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Voortgangsverslag

Samenvatting
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Huisartsen in opleiding leren in de praktijk (werkplekleren) en tijdens terugkomdagen in het opleidingsinstituut. Ouderenzorg vormt een belangrijk onderdeel van de huisartsopleiding. Het is een complexe zorg gezien de multipele problematiek die ouderen vaak hebben, zowel op somatisch als op sociaal, psychisch en functioneel gebied en de daarmee samenhangende polyfarmacie. Competente huisartsen, die de chronische zorg voor de groeiende populatie van kwetsbare ouderen verzorgen, zullen in de toekomst steeds noodzakelijker worden.

Er is daarentegen nog maar weinig onderzoek voor handen om na te gaan of de huisartsen van de toekomst voldoende competent worden opgeleid om dergelijke zorg te verlenen. Het hoofddoel van dit onderzoek is om te onderzoeken hoe huisartsen in opleiding het beste kunnen leren om goede complexe ouderenzorg te leveren. Het project zal opleveren welke leermethoden het beste werken voor huisartsen in opleiding en hun docenten en hoe oude leermethoden verbeterd kunnen worden.

 

Resultaten
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De hoofdonderzoeker heeft zich de afgelopen tijd beziggehouden met de eerste en tweede onderzoeksvraag. Aangezien het een AIOTHO-traject betreft, waarin de huisartsopleiding wordt gecombineerd met een promotietraject (6 jaar in totaal), zijn er nu in totaal 15 maanden onderzoek verricht. In deze maanden zijn alle data verzameld en geanalyseerd voor de onderzoeksvraag: Which educational interventions contribute to learning complex elderly care and what are the underlying mechanisms?

 

Voor de documentanalyse zijn reeds alle beschikbare documenten van de participerende universiteiten aangaande ouderenzorg onderwijs verzameld, gecodeerd en geanalyseerd. Daarnaast zijn er 30 verschillende onderwijsmomenten geobserveerd en 29 interviews afgenomen. Alle verbatim-verslagen zijn reeds gecodeerd en geanalyseerd. Naar aanleiding van deze analyses worden momenteel nog enkele laatste aanvullende interviews verricht.

 

Uit deze analyses blijkt dat de opleidingen goed zijn in het ondersteunen van AIOS bij het uit elkaar rafelen van complexe casus en dat zij verantwoordelijkheid en het stimuleren van samenwerken inzetten om AIOS te verleiden zich in complexiteit te verdiepen. Er valt winst te behalen bij het ondersteunen van AIOS in het integreren van de verschillende aspecten van een casus om deze holistisch te bekijken. De ruimte voor verbetering is er ook ten aanzien van het ondersteunen van AIOS in het omgaan met uitdagingen, frustratie en onzekerheid.

 

Samenvatting van de aanvraag

Samenvatting
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'Complex patients' have multiple chronic diseases, require complicated medical management, have limited functional ability, and need social support. They are usually old. GPs have to look after increasing numbers of complex patients because the population is ageing, sick people live longer thanks to modern medicine, and many complex patients are being transferred from secondary to primary care. Therefore, GP education must prepare residents to care for complex patients.

 

In everyday speech, 'complex' means ‘there is a lot wrong with this patient'. Theoretically, however, 'complex' means there are many interactions between patients’ medical and social circumstances, and those factors interact in such uncertain ways, that patients’ diseases behave unpredictably. As a result, the art of medicine in complex care is about dealing with uncertainty, instability, uniqueness, and value-conflict. It is as important that doctors are good at framing problems as at implementing solutions, and solutions have to be found by an iterative process of framing the problem, trying a solution, evaluating its effects, and repeating the process. The main emphasis in medical education, recently, has been towards managing well-described, recurrent problems in evidence-based ways. Education for the creative, individualised care of patients with non-standard problems has received less attention. Moreover, research has shown that complex patients tend to be managed by trained rather than trainee GPs. We theorise that educational interventions should provide a scaffolding, which guides trainees to:

• Engage in patient problems at the most complex level they can manage and work through them in their zones of proximal development

• Frame and reframing problems interactively until minimal disruptive solution are found that fit multiple goals and are acceptable for the patient and his/her social system

• Evaluate solutions over time

The overarching question guiding this research is:

• How can general practice residents learn to competently frame complex problems in elderly people, evaluate the solutions they implement, and find the least disruptive and simplest solutions?

 

The study will use design-based research methodology. This is akin to action research in that it is conducted within normal educational practice, involves the naturalistic implementation of one or more educational designs, and evaluates how future practice can be improved in light of the findings. It differs from action research in that the "design" is theorised and empirical observations are used to further strengthen the theory. General practice training programs in Maastricht, Nijmegen, Rotterdam, and Leuven, all of which provide education for complex care, will provide a context for the research. Although the four interventions were not designed specifically for this research, they will be regarded as "quasi experiments", which complement one another because of differences between them. The research will have three phases.

 

Phase 1 (observational) will answer the question "Which educational interventions contribute to learning complex elderly care?" by gathering qualitative data from three sources: analysis of curriculum documents, direct observation of existing practice, and in-depth, critical incident interviews with a maximum variation sample of key respondents. The data will be analysed to develop a working theory of how education for complex elderly care can be improved, based on experience in the 4 sites.

 

Phase 2 (implementation of design-based intervention) will answer the question "How can educational interventions be optimised for learning complex care?” by conducting a series of 3 meetings on all four sites to feed back the findings of Phase 1, support the sites in enhancing their programs, and evaluating how the programs respond. Data from Phase 2 will further refine the working theory of education for complex care.

 

Phase 3 (further observation) will answer the question "What do trainees learn with regard to complex elderly care during the third year of GP training?" Using two methods: case-based discussions with GP trainees at the start and end of their third year, using a stimulated recall technique; and conversation analysis of audio recordings of consultations between GP trainees and elderly patients, exploring how patients' problems are framed and management plans are formulated and negotiated.

 

The outputs of the research are relevant to education practice because they will increase awareness of education for complex care, highlight triggers for learning, and provide a blueprint for scaffolding learning for complex care. Whilst benefits to patients cannot be evaluated within the scope of this study, the interventions in question will contribute towards the cost effectiveness of elderly care and maintenance of autonomy for elders living in community settings.

 

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