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Between Trust and Accountability: Different Perspectives on the Modernization of Postgraduate Medical Training in the Netherlands

Wallenburg, Iris MSc; van Exel, Job MSc; Stolk, Elly PhD; Scheele, Fedde MD, PhD; de Bont, Antoinette PhD; Meurs, Pauline PhD

doi: 10.1097/ACM.0b013e3181dc1f0f
Academic Medicine in the Netherlands

Purpose Postgraduate medical training was reformed to be more responsive to changing societal needs. In the Netherlands, as in various other Western countries, a competency-based curriculum was introduced reflecting the clinical and nonclinical roles a modern doctor should fulfill. It is still unclear, however, what this modernization process exactly comprises and what its consequences might be for clinical practice and medical work.

Method The authors conducted a Q methodological study to investigate which different perspectives exist on the modernization of postgraduate medical training among actors involved.

Results The authors found four distinct perspectives, reflecting the different features of medical training. The accountability perspective stresses the importance of formal regulations within medical training and the monitoring of results in order to be more transparent and accountable to society. According to the educational perspective, medical training should be more formalized and directed at the educational process. The work–life balance perspective stresses the balance between a working life and a private life, as well as the changing professional relationship between staff members and residents. The trust-based perspective reflects the classic view of medical training in which role modeling and trust are considered most important.

Conclusions The four perspectives on the modernization of postgraduate medical training show that various aspects of the modernization process are valued differently by stakeholders, highlighting important sources of agreement and disagreement between them. An important source of disagreement is diverging expectations of the role of physicians in modern medical practice.

Ms. Wallenburg is researcher, Institute of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands.

Dr. Van Exel is assistant professor, Institute of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands.

Mr. Stolk is assistant professor, Institute of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands.

Dr. Scheele is full professor, Institute for Medical Education and Training, VU University, Amsterdam, the Netherlands.

Dr. de Bont is associate professor, Institute of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands.

Dr. Meurs is full professor, Institute for Health Policy and Management, Erasmus University, Rotterdam, the Netherlands.

Correspondence should be addressed to Dr. de Bont, Institute of Health Policy and Management, Erasmus University, Post Box 1738, 3000 DR Rotterdam, the Netherlands; telephone: +0031104088548; e-mail:

Editor's Note: A commentary on this article appears on pages 932–934.

In many Western countries, including the Netherlands, postgraduate medical training is facing reforms intended to make medical practice more responsive to societal needs for, among other things, integrated care and efficient health care delivery.1–3 In many of these cases, medical training is reformed by expanding the competency framework of medical practice.2,3 In the United States, for example, new training programs focus on quality, patient safety, and systems-based practice.1 In the United Kingdom the government tries to enhance management skills of doctors within health care institutes by offering management courses to medical residents.3 In the Netherlands—the central focus of this report—all scientific boards of the various medical specialties have been explicitly instructed to revise their vocational programs according to the CanMEDS 2000 model specifying the various roles a “modern doctor” should fulfill: medical expert, communicator, collaborator, health advocate, scholar, professional, and manager.4 Details of this process are discussed below. Following this model, medical training should not only concentrate on acquiring technical skills; medical residents also must learn to communicate effectively with patients, collaborate with other health care professionals, and manage health services.4 To monitor and assess residents' competencies within this new framework, educational tools and teaching courses have been introduced to both staff members and residents.

The introduction of a competency-based curriculum causes a change in the organization of medical training in teaching hospitals. The reform means a shift from the old, implicit model of medical training of learning by doing and role modeling to a more explicit approach of encoded knowledge and maintaining standards in practice.5,6 As Nettleton et al5 point out, this policy shift based on an explicit set of criteria (i.e., competencies) is thought to bring about changes in medical training and medical practices and will therefore have consequences for the transmission and nature of medical work. The changing nature of medical practice is also described by McDonald et al,6 who argue that the modernization of medical training and the emphasis on formal training guidelines that comes with it may erode the values on which medical practice was originally based, such as vocation, reciprocity, and selflessness.

In the Netherlands, the modernization of medical training was initiated by the central government and subsequently taken over by the Dutch Medical Association. Following a decree of the Central College of Medical Specialists, a regulating body of the Dutch Medical Association, all medical specialties have been rewriting their educational programs according to the competency model. During these revisions, specialty boards define objectives and standards for education based on CanMEDS 2000. When this article was written, the first new curricula were being implemented in the specialties of gynecology and pediatrics, and other medical specialties had plans to follow. What this modernization exactly comprises and what its consequences might be for clinical practice and medical work, however, are still unclear. Moreover, little has been reported on the views of the physicians and policy makers who carry out this novel form of medical training. At the start of the implementation of the new curricula, we therefore investigated which different perspectives exist on the modernization of postgraduate medical training. We did not investigate education programs themselves but, rather, how the different stakeholders involved give meaning to this concept of modernization. What do they think modern medical training is or should be about? The second aim of our study was to relate, in a more limited and tentative way, these different understandings of the modernization of medical training to the broader changes that are taking place in medical work.

We conducted a Q methodological study to identify and describe the different perspectives on the modernization of medical training among stakeholders involved in this process, as well as the principal similarities and differences between these perspectives. The method will be explained in the next section. From our study, it seems that modernization is a fuzzy concept entailing different, more or less conflicting perspectives on medical training reform. We argue that the frictions between these perspectives reflect existing tensions between diverging expectations of modern medical practice as well as between the medical profession and society and within the medical profession itself.

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Q methodology

Q methodology is a mixed qualitative–quantitative method that provides a scientific foundation for studying subjectivity, such as people's viewpoints, beliefs, attitudes, feelings, and opinions. It is a fairly novel method in the field of health services research, but it has been well established in other fields during the past 70 years.7–10 In recent years, a number of studies using Q methodology were published in the field of health.8,11–16 The aim of Q methodology is to access as many alternative existing views as possible on a certain topic (here, the modernization of postgraduate medical training). Typically, respondents, called the P set, are presented with a sample of statements (called the Q set) and are asked to rank-order these statements. By ordering them, respondents give their subjective meaning to the sample of statements and reveal their subjective viewpoint.17,18 Q methodology has been presented as an inversion of conventional factor analysis, in the sense that Q correlates persons instead of tests.10 Correlation between individual rankings of statements is seen as indicating similar viewpoints; if each respondent had an independent viewpoint, the Q sorts of these respondents would not correlate. If, however, significant clusters of correlations exist, they could be identified through factor analysis, described as common viewpoints, and individual respondents could be mapped to these viewpoints. Q methodology is used to describe a population of viewpoints and not—like in regular survey analysis—a population of people.8 For this purpose, a small, purposively selected sample of respondents is sufficient.8,15,18

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Developing the Q set

Our first step in conducting this study was developing the Q set. This set of opinion statements forms the actual research instrument and is the basis for a Q methodological study. Consequently, it is important that the statements are representative of the subject area of study and are grounded in real existence.19 To capture the topic and formulate statements, we first explored commonly held opinions about the modernization of medical training nationally and internationally. We scanned the literature using PubMed and studied policy documents and professional literature about the modernization of medical training. Subsequently, we held in-depth, semistructured interviews with a purposively selected sample of medical specialists, medical residents, and a hospital manager. From all these sources, we extracted a long list of issues related to the modernization of medical training, which we brought back to a manageable number to create the Q set.

From the literature search, we obtained a basic understanding of existing views on the modernization of medical training. Our understanding was deepened by the interviews. In line with the aim of Q methodology (i.e., to identify different opinions toward a certain topic), we selected our interviewees using the purposive sampling method of “maximum variation.”20 On the basis of document analysis and informal conversations with members of the project team, we anticipated different views of the new curricula among doctors related to age, gender, seniority, and medical background (gynecology or pediatrics, as these were the specialties implementing competency-based educational reforms at the time of this study). We were also aware that there might be a difference in opinion between university and regional teaching hospitals, because in the Netherlands medical training is one of the core businesses of university hospitals, whereas regional hospitals are more directed toward health service delivery. We therefore chose to select respondents from different educational regions and from different types of hospitals (university and nonuniversity), with different professional backgrounds and different degrees of seniority. We selected men and women to reflect current clinical practice, in which most staff members are men, as well as younger clinicians, who are more likely to be women. Finally, we accounted for possible differences between “ex post” and “ex ante” preferences for the new curricula using regional sampling based on the observation that speed of implementation of new curricula differed between educational regions in the country. (In the Netherlands, medical training is organized in eight different regions. In each region, a university hospital collaborates with a few local teaching hospitals, so-called “affiliation hospitals”).

In March 2007, the selected respondents were approached for cooperation by e-mail or telephone by the gynecologists and pediatricians from the project team. These project members knew the potential respondents personally through clinical work and from their experiences heading professional organizations. All the persons approached agreed to the interview. We interviewed 6 gynecologists (3 working in a university hospital, 3 working in a regional teaching hospital; 2 women, 4 men) and 6 pediatricians (2 working in a university hospital, 4 working in a nonuniversity hospital; 1 woman, 5 men). We also interviewed 5 medical residents (2 gynecologist residents and 3 pediatrician residents, all women) working in different educational regions of the country. Subsequently, we interviewed one hospital manager working in a nonuniversity teaching hospital to get a better notion of the meaning of the curriculum reform for hospital management. The interviewees were not compensated for their time.

The interviews covered three broad areas: (1) the structure and process of medical training within the hospital, (2) the position and function of medical training within the hospital organization, and (3) the influence of societal developments on medical training. The interviews were conducted by two authors (I.W. and A.B.) between March and May 2007. All interviews were tape recorded and transcribed. Additional informal interviews were conducted with educational experts involved in the modernization process and members of the national project team entrusted with the modernization of medical training in the Netherlands. Furthermore, between February and December 2007 we attended three national conferences about the reform, and we observed the three weekly meetings of the project team. We made notes about these informal interviews and observations and analyzed them as well.

The literature review, interviews, and observations together resulted in a long list of 89 issues related to the modernization of medical training. The list was structured around those issues that emerged as the most important from the interviews and literature: (1) concerns with the goals and contents of medical education and the use of specific educational methods and tools, (2) the relationship between medical training and health policy, and (3) the relationship between medical training and society. We stripped the list of double and comparable statements, which resulted in a list of 38 statements (see Table 1). The items were checked by various physicians and educational experts to ensure that the Q set was complete and the statements were unambiguous and expressed in clear language. Finally, the statements were edited, randomly assigned numbers, and printed on cards.

Table 1

Table 1

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Collecting Q sorts

After developing the Q set, we conducted the Q sorts interviews. As Q methodology aims to study diversity of understanding rather than prevalence of understanding, participants were not selected randomly for statistical representativeness but purposefully for anticipated viewpoint or a certain type of experience.15 Copying the purposive sampling method used in selecting interviewees, respondents invited for participation in the Q sort represented a heterogeneous group. Expecting differences in opinion between people with different professional backgrounds and from different geographical regions, medical specialties, and hospital settings, we consecutively invited 65 professionals to participate in the study. Q methodological studies typically include between 25 and 40 selected respondents, which is considered sufficient to reveal the diversity of opinion on a subject matter because these respondents are purposively sampled and perform a large number of tests (by mutually comparing and ranking a large set of statements).18,19 Because respondents were involved with the subject of study, but conducting a Q sort is a cognitively demanding and time-consuming task (approximately 30–45 minutes), a moderate to good response rate (50%–80%) was anticipated. Therefore, more professionals were approached than were necessary for the analysis.

The group consisted of gynecologists and gynecology residents, pediatricians and pediatrics residents, medical educational experts, hospitals managers, and policy makers involved in medical training. The medical doctors were selected on the basis of the educational region in which they work and their medical specialty. We approached one “type” of doctor in each educational region (i.e., one gynecology resident in the northeast region of the country, one pediatrician in the southeast). In total, 48 medical doctors were approached. As with the interviews, all respondents were first personally asked for cooperation by a member of the project team, after which the researcher (I.W.) sent them the Q study materials. The hospital managers we interviewed worked in both university and nonuniversity teaching hospital settings in different regions of the country. Three of them were asked for cooperation by a member of the project team before being interviewed. All of them agreed to participate. The other five hospital managers were approached by one author (F.S.) during a national meeting about medical training reform in July 2007. The five selected policy makers were first asked to participate by two of the authors (I.W. and P.M.), after which the interviews took place. Finally, the four selected educational experts were asked to participate by their colleague, who was on the project team. We approached more physicians than educational experts, hospital managers, or policy makers because the reform is designed and executed by the medical profession. All Q respondents were volunteers, meaning that they were not rewarded for their participation. The Q interviews were conducted anonymously, meaning that the respondents were not asked for their names or to mention the names of the hospitals they worked for. We only asked for their gender, seniority (whether they were a staff member or resident), and whether they were working for a university hospital or regional teaching hospital. The completed Q sorts we received were numbered in order for use in the factor analysis.

We asked two distinct research ethics committees to review our study. The first was the research ethical committee of the Academic Medical Centre in Amsterdam, a Dutch university hospital. The second committee was affiliated with the Saint Lucas Andreas Hospital, a regional teaching hospital in Amsterdam. According to the committees, no approval was needed because the study carried no ethical risks and would have no or minimal intrusion on patients.

Between June and August 2007, the interviews were administered via mail. A cover letter outlined the aims of the study and assured confidentially. Respondents were asked to read through the 38 statements and divide them into three piles: agree, disagree, neutral. Next, they were asked to take the “agree” pile, read through the statements again, select the two statements they agreed with most, and place these in the two spots at the right side of the score sheet (see Figure 1). Then they were asked to read through the remaining statements in the “agree” pile, select the next two they agreed with most, and place them in the next column. This process was repeated until no statements remained in the pile. A similar procedure was followed for the cards in the “disagree” pile (working from left to right on the score sheet shown in Figure 1), and finally the statements from the “neutral” pile were ranked in the middle.

Figure 1

Figure 1

After finishing, respondents were asked to explain their ranking and to complete a few additional questions regarding their gender, age, position, and whether they were working in a university hospital or a regional teaching hospital.

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Analysis of the Q sorts

The individual Q sorts were analyzed using PQMethod 2.11. By-person factor analysis was conducted to reveal the number of distinct ways in which the statements were Q sorted (extraction method: centroid factor analysis; rotation method: varimax followed by a small judgmental rotation to lose a confounder).7 For each resulting factor, a composite (or idealized) Q sort was computed, which represents the way in which a person loading 100% on that factor would have ranked the statements. The composite sort of each factor was computed using the Q sorts loading statistically significantly (P < .05) on that factor and the correlation coefficients of these Q sorts with the factor as weights. The factors (i.e., different perspectives on the modernization of postgraduate medical training) were interpreted and described using the characterizing and distinguishing statements for each factor and the explanations of the respondents.

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Thirty-nine persons performed the Q sort for a 60% response rate. Among them were 3 hospital managers, 2 policy makers, 6 pediatricians, 4 pediatrics residents, 10 gynecologists, 10 gynecology residents, and 4 educational experts. It is no surprise that the majority of the respondents are physicians, because we approached more doctors than representatives from other professions.

Q analysis revealed four distinct factors, each representing a different perspective on the modernization of medical training. The first perspective we called the accountability perspective, reflecting the changing nature of the doctor–society contract toward more transparency and accountability. The second we labeled the educational perspective, which is about the structure of the education program. The third perspective reflects a somewhat different view. We called this the work–life balance perspective, meaning that this perspective stresses the balance between working life and private life. This perspective also shows the changing professional relationship between staff members and residents. Finally, the fourth perspective we called the trust-based perspective, reflecting the more traditional way of training in which role modeling and trust are considered most important. In the following sections, we will describe the four perspectives in greater depth, highlighting the elements that separate each perspective from the others. We will concentrate on the statements that were, in terms of their placement, most important. In the description of the perspectives, we share some remarks of the respondents that explain their Q sorts. The remarks were translated into English, and some small adaptations were made to use them as quotations. We note statement numbers in parentheses following each statement used in the descriptions of the different perspectives.

The four factors had between 15 and 5 defining variables (i.e., respondents statistically significantly associated with the factor). Together, the factors accounted for 58% of the variance in the Q sorts (see Table 2). The complete list of statements and the composite ranking of the statements for each factor score are shown in Table 1.

Table 2

Table 2

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The accountability perspective

The accountability perspective reflects strong support for more transparency and accountability in medical training. Individuals adhering to this perspective stressed the importance of an education system in which residents' performance and skills are monitored and assessed. Educational instruments like mini-clinical evaluation exercises could be used for such assessments (4). More than others, these individuals believed that a system of formally awarded responsibilities21 should be implemented in medical training (11) to improve patient safety. Hospitals should no longer be a place of “free practice” in which residents practice their skills on real patients. Instead, residents should first be required to show their competency in an assessment procedure. In this view, a system of formally awarded responsibilities provides insight into the skills and techniques a resident has mastered and is therefore capable to provide on his or her own: “A statement of formally awarded responsibilities is a written agreement between a physician and his environment and as such the essence of the profession.”

Individuals sharing this perspective were least likely to say that the old “master–mate” system should be central in medical training (10): “The master–mate system contains too much hierarchy, which does not fit this age.” Instead, they believed that formal agreements were important, both within the group of physicians and outside this group, in contacts with society. In general, the accountability perspective seemed to mirror a change in the so-called contract between the medical profession and society. Whereas this contract used to be based on authority and trust, now formal training guidelines, monitoring of results, and explicitness are increasingly important.22–24

Five participants were associated with the accountability perspective: three pediatricians, one gynecologist, and one hospital manager. They all worked in nonuniversity hospitals.

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The educational perspective

Individuals adhering to the educational perspective stressed the importance of a more structured and explicit educational program with emphasis on specific educational methods in which residents learn the skills and habits of their medical specialty. In comparison with the accountability perspective, which is more focused on residents' performance and skills, the educational perspective focuses on the subject of medical training itself, reflecting a strong positive view of current, competency-based curriculum reform. Individuals adhering to the educational perspective believed that a competency-based curriculum helps to structure and therefore improve medical training. Individuals sharing this perspective were least likely to say that competency-based education appears to be a fad (14). More than others, they believed that a competency-based medical curriculum will produce better doctors (23): “Competencies offer an instrument to judge whether a resident has the right capacities at his disposal to become a good doctor.” Individuals adhering to this perspective demonstrated great faith in the use of specific educational instruments and methods (such as the portfolio, clinical evaluation exercises, and multisource feedback) to make residents' performance visible and explicit (33, 3, 26). Moreover, they believed that staff members should provide constructive feedback to residents about their performances and learning process (4): “A resident does not learn from implicit assessment; transparency is necessary to learn how to do things better.” Also, “Explicit assessment increases transparency and offers a resident insight into the competencies that have to be developed.” It was also stressed that there should be enough time for cursory education during medical training (24).

Individuals sharing the educational perspective did not believe the use of educational instruments would be too time-consuming or too difficult to fit into daily clinical practice (26, 27, 34): “Clinical evaluation exercises and so on, are easy to realize in practice. Especially if learning goals are used, these instruments provide a quick and in-depth assessment.” Moreover, they did not think that a competency-based curriculum would cause a big change in the contents of medical training itself, because “We now make explicit what we always did implicitly.”

Finally, more than the other perspectives, the educational perspective stresses residents' responsibilities for their own learning processes (30): “Professional behavior is one of the cornerstones of the modernization process. A resident can learn more by stimulating his surroundings to provide feedback by asking for assessment.”

The Q sorts of 15 participants aligned with the educational perspective. Educational experts played an important role in this perspective; all four participating educational experts fell in this group. The involvement of educational experts in medical training also reflects another interesting feature of medical training reform, which is the involvement of stakeholders usually working outside the historically closed domain of medical training. Other participants belonging to the educational perspective were three academic pediatricians and one pediatrician working in a local teaching hospital, two academic gynecologists and two nonacademic gynecologists, two pediatrician residents, one hospital manager, and one staff member.

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The work–life balance perspective

More than the other three perspectives, the work–life balance perspective reflects a shift in medical identity. While in the past, medical work was more or less the clear priority in a physician's life, nowadays doctors want to have a private life as well. Accordingly, the statement about part-time work was found to be most important in this perspective (21). Individuals adhering to the work–life balance perspective did not think that part-time work will harm medical training, because “Private circumstances are of great importance to the mental and physical well-being of the resident. These circumstances need to be taken seriously. In the end this will also benefit medical training.” As one participant pointed out, “Every job can be done part-time, why not medical training?”

The views of people belonging to the work–life balance perspective on medical training were in line with their views on medical identity. They believed that medical training should become more formalized and more directed at structured education of residents rather than focusing on the socialization process of trainees. These individuals also believed that the relationship between residents and staff should be more equal. Accordingly, they disagreed more than others with the statement that the old master–mate system should be central in medical training (10), and they were least likely to see staff members as role models for residents (37): “In my view, the master–mate system is the opposite of a safe clinical environment.”

In the work–life balance perspective, the learning process of residents is put at the forefront. It was stressed that residents do not learn only by providing services (1) but that residents should get the opportunity to do those things they can really learn from. According to one participant, “Residents do not learn by simply ‘being there.’ Most important is what they can get out of clinical practice,” meaning that work schedules should be adapted to the learning goals of residents. Accordingly, it was believed that internships should be divided among university and nonuniversity teaching hospitals because, in this way, residents can experience all different aspects of medical work during their training periods (38, 8): “The combination of university and nonuniversity internships frames medical training.”

Although individuals adhering to the work–life balance perspective supported reforms of medical training, they were not convinced that a competency-based curriculum is the answer to existing problems. They felt that explicit assessment of residents is important (27, 33) but doubted whether this would be feasible in daily work (34). They feared that the introduction of a competency-based curriculum could intensify the already-heavy workload of residents.

Four participants were associated with the work–life balance perspective. It did not come as a surprise that three of them were medical residents (gynecology and pediatrics). The other person adhering to this view worked as a gynecologist in a university hospital.

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The trust-based perspective

The trust-based perspective differs from the other three perspectives in the sense that it reflects a more expectant view toward competency-based curriculum reform. It is based on the belief that becoming a physician means more than following an educational program. In this view, medical training is considered to be about “hands-on experience” within a socialization process in which inherent values, norms, and skills are transferred from experienced doctors to their trainees.

Individuals sharing this perspective were least likely to say that the new curriculum would provide better doctors (23) and did not believe that the reform would improve patient-centered care (22): “I do not see a relationship between the new curriculum and patient-centered care. What does this mean, anyway? This whole new education system is just a lot of paperwork and talk.” They were also most likely to say that the use of portfolios takes a lot of paperwork and is a waste of time (26). Instead, they felt that medical training is about gaining experience, role modeling, and trust. These values can be considered the “old” moral values that are transferred and acquired during professional training (e.g., see others25,26). Accordingly, people in this perspective considered medical training to be more than just an education; it is also a moral learning process.

The trust-based perspective stresses the importance of tacit knowledge in medical training. The socialization process is at the forefront, although it should be noted that individuals adhering to the trust-based perspective were not declared opponents of a competency-based curriculum. The statements considering the competency-based reform were not placed at the extremes of the distribution, indicating that the reform was not totally rejected, but those adhering to the trust-based perspective put emphasis on other aspects of medical training (statements that were at the extremes of the distribution). First, they believed that a resident learns by doing (1) and role modeling (37). The master–mate system should therefore be central in medical training (10): “For a big part of the not assessable aspects of the medical profession, you depend on your teacher.” Second, individuals sharing the trust-based perspective strongly disagreed with the statement that residents should be strictly supervised by a staff member to prevent medical errors (13): “Strict supervision means that every step must be controlled. This will be very unpleasant for both residents and staff members. It will not reduce medical errors.” Another respondent put it simply: “Strict supervision is unnecessary in a safe clinical environment.” Not strict supervision, but trust in each other was considered most important, as was professional autonomy. Accordingly, participants adhering to this perspective disagreed (more so than in the other perspectives) that there are too many medical specialists and too few general medical doctors in medical practice (17). As one participant articulated, “I believe that specialists are necessary, especially in university hospitals.” Another emphasized the point, noting that “practice shows that specialists are necessary.”

Five participants aligned with the trust-based perspective. Two of them were gynecology residents, and two were gynecologists working in a regional teaching hospital. One participant in this category was a pediatrician also working in a nonuniversity hospital.

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In this report, we were able to reconstruct the main perspectives on the modernization of medical training using Q methodology. These four distinct perspectives show that modernization encompasses various issues. It is about increasing transparency and accountability in health care practice as well as about the structuring of medical education and transparency within the training process itself. Modernization of medical training is also about the changing nature of medical identity. Medical work is becoming more and more like a “normal” job instead of a way of life. We may say that the formalization of working relationships is probably enhanced by other, more general developments touching on the medical professions, such as the introduction of the European Working Time Directive, which restricts the number of hours residents are allowed to work. At the same time, however, our results stress that medical training is about the transfer of implicit information and moral values, which cannot be taught without intensive contact between the medical expert and trainee.

We recognize the mixed meanings of modernization in the “consensus statements” we observed. The consensus statements are the statements that were more or less equally valued in all four perspectives. In all perspectives, a safe learning environment (2) was considered the most important aspect of medical training. There was also agreement about the mutual relationship between a safe learning environment and patient safety (5). Consensus on these two items indicates the importance of safety in medical training. What is meant by safety and how this should be accomplished, however, is a point of disagreement (this becomes clear from the placement of these statements in the composite sorts of the four perspectives relative to the placement of other statements in those sorts). Individuals belonging to the educational perspective, for example, think that safety can be improved by the structuring and overspecification of medical curricula, while followers of the trust-based perspective believed that safety should be embedded in the socialization process of training. It would therefore be too simple to characterize modernization as a shift from the “old” implicit model of medical training of learning by doing and role modeling to a more explicit approach of encoded knowledge and maintaining standards in practice. Instead, modernization is also about a change in the moral ideals of medical training.

These distinct perspectives on modernization of medical training not only differ but may also conflict with each other. When medical training is considered to be first and foremost a moral education and is about the transfer of values like vocation, selflessness, and reciprocity, this takes time and much contact—formal and informal—between experts and trainees. This clashes with a more formal approach of training directed at the education process in which residents complete temporary rotations and work in shifts. In addition, the restriction of the working hours of medical doctors (because of EU regulation or popular part-time work schedules) might conflict with another development in health care, which is an increasing attention to patient safety. Although these developments are not contradictory in principle, they have consequences for the way medical practice is organized. In the recent past, continuity of care was ensured through frequent attendance from the same doctors and close collaboration between them. Now, more formal regulations and moments of consultation are needed to organize continuity of care. A third possible conflict has to do with trust. More transparency and accountability in medical work are demanded, changing the relationship between a physician and the individual patient as well as between physicians and the society as a whole. At the same time, however, more transparency may even cause distrust because a layperson does not have the expertise to interpret and understand the information available to the physician.27 Moreover, it is argued that trust, an important aspect of the doctor–patient relationship, could be damaged if too much emphasis is placed on accountability and transparency.28

The changes within medical training are strongly entwined with changes in the wider social and economic environment. In the last two decades, the role of professionals in the public sector has changed as a consequence of the restructuring of welfare states into more market-oriented areas, redefining citizens as consumers, and accentuating client participation.29,30 Performances are measured and work has become more standardized by use of clinical guidelines and protocols, which touches on the old tradition of professional self-governance.31 However, our study also shows that the changes of medical work and medical practice are not only the results of external demands but also originate in the profession itself, as young doctors are striving for a more balanced life between the private sphere and work, as well as formalization of the old master–mate relationship.

The social status and authority of medical professionals have been further affected by the empowerment of patients. The position of patients within health care institutes has been strengthened by a legal obligation to install client councils that are given a voice in hospital management, as well as a legal right to complain about health care professionals to a complaints committee.32 These changes can be seen as attempts to balance the historically unequal relationship between medical doctors and patients. At the same time, however, medical doctors are not supposed to completely give up their logic of professionalism,33 as they are still expected to be devoted to the client's interest more than personal or commercial profit.34 The interconnectedness of these “old” and “new” values of medical work is evident in the four different perspectives on the modernization of postgraduate medical training in the Netherlands revealed in our study.

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The authors wish to thank VU University for funding the research project. Furthermore, the authors like to thank the former and sitting members of InVIVO, as well as the members of the section Healthcare Governance of the Erasmus University for their helpful comments. The authors also gratefully acknowledge the respondents for their contribution to the research project and three anonymous reviewers for their constructive suggestions.

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Funding for this work was received from the VU University in Amsterdam, the Netherlands.

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Other disclosures:


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Ethical approval:

The study was reviewed by the research ethical committee of the Academic Medical Centre in Amsterdam, a Dutch university hospital, and by a second committee affiliated with the Saint Lucas Andreas Hospital, a regional teaching hospital in Amsterdam. According to the committees, no approval was needed, as the study carried no ethical risks and would have no or minimal intrusion on patients.

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Previous presentations:

An earlier version of this paper was presented at the AMEE conference in Trondheim, Norway, in August 2007, and at the conference for Dutch medical education (NVMO conference) in November 2007, in the Netherlands.

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