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.

Depression and functioning are important to subjective quality of life after a first episode psychosis.

BACKGROUND: Subjective quality of life (S-QoL) is an important outcome measure in first-episode psychosis, but its associations with clinical predictors may vary across the illness course. In this study we examine the association pattern, including both direct and indirect effects, between specific predefined clinical predictors (insight, depression, positive psychotic symptoms and global functioning) and S-QoL the first ten years after a first-episode psychosis. METHODS: Three hundred and one patients with a first-episode psychosis were included at first treatment, and reassessed at 3 months, 1 year, 2 years, 5 years and 10 years after inclusion. At 10-year follow-up 186 participated. S-QoL was assessed with Lehman's Quality of Life Interview. Applying a structural equation model, we investigated cross-sectional association patterns at all assessments between the predefined clinical predictors and S-QoL. RESULTS: At baseline, only depression was significantly associated with S-QoL. At all follow-up assessments, depression and functioning showed significant associations with S-QoL. Insight was not associated with S-QoL at any of the assessments. Better insight, less depressive symptoms and less positive psychotic symptoms were all associated with higher functioning at all assessments. Functioning seems to mediate a smaller indirect inverse association between positive psychotic symptoms and S-QoL. The association pattern was stable across all follow-up assessments. CONCLUSIONS: Together with depression, functioning seems to be important for S-QoL. Functioning seems to be a mediating factor between positive symptoms and S-QoL. A focus on functional outcome continues to be important.

Contextual Factors and Mental Distress as Possible Predictors of Hazardous Drinking in Norwegian Medical Doctors: A 15-Year Longitudinal, Nationwide Study.

BACKGROUND: We have previously identified long-term individual predictors of hazardous drinking in doctors, but longitudinal studies on contextual factors (work and life stress) and mental distress being independently linked to hazardous drinking over the first 15 years of a medical career are lacking. METHODS: Two nationwide cohorts of Norwegian doctors (n = 1,052) from all 4 Norwegian universities were surveyed in their final year of medical school (1993/1994 and 1999) (T1), and 4 (T2), 10 (T3), and 15 (T4) years later. Hazardous drinking was measured using a validated 9-item version of the Alcohol Use Disorder Identification Test. Work-related and other predictors were analysed using generalized estimating equations. RESULTS: Ninety percent (947/1,052) responded at least once, and 42% (450/1,052) responded at all 4 time points. Hazardous drinking was reported by 16% at T1, 14% at T2 and T3, and 15% at T4. Life events (p = 0.009) and mental distress (p = 0.002) were adjusted predictors of hazardous drinking, in addition to male gender, no religious activity, drinking to cope with tension, and low conscientiousness. CONCLUSIONS: Doctors' work-related stress was not linked to hazardous drinking, but life events, mental distress, and drinking to cope were. Prevention should target mental distress and drinking to cope with tension.

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.

Risk Factors Measured During Medical School for Later Hazardous Drinking: A 10-year, Longitudinal, Nationwide Study (NORDOC).

AIMS: To investigate the prevalence and temporal patterns of hazardous drinking and risk factors during medical school for future hazardous drinking among doctors. METHODS: Two cohorts of graduating medical students (N = 1052) from all four Norwegian universities (NORDOC) were surveyed in their final year of medical school training (1993/94 and 1999) (T1) and again 4 (T2) and 10 (T3) years later. Longitudinally, 53% (562/1052) of the sample responded at all three time points. Hazardous drinking was defined as drinking five or more drinks during one session at least 2-3 times per month. Predictors of hazardous drinking, identified by logistic regression models after controlling for cohort, included a parental history of alcohol problems, having children, no religious activity, use of alcohol to cope with tension and some personality traits. RESULTS: There was a significant decline in the prevalence of hazardous drinking from T1 (14%) to T2 (10%) but not from T2 to T3 (8%). Approximately 23% of hazardous drinkers at T1 remained hazardous drinkers at T3 (N = 18). At T2, significant adjusted predictors included male gender (OR = 2.0, P = 0.04), use of alcohol as a coping strategy (OR = 2.2, P = 0.03) and hazardous drinking at T1 (OR = 9.8, P < 0.001). The significant adjusted predictors at T3 included older age (OR = 1.1, P = 0.01), male gender (OR = 3.6, P = 0.002) and hazardous drinking at T1 (OR = 7.5, P < 0.001). CONCLUSIONS: Hazardous drinking and drinking to cope with tension during medical school were the most important predictors of later hazardous drinking and should be targets of preventive efforts in medical schools.

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.

Is there an optimal factor structure of the Positive and Negative Syndrome Scale in patients with first-episode psychosis?

The Positive and Negative Syndrome Scale (PANSS) is the most widely used scale to assess a variety of symptoms in patients with schizophrenia and other psychoses. The factor structure of the PANSS has been examined with confirmatory factor analyses in several studies, but not in a well-defined first-episode psychosis sample. The aim of this paper is to examine the statistical fit of five different PANSS models in a first-episode, non-affective psychosis sample. Confirmatory factor analyses were performed on PANSS data (n = 588). A main criterion for best fit was defined as the Expected Cross Validation Index (ECVI). No tested model revealed an optimally satisfactory model fit index. The Wallwork/Fortgang five-factor model demonstrated the most optimal psychometric properties. The corresponding subscales of all evaluated five-factor models were strongly intercorrelated. The Wallwork/Fortgang five-factor model was found to be statistically and clinically ideal among patients with first-episode psychosis. Therefore, we recommend this model in forthcoming studies among patients with first-episode psychosis. However, to prevent the loss of clinically valuable information on an item level, we do not recommend removing any items from the original form. Our study also implies that the specific choice of model will not have a substantial effect on outcome results in studies on the course and outcome in first-episode psychosis.

A comparison of adolescent- and adult-onset first-episode, non-affective psychosis: 2-year follow-up.

This study aimed to compare 2-year outcome among individuals with early-onset (EO; <18 years) versus adult-onset (AO) first-episode, non-affective psychosis. We compared clinical and treatment characteristics of 43 EO and 189 AO patients 2 years after their inclusion in a clinical epidemiologic population-based cohort study of first-episode psychosis. Outcome variables included symptom severity, remission status, drug abuse, treatment utilization, cognition and social functioning. At baseline, EO patients were more symptomatically compromised. However, these initial baseline differences were no longer significant at the 2-year follow-up. This study challenges the findings of a larger and older literature base consisting primarily of non-comparative studies concluding that teenage onset indicates a poor outcome. Our results indicate that adolescent-onset and adult-onset psychosis have similar prognostic trajectories, although both may predict a qualitatively different course from childhood-onset psychosis.

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.

Patient satisfaction with treatment in first-episode psychosis.

PURPOSE: To examine first-episode psychotic patients' satisfaction with elements of a comprehensive 2-year treatment program. SUBJECTS AND METHOD: The TIPS (Early Treatment and Intervention in Psychosis) project provided a 2-year treatment program consisting of milieu therapy (inpatient), individual psychotherapy, family intervention and medication. Of 140 patients at baseline, 112 were included at 2-year follow-up. Eighty-four participants were interviewed using a questionnaire eliciting levels of satisfaction with different treatment elements at two of the four sites. RESULTS: Participants and non-participants did not differ on demographic or clinical data at baseline. Of those participating, 75% were satisfied with treatment in general. Individual and milieu therapy received higher rating than medication or family intervention. No predictors of general satisfaction with treatment were found, but continuously psychotic patients were the least satisfied with medication treatment. DISCUSSION: As in most patient satisfaction studies within mental health treatment networks, there was high level of general satisfaction with the total package of treatment but considerable variation in satisfaction for specific interventions. In this sample of first-episode psychosis patients, there was general satisfaction with treatments based on one-to-one relationships while multi-family group intervention was consistently valued less enthusiastically.

Neurocognition and occupational functioning in patients with first-episode psychosis: a 2-year follow-up study.

Neurocognitive deficits are a core feature of schizophrenia that is associated with poor occupational functioning. Few studies have investigated this relationship in patients with first-episode psychosis. The current study examined the characteristics of employed and unemployed patients with first-episode psychosis at baseline and 2-year follow-up, and the predictive value of neurocognition on employment status. One-hundred and twenty-two first-episode psychosis patients were assessed with clinical and neurocognitive measures at baseline. Occupational status was assessed at baseline and 2-year follow-up. Those unemployed at baseline were rated lower on global functioning and were more likely to have a schizophrenia spectrum disorder. Total employment rates were 41% at baseline and 38% at 2-year follow-up. Four employment paths emerged at follow-up, defined as persistently employed, becoming unemployed, entering employment and persistently unemployed. The persistently employed group had the highest global functioning score. For the total sample, baseline employment status and sustained attention predicted employment status at follow-up. For those employed at baseline, better sustained attention, higher global functioning, more positive symptoms and less alcohol use predicted persistent employment at follow-up. For those unemployed at baseline, none of the variables predicted change in employment status. Implications of these results are discussed.

Contrasting monosymptomatic patients with hallucinations and delusions in first-episode psychosis patients: a five-year longitudinal follow-up study.

BACKGROUND: The main aim of this study was to identify subgroups of patients characterized by having hallucinations only or delusions only and to examine whether these groups differed with regard to demographic characteristics, clinical characteristics and outcome factors, including suicidality. METHODS: Out of 301 consecutively admitted patients with first-episode psychosis, individuals with delusions only (D) and hallucinations only (H) were identified based on Positive and Negative Syndrome Scale (PANSS) items P1 (delusions) and P3 (hallucinations) scores at baseline and through 4 follow-up interviews over 5 years. The subgroups were compared with regard to demographic data, premorbid functioning, duration of untreated psychosis, clinical variables, time to remission and suicidality. RESULTS: Two groups of patients were identified; H (n = 16) and D (n = 106). 179 patients experienced both hallucinations and delusions (dual symptom group). The H group was significantly younger, had a longer duration of untreated psychosis, poorer premorbid function and better insight than the D group. Notably, the H group scored higher on measures of suicidality, and at 5 years follow-up a significantly higher proportion of patients was lost to suicide in this group. The dual symptom group was closer to the D group on significant parameters, including suicidality and suicide rate. CONCLUSIONS: Patients with hallucinations only can be separated from patients with delusions only and the subgroups differ with regard to demographical data, clinical variables and notably with regard to suicidality. These findings suggest distinctions in the underlying biological and psychological processes involved in hallucinations and in delusions.

Parental bonding and self-esteem as predictors of severe depressive symptoms: a 10-year follow-up study of Norwegian physicians.

Elevated rates of suicide and depression among physicians have been reported. The associations between perceived parental bonding and depressive symptoms have yet to be studied longitudinally in this occupational group. In a nationwide cohort, we sought to study parental bonding as a predictor for severe depressive symptoms and to determine whether self-esteem mediates this relationship. After graduation (T1), medical students (N = 631) were followed-up after 1 (T2), 4 (T3), and 10 (T4) years. There were no gender differences in mean depressive scores. Female physicians reported higher levels of care from their mothers (p < 0.05) and less overprotection from their fathers (p < 0.05). Low-care from the mother predicted severe depressive symptoms (p = 0.01), an effect shown to be stronger for male than for female physicians. The relationship between perceived parental bonding and depressive symptoms was partially mediated by low self-esteem for both sexes.