Attitude change during medical school: a cohort study

Decline in medical students' attitudes to interprofessional learning and patient-centredness

CONTEXT

Interprofessional learning (IPL) is valuable in preparing health care students to work collaboratively in teams, with patients' needs at the core. Patient-centredness is the impetus for communication and collaboration in health care. Debate continues on when it is best to develop positive student attitudes towards these aspects of care. Should IPL commence early before attitudes to patients, professional stereotypes and identity are formed, or later for advanced learners with greater experience of their roles and responsibility in health care? This study explores graduate-entry medical students' attitudes to IPL and patient-centred care, on programme entry and after an early interdisciplinary clinical experience (ICE).

METHODS

An extended version of the Readiness for Interprofessional Learning Scale (RIPLS) was administered to four cohorts of medical students (n = 279) on entry and after the 3-week placement. This 26-item RIPLS comprised four subscales: team work and collaboration; professional identity; roles and responsibilities; and patient-centredness. The impact of the placement on students' attitudes was assessed by using repeated measures analysis of variance to compare pre- and post-ICE subscale scores.

RESULTS

There were significant main effects of time (pre- versus post-ICE) for the subscales of teamwork and collaboration, professional identity and patient-centredness, but not for roles and responsibilities. Scores for teamwork and collaboration, professional identity and patient-centredness were all lower post-ICE.

CONCLUSIONS

The students' less positive attitudes to teamwork and collaboration and professional identity may be due to the experience itself, or because it reinforced negative beliefs about the value of learning from non-medical health professionals. Perhaps the students' idealised view of their future role as a doctor was challenged by the experience, or they had an underdeveloped professional identity. Limited student experience of patients having an active role in their own health care may explain the decrease in attitudes to patient-centredness. A longitudinal qualitative study will explore these results.

Mental health issues amongst medical students in Asia: a systematic review [2000-2015]

BACKGROUND

Studies have shown that the stress experienced by medical students is far greater than that experienced by other university students. In this study, we aim to understand the consequent mental health issues that are experienced by medical students, particularly in Asia, via a systematic review of the current literature.

METHODS

Initial searches on MEDLINE, Embase and SpringerLink came up with a total of 1,033 unique articles. Studies not focusing on medical students alone, not mentioning mental health issues or not containing prevalence values were excluded.

RESULTS

We included 14 articles in our analysis. ADs had a prevalence of 7.04% (100/1,420). Depression was prevalent in 11.0% (1,115/10,147) of students. A total of 12.9% (54/420) and 12.9% (41/319) of male and female medical students respectively were screened for depression. Preclinical students were also 1.63 times more likely to be depressed compared to clinical students, with 98.0% (48/49) pre-clinical students having screened for depression, compared to 60% (27/45) clinical students. Home staying medical students are 1.33 times more likely to be depressed compared to hostel-stayers, with 12.1% (29/239) of home stayers being depressed compared to 9.2% (37/402) of hostel stayers.

CONCLUSIONS

We found that mental health issues affect a significant proportion of medical students and they are more prevalent in certain subpopulations of medical students. Our data revealed that preclinical and home staying students can be more susceptible to depression. More research should be done regarding this issue. With such information, it is hoped that appropriate interventions can be designed to improve the mental health of medical students.

Medical Students' Stress, Psychological Morbidity, and Coping Strategies: a Cross-Sectional Study from Pakistan

OBJECTIVE

The authors studied the prevalence of psychological morbidity, sources and severity of stresses, as well as coping strategies in Pakistani medical students.

METHODS

Medical students in Lahore, Pakistan, completed a cross-sectional, self-administered questionnaire in 2013 on the sources and severity of various stressors. The General Health Questionnaire-12 (GHQ-12) and Brief COPE assessed the psychological morbidity and coping strategies.

RESULTS

Out of 1500 students, 527 responded to the survey. The prevalence of psychological morbidity was 23.3%; 52.3% respondents showed evidence of distress. By logistic regression analysis, GHQ-12 caseness was associated with being male and occurrence of health-related stressors. The most common stressors were related to academic concerns. Coping strategies showed variation by GHQ-caseness.

CONCLUSION

The significant psychological morbidity and distress warrants establishing support systems to support students and bringing about evidence-based changes to teaching and evaluation systems. Adequate counseling facilities should be made available and students encouraged to seek help.

Stress, Burnout and Coping Strategies in Preclinical Medical Students

It is acknowledged that physicians do not seek the same expert aid for themselves as they would offer their patients. In their preclinical years, medical students appear to espouse comparable behavior. To many, medicine is described as a never-ending path that places the student under heavy stress and burnout from the beginning, leaving him/her vulnerable and with insufficient coping methods. Hence, the objective of this study is to 1) explore the prevalence of stress and burnout among preclinical medical students, and 2) propose solutions to decrease stress and burnout and improve medical education in the preclinical years. A detailed scholarly research strategy using Google Scholar, Scopus, Embase, MEDLINE and PubMed was implemented to highlight key themes that are relevant to preclinical medical students' stress and burnout. Stress varied among different samples of medical students and ranged between 20.9% and 90%. Conversely, burnout ranged between 27% and 75%. Methods that help in reducing the incidence of stress and burnout by promoting strategies that focus on personal engagement, extracurricular activities, positive reinterpretation and expression of emotion, student-led mentorship programs, evaluation systems, career counseling and life coaching should be adopted.

The mixed impact of medical school on medical students' implicit and explicit weight bias

CONTEXT

Health care trainees demonstrate implicit (automatic, unconscious) and explicit (conscious) bias against people from stigmatised and marginalised social groups, which can negatively influence communication and decision making. Medical schools are well positioned to intervene and reduce bias in new physicians.

OBJECTIVES

This study was designed to assess medical school factors that influence change in implicit and explicit bias against individuals from one stigmatised group: people with obesity.

METHODS

This was a prospective cohort study of medical students enrolled at 49 US medical schools randomly selected from all US medical schools within the strata of public and private schools and region. Participants were 1795 medical students surveyed at the beginning of their first year and end of their fourth year. Web-based surveys included measures of weight bias, and medical school experiences and climate. Bias change was compared with changes in bias in the general public over the same period. Linear mixed models were used to assess the impact of curriculum, contact with people with obesity, and faculty role modelling on weight bias change.

RESULTS

Increased implicit and explicit biases were associated with less positive contact with patients with obesity and more exposure to faculty role modelling of discriminatory behaviour or negative comments about patients with obesity. Increased implicit bias was associated with training in how to deal with difficult patients. On average, implicit weight bias decreased and explicit bias increased during medical school, over a period of time in which implicit weight bias in the general public increased and explicit bias remained stable.

CONCLUSIONS

Medical schools may reduce students' weight biases by increasing positive contact between students and patients with obesity, eliminating unprofessional role modelling by faculty members and residents, and altering curricula focused on treating difficult patients.

Knowledge of and Attitudes toward Medical Professionalism among Students and Junior Doctors in Trinidad and Tobago

BACKGROUND

The past decade has seen an increasing focus on professionalism within the medical school curriculum. This reflects the growing demand for doctors who demonstrate empathy and uphold the altruistic values of the Hippocratic Oath. Such is often challenged by the resource-constrained environments of developing nations requiring uniquely tailored interventions within these regions.

PURPOSE

As part of a wider effort to develop training of medical professionalism at our institution, an initiative was pursued to assess the current knowledge about and attitudes toward medical professionalism.

METHODS

The study was designed as a cross-sectional descriptive study of fourth and fifth year medical students and junior doctors. A questionnaire was adapted and revised from a previously published study. Questions were grouped into categories pertaining to knowledge about professionalism and attitudes toward professionalism. Overall, 191 questionnaires were analysed (168 students and 23 doctors).

RESULTS

Junior doctors' scores were higher than medical students for all knowledge subscales but scores on the attitude subscales were significantly lower than medical students. Overall, in both groups, attitude scores were higher than knowledge scores. There was an overall trend of decreasing attitude scores as persons progressed through their training years and into clinical practice.

CONCLUSIONS

Results demonstrate limited knowledge about medical professionalism but good attitudes toward this trait. Taken together, this perhaps highlights a receptivity toward more formal training within this area that is also justified by the marked decline in attitude scores over time.

Does Medical School Training Relate to Practice? Evidence from Big Data

On April 2nd, 2014, the Department of Health and Human Services (HHS) announced a historic policy in its effort to increase the transparency in the American healthcare system. The Center for Medicare and Medicaid Service (CMS) would publicly release a dataset containing information about the types of Medicare services, requested charges, and payments issued by providers across the country. In its release, HHS stated that the data would shed light on "Medicare fraud, waste, and abuse." While this is most certainly true, we believe that it can provide so much more. Beyond the purely financial aspects of procedure charges and payments, the procedures themselves may provide us with additional information, not only about the Medicare population, but also about the physicians themselves. The procedures a physician performs are for the most part not novel, but rather recommended, observed, and studied. However, whether a physician decides on advocating a procedure is somewhat discretionary. Some patients require a clear course of action, while others may benefit from a variety of options. This article poses the following question: How does a physician's past experience in medical school shape his or her practicing decisions? This article aims to open the analysis into how data, such as the CMS Medicare release, can help further our understanding of knowledge transfer and how experiences during education can shape a physician's decision's over the course of his or her career. This work begins with an evaluation into similarities between medical school charges, procedures, and payments. It then details how schools' procedure choices may link them in other, more interesting ways. Finally, the article includes a geographic analysis of how medical school procedure payments and charges are distributed nationally, highlighting potential deviations.

Do medical students like communication? Validation of the German CSAS (Communication Skills Attitude Scale)

OBJECTIVES

Attitudes towards communication skills of medical undergraduates can be gathered using the Communication Skills Attitude Scale (CSAS). We aimed to develop a German version of the CSAS (CSAS-G) in order to explore attitudes towards communication skills in a German cohort. Additionally the potential influence of demographic factors was examined.

METHODS

We realized the CSAS-G and conducted a survey with 529 participants from 3 different years of study. We then carried out an explorative as well as confirmatory factor analysis and compared the attitudinal scores. Multiple regression analysis was performed.

RESULTS

The confirmatory analysis confirmed the two-subscale system revealed by the explorative factor analysis. Students indicate low levels of negative attitudes and moderate levels of positive attitudes. Attitudinal scores differ significantly in relation to gender.

CONCLUSION

The CSAS-G can be used in German cohorts to evaluate attitudes towards communication skills. Medical students in our study show basically a positive approach. Further investigation is necessary to explore and understand attitudes towards communication skills of German medical students.

"Should I prioritize medical problem solving or attentive listening?": the dilemmas and challenges that medical students experience when learning to conduct consultations

OBJECTIVE

Communication skills can be trained alongside clinical reasoning, history taking or clinical examination skills. This is advocated as a solution to the low transfer of communication skills. Still, students have to integrate the knowledge/skills acquired during different curriculum parts in patient consultations at some point. How do medical students experience these integrated consultations within a simulated environment and in real practice when dealing with responsibility?

METHODS

Six focus groups were conducted with (pre-)/clerkship students.

RESULTS

Students were motivated to practice integrated consultations with simulated patients and felt like 'real physicians'. However, their focus on medical problem solving drew attention away from improving their communication skills. Responsibility for real patients triggered students' identity development. This identity formation guided the development of an own consultation style, a process that was hampered by conflicting demands of role models.

CONCLUSION

Practicing complete consultations results in the dilemma of prioritizing medical problem solving above attention for patient communication. Integrated consultation training advances this dilemma to the pre-clerkship period. During clerkships this dilemma is heightened because real patients trigger empathy and responsibility, which invites students to define their role as doctor.

PRACTICE IMPLICATIONS

When training integrated consultations, educators should pay attention to students' learning priorities and support the development of students' professional identity.

The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors

PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care.

APPROACH

Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation.

FINDINGS

Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.

Psychological distress and academic self-perception among international medical students: the role of peer social support

BACKGROUND

Psychological distress among medical students is commonly observed during medical education and is generally related to poor academic self-perception. We evaluated the role of peer social support at medical schools in the association between psychological distress and academic self-perception.

METHODS

An online survey was conducted in a medical degree program for 138 international students educated in English in the Czech Republic. The Medical Student Well-Being Index was used to define the students' psychological distress. Perceived peer social support was investigated with the Multidimensional Scale of Perceived Social Support. Poor academic self-perception was defined as the lowest 30% of a subscale score of the Dundee Ready Education Environment Measure. Analyses evaluated the presence of additive interactions between psychological distress and peer social support on poor academic self-perception, adjusted for possible confounders.

RESULTS

Both psychological distress and low peer social support were negatively associated with poor academic self-perception, adjusted for local language proficiency and social support from family. Students with psychological distress and low peer social support had an odds ratio of 11.0 (95% confidence interval (CI): 2.1-56.6) for poor academic self-perception as compared with those without distress who had high peer social support. The presence of an additive interaction was confirmed in that the joint association was four times as large as what would have been expected to be on summing the individual risks of psychological distress and low peer social support (synergy index = 4.5, 95% CI: 1.3-14.9).

CONCLUSIONS

Psychological distress and low peer social support may synergistically increase the probability of poor academic self-perception among international medical students. Promoting peer social relationships at medical school may interrupt the vicious cycle of psychological distress and poor academic performance.

Changes in wellbeing and professional values among medical undergraduate students: a narrative review of the literature

BACKGROUND

Educators are concerned by the high prevalence of emotional distress among medical students, and by the alleged decline in their humanitarian values.

OBJECTIVE

To re-examine these concerns by reviewing studies of medical students' wellbeing and development.

METHOD

Narrative review of the literature.

MAIN FINDINGS

(a) Medical students' emotional distress increases during their undergraduate training. However, although higher than in the general population, the prevalence of distress among medical students is similar to that among other university students. (b) Medical students' distress is independently related to endogenous factors (personality traits and life events) and to their perception of the medical learning environment. (c) Medical students do not display a measurable increase in moral reasoning, empathy and tolerance of uncertainty. (d) Students' wellbeing, moral development, reflectivity and tolerance of uncertainty have been shown to be interrelated, and associated with clinical performance.

CONCLUSIONS

The findings of this review endorse the concerns about the wellbeing and development of undergraduate medical students. The design of the reviewed studies does not permit inferences about causality. Yet, these findings are consistent with the hypothesis that medical training causes emotional distress that delays students' development and affects their clinical performance.

International surgical residency electives: a collaborative effort from trainees to surgeons working in low- and middle-income countries

In today's ever-globalizing climate, the academic sector bears a certain responsibility to incorporate global health opportunities into residency training programs. The worldwide unmet surgical need has been growing; it has been estimated by the World Health Organization that by 2030, surgical diseases will contribute significantly to the burden of global health. International electives (IE) offered during training may partially address this growing need. In addition, it can help trainees develop a heightened awareness of the social determinants of health in resource-limited areas, as well as gain insight into different cultures, health beliefs, and pathologic conditions. General surgery residency programs that offer IE may also stand to benefit by attracting a broader applicant pool, as well as by having the ability to train residents to rely less upon expensive tests and equipment, while further developing residents' physical examination and communications skills. The challenges that IE pose for trainees include the required adaptation to an environment devoid of an advanced and modern medical system, and a difficulty in learning a new language, culture, and local customs. However, IE may also be hazardous for home institutions as they may drain local resources and take limited educational experiences away from local providers. Despite the active promotion of international volunteerism by the American Board of Surgery, few surgery residency programs offer IE as part of the curriculum, with cost and supervision being the major obstacles to overcome. Consequently, it may be difficult to generate American surgical leaders in international health. In this article, we outline the steps needed to bring IE to an institution and how general surgery residency programs can help bridge the gap between surgeons in high-income countries and the growing surgical needs of the international community.

Formation of medical student professional identity: categorizing lapses of professionalism, and the learning environment

BACKGROUND

Acquiring the values of medical professionalism has become a critical issue in medical education. The purpose of this study was to identify lapses in professionalism witnessed by medical students during their four year MD curriculum, and to categorize, from the students' perspective, who was responsible and the settings in which these occurred.

METHODS

An electronic survey, developed by faculty and medical students, was sent to all students with two email reminders. It included quantitative responses and some open-ended opportunities for comments. All analyses were performed with SAS version 9.1.

RESULTS

The response rate was 45.6% (255 of 559 students) for all four years of the medical school curriculum. Thirty six percent of students had witnessed or been part of an exemplary demonstration of professionalism; 64% responded that they had witnessed a lapse of professionalism. At the pre-clerkship level, the most frequent lapses involved students: arrogance (42.2%), impairment (24.2%), followed by cultural or religious insensitivity (20.5%). At the clerkship level of training, where students are exposed to real clinical situations, the lapses involved primarily faculty (including preceptor and clinician) or other staff; these included arrogance (55.3%), breach of confidentiality (28.3%), and cultural or religious insensitivity (26.6%); impairment involved mostly students (25.5%). These findings are analyzed from the perspective of role modeling by faculty and in the context of the learning environment.

CONCLUSIONS

Medical students witnessed a lapse of professionalism involving both fellow students as well as faculty and administrative staff, in several domains. Results from this study emphasize the importance of role modeling and the need for faculty development, to improve the learning environment. This study adds to the limited emerging literature on the forces that influence medical student professional identity formation.

The correlation between global health experiences in low-income countries on choice of primary care residencies for graduates of an urban US medical school

This study sought to determine whether medical students who participate in a global health elective in a low-income country select residencies in primary care at higher rates compared with their classmates and US medical graduates in general. Given the projected increase in demand for primary care physicians, particularly in underserved areas, understanding possible factors that encourage training in primary care or enhance interest in the care of underserved populations may identify opportunities in medical school training. The authors used data from the Office of Student Affairs, SUNY Downstate College of Medicine and the National Residency Matching Program to compare rates of primary care residency selection from 2004 to 2012. Residency selections for students who participated in the SUNY Downstate School of Public Health Global Health Elective were compared with those of their classmates and with residency match data for US seniors. In 7 of the 8 years reviewed, students who participated in the SUNY Downstate School of Public Health Global Health Elective selected primary care residencies at rates higher than their classmates. Across years, 57% of the students who completed the elective matched to primary care residences, which was significantly higher than the 44% for the remainder of Downstate's medical student class (p = 0.0023). In 6 of the 8 years, Downstate students who participated in the Global Health Elective selected primary care residencies at rates higher than US medical school seniors in general; rates were the same for both Downstate Global Health Elective students and US medical school seniors in 2009. Students who participated in a global health experience in a low-income country selected primary care residencies at higher rates than their classmates and US medical school graduates in general. Understanding how these experiences correlate with residency selection requires further investigation; areas of future study are discussed.

Beyond prevalence to process: the role of self and identity in medical student well-being

CONTEXT

Problematic stress levels among medical students have been well established. This stress can lead to depression, suicidal ideation, substance abuse, burnout and cynicism, having a negative effect on students and their patients.

METHODS

We propose to move towards examining the processes underlying well-being in some medical students and vulnerability in others. We draw upon social psychological literature to propose that self-complexity, medical student identity and associated norms all have the capacity to influence medical students' well-being in both positive and negative ways.

RESULTS

We identify two key dilemmas facing medical students with regard to the social psychological factors investigated. First, a diverse set of interests and a high level of self-complexity is thought to buffer against the effects of stress and might also be beneficial for medical practitioners, but the intensive nature of medical education makes it difficult for students to pursue outside interests, leading to a strongly focused identity. Second, a strong group identity is associated with high levels of social support and improved well-being, but unhealthy group norms may have a greater influence on individuals who have a strong group identity, encouraging them to engage in behaviours that place their well-being at risk. A model is proposed outlining how these potentially contradictory social psychological processes may combine to impact upon medical students' well-being.

CONCLUSIONS

There is great scope for investigating the role of self-complexity, identity and norms in the medical education context, with room to investigate each of these factors alone and in combination. We highlight how our proposed model can inform medical educators as to the students who may be most vulnerable to the effects of stress and the potential interventions from which they may benefit. We conclude that social psychological factors make a valuable contribution to understanding the complex issue of well-being in medical education.

The temporal decline of idealism in two cohorts of medical students at one institution

BACKGROUND

A number of studies have indicated that students lose idealistic motivations over the course of medical education, with some identifying the initiation of this decline as occurring as early as the second year of the traditional US curricula. This study builds on prior work testing the hypothesis that a decline in medical student idealism is detectable in the first two years of medical school.

METHODS

The original study sought to identify differences in survey responses between first-year (MS1) and second-year (MS2) medical students at the beginning and end of academic year 2010, on three proxies for idealism. The current study extends that work by administering the same survey items to the same student cohorts at the end of their third and fourth years (MS3 and MS4), respectively. Survey topics included questions on: (a) motivations for pursuing a medical career; (b) specialty choice; and (c) attitudes toward primary care. Principle component analysis was used to extract linear composite variables (LCVs) from responses to each group of questions. Linear regression was then used to test the effect of the six cohort/time-points on each composite variable, controlling for demographic characteristics.

RESULTS

Idealism in medicine decreased (β = -.113, p < .001) while emphasis on employment and job security increased (β = .146, p < .001) as motivators of pursuing a career in medicine at each medical school stage and time period. Students were more likely to be motivated by student debt over interest in content in specialty choice (β = .077, p = .004) across medical school stages. Negative attitudes towards primary care were most sensitive to MS group and time effects. Both negative/antagonistic views (β = .142, p < .001) and negative/sympathetic views (β = .091, p < .001) of primary care increased over each stage.

CONCLUSIONS

Our results provide further evidence that declines in medical student idealism may occur as early as the second year of medical education. Additionally, as students make choices in their medical careers, such as specialty choice or consideration of primary care, the influences of job security, student debt and social status increasingly outweigh idealistic motivations.

Expectations, experiences, and attitude change during medical school: through the eyes of Polish medical students

BACKGROUND

Pressures related to medical training influence individual experiences in the course of study, which in turn can lead to changes in students' professional attitudes.

PURPOSES

The aim of this investigation was to explore expectations, experiences, and attitude changes among Polish students as they progressed through a medical university.

METHODS

The study used a longitudinal approach in which the same cohort of students was surveyed over time, with the same questionnaire administered, at the end of Year 1 and Year 6.

RESULTS

The results showed that the disparity between students' expectations about studying medicine and the reality increased between Year 1 and Year 6 (p<.0001). The biggest gap concerned "technical support" and "contacts with faculty"-the observed effect size was medium with the respective Cohen's d values 0.507 and 0.368. Students in Year 1 were most disappointed by the "lack of support from faculty and their lack of interest in teaching," whereas, in Year 6, students were most concerned about an approach to teaching that equipped them in theoretical knowledge at the expense of practical skills. Students in Year 6 noticed more changes in themselves and their perception of the world as a result of medical training than students in Year 1. However, the proportion of positive changes to negative ones was 5.4:1 for Year 1 and 1.4:1 for Year 6 students.

CONCLUSIONS

Our findings show that medical training constitutes a strong socializing experience, which has positive and negative impacts. Negative changes perceived by students include an increase in distrust and cynicism, whereas positive changes consist of enhanced maturity, self-confidence, and empathy, which are likely to have an impact on future doctors' professional practice.

Abridged mindfulness intervention to support wellness in first-year medical students

BACKGROUND

Medical students experience a high burden of stress and suffer elevated rates of depression, burnout, and suicide compared to the general population, yet there is no consensus on how to address student wellness.

PURPOSES

The purpose of this study was to determine whether an abridged mindfulness based stress reduction (MBSR) intervention can improve measures of wellness in a randomized sample of 1st-year medical students.

METHODS

Fifty-eight participants were randomized to control or 8-week MBSR intervention and then invited to participate in the study. All participants were assessed using the Perceived Stress Scale (PSS), the Resilience Scale (RS), and Self-Compassion Scale (SCS) at 3 separate time points: baseline, at the conclusion of the study intervention (8 weeks), and at 6 months after the conclusion of the intervention. The intervention consisted of 75 minutes of weekly class time, suggested meditation at home, and a half-day retreat in the last week.

RESULTS

The intervention group achieved significant increase on SCS scores both at the conclusion of the study (0.58, p=.002), 95% confidence interval (CI) [0.23, 0.92], and at 6 months (0.56, p=.001), 95% CI [0.25, 0.87]. PSS scores achieved significant reduction at the conclusion of the study (3.63, p=.03), 95% CI [0.37, 6.89], but not at 6 months poststudy (2.91, p=.08), 95% CI [-0.37, 6.19]. The study did not demonstrate a difference in RS after the intervention, though RS was significantly correlated with both SCS and PSS.

CONCLUSIONS

An abridged MBSR intervention improves perceived stress and self-compassion in 1st-year medical students and may be a valuable curricular tool to enhance wellness and professional development.

Medical students' attitudes toward people with dementia: an international investigation

BACKGROUND

The changing demographics of societies mean that medical students worldwide must be sufficiently prepared to care competently for patients with dementia through development of appropriate knowledge, skills, and attitudes. No previous research had explored undergraduate medical students' attitudes toward people with dementia.

METHODS

An adapted version of the Approaches to Dementia Questionnaire (ADQ) was completed by 501 medical undergraduates in years 1, 3, and 5 of their degree programs in the UK and Malaysia. Non-parametric statistical analysis focused on any differences between year groups and geographical locations.

RESULTS

The mean ADQ response indicated a generally positive attitude across the sample, comparable with other healthcare professionals previously surveyed. Year 3 and year 5 students expressed significantly more positive attitudes than year 1 students. Year 1 students based in the UK expressed significantly more positive attitudes than year 1 student based in Malaysia, but there were no significant differences between year 3 students based in different locations.

CONCLUSION

The more positive attitudes found amongst year 3 and year 5 students compared to year 1 may be a result of teaching emphasizing a person-centered approach. The differences between entry-level students from Malaysia and the UK may reflect variance in cultural norms and expectations, or the ADQ's "Western" origin. Medical schools aiming to equip students with dementia-specific skills and knowledge can draw on the generally positive attitudes found in this study.

Connectedness, sense of community, and academic satisfaction in a novel community campus medical education model

PURPOSE

Developing a sense of community and establishing connectivity are important in enhancing learners' success and preventing their sense of isolation. The A.T. Still University School of Osteopathic Medicine in Arizona (SOMA) has implemented a novel approach to medical education in which, beginning in the second year, students are geographically dispersed to 11 community campuses associated with community health centers around the United States, at both inner-city and rural locations. This study assessed students' sense of community, academic satisfaction, and level of connectedness in their first through fourth years of medical school at SOMA.

METHOD

The Rovai Classroom Community Scale and open-ended questions were administered via an online survey instrument to 412 students enrolled at SOMA for the 2011-2012 academic year. Participation was voluntary, and all results were anonymous. Data were analyzed using one-way ANOVA to compare results between classes.

RESULTS

Comparisons revealed an increasing degree of isolation and a decreasing sense of community and academic satisfaction progressing from the first through fourth years of medical school. Students suggested possible solutions that may be applied to medical schools and other graduate schools to improve the level of connectedness for students who are learning at a distance.

CONCLUSIONS

Connectivity, sense of community, and academic satisfaction may decrease for students in undergraduate medical education participating in a combination of distance learning and intermittent in-person activities. Interventions have the potential to improve these parameters. Long-term follow-up of students' satisfaction is suggested.

Attitudes towards homeless people among emergency department teachers and learners: a cross-sectional study of medical students and emergency physicians

BACKGROUND

Medical students' attitudes and beliefs about homeless people may be shaped by the attitudes of their teachers and one of the most common sites for learning about homeless patients is the emergency department. The objective of this study was to determine if medical students in the preclinical and clinical years and emergency medicine faculty and residents have different attitudes and beliefs about homeless people.

METHODS

The Health Professional Attitudes Toward the Homeless Inventory (HPATHI), was administered to all medical students, and emergency medicine physicians and residents at a large academic health sciences center in Canada. The HPATHI examines attitudes, interest and confidence on a 5-point Likert scale. Differences among groups were examined using the Kruskal Wallis test and Pearson's chi-square test.

RESULTS

The HPATHI was completed by 371 individuals, for an overall response rate of 55%. Analysis of dichotomized median and percentage results revealed 5/18 statements were significant by both methods. On the attitudes subscales physicians and residents as a group were more negative for 2/9 statements and on the confidence subscale more positive for 1/4 statements. The interest subscale achieved overall statistical significance with decreased positive responses among physicians and residents compared to medical students in 2/5 statements.

CONCLUSION

This study revealed divergences in attitudes, interests and beliefs among medical students and emergency medicine physicians and residents. We offer strategies for training interventions and systemic support of emergency faculty. Emergency medicine physicians can examine their role in the development of medical students through both formal and informal teaching in the emergency department.

Decline of medical student idealism in the first and second year of medical school: a survey of pre-clinical medical students at one institution

BACKGROUND

Idealism declines in medical students over the course of training, with some studies identifying the beginning of the decline in year 3 of US curricula.

PURPOSES

This study tested the hypothesis that a decline in medical student idealism is detectable in the first two years of medical school.

METHODS

We sought to identify differences in survey responses between first-year (MS1) and second-year (MS2) medical students at the beginning (T1) and end (T2) of academic year 2010 on three proxies for idealism, including items asking about: (a) motivations for pursuing a medical career; (b) specialty choice; and (c) attitudes toward primary care. Principle component analysis was used to extract linear composite variables (LCVs) from responses to each group of questions; linear regression was then used to test the effect of on each LCV, controlling for race, ethnicity, rural or urban origins, gender, and marital status.

RESULTS

MS2s placed more emphasis on status/income concerns (β=0.153, p<0.001), and much less emphasis on idealism as a motivator (β=-0.081, p=0.054), in pursuing a medical career; more likely to consider lifestyle and family considerations (β=0.098, p=0.023), and less likely to consider idealistic motivations (β=-0.066, p=NS); and were more likely to endorse both negative/antagonistic (β=0.122, p=0.004) and negative/sympathetic (β=0.126, p=0.004) attitudes toward primary care.

CONCLUSIONS

The results are suggestive that idealism decline begins earlier than noted in other studies, implying a need for curricular interventions in the first two years of medical school.

Walking a fine line: is it possible to remain an empathic physician and have a hardened heart?

Establishing an empathic physician-patient relationship is an essential physician skill. This chapter discusses the sexually dimorphic aspects of the neural components involved in affective and cognitive empathy, and examines why men and women medical students or physicians express different levels of empathy. Studies reveal levels of medical student affective or cognitive empathy can help reveal which medical specialty a student will enter. The data show students or physicians with higher empathy enter into specialties characterized by large amounts of patient contact and continuity of care; and individuals with lower levels of empathy desire specialties having little or no patient contact and little to no continuity of care. Burnout and stress can decrease the empathy physicians had when they first entered medical school to unacceptable levels. Conversely, having a too empathetic physician can let patient conditions and reactions interfere with the ability to provide effective care. By learning to blunt affective empathic responses, physicians establish a certain degree of empathic detachment with the patient in order to provide objective care. However, a physician must not become so detached and hardened that their conduct appears callous, because it is still important for physicians, especially those in specialties with a large amount of patient contact, to use empathic communication skills.

'More shades of grey in my answers': an interview study revisiting attitude erosion during clerkships

CONTEXT

Small declines in patient-centred attitudes during medical education have caused great concern. Although some of the self-report scales applied have solid psychometric foundations, validity evidence for the interpretation of attitude erosion during clerkships remains weak.

OBJECTIVES

We sought to address this gap in a qualitative study of the relationships between scores on four commonly used attitude scales and participants' experiences and reflections. Our aim was to gain a better understanding of the score changes from the participants' perspectives.

METHODS

We conducted semi-structured interviews with 15 junior doctors from a cohort (n = 37) that had previously shown a small decline in patient-centred attitudes during clerkships, measured on four self-report scales. In the interviews, we explored interviewees' experiences of their development of patient-centredness and subsequently discussed their scale scores, particularly for those items that contributed to a rise or decline in scores. We analysed the data using a process of constant comparison among personal experiences, scale scores and participants' explanations of score changes, applying the coding techniques of grounded theory.

RESULTS

The analysis revealed important response distortions that might be responsible for small declines in scores during clerkships separately from changes in attitudes. The drastic alterations to the participants' frame of reference, attributable to the transition to clinical practice, represented the most prominent cause of distortion. More nuanced, context-specific, patient-centred reasoning resulted in more neutral responses after clerkships, paradoxically causing a decline in scores. In addition to response distortions, the interviews revealed shortcomings in content validity such as an 'extreme' construct of patient-centredness.

CONCLUSIONS

This study calls into question the validity of the interpretation of attitude erosion during clerkships. The findings suggest that small declines in scores on self-report attitude scales are related to a recalibration of trainees' understandings of patient-centredness as they grow more clinically experienced. The evolved construct of patient-centredness and the way attitudes are measured require special attention in the development of future instruments.

Burnout and career choice motivation in medical students

BACKGROUND

Burnout is a stress-induced syndrome, which affects medical students. Some environmental and personal factors can favor burnout onset and its serious consequences as dropping out, sleep disorders, depression, and suicide. The motivation for choosing medicine is a personal aspect that can modulate the distress with academic demands.

METHODS

We applied self-administered questionnaires in 277 medical students to investigate the predictive role of career choice motivations on burnout dimensions. Specifically, we studied the influence of the main reasons for choosing medicine on emotional exhaustion, cynicism, and academic efficacy.

RESULTS

Intellectual curiosity, professional autonomy, altruism, and interest in human relationships were the most common reasons for choosing medicine. However, the medical students motivated by personal illness or family member's illness or death revealed a significant greater emotional exhaustion when compared with the students with other motivations.

CONCLUSION

The students who apply for medical school motivated by illness/death experiences are at a great risk for burnout. We suggest that students who are at risk for emotional exhaustion can be identified at the admission of medical school. Primary prevention strategies for burnout should consider this risk group.

Creating a longitudinal environment of awareness: teaching professionalism outside the anatomy laboratory

Anatomy educators have long understood the role that professionalism education plays in the dissection laboratory. The process of dissecting human material forces students to address such issues as human mortality, their responsibility to the vulnerability of the deceased, their privileged position in society, and their commitment to scientific ideals. Educators have offered a wealth of opinions and curricula dedicated to teaching professionalism in first-year anatomy courses. That they have risen to this challenge is laudable. However, professionalism education is a longitudinal process of acculturation. What happens, then, to students after they leave the anatomy classroom? As it is not taught in other basic science courses, professionalism education effectively becomes a null curriculum, teaching students to compartmentalize professionalism questions so that they can be addressed in anatomy courses or during dedicated professionalism course work. In their training, medical students spend 4 to 12 years navigating this shifting environment of hidden, null, or explicit curricula, which have a significant impact on their attitudes and character.In this perspective, the author highlights, from his experience as a medical student, specific professionalism challenges in anatomy--such as encountering mortality, enacting contracts with society and those who are most vulnerable, and upholding scientific excellence--and discusses how these challenges are addressed by anatomy educators. He then provides analogous examples of opportunities to teach professionalism in other basic science courses, such as pathology, microbiology, and pharmacology. He concludes by describing the goal of incorporating professionalism into all basic science courses--a longitudinal, cohesive environment of awareness.

Exploring the hidden curriculum: a qualitative analysis of clerks' reflections on professionalism in surgical clerkship

BACKGROUND

Professionalism is an important part of the hidden curriculum that is gaining attention in surgical education. McMaster University, Hamilton, Ontario, Canada, has introduced a small group discussion model using critical incident reports (CIRs) to elicit students' reflections on ethical, communication, and professionalism challenges during surgical clerkship. We described the themes identified by surgical clerks in their CIRs.

METHODS

Using thematic analysis, 4 investigators coded 64 CIRs iteratively until conceptual saturation. Rigor and validity were ensured throughout the process. Data were further explored to compare the CIRs of junior and senior clerks.

RESULTS

Twenty-seven themes and 4 relationship domains emerged: the clerk's relationship to patients, the health care team, the health care system, and self. Challenges with communication, the consent process, and breaking bad news were most commonly cited. Theme frequencies differed between junior and senior clerks.

CONCLUSIONS

Small group discussions of critical incident reports allow surgical clerks to reflect on their developing professional relationships. The themes that have been identified can be used to guide professionalism education and uncover the hidden curriculum.

The Knowledge-Attitude Dissociation in Geriatric Education: Can It be Overcome?

Introduction: A knowledge-attitude dissociation often exists in geriatrics where knowledge but not attitudes towards elderly patients improve with education. This study aims to determine whether a holistic education programme incorporating multiple educational strategies such as early exposure, ageing simulation and small group teaching results in improving geriatrics knowledge and attitudes among medical students. Materials and Methods: We administered the 18-item University of California Los Angeles (UCLA) Geriatric Knowledge Test (GKT) and the Singapore-modified 16-item UCLA Geriatric Attitudes Test (GAT) to 2nd year students of the old curriculum in 2009 (baseline reference cohort, n = 254), and before and after the new module to students of the new curriculum in 2010 (intervention cohort, n = 261), both at the same time of the year. Results: At baseline, between the baseline reference and intervention cohort, there was no difference in knowledge (UCLA-GKT Score: 31.6 vs 33.5, P = 0.207) but attitudes of the intervention group were worse than the baseline reference group (UCLA-GAT Score: 3.53 vs 3.43, P = 0.003). The new module improved both the geriatric knowledge (UCLA-GKT Score: 34.0 vs 46.0, P<0.001) and attitudes (UCLA-GAT Score: 3.43 vs 3.50, P <0.001) of the intervention cohort. Conclusion: A geriatric education module incorporating sound educational strategies improved both geriatric knowledge and attitudes among medical students. Key words: Asian medical school, Geriatrics attitudes, Geriatrics knowledge, Undergraduate medical student

Stigmatization of 'psychiatric label' by medical and non-medical students

BACKGROUND

Stigmatization of psychiatric patients is present both in the general population and among healthcare professionals.

AIM

To determine the attitudes and behaviour of medical students towards a person who goes to a psychiatrist, before and after psychiatric rotation, and to compare those attitudes between medical and non-medical students.

METHODS

The study included 525 medical students (second and sixth year of studies) and 154 students of law. The study instrument was a three-part self-reported questionnaire (socio-demographic data, Rosenberg Self-Esteem Scale and a vignette depicting a young, mentally healthy person). The experimental intervention consisted of ascribing a 'psychiatric label' to only one set of vignettes. All the vignettes (with or without the 'psychiatric label') were followed by 14 statements addressing the acceptance of a person described by vignette, as judged by social distance (four-point Likert scale).

RESULTS

Higher tendency to stigmatize was found in medical students in the final year, after psychiatric rotation (Z(U) = -3.12, p = .002), particularly in a closer relationship (Z(U) = -2.67, p = .007) between a student and a hypothetical person who goes to a psychiatrist. The non-medical students had a similar tendency to stigmatize as medical students before psychiatric rotation (Z(U) = -0.03, p = .975). Neither gender, nor the size of student's place of origin or average academic mark was associated with the tendency to stigmatize in our sample. However, student's elf-esteem was lower in those with a tendency to stigmatize more in a distant relationship (ρ = -0.157, p = .005).

CONCLUSIONS

Psychiatric education can either reinforce stigmatization or reduce it. Therefore, detailed analyses of educational domains that reinforce stigma will be the starting point for anti-stigma action.

Pre-registration dietetic students' attitudes to learning communication skills

BACKGROUND

  Communication is a core skill and a prerequisite for dietitians' clinical competence. It is generally acknowledged that communication skills can be taught and learned. There is a paucity of published work identifying dietetic students' attitudes towards learning communication skills, and understanding this is important.

METHODS

  The present cross-sectional study aimed to address this issue using an adapted version of the Communication Skills Attitude Scale (CSAS), which was designed to capture information concerning positive and negative attitudes to learning communication skills. An online questionnaire was sent to all undergraduate and post-graduate dietetic programmes in the UK.

RESULTS

  Of the students' solicited for enrolment in the study, 33.4% (n = 300) completed the questionnaire. A one-way analysis of variance showed attitudes to learning communication skills differed significantly between years of study on both subscales of the CSAS. Subsequent analyses indicated that first-year students' attitudes to learning communication skills were significantly more positive than those of fourth-year students (P = 0.042). Third-year students had significantly more positive attitudes to learning communication skills than fourth-year students (P = 0.028). Negative attitudes were also linked to the year of study with fourth-year students having significantly more negative attitudes than third-year students (P = 0.046). Sex, practice placement experience and parental occupation did not significantly influence attitudes to learning communication skills.

CONCLUSIONS

  These findings indicate that efforts are required to maintain positive attitudes to learning communication skills. Further longitudinal studies are recommended in this respect.

Perspective: a proposed medical school curriculum to help students recognize and resolve ethical issues of global health outreach work

Medical students' interest in global health outreach work is intense and growing. Yet, medical students' global health outreach work is fraught with ethical complexity: Students must make challenging resource allocation decisions in an unfamiliar setting while providing complicated care with evolving expertise across power gradients and geographical as well as cultural boundaries. Inadequate training in the recognition and resolution of the ethical issues inherent in this work likely endangers future service work participation and undercuts the efficacy of medical students' global health outreach work. The author describes how the medical school curriculum can empower medical students to recognize and resolve ethical issues encountered in global health outreach work. To achieve this goal, he proposes a curriculum in the ethics of global health outreach to train students to understand (1) the ethical justifications for global health outreach work, (2) the drivers of global health disparities, (3) the key ethical issues raised by global health outreach, and (4) how to resolve ethical quandaries encountered during global health outreach work through collaboration. Beyond specific topical content, a medical school curriculum in the ethics of global health outreach should emphasize the importance of local collaboration and longitudinal mentorship of medical students. Medical school training in the recognition and resolution of the ethical issues attendant on global health outreach work prepares students not only for more sophisticated work in international settings but also for the ethical complexities of medical practice closer to home.

Effectively training pediatric residents to deliver diagnoses of Down syndrome

Physicians and parents report a need for pediatricians to have additional training in delivering a diagnosis of Down syndrome (DS). This study tested a web-based tutorial to assess its effectiveness in improving physicians' perceived comfort with both ambiguous and more medically factual situations as they deliver diagnoses of DS. Based on this web tutorial that integrated prenatal and postnatal information into virtual patient scenarios, the study assessed pediatrics residents' knowledge and comfort in delivering a diagnosis of DS pre and postnatally. A separate survey, given at the same time, asked for residents' perception of their need for this training. Ninety-one volunteer residents from 10 pediatric training programs across the country participated. The tutorial yielded significant improvement in knowledge and a significant decrease in perceived level of discomfort in both ambiguous situations and more medically certain contexts related to a DS diagnosis. In addition, across all pediatric resident groups (by year, gender, and performance on the knowledge test and the comfort scale), residents strongly agreed that this type of training was beneficial for themselves, other residents, practicing physicians, and other medical professionals. This study suggests that web-based, interactive, multi-media training may be an effective tool for improving resident physician comfort with both ambiguous and more medically certain situations in delivering a diagnosis of DS to families.

Patient-centredness from education to practice: the 'lived' impact of communication skills training

BACKGROUND

Although communication skills training (CST) enhances patient-centred skills and attitudes, the literature indicates a problematic transfer of these from education into practice.

AIM

We explored 'lived' experiences of medical students and doctors to gain a better understanding of the impact of CST on patient-centredness in the transition to real practice.

METHODS

From a phenomenological perspective, we conducted 15 interviews and 11 focus groups with 4-9 participants/group (n = 67) at two universities and carried out constant comparative analysis.

RESULTS

The gap between education and practice is the central phenomenon. Although CST raises students' communication awareness and self-efficacy in an 'ideal' context, this paradoxically seems to jeopardize their ability to bridge the gulf. In addition, CST does not come to grips with students' attitudes. However, CST appears to be successful in equipping students with long-lasting 'handles'. Yet students need more support to mould the provided 'ideal' models into their own unique style of context-specific patient-centred behaviour. This implies: raising students' awareness of own attitudes and communication styles, offering a more realistic training ground, integrating CST with clinical experience and translating the primary-care-rooted concept of patient-centredness into various specialization contexts.

CONCLUSION

CST could raise its impact by supporting students' recycling processes towards a personal style of context-sensitive patient-centredness.

Differences in physician attitudes towards patient-centredness: across four medical specialties

AIMS

There is limited study on patient-centred attitudes with regards to the patient-physician relationship in physicians. The objective of this study was to examine and compare physician attitudes toward patient-centredness in four different medical settings.

METHODS

The present study utilised a cross-sectional survey design and purposive sampling to recruit physicians from a single academic medical centre via face-to-face interviews. Patient-centred attitudes of physicians specialising in surgery, oncology, obstetrics and gynaecology and primary care (N = 78) were compared on the Patient-Practitioner Orientation Scale (PPOS) using an independent one-way analysis of variance (ANOVA). The four medical specialties comprised the four levels, with role orientation (patient-centred orientation vs. doctor-centred orientation) as the dependent measure.

RESULTS

A significant level of difference (p < 0.001) was found between the four specialisations: oncologists were found to have the highest level of patient-centeredness, followed by obstetricians & gynaecologists and primary care physicians, with surgeons being the least patient-centred among specialisations sampled.

CONCLUSION

These data are the first from the South-East Asian region to demonstrate differences in physician attitudes between medical specialties. Our findings prompt further investigation and confirmation as to whether physicians with particular attitudinal traits are attracted to any particular specialties of medicine, or if physician attitudes are acquired through professional experience and training. In addition, this study offers better insight into the attitudinal differences of physician between medical specialities.

Medical students - self-assessed confidence level before a major physiology examination: affective factors in a nigerian medical school

Self-reported confidence before any examination in all levels of medical training is a product of previous experience, attitudinal inclinations overtime, degree of self subjection to tenets of professionalism and possibly, the inadvertent role of the medical school environment including colleagues, teachers and faculty members, comfort, satisfaction and psychosocial stability; which may be addressed as sub-factors that determine the level of preparedness. Let medical schools in Nigeria; adopt a continuous and regular assessment of students’ self confidence before any minor or major examination, to monitor and ensure a certain psychological and academic level of preparedness among the students. This will avoid some cases of attrition resulting from self-doubt and lack of preparedness.

Medical students trained in communication skills show a decline in patient-centred attitudes: an observational study comparing two cohorts during clinical clerkships

OBJECTIVE

Literature indicates a decline in patient-centredness in medical students, especially during clinical clerkships. We examined the impact of preclinical communication skills training (CST) on students' development of patient-centred attitudes and attitudes toward CST during clerkships.

METHODS

We prospectively compared two cohorts before and after clerkships: one cohort (n=48) had not received CST, whereas the other (n=37) had received a five-year CST. We assessed the impact using five validated questionnaires.

RESULTS

Communication trained students slightly but significantly declined in patient-centred attitudes (3/4 scales) and attitudes toward CST during clerkships, whereas the scores of the untrained students remained stable (5/5 scales). Both cohorts did not differ in attitudes before clerkships. In the trained cohort, males mostly showed a sharper decline than females. In the total group (n=85), females demonstrated higher attitude scores toward CST, and in 1/4 scales measuring patient-centred attitudes.

CONCLUSION

This cohort study suggests that CST might make students more vulnerable to decline in attitude scores during clerkships.

PRACTICE IMPLICATIONS

These remarkable findings, contrary to what educators would expect to result from their efforts, challenge medical education to address the new questions that are raised about the validity of the questionnaires, the impact of CST and the learning processes involved in the development of patient-centredness.

Efficacy of a brief screening tool to identify medical students in distress

PURPOSE

To determine whether the Medical Student Well-Being Index (MSWBI) can serve as a brief assessment tool to identify medical students in severe psychological distress.

METHOD

The authors used data from 2,248 medical students at seven U.S. medical schools who responded to a 2007 survey to explore the accuracy of the MSWBI in identifying medical students with three outcomes: low mental quality of life (QOL; defined by having a Medical Outcomes Study Short-Form Health Survey mental component summary score ≥1/2 standard deviation below that of the age- and gender-matched population norm), suicidal ideation, or serious thoughts of dropping out. The authors confirmed their analyses using data from a separate sample of 2,682 students evaluated in 2009.

RESULTS

Students with low mental QOL, suicidal ideation, or serious thoughts of dropping out were more likely to endorse each individual MSWBI item and a greater number of total items than were students without such distress (all P < .001). The likelihood ratio for low mental QOL among students with MSWBI scores <4 was 0.47 as compared with 4.79 for those with scores ≥4. At an MSWBI threshold score of ≥4, the MSWBI's sensitivity and specificity for identifying students with low mental QOL or recent suicidal ideation/serious thoughts of dropping out were both ≥90%. On multivariable logistic regression, all MSWBI items were independently associated with at least one outcome.

CONCLUSIONS

The MSWBI is a useful brief screening tool to help identify students with severe distress.

The association between intolerance of ambiguity and decline in medical students' attitudes toward the underserved

PURPOSE

Little published research details the risk factors for the decline in students' attitudes toward underserved populations during medical school. The authors assessed the association between this attitude change and intolerance of ambiguity (the tendency to perceive novel or complex situations as sources of threat), since treating underserved populations often involves a high level of complexity.

METHOD

The University of New Mexico School of Medicine administered a survey assessing attitudes toward underserved populations at matriculation and at graduation to seven consecutive medical school classes (matriculation years 1999 to 2005). The university also administered a survey measuring tolerance of ambiguity at matriculation. Five hundred twenty-nine students were eligible to complete both surveys between 1999 and 2009.

RESULTS

Three hundred thirteen (59%) students completed the attitude survey at matriculation and graduation. Attitude scores for a majority of students (69%) decreased from matriculation to graduation. Changes in scores ranged from +25 to -35; the average change was -4.5. Linear regression analysis showed that those who were tolerant of ambiguity (top 20% of tolerance of ambiguity scores) were significantly less likely to have declines in attitudes toward the underserved; the coefficient was 3.69 (P = .003). Other factors independently associated with maintaining high attitude scores were being female and starting medical school at age 24 or younger.

CONCLUSIONS

Attention to, and practice with, ambiguous situations may help moderate decreases in attitudes toward underserved populations. Medical education should address the fact that physicians face much ambiguity and should offer students tools to help them respond to ambiguous clinical situations.

Does the inclusion of 'professional development' teaching improve medical students' communication skills?

BACKGROUND

This study investigated whether the introduction of professional development teaching in the first two years of a medical course improved students' observed communication skills with simulated patients. Students' observed communication skills were related to patient-centred attitudes, confidence in communicating with patients and performance in later clinical examinations.

METHODS

Eighty-two medical students from two consecutive cohorts at a UK medical school completed two videoed consultations with a simulated patient: one at the beginning of year 1 and one at the end of year 2. Group 1 (n = 35) received a traditional pre-clinical curriculum. Group 2 (n = 47) received a curriculum that included communication skills training integrated into a 'professional development' vertical module. Videoed consultations were rated using the Evans Interview Rating Scale by communication skills tutors. A subset of 27% were double-coded. Inter-rater reliability is reported.

RESULTS

Students who had received the professional development teaching achieved higher ratings for use of silence, not interrupting the patient, and keeping the discussion relevant compared to students receiving the traditional curriculum. Patient-centred attitudes were not related to observed communication. Students who were less nervous and felt they knew how to listen were rated as better communicators. Students receiving the traditional curriculum and who had been rated as better communicators when they entered medical school performed less well in the final year clinical examination.

CONCLUSIONS

Students receiving the professional development training showed significant improvements in certain communication skills, but students in both cohorts improved over time. The lack of a relationship between observed communication skills and patient-centred attitudes may be a reflection of students' inexperience in working with patients, resulting in 'patient-centredness' being an abstract concept. Students in the early years of their medical course may benefit from further opportunities to practise basic communication skills on a one-to-one basis with patients.

An International Health Track Is Associated With Care for Underserved US Populations in Subsequent Clinical Practice

BACKGROUND

Recent efforts to increase insurance coverage have revealed limits in primary care capacity, in part due to physician maldistribution. Of interest to policymakers and educators is the impact of nontraditional curricula, including global health education, on eventual physician location. We sought to measure the association between graduate medical education in global health and subsequent care of the underserved in the United States.

METHODS

In 2005, we surveyed 137 graduates of a family medicine program with one of the country's longest-running international health tracks (IHTs). We compared graduates of the IHT, those in the traditional residency track, and graduates prior to IHT implementation, assessing the anticipated and actual involvement in care of rural and other underserved populations, physician characteristics, and practice location and practice population.

RESULTS

IHT participants were more likely to practice abroad and care for the underserved in the United States in the first 5 years following residency than non-IHT peers. Their current practices were more likely to be in underserved settings and they had higher percentages of uninsured and non-English-speaking patients. Comparisons between pre-IHT and post-IHT inception showed that in the first 5 years following residency, post-IHT graduates were more likely to care for the underserved and practice in rural areas and were likely to offer volunteer community health care services but were not more likely to practice abroad or to be in an academic practice.

CONCLUSIONS

Presence of an IHT was associated with increased care of underserved populations. After the institution of an IHT track, this association was seen among IHT participants and nonparticipants and was not associated with increased long-term service abroad.

Developing personal values: trainees' attitudes toward strikes by health care providers

Worldwide, health care providers use strikes and job actions to influence policy. For health care providers, especially physicians, strikes create an ethical tension between an obligation to care for current patients (e.g., to provide care and avoid abandonment) and an obligation to better care for future patients by seeking system improvements (e.g., improvements in safety, to access, and in the composition and strength of the health care workforce). This tension is further intensified when the potential benefit of a strike involves professional self-interest and the potential risk involves patient harm or death. By definition, trainees are still forming their professional identities and values, including their opinions on fair wages, health policy, employee benefits, professionalism, and strikes. In this article, the authors explore these ethical tensions, beginning with a discussion of reactions to a potential 2005 nursing strike at the University of California, Davis, Medical Center. The authors then propose a conceptual model describing factors that may influence health care providers' decisions to strike (including personal ethics, personal agency, and strike-related context). In particular, the authors explore the relationship between training level and attitudes toward taking a job action, such as going on strike. Because trainees' attitudes toward strikes continue to evolve during training, the authors maintain that open discussion around the ethics of health care professionals' strikes and other methods of conflict resolution should be included in medical education to enhance professionalism and systems-based practice training. The authors include sample case vignettes to help initiate these important discussions.

Medical students' exposure to and attitudes about the pharmaceutical industry: a systematic review

BACKGROUND

The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.

METHODS AND FINDINGS

We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students' exposure to the drug industry, as well as students' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%-100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%-69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%-71%) were more likely than preclinical students (29%-62%) to report that promotional information helps educate about new drugs.

CONCLUSIONS

Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education. Please see later in the article for the Editors' Summary.

Patient safety: a consumer's perspective

In this article we provide a reconceptualization of patient-centered health care practice through a collaborative person-centered model for enhanced patient safety. Twenty-one participants were selected and interviewed from the internationally diverse population of individuals attending the Chicago Patient Safety Workshop (CPSW) sponsored by Consumers Advancing Patient Safety (CAPS). Analysis of the participant transcripts revealed three findings related to patient experience: the impact and meaning of communication and relationship within the health care setting, trust and expectation for the patient and family with the health care provider, and the meaning and application of patient-centeredness. Researchers concluded that successful planning toward enhanced patient-centered care requires multiple perspectives, including the voices of the patient and family members who have experienced the trauma of preventable medical error. Collaborative initiatives such as the CPSW and CAPS offer a positive way forward for enhanced patient safety and quality of care.

Assessing student mental health at the Vanderbilt University School of Medicine

PURPOSE

To determine the prevalence rates of four major categories of mental illness among medical students and to examine associations between these illnesses and a range of demographic variables.

METHOD

The authors invited all 330 first-, second-, and third-year medical students at Vanderbilt University School of Medicine to participate in a survey during winter 2008-2009. Students completed an anonymous written questionnaire assessing the prevalence of depression, anxiety, eating disorders, and alcohol and drug use disorders. Additionally, the authors obtained student demographic information to investigate variations in rates of illness based on interindividual differences.

RESULTS

Most students (301; response rate: 91.2%) completed the survey. The authors found that depression and anxiety were more prevalent in the Vanderbilt medical student population than in their nonmedical peer group. The authors found that 37 (12%) of the students were borderline for possible alcohol abuse and 3 (1%) were problem drinkers, 1 (0.3%) had a possible drug abuse disorder, and 3 (1%) had possible eating disorders. Whereas exercising one to three times per week was associated with lower rates of both depression and anxiety, having a family history of mental illness was associated with higher eating disorder scores and anxiety. There was an association between gender and all disorders.

CONCLUSIONS

Insight into the prevalence of mental health disorders in the medical student population and the variables that may influence them provides important information for medical schools as they develop more robust and effective wellness programs to help students in these very stressful learning environments.

Can teaching veterinary and animal-science students about animal welfare affect their attitude toward animals and human-related empathy?

Attitudes toward animals are important in influencing how animals are treated. Few studies have investigated attitudes toward animals in veterinary or animal-science students, and no studies have compared attitudes to animals before and after a course teaching animal welfare and ethics. In this study, students enrolled in veterinary (first-year) or animal-science (first- and third-year) programs completed a questionnaire on attitudes toward different categories of animals before and after the course. Higher attitude scores suggest a person more concerned about how an animal is treated. Normally distributed data were compared using parametric statistics, and non-normally distributed data were compared using non-parametric tests, with significance p < .05. Attitudes toward pets (45.5-47.6) were higher than those toward pests (34.2-38.4) or profit animals (30.3-32.1). Attitude scores increased from before to after the course in the veterinary cohort on the Pest (36.9 vs. 38.4, respectively, n = 27, p < .05) and Profit (30.3 vs. 32.1, respectively, n = 28, p < .05) subscales, but not in the animal-science cohorts. Attitude scores in all categories were higher for women than for men. Currently having an animal was associated with higher pet scores (46.8 vs. 43.8, ns = 120 and 13, respectively, p < .05), and having an animal as a child was associated with higher profit scores (31.0 vs. 26.6, ns = 129 and 8, respectively, p < .05). Students electing to work with livestock had lower scores on the Pest and Profit subscales, and students wanting to work with wildlife had significantly higher scores on the Pest and Profit subscales. This study demonstrates attitudinal changes after an animal-welfare course, with significant increases in veterinary but not animal-science students.

Learning health professionalism at Makerere University: an exploratory study amongst undergraduate students

BACKGROUND

Anecdotal evidence shows that unprofessional conduct is becoming a common occurrence amongst health workers in Uganda. The development of appropriate professional values, attitudes and behaviors is a continuum that starts when a student joins a health professional training institution and as such health professionals in training need to be exposed to the essence of professionalism. We sought to explore undergraduate health professions students' perceptions and experiences of learning professionalism as a preliminary step in addressing the problem of unprofessional conduct amongst health workers in Uganda.

METHODS

Eight focus group discussions were conducted with 49 first to fifth year health professions undergraduate students of the 2008/2009 academic year at Makerere University College of Health Sciences. The focus group discussions were recorded and transcribed, and were analyzed using content analysis with emergent coding.

RESULTS

The difference in the way first and fifth year students of Makerere University College of Health Sciences conceptualized professionalism was suggestive of the decline in attitude that occurs during medical education. The formal curriculum was described as being inadequate while the hidden and informal curricula were found to play a critical role in learning professionalism. Students identified role models as being essential to the development of professionalism and emphasized the need for appropriate role modeling. In our setting, resource constraints present an important, additional challenge to learning universal standards of health professionalism. Furthermore, students described practices that reflect the cultural concept of communalism, which conflicts with the universally accepted standard of individual medical confidentiality. The students questioned the universal applicability of internationally accepted standards of professionalism.

CONCLUSIONS

The findings call for a review of the formal professionalism curriculum at Makerere University College of Health Sciences to make it more comprehensive and to meet the needs expressed by the students. Role models need capacity building in professionalism as health professionals and as educators. In our setting, resource constraints present an additional challenge to learning universal standards of health professionalism. There is need for further research and discourse on education in health professionalism in the Sub-Saharan context of resource constraints and cultural challenges.