Activities Report Department of Social Medicine VU University Medical Center 2001-2002
Colophon Editing Inge van der Leden, Mireille van Poppel, Marc Soethout, Gerrit van der Wal Translation Faith Maddever Coverdesign Etienne Wolfs Edition 900 2
Content Preface...4 Leadership, Strategy and Policy...6 Mission...7 Education...8 Research...9 Academic workplaces...9 Employees... 10 Resources... 16 Education...17 Research...17 Processes... 19 Education...20 Research...26 Projects Quality of care and prevention...32 Projects Public health at the end of life...38 Projects Work and health...45 Projects Physical activity and health...51 Customer appreciation... 59 Education (students)...60 Research...63 Employee satisfaction... 66 Societal recognition... 68 Final Results... 71 Finances...72 Education...72 Research...75 Publications Quality of care and prevention...76 Publications Public health at the end of life...81 Publications Work and health...84 Publications Physical activity and health...88 Appendix 1: INK Model...92 Appendix 2: Criteria and indicators of societal impact of research output.93 Appendix 3: Further publications...94 Quality of care and prevention...94 Public health at the end of life...97 Work and health...100 Physical activity and health...102 Appendix 4: Scientific and societal activities...105 Congresses and lectures...105 Functions and activities...118 3
Preface This is our third 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. This is the first time that our Activities Report has been compiled according to the so-called INK-model. This management model is based on the European EFQM Excellence Model. Although it has not been developed for academic institutions, it may help us to integrate the professional, organizational, relational and financial domains of our core activities, i.e. education and research. The model consists of nine areas which, linked together, determine the success of the organization (see Appendix 1). This new Activities Report confirms that again there has been a substantial increase in both the nature and the extent of the education and research programs. The educational activities have been extended, mainly through participation in a new branch of studies at our university, i.e. Health Sciences. A considerable critical mass of scientific personnel has been formed, albeit mainly as a result of external finance. Again the Department grew substantially, to a large extent due to establishment of the Research Center Body@Work TNO-VU, in which the Department and the EMGO Institute collaborate with TNO Work and Employment and TNO Prevention and Health (see internetsite: www.bodyatwork.nl). There are now approximately 75 members of the scientific staff (totaling almost 50 fte) and 10 members of the administrative staff (totaling more than 6 fte). At the end of 2002 there were 53 projects in progress, 46 of which will result in a thesis. In addition, there are also a number of external PhD students. The number of articles that were published in national and international journals is satisfying, taking into account the field of research and the time lag of 3-5 years between the initiation of (recently started) research projects and their completion. However, many of the papers were published in high-impact journals. Our continuous efforts to create academic workplaces were successful in the end. The Board of Directors of the VU University Medical Center provided funding per 1-1-2003 for an academic network for research in the field of youth 4
health care. In 2002 we were reinforced with the appointment of two new honorary part-time professors, Tjabe Smid, specializing in labour conditions and Paulien Bongers, specializing in the prevention of musculoskeletal complaints by work-intensification funded by KLM and TNO, respectively. We were also delighted that two of our senior staff members, Bregje Onwuteaka- Philipsen and Allard van der Beek have both been appointed as Associate Professor. Bregje was successful in winning one of the scarce and desired Aspasia positions ( a program for promoting female researchers to Associate Professor). Although the economic recession makes it difficult to acquire grants and despite a cut of 4% in the VU University Medical Center budget from 2003 onwards, we are confident about the future. We consider 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 Social Medicine within the VU University Medical Center. There are more than enough new challenges, e.g. participating in the development of the new medical curriculum, set up a research center for the assessment of workdisability, and further implementing the Knowledge Center Overweight. On behalf of all members of the staff, Gerrit van der Wal, Head of the Department 5
Leadership, Strategy and Policy 6
Leadership, Strategy and Policy Introduction Social Medicine is one of the eleven core disciplines included in the undergraduate medical training, and can be considered as the link between medicine and society. Social Medicine 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 of Social Medicine consists of two main streams: Community Medicine and Occupational Medicine. 20-25% of all physicians in the Netherlands are involved in a Social Medicine profession. Most, but not all of these physicians are officially registered as such. The scientific domain of Social Medicine is more extensive than the practical domain. As a scientific discipline, Social Medicine is involved in two major issues: Public s 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 Social Medicine 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 aim to create friendly, stimulating and productive working conditions within the Department. 7
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 daily practice of a physician: 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. A contribution towards scientific training is an explicit component of this. The basic principle of our education is that each future physician must have adequate knowledge of Social Medicine. This is important because in individual patient care (mostly provided by curative physicians) e.g. working conditions and health must be integrated. Also the influence of the social systems are important for patient care (e.g. social insurance s, and the structure and finance of the health care system). Furthermore an introduction to the practical aspects of Social Medicine is essential to enable curative physicians to collaborate with social medicine physicians (e.g. general practitioners and occupational physicians in the supervision of sickness absenteeism). Finally to create the opportunity for a professional orientation, because, in fact, a considerable number of students eventually opt for a career in Social Medicine. Other undergraduate education In 2001, a new program of Health Sciences started by the Faculty of Earth and Life Sciences at the Vrije Universiteit in Amsterdam. A majority of these students will finally work in management, policy or research in the field of Preventive and Social Medicine, so the Department was requested to make a major contribution to this new education program. Postgraduate medical education We intend 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 limited on activities involved in the professional training for occupational physicians, and to a lesser extent on training for forensic physicians. 8
Research We have decided to concentrate our research projects on the following 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 Institute 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, and assessment of quality of the research proposals by the Scientific Committee (see Internetsite: www.emgo.nl). 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 (GGD s), 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. 9
Employees 10
Employees In achieving the above-mentioned ambitions, adequate human resource management is of crucial importance. Thus we aim for a reasonable remuneration, pleasant working conditions, good support, adequate potentials for (internal) training, methodological and conceptual discussions ( stimulating environment ), adequate career prospects and an active postdoc 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 must be addressed. In recent years there was a considerable increase in personnel. At present there are almost 75 members scientific staff and approximately 10 members non-scientific staff. The majority is junior researcher and has a formal contract with the EMGO Institute. There are two full-time Endowed Professors, a part-time Endowed Professor and, since 2002, two Honorary Professors. With the recent appointments, there are now three Associate Professors in the Department. In view of the number of junior researchers that have to be supervised, the number of directly funded senior staff members is relatively low, and the administrative support is inadequate. 11
Appointment per 31/12/2002 Names Function Education Research Direct funding Direct funding Indirect funding Ms E Althuizen, MSc PhD Student 0.8 JR Anema, MD Researcher 0.4 Ms GAM Ariëns, PhD Senior Researcher 1.0 G Asad Abdullah Research Assistant 0.8 AJ v/d Beek, PhD Associate 0.03 0.97 Professor M v/d Berg, MSc PhD Student 1.0 Ms C Bernaards, PhD Post-doc 0.8 Ms J de Bie, MA Junior Researcher 0.8 JA Bijlsma, MD, PhD Researcher 0.3 Ms P Bongers, PhD Senior Researcher 0.2 S Borgsteede, MSc PhD Student 1.0 Mw B Blatter, PhD Senior Researcher 0.2 DJ Bruinvels, MD, PhD Senior Researcher 0.3 Ms MJM Chin A Paw, PhD Senior Researcher 0.5 0.4 Ms JM Cuperus-Bosma,LLM, Senior Researcher 0.1 0.4 0.3 MD, PhD Ms C Dekkers, PhD Post-doc 1.0 L Deliens, PhD Senior Researcher 0.5 Ms MAM Dijkman Research Assistant 0.6 M Echteld, MA Researcher 1.0 Ms M Ershadi Secretary 0.5 0.2 0.3 Ms E Garcia, PhD PhD Student 0.5 Ms C v/d Geest, MSc Research Assistant 0.75 Ms M Gerritsen Research Assistant 0,15 JJ Georges, MA Junior Researcher 0.8 Ms G Gutschow, MA Research Assistant 0.4 Ms L Henneman, PhD Post-doc 0.8 Ms I Hendriksen, PhD Senior Researcher 0.2 MW Heymans, MSc PhD Student 1.0 VH Hildebrandt, MD, PhD Senior Researcher 0.2 12
Name Function Education Research Direct funding Direct funding Indirect funding H Hlobil, MD Researcher 0.3 RA Hira Sing, MD, PhD Professor 0.1 0.2 Ms M Hopman-Rock, PhD Senior Researcher 0.2 FAG Hout, MSc Researcher 0.8 Ms AC Huizink, PhD Post-doc 0.9 S IJmker, MSc Junior Researcher 1.0 Ms M Jansen-v/d Weide, MA PhD Student 1.0 Ms JH Kleinveld, MA PhD Student 0.8 Ms M Klinkenberg, MSc Junior Researcher 0.8 Ms AMM Kuin, PhD Post-doc 0.5 Ms I v/d Leden Secretary 0.5 0.4 0.1 W van Mechelen, MD, PhD Professor 0.2 0.8 M Muller, PhD Researcher 0.6 Ms BD Onwuteaka- Associate 0.03 0.87 0.1 Philipsen, PhD Professor J Oudhoff, MSc Junior Researcher 1.0 Ms HRW Pasman, MA Junior Researcher 1.0 Ms AMC Plass, MA Junior Researcher 0.8 HP van der Ploeg, MSc PhD Student 1.0 HN Plomp, PhD Associate 0.55 Professor Ms MNM van Poppel, PhD Senior Researcher 0.13 0.47 0.1 Ms KI Proper, MSc Junior Researcher 0.4 DS Rebergen, MA PhD Student 0.8 Ms CM Renders, PhD Researcher 1.0 Ms M Rurup, MA Junior Researcher 1.0 Ms H Brandt, MA PhD Student 1.0 Ms WE Schimmel, MSc PhD Student 1.0 Ms AS Singh, MSc PhD Student 1.0 Ms P Slottje, MSc Junior Researcher 1.0 Ms EMF van Sluijs, MSc PhD Student 1.0 13
Name Function Education Research Direct funding Direct funding Indirect funding T Smid, PhD Professor 0.2 MBM Soethout, MD Education Coordinator 1.0 Ms M Spoelstra Research Assistant 0.5 JB Staal, MSc PhD Student 1.0 Ms JT v/d Steen, PhD Post-doc 0.5 I Steenstra, MSc PhD Student 1.0 Ms SGM Stomp-v/d Berg, Junior Researcher 0.8 MSc Ms DRM Timmermans, PhD Senior Researcher 0.03 0.97 Ms BAM The, LL M, PhD Senior Researcher 0.7 Ms JGZ van Uffelen, MSc Junior Researcher 1.0 EALM Verhagen, MSc PhD Student 1.0 G van der Wal, MD, PhD Professor 0.5 0.5 HJ Weevers, MA PhD Student 0.8 Ms MC v/d Weide, MSc Junior Researcher 0.8 Ms MJ Westerman, MSc PhD Student 1.0 Ms P van Wigcheren, MSc Research Assistant 0.5 Ms M van Wier, MSc Junior Researcher 1.0 Ms A Witteveen, MSc Junior Researcher 0.6 Total 3.67 6.78 47.0 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 A Bulk, MD, PhD (Youth Health Physician, Home Care Organization Amstelland de Meerlanden)? Ms JH Choufoer, MD (Occupational Physician, Occupational Health and Safety Service, VU/VU University Medical Center) 14
? Prof RA Coutinho, MD, PhD (Head of the Amsterdam Municipal Health Services)? D Fangidaej, MD (Occupational Physician, ArboNed)? Prof JH Hubben, LLD (Faculty of Law, VU University Amsterdam)? Ms M Muris, MD (Occupational Physician, ArboNed)? A Klomp, MD (Head of the Zaanstreek Waterland Municipal Health Services)? Ms D Kuyvenhoven, MD (Youth Health Physician, West-Friesland Municipal Health Services)? Ms M Oosting, MD (Youth Health Physician, Zaanstreek Waterland Municipal Health Services)? T Pal, MD, PhD (Occupational Physician, Netherlands Center for Occupational Diseases)? UJL Reijnders, MD, PhD (Forensic Physician, Amsterdam Municipal Health Services)? Ms HJC Smink, LL M (Faculty of Law, VU University Amsterdam)? P Thung, MD (Occupational Physician, Occupational Health and Safety Service, VU/VU University Medical Center)? MJ van Til, MD (Head of the Occupational Health and Safety Service, VU/VU University Medical Center)? M Verkuil, MD (Occupational Physician, Arbo-Unie)? A Voorbij, MD (Occupational Physician, ArboNed)? A van der Zeijden (Dutch Council for the Chronically Ill and the Disabled) The following people left the Department during the period of reporting: Ms J Bosboom, Ms D Brunsting, Ms D van Dam, E Eerkens, Ms E Enting, T Hak, Ms I Haverkate, L Heintz, GLM Hilkhuysen, Ms L Ter Hofstede-Ruiter, Ms WE Hoogendoorn, Ms M van der Horst, Ms L Ingen-Housz, Ms M Kok, Ms L Kooiman, Ms Y de Liver, Ms D van Koolwijk, Ms S Mak-Kregar, D Mehr, Ms F Norwood, Ms A Paauw, Ms MAJ Verdurmen, Ms BJL Wieman, DL Willems. 15
Resources 16
Resources Education Undergraduate medical education Funding ( ), scientific personnel (SP) and non-scientific personnel (NSP) per 31/12/01 and 31/12/02 2001 2002 Direct funding Indirect funding Direct funding Indirect funding Finance 53.372-58.019 - Personnel SP 3.40-3.27 0.30 Personnel NSP 1.0-1.0 0.1 Health Sciences education Funding ( ), scientific personnel (SP) and non-scientific personnel (NSP) per 31/12/01 and 31/12/02 2001 2002 Direct funding Indirect funding Direct funding Indirect funding Finance - - 1.892 - Personnel SP - - 0.11 0.20 Personnel NSP - - 0.02 - Research Funding ( ), scientific personnel (SP) and non-scientific personnel (NSP) per 31/12/01 and 31/12/02 2001 2002 Direct funding Indirect funding a Direct funding Indirect funding 1 Finance 26.000 4.570.000 21.000 3.645.000 Personnel SP 6.68 30.4 6.68 38.7 Personal NSP 0.6 5.3 0.60 4.55 a Finance is including personnel 17
A pressing problem in the past two years concerned housing, due to the growth of the Department. 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. Mainly as a consequence of the merging of the medical faculty and the academic university hospital at the beginning of 2001 there have been considerable financial, administrative and technical problems in the past two years. This has tested our patience, but we hope that most of these problems will be solved in the near future. 18
19
Processes Education Undergraduate medical education During the period of reporting the number of first-year students increased from 245 to 324 in 2002 (10 extra students from Norway are not included). This growing number of students has had a great impact on the capacity of tutors, especially in departments such as Social Medicine with a small education staff. The Department participated in the development of a new medical curriculum, which will start in September 2004. Early patient contact in different departments, including Social Medicine, and a final preparation year for postgraduate medical education are the main components of this curriculum. Together with the Department of Social Medicine at the Academic Medical Center in Amsterdam, we obtained funding to develop a final preparation year in Social Medicine. Our Department participated in the first four years of education, mainly in the thematic courses 'Man, Medicine, Society' and 'Health Care', and to a lesser extent in the courses 'Growing Up' and Aging. We also contributed to Experience training and contributed to the problem-orientated Clinical training. The subject matter for Social Medicine consists of texts in the various course books and in the textbook Public s Health and Health Care ( Volksgezondheid en Gezondheidszorg ) edited by PJ van der Maas and JP Mackenbach, Elsevier, Bunge 1998. In the last two study years we provided a discipline-oriented internship, and also offered various elective internships. Furthermore we organized some themes for the interdisciplinary training (Figure 1). 20
Figure 1: Undergraduate medical curriculum at the VU University Medical Center 1st study year Course Man, Medicine, Society Clinical training / Experience training / Skills training 2nd study year Clinical training / Experience training / Skills training 3rd study year Clinical training / Experience training /Skills training 4th study year Course Course Aging Course Health Care Growing Up Clinical training / Experience training /Skills training Elective course Scientific research training 5th study year Interdisciplinary training 6th study year Social Medicine internship Interdisciplinary training Elective internships Senior internship 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. Together with the participating tutors, the Chair of an education module is responsible for the quality of the education in this. 21
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 is discussed. The Chair persons of the education modules meet three times a year. The Director of Education of the 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 tutors and students involved. These evaluations are also discussed in the meetings of the Medical Education Committee. This Committee advises the Director of Education and the Board of Directors of the Medical Center about necessary adaptations in the education program. The quality assurance policy with regard to the examinations is the responsibility of the Examination Committee. This committee advices the Director of Education and the Board of Directors. The faculty quality assurance policy is assessed by an external institute, the Inspection Committee of the Association of Universities in the Netherlands (VSNU). Course 'Man, Medicine, Society' The disciplines Medical Psychology (Chair), Metamedics, Psychiatry, General Practice, Social Medicine and Physiology participate in this course. The course consists of lectures, supplemented with tutorials and problem-oriented training. Our Department organizes seven lectures, focussing on Social meaning and implications of illness and health, Patients organizations and the chronically ill, Social security and Structure and functioning of the health care system. These last two themes are further explored in two 2 hours tutorials (a total of 28 groups of approx. 12 students with supervisors). The Department participates in 3 themes of problem-oriented training; in addition to participation in six plenary meetings, it organizes 15 hours of tutorials twice (of 2 groups with supervisors). The themes are Chronic illness, Sexuality and Pain. 22
Course 'Aging' and course 'Growing Up' Also in these courses various disciplines participate. Our Department organizes 3 lectures, with the following subjects: Epidemiology, Aging of the population, The relationship between aging and chronic diseases, Prevention strategies, Aging in the future and Government policies'. In the course 'Growing Up', we have one lecture on Chronically ill children. Course 'Health Care (and the public s health)' In the course 'Health Care (and the public s health)' the disciplines of General Practice, Metamedics and Social Medicine (Chair) collaborate. The course consists of lectures, supplemented with tutorials. Our Department organizes 19 lectures and 12.5 hours of tutorials (20 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: The Public s Health and Health Care, Quality of care, Forensic medicine, Handling errors, Physical inactivity, Life-style and health, Prevention, Youth health care, Work and health, Occupational health care, Health law, Health economics, and Medical end-of-life decisions. A special course of 3 tutorials focusing on health care and the public s health in the Netherlands was organized for non-ec medical doctors who entered the medical curriculum at a later point in time. Clinical training Clinical problem solving takes place during patient demonstrations and tutorials. In 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 23
medical practice from various angles, focusing not only on the user of care, but also on the care system itself. It is intended to encourage the students to reflect on their own reactions and functioning as future care-providers in the health care system. All 3rd year students visit in groups of 10 to 12 persons, one 2-hour period of Occupational Medicine at an Occupational Health and Safety Service, and one 2-hour period of Community Medicine at a Municipal Health Service. Scientific research training The scientific research training has duration of 10-12 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 public or occupational health services, supervised by a senior researcher from the Department. Internships The final two years of the undergraduate curriculum consists of internships in different departments of hospitals, general practices and public or occupational health services. A new 2-week internship started in 2000. An introduction day at the faculty 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 Organisation (Parent and Child Care). On the introduction day professionals in the field inform students about the two main streams of Social Medicine: Occupational Medicine and Community Medicine. Examples from daily practice are used as illustration. Simulated patients are used for the skillstraining in Social Medicine. During the practical training, the students gain insight in the work of the institution or service they have chosen, and in the tasks of the Social Medicine physicians and other people that work there. They practice a number of pre-defined skills in Social Medicine, 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 24
faculty, the interns exchange their experiences, and give a presentation of their public health problem. The preference of the intern about the place of practical training is taken into account in the final allocation of the internship. Unfortunately, however, in view of the limited offer of internships made by services and organizations during a certain period, it is not always possible to honour these preferences. In recent years there has been a marked increase in the number of interns who had a definite preference for their internship. At present, approximately two thirds of the students make use of the possibility of stating their preference beforehand. Elective internships Students can devote 6 weeks of their internships to electives. In 2001 and 2002, respectively, 14 and 20 interns completed an elective internship in Social Medicine (see Chapter 9). We are glad to report that during recent years there has been an increase in the number of elective internships in Social Medicine. Of all elective internships in the faculty, Social Medicine is second only to Radiology in popularity. Interdisciplinary training During the internships in the 5 th and 6 th study 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 interns. 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 Health Sciences is a new program at the faculty of Earth and Life Sciences. The 5-year curriculum is based on to the Bachelor-Master structure. The Department is one of the main participating disciplines, and is responsible for the co-organization of the curriculum. 25
We chair the courses Health care in the Netherlands, Prevention and Policy research. The course Health care in the Netherlands is given during the first year, in collaboration with the Departments of Health Care and Culture and Medical History. It focuses on problem-oriented teaching (PGO) with emphasis on the themes: Infectious diseases, Demand and supply in the health care system and Position of the patient in the health care system. The course on Prevention aims to give a broad overview of the theory and practice of health prevention. Students have to write a paper in which they give a review and a critical analysis of a specific prevention project they have visited. The course Policy research in the third Bachelor year is still being developed. Postgraduate medical education Our Department participates in the management and content of some courses of the Netherlands School of Public Health (NSPH) and the Netherlands School of Occupational Health (NSOH). The postgraduate education provided in both schools includes both main streams of Social Medicine. Professor Gerrit van der Wal is Vice-Dean and member of the Advisory Board of both the NSPH and the NSOH. These two schools were fully merged by January 2003. Research Embedding Research in our Department is integrated in four research lines, which all focus on Public s 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 co-ordinator 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 26
Netherlands School of Primary Care Research (CaRe), which was reacknowledged in 2000 by the Royal Netherlands Academy of Arts and Sciences (KNAW) for a second period of five years. Quality of care and prevention Quality of care and prevention concerns the extent to which care and prevention contribute to a good quality and duration of life for the patient/client. This care must be technically good, cost-effective and patient/client-oriented. Technically good care or prevention, according to current professional standards, is given to the right person at the right moment. Care or prevention is cost-effective if the benefits in terms of health gains are favorably balanced against the costs. Patient/client-oriented care or prevention includes aspects such as the inter-action between care-provider and patient, the quality of the communication and decision making, the provision of adequate information, and maintaining a good relationship with the patient/client. The exact definition of what constitutes good quality of care, depends on one s perspective. The opinions of the care-providers, as well as the opinion of those who receive care, the health insurance companies and the government are important. Our research in this field is directed towards providing the patients/clients with adequate information, in order to enable them to make an informed decision about the way in which they use the care, e.g. pregnant women with regard to prenatal screening, and patients with regard to consulting a general practitioner. Other research projects investigate the consequences for patients of waiting for an operation, and the acceptability of waiting-list times, evaluated by the various parties involved. Finally, research is being carried out to evaluate the Individual Health Care Professions Act (BIG Act) and the effectiveness of prevention programs in youth health care. 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, 27
competence and integrity. Not only, for instance, in the case of euthanasia and physician-assisted 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 complaints of the musculoskeletal system. These complaints are the cause of approximately one third of all sickness absenteeism and work disability in the Netherlands. The etiological research investigates the development of work-related back, neck and upper extremity complaints and work-related complaints of the musculoskeletal system in general practice, with particular focus on the collaboration between general practitioner and occupational physician. The risk of prolonged sickness absence and work disability, and gender differences in occupational exposure and exposure at home are also being studied. Research on the prevention of work-related complaints of the musculoskeletal system concerns various programs that are implemented as secondary preventive measures in the treatment of workers who are unable to work, due to nonspecific low back complaints. Finally, this research line also investigates the quality of occupational health care, with specific focus on the effectiveness and credibility of occupational health care in general, and the activities of the occupational physician in particular. For example, research on the effectiveness and quality of occupational health care on return to work after childbirth, research on gender differences in occupational health care, or research on the effectiveness of the Dutch guidelines for the management by occupational physicians of workers with mental health problems. Recently research regarding the prevention of psychological work complaints was added to this line. 28
In 2002, the Research Center Body@Work TNO-VU, collaboration between the VU and TNO, was established. One of the two main areas of interest of the Research Center is work and health, and Body@Work TNO-VU is funding two studies in which the relationship between work and health is being studied. 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 Body@Work TNO-VU is physical activity and health, and the center is funding three studies in which physical activity is promoted. Overweight is becoming an increasingly urgent problem in public health care for which physical inactivity is a strong risk factor. In order to tackle this health problem, a Center of Expertise regarding the prevention of overweight and obesity has been established within the EMGO Institute, the Knowledge Center Overweight. The Department of Social Medicine is an important contributor, and the primary aim of the Center is to provide intermediary professionals with state-of-the-art knowledge with regard to the prevention of overweight and obesity (see www.overgewicht.org). Furthermore, several studies on the prevention or reduction of overweight and obesity have been initiated, focussing 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 is, for instance, directed towards the prevention of ankle injuries among volleyball players by introducing a special device (a balance board) for 29
balance training (see Internetsite: www.abbastudy.nl). In 2002, a special grant was obtained from the Ministry of Health, Welfare and Sports, as part of a large-scale program that aims at stimulating sports medicine research in the Netherlands. Thanks to this grant, a study on the etiology and prevention of sports injuries in adolescents will be initiated in 2003. Procedures Project leaders of research projects are senior investigators. They are responsible for supervising junior researchers and PhD students and the daily management. A professor is finally responsible 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 in financial affairs the financial administrator at the EMGO Institute supports all project leaders. 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 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 made, including all patient information and questionnaires and is submitted to the VUMC Medical Ethics Committee. This Committee assesses the ethical consequences of all research involving humans or animals. The quality of the data-gathering, data-storage and data analyses was previously not monitored. Recently a Quality Committee is established at the EMGO Institute to monitor and improve the research process by means of 30
audits of ongoing projects. In 2002 also an introductory course on datamanagement for new researchers was initiated. 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. More specialized meetings 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 bi-monthly 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 a called double-publication. The quality of these papers is therefore widely assessed. A Thesis Committee assesses the quality of a dissertation, in which four to six (Associate) Professors with expertise in a relevant line of research participate. Collaboration with other research groups There is substantial collaboration with other research groups within the EMGO Institute (e.g. Nursing Home Medicine, General Practice), with other departments within the VU University Medical Center (e.g. Clinical Genetics, Gynaecology and Obstetrics) and with other faculties within the University (e.g. Clinical Psychology, Health Law). There is a structural collaboration within the Research Center Body@Work TNO-VU, with TNO Work and Health, and with TNO Prevention and Health. This collaboration was recently extended to include the Faculty of Human Movement Sciences of the Vrije Universiteit on informal basis. There is external collaboration, both nationally (e.g. Institute for Public Health of the Erasmus Medical Center Rotterdam) and internationally (e.g. the European research on end-of-life decision-making). 31
During the course of 2000/2001 the following research projects were carried out (in chronological order of starting date): Projects Quality of care and prevention Title Prevention of passive smoking among children Period 01.95 12.03 Funding Netherlands Organisation for Health Research and Development (ZonMw), TNO Prevention and Health (TNO-PG) Investigators MR Crone 1, SA Reijneveld 1, SP Verloove-Vanhorick 1, RA Hirasing Objectives To assess prevalence, health consequences and determinants of passive smoking in young children and the effect of a systematic education program. Title Diabetes mellitus (NIDDM) in primary care Period 04.96 04.01 Funding Netherlands Organisation for Scientific Research (NWO) Investigators CM Renders, GD Valk 2, JThM van Eijk 3, PD Bezemer 4, G van der Wal Objectives To determine the effect of a quality management system, including education, feedback on performance and audit, on the performance of general practitioners, glycaemic control, cardiovascular risk factors and perceived health of patients with type 2 diabetes mellitus in general practice. Title Evaluation of a program of diabetes education for South Asian diabetes patients Period 10.97 06.01 Funding Prevention Fund, Municipal Health Services The Hague, VU Medical Center Investigators BJC Middelkoop 5, G van der Wal 32
Objectives To determine the effect of a program of diabetes education for South Asian patients, including culture-specific advices on their nutritional habits and culture, on patient compliance, glycaemic control and cardiovascular risk factors. Title The effect of educational information about daily complaints on self care behavior and health care demands of Turkish and Dutch inhabitants of disadvantaged districts of The Hague: evaluation of an intervention Period 08.98 05.03 Funding Municipal Health Services The Hague, Netherlands Organisation for Health Research and Development (ZonMw) Investigators AMC Plass, DRM Timmermans, G van der Wal, Objectives To evaluate the effect of providing information about minor ailments on self-care and health care use of Turkish and Dutch patients. Title Maximum acceptable waiting times in elective surgery Period 09.99 01.05 Funding Ministry of Health, Welfare and Sport (VWS) Investigators J Oudhoff, DRM Timmermans, J Kievit 6, G van der Wal Objectives To determine maximal acceptable waiting times for the treatment of varicose veins, gallstones, mammary cancer and inguinal hernia, with generalisations to other common surgical treatments. Title Psychological well-being of pregnant women who are offered prenatal screening for congenital defects Period 09.99 08.05 Funding Netherlands Organisation for Health Research and Development (ZonMw) Investigators JH Kleinveld, M van den Berg, DRM Timmermans, J van Vugt 7, L Ten Kate 8, D de Smit 9, JThM van Eijk 3, G van der Wal Objectives To determine the effect of offering pregnant women prenatal screening on their psychological well-being in the short and the long term. 33
Title Risk perception and decision making of pregnant women who are offered prenatal screening for congenital defects Period 09.99 01.06 Funding Netherlands Organisation for Health Research and Development (ZonMw) Investigators M van den Berg, JH Kleinveld, DRM Timmermans, J van Vugt 7, L Ten Kate 8, D de Smit 9, JThM van Eijk 3, G van der Wal Objectives To determine the effect of offering pregnant women prenatal screening on their risk perception and decision making. Title Nocturnal Enuresis Period 01.00 11.03 Funding Ferring Nederland b.v. and TNO Prevention and Health. Investigators FJM van Leerdam 1, AJ van der Heijden 10, RA Hirasing Objectives To describe the epidemiology of enuresis (in different subgroups) and the effect of alarmtreatment (in different subgroups). Title Evaluation of the Individual Health Care Professions Act Period 06.00 09.02 Funding Netherlands Organisation for Health Research and Development (ZonMw) Investigators JM Cuperus-Bosma, J de Bie, FAG Hout, G van der Wal (in collaboration with three Health Law departments Roscam Abbing HDC, Utrecht University, Gevers JKM, University of Amsterdam, Hubben JH, Vrije Universiteit, Amsterdam) Objectives To gain insight into the extent to which the Individual Health Care Professions Act (BIG Act) serves its purposes of protecting patients against professional carelessness and incompetence (1) and of fostering and monitoring high standards of professional practice (2). The study focuses on five aspects, which are: the registration and title protection, the preserved procedures, article 40 (quality aspects of professional practice), the disciplinary code and penal provisions. 34
Title Practice concerning reserved and other risky procedures in Dutch health care; impact of the Individual Health Care Professions Act Period 08.00 01.04 Funding Netherlands Organisation for Health Research and Development (ZonMw) Investigators J de Bie, JM Cuperus-Bosma, JKM Gevers 11, G van der Wal, Objectives To gain insight into the extent to which the regulation of 'reserved procedures' of the Individual Health Care Professions Act (BIG Act) serves its purposes of protecting patients against professional carelessness and incompetence and of fostering and monitoring high standards of professional practice. Title The Dutch disciplinary code of health care Period 09.00 01.04 Funding Netherlands Organisation for Health Research and Development (ZonMw) Investigators FAG Hout, JM Cuperus-Bosma, JH Hubben 12, G van der Wal Objectives To gain insight into the functioning of the disciplinary code of the Individual Health Care Professions Act (BIG Act) and into the extent to which this code serves its purposes of fostering and monitoring high standards of professional practice and of protecting patients against professional carelessness and incompetence of the professionals that are covered by the disciplinary code. Title Factors influencing the choice of a medical career Period 01.01 06.05 Funding - Investigators MBM Soethout, ThJ ten Cate 13, G van der Wal Objectives To obtain information about career preference of (coming) medical students in different stages of their study and recent qualified medical doctors in the Netherlands and their final medical occupation, and to identify factors influencing the 35