Family attitudes in youth as a possible precursor of cancer among physicians: a search for explanatory mechanisms

Declining empathy trends throughout medical curriculum and association factors of low empathy among medical students and residents: a single center study

BACKGROUND

A physician's empathy level substantially impacts clinical competence, patient relationships, and treatment outcomes. Yet, understanding empathy trends from medical students to resident doctors within a single institution is limited. This study delves into empathy trends within a single-center academic setting and identifies factors associated with low empathy.

METHODS

This cross-sectional study enrolled the second-to sixth-year medical students of Phramongkutklao College of Medicine and the first-to second-year residents at Phramongkutklao Hospital. It utilized a standardized questionnaire covering demographics, family relationships, the Maudsley Personality Inventory (MPI), and the Jefferson Scale of Empathy (JSE). The relationship between variables and JSE scores was analyzed using independent t-test, one-way ANOVA, and Chi-square tests. Multivariable logistic and linear regression analyses examined associated factors and trends across educational levels. A quadratic term was incorporated to evaluate the presence of a nonlinear trend.

RESULTS

A total of 520 participants, comprising 189 (36.4%) preclinical students, 153 (29.4%) clinical students, and 178 (34.2%) residents, completed the survey. The JSE showed a Cronbach's alpha of 0.83. The average empathy score was 103.8 ± 15.0, with 27.1% of low empathy levels. Specialty preference and sex-adjusted average empathy scores decreased from 114.5 (95%CI: 112.0-117.0) among second-year medical students to 95.2 (95%CI: 92.2-98.2) among second-year residents (Pnon-linear<0.001). The adjusted proportion of low empathy is highest among sixth-year medical students (54.4%, 95%CI: 34.4-73.2%). Factors associated with low empathy included those preferring procedure-oriented specialties (AOR: 4.16, 95%CI: 1.54-11.18) and a higher parental income (AOR: 2.97, 95%CI: 1.09 to 8.10). Subgroup analysis revealed that residents with a GPAX above 3.5 and those in technology-oriented specialties were also associated with lower empathy (AOR: 3.46, 95%CI: 1.40-8.59 and AOR: 2.93, 95%CI: 1.05-8.12, respectively).

CONCLUSION

A declining empathy trend was observed among medical students, which then plateaued among residents. Additionally, residents in technology-oriented specialties may require empathy enhancements due to their ongoing patient consultations. Addressing these issues requires collaborative planning between students and teachers to foster empathy throughout the medical curriculum.

Family climate in children living with parents who harmfully consume alcohol

The family climate has notable impact on cognitive, emotional, behavioural, social and physical development of children and adolescents and can be influenced by parents' health status. The present study aimed at evaluating whether living with a parent with alcohol use disorder negatively influences the perceived emotional family climate, parental attitudes and internal representations of family relationships. Forty-five children living with a parent with alcohol use disorder and 45 controls, matched for sex and age, completed the Level of Expressed Emotion Scale and the Family Attitudes Questionnaire. Their significant parent completed the Parental Attitudes Scale. The results suggested that living with a parent with an alcohol use disorder increased the risk of having perceived higher levels of emotional response, attitude towards illness and expectations from their parents; it also increased the probability of being exposed to lower parental pleasure and of having represented worse family relationships. Emotion regulation interventions might be useful to protect children living with a parent with alcohol use disorder from a potential chaotic and unpredictable family environment.

Childhood experiences of parenting and cancer risk at older ages: findings from the English Longitudinal Study of Ageing (ELSA)

Objectives

Despite the importance of childhood experiences for adult health and psychosocial factors for cancer development, parenting, a key childhood psychosocial exposure, has yet to be studied in relation to cancer risk at older ages. We examined whether childhood experiences of poor-quality parenting are associated with an increased risk of cancer at older ages.

Methods

We used a sample of 4471 community dwellers aged ≥ 55 years in 2007. Poor-quality parenting was defined as low levels of parental care and high levels of parental overprotection.

Results

Overall poorer experiences of parenting, decreasing parental care and increasing parental overprotection were associated with increased risk of incident all-site and skin cancer in men, but not in women. Increasing paternal overprotection was also associated with increased risk of incident colorectal cancer in men. Overall poorer experiences of parenting and increasing paternal overprotection were associated with increased risk of prevalent all-site and colorectal cancer in women. Adjustment for covariates explained a small part of these associations.

Conclusions

Older adults who reported childhood experiences of poorer quality parenting appear to have an increased risk of cancer. These findings improve our understanding of the role of psychosocial factors in cancer over the life course.

Electronic supplementary material

The online version of this article (10.1007/s00038-018-1117-3) contains supplementary material, which is available to authorized users.

A case-control study of the association between psychosocial factors and the occurrence of laryngeal cancer

The aim of the present study was to investigate the association between social psychological factors and the occurrence of laryngeal cancer. A 1:1 matched case-control study was conducted. The participants completed questionnaires that included general information, such as the Life Event Scale, the Social Support Rating Scale, and the Eysenck Personality Questionnaire (EPQ). Scores were compared between the groups using paired t-tests and Wilcoxon's signed-rank tests. No significant difference in the psychoticism scale of the EPQ was observed between the two groups (P>0.05). However, significant differences were observed in scores on the life events and social support scales and in the remaining dimensions of the EPQ (all P-values <0.05). Positive life events may be protective factors for laryngeal cancer, whereas reduced utilization of social support may be a risk factor for laryngeal cancer.

Parenting style in childhood and mortality risk at older ages: a longitudinal cohort study

BACKGROUND

Parenting style is associated with offspring health, but whether it is associated with offspring mortality at older ages remains unknown.

AIMS

We examined whether childhood experiences of suboptimal parenting style are associated with increased risk of death at older ages.

METHOD

Longitudinal cohort study of 1964 community-dwelling adults aged 65-79 years.

RESULTS

The association between parenting style and mortality was inverse and graded. Participants in the poorest parenting style score quartile had increased risk of death (hazard ratio (HR) = 1.72, 95% CI 1.20-2.48) compared with those in the optimal parenting style score quartile after adjustment for age and gender. Full adjustment for covariates partially explained this association (HR = 1.49, 95% CI 1.02-2.18). Parenting style was inversely associated with cancer and other mortality, but not cardiovascular mortality. Maternal and paternal parenting styles were individually associated with mortality.

CONCLUSIONS

Experiences of suboptimal parenting in childhood are associated with increased risk of death at older ages.

Attachment and Cancer: A Conceptual Integration

Cancer traditionally has been explained by the biomedical model; however, it is limited in comprehensively accounting for all factors in this disease. Recently, it has been suggested that a broader theoretical framework that includes psychosocial components in cancer is needed to complement the traditional approach. The purpose of this article, therefore, is to explore the utility of attachment theory as a biopsychosocial model of both development and health. Attachment, a developmental theory, explains how repeated interactions between caregiver and child in the early years establish lifelong psychosocial, physiological, affective, and cognitive patterns as well as enduring patterns of stress response to threat or illness. Despite attachment theory’s biopsychosocial foundation, the application of attachment security as a factor in physical health and psychosomatic medicine is relatively recent. The current work reviews attachment theory and psychosocial literature with regard to cancer and follows with a novel attempt to conceptually integrate both bodies of literature. A concluding integrative model of attachment theory and the type C behavior pattern is provided to illustrate potential links and integrative processes that may lead to disease resilience or vulnerability.

Psychological factors and cancer development: Evidence after 30 years of research

The question whether psychological factors affect cancer development has intrigued both researchers and patients. This review critically summarizes the findings of studies that have tried to answer this question in the past 30 years. Earlier reviews, including meta-analyses, covered only a limited number of studies, and included studies with a questionable design (group-comparison, cross-sectional or semiprospective design). This review comprises only longitudinal, truly prospective studies (N=70). It was concluded that there is not any psychological factor for which an influence on cancer development has been convincingly demonstrated in a series of studies. Only in terms of 'an influence that cannot be totally dismissed,' some factors emerged as 'most promising': helplessness and repression seemed to contribute to an unfavorable prognosis, while denial/minimizing seemed to be associated with a favorable prognosis. Some, but even less convincing evidence, was found that having experienced loss events, a low level of social support, and chronic depression predict an unfavorable prognosis. The influences of life events (other than loss events), negative emotional states, fighting spirit, stoic acceptance/fatalism, active coping, personality factors, and locus of control are minor or absent. A methodological shortcoming is not to have investigated the interactive effect of psychological factors, demographic, and biomedical risk factors.

What are the costs of marital conflict and dissolution to children's physical health?

Do parental marital conflict and dissolution influence the risk trajectory of children's physical health risk? This paper reviews evidence addressing this question in the context of understanding how early environmental adversities may trigger a succession of risks that lead to poor health in childhood and greater risk for chronic health problems in adulthood. We first review existing evidence linking marital conflict and dissolution to offspring's physical health outcomes. Next, we provide evidence supporting biopsychosocial pathways that may link marital conflict and dissolution with accelerated health risk trajectories across the lifespan. Specifically, we posit that consequential to the stresses associated with marital conflict and disruption, parenting practices are compromised, leading to offspring deficits in affective, behavioral, and cognitive domains. These deficits, in turn, are hypothesized to increase health risk through poor health behaviors and by altering physiological stress-response systems, including neuroendocrine, cardiovascular, and neurotransmitter functioning. On the basis of the available direct evidence and theoretically plausible pathways, it appears that there is a cost of marital conflict and disruption to children's health; however, more comprehensive investigations are needed to further elucidate this relationship. In the final section, we address limitations in the current literature and identify research that is needed to better evaluate the association between marital conflict and dissolution and children's physical health.

Temperament as a potential predictor of mortality: evidence from a 41-year prospective study

Psychological factors were hypothesized to influence mortality, in particular, early versus later mortality. To explore the relationship between temperament, a psychological factor, and mortality in a prospective study of 1337 medical students, we constructed a measure portraying three temperament types, using latent class analysis. Death occurred in 113 subjects over 25-41 years of follow-up. In univariate survival analysis, subjects tending to direct tension "inward" when under stress ("Tension-In") had a higher risk of mortality than "Tension-Out" or "Stable" types. These associations persisted after adjustment for age, smoking, cholesterol level, and Quetelet Index. The relative risk (RR) of mortality for Tension-In was 1.56 (95% confidence interval, 1.00-2.44) compared with the Stable group. The risk was due entirely to the excess risk in persons under 55 years of age (RR, 2.59; 95% confidence interval, 1.46-4.62); the corresponding risk of death in older persons was 0.66 (0.30-1.48). Thus temperament is a significant risk factor for mortality, in particular, premature death.

Symptoms of illness in late adulthood are related to childhood social deprivation and misfortune in men but not in women

Experiencing adverse life events during childhood may increase vulnerability to physical illnesses and psychological disorders during adulthood. We developed an Early Life Events Questionnaire (ELEQ) with 12 scales and administered it to 92 relatively healthy elderly individuals (29 men and 63 women). A canonical-correlation analysis of the 12 ELEQ scales and physical and psychological symptoms revealed a significant canonical correlation. The results indicate that those who grew up in a family with a harsh climate and whose affiliation needs were not met tended to have more psychological and physical symptoms in old age. Regression analysis revealed that, in men, early life events accounted for 42% of the variance in physical symptoms and 39% in psychological symptoms. No significant relationship, however, was found between ELEQ scales and health outcomes in women. These results suggest that women may be less vulnerable than men to the adverse health consequences of childhood deprivation and other misfortunes.

Youthful precursors of alcohol abuse in physicians

PURPOSE

This study was designed to determine youthful precursors of alcohol abuse in physicians.

SUBJECTS AND METHODS

We analyzed data from an ongoing prospective study of 1,014 male medical students enrolled in the graduating classes of 1948-1964 at the Johns Hopkins School of Medicine. The cohort, now physicians aged 52 to 68 years, has been contacted regularly since medical school to identify major disease. In 1986, the CAGE alcoholism screening questionnaire was administered. Alcohol abuse was defined as self-admitted alcoholism, excessive consumption of four or more beverages per day on average, or a score of 2 or higher on the CAGE questionnaire.

RESULTS

By these criteria, 131 of 1,014 (12.9%) patients abused alcohol. Medical school precursors associated (p less than 0.05) with subsequent alcohol abuse were as follows: non-Jewish ancestry (relative odds [RO] = 3.1), lack of religious affiliation (RO = 4.1), cigarette use of one pack or more per day (RO = 2.6), regular use of alcohol (RO = 3.6), anxiety (RO = 1.8) or anger (RO = 1.8) as a reaction to stress, frequent use of alcohol in nonsocial settings (RO = 1.6), past history of alcohol-related difficulty (RO = 3.1), and maternal alcoholism or mental illness (RO = 1.9). Precursors found not to be associated with alcohol abuse included sleep habits, use of sedatives or amphetamines, interest in athletics or hobbies, and parental relationship.

CONCLUSION

Our results suggest that there are several identifiable medical school precursors of alcohol abuse in physicians.

Clustering of personality traits in youth and the subsequent development of cancer among physicians

Using 14 personality measures obtained while the subjects were in medical school, the resulting profiles of 972 physicians were clustered into five groups using a two-stage cluster analysis procedure. Subjects were followed over a 30-year period to determine the cumulative survival rate (proportion of subjects remaining free of cancer) in each group. Statistically significant group differences in survival rate were found, with the group characterized by acting out and emotional expression having the most favorable curve (less than 1% developing cancer). The group characterized as "loners," who may well have suppressed their emotions, had the most unfavorable survival curve and was 16 times more likely to develop cancer than was the group characterized by acting out and emotional expression.

A possible relationship between figure drawing data collected in medical school and later health status among physicians

Figure drawings obtained while subjects were in medical school were scored using two different scales: (a) Sophistication-of-Body-Concept, a scoring system that measures the overall quality of the drawings; and (b) Conventionality/deviancy of the drawings, as determined by the relative frequency with which 42 different characteristics occurred in the total sample of drawings. Figure drawings were obtained from 1951 to 1964. As of 1984, subjects were classified into 1 of 11 health outcome (disease) categories plus a "healthy" category. Statistical analysis included one-way analyses of variance and multiple logistic regression in which age and cigarette consumption were controlled. Several statistically significant differences among groups were noted with respect to Conventionality/deviancy, but not with respect to Sophistication-of-Body-Concept.

The relationship of psychosocial factors to prognostic indicators in cutaneous malignant melanoma

This study investigated the relationship between prognosis (estimated by histopathologic indicators) in cutaneous malignant melanoma and a comprehensive set of physical risk, demographic, psychosocial, and situational variables. These variables were derived from the medical examination, the pathology report, psychosocial self-report measures, and an hour-long videotaped interview with 59 patients from two melanoma clinics in San Francisco. Variables significantly correlated with tumor thickness were: darker skin/hair/eye coloring, longer patient delay in seeking medical attention, two correlated dimensions within an operationally defined 'Type C' constellation of characteristics, two character style measures, and less previous knowledge of melanoma and understanding of its treatment. Of these variables, delay was the most significant in a hierarchical multiple regression analysis in which tumor thickness was the dependent variable. Associations between tumor thickness and psychosocial measures of Type C were considerably stronger and more significant for subjects less than age 55, suggesting that the role of behavioral and psychosocial factors in the course of malignant melanoma is more potent for younger than for older subjects.

The experience of cancer during early and advanced stages: the views of patients and their mates

Problems, coping mechanisms and problem resolution were assessed in 112 individuals: patients with early stage cervical cancer or pre-cancer (N = 42) and their mates (N = 19), and patients with advanced stage breast or gynecological cancer (N = 31) and their mates (N = 20). The most common source of concern for all groups was the disease itself; the men were also more likely than the patients to be disturbed by the possibility of the women dying. Taking firm action was the most frequently-mentioned coping strategy; information-seeking was also common among the early stage groups, and religious faith often cited by the advanced stage respondents. Analysis of a particular problem--fear of cancer--showed different coping strategies to be predominant; mates, in contrast to patients, were likely to take direct action and advanced stage groups more likely to discuss their fear of cancer with others. Problem resolution did not vary from group to group. Overall, the similarities among reactions of early and advanced stage patients and mates were more striking than differences, indicating the profound impact of cancer over the course of the disease on patient and family alike.

A multivariate analysis of circulatory data and their relationship to later disease

Measurements on 21 separate variables involving blood pressure and heart rate were obtained under casual, resting, and controlled conditions as part of the baseline evaluation of 1087 white males participating in a prospective investigation of possible precursors of premature disease and death. These measurements were subjected to a components-type factor analysis with orthogonal rotation of component vectors in an effort to construct statistically independent composites of greater predictive power and generality as well as to minimize problems in interpretation introduced by partially redundant variables. Multivariate and univariate techniques were afterwards used to test differences between groups of subjects who developed specific major disorders and those who remained in good health. Comparison of factor scores with original circulatory measures in a series of prospective analyses revealed that the former had the greater predictive power. Although only the hypertension group could be unequivocally differentiated from all others, a number of nominally-significant findings may provide leads for further research.

Youthful habits of work and recreation and later cancer among physicians

Scores on seven factors derived from a Habits of Work and Recreation Survey administered to 1,038 white male medical students 17 to 35 years ago were used to compare students who subsequently developed some form of major cancer with those who did not. With the Type I error rate controlled through use of multivariate analysis of variance and age and smoking ruled out as possible confounding variables, the two groups were significantly differentiated, primarily in terms of intellectual interests--cancer cases having fewer. Students at or below the overall mean on the intellectual interests measure were more than three times as likely to develop cancer as were students with scores above the mean. In this population, the results appear interpretable in terms of the stamina concept, in which few intellectual interests may reflect an absence of stamina and spontaneity and/or failure to meet subcultural expectations--factors possibly associated with increased cancer risk.