Colophon Inge van der Leden, Mireille van Poppel, Marc Soethout, Gerrit van der Wal

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1 1 Activities report Department of Public Health and Occupational Health

2 2

3 3 Colophon Editing Inge van der Leden, Mireille van Poppel, Marc Soethout, Gerrit van der Wal Translation Faith Maddever Layout Inge van der Leden Coverdesign James van der Leden, Inge van der Leden Photo on the cover Audiovisueel Centrum VUmc Edition 1200

4 4 PREFACE 5 LEADERSHIP AND POLICY 7 Mission 8 Organization 8 Education 9 Research 10 Academic workplaces 10 Employees 11 RESOURCES 17 Education 18 Research 18 PROCESSES 20 Undergraduate medical education 21 Health sciences education 27 Research 29 Projects Quality of care and prevention 37 Projects Health at the end of life 43 Projects Work and health 50 Projects Physical activity and health 57 Academic workplaces 63 CUSTOMER APPRECIATION 64 Undergraduate medical education 65 Health sciences education 67 Research 68 EMPLOYEE SATISFACTION 70 SOCIETAL RECOGNITION 73 FINAL RESULTS 76 Finances 77 Undergraduate medical education 77 Health sciences education 79 Research 80 Publications Quality of care and prevention 81 Publications Health at the end of life 85 Publications Work and Health 89 Publications Physical Activity and Health 94 APPENDIX 1: FURTHER PUBLICATIONS 98 Quality of care and prevention 98 Public health at the end of life 101 Work and Health 105 Physical Activity and Health 107 APPENDIX 2: SCIENTIFIC AND SOCIETAL ACTIVITIES 111 Congresses an Lectures 111 Functions and activities 127

5 Preface 5 Preface This is our fourth biannual Activities Report. It is intended for the public health and occupational health services with which we collaborate in the field of education and research, interested colleagues within our Medical Center and University, nationally and internationally affiliated institutes, and others who wish or need to be informed about our activities. In 2004 we changed the name of the Department from Social Medicine to Public and Occupational Health. We feel that the latter is a more adequate and more widely understood at least internationally - description of what we are and what we do. This new Activities Report shows that after a period of rapid growth the Department is now in a state of dynamic equilibrium. Only the educational activities have continued to increase, mainly through participation in a new branch of studies at our University, i.e. Health Sciences. Furthermore we were able to increase our tenured staff with two members, Frank van Leerdam and Han Anema, whose task is to develop our extramural workplaces. To date there is a considerable critical mass of scientific personnel, albeit mainly as a result of external finance. There are now approximately 70 members of the scientific staff (totalling over 50 fte), and approximately 20 members of the administrative and supportive staff (totalling over 10 fte) compared with 65, 50, 10, and 5, respectively at the end of 2002; this is exclusive of the financial and ICT-staff at the EMGO-Institute. Compared to 2002, in 2004 there were relatively more senior researchers and post-docs and also more administrative and supportive staff; this was the intended policy. The number of articles that were published in national and international peer-reviewed journals increased considerably, a substantial number were published in general biomedical high-impact journals, and about half reached in the upper quartile of their field. Furthermore, 16 PhD students/junior researchers succesfully defended their thesis. Numerous other articles, (chapters in) books and reports were published. At the end of 2004 there were over 40 projects in progress, over 35 of which will result in a dissertation. There are also a number of external PhD students working with the Department. We are very happy that our research as a substantial part of the research carried out at the EMGO-Institute was rated as excellent by an International Review Committee at the end of Our continuous efforts to create academic workplaces were eventually successful in the end. The Board of Directors of the VU University Medical Center provided funding per for an academic network for research and education in the field of youth health care, and per also in the field of occupational health. Unfortunately, the planned

6 Preface 6 expansion in 2005 will not take place because the VUmc had to take measures to economize. These measures include a structural spending cut of approximately 10% in our budget. In recent years the research budgets of the funding bodies have also decreased. These circumstances make it difficult for us to expand and to acquire grants, but nevertheless we remain confident about the future. This is, among other things, based on a large grant we received in December 2004 for a comprehensive research programme on patientsafety and the research perspectives of the Knowledge Center for Health Insurance Medicine, for which an agreement was signed in January This Center is based on collaboration between our Department (and the EMGO-Institute), our colleages from the University of Amsterdam and the Institute for Employee Benefit Schemes (UWV); and will increase our research staff with approximately 4.5 fte. Finally, in 2004 our position was reinforced with the appointment of Therese Marteau (King s College London) as an honorary part-time Professor, specializing in risk communication and decision-making in health care. We consider that this report will not only be a reflection on past activities, but also a starting point for the further development of education and research in the field of Public and Occupational Health within the VU University Medical Center. There are more than enough new challenges for us to meet. On behalf of all members of the staff, Gerrit van der Wal, Head of the Department

7 Leadership and Policy 7 Leadership and Policy

8 Leadership and Policy 8 Public and Occupational Health (Sociale Geneeskunde) is one of the eleven core disciplines included in the undergraduate medical training, and can be considered as the link between medicine and society. Public and Occupational Health physicians direct their activities towards interaction with the environment, in particular in the field of prevention, and the establishment of organizational conditions. In this respect, the focus is more on a (sub-)population than on the individual. The practical domain consists of two main streams: Community Medicine, and Occupational Medicine. Of all physicians in the Netherlands (20-25%) are involved in a Public and Occupational Health profession, and most, but not all of these physicians are officially registered as such. The scientific domain of Public and Occupational Health is more extensive than the practical domain. As a scientific discipline, Public and Occupational Health is involved in two major issues: Publics Health and Health Care. The research is mainly of an epidemiological and social-scientific nature, and consists of applied and multidisciplinary research carried out in collaboration with sociologists, psychologists, health scientists, human movement scientists, anthropologists, etc. This is reflected in the composition of the staff of the Department. Mission Because Public and Occupational Health is one of the three mainstreams in Dutch medical specialization, our Department strives for a substantial position and excellent teaching reputation in the current and future new medical curriculum. It is our ambition to achieve a prominent national and international position in our own specific fields of research. We try to integrate education, research and practice, in particular via academic workplaces, and aim to achieve societal recognition of our scientific work. We also aim to create friendly, stimulating and productive working conditions within the Department. Organization The structure of the Department is quite simple. There is a Head of the Department (Prof. Gerrit van der Wal) and a Vice-Head (Prof. Willem van Mechelen). They each supervise two research lines, which has a senior researcher as coordinator (Danielle Timmermans, Bregje Onwuteaka-Philipsen, Allard van der Beek and Mireille van Poppel). Each research project has a project leader, who coaches the junior researchers and has considerable power of decision, but must report to one of the Professors. Another staff member is Education Coordinator (Marc Soethout), supervised by the Head. All these together form the staff, and they meet every fortnight to discuss matters concerning education, research and

9 Leadership and Policy 9 management. There is a bi-weekly meeting of all members of the Department which is of scientific character, but there is also oppurtunity to discuss issues concerning policy and strategy, including routine business and household affairs. Education Undergraduate medical education In the undergraduate medical education, the Department aims to accentuate the general objectives of the basic training: 'knowledge, skills and attitudes that are necessary for a physician in daily practice: aspects related to society, the health care system and prevention' (Blueprint 2001). Various forms of education, based on both theory and practice, are spread over the 6-year study period, and a contribution towards scientific training is an explicit component. The basic principle of our education is that each future physician must have basic knowledge of Public and Occupational Health. This is important because, for instance, in individual patient care (mostly provided by curative physicians) working conditions and health need an integrated approach. The influences of different societal systems are also important for patient care (e.g. social insurances, and the structure and finance of the health care system). Furthermore an introduction to the practical aspects of the different professionals in the field of Public and Occupational Health is essential to enable curative physicians to collaborate with public and occupational health physicians (e.g. general practitioners and occupational health physicians in the supervision of sickness absenteeism). Finally, it is important to create an opportunity for professional orientation, because, in fact, a considerable number of medical students eventually opt for a career in Public and Occupational Health. Health Sciences education The Faculty of Earth and Life Sciences at the Vrije Universiteit in Amsterdam organizes the Health Sciences education programme. A majority of these students will finally work in management, policy or research in the field of Preventive Medicine and Public and Occupational Health. Because of the available expertise, the Department makes a major contribution to the courses of this education program. There is a promising spin-off for the Department because an increasing number of students participate in several research projects; this implies not only a contribution to the work that has been done, but also an opportunity to scout for new research talent.

10 Leadership and Policy 10 Postgraduate medical education The Department intends to play a more significant role in postgraduate education and, in particular, in the training programs of the Netherlands School for Public and Occupational Health. In the past, the emphasis was mainly restricted to activities involved in the professional training for occupational health physicians, but the Department has now started to participate in the public health education program. Finally we are substantially involved in the postgraduate training of youth health care physicians. Research The Department has decided to concentrate on the following research lines: 1) Quality of care and prevention, 2) Public health at the end of life, 3) Work and health, and 4) Physical activity and health. Cross-links between these lines are stimulated. The research projects are embedded in the Institute for Research in Extramural Medicine (EMGO Institute), which implies that, in principle, the research lines must fit into the EMGO research programs. Research must be extramurally or transmurally orientated, and outcome measures are patient, individual, or population-orientated, i.e. the dependent variables are preferably a health outcome. Our Department uses the infrastructure of the EMGO Institute, i.e. the financial administration of research projects, epidemiological and statistical expertise, assessment of the quality of the research proposals by the Scientific Committee and monitoring the quality of the scientific process by the Quality Committes. (see: Academic workplaces The aim is to create academic workplaces in public and occupational health services and institutions where work is carried out at an academic level, and with which the Department will collaborate closely in the field of education and research. Examples are the larger Municipal and Community Health Services (GGDs), Home Care Services (Parent and Child Care), Occupational Health and Safety Services (ARBO services) and the Institution for Employee Benefit Schemes (UWV) that mainly deals with the disability regulations.

11 Employees 11 Employees

12 Employees 12 In achieving the ambitions mentioned in the previous chapter, adequate human resource management is of crucial importance. Thus we aim to provide reasonable remuneration, pleasant working conditions, good support, adequate potentials for (internal) training, methodological and conceptual discussions ( stimulating environment ), adequate career prospects and an active post-doc policy (including international exchanges). The aims of the management are based on support and motivation, and creativity, precision and productivity are appreciated. We are watchful for sub-optimal performance and undesirable conduct. Performance is assessed annually with each individual member of our staff, and attention is paid to training and career development. Change-over in personnel is minimal and the rate of sick-leave is low. An optimal combination of work and private life is considered to be important, the working hours are flexible, and it is possible to work at home. However, the pressure of work is high for many members of our staff, so this problem has to be addressed continuously. After a rapid increase in personnel between 1997 and 2002 the Department is now in state of dynamic equilibrium. At present there are approximately 70 members of the scientific staff and approximately 20 members of the non-scientific staff. The majority are PhD students/junior researchers, who have a formal contract with the EMGO Institute. There are now two full-time Endowed Professors, a part-time Endowed Professor, three Honorary Professors and three Associate Professors in the Department. However, in view of the number of PhD students/junior researchers who have to be supervised, the number of directly funded senior staff members is relatively low. Appointment per 31/12/2004 Names Function Education Research Direct funding Direct funding Indirect funding Ms E Althuizen, MSc PhD Student 0.8 JR Anema, MD, PhD Assistant Professor 1.0 Ms GAM Ariëns, PhD Senior Researcher 0.9 Ms MA Bak, MA Research Assistant 0.5 Ms B Blatter, PhD Researcher 0.2 AJ v/d Beek, PhD Associate Professor M v/d Berg, MSc PhD Student 1.0 Ms CM Bernaards, PhD Post-doc 0.8 JA Bijlsma, MD, PhD Researcher 0.2

13 Employees 13 Names Function Education Research Direct funding Direct funding Indirect funding Ms PM Bongers, PhD Professor 0.2 S Borgsteede, MSc PhD Student 1.0 Ms K Brouwer, MA Secretary 0.5 Ms A Bulk, MD, PhD Senior Researcher DJ Bruinvels, MD, PhD Senior Researcher 0.3 GJ de Bruijn, MSc PhD student 0.2 Ms MJM Chin A Paw, PhD Senior Researcher Ms EAM Claassen, MA PhD Student 1.0 Ms I Christiaans, LLM Junior Researcher 0.2 Ms JM Cuperus-Bosma, LLM,MD,PhD Senior Researcher Ms JC Dekkers, PhD Post-doc 1.0 L Deliens, PhD Senior Researcher 0.5 L Engbers, MSc Junior Researcher 1.0 Ms M Ershadi Secretary Ms M Gademan, MA Research Assistant* 0.8 Ms E Garcia, PhD PhD Student 0.5 JJ Georges, MA Junior Researcher 0.8 Ms J Goedhart, MA Research Assistant 0.5 Ms H Hamberg-van Reenen, MSc Junior Researcher 0.8 Ms IJM Hendriksen, PhD Researcher 0.2 Ms L Henneman, PhD Post-doc 0.7 MW Heymans, PhD Post-doc 1.0 VH Hildebrandt, PhD Researcher 0.2 RA Hira Sing, MD, PhD Professor H Hlobil, MD Researcher 0.3 Ms L ter Hofstede Research Assistant 0.5 Ms M Hollander Research Assistant* 0.8 Ms WE Hooftman-Schimmel, MSc PhD Student 1.0 Ms LHF Hoonhout, MSc Junior Researcher 0.9 Ms M Hopman-Rock, PhD Researcher 0.2 Ms PK Houwen, MA Research Assistant* 0.5 Ms AC Huizink, PhD Post-doc 0.2 S IJmker, MSc Junior Researcher 1.0 Ms JH Kleinveld, MA PhD Student 0.8 Ms M.A. Kollau, MA Secretary 0.4 L Koppes, PhD Post-doc 1.0

14 Employees 14 Names Function Education Research Direct funding Direct funding Indirect funding Ms AMM Kuin, PhD Post-doc 0.7 Ms CWE v/d Laar, MSc Junior Researcher 1.0 Ms I v/d Leden Secretary FJM van Leerdam, MD Assistant Professor 0.8 Ms M van Leeuwe-Bankespoor, MSc Junior Researcher 0.4 Ms JE van Leeuwen, MA Research Assistant 0.5 Ms Th Marteau, PhD Professor 0.05 W van Mechelen, MD, PhD Professor Ms A Nooyens, MSc PhD Student 0.2 Ms BD Onwuteaka-Philipsen, PhD Associate Professor Ms ME Ooms, MSc Research Assistant 0.4 Ms N Oostdam, MSc Research Assistant* 0.5 Ms E Paap, MA Research Assistant 0.8 Ms C Pennings, MA Research Assistant 0.4 HP v/d Ploeg, MSc PhD Student 0.8 HN Plomp, PhD Associate Professor 0.55 Ms MNM van Poppel, PhD Senior Researcher DS Rebergen, MA PhD Student 0.8 Ms CM Renders, PhD Researcher 1.0 Ms ML Rurup, MA Junior Researcher 1.0 DCM Ruys, MD Researcher 0.2 Ms M Simons Research Assistant 0.5 Ms AS Singh, MSc PhD Student 1.0 SM Slootmaker, MSc Junior Researcher 1.0 Ms P Slottje, MSc Junior Researcher 1.0 T Smid, PhD Professor 0.2 Ms N Smidt, PhD Post-doc 1.0 MBM Soethout, MD Assistant Professor Ms SGM Stomp-v/d Berg, MSc Junior Researcher 0.8 Ms MM van Stralen, MA Research Assistant* 0.8 Ms DRM Timmermans, PhD Senior Researcher Ms BAM The, LLM, PhD Senior Researcher 0.7 Ms K Uegaki, MSc PhD Student 1.0 Ms JGZ van Uffelen, MSc Junior Researcher 1.0 EALM Verhagen, PhD Post-doc 1.0 Ms CF Vermey, MA PhD Student 1.0

15 Employees 15 Names Function Education Research Direct funding Direct funding Indirect funding Ms TT Vreden, MA Research Assistant 0.5 R Waaijman, MSc Research Assistant 0.4 G v/d Wal, MD, PhD Professor Ms BG v/d Wal, MSc Research Assistant 0.6 Ms MM v/d Wal, MSc Research Assistant* 0.8 HJ Weevers, MSc PhD Student 1.0 Ms MJ Westerman, MSc PhD Student 1.0 Ms MF van Wier, MSc Junior Researcher 1.0 Ms P van Wigcheren, MSc Junior Researcher 0.6 Ms A Witteveen, MSc Junior Researcher 0.4 Ms M van Zuidam, MA Research Assistant 0.6 Total *Counsellor Most researchers have participated in the undergraduate curriculum tutorials. The following people have also contributed to the undergraduate medical curriculum and the Health Sciences curriculum: FJA Beumer, LLM (Inspectorate for Health Care) Ms JH Choufoer, MD (Occupational Health and Safety Service, VU University Amsterdam/VU University Medical Center) C Das, LLM, MD, PhD (Amsterdam Municipal Health Services) B Elzerman, MD (ArboNed) Prof RA Coutinho, MD, PhD (Amsterdam Municipal Health Services) Ms M Johannes, MD (Amsterdam Municipal Health Services) R Greeven, MD (Arbo-Unie) Ms C v/d Hoeven, MD (Zaanstreek Waterland Municipal Health Services) Prof JH Hubben, LLD (Faculty of Law, VU University Amsterdam) Ms M Muris, MD (ArboNed) A Klomp, MD (Zaanstreek Waterland Municipal Health Services) P Kohne, MD (Haarlem Municipal Health Services) Ms D Kuyvenhoven, MD (West-Friesland Municipal Health Services) L v/d Leijden, MD (ArboNed)

16 Activities Report Employees 16 Ms A Nielen, MD (Amsterdam Municipal Health Services) Ms M Oosting, MD (Zaanstreek Waterland Municipal Health Services) T Pal, MD, PhD (Netherlands Center for Occupational Diseases) J Penders, MD (KLM Arbo Services) UJL Reijnders, MD, PhD (Amsterdam Municipal Health Services) Ms R Rip (IJmond and Kennemer Home Care) Ms HJC Smink, LL M (Department of Medical Affairs, VU University Medical Center ) JE van Steenbergen, MD (Dutch Infections Disease Control) A Straatman, MD (ArboNed) P Thung, MD (Occupational Health and Safety Service, VU/VU University Medical Center) MJ van Til, MD (Occupational Health and Safety Service, VU/VU University Medical Center) M Verkuil, MD (Arbo Unie) R Vissers, MD (Evean Youth Care) A Voorbij, MD (ArboNed) P de Wolf, MD ((Zaanstreek Waterland Municipal Health Services) A van der Zeijden, MA (Dutch Council for the Chronically Ill and the Disabled) JE van Steenbergen, MD (Dutch Infections Disease Control) The following people left the Department during the period of reporting: G Asad, Ms J de Bie, Ms H Brandt, M Echteld, Ms MAM Dijkman, Ms C v/d Geest, Ms M Gerritsen, Ms G Gutschow, FAG Hout, Ms M Jansen-v/d Weide, Ms M Klinkenberg, Ms L van der Maas, Ms KB Monsjou, MT Muller, J Oudhoff, Ms AMC Plass, Ms KI Proper, Ms HRW Pasman, D Samoocha, Ms EMF van Sluijs, Ms M Spoelstra, JB Staal, Ms J v/d Steen, IA Steenstra, Ms M Uittenbosch, Ms C Wijnholts.

17 Resources 17 Resources

18 Resources 18 Education Undergraduate medical education Funding ( ), scientific personnel (SP) and non-scientific personnel (NSP) per 31/12/03 and 31/12/ Direct funding Indirect funding Direct funding Indirect funding Finance SP NSP Health Sciences education Funding ( ), scientific personnel (SP) and non-scientific personnel (NSP) per 31/12/03 and 31/12/ Direct funding Indirect funding Direct funding Indirect funding Finance SP NSP Research Direct funding Indirect Funding ( ), scientific personnel (SP) and non-scientific personnel (NSP) per 31/12/03 and 31/12/ Direct funding Indirect funding 1 funding 1 Finance SP NSP Finance is including personnel 2 Including 0.98 fte for the academic network 3 Including 1.90 fte for the academic network

19 Resources 19 A pressing problem that remained in the past two years was housing. A temporary solution was found by renting office space near the campus for colleagues from other groups of the EMGO Institute. Nevertheless, many of our co-workers have their workplace far from the central offices of the Department. Unfortunately, because of problems in the financial situation of the VUmc, the Department has twice been confronted with spending cuts. The structural netto effect is a decrease of in our annual budget. Furthermore, the expected increase in academic workplaces had to be postponed.

20 Processes 20 Processes

21 Processes 21 Undergraduate medical education During the period of reporting the number of first-year students increased from 324 in 2002 to 350 in 2004 (10 extra students from Norway are not included). This growing number of students, following the increase from 245 to 324 that had already taken place in 2001 and 2002, has had a great impact on the capacity of tutors, especially in departments such as Public and Occupational Health, which have a relatively small education staff. In the current curriculum our Department participated in the first four years of education, mainly in the thematic courses on 'Man, Medicine, Society' and 'Health Care', and to a lesser extent in the courses on 'Growing Up' and Aging. We also contributed to Experience training and to the problem-orientated Clinical training, and an elective profile Child and health care (a combination of an elective course, a scientific research course and a elective clerkship on child and health care). The subject matter for Public and Occupational Health consists of texts in the various course books and the renewed textbook Public s Health and Health Care ( Volksgezondheid en Gezondheidszorg ) edited by JP Mackenbach and PJ van der Maas, Elsevier, 2004). This textbook is used in all Dutch medical faculties. Several co-workers of our Department are (co-)author of different chapters. In the last two study years we provided a discipline-oriented clerkship, and also offered various elective clerkships. Furthermore we organized an inter-disciplinary training ( Stage Overstijgend Onderwijs ) with various themes (Figure 1).

22 Processes 22 Figure 1: Undergraduate medical curriculum at the VU University Medical Center 1st study year 2nd study year Course Man, Medicine, Society Clinical training / Experience training / Skills training 3rd study year Clinical training / Experience training / Skills training Elective course Clinical training / Experience training /Skills training 4th study year Course Health Course Aging Course Growing Care Up Clinical training / Experience training /Skills training Scientific research training 5th study year 6th study year Interdisciplinary training Public & Occupational Health clerkship Interdisciplinary training Elective clerkship Senior clerkship The Department participated in the development of a new medical curriculum, which will start in September Context-learning (early patient contact) based on competences and student tasks in a Bachelor-Master structure is the main component of this curriculum. Prof. Gerrit van der Wal is Vice-Chair of the Faculty Curriculum Committee, and we are preparing a practical course for the third year (Chair: Marc Soethout) and two second year courses; Adult, Work and Health (Chair:Prof. Willem van Mechelen) and From Baby till Adult (Chair:Prof. Remy Hira Sing). A clerkship is planned for the fifth year, and in the sixth year there will be a 20-weeks final preparation clerkship.

23 Processes 23 Embedding The national requirements for medical training (Blueprint 2001) are the guidelines for the content of the medical curriculum. The curriculum consists of modules, and the Department participates in some of these modules. Together with the participating tutors, the Chair of an education module is responsible for the quality of the education. Procedures At least once every year there is an education module (or course) meeting, in which the organization, the content and the results of the student evaluation are discussed. The Chair persons of the education modules meet three times a year. The Director of Education at the VU University Medical Center chairs these meetings. The educational responsibilities of the Department are formulated in a written education agreement. Quality assurance Each module is evaluated and a report is written and discussed with the tutors and students involved. These evaluations are also discussed in the meetings of the Faculty Medical Education Committee. This Committee advises the Director of Education and the Board of Directors of the VU Medical Center about any necessary adaptations in the education program. The quality assurance policy for the examinations is the responsibility of the Examination Committee, which advises of the Director of Education and the Board of Directors. An external body, the Inspection Committee of the Association of Universities in the Netherlands, assesses the faculty quality assurance policy. Course on 'Man, Medicine, Society' The disciplines of Medical Psychology (Chair), Metamedics, Psychiatry, General Practice, Public and Occupational Health, and Physiology participate in this course. The course consists of lectures, supplemented with tutorials and problem-oriented training. Our Department organizes seven lectures, focusing on daily practice in public and occupational health. Social security and Structure and functioning of the health care system are further explored in two 2-hour tutorials (a total of 30 groups of approximately 12 students with supervisors). The Department participates in 3 themes of problemoriented training; in addition to participation in six plenary meetings, it organizes two 15- hour tutorials (2 groups with supervisors). The three themes are Chronic illness, Pain and Sexuality.

24 Processes 24 Course on 'Aging' and course on 'Growing Up' Various disciplines also participate In these courses. Our Department organizes 2 lectures in the course on Aging: Epidemiology of aging and Pros and cons of aging. In the course on 'Growing Up', we provide one lecture on Chronically ill children. Course on 'Health Care (and Public s Health)' In the course on 'Health Care (and Public s Health)' the disciplines of General Practice, Metamedics and Public and Occupational Health (Chair) collaborate. The course consists of lectures, supplemented with tutorials. Our Department organizes 12 lectures and 12.5 hours of tutorials (24 different groups of approx. 12 students). In the tutorials, 4 public health themes are studied in more depth: Errors in medicine and quality of care, Terminal and palliative care, Work and health, and Life-style and health. The tutorials involve visits to practices, group meetings, presentations, and writing a paper. The following subjects are addressed in the lectures: Public health and health care, Quality of care, Forensic medicine, Handling errors, Life-style and health, Prevention, Youth health care, Work and health, Health law and Health economics. The contents of the course and powerpoint presentations of the lectures were presented on the Internet (Blackboard). A special course of 3 tutorials, focusing on health care and public health in the Netherlands, was organized for non-ec medical doctors who followed the medical curriculum at a later point in time. Clinical training Clinical problem-solving is taught during patient demonstrations and tutorials. In the tutorials a multidisciplinary case is discussed under the supervision of a clinician. The Department has made contributions in the form of issues related to youth health care and occupational health care in the 4th year. Experience training The experience training provides a practical introduction to the profession of a physician. The goal of this training is to introduce the medical student to medical practice from various angles, focusing not only on the user of the care, but also on the care system itself. It is intended to encourage the students to reflect on their own reactions, functioning as future care-providers in the health care system. All 3rd year students, visit in groups of 10 to 12 persons. Make one 2-hour visit to at an Occupational Health and Safety Service (Arbo services), and one 2-hour visit to a Municipal Health Service (GGD).

25 Processes 25 In the final year all information for students was presented on the Internet (Blackboard), and for practical reasons the site visits were replaced by interactive tutorials at the faculty, where tutors from the field of public and occupational health discuss interactive casereports and demonstrate daily practice with short video-tapes. Scientific research training The scientific research training has a duration of weeks in the 4th year. Students participate in scientific research in one of the medical departments or research institutes. The research period ends with a written paper. Students can participate in research projects in our Department, or they can participate in a research project in one of the Public or Occupational Health Services, supervised by a senior researcher from the Department. Clerkships The final two years of the undergraduate medical curriculum consist of clerkships in different departments of hospitals, general practices and Public or Occupational Health Services. The department organizes a 2-week Public and Occupational Health clerkship. An introduction day and a final day at the faculty structure the program. In the interim period, practical training is provided by a Municipal Health Service (GGD), an Occupational Health and Safety Service (ARBO service), the Institute for Employee Benefit Schemes (UWV) or a Home Care Organization (Parent and Child Care). On the introduction day professionals in the field inform students about the two main streams of Public and Occupational Health: Occupational Medicine and Community Medicine. Examples from daily practice are used as illustration. Simulated patients are used for the skill straining. During the practical training, the students gain insight into the work of the institution or service they have chosen, and the tasks of the public and occupational health physicians and other people who work there. They practice a number of pre-defined skills in public and occupational health, and they also have to find, in a structured way, a solution to a public health problem that was given to them on the introduction day at the faculty. During the final day at the faculty, the students exchange experiences, and give a structured presentation of their public or occupational health problem, based on by the PREPAREmodel (Figure 2). The model was designed in our Department and further developed at a national level to deal with public and occupational health problems in a structured and evidence-based way. The preference of the students with regard to the location of practical training is taken into account in the final allocation of the clerkship. Unfortunately, however, in view of the

26 Processes 26 limited offer of clerkships made by services and organizations during a certain period, it is not always possible to honor these preferences. In recent years there has been a marked increase in the number of students who had a definite preference for their clerkship. At present, approximately two thirds of the students make use of the possibility of stating their preference beforehand. Figure 2: Methodology (PREPAREmodel) for public and occupational health problems Steps Remarks P Problem What is the problem? - What is the case? R Relevance What is the relevance? - What are the determinants? E Evidence What is the evidence of intervention and prevention? - What is the source of information? P Preventive Which preventive measurements can be taken, and why? - Primary / secondary / tertiary (individual and group)? A Advise Which advice/information can be given? - Individual/ group/society? R Record Which written record is necessary, and why? - Is there a duty to report? E Evaluation Is evaluation necessary, and why? MS/09/ Individual/group/society?

27 Processes 27 Elective clerkships Students can devote 6 weeks of their clerkships to electives. In the past two years 31 students completed an elective clerkship in Public and Occupational Health (see Chapter 9). Elective profile The medical curriculum has 10 different elective profiles. A profile consists of a combination of a theoretical elective in the 3 rd year, a period of scientific research training in the 4 th year, and an elective clerkship in the final years. The Department participates in the elective profile Child and Youth Health. Interdisciplinary training During the clerkships in the 5 th and 6 th years, interdisciplinary revision days are held at the faculty ( Stage Overstijgend Onderwijs ). Each session consists of a 3-hour period, and there are now approximately 10 sessions scheduled, 7 of which are compulsory for all students. Our Department organizes and participates in 3 sessions, i.e. Forensic medicine, Health law and Occupational diseases. Case-histories are discussed in a multidisciplinary way. We collaborate with several clinical departments and with the Forensic Department of the Municipal Health Services in Amsterdam, the Faculty of Law, and the Netherlands Center for Occupational Diseases. Health Sciences education The faculty of Earth and Life Sciences organizes Health Sciences. The 4-5-year curriculum is based on the Bachelor-Master structure. The Department is one of the main participating disciplines, and is responsible for the co-organization of the curriculum. We participate in the Bachelor courses on Health care, Prevention and Policy research and we are currently developing a course on Regulation and organization of health care for the Master course (Figure 3).

28 Processes 28 Figure 3: Health Sciences curriculum at the VU University 1 st study year (Bachelor) Course Health Care 2 nd study year (Bachelor) 3 rd study year (Bachelor) Course Prevention Course Policy Research 4 th /5 th study year (Master) Course Regulation and organization of health care Course on Health Care The course on Health Care is given during the first year, in collaboration with the Department of Health Care and Culture and the Department of Medical History. Our Department is Chair of this course. The aims of the course are to offer first-year students an overview of the development of the health service systems (especially in the Netherlands) and how they are embedded in society, and in the development of the health status of the population over the last 150 years. In problem-oriented learning groups, special attention is paid to three themes: infectious diseases, development of the supply and demand of health services, and the perspective of the patient. In the final term there is an examination, and the students have to write a paper on one of the three themes. Course on Prevention This course aims to introduce students to the theory and practice of disease prevention and health promotion. The theory is taught through lectures and tested in an examination. Practical knowledge on prevention is gained by visiting a specific prevention program (interviewing the program leader) and by writing a scientific paper, which contains a description and a critical evaluation of the program and an overview of the relevant scientific literature. Our Department is Chair of this course, which is organized together with the Department of Nutrition and Health of the Faculty of Earth and Life Sciences.

29 Processes 29 Course on Policy Research This course does prepare students for their Bachelor research apprenticeships in public health. The aims are to integrate the methodological knowledge that was gained in preceding courses and to apply this knowledge to practical problems that were encountered in prevention and health services. The course has three components: principles of policy research, health services, research and qualitative data-collection and analysis. The students have to take an exam and they also have to formulate a research protocol for a practical problem, which is feasible and also meets the methodological and theoretical standards. Our Department organizes this course. Course on Regulation and Organization of Health Care The aim of this course is to offer students the tools (concepts and methods) to describe and analyse the organization, management and quality of health care systems and health care services at an operational level. The course is still being developed, but will be chaired by our Department. Postgraduate medical education Our Department participates in the management and content of some courses organized by the Netherlands School of Public and Occupational Health (NSPOH), of which Professor Gerrit van der Wal is Vice-Dean. The postgraduate education includes both main streams of Public and Occupational Health. Research Embedding The research in our Department is integrated in four research lines, all of which focus on Public Health and Health Care. These research lines are: 'Quality of care and prevention', 'Public health at the end of life', 'Work and health', and 'Physical activity and health'. A senior researcher from these four research lines participates in the two-weekly staff meetings, together with the three Professors, the Education Coordinator and members of the administrative staff. All research projects are embedded in the Institute for Research in Extramural Medicine (EMGO Institute) and all research projects fit into one the programs of the Institute. The EMGO Institute participates in the Netherlands School of Primary Care Research (CaRe), which was re-acknowledged in 2000 by the Royal Netherlands Academy of Arts and Sciences (KNAW) for a second period of five years.

30 Processes 30 Quality of Care and Prevention Quality of care and prevention concerns the extent to which (preventive) care contributes to good quality of life and the length of the life of a patient or client. It must be technically good care, cost-effective care, and patient-oriented care. Technically good care is care that, according to the current professional standards, is given to the right person at the right moment. This implies that physicians not only have to make the right choice of treatment for a patient, but they must also be able to provide the care in an expert and adequate manner. Cost-effective care implies that the results of the care in terms of health benefits must be in balance with the costs of the care. Patient-oriented care refers, among other things, to the interactions between the physician and the patient: the quality of the communication, the provision of adequate patient information, and the maintenance of a good relationship with the patient. According to this definition, research in the field of quality of care and prevention is just as comprehensive as research in the entire field of public health. It is therefore necessary to determine the focus of research within this broad concept. Quality of care research can focus on the invidual providers and receivers of the care, or on the organization of the care.a considerable body of the research that takes place in the Department of Social Medicine focusses on the first type of care, for instance research on care that is or is not provided (e.g. the Maximum Acceptable Waiting Times project) and on care that is or is not utilized (e.g. the Prenatal Screening project). The research line Dealing with risks and decision-making focusses on the provision of information to care-users, the way in which patients and the general public understand this information and take it into consideration in decisions concerning their health, and the skills that are needed to form an opinion and to make a decision. One project that focusses on the organization of care is the evaluation of the Individual Health Care Professions (IHCP) Act. The aim of this evaluation was to investigate how the IHCP Act functions in daily practice, and to determine the extent to which the aims of the Act protecting the general public against incompetence and carelessness in individual health care, and the promotion and assurance of quality in professional practice are achieved. Certain aspects of youth health care are also investigated in this line of research, namely research on the appropriateness and effectiveness of youth health care prevention programmes. The research programme Patient safety, that started in 2004, will not only focus on the individual care-provider, but also on the organization of care. The health care sector is characterized by complex processes that are carried out for and by individuals. There is often a question of dependence, for instance, on technology, other care-providers, the organization, or the patients themselves. Moreover, medical errors can be made by the best doctors and in the best health care systems. This project also includes research on the

31 Processes 31 incidence of medical errors, or rather, adverse events in the Netherlands, and the causes of adverse events. Interventions to improve the safety of patients are also being evaluated. Public health at the end of life Public health at the end of life concerns research on the incidence and the prevalence of health and illness in the population in the final phase of life, their determinants, and the measures that can have a positive influence on these determinants and health-related quality of life. This field of research includes palliative care, and the decisions involved may have the result of hastening death. End-of-life care demands a high level of expertise, competence and integrity. Not only, for instance, in the case of euthanasia and physicianassisted suicide, but also with regard to such aspects as forgoing life-prolonging treatment, the medical profession must formulate requirements for prudent practice and be open to evaluation. The public health research focuses on the epidemiological aspects of health and illness in the final phase of life and the development of good measurement instruments, outcome measures and indicators for responsible end-of-life care. Research is also being carried out to investigate ways in which to maintain or improve functional autonomy and the social support that patients receive. Finally, the research also investigates the various ways in which, and the conditions under which, end-of-life care can be organized. Work and health Research in the field of work and health mainly concentrates on the etiology and prevention of work-related disorders of the musculoskeletal system. These disorders cause approximately one third of sickness absenteeism and work disability in the Netherlands. The etiological research studies the development of back, neck and upper extremity disorders in the occupational setting, and also work-related disorders of the musculoskeletal system in general practice. In prospective cohort studies, special attention is paid to exposure assessment and the risk of sickness absence due to musculoskeletal disorders. Research on the prevention of work-related disorders of the musculoskeletal system concerns various programs treating workers who are absent from work due to nonspecific low back pain. Several large Randomized Controlled Trials (RCTs) have focussed on this topic, all with the appropiate cost-effectiveness analysis. Within this research line many systematic reviews of the literature are being carried out, some within the framework of the Cochrane Collaboration. In this research line attention is also paid to female workers in two PhD projects. Gender differences in work-related exposures and in the risk of (sickness absence due to) musculoskeletal disorders are being studied, and the effectiveness of occupational health

32 Processes 32 care on return to work after childbirth is being investigated in an RCT. Finally, an RCT is being carried out to evaluate the effectiveness of the Dutch guidelines for the management by occupational physicians of workers with mental health problems. It is aimed to add more research on the prevention of psychological complaints to this line. In 2002, the Research Center TNO VUmc, a collaboration between the VU University Medical Center and TNO, was established. One of the two main areas of interest of this Research Center is work and health. Hence, TNO VUmc is funding six studies in which the relationship between work and musculoskeletal disorders is being investigated. Physical activity and health Physical activity has a strong influence on health, both negatively and positively. Adequate physical activity is extremely beneficial for the health status, but a possible negative effect of sport and physical activity is that they increase the risk of (sports) injuries. Research in this field concentrates on the health consequences of various physical activity and training programs, for instance for the residents of long-term care facilities. Since it is a well-known fact that approximately 60% of the population in the Netherlands is insufficiently physically active, effective methods to stimulate a physically active life-style are also being investigated. This is taking place, in particular, in occupational health care, general practice, and rehabilitation centers. The second of the two main areas of interest of the Research Center TNO-VU is physical activity and health, and the center is funding three studies in which physical activity is promoted. Overweight, for which physical inactivity is a strong risk factor, is becoming an increasingly urgent problem in public health care. In order to tackle this problem, a Center of Expertise on the prevention of overweight and obesity has been established within the EMGO Institute: the Knowledge Center Overweight. The Department of Public and Occupational Health is an important contributor, and the primary aim of the Center is to provide intermediary professionals with state-of-the-art knowledge concerning the prevention of overweight and obesity (see: Furthermore, several studies on the prevention or reduction of overweight and obesity have been initiated, focusing on working populations, adolescents, and pregnant women. In all these studies the promotion of physical activity plays an important role. From the public health perspective, the prevention of sport injuries is important. Research on the negative aspects of physical activity and sport, for instance, is directed towards the prevention of sports injuries among youth.

33 Processes 33 Procedures The project leaders of the research projects are senior investigators, who are responsible for the supervision of junior researchers and PhD students and the daily management of the research. A Professor has the final responsibility for the scientific content, the project management, and the dissertation of the junior researcher or PhD student. All projects can receive statistical and methodological support from a senior member of the Department of Clinical Epidemiology and Biostatistics at the EMGO Institute. Similarly, for all projects some assistance with the design and execution of the data-management is available, and the Financial Administrator at the EMGO Institute assists all project leaders with financial affairs. Quality assurance The majority of the research projects are externally funded, and most funding organizations have a strict procedure for assessment of the relevance and quality of a research proposal. This usually entails a peer review by several (national and international) referees. Research that is of insufficient quality will have less chance of being funded. In addition to this external quality control, all research proposals must be submitted to the Scientific Committee of the EMGO Institute. Two senior researchers assess the proposals with regard to compliance with the EMGO research programs and the scientific quality and feasibility of the project. After funding has been obtained (internally or externally), but before the actual data-collecting takes place, a detailed protocol is formulated, including all patient information and questionnaires. This protocol is submitted to the VUmc Medical Ethics Committee, which assesses the ethical consequences of all research involving humans or animals. The quality of the data-gathering, data-storage and data-analyses is monitored by the Quality Committee of the EMGO Institute, by means of audits of ongoing projects. In order to improve the quality of both the research and the researchers, meetings are held every two weeks for all researchers in our Department. In more specialized meetings that are held regularly in each of the four research lines, methodological and practical issues are discussed, thus improving the research projects and broadening the horizons of the researchers involved. The researchers also attend meetings held within the EMGO Institute research programs. Most research projects will result in several papers and a dissertation. The papers are mainly submitted to international peer reviewed journals for publication. Some papers are also submitted to national peer-reviewed journals, partly in the form of a so-called double-

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