but as early as 1981 , an article in the lancet reported a lack of skills among house - officers being tested on cardiopulmonary resuscitation.1 similar results were found in studies at the addenbrooke s hospital of cambridge ( uk ) in 19842 and the wellington school of medicine ( new zealand ) in 1989.3 a study from 1989 among family physicians and pediatricians in chicago ( usa ) reported that they were not trained in basic life support at all.4 possible inadequate competence of physicians relating to aspects of emergency care has later been confirmed by studies from australia ( 1999),5 the united states ( 2001),6 norway ( 2001),7 denmark ( 2002),8 south africa ( 2005)9 and the netherlands ( 2006),10 indicating that little progress has been made since . in belgium , no similar studies have been performed , but our own research in 2008 among medical students and junior graduates in their postgraduate training to become a family physician suggest at least a low confidence in their own skills and knowledge regarding emergency medical care . a number of publications express the need for better education in medical emergency skills , and better and more accessible training modules for physicians.11,12,13 also , the need for repetitive and continuous re - education has been illustrated by numerous studies,1417 suggesting that 6 months is the optimal time interval with which skills should be recapped.1820 based on these scientific results , initiatives to improve education in clinical skills and emergency care were set up in several countries . these initiatives involve , for example , reviewing of university curricula in medicine,21 supporting rural family physicians in acquiring and retaining urgency skills,22,23 formulating clearer final qualifications for medicine graduates,24,25 evaluating clinical skills using objective structured clinical examinations11 and incorporating clinical skills assessments in medical license exams.25 even though the study groups and assessed skills were rather heterogeneous among the different publications , we can safely say that practical knowledge of emergency medical care among physicians seems to be insufficient worldwide . however , almost no data is available concerning physicians in belgium.11 it is essential for belgian family physicians to be able to manage emergency conditions . basic emergency care is done by family physicians within their own practice or during on - call hours . especially outside of the cities , people usually do nt seek care in emergency departments without first seeing their own family physician . belgium is said to have one of the highest health care standards in the world , which implies that its physicians are probably confident and skilled . the aim of this study was to ascertain how confident dutch - speaking family physicians in belgium feel about their ability to give adequate emergency medical care and to examine their assessment of knowledge of relevant medical conditions . all local family physician organizations of dutch - speaking physicians in belgium were asked to invite their members to take part in our study in september 2009 . a convenience sample consisting of 974 family practitioners was contacted through email and asked to complete a web - based questionnaire . physicians in their postgraduate training to become a family physician were also included , since they work independently as qualified physicians and are an integral part of the medical corps in belgium . we opted for this subgroup of belgian physicians because they consist of a homogenous group . the two main language groups in belgium ( french and dutch ) have a different organization of medical studies . curricula are different , and contrary to their french - speaking counterparts , flemish physicians have been trained in an interuniversity setting for more than 25 years . because the vast majority of dutch - speaking physicians work in flanders and brussels , we performed our study only in these two parts of the country . we opted for an online questionnaire , hosted on server space of the vrije universiteit brussel . cookies as well as ip address analysis were used to avoid single users filling in the questionnaire multiple times . for each skill , the participant was asked for a self - assessment , using a likert scale with the following possibilities : 0 , has no experience or knowledge whatsoever ; 1 , has theoretical knowledge ; 2 , has had a demonstration of the skill or has observed it ; 3 , is able to perform the skill independently ; and 4 , has proficiency in the respective skill . the second part consisted of 31 questions ascertaining the participant s knowledge of conditions relevant to urgent medical care . again , a likert scale was used as follows : 0 , has never heard of the disease or condition ; 1 , has heard of the disease / condition but is unable to manage it ; 2 , can manage the disease / condition ; 3 , can diagnose the disease / condition ; and 4 , can independently treat the disease / condition . our questionnaire was based on a list used by hekkert in a similar study in the netherlands.21 a test study has been performed on medical students , using the same methodology and questionnaire.11 using the information gained from that study , changes were made to scales , descriptions , questions , and questionnaire setup . however , we limited these changes to the essential ones , in order to maintain our possibility to compare . it is unclear in what way the original instrument was validated by the composers , but since hekkert used the validated criteria set from the dutch raamplan 200124 and based on consistency within and comparison with other studies using the same questionnaire , we estimated the questionnaire to be valid and reliable . the dutch raamplan is also used in belgium , as a basis for the final qualifications in medical studies . the participants were divided into subgroups : based on sex , age ( five groups ) , geographical location ( rural , urban , metropolitan ) , size of the family practice ( four groups ) , and on the organization of the practice ( five groups ) . they were also asked if and when they had taken any additional training in emergency care . the context of this training was not further defined , meaning that every initiative being regarded as additional training by the participant was included . for each participant , a mean score for skills and although a decimal score on a likert scale has no meaning as such , we assumed that means would provide more information than the raw score itself . questionnaires in which a participant indicated the same score on each question , or where the pattern of answers showed a consequent algorithm , were assumed to be intentionally misleading and were excluded . the raamplan states that at the end of the medical studies , a physician should be able to perform skills  in an appropriate manner , not always by acting independently but also by referring out , if needed.24 in our opinion , having had a demonstration of a skill ( likert score 2 ) does not comply with this criterion . therefore , we set the minimum criterion to meet our standards at likert score 3 , meaning the participant was able to perform the skill independently . even though it could be theoretically assumed that a licensed physician meets this criterion in all mentioned skills , this assumption is highly unrealistic . hence , we assumed that a participant met our standards in a reasonable manner when scoring 3 on at least half of the questioned skills . for assessing knowledge of relevant conditions , we used the appendix to the raamplan , which differentiates between the conditions . we assumed that a participant fulfilled the criteria in a reasonable way if he or she met the set criterion on at least half of the questioned pathologies . for statistical interpretation , we used spss statistics for windows , version 19.0 ( ibm corporation , armonk , ny , usa ) . due to the small subgroups and the presence of some extreme results , we could not assume a normal distribution of our data , as was indicated by a shapiro however , we decided to include extremes in our statistics , in line with growing statistical belief.26 in most cases , we used a kruskal  wallis test to compare subgroups . we used a mann  whitney u - test to compare men and women , and to compare holders of an ecg or spirometry certificate to those without . in order to compare the number of physicians in the subgroups meeting our set standards , we used a chi - square test however , we kept the nonparametric results , with their stronger stratification and bigger distribution independence , since this did not differentiate any additional significance . all local family physician organizations of dutch - speaking physicians in belgium were asked to invite their members to take part in our study in september 2009 . a convenience sample consisting of 974 family practitioners was contacted through email and asked to complete a web - based questionnaire . physicians in their postgraduate training to become a family physician were also included , since they work independently as qualified physicians and are an integral part of the medical corps in belgium . we opted for this subgroup of belgian physicians because they consist of a homogenous group . the two main language groups in belgium ( french and dutch ) have a different organization of medical studies . curricula are different , and contrary to their french - speaking counterparts , flemish physicians have been trained in an interuniversity setting for more than 25 years . because the vast majority of dutch - speaking physicians work in flanders and brussels , we performed our study only in these two parts of the country . we opted for an online questionnaire , hosted on server space of the vrije universiteit brussel . cookies as well as ip address analysis were used to avoid single users filling in the questionnaire multiple times . for each skill , the participant was asked for a self - assessment , using a likert scale with the following possibilities : 0 , has no experience or knowledge whatsoever ; 1 , has theoretical knowledge ; 2 , has had a demonstration of the skill or has observed it ; 3 , is able to perform the skill independently ; and 4 , has proficiency in the respective skill . the second part consisted of 31 questions ascertaining the participant s knowledge of conditions relevant to urgent medical care . again , a likert scale was used as follows : 0 , has never heard of the disease or condition ; 1 , has heard of the disease / condition but is unable to manage it ; 2 , can manage the disease / condition ; 3 , can diagnose the disease / condition ; and 4 , can independently treat the disease / condition . our questionnaire was based on a list used by hekkert in a similar study in the netherlands.21 a test study has been performed on medical students , using the same methodology and questionnaire.11 using the information gained from that study , changes were made to scales , descriptions , questions , and questionnaire setup . however , we limited these changes to the essential ones , in order to maintain our possibility to compare . it is unclear in what way the original instrument was validated by the composers , but since hekkert used the validated criteria set from the dutch raamplan 200124 and based on consistency within and comparison with other studies using the same questionnaire , we estimated the questionnaire to be valid and reliable . the dutch raamplan is also used in belgium , as a basis for the final qualifications in medical studies . the participants were divided into subgroups : based on sex , age ( five groups ) , geographical location ( rural , urban , metropolitan ) , size of the family practice ( four groups ) , and on the organization of the practice ( five groups ) . they were also asked if and when they had taken any additional training in emergency care . the context of this training was not further defined , meaning that every initiative being regarded as additional training by the participant was included . for each participant , a mean score for skills and although a decimal score on a likert scale has no meaning as such , we assumed that means would provide more information than the raw score itself . questionnaires in which a participant indicated the same score on each question , or where the pattern of answers showed a consequent algorithm , were assumed to be intentionally misleading and were excluded . the raamplan states that at the end of the medical studies , a physician should be able to perform skills  in an appropriate manner , not always by acting independently but also by referring out , if needed.24 in our opinion , having had a demonstration of a skill ( likert score 2 ) does not comply with this criterion . therefore , we set the minimum criterion to meet our standards at likert score 3 , meaning the participant was able to perform the skill independently . even though it could be theoretically assumed that a licensed physician meets this criterion in all mentioned skills , this assumption is highly unrealistic . hence , we assumed that a participant met our standards in a reasonable manner when scoring 3 on at least half of the questioned skills . for assessing knowledge of relevant conditions , we used the appendix to the raamplan , which differentiates between the conditions . we assumed that a participant fulfilled the criteria in a reasonable way if he or she met the set criterion on at least half of the questioned pathologies . for statistical interpretation , we used spss statistics for windows , version 19.0 ( ibm corporation , armonk , ny , usa ) . due to the small subgroups and the presence of some extreme results , we could not assume a normal distribution of our data , as was indicated by a shapiro however , we decided to include extremes in our statistics , in line with growing statistical belief.26 in most cases , we used a kruskal  wallis test to compare subgroups . we used a mann  whitney u - test to compare men and women , and to compare holders of an ecg or spirometry certificate to those without . in order to compare the number of physicians in the subgroups meeting our set standards , we used a chi - square test however , we kept the nonparametric results , with their stronger stratification and bigger distribution independence , since this did not differentiate any additional significance . the recruitment rate to our email invitation was approximately 22% ( n = 210 ) . after exclusion of incomplete questionnaires ( n = 51 ) or those with obviously intentional misleading answers ( n = 1 ) , our study group consisted of 158 family physicians , meaning a completion rate of 75% . this sample size was adequate , and by comparing its composition to the demographic composition of belgian family physicians , it seemed to be highly representative . additional training in emergency medical care had been completed by 39% of participants , an ecg certificate was held by 92% , and 61% held a spirometry certificate . holders of a spirometry certificate scored higher than their colleagues without such a certificate ( 2.94 and 2.72 respectively ; p = 0.035 ) . also , family physicians with an additional training in emergency care had clearly higher scores than those without ( p < 0.001 ; means , 3.07 and 2.72 respectively ) . any influence of time ( delay ) pertaining to additional training no other significant differences between subgroups were found . the mean likert score on skills was 2.50 . based on the questionnaire results , the least - known skills were : tilting to recovery position ( mean , 1.30 ) , use of an external defibrillator ( 1.79 ) , and resuscitation of a child ( 1.93 ) . the best - known skills were : removal of a foreign body ( 3.53 ) , applying bandages ( 3.09 ) , and external heart massage ( 3.08 ) . our minimum criteria were met by 64% of participants . in 14 of the 22 skill items , the skills criteria met by the highest number of participants were : removal of a foreign body ( 92% ) , external heart massage ( 87% ) , and applying bandages ( 80% ) . the skills criteria met by the lowest number of participants were : tilting to recovery position ( 19% ) , use of the external defibrillator ( 28% ) , and safe transport of an accident victim ( 29% ) ( table 1 ) . holders of a spirometry certificate scored higher than their colleagues without such a certificate ( 2.61 and 2.34 respectively ; p = 0.035 ) . also , family physicians with an additional training in emergency care had clearly higher scores than those without ( p < 0.001 ; means , 2.81 and 2.31 respectively ) , with more meeting our criteria ( 77% versus 56% ; p = 0.006 ) . the least - known diseases or conditions were : a fall from great height ( mean , 2.09 ) , skull base fracture ( 2.28 ) , and electrocution ( 2.28 ) . the best - known diseases or conditions were : superficial wounds ( 3.91 ) , insect bites ( 3.86 ) , and hyperventilation ( 3.85 ) . our minimum criteria were met by 55% of participants . on 24 of the 31 diseases / conditions , at least half of the physicians met our criteria . the skills criteria met by the highest number of participants were : superficial wounds ( 99% ) , cerebrovascular abnormalities ( 99% ) , and epilepsy ( 97% ) . the skills criteria met by the lowest number of participants were : electrocution ( 11% ) , poisoning ( 11% ) , and a fall from great height ( 13% ) ( table 3 ) . more holders of a spirometry certificate met our criteria than their colleagues without this certificate ( 63% versus 43% ; p = 0.013 ) . also , family physicians with additional training in emergency care had clearly higher scores than those without ( p = 0.003 ; means , 3.33 and 2.14 respectively ) , with more meeting our criteria ( 70% versus 45% ; p = 0.002 ) . the mean score of physicians working in rural areas was higher than that of those working in urban or metropolitan areas ( p = 0.033 ; means , 3.25 and 3.15 respectively ) . more physicians from rural areas met our criteria compared to those from urban or metropolitan areas ( 61% versus 45% ; p = 0.047 ) ( table 2 ) . no significant differences between men and women , age groups , or practice size could be found . whether or not the physician was the holder of an ecg certificate did not have a significant influence on the results . the recruitment rate to our email invitation was approximately 22% ( n = 210 ) . after exclusion of incomplete questionnaires ( n = 51 ) or those with obviously intentional misleading answers ( n = 1 ) , our study group consisted of 158 family physicians , meaning a completion rate of 75% . this sample size was adequate , and by comparing its composition to the demographic composition of belgian family physicians , it seemed to be highly representative . additional training in emergency medical care had been completed by 39% of participants , an ecg certificate was held by 92% , and 61% held a spirometry certificate . holders of a spirometry certificate scored higher than their colleagues without such a certificate ( 2.94 and 2.72 respectively ; p = 0.035 ) . also , family physicians with an additional training in emergency care had clearly higher scores than those without ( p < 0.001 ; means , 3.07 and 2.72 respectively ) . any influence of time ( delay ) pertaining to additional training could not be proven from our results ( p = 0.091 ) . no other significant differences between subgroups were found . the mean likert score on skills was 2.50 . based on the questionnaire results , the least - known skills were : tilting to recovery position ( mean , 1.30 ) , use of an external defibrillator ( 1.79 ) , and resuscitation of a child ( 1.93 ) . the best - known skills were : removal of a foreign body ( 3.53 ) , applying bandages ( 3.09 ) , and external heart massage ( 3.08 ) . our minimum criteria were met by 64% of participants . in 14 of the 22 skill items , at least half of the physicians met our criteria . the skills criteria met by the highest number of participants were : removal of a foreign body ( 92% ) , external heart massage ( 87% ) , and applying bandages ( 80% ) . the skills criteria met by the lowest number of participants were : tilting to recovery position ( 19% ) , use of the external defibrillator ( 28% ) , and safe transport of an accident victim ( 29% ) ( table 1 ) . holders of a spirometry certificate scored higher than their colleagues without such a certificate ( 2.61 and 2.34 respectively ; p = 0.035 ) . also , family physicians with an additional training in emergency care had clearly higher scores than those without ( p < 0.001 ; means , 2.81 and 2.31 respectively ) , with more meeting our criteria ( 77% versus 56% ; p = 0.006 ) . the least - known diseases or conditions were : a fall from great height ( mean , 2.09 ) , skull base fracture ( 2.28 ) , and electrocution ( 2.28 ) . the best - known diseases or conditions were : superficial wounds ( 3.91 ) , insect bites ( 3.86 ) , and hyperventilation ( 3.85 ) . our minimum criteria were met by 55% of participants . on 24 of the 31 diseases / conditions , at least half of the physicians met our criteria . the skills criteria met by the highest number of participants were : superficial wounds ( 99% ) , cerebrovascular abnormalities ( 99% ) , and epilepsy ( 97% ) . the skills criteria met by the lowest number of participants were : electrocution ( 11% ) , poisoning ( 11% ) , and a fall from great height ( 13% ) ( table 3 ) . more holders of a spirometry certificate met our criteria than their colleagues without this certificate ( 63% versus 43% ; p = 0.013 ) . also , family physicians with additional training in emergency care had clearly higher scores than those without ( p = 0.003 ; means , 3.33 and 2.14 respectively ) , with more meeting our criteria ( 70% versus 45% ; p = 0.002 ) . the mean score of physicians working in rural areas was higher than that of those working in urban or metropolitan areas ( p = 0.033 ; means , 3.25 and 3.15 respectively ) . more physicians from rural areas met our criteria compared to those from urban or metropolitan areas ( 61% versus 45% ; p = 0.047 ) ( table 2 ) . no significant differences between men and women , age groups , or practice size could be found . whether or not the physician was the holder of an ecg certificate based on the results of our study , we can confidently state that dutch - speaking family physicians in belgium do not feel able to adequately administer most aspects of emergency care . as described in the introduction , this is in line with studies in many other countries.110 our results were also highly comparable with those obtained in our similar study from 2008 by junior doctors in their postgraduate training to become family physicians.11 factors of influence on skills and knowledge relating to urgent medical care seem limited . having taken an additional training in emergency medicine is the most influencing positive factor on both skills and knowledge . this sounds logical , but could be a result of the profile of the participant rather than of the training itself . holding a spirometry certificate proves to be of positive influence on the physician s self - assessed skills and knowledge . holding an ecg certificate , however , had no influence on the physician s skills and knowledge in emergency medical care , probably because the certified training is incorporated in the basic curriculum for most medicine students and is therefore independent of the student s profile . in most cases , obtaining an ecg certification is independent of the physician s personal interests and preparedness to take additional training , whereas obtaining a spirometry certificate is highly influenced by these factors . it is plausible that a doctor seeking additional training has an overall more proactive professional approach . therefore , the found link between the certified emergency , ecg or spirometry training , and the assessed confidence could be a result of the physician s profile rather than of the certified training itself . this seems likely , because spirometry is of little practical use in emergency medical care . according to our results , family physicians in rural areas are more confident about relevant knowledge than their urban or metropolitan counterparts . this could be explained by the proximity of hospital emergency services for urban patients , lowering the threshold and thus surpassing the family physician . even though the participants indicated a lack of confidence in skills and knowledge relating to emergency care , this needs to be seen in perspective . most physicians felt quite confident in topics they had experience with or that were common in daily practice . the items on which they indicated low confidence were generally less common and mostly treated by specialist care anyway . this may limit the practical implications of our results . also , we need to stress that it was not our aim to test individual skills , but to assess the overall confidence of the physician . however , we did include a mention of individual skills , since this provides a good idea of the specific areas in which the physician lacks confidence . specific confidence or skill in the different aspects of individual emergencies needs to be the subject of further research . . these may be the organization of education in emergency medicine in our universities , the lack of additional training and recapping , a noticeable inconsistency for some guidelines , or the frequency with which these guidelines change.2729 finally , it is important to underline that this study only assessed physician s confidence in a very specific area . our study does show , however , that dutch - speaking belgian family physicians do nt feel very confident in the area of emergency care , regardless of the quality of the care they provide . throughout our study , we have guarded the validity and reliability of the instruments used , thus ensuring the quality and relevance of our results . we used an existing questionnaire11,21 based on final qualifications described in the raamplan.24 the relevancy of our results obviously depends on the relevancy of the criteria set in the raamplan . but these qualifications were established after a long and careful process , likely ensuring their relevancy . we tried to avoid as many confounders as possible and limit expectation and confirmation bias by carefully designing and respecting the study protocol . we are aware of the fact that our method held a risk of selection bias , but by randomly choosing the potential participants , we attempted to limit this as well . self - assessment is not the most adequate instrument to evaluate skills.9,30 an objective structured clinical examination would have been more appropriate,18 but was not feasible within the context of this study . also , the tested items are only surrogate markers . it is plausible that with lesser confidence , training , or knowledge a good outcome is still possible with a proper attitude and awareness of the physician s own limitations . it is regrettable that only a small sample of family physicians were prepared to take part in our study . it is possible that due to the small study group , we were not able to prove the influence of all relating factors . however , in comparison to the official rapport of the belgian medical corps,31 we are confident that our study group is representative of the entire population of family physicians ( table 4 ) . many epidemiological studies have been performed with a representative sample of only 1%2%.32 even with the limitations of our study in mind , we feel secure in stating that the scientific value of our study is assured . throughout our study , we have guarded the validity and reliability of the instruments used , thus ensuring the quality and relevance of our results . we used an existing questionnaire11,21 based on final qualifications described in the raamplan.24 the relevancy of our results obviously depends on the relevancy of the criteria set in the raamplan . but these qualifications were established after a long and careful process , likely ensuring their relevancy . we tried to avoid as many confounders as possible and limit expectation and confirmation bias by carefully designing and respecting the study protocol . we are aware of the fact that our method held a risk of selection bias , but by randomly choosing the potential participants , we attempted to limit this as well . self - assessment is not the most adequate instrument to evaluate skills.9,30 an objective structured clinical examination would have been more appropriate,18 but was not feasible within the context of this study . also , the tested items are only surrogate markers . the real clinical relevance of emergency care is determined by patient outcome . it is plausible that with lesser confidence , training , or knowledge a good outcome is still possible with a proper attitude and awareness of the physician s own limitations . it is regrettable that only a small sample of family physicians were prepared to take part in our study . it is possible that due to the small study group , we were not able to prove the influence of all relating factors . however , in comparison to the official rapport of the belgian medical corps,31 we are confident that our study group is representative of the entire population of family physicians ( table 4 ) . many epidemiological studies have been performed with a representative sample of only 1%2%.32 even with the limitations of our study in mind , we feel secure in stating that the scientific value of our study is assured . almost half of the family physicians in the dutch - speaking area of belgium feel insufficiently competent to offer most aspects of emergency medical care . it is not clear if this lack of confidence has any consequences for the quality and outcome of patient care . it does prove , however , that family physicians know the limits of their own medical skills .