Testing times: the association of intolerance of uncertainty and metacognitive beliefs to test anxiety in college students.

BACKGROUND: Test anxiety has a detrimental effect on test performance but current interventions for test anxiety have limited efficacy. Therefore, examination of newer psychological models of test anxiety is now required. Two transdiagnostic psychological models of emotional disorders that can account for anxiety are the intolerance of uncertainty model (IUM) and the Self-Regulatory Executive Function (S-REF) model. Intolerance of uncertainty, the stable disposition to find uncertainty distressing, is central to the IUM, while beliefs about thinking, metacognition, are central to the S-REF model. We tested for the first time the role of both intolerance of uncertainty and metacognitive beliefs in test anxiety. METHODS: A cross-sectional design was used, with college students (n = 675) completing questionnaires assessing their test anxiety, intolerance of uncertainty, and metacognitive beliefs. Hierarchical linear regressions examined if intolerance of uncertainty and metacognitive beliefs were associated with test anxiety, after controlling for age and gender. RESULTS: Females reported significantly more test anxiety than males. Partial correlations, controlling for gender, found intolerance of uncertainty and metacognitive beliefs were significantly and positively correlated with test anxiety. Hierarchical linear regressions found metacognitive beliefs explained an additional 13% of variance in test anxiety, after controlling for intolerance of uncertainty. When the order of entry was reversed, intolerance of uncertainty was only able to explain an additional 2% of variance, after controlling for metacognitive beliefs. In the final regression model, gender, intolerance of uncertainty and the metacognitive belief domains of 'negative beliefs about the uncontrollability and danger of worry' and 'cognitive confidence' were all significantly associated test anxiety, with 'negative beliefs about the uncontrollability and danger of worry' having the largest association. CONCLUSIONS: Both intolerance of uncertainty and metacognitive beliefs are linked to test anxiety, but results suggest metacognitive beliefs have more explanatory utility, providing greater support for the S-REF model. Modification of intolerance of uncertainty and metacognitive beliefs could alleviate test anxiety and help students fulfil their academic potential.

Essential role of γ-clade RNA-dependent RNA polymerases in rice development and yield-related traits is linked to their atypical polymerase activities regulating specific genomic regions.

RNA-dependent RNA polymerases (RDR) generate double-stranded (ds)RNA triggers for RNA silencing across eukaryotes. Among the three clades, α-clade and ß-clade members are key components of RNA silencing and mediators of stress responses across eukaryotes. However, γ-clade members are unusual in that they are represented in phylogenetically distant plants and fungi, and their functions are unknown. Using genetic, bioinformatic and biochemical methods, we show that γ-clade RDRs from Oryza sativa L. are involved in plant development as well as regulation of expression of coding and noncoding RNAs. Overexpression of γ-clade RDRs in transgenic rice and tobacco plants resulted in robust growth phenotype, whereas their silencing in rice displayed strong inhibition of growth. Small (s)RNA and RNA-seq analysis of OsRDR3 mis-expression lines suggested that it is specifically involved in the regulation of repeat-rich regions in the genome. Biochemical analysis confirmed that OsRDR3 has robust polymerase activities on both single stranded (ss)RNA and ssDNA templates similar to the activities reported for α-clade RDRs such as AtRDR6. Our results provide the first evidence of the importance of γ-clade RDRs in plant development, their atypical biochemical activities and their contribution to the regulation of gene expression.

Stability of Begomoviral pathogenicity determinant ßC1 is modulated by mutually antagonistic SUMOylation and SIM interactions.

BACKGROUND: To successfully invade new hosts, plant viruses must break host resistance and be competent to move within and between plant cells. As a means, viral proteins known as pathogenicity determinants have evolved to coordinate a network of protein interactions. The ßC1 protein encoded by specific geminiviral satellites acts as a key pathogenicity determinant for this disease-causing family of plant viruses. Post-translational modifications (PTMs) such as ubiquitination and phosphorylation of the ßC1 protein have been shown to occur in diverse viruses. However, the relevance of these and other layers of PTMs in host-geminiviral interactions has not been fully understood. RESULTS: Here we identified the significance of a novel layer of PTMs in the ßC1 protein of Synedrella yellow vein clearing virus (SyYVCV), a newly identified member of the Begomovirus genus of Geminiviruses. This protein has conserved SUMOylation and SUMO-interacting motifs (SIMs), and we observed SUMOylation of SyYVCV ßC1 in host plants as a defensive strategy against ubiquitin-mediated degradation. Counteracting this, SIMs encoded in ßC1 mediate the degradation of ßC1; however, both these PTMs are essential for the function of ßC1 protein since SIM and SUMOylation motif mutants failed to promote pathogenicity and viral replication in vivo. SUMOylation in different motifs of ßC1 led to functionally distinct outcomes, regulating the stability and function of the ßC1 protein, as well as increased global SUMOylation of host proteins. CONCLUSION: Our results indicate the presence of a novel mechanism mediating a fine balance between defence and counter-defence in which a SIM site is competitively sought for degradation and, as a counter-defence, ßC1 undergoes SUMOylation to escape from its degradation.

The efficacy of interventions for test-anxious university students: A meta-analysis of randomized controlled trials.

Test anxiety (TA) is highly distressing and can significantly undermine academic performance. Many randomized controlled trials (RCTs) of interventions for university students with TA have been conducted, but there has been no systematic review of their efficacy. This meta-analysis examines the efficacy of interventions for test-anxious university students in: (i) reducing TA, and (ii) improving academic performance. We searched for RCTs published in English language peer-reviewed journals. Forty-four RCTs met our eligibility criteria (n = 2,209). Interventions were superior to control conditions at post-treatment for reducing TA (g = -0.76) and improving academic performance (g = 0.37). Interventions were superior to control conditions at follow-up. Subgroups analyses found most support for behaviour therapy. Cognitive-behavioural therapy, study skills training, and combined psychological and study skills training interventions show promise but lack evidence for their longer-term efficacy, and results are based upon a small number of studies. Evidence of publication bias was found and poor quality of reporting meant that confidence in results should be moderated. Future RCTs should be conducted and reported with greater rigour, have larger samples, and examine newer interventions.

A Framework for Understanding Lapses in Professionalism Among Medical Students: Applying the Theory of Planned Behavior to Fitness to Practice Cases.

Fitness to practice decisions are often based on a student's digression from the regulations, with limited exploration of the reasoning behind the student's behavior. However, behavior is underpinned by complex, "hidden" variables, including an individual's attitudes and social norms. Examining hidden determinants of professionalism, such as context, interpersonal relationships, social norms, and local cultures, then allows medical educators to develop a richer understanding of unprofessional behavior.In this article, the authors propose the use of the theory of planned behavior (TPB) as a framework to help evaluate unprofessional behavior in students. The TPB is a deliberative processing model that explains how an individual's behavior is underpinned by his or her cognitions, with behavior being primarily dependent on the intention to perform the behavior (behavioral intention). Intention, in turn, is determined by three variables: attitude, subjective norm, and perceived behavioral control.To understand the practical use of the TPB, the authors present four complex, anonymized case studies in which they employed the TPB to help deal with serious professionalism lapses among medical students. The outcomes of these cases as well as the student and program director perspectives, all explained via the TPB variables, are presented. The strengths and limitations of the TPB are discussed.

Professionalism under fire: Conflict, war and epidemics.

Today's medical students (tomorrow's doctors) will be entering a world of conflict, war and regular outbreaks of infectious diseases. Despite numerous international declarations and treaties protecting human rights, the last few decades has been fraught with reports of "lapses" in medical professionalism involving torture and force-feeding of detainees (e.g. captured during the War on Terror) and health care professionals refusing to treat infected patients (e.g. HIV and Ebola). This paper provides some historical background to the changing status of a physician's duty to treat and how medical practitioners came to be involved in the inhumane treatment of detainees during the War on Terror, culminating in reports of "lapses" in professionalism. The Theory of Planned Behavior, which takes into account the individual, the environment and the social context, is used to explain the factors that might influence an individual's behavior in challenging situations. The paper concludes with some recommendations for medical and health professions education. The recommendations include selecting students who, as a minimum, can provide evidence of "basic" professionalism, engaging them in exploring the history of the medical profession, exposing them to contexts of uncertainty and moral dilemmas and challenging them to reflect on their responses.

Medical professionalism across cultures: a challenge for medicine and medical education.

BACKGROUND: The recognition of medical professionalism as a complex social construct makes context, geographical location and culture important considerations in any discussion of professional behaviour. Medical students, medical educators and practitioners are now much more on the move globally, exposing them to cultural and social attitudes, values and beliefs that may differ from their own traditional perceptions of professionalism. AIMS AND METHODS: This paper uses the model of the intercultural development continuum and the concept of "cultural fit" to discuss what might transpire when a student, teacher or doctor is faced with a new cultural environment. Using our own experiences as medical educators working abroad and supported by evidence in the literature, we have developed four anecdotal scenarios to highlight some of the challenges that different cultural contexts bring to our current (Western) understanding of professionalism. RESULTS AND CONCLUSIONS: The scenarios highlight some of the potentially different regional and/or cultural perspectives and nuances of professional behaviours, attitudes or values that many of us either take for granted or find difficult, depending on our training and socio-cultural upbringing. With this paper, we hope to start a long overdue conversation about global professionalism amongst medical educators, identify potential areas for research and highlight a need for medical schools to embrace a "global" approach to how professionalism is embedded in their curricula.

Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness of patient safety for doctors in training.

BACKGROUND: Patient safety training often provides learners with a health professional's perspective rather than the patient's. Personal narratives of health-related harm allow patients to share their stories with health professionals to influence clinical behaviour by rousing emotions and improving attitudes to safety. AIM: This study measured the impact of patient narratives used to train junior doctors in patient safety. METHODS: An open, multi-centre, two-arm, parallel design randomised controlled trial was conducted in the North Yorkshire East Coast Foundation School (NYECFS). The intervention consisted of 1-h-long patient narratives followed by discussion. The control arm received conventional faculty-delivered teaching. The Attitude to Patient Safety Questionnaire (APSQ) and the Positive and Negative Affect Schedule (PANAS) were used to measure the impact of the intervention. RESULTS: 142 trainees received the intervention; 141 the control teaching. There was no evidence of a difference in post-intervention APSQ scores between the groups. There was a statistically significant difference in the underlying distribution of both post PA (positive affect) and post NA (negative affect) scores between the groups on the PANAS (p<0.001) with indications of both higher PA and NA scores in the intervention group. CONCLUSIONS: Involving patients with experiences of safety incidents in training has an ideological appeal and seems an obvious choice in designing safety interventions. On the basis of our primary outcome measure, we were unable to demonstrate effectiveness of the intervention in changing general attitudes to safety compared to control. While the intervention may impact on emotional engagement and learning about communication, we remain uncertain whether this will translate into improved behaviours in the clinical context or indeed if there are any negative effects. TRIAL REGISTRATION NUMBER: Grant reference no. RP-PG-0108-10049.

Estimating and comparing the reliability of a suite of workplace-based assessments: an obstetrics and gynaecology setting.

This paper reports on a study that compares estimates of the reliability of a suite of workplace based assessment forms as employed to formatively assess the progress of trainee obstetricians and gynaecologists. The use of such forms of assessment is growing nationally and internationally in many specialties, but there is little research evidence on comparisons by procedure/competency and form-type across an entire specialty. Generalisability theory combined with a multilevel modelling approach is used to estimate variance components, G-coefficients and standard errors of measurement across 13 procedures and three form-types (mini-CEX, OSATS and CbD). The main finding is that there are wide variations in the estimates of reliability across the forms, and that therefore the guidance on assessment within the specialty does not always allow for enough forms per trainee to ensure that the levels of reliability of the process is adequate. There is, however, little evidence that reliability varies systematically by form-type. Methodologically, the problems of accurately estimating reliability in these contexts through the calculation of variance components and, crucially, their associated standard errors are considered. The importance of the use of appropriate methods in such calculations is emphasised, and the unavoidable limitations of research in naturalistic settings are discussed.

Interprofessional education about patient decision support in specialty care.

Specialty care involves services provided by health professionals who focus on treating diseases affecting one body system. In contrast to primary care - aimed at providing continuous, comprehensive care - specialty care often involves intermittent episodes of care focused around specific medical conditions. In addition, it typically includes multiple providers who have unique areas of expertise that are important in supporting patients' care. Interprofessional care involves multiple professionals from different disciplines collaborating to provide an integrated approach to patient care. For patients to experience continuity of care across interprofessional providers, providers need to communicate and maintain a shared sense of responsibility to their patients. In this article, we describe challenges inherent in providing interprofessional patient decision support in specialty care. We propose ways for providers to engage in interprofessional decision support and discuss promising approaches to teaching an interprofessional decision support to specialty care providers. Additional evaluation and empirical research are required before further recommendations can be made about education for interprofessional decision support in specialty care.

A randomised controlled trial of patient led training in medical education: protocol.

BACKGROUND: Estimates suggest that approximately 1 in 10 patients admitted to hospital experience an adverse event resulting in harm. Methods to improve patient safety have concentrated on developing safer systems of care and promoting changes in professional behaviour. There is a growing international interest in the development of interventions that promote the role of patients preventing error, but limited evidence of effectiveness of such interventions. The present study aims to undertake a randomised controlled trial of patient-led teaching of junior doctors about patient safety. METHODS/DESIGN: A randomised cluster controlled trial will be conducted. The intervention will be incorporated into the mandatory training of junior doctors training programme on patient safety. The study will be conducted in the Yorkshire and Humber region in the North of England. Patients who have experienced a safety incident in the NHS will be recruited. Patients will be identified through National Patient Safety Champions and local Trust contacts. Patients will receive training and be supported to talk to small groups of trainees about their experiences. The primary aim of the patient-led teaching module is to increase the awareness of patient safety issues amongst doctors, allow reflection on their own attitudes towards safety and promote an optimal culture among the doctors to improve safety in practice. A mixture of qualitative and quantitative methods will be used to evaluate the impact of the intervention, using the Attitudes to Patient Safety Questionnaire (APSQ) as our primary quantitative outcome, as well as focus groups and semi-structured interviews. DISCUSSION: The research team face a number of challenges in developing the intervention, including integrating a new method of teaching into an existing curriculum, facilitating effective patient involvement and identifying suitable outcome measures. TRIAL REGISTRATION: Current controlled Trials: ISRCTN94241579.

Patient involvement in teaching and assessing intimate examination skills: a systematic review.

OBJECTIVES: There are recognised difficulties in teaching and assessing intimate examination skills that relate to the sensitive nature of the various examinations and the anxiety faced by novice learners. This systematic review provides a summary of the evidence for the involvement of real patients (RPs) and simulated patients (SPs) in the training of health care professionals in intimate examination skills. METHODS: For the review, 'intimate examinations' included pelvic, breast, testicular and rectal examinations. Major databases were searched from the start of the database to December 2008. The synthesis of findings is integrated by narrative structured to address the main research questions, which sought to establish: the objectives of programmes involving RPs and SPs as teachers of intimate examination skills; reasons why SPs have been involved in this training; the evidence for the effectiveness of such training programmes; the evidence for measures of anxiety in students learning how to perform intimate examinations; how well issues of sexuality are addressed in the literature; any reported negative effects of involvement in teaching on the patients, and suggestions for practical strategies for involving patients in the teaching of intimate examination skills. RESULTS: A total of 65 articles were included in the review. Involving patients in teaching intimate examination skills offers advantages over traditional methods of teaching. Objective evidence for the effectiveness of this method is demonstrated through improved clinical performance, reduced anxiety and positive evaluation of programmes. Practical strategies for implementing such programmes are also reported. CONCLUSIONS: There is evidence of a short-term positive impact of patient involvement in the teaching and assessment of intimate examination skills; however, evidence of longer-term impact is still limited. The influences of sexuality and anxiety related to such examinations are explored to some extent, but the psychological impact on learners and patients is not well addressed.

What educators and students really think about using patients as teachers in medical education: a qualitative study.

OBJECTIVES: Patients play an integral part in medical education, either as passive, clinical exemplars or as more active facilitators in the development of skills. In theory, the patient-teacher may enhance the student learning experience by creating an environment similar to that of the medical workplace and encouraging the process of becoming a professional. Although many medical schools have integrated patient-teachers within their curricula, there is little evidence of how those involved in providing or receiving medical education view patient-teachers' contributions to their education. This study investigates the views and experiences of medical tutors and students of involving patients in undergraduate curricula. METHODS: We conducted a cross-sectional survey employing qualitative research methods. Semi-structured focus group interviews were used to elicit participants' views and experiences of patient involvement in medical education. The transcripts were content-analysed using a coding framework. RESULTS: A total of 46 participants consisting of medical educators and medical students took part in nine focus groups. Four themes emerged: the role of the patient in learning and teaching; the impact of the patient-teacher; the impact of being the storyteller, and mechanisms to explain the patient-teacher role in medical training. CONCLUSIONS: There is support for patient involvement in teaching. The logistics involved in supporting programmes of patient involvement and the need to link the teaching to overall course objectives should be addressed.

Strategies and interventions for the involvement of real patients in medical education: a systematic review.

OBJECTIVES: There is increasing emphasis on encouraging more active involvement of patients in medical education. This is based on the recognition of patients as 'experts' in their own medical conditions and may help to enhance student experiences of real-world medicine. This systematic review provides a summary of evidence for the role and effectiveness of real patient involvement in medical education. METHODS: MEDLINE, EMBASE, ERIC, PsychINFO, Sociological Abstracts and CINAHL were searched from the start of the databases to July 2007. Three key journals and reference lists of existing reviews were also searched. Articles published in English and reporting primary empirical research on the involvement of real patients in medical education were included. The synthesis of findings is integrated by narrative structured in such a way to address the research questions. RESULTS: A total of 47 articles were included in the review. The majority of studies reported patients in the role of teachers only; others described patient involvement in assessment or curriculum development or in combined roles. Patient involvement was recommended in order to bring the patient voice into education. There were several examples of how to recruit and train patients to perform an educational role. The effectiveness of patient involvement was measured by evaluation studies and reported improvements in skills. CONCLUSIONS: There was limited evidence of the long-term effectiveness of patient involvement and issues of ethics, psychological impact and influence on education policy were poorly explored. Future studies should address these issues and should explore the practicalities of sustaining such educational programmes within medical schools.

A systematic review of studies assessing and facilitating attitudes towards professionalism in medicine.

OBJECTIVES: An essential aspect of medical education is to facilitate the development and assessment of appropriate attitudes towards professionalism in medicine. This systematic review provides a summary of evidence for measures that have been used to assess these attitudes and their psychometric rigour. It also describes interventions that have been found to be effective in changing such attitudes. METHODS: MEDLINE, EMBASE, ERIC, PsychINFO, Sociological Abstracts and CINAHL were searched from the respective start date of each database to May 2006. Three key journals and reference lists of existing reviews were also searched. Articles that were published in English and reported primary empirical research measuring medical students' attitudes towards medical professionalism were included. The findings are integrated in narrative structured in such a way as to address the research questions. RESULTS: A total of 97 articles were included in the review. Most measures of attitudes assessed attitudes towards attributes of professionalism such as ethical issues, the patient-doctor relationship and cultural issues. Fourteen studies measured attitudes towards professionalism as a whole and 44 studies reported both the reliability and validity of measures. No interventions reported a change in attitudes over time. CONCLUSIONS: There is little evidence of reported measures that are effective in assessing attitudes towards professionalism in medicine as a whole. Likewise, there is scant evidence of interventions that influence attitude change over a period of time. Future studies should take into account the need to measure more global attitudes rather than attitudes towards specific issues in professionalism and the need to track attitudes throughout the curriculum.

The Yorkshire Modular Training Programme: a model for structured training and quality assurance in obstetrics and gynaecology.

Recent changes in postgraduate education have highlighted the need for structured training to ensure quality in training and optimize patient care. In Yorkshire, a "modular" approach to postgraduate education in obstetrics and gynaecology has been adopted through the Yorkshire Modular Training Programme (YMTP). The curriculum for trainees is divided into "modules" organized over five years. This provides a comprehensive educational package covering all aspects of obstetrics and gynaecology for trainees in the specialty. The YMTP provides a framework for region-wide integration and ownership of responsibility for teaching and training. It also provides quality assurance in education throughout the region and provides an "educational continuum" in which the different modules work together to meet the educational requirements of the trainees. It also aims to integrate "training" and "education" for the trainees. This paper describes the organization of the programme including its educational principles. It discusses its strengths and weaknesses. It provides a useful framework for postgraduate education that could be used by other regions.