: HIV-infected patients with cryptococcal meningitis were randomized to treatment with either liposomal amphotericin B (AmBisome) 4 mg/kg daily or standard amphotericin B 0.7 mg/kg daily for 3 weeks, each followed by fluconazole 400 mg daily for 7 weeks. During the first 3 weeks, clinical efficacy was assessed daily. Mycological response was primarily evaluated by cerebrospinal fluid (CSF) cultures at days 7, 14, 21 and 70. RESULTS: Of the 28 evaluable patients, 15 were assigned to receive AmBisome and 13 to receive amphotericin B. Baseline characteristics were comparable. The time to and the rate of clinical response were the same in both arms. AmBisome therapy resulted in a CSF culture conversion within 7 days in six out of 15 patients versus one out of 12 amphotericin B-treated patients (P = 0.09), within 14 days in 10 out of 15 AmBisome patients versus one out of nine amphotericin B patients (P = 0.01), and within 21 days in 11 out of 15 AmBisome patients versus three out of eight amphotericin B patients (P = 0.19). When Kaplan-Meier estimates were used to compare time to CSF culture conversion, AmBisome was more effective (P 21 days for amphotericin B). AmBisome was significantly less nephrotoxic. CONCLUSIONS: A 3-week course of 4 mg/kg AmBisome resulted in a significantly earlier CSF culture conversion than 0.7 mg/kg amphotericin B, had equal clinical efficacy and was significantly less nephrotoxic when used for the treatment of primary episodes of AIDS-associated cryptococcal meningitis

Background: Research on the correlation between personality and students' specialty choice is helpful in their career counselling process and in predicting the future distribution of the specialties in a country.Aims: This study is the first of its kind in the Arab world. The research questions were: (1) What is the influence of gender on the personality profiles of medical students? (2) What are the personality profiles of students categorized according to their preferred specialist choices? (3) What are the preferred career choices of students categorized according to the stage of their medical education?Method: A cross-sectional study was performed at King Khalid University Medical School including 590 students during the academic year 2010-2011. A long version of the Zuckerman-Kuhlman personality questionnaire measuring five personality factors was used. Students were also asked for their specialty interests. Students were asked by means of a written questionnaire.Results: Study response was 92.5%. Surgery was the single most popular specialty amongst both male and female students. Males had significantly higher scores on the 'impulsive sensation seeking' scale and students preferring a surgery specialty had the highest score on the 'impulsive sensation seeking', 'neuroticism-anxiety', 'aggression-hostility' and 'sociability' scales. Hospital-based, surgical and primary care specialties became more popular as students progressed through their undergraduate years.Conclusions: Different personality types have distinct preferences in medical students' choice of careers. Personality and specialty choice research can enhance career counselling of medical students and fresh graduates. This also has implications for predicting the specialty distribution of the future health careers.

Objective: To examine whether physicians differ in job satisfaction in different career stages, controlling for “gender”, “specialty area” and “level of income”.Methods: Survey of three cohorts of physicians who started studying in 1972-75 (n = 704), 1982/83 (n = 301) and 1992/93 (n = 296) at the University of Groningen. Physicians in the begin, mid and end career stage practiced for 10, 20 and 30 years respectively. Data were collected by telephonic interviews and written questionnaires. We selected 13 job satisfaction aspects which could be mapped unto Ostroff’s taxonomy of organizational climate perceptions. Influences of gender, specialty area and level of income were taken into account.Results: Physicians in begin, mid and end career stage differed on eight aspects. Taking into account gender, specialty area and level of income, differences between career stages were significant for three aspects: appreciation from support personnel, appreciation from patients and satisfaction with income. Specialty area was the most important covariate.Conclusions: Physicians from different career stages differed in job satisfaction, but specialty area accounted to a large extent for these differences. We recommend taking into account physicians’ career stage, gender and specialty area when studying physicians’ job satisfaction.

Patterns in the costs of hospital in-patient care and in-patient drug treatment of 121 symptomatic, HIV-infected patients are described for a university hospital between 1987 and 1991. Trend analyses have been performed on quarterly and yearly data using parametric and non-para-metric statistical techniques. During the 5-year study period the demand for hospital beds almost quadrupled despite a constant number of admissions per person-year and a 40% decrease in the average length of stay. The demand for beds was highest in the autumn and winter months. The impact of female and/or heterosexual subgroups on the yearly utilization of resources increased and reasons for hospitalization became more diverse; there were fewer hospitalizations for Pneumocystis carinii pneumonia infection. Antimicrobial drug treatment accounted for the increased drug treatment costs. The implications for AIDS-treating specialists, hospital managers, and scenario analysts are discussed.

Objective: To assess the economic impact of HIV/AIDS on the health care system in The Netherlands. Data and methods: Two types of data are used: (i) routine surveillance data on AIDS incidence and (ii) information on hospital resource utilisation and corresponding monetary costs. Progression of disease is modelled using a multi-stage model, with stages corresponding to clinical classifications and to different phases of health care need. Economic impact is analysed for all stages in three scenarios: the reference and two alternative scenarios. Results: In the year 2000 hospital bed need would reach 220 beds if yearly new HIV infections in the 1990s remain at the level estimated for the end of the 1980s, and if the intensity of hospital care remains constant. A minimum need of 125 beds is projected if no new HIV infections occur in the 1990s. Hospital costs in 1993 are estimated to amount to 33.8 million ECUs. Scenarios indicate a range of 26.7–50.7 million ECUs for the year 2000 (price level: 1993). The proportion of the costs of hospital inpatient care and cure in total hospital costs increases, whereas the proportion for outpatient services decreases. Conclusions: Projected hospital bed need of 125–220 for HIV/AIDS in the year 2000 is limited compared to the projections for coronary heart disease and stroke, but approaches that for lung cancer, pneumonia and diabetes. We estimate hospital costs to have been 85% of total health care costs for HIV/AIDS in 1993. In 1993, the estimated proportions in hospital costs are 41% for inpatient care, 20% for inpatient cure and 39% for outpatient facilities. Our scenarios indicate a decreasing share of outpatient costs — possibly to 30% of total hospital costs for HIV/AIDS in 2000 — illustrating the growing relative importance of the AIDS stage for the hospital costs. We project hospital costs for HIV/AIDS in 2000 to reach up to 0.53% of projected hospital costs for all diseases. A present value of 38 million ECUs (23%) of hospital costs projected in the reference scenario might be avoidable, during the period 1994–2000. However, with unchanged treatment patterns a present value of 127 million ECUs for hospital costs during the same period is projected to represent unavoidable costs (discount rate: 5%). In The Netherlands, data needs in the field of economic impact assessment of HIV/AIDS especially refer to registrations of non-hospital outpatient resource utilisation and costs.

Background: Internationally, postgraduate medical education (PGME) has shifted to competency-based training. To evaluate the effects of this shift on the outcomes of PGME appropriate instruments are needed.Aim: To provide an inventory of tasks specialists perform in practice, which can be used as an instrument to evaluate the outcomes of PGME across disciplines.Methods: Following methodology from job analysis in human resource management, we used document analyses, observations, interviews and questionnaires. Two thousand seven hundred and twenty eight specialists were then asked to indicate how frequently they performed each task in the inventory, and to suggest additional tasks. Face and content validity was evaluated using interviews and the questionnaire. Tasks with similar content were combined in a total of 12 clusters. Internal consistency was evaluated by calculating Cronbach's alpha. Construct validity was determined by examining predefined differences in task performance between medical, surgical and supportive disciplines.Results: Seven hundred and six specialists (36%) returned the questionnaire. The resulting inventory of 91 tasks showed adequate face and content validity. Internal consistency of clusters of tasks was adequate. Significant differences in task performance between medical, surgical and supportive disciplines indicated construct validity.Conclusion: We established a comprehensive, generic and valid inventory of tasks of specialists which appears to be applicable across medical, surgical and supportive disciplines.

Peripheral blood mononuclear cells from 36 asymptomatic HIV-1 seropositive individuals were tested longitudinally for in vitro T-cell proliferation and IL-2 production in response to synthetic peptides spanning the entire gp120 of HIV-1. At baseline, significant T-cell proliferative to pooled and individual peptides was observed in 15 of the 36 donors. After 12 months, proliferative responses to peptide pools were lost or decreased significantly in most donors. Responses appeared to fluctuate over time: at 12 months new recognition sites were detected in four of 10 donors showing T-cell proliferation at baseline, as well as in five of 15 donors with no previous proliferative responses. IL-2 production appeared to be a more sensitive and longer preserved parameter of T-helper cell function: at baseline the majority of donors with no T-cell proliferation produced IL-2 in response to pooled peptides. This response was not decreased significantly after 12 months. The overall patterns of response to both pooled and individual peptides were heterogeneous among donors. Multiple recognition sites were detected in both variable and conserved regions of gp120, but no pool or individual peptide was recognized by all responders. Functional T-cell responses were not statistically correlated to CD4+ cell percentile and absolute numbers.

Trends in the utilization of various hospital resources by HIV-infected persons between January 1987 and June 1990 have been studied to support health care planning. Data on 126 asymptomatic and symptomatic HIV-infected persons have been recorded at a patient level and analyzed at half-yearly intervals. At a hospital level, increasing utilization trends were observed. At the patient level, a decreasing utilization intensity was measured for admissions, inpatient days, inpatient diagnostic examinations, and outpatient consultations. Increasing utilization intensity was measured for care during admissions. A constant utilization intensity was observed for outpatient diagnostic examinations and inpatient medication days. Use of interventions tended to increase at the end of the study period. Discriminating between trends in the utilization of different hospital resources can improve the management of hospital health care demands of HIV-infected people.

In a randomized, parallel arm, open-label study, the effect of switching from ritonavir to either nelfinavir or nelfinavir plus saquinavir as part of a triple antiretroviral regimen was investigated in 16 patients with undetectable HIV-1 loads. Patients continued to use the same nucleoside reverse transcriptase inhibitors as before the switch of protease inhibitor. The period of follow-up was 48 weeks. In all patients HIV-1 load remained undetectable, whereas CD4 cell counts remained stable. Furthermore, lipid markers improved after the switch.

To examine how the job satisfaction of a cohort Dutch physicians developed between 2000 and 2009.Longitudinal.In 2000 and 2009 physicians who had begun studying medicine in 1982 and 1983 at the University of Groningen were interviewed over the telephone about different variables of job satisfaction. We analysed differences between each year and between male and female physicians. Additionally, clusters of job satisfaction variables were examined.We traced 292 of the 333 graduates. A total of 275 physicians (140 men, 135 women) agreed to an interview (response rate 92%). Between 2000 and 2009, average job satisfaction remained stable or even increased slightly. No differences in levels of job satisfaction were found between male and female physicians. Satisfaction on variables representing direct control such as relationships with patients and colleagues was high. It was lower on variables on which physicians have only minor influence such as organizational and administrative aspects.We could not confirm the fear that exists both inside and outside the Netherlands that job satisfaction among physicians is declining.

OBJECTIVE Reports from the United States that urinary tract infections (UTI) are more common in homosexual than in heterosexual men have not been confirmed in Europe. The occurrence of several UTI in men infected with HIV-1 has been recorded in The Netherlands. We therefore analysed the relationship between the presence of bacteriuria and the immune status (CD4+ cell count) in these HIV-1-infected patients. DESIGN Urinary cultures were obtained prospectively for 2 years, during the first visit and every 6 months thereafter, when signs and symptoms of UTI occurred and when patients had fever of unknown origin. CD4+ cell counts were measured at the same time. SETTING The study was performed at the University Hospital, Utrecht, The Netherlands. PATIENTS, PARTICIPANTS One hundred and thirty HIV-1-infected men attended our hospital. Data from 98 were analysed. Eighty-nine (91%) of these men were either homo- or bisexual. MAIN OUTCOME MEASURES Positive urinary culture. RESULTS Group 1 (CD4+ cell count less than 200 x 10(6)/l) consisted of 47 patients; 30% had at least one period of bacteriuria, with 21 episodes. Group 2 (CD4+ cell count 200-500 x 10(6)/l) consisted of 27 patients; 11% had at least one period of bacteriuria, with five episodes. We did not find bacteriuria in the 24 patients in group 3 (CD4+ cell count greater than 500 x 10(6)/l). The rate of bacteriuria per patient-month, 4 (group 1) versus 2 (group 2), differed significantly (P less than 0.001). A significant relationship between CD4+ cell count and bacteriuria was found (P = 0.00003); no relationship, however, was found with anal intercourse, hospitalization, Karnofsky score, follow-up, or age. CONCLUSION We conclude that men infected with HIV and presenting with a CD4+ cell count less than 200 x 10(6)/l are at increased risk for bacteriuria.

Background: Recently, many medical curricula have been changed into vertically integrated programmes. One of the aims of vertical integration is to facilitate the transition from theoretical to clinical education and from medical school to postgraduate training.Aims: The aim of this study was to determine whether a vertically integrated curriculum affects the transition from medical school to postgraduate training.Method: We carried out a survey study among graduates of two cohorts of the Utrecht Medical School, who followed either the traditional or the innovative, vertically integrated, curriculum. Topics of the questionnaire were: (a) activities since medical school, (b) required amount of time and number of applications to get admitted to residency, (c) the process of making career choices.Results: Graduates from the vertically integrated curriculum had made their definite career choice earlier compared to those who followed a traditional programme. Graduates of the new curriculum also needed less time and fewer applications to obtain a residency position.Conclusions: A vertically integrated curriculum at medical school positively affects the transition to postgraduate training. Additional research, among a larger population, is required to determine which components of the curriculum cause this effect and to specify under which conditions these effect occurs.

Medicine is a science and evidence-based profession. Therefore, medical education and training should offer optimal conditions to help students to become a medical expert. However, in order to become a ‘good doctor’ the development of additional skills should also be stimulated. By including subjects like philosophy of science, medical history and sociology, the link between literature and medicine, and other ‘unrelated and irrelevant’ academic subjects, medical education programmes can stimulate that future doctors will broaden their mind. This will contribute to their professional performance. Medicine is a science and evidence-based profession. Knowledge and innovations in the area of basic science in the clinical context are at the bottom of the adequate practice of future doctors. Consequently, medical education and training should offer optimal conditions to help the students to become a medical expert. But, although such doctors may be clever clogs, this does not mean that they are ‘good doctors’ too. For being a good doctor other additional skills are required. Additional skills that can be considered as academic skills but that deal with more than just being able to give a presentation during a grand round or conference, being able to write a scientific paper or being able to find your way in PubMed. The skills I refer to belong to the so-called Medical Humanities, training programmes that include the development of qualities that broaden students’ and residents’ view of medical profession. In many countries modernization of medical training programmes occurs by applying the CanMEDS model (The CanMEDS 2005 Physician Competency Framework 2005). Originally this model was designed for postgraduate training, but it appears to be useful also for undergraduate training. The model describes seven roles of the doctor. The medical expert has diagnostic and therapeutic skills for effective and ethical patient care. The communicator establishes therapeutic relationship with patients and their family. The collaborator works effectively together with other physicians and health care professionals. The manager utilizes resources effectively to balance patient care, learning needs and outside activities. The health advocate contributes effectively to improved health of patients and communities, and recognizes and responds adequately to mistakes made in health care. The definition of the scholar is interesting because it refers to the one who learns as well as to the one who teaches others. And finally, the professional delivers highest quality of care with integrity, honesty and compassion, exhibits appropriate personal and interpersonal professional behaviour and is also aware of his/ her limitations with consequences for his actions. Although these roles, if applied integrally, are all part of the concept of a ‘good doctor’, professionalism is the major keystone of the performance as such. In order to teach professionalism convincingy, it is required that learning environments of the academic institutions support students’ and residents’ professional development, that the institutional culture demonstrates that professionalism is important, and that teachers behave as role models by demonstrating the relevance of reflection in daily practice (Whitcomb 2007). Philosophy of science, medical history and sociology, the link between literature and medicine, and other ‘unrelated and irrelevant’ academic subjects may contribute to doctors’ professional performance. Subjects that fit with the meaning of the term ‘academic’ as presented in the Oxford Dictionary: ‘not relevant to practical affairs, of theoretical interest only’ (Hornby 1995). Medical Humanities deal with training programs that focus on the reflection on one’s own action, reflection on our ‘western’ way of medical practice in comparison with the practice in other cultures, diversity, ethics, philosophy of science and history of medicine. Teaching modules that help students to realize the presence of other, mostly non-western paradigms in medicine that might be complementary to the commonly used models; modules that help students to recognize the responsibilities of doctors towards their patients; modules that focus on the changed cultural and social context in which medicine is practiced with diversity as major characteristic for the perception of disease and for the patient’s expectations towards the doctor. In this respect we can learn from medical training programmes in many Anglo-Saxon countries. Several universities, in particular those in the United States of America, have implemented teaching modules that focus on a broad and more general education (Dittrich & Farmakidis 2003). Actually, by

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.

International audience; Abstract In order to explore and clarify the underlying processes which lead to (non)-adherence behavior in patients treated with highly active antiretroviral therapy (HAART), a qualitative study was conducted. Thirty-seven in-depth interviews were held with 30 Caucasian HIV-positive patients. Additional data were collected by diaries kept by some participants. The analysis took place in a cyclic process; selection of themes was alternated with input of new material. Adherence to HAART is mainly influenced by the experience of being HIV-positive. Acceptance or non-acceptance of HIV leads to one of two basic attitudes toward adherence: ‘being determined to be adherent' or ‘medication is subordinate to other priorities in life'. This attitude determines the commitment to therapy and influences how patients cope with adherence. Patients who are determined to be adherent find solutions to adherence problems. Patients who are not determined to be adherent solve problems only if the solution does not compromise important aspects of their lives. Insight is provided into the manner in which prevalent themes; ‘start of HAART', ‘attitude toward medication', ‘HAART in daily life', ‘contextual factors', ‘health and HAART' and ‘being informed', influence adherence behavior. Before starting HAART the focus should be on helping the patient to accept HIV as a part of life. The findings need to be taken into account in adherence-promoting interventions.

Contains fulltext : 71015.pdf (Publisher’s version ) (Closed access) CONTEXT: Sexual harassment of medical students has been the focus of many international studies. Prevalence rates from 18% to over 60% have been reported. However, a Dutch study at Nijmegen Medical School found the prevalence rate to be lower (13.3% in the total group; 20% among female students only). OBJECTIVES: We aimed to identify whether Nijmegen constitutes a positive sample of Dutch medical schools or whether incidents of sexual harassment are less prevalent in the Netherlands than elsewhere, and to establish if and how these experiences impact the professional lives of students. METHODS: Students received a semi-structured questionnaire containing questions about their experiences of sexual harassment during clerkships. The questions referred to students' reactions to any incidents, the possible consequences for their wellbeing or professional functioning and the way cases of sexual harassment were handled. RESULTS: The prevalence of sexual harassment was significantly higher in Utrecht than in Nijmegen. In both studies rates were relatively low compared with international data. Nevertheless, 1 in 3-5 Dutch female medical students had experienced unwelcome sexual attention from patients, colleagues or supervisors. Three of 10 students who had experienced such an incident stated that it had a negative impact on their functioning afterwards. CONCLUSIONS: Prevalence rates of sexual harassment in medical schools in the Netherlands are low compared with international rates. However, the number of women students who experience sexual harassment is still 1 in 3-5. The occurrence of and ways to deal with these incidents should be important topics in the training of medical students and supervisors.

It remains uncertain whether full T cell reconstitution can be established in HIV-infected children and adults with long-term sustained virological control by highly active antiretroviral therapy (HAART). In this study, we comprehensively analyzed various phenotypical markers of CD4 T cell recovery. In addition to measuring T cell activation and proliferation markers, CD4 T cell generation and aging of the CD4 T cell compartment were assessed by measuring TCR excision circles and the fraction of CD31-expressing naive CD4 T cells. In all children and in adults with relatively high CD4 T cell counts at start of therapy (>200 cells/μl), total CD4 T cell numbers normalized within 1 year of therapy. After long-term HAART (4.4–9.6 years), naive CD4 T cell counts had normalized in both groups. Although in adults with low baseline CD4 T cell counts (