The longitudinal association of symptom-related and psychological factors with health-related quality of life in patients with chronic pelvic pain syndrome.

OBJECTIVE: To analyze the course of symptom-related measures, psychological variables and health-related quality of life (HRQoL) over a 12-month period, and to longitudinally examine symptom-related and psychological factors as predictors for HRQoL in male and female patients with chronic pelvic pain syndrome (CPPS). METHODS: Data from 125 patients aged 19-83 years at baseline attending an interdisciplinary outpatient clinic for CPPS were analyzed. Participants completed a self-administered questionnaire on subjective health issues, and a postal follow-up survey was conducted 12 months later. We assessed physical and mental HRQoL, CPPS symptom severity, pain intensity, severity of somatic, depressive and anxiety symptoms, pain catastrophizing, and data on treatments during the follow-up period. Data were analyzed using multilevel linear modelling. RESULTS: CPPS symptom severity, pain intensity, and pain catastrophizing significantly decreased over time. HRQoL and levels of somatic symptoms, depressive symptoms and anxiety remained stable. Lower baseline levels of somatic symptoms were associated with an increase in physical HRQoL, and lower baseline levels of depressive symptoms, anxiety and pain catastrophizing were associated with an increase in mental HRQoL after 12 months. Treatment utilization was neither related to decrease in CPPS symptom severity, pain intensity and pain catastrophizing, nor to HRQoL after 12 months. CONCLUSIONS: Our data suggest that CPPS is related to persistently diminished HRQoL. Somatic symptoms and psychological factors are important determinants of HRQoL and potential therapeutic targets. To evaluate the efficacy and impact of treatment on CPPS-related outcomes, future large-scaled studies should systematically assess detailed data about therapies patients receive in routine care.

Physiotherapy and combined cognitive-behavioural therapy for patients with chronic pelvic pain syndrome: results of a non-randomised controlled feasibility trial.

OBJECTIVE: To explore feasibility in terms of delivering and evaluating a combination of physiotherapy and psychotherapy for patients with chronic pelvic pain syndrome (CPPS). DESIGN: Prospective non-randomised controlled pilot study. SETTING: Tertiary care facility with a specialised interdisciplinary outpatient clinic for patients with CPPS. PARTICIPANTS: A total of 311 patients was approached; 60 participated. 36 patients were included in the intervention group (mean age ±SD 48.6 years±14.8; 52.8% female) and 24 in the control group (mean age ±SD 50.6 years±14.5; 58.3% female). Fourteen participants were lost to follow-up. INTERVENTIONS: Participants were non-randomly allocated to the intervention group with two consecutive treatment modules (physiotherapy and cognitive behavioural therapy) with a duration of 9 weeks each or to the control group (treatment as usual). MAIN OUTCOME MEASURES: Feasibility was operationalised in terms of delivering and evaluating the therapeutic combination. Regarding eligibility as the first aspect of feasibility, willingness to participate, dropout and satisfaction were assessed; for the second aspect, standardised self-report questionnaires measuring health-related quality of life, depression severity and pain were applied. RESULTS: Although eligibility and willingness-to-participate rates were low, satisfaction of the participants in the intervention group was high and dropout rates were low. Results indicated a small and non-significant intervention effect in health-related quality of life and significant effects regarding depression severity and pain. CONCLUSIONS: The combination of physiotherapy and psychotherapy for patients with CPPS seems to be feasible and potentially promising with regard to effect. However, a subsequent fully powered randomised controlled trial is needed. TRIAL REGISTRATION NUMBER: German Clinical Trials Register (DRKS00009976) and ISRCTN (ISRCTN43221600).

Somatic and psychosocial determinants of symptom severity and quality of life in male and female patients with chronic pelvic pain syndrome.

AIMS: To investigate the combined impact of somatic and psychosocial factors on symptom severity and physical and mental quality of life (QoL) in male and female patients with chronic pelvic pain syndrome (CPPS). METHODS: We examined 234 patients aged 18 to 84 years attending an interdisciplinary outpatient clinic for patients with CPPS in Hamburg, Germany. Using self-reports, we assessed CPPS symptom severity (NIH-CPSI), with the female counterpart of each male anatomical site used in the questionnaire for women; physical and mental QoL (SF-12) as well as symptoms of depression (PHQ-9) and anxiety (GAD-7); pain catastrophizing cognitions (PCS); social support (F-SozU) and medication intake. The presence of trigger and tender points was assessed in a physiotherapy examination. Hierarchical multiple regression analysis was calculated to analyze the contribution of somatic and psychosocial variables on CPPS symptom severity. Analyses were repeated with physical and mental QoL as outcomes. RESULTS: In the overall model, the intake of pain medication (B = 3.78, SE = 1.25, p = .006), the presence of depressive symptoms (B = 0.40, SE = 0.15, p = .01) and pain catastrophizing (B = 0.18, SE = 0.05, p = .001) significantly predicted CPPS symptom severity. Corresponding analyses revealed a differential pattern of factors predicting physical and mental QoL, whereas higher levels of depressive symptoms were consistently associated with diminished mental (B = -0.63; p < .001) and physical QoL (B = -0.85; p < .001). CONCLUSION: Present results emphasize the importance of psychosocial factors, in particular of depression, in CPPS symptom severity and both physical and mental QoL and give support to an integrated treatment concept encompassing both psychological support and somatic aspects of the disease.

Predictors of pain, urinary symptoms and quality of life in patients with chronic pelvic pain syndrome (CPPS): A prospective 12-month follow-up study.

OBJECTIVE: Chronic pelvic pain syndrome (CPPS) can affect both men and women and often causes substantial impairment to quality of life. Although cross-sectional studies have suggested that psychosocial aspects may constitute important factors in the etiology and maintenance of CPPS, longitudinal studies are rare. Therefore, the present study examines psychosocial factors as prospective predictors of pain intensity, urinary symptoms and impediments to quality of life in men and women with CPPS. METHODS: Data were collected from patients during visits to a specialized, interdisciplinary outpatient clinic and after 12 months. Outcomes included pain intensity, urinary symptoms and impediments to quality of life, all of which were measured with the NIH-CPSI. Age, sex, depressive-anxious symptomatology (PHQ-ADS), pain catastrophizing (PCS), health anxiety (WI-7) and social support (FSozU) were examined as predictors in multivariate linear regressions. RESULTS: Data from 109 patients (59.6% female; age M = 49.3, SD = 16.7) were analyzed. Pain severity (ß = .30, p = .004), age (ß = .22, p = .02), urinary symptoms (ß = .24, p = .01) and depressive-anxious symptomatology (ß = .29, p = .009) at baseline emerged as predictors of pain at follow-up. Urinary symptoms were predicted by urinary symptoms (ß = .53, p < .001) and depressive-anxious symptomatology (ß = .25, p = .01) at baseline; impediments to quality of life were predicted by depressive-anxious symptomatology (ß = .27, p = .01). CONCLUSION: Psychological factors, especially depressive-anxious symptomatology, predict CPPS-specific symptom severity and impediments to quality of life after 12 months and thus substantially contribute to the chronification of CPPS. It is recommended to address anxiety and depression in patients with CPPS as early as possible in biopsychosocially oriented treatment approaches.

Combined Cognitive-Behavioural and Physiotherapeutic Therapy for Patients with Chronic Pelvic Pain Syndrome (COMBI-CPPS): study protocol for a controlled feasibility trial.

BACKGROUND: Chronic pelvic pain syndrome (CPPS) is a pain condition perceived in the pelvic area for at least 6 months. While evidence of the aetiology and maintenance of CPPS is still unclear and therapy options are rare, there is preliminary evidence for the efficacy of cognitive behavioural therapy and physiotherapy. However, an integrated treatment has not yet been studied. The primary aim of this study is therefore to test the feasibility of combined psychotherapy and physiotherapy for female and male patients with CPPS. The secondary aim is to explore changes in patient-relevant and economic outcomes compared to a control group. METHODS: A feasibility study with a crossover design based on the principles of a 'cohort multiple randomized controlled trial' will be conducted to test a combined therapy for patients with CPPS. The study will consist of two consecutive treatment modules (cognitive behavioural group psychotherapy and physiotherapy as individual and group sessions), which will be applied in varying order. The modules will consist of nine weekly sessions with a 4-week break between the modules. The control group will undergo treatment as usual. Study subjects will be recruited from the interdisciplinary outpatient clinic for CPPS at the University Medical Center Hamburg-Eppendorf. Thirty-six patients will be assigned to the intervention, and 18 patients will be assigned to the control group. The treatment groups will be gender homogeneous. Feasibility as the primary outcome will be analysed in terms of the demand, acceptability, and practicality. Secondary study outcomes will be measured using validated self-rating-scales and physical examinations. DISCUSSION: To the best of our knowledge, this study is the first to investigate the feasibility of combined psychotherapy and physiotherapy for patients with CPPS. In addition to testing feasibility, the results can be used for the preliminary estimation of therapeutic effects. The results from this study will be used to generate an enhanced therapeutic approach, which might be subject to further testing in a larger study. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00009976 . Registered on 15 March 2016. ISRCTN, ISRCTN43221600 . Registered on 10 May 2016.

Mental disorders in patients with chronic pelvic pain syndrome (CPPS).

OBJECTIVE: Chronic pelvic pain syndrome (CPPS) is a debilitating pain condition with prevalence rates between 2.0% and 26.6%. Studies indicate that CPPS is often associated with psychosocial factors, but little is known about the presence of full-blown mental disorders in female and male patients with CPPS. Therefore, the aim of this study was to investigate the frequencies of mental disorders in patients with CPPS. METHODS: Cross-sectional data were collected from patients visiting a specialized outpatient clinic. Frequencies of mental disorders were investigated using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and compared to the general population. Furthermore, self-rating questionnaires were used to assess somatic symptom severity (PHQ-15), depression severity (PHQ-9) and anxiety severity (GAD-7). RESULTS: Data from 178 CPPS patients (60.1% female; age M=49.1, SD=18.0) were analyzed. Of the total sample, 95.2% (95% CI 90.8-97.9) suffered from at least one mental disorder. The most prevalent mental disorders were somatoform disorders (91.7%; 95% CI 86.4-95.4), followed by mood disorders (50.6%; 95% CI 42.8-58.4) and anxiety disorders (32.1%; 95% CI 25.2-39.8). The self-reported symptom burden was also significantly higher than in the general population. Compared to men, women met the diagnoses of somatoform (p=0.012) and anxiety disorders (p=0.027) significantly more often and reported a significantly higher total somatic symptom severity (p=0.001). CONCLUSION: Our results provide evidence for a clinically relevant psychosocial symptom burden in patients with CPPS, indicating the need for the examination of psychopathologies and multi-professional treatment for this patient group.

Influence of motivation, self-efficacy and situational factors on the teaching quality of clinical educators.

BACKGROUND: Being exposed to good teachers has been shown to enhance students' knowledge and their clinical performance, but little is known about the underlying psychological mechanisms that provide the basis for being an excellent medical teacher. Self-Determination Theory (SDT) postulates that more self-regulated types of motivation are associated with higher performance. Social Cognitive Theory (SCT) focuses on self-efficacy that has been shown to be positively associated with performance. To investigate the influences of different types of teaching motivation, teaching self-efficacy, and teachers' perceptions of students' skills, competencies and motivation on teaching quality. METHODS: Before the winter semester 2014, physicians involved in bedside teaching in internal medicine at the University Medical Center Hamburg-Eppendorf completed a questionnaire with sociodemographic items and instruments measuring different dimensions of teaching motivation as well as teaching self-efficacy. During the semester, physicians rated their perceptions of the participating students who rated the teaching quality after each lesson. We performed a random intercept mixed-effects linear regression with students' ratings of teaching quality as the dependent variable and students' general interest in a subject as covariate. We explored potential associations between teachers' dispositions and their perceptions of students' competencies in a mixed-effects random intercept logistic regression. RESULTS: 94 lessons given by 55 teachers with 500 student ratings were analyzed. Neither teaching motivation nor teaching self-efficacy were directly associated with students' rating of teaching quality. Teachers' perceptions of students' competencies and students' general interest in the lesson's subject were positively associated with students' rating of teaching quality. Physicians' perceptions of their students' competencies were significantly positively predicted by their teaching self-efficacy. CONCLUSIONS: Teaching quality might profit from teachers who are self-efficacious and able to detect their students' competencies. Students' general interest in a lesson's subject needs to be taken into account when they are asked to evaluate teaching quality.

Psychometric properties of the newly developed Physician Teaching Self-Efficacy Questionnaire (PTSQ).

BACKGROUND: High teaching quality and students' corresponding learning progress are the most important indicators of teachers' work performance. Theory and numerous empirical studies indicate that self-efficacy, a person's belief in her or his ability to accomplish a task, is an important predictor of work performance. Accordingly, it can be assumed that teaching self-efficacy also influences teaching performance and students' learning progress with regard to physicians who teach in undergraduate medical education. Therefore, the aim of this study was to develop and validate an instrument measuring clinical teaching self-efficacy in physicians. METHODS: We developed 16 items reflecting physicians' beliefs to provide high quality clinical teaching when facing regularly occurring critical teaching situations. These constitute the Physician Teaching Self-Efficacy Questionnaire (PTSQ). For its validation, we used data from a sample of 247 physicians from internal medicine and surgery at six German medical faculties. Regarding factorial validity, we performed exploratory structural equation modelling (ESEM) as well as confirmatory factor analysis (CFA). Regarding criterion validity, correlations with the scales of the Physician Teaching Motivation Questionnaire (PTMQ), teaching experience and perceived teaching involvement were calculated. Additionally, we conducted the same analyses with a short 6-item version. RESULTS: ESEM delivered evidence for a three-factor structure with a superordinate general factor, which was confirmed by local and global fit indicators in CFA (RMSEA = .055, TLI = .939, SRMR = .048, CFI = .948). We identified the following three subfactors: teaching self-efficacy with respect to self-regulation, dyadic regulation involving students, and triadic regulation involving students and patients. Internal consistencies indicated acceptable to excellent reliability for all scales (Cronbach's alpha = .77-.90). Theory-consistent correlations with the PTMQ scales, teaching experience, and teaching involvement confirmed criterion validity. Besides excellent global fit, the short version of the PTSQ also fulfilled all other validity criteria. CONCLUSIONS: The PTSQ is a valid instrument to assess physicians' clinical teaching self-efficacy. It could be used in faculty development programmes and for educational research. The short version could be used in situations that are time-critical for physicians in order to ensure high response rates.

Translating medical documents improves students' communication skills in simulated physician-patient encounters.

BACKGROUND: Patient-physician communication should be based on plain and simple language. Despite communication skill trainings in undergraduate medical curricula medical students and physicians are often still not aware of using medical jargon when communicating with patients. The aim of this study was to compare linguistic communication skills of undergraduate medical students who voluntarily translate medical documents into plain language with students who do not participate in this voluntary task. METHODS: Fifty-nine undergraduate medical students participated in this study. Twenty-nine participants were actively involved in voluntarily translating medical documents for real patients into plain language on the online-platform https://washabich.de (WHI group) and 30 participants were not (non-WHI group). The assessment resembled a virtual consultation hour, where participants were connected via skype to six simulated patients (SPs). The SPs assessed participants' communication skills. All conversations were transcribed and assessed for communication skills and medical correctness by a blinded expert. All participants completed a self-assessment questionnaire on their communication skills. RESULTS: Across all raters, the WHI group was assessed significantly (p = .007) better than the non-WHI group regarding the use of plain language. The blinded expert assessed the WHI group significantly (p = .018) better regarding the use of stylistic devices of communication. The SPs would choose participants from the WHI group significantly (p = .041) more frequently as their personal physician. No significant differences between the two groups were observed with respect to the medical correctness of the consultations. CONCLUSION: Written translation of medical documents is associated with significantly more frequent use of plain language in simulated physician-patient encounters. Similar extracurricular exercises might be a useful tool for medical students to enhance their communication skills with respect to using plain language in physician-patient communication.

Validation of the Physician Teaching Motivation Questionnaire (PTMQ).

BACKGROUND: Physicians play a major role as teachers in undergraduate medical education. Studies indicate that different forms and degrees of motivation can influence work performance in general and that teachers' motivation to teach can influence students' academic achievements in particular. Therefore, the aim of this study was to develop and to validate an instrument measuring teaching motivations in hospital-based physicians. METHODS: We chose self-determination theory as a theoretical framework for item and scale development. It distinguishes between different dimensions of motivation depending on the amount of self-regulation and autonomy involved and its empirical evidence has been demonstrated in other areas of research. To validate the new instrument (PTMQ = Physician Teaching Motivation Questionnaire), we used data from a sample of 247 physicians from internal medicine and surgery at six German medical faculties. Structural equation modelling was conducted to confirm the factorial structure, correlation analyses and linear regressions were performed to examine concurrent and incremental validity. RESULTS: Structural equation modelling confirmed a good global fit for the factorial structure of the final instrument (RMSEA = .050, TLI = .957, SRMR = .055, CFI = .966). Cronbach's alphas indicated good internal consistencies for all scales (α = .75 - .89) except for the identified teaching motivation subscale with an acceptable internal consistency (α = .65). Tests of concurrent validity with global work motivation, perceived teaching competence, perceived teaching involvement and voluntariness of lesson allocation delivered theory-consistent results with slight deviations for some scales. Incremental validity over global work motivation in predicting perceived teaching involvement was also confirmed. CONCLUSIONS: Our results indicate that the PTMQ is a reliable, valid and therefore suitable instrument for assessing physicians' teaching motivation.

"Teaching is like nightshifts ": a focus group study on the teaching motivations of clinicians.

BACKGROUND: To ensure the highest quality of education, medical schools have to be aware of factors that influence the motivation of teachers to perform their educational tasks. Although several studies have investigated motivations for teaching among community-based practitioners, there is little data available for hospital-based physicians. PURPOSES: This study aimed to identify factors influencing hospital-based physicians' motivations to teach. METHODS: We conducted 3 focus group discussions with 15 clinical teachers from the Medical Faculty at Hamburg University. Using a qualitative inductive approach, we extracted motivation-related factors from the transcripts of the audio-recorded discussions. RESULTS: Three main multifaceted categories influencing the motivation of teachers were identified: the teachers themselves, the students, and the medical faculty as an organization. Participants showed individual sets of values and beliefs about their roles as teachers as well as personal notions of what comprises a "good" medical education. Their personal motives to teach comprised a range of factors from intrinsic, such as the joy of teaching itself, to more extrinsic motives, such as the perception of teaching as an occupational duty. Teachers were also influenced by the perceived values and beliefs of their students, as well as their perceived discipline and motivation. The curriculum organization and aspects of leadership, human resource development, and the evaluation system proved to be relevant factors as well, whereas extrinsic incentives had no reported impact. CONCLUSIONS: Individual values, beliefs, and personal motives constitute the mental framework upon which teachers perceive and assess motivational aspects for their teaching. The interaction between these personal dispositions and faculty-specific organizational structures can significantly impair or enhance the motivation of teachers and should therefore be accounted for in program and faculty development.

Bedside Teaching: general and discipline-specific teacher characteristics, criteria for patient selection and difficulties.

OBJECTIVE: With regard to bedside teaching (BST), which has an important function in medical education for practicing history taking and clinical examination, only few studies can be found which define recommendations for its realization. However, difficulties with this teaching method are often reported in evaluations. Hence, the goal of this study is to collect important general requirements for bedside teaching and to identify important aspects of patient selection. METHODS: A newly designed questionnaire with closed and open questions concerning the organisation, the execution and the design of BST as well as patient selection was sent to a total of 134 teachers from the departments of surgery, internal medicine and psychiatry. The collected data were analysed using quantitative and qualitative methods. RESULTS: Teachers from internal medicine were significantly older than teachers from both other disciplines. In surgery, a significantly higher number of hours was taught by younger residents. Patient consent and the match of their diseases to the learning objectives were stated to be the most important factors for patient selection across disciplines. Psychiatrists put significantly more emphasis on patients' German language skills according to their own declaration. By trend, an acute deterioration of the state of health was mentioned more often in surgery to lead to an exclusion from BST. CONCLUSION: With regard to planning of content, organisation and patient selection for BST, aspects mentioned by teachers as well as discipline specific characteristics should be considered for and addressed during teacher trainings.