Have medical students' attitudes towards clinical communication skills changed over a 12- year period? A comparative long-term study.

BACKGROUND: Attitudes towards learning clinical communication skills at the end of medical school are likely to reflect the students' training and motivation for the continued development of their skills as doctors. Students from two Norwegian medical schools, one with a traditional, and the other with an integrated curriculum, were approached in 2003 and 2015; with regard to changes in students' attitudes towards acquiring communication skills in two diverse learning environments. This comparison might reveal the effects of the training programs from a long-term perspective, as neither of the medical schools made any major curriculum changes within the study period. METHODS: The samples comprised final-year medical students. Two separate cross-sectional surveys performed 12 years apart (2003 and 2015) used items from the Communication Skills Attitude Scale in addition to age and gender. The traditional curriculum included only theoretical teaching and no contact with patients was made during the first 2 to 2.5 years of medical school. However, the integrated curriculum combined training in theoretical and clinical communication skills with early patient contact from the beginning. RESULTS: Attitudes improved from the first to the second survey at both schools, however, students from the integrated school reported more positive attitudes than those from the traditional school. Female students from the integrated school contributed the most to the difference in attitudes in both surveys. CONCLUSIONS: Students in both traditional and integrated curricula improved their attitudes from the first to the second assessment. However, compared with the traditional curriculum, the integrated one fostered even higher levels of positive attitudes towards acquiring communication skills, and a pronounced influence was observed on female students. These findings suggest that an educational program with greater emphasis on improving attitudes among male students may be required.

Feedback in Couple and Family Therapy: A Randomized Clinical Trial.

Routine Outcome Monitoring (ROM) is recommended as a psychotherapy procedure to serve as clinical feedback in order to improve client treatment outcomes. ROM can work as a warning signal to the therapist if the client shows signs of no change or deterioration. This study has investigated whether any difference in outcome could be detected between those clients in couple and family therapy who used the Systemic Therapy Inventory of Change (STIC) feedback system (ROM condition) versus those who were offered treatment without the use of STIC ("treatment as usual" or TAU condition). A sample of 328 adults seeking couple and family therapy in Norway was randomly assigned to ROM versus TAU conditions. Outcome measures were The Outcome Questionnaire-45 and The Revised Dyadic Adjustment Scale. The results demonstrated no significant differences in outcomes between the ROM and TAU. Possible explanations of this result related to design and implementation issues are discussed.

Do medical students and young physicians assess reliably their self-efficacy regarding communication skills? A prospective study from end of medical school until end of internship.

BACKGROUND: This prospective study from end of medical school through internship investigates the course and possible change of self- reported self-efficacy in communication skills compared with observers' ratings of such skills in consultations with simulated patients. METHODS: Sixty-two medical students (43 females) from four Norwegian universities performed a videotaped consultation with a simulated patient immediately before medical school graduation (T1) and after internship (internal medicine, surgery and family medicine, half a year each - T2). Before each consultation, the participants assessed their general self-efficacy in communication skills. Trained observers scored the videos and applied a well-validated instrument to rate the communication behaviour. Results from the two assessment methods were correlated at both time points and possible differences from T1 to T2 were explored. RESULTS: A close to zero correlation between self-efficacy and observed communication skills were found at T1. At T2, participants' self-efficacy scores were inversely correlated with levels of observed skills, demonstrating a lack of concordance between young physicians' own assessment of self-efficacy and observers' assessment. When dividing the sample in three groups based on the observers' scores (low <1/3-, medium 1/3 to 2/3-, high competence >2/3), the group of male physicians showed higher levels of self-efficacy than females in all the three performance groups at T1. At T2, those having a high performance score yielded a low self-efficacy, regardless of gender. CONCLUSIONS: The lack of positive correlations between self-efficacy assessment and expert ratings points to limitations in the applicability of self-assessment measures of communication skills. Due to gender differences, groups of female and male physicians should be investigated separately. Those obtaining high-performance ratings from observers, through the period of internship, may become more conscious of how demanding clinical communication with patients may be. This insight may represent a potential for growth, but could in some physicians represent too much of a self-critical attitude. Active supervision of young physicians throughout internship is important in order to help physicians to be more aware of their strengths and weaknesses, in order to gain increased mastery in the art of doctoring.

Parent being a physician: Any influence upon job stress in young physicians? A Norwegian prospective and longitudinal cohort study.

OBJECTIVE: To investigate whether being the child of a physician would be of importance for how young physicians experience job stress. METHOD: In a national representative prospective and longitudinal study with five assessment points (NORDOC), young physicians were followed over twenty year after graduation from medical school. RESULTS: Female physicians with a physician parent reported higher levels of job stress over the whole period compared with males with a physician parent. This gender difference did not occur within the group without a physician parent. Male young physicians showed a trend (not quite significant) to be less stressed than their peers without a physician parent. Women physicians were overrepresented in a group with persisting high stress level over the period. CONCLUSIONS: Male physicians with physician parent reporting lower stress levels than their female peers can be interpreted as a consequence of male physicians having more male models during their first working years as the main proportion of older physicians still are men. A father-son relationship may also promote an easier way to lower stress and achieve an identification with the role of doctor than for the females with a father-daughter relationship. With the increasing number of female physician, this gender difference may be prone to changes over time.

How and when feedback works in psychotherapy: Is it the signal?

OBJECTIVE: Monitoring of ongoing psychotherapy is of crucial importance in improving the quality of mental health care, and feedback (FB) about patients' progress has been established as a viable means. The essential feature of FB models is that patient progress is measured continuously through therapy. AIM: This study investigated the effect of receiving a warning signal when a patient is not achieving expected improvement (not-on-track), monitored with the Norwegian version of the patient FB system OQ®-Analyst. METHOD: Patients from six psychiatric clinics in Southern Norway (N = 259) were randomized to FB or no feedback (NFB). RESULTS: For the total sample, the FB effects appeared early (session three). Receiving a warning signal did not change the slope of patients' progress after the signal was given (FB versus NFB). FB seemed to be more effective with more severely distressed patients, although insignificant. Therapists indicated that the graphs imaging patient progress, and the accompanying discussion with the patient, were the most important aspects of FB. CONCLUSIONS: The use of OQ®-Analyst should be recommended in psychotherapeutic settings in Norway. Given the inconsistent results regarding the effect of warning signals, definitive conclusions about their effect may depend upon how and for whom it is used.

Work-home interface stress: an important predictor of emotional exhaustion 15 years into a medical career.

The importance of work-home interface stress can vary throughout a medical career and between genders. We studied changes in work-home interface stress over 5 yr, and their prediction of emotional exhaustion (main dimension of burn-out), controlled for other variables. A nationwide doctor cohort (NORDOC; n=293) completed questionnaires at 10 and 15 yr after graduation. Changes over the period were examined and predictors of emotional exhaustion analyzed using linear regression. Levels of work-home interface stress declined, whereas emotional exhaustion stayed on the same level. Lack of reduction in work-home interface stress was an independent predictor of emotional exhaustion in year 15 (ß=-0.21, p=0.001). Additional independent predictors were reduction in support from colleagues (ß=0.11, p=0.04) and emotional exhaustion at baseline (ß=0.62, p<0.001). Collegial support was a more important predictor for men than for women. In separate analyses, significant adjusted predictors were lack of reduction in work-home interface stress among women, and reduction of collegial support and lack of reduction in working hours among men. Thus, change in work-home interface stress is a key independent predictor of emotional exhaustion among doctors 15 yr after graduation. Some gender differences in predictors of emotional exhaustion were found.

The effect of implementing the Outcome Questionnaire-45.2 feedback system in Norway: A multisite randomized clinical trial in a naturalistic setting.

It has been claimed that the monitoring of ongoing psychotherapy is of crucial importance for improving the quality of mental health care. This study investigated the effect of using the Norwegian version of the patient feedback system OQ-Analyst using the Outcome Questionnaire-45.2. Patients from six psychiatric clinics in Southern Norway (N = 259) were randomized to feedback (FB) or no feedback (NFB). The main effect of feedback was statistical significant (p = .027), corroborating the hypothesis that feedback would improve the quality of services, although the size of the effect was small to moderate (d = 0.32). The benefits of feedback have to be considered against the costs of implementation.

Psychometric properties of the outcome questionnaire-45.2: the Norwegian version in an international context.

OBJECTIVE: Monitoring of ongoing psychotherapy is of crucial importance in improving the quality of mental health care by detecting therapies being off track, which requires that the instrument used is psychometrically sound. This study investigates the psychometric properties of the Norwegian version of the Outcome Questionnaire 45.2 (OQ-45) and situates the results in an international context. METHOD: Data from one non-clinical sample (N = 338) and one clinical sample (N = 560) were compared to international samples investigating reliability, cut-offs, and factor structure. RESULTS: The results show adequate reliability and concurrent validity. CONCLUSIONS: The means, clinical cut-offs, and the reliable change index vary across countries. However, the means of the OQ-45 for nonclinical samples correlate highly with external values of national well-being, indicating that the OQ-45 is a valid instrument internationally. The factor analyses in the present study do not confirm the hypothesized factor structure of the OQ-45, but are similar to the results internationally.

A few more minutes make a difference? The relationship between content and length of GP consultations.

OBJECTIVES: To investigate the relationship between the length of a medical consultation in a general practice setting and the biopsychosocial information obtained by the physician, and to explore the characteristics of young physicians obtaining comprehensive, especially psychosocial information. DESIGN: A prospective, longitudinal follow-up study. SETTING: Videotaped consultations with standardized patients on two occasions were scored for the amount of biopsychosocial information obtained. Consultation length was recorded in minutes. Subjects. Final-year (T-1) medical school students (n = 111) participated in the project. On completion of their internship one and a half years later (T-2), 62 attended a second time, as young physicians. MAIN OUTCOME MEASURES: Content lists. RESULTS: Pearson's r correlations between content and length at T-1 and T-2 were 0.27 and 0.66, respectively (non-overlapping confidence intervals). Psychosocial content increased significantly when consultations exceeded 13 minutes (15 minutes scheduled). Physicians using more than 13 minutes had previously, as hospital interns, perceived more stress in the emergency room and had worked in local hospitals. CONCLUSIONS: A strong association was found between consultation length and information, especially psychosocial information, obtained by the physicians at internship completion. This finding should be considered by faculty members and organizers of the internship period. Further research is needed to detect when, during the educational process, increased emphasis on communication skills training would be most beneficial for students/residents, and how the medical curriculum and internship period should be designed to optimize young physicians' use of time in consultations.

Risk factors at medical school for later severe depression: a 15-year longitudinal, nationwide study (NORDOC).

BACKGROUND: Doctors have an increased risk of suicide, and depressive symptoms are prominent among young doctors. We lack prospective studies that identify risk factors to be targeted in medical schools. METHODS: From 1993 to 2008, graduating medical students (n=631) from all four Norwegian universities participated in the Longitudinal Study of Norwegian Medical Students and Doctors (NORDOC). After their graduating term (T1), they were followed up 1 (T2), 4 (T3), 10 (T4), and 15 (T5) years later with postal surveys. Severe depressive symptoms were measured by the General Health Questionnaire-28 (T1, T2, T3, T4, and T5) and analyzed by generalized estimating equations. RESULTS: At T1 and T5, 13.7% and 7.2%, respectively, of the doctors reported severe depressive symptoms; a significant reduction over time (p=0.001) in both genders (response rates 56-83%). Independent risk factors for future depressive symptoms were: young age (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.04-1.2, p=0.003); high neuroticism (OR 3.4, 95% CI 1.5-7.6, p=0.003); high reality weakness (OR 2.3, 95% CI 1.2-4.2, p=0.008); and severe depressive symptoms at T1 (OR 3.6, 95% CI 2.1-6.1, p<0.001). LIMITATIONS: Selection bias and concurrent life and work stress may have influenced the results. CONCLUSIONS: In addition to low age, high neuroticism yielded a threefold increased risk over the 15-year follow-up, whereas high reality weakness, which is linked to personality pathology, doubled the risk. These factors are clinically relevant for identification of students at risk.

Existential dynamic therapy ("VITA") for treatment-resistant depression with cluster C disorder: matched comparison to treatment as usual.

Existential suffering may contribute to treatment-resistant depression. The "VITA" treatment model was designed for such patients with long-standing depression accompanied by existential and/or religious concerns. This naturalistic effectiveness study compared the VITA model (n = 50) with a "treatment as usual" comparison group (TAU; n = 50) of patients with treatment-resistant depression and cluster c comorbidity. The TAU patients were matched on several characteristics with the VITA patients. The VITA model included existential, dynamic, narrative and affect-focused components. The VITA group had significantly greater improvement on symptom distress and relational problems during treatment and from pre-treatment to 1-year follow-up. Patients in the VITA, at follow-up, were more likely to be employed and less likely be using psychotropic medications.

Will sick leave after a counselling intervention prevent later burnout? A 3-year follow-up study of Norwegian doctors.

INTRODUCTION: Burnout and mental distress in working doctors increase the risk for both suboptimal treatment of patients and negative health consequences for the doctors. Doctors have low rates of sickness absence and are reluctant to seek help, especially for mental distress. We examined whether a spell of sickness absence after a counselling intervention could predict reduction in emotional exhaustion among doctors at work 3 years later. METHODS: A 3-year follow up after a counselling intervention for burnout at the Resource Centre Villa Sana in Norway in 2003-05 was completed by 184/227 doctors. Self-report assessments were administered at baseline, 1-, and 3-years. The effect of number of weeks of sickness absence on reduction in emotional exhaustion among doctors working 3 years after the intervention was assessed by linear regression. RESULTS: Of the 184 doctors completing assessment, 149 were working at 3-year follow up. Emotional exhaustion (scale 1-5) was significantly reduced at follow up (from 3.00±0.96 to 2.37±0.79, p<0.001). The number of weeks of sickness absence after the intervention was a significant positive predictor of this reduction (ß=0.31, p<0.001), also after including sex, age, neuroticism, reduction of work hours, and other forms for treatment in the model. CONCLUSIONS: The number of weeks of sickness absence after a counselling intervention for burnout had a positive predictive effect on reduction in emotional exhaustion among doctors at work 3 years later. Sick leave thus seems to "prevent" later burnout, which can be of importance both for their patients and for the doctors themselves.

The impact of change in a doctor's job position: a five-year cohort study of job satisfaction among Norwegian doctors.

BACKGROUND: Job satisfaction among physicians may be of importance to their individual careers and their work with patients. We lack prospective studies on whether a change in a doctor's job position influences their job satisfaction over a five-year period if we control for other workload factors. METHODS: A longitudinal national cohort of all physicians who graduated in Norway in 1993 and 1994 was surveyed by postal questionnaire in 2003 (T1) and 2008 (T2). Outcomes were measured with a 10-item job satisfaction scale. Predictor variables in a multiple regression model were: change in job position, reduction in work-home interface stress, reduction in work hours, age, and gender. RESULTS: A total of 59% of subjects (306/522) responded at both time points. The mean value of job satisfaction in the total sample increased from 51.6 (SD = 9.0) at T1 to 53.4 (SD = 8.2) at T2 (paired t test, t = 3.8, p < 0.001). The major groups or positions at T1 were senior house officers (45%), chief specialists in hospitals (23%), and general practitioners (17%), and the latter showed the highest levels of job satisfaction. Physicians who changed position during the period (n = 176) experienced an increase in job satisfaction from 49.5 (SD = 8.4) in 2003 to 52.9 (SD = 7.5) in 2008 (paired t test, t = 5.2, p < 0.001). Job satisfaction remained unchanged for physicians who stayed in the same position. There was also an increase in satisfaction among those who changed from positions other than senior house officer at T1 (p < 0.01). The significant adjusted predictor variables in the multiple regression model were the change in position from senior house officer at T1 to any other position (ß = 2.83, p < 0.001), any change in job position (from any position except SHO at T1) (ß = 4.18, p < 0.01) and reduction in work-home interface stress (ß = 1.04, p < 0.001). CONCLUSIONS: The physicians experienced an increase in job satisfaction over a five-year period, which was predicted by a change in job position and a reduction in work-home stress. This study has implications with respect to career advice for young doctors.

A three-year cohort study of the relationships between coping, job stress and burnout after a counselling intervention for help-seeking physicians.

BACKGROUND: Knowledge about important factors in reduction of burnout is needed, but there is a dearth of burnout intervention program studies and their effects among physicians. The present three-year follow-up study aimed to investigate the roles of coping strategies, job stress and personality traits in burnout reduction after a counselling intervention for distressed physicians. METHODS: 227 physicians who attended a counselling intervention for burnout at the Resource Centre Villa Sana, Norway in 2003-2005, were followed with self-report assessments at baseline, one-year, and three-year follow-up. Main outcome measures were emotional exhaustion (one dimension of burnout), job stress, coping strategies and neuroticism. Changes in these measures were analyzed with repeated measures ANOVA. Temporal relationships between changes were examined using structural modelling with cross-lagged and synchronous panel models. RESULTS: 184 physicians (81%, 83 men, 101 women) completed the three-year follow-up assessment. Significantly reduced levels of emotional exhaustion, job stress, and emotion-focused coping strategies from baseline to one year after the intervention, were maintained at three-year follow-up.Panel modelling indicated that changes in emotion-focused coping (z = 4.05, p < 0.001) and job stress (z = 3.16, p < 0.01) preceded changes in emotional exhaustion from baseline to three-year follow-up. A similar pattern was found from baseline to one-year follow-up. CONCLUSION: A sequential relationship indicated that reduction in emotion-focused coping and in job stress preceded reduction in emotional exhaustion. As a consequence, coping strategies and job stress could be important foci in intervention programs that aim to reduce or prevent burnout in help-seeking physicians.