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29. A phenomenology of direct observation in residency:Is Miller's ‘does’ level observable?

Author

Rietmeijer, Chris B.T., van Esch, Suzanne C.M., Blankenstein, Annette H., van der Horst, Henriëtte E., Veen, Mario, Scheele, Fedde, Teunissen, Pim W., Rietmeijer, Chris B.T., van Esch, Suzanne C.M., Blankenstein, Annette H., van der Horst, Henriëtte E., Veen, Mario, Scheele, Fedde, and Teunissen, Pim W.

Abstract

Introduction: Guidelines on direct observation (DO) present DO as an assessment of Miller's ‘does’ level, that is, the learner's ability to function independently in clinical situations. The literature, however, indicates that residents may behave ‘inauthentically’ when observed. To minimise this ‘observer effect’, learners are encouraged to ‘do what they would normally do’ so that they can receive feedback on their actual work behaviour. Recent phenomenological research on patients' experiences with DO challenges this approach; patients needed—and caused—some participation of the observing supervisor. Although guidelines advise supervisors to minimise their presence, we are poorly informed on how some deliberate supervisor participation affects residents' experience in DO situations. Therefore, we investigated what residents essentially experienced in DO situations. Methods: We performed an interpretive phenomenological interview study, including six general practice (GP) residents. We collected and analysed our data, using the four phenomenological lenses of lived body, lived space, lived time and lived relationship. We grouped our open codes by interpreting what they revealed about common structures of residents' pre-reflective experiences. Results: Residents experienced the observing supervisor not just as an observer or assessor. They also experienced them as both a senior colleague and as the patient's familiar GP, which led to many additional interactions. When residents tried to act as if the supervisor was not there, they could feel insecure and handicapped because the supervisor was there, changing the situation. Discussion: Our results indicate that the ‘observer effect’ is much more material than was previously understood. Consequently, observing residents' ‘authentic’ behaviour at Miller's ‘does’ level, as if the supervisor was not there, seems impossible and a misleading concept: misleading, because it may frustrate residents and cause supervisors t

Published
2023

31. Effectiveness of psychosomatic therapy for patients with persistent somatic symptoms:Results from the CORPUS randomised controlled trial in primary care

Author

Wortman, Margreet S.H., van der Wouden, Johannes C., Twisk, Jos W.R., Visser, Bart, Assendelft, Willem J.J., van der Horst, Henriëtte E., Olde Hartman, Tim C., General practice, APH - Aging & Later Life, APH - Quality of Care, Epidemiology and Data Science, APH - Health Behaviors & Chronic Diseases, APH - Methodology, APH - Mental Health, Lectoraat Oefentherapie, and Urban Vitality

Subjects
Psychiatry and Mental health, Clinical Psychology, All institutes and research themes of the Radboud University Medical Center, Healthcare improvement science Radboud Institute for Health Sciences [Radboudumc 18]
Abstract

ObjectiveTo evaluate the effectiveness of psychosomatic therapy versus care as usual in primary care for patients with persistent somatic symptoms (PSS).MethodsWe conducted a pragmatic, two-armed, randomised controlled trial among primary care patients with PSS in the Netherlands that included 39 general practices and 34 psychosomatic therapists. The intervention, psychosomatic therapy, consisted of 6–12 sessions delivered by specialised exercise- and physiotherapists. Primary outcome measure: patient's level of functioning. Secondary outcomes: severity of physical and psychosocial symptoms, health-related quality of life, health-related anxiety, illness behaviour and number of GP contacts.ResultsCompared to usual care (n = 85), the intervention group (n = 84) showed no improvement in patient's level of functioning (mean difference − 0.50 [95% CI -1.10 to 0.10]; p = .10), and improvement in health-related anxiety (mean difference − 1.93 [95% CI -3.81 to −0.04]; p = .045), over 12 months. At 5-month follow-up, we found improvement in physical functioning, somatisation, and health-related anxiety. The 12-month follow-up revealed no therapy effects. Subgroup analyses showed an overall effect in patient's level of functioning for the group with moderate PSS (mean difference − 0.91 [95% CI -1.78 to −0.03]; p = .042). In the year after the end of therapy, the number of GP contacts did not differ significantly between the two groups.ConclusionWe only found effects on some secondary outcome measures, and on our primary outcome measure especially in patients with moderate PSS, the psychosomatic therapy appears promising for further study.Trial registration: the trial is registered in the Netherlands Trial Registry, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7356 under ID NTR7356.

Published
2023

49. Off‐label low dose amitriptyline for insomnia disorder: Patient‐reported outcomes.

Author

Bakker, Mette H., Hugtenburg, Jacqueline G., Smits, Marcel G., van der Horst, Henriëtte E., and Slottje, Pauline

Abstract

Purpose: Low dose amitriptyline is prescribed off‐label to improve sleep maintenance in patients with insomnia disorder. Data on treatment outcomes are limited. We aimed to assess patient‐reported treatment effect and side effects of low dose amitriptyline for insomnia in routine care data. Methods: Cross‐sectional study: Seven hundred fifty‐two consecutive patients with insomnia disorder having sleep maintenance problems were treated in an outpatient sleep clinic with low dose amitriptyline (10–20 mg based on self‐titration). Treatment was intended to improve sleep maintenance. Before the planned follow‐up consultation (approximately 6 weeks after start treatment) patients completed an online treatment evaluation questionnaire. Treatment (dose, adherence), sleep, fatigue, satisfaction and side effects were assessed by multiple‐choice questions with room for free‐text elaboration. Results: 53.7% of the patients reported to use amitriptyline up to 10 mg/day, 42.9% used a self‐increased dose of mostly 20 mg/day, while 3.5% had discontinued treatment. 73.9% of the total study population reported improvement of sleep maintenance, 31.3% improved sleep onset, 35.2% improved daytime fatigue, and 45.8% reported to be (very) satisfied with treatment results. 66.1% reported at least one side effect. The reported side effects were generally the already known side effects of amitriptyline. Conclusion: These patient‐reported outcomes support the clinical observations that low dose amitriptyline improves sleep maintenance on the short term and that it is generally well tolerated. This further justifies randomized controlled trials in patients with insomnia disorder and sleep maintenance problems to assess the effectiveness and safety of low dose amitriptyline on the short and long term. [ABSTRACT FROM AUTHOR]

Published
2023
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50. A phenomenology of direct observation in residency: Is Miller's 'does' level observable?

Author

Rietmeijer, Chris B. T., van Esch, Suzanne C. M., Blankenstein, Annette H., van der Horst, Henriëtte E., Veen, Mario, Scheele, Fedde, and Teunissen, Pim W.

Subjects
NATIONAL competency-based educational tests, TEACHER-student relationships, WORK environment, HOSPITAL medical staff, ATTITUDES of medical personnel, FAMILY medicine, HONESTY, INTERVIEWING, INTERNSHIP programs, EXPERIENCE, PHENOMENOLOGY, JOB involvement, CLINICAL competence, STUDENTS, INTERPROFESSIONAL relations, PHILOSOPHY of education, SUPERVISION of employees, STUDENT attitudes, MEDICAL practice, MEDICAL education
Abstract

Introduction: Guidelines on direct observation (DO) present DO as an assessment of Miller's 'does' level, that is, the learner's ability to function independently in clinical situations. The literature, however, indicates that residents may behave 'inauthentically' when observed. To minimise this 'observer effect', learners are encouraged to 'do what they would normally do' so that they can receive feedback on their actual work behaviour. Recent phenomenological research on patients' experiences with DO challenges this approach; patients needed—and caused—some participation of the observing supervisor. Although guidelines advise supervisors to minimise their presence, we are poorly informed on how some deliberate supervisor participation affects residents' experience in DO situations. Therefore, we investigated what residents essentially experienced in DO situations. Methods: We performed an interpretive phenomenological interview study, including six general practice (GP) residents. We collected and analysed our data, using the four phenomenological lenses of lived body, lived space, lived time and lived relationship. We grouped our open codes by interpreting what they revealed about common structures of residents' pre‐reflective experiences. Results: Residents experienced the observing supervisor not just as an observer or assessor. They also experienced them as both a senior colleague and as the patient's familiar GP, which led to many additional interactions. When residents tried to act as if the supervisor was not there, they could feel insecure and handicapped because the supervisor was there, changing the situation. Discussion: Our results indicate that the 'observer effect' is much more material than was previously understood. Consequently, observing residents' 'authentic' behaviour at Miller's 'does' level, as if the supervisor was not there, seems impossible and a misleading concept: misleading, because it may frustrate residents and cause supervisors to neglect patients' and residents' needs in DO situations. We suggest that one‐way DO is better replaced by bi‐directional DO in working‐and‐learning‐together sessions. Investigating direct observation in residency, Rietmeijer et al. report that the observer effect is much more material than previously understood, causing concern about the capacity to ever truly witness Miller's 'does' level of performance. [ABSTRACT FROM AUTHOR]

Published
2023
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