Integrating climate change and health topics into the medical curriculum - a quantitative needs assessment of medical students at Heidelberg University in Germany.

Objectives: Climate change (CC) is of major importance for physicians as they are directly confronted with changing disease patterns, work in a greenhouse gas intensive sector and can be potential advocates for healthy people on a healthy planet. Methods: We assessed third to fifth year medical students' needs to support the integration of CC topics into medical curricula. A questionnaire with 54 single choice-based items was newly designed with the following sections: role perception, knowledge test, learning needs, preference of educational strategies and demographic characteristics. It was administered online to students at Heidelberg medical faculty. Data sets were used for descriptive statistics and regression modelling. Results: 72.4% of students (N=170, 56.2% female, 76% aged 20-24 years) (strongly) agreed that physicians carry a responsibility to address CC in their work setting while only 4.7% (strongly) agreed that their current medical training had given them enough skills to do so. Knowledge was high in the area of CC, health impacts of CC, vulnerabilities and adaptation (70.1% correct answers). Knowledge gaps were greatest for health co-benefits and climate-friendly healthcare (55.5% and 16.7% of correct answers, respectively). 79.4% wanted to see CC and health included in the medical curriculum with a preference for integration into existing mandatory courses. A multilinear regression model with factors age, gender, semester, aspired work setting, political leaning, role perception and knowledge explained 45.9% of variance for learning needs. Conclusion: The presented results encourage the integration of CC and health topics including health co-benefits and climate-friendly healthcare, as well as respective professional role development into existing mandatory courses of the medical curriculum.

Considering vocational training as selection criterion for medical students: evidence for predictive validity.

Prior work experience in a relevant medical profession is an important admission criterion currently used at many German medical schools in addition to cognitive criteria. In other countries, work experience is often considered in later admission stages (e.g., interviews with pre-selected subgroups of applicants). However, evidence for its predictive validity for study success in addition to cognitive admission criteria is currently lacking. We therefore assessed whether completed vocational training in a relevant medical profession can predict study performance in the first two years of study in addition to cognitive admission criteria. Admission and study performance data of all currently enrolled medical students at two German medical schools (Göttingen and Heidelberg) beginning with the 2013/14 cohort were retrospectively analyzed. Cognitive admission criteria in our sample were GPA grades and a cognitive test ("Test für Medizinische Studiengänge", TMS). We defined the study outcome parameter as the mean percentile rank over all performance data points over the first two years of study for each location, respectively. A multi-level model with varying intercepts by location, GPA, TMS, vocational training, and sex as predictors accounted for 14.5% of the variance in study outcome. A positive predictive association with study outcome was found for vocational training (ß = 0.33, p = .008) beyond GPA (ß = 0.38, p < .001) and TMS (ß = 0.26, p < .001). Our results support the use of prior vocational training as a selection criterion for medical studies potentially adding predictive validity to cognitive criteria.

Assessing distinguishable social skills in medical admission: does construct-driven development solve validity issues of situational judgment tests?

BACKGROUND: Social skills are important for future physicians and are therefore increasingly considered in selection processes. One economic assessment method from which different social skills can be inferred are Situational Judgment Tests (SJTs) in which applicants are asked to rate behavioral responses in context-relevant situations. However, traditional SJTs have so far failed to distinctively measure specified constructs. To address this shortcoming in the medical admission context, we applied a construct-driven approach of SJT development in which test development was deductively guided by agency and communion as target constructs. METHOD: The final version of the construct-driven SJT includes 15 items per construct with three behavioral responses. Medical school applicants (N = 1527) completed the construct-driven SJT, a traditional SJT, and an aptitude test under high-stakes condition as part of their application. A subsample (N = 575) participated in a subsequent voluntary online study with self-report measures of personality and past behavior. RESULTS: The proposed two-factor structure and internal consistency of the construct-driven SJT was confirmed. Communal SJT scores were positively associated with self-reported communal personality and communal behavior, yet effects were smaller than expected. Findings for agentic SJT scores were mixed with positive small associations to self-reported agentic personality scores and agentic behavior but unexpected negative relations to communal self-reported measures. CONCLUSIONS: Results suggest that construct-driven SJTs might overcome validity limitations of traditional SJTs, although their implementation is challenging. Despite first indicators of validity, future research needs to address practical points of application in high-stakes settings, inclusion of other constructs, and especially prediction of actual behavior before the application of construct-driven SJTs for selection purposes in medical admission can be recommended.

Influence of doctor-patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study.

BACKGROUND: Most cancers are diagnosed following contact with primary care. Patients diagnosed with cancer often see their doctor multiple times with potentially relevant symptoms before being referred to see a specialist, suggesting missed opportunities during doctor-patient conversations. OBJECTIVE: To understand doctor-patient communication around the significance of persistent or new presenting problems and its potential impact on timely cancer diagnosis. RESEARCH DESIGN: Qualitative thematic analysis based on video recordings of doctor-patient consultations in primary care and follow-up interviews with patients and doctors. 80 video observations, 20 patient interviews and 7 doctor interviews across 7 general practices in England. RESULTS: We found that timeliness of diagnosis may be adversely affected if doctors and patients do not come to an agreement about the presenting problem's significance. 'Disagreements' may involve misaligned cognitive factors such as differences in medical knowledge between doctor and patient or misaligned emotional factors such as patients' unexpressed fear of diagnostic procedures. Interviews suggested that conversations where the difference in views is either not recognised or stays unresolved may lead to unhelpful patient behaviour after the consultation (eg, non-attendance at specialist appointments), creating potential for diagnostic delay and patient harm. CONCLUSIONS: Our findings highlight how doctor-patient consultations can impact timely diagnosis when patients present with persistent or new problems. Misalignments were common and could go unnoticed, leaving gaps for potential to cause patient harm. These findings have implications for timely diagnosis of cancer and other serious disease because they highlight the complexity and fluidity of the consultation and the subsequent impact on the diagnostic process.

Exploring public attitudes towards the new Faster Diagnosis Standard for cancer: a focus group study with the UK public.

BACKGROUND: The Faster Diagnosis Standard (FDS) is to be introduced in England in 2020. This standard is a new policy in which patients should have cancer ruled out or diagnosed within 28 days of referral. AIM: To explore public attitudes towards the FDS within the context of their recent referral experiences. DESIGN AND SETTING: Four 90-minute focus groups (two in Guildford, two in Bradford). METHOD: Participants aged >50 years without a current cancer diagnosis (N = 29), who had completed certain diagnostic tests, for example, ultrasound, and received results within the last 6 months were recruited. Age, education, and sex were evenly distributed across groups through purposive sampling. RESULTS: The largest cause of concern was the waiting process for obtaining test results. Most had experienced swift referral, and it was difficult for participants to understand how the new standard could impact upon time progressing through the system. Responsibility for meeting the standard was also a concern: participants did not see their own behaviours as a form of involvement. The GP's role was conceptualised by patients as communicating about their referral, establishing patients' preferences for information, and continued involvement at each stage of the referral process. The standard legitimised chasing for test results, but 28 days was considered too long. CONCLUSION: Patients should be asked what they would like to know about their referral. GPs should be more transparent about the referral process and the potential for a lack of clarity around next steps.

Impact of attachment behavior on the treatment process of chronic pain patients.

BACKGROUND: Insecure attachment patterns are related to the onset and development of chronic pain. However, it is less documented on how short- and long-term effects of pain therapy might differ with the attachment style in interaction with specific pain conditions. We therefore examined how two different groups of chronic pain patients differ in their treatment trajectories and in regard to attachment. METHOD: N=85/76/67 (T1/T2/T3) patients with medically unexplained musculoskeletal pain (UMP group) were compared to n=89/76/56 patients with joint pain from osteoarthritis (OA group), using multilevel modeling. UMP patients received a multimodal pain program, and OA patients received surgery. Pain intensity before (T1) and after (T2) treatment and at a 6 months follow-up (T3) was assessed by using a visual analog scale of pain. RESULTS: Pain patients report a significant reduction in pain intensity upon the completion of the treatment compared to T1. Over the next 6 months, the pain intensity has further declined for patients with low attachment anxiety. In contrast, patients with highly anxious attachment report an increase in pain intensity. This main effect of anxious attachment on pain is significant when predicting changes both in acute treatment and during follow-up while controlling for group effect. In addition, there is also an interactive effect of group by avoidant attachment. In the UMP group, high scores in avoidant attachment were associated with the lower reduction in pain severity, while in the OA group, high scores in attachment avoidance were associated with a steeper reduction in pain severity. CONCLUSION: The results indicate that insecurely attached patients with pain symptoms only benefit from a multimodal pain therapy in limited ways in regard to posttreatment trajectories. Maintaining positive results over a period of 6 months is a challenge, compared with securely attached patients. SIGNIFICANCE: The results of this study suggest the importance of direct and indirect mechanisms of attachment and its relevance for the management of pain experiences. Therefore, to include the individual attachment patterns in the treatment may be a promising way to enhance the treatment prospects.

How Well Do COP22 Attendees Understand Graphs on Climate Change Health Impacts from the Fifth IPCC Assessment Report?

Graphs are prevalent in the reports of the Intergovernmental Panel on Climate Change (IPCC), often depicting key points and major results. However, the popularity of graphs in the IPCC reports contrasts with a neglect of empirical tests of their understandability. Here we put the understandability of three graphs taken from the Health chapter of the Fifth Assessment Report to an empirical test. We present a pilot study where we evaluate objective understanding (mean accuracy in multiple-choice questions) and subjective understanding (self-assessed confidence in accuracy) in a sample of attendees of the United Nations Climate Change Conference in Marrakesh, 2016 (COP22), and a student sample. Results show a mean objective understanding of M = 0.33 for the COP sample, and M = 0.38 for the student sample. Subjective and objective understanding were unrelated for the COP22 sample, but associated for the student sample. These results suggest that (i) understandability of the IPCC health chapter graphs is insufficient, and that (ii) particularly COP22 attendees lacked insight into which graphs they did, and which they did not understand. Implications for the construction of graphs to communicate health impacts of climate change to decision-makers are discussed.

Household preferences for reducing greenhouse gas emissions in four European high-income countries: Does health information matter? A mixed-methods study protocol.

BACKGROUND: It is now universally acknowledged that climate change constitutes a major threat to human health. At the same time, some of the measures to reduce greenhouse gas emissions, so-called climate change mitigation measures, have significant health co-benefits (e.g., walking or cycling more; eating less meat). The goal of limiting global warming to 1,5° Celsius set by the Conference of the Parties to the United Nations Framework Convention on Climate Change in Paris in 2015 can only be reached if all stakeholders, including households, take actions to mitigate climate change. Results on whether framing mitigation measures in terms of their health co-benefits increases the likelihood of their implementation are inconsistent. The present study protocol describes the transdisciplinary project HOPE (HOuseholds' Preferences for reducing greenhouse gas emissions in four European high-income countries) that investigates the role of health co-benefits in households' decision making on climate change mitigation measures in urban households in France, Germany, Norway and Sweden. METHODS: HOPE employs a mixed-methods approach combining status-quo carbon footprint assessments, simulations of the reduction of households' carbon footprints, and qualitative in-depth interviews with a subgroup of households. Furthermore, a policy analysis of current household oriented climate policies is conducted. In the simulation of the reduction of households' carbon footprints, half of the households are provided with information on health co-benefits of climate change mitigation measures, the other half is not. Households' willingness to implement the measures is assessed and compared in between-group analyses of variance. DISCUSSION: This is one of the first comprehensive mixed-methods approaches to investigate which mitigation measures households are most willing to implement in order to reach the 1,5° target set by the Paris Agreement, and whether health co-benefits can serve as a motivator for households to implement these measures. The comparison of the empirical data with current climate policies will provide knowledge for tailoring effective climate change mitigation and health policies.

Study protocol - efficacy of an attachment-based working alliance in the multimodal pain treatment.

BACKGROUND: The concept of attachment is relevant for the onset and development of chronic pain. Insecure attachment styles negatively affect therapeutic outcome. Insecurely attached patients seem to be less able to sustain positive effects of a multimodal treatment program. However, it has never been tested before if an attachment-oriented approach can improve treatment results of insecurely attached patients in a multimodal outpatient setting. To test this assumption, we compare the short- and long-term outcomes for pain patients who will receive multidisciplinary, attachment-oriented treatment with the outcomes for patients in a control group, who will receive the multidisciplinary state-of-the-art treatment. METHODS: Two patient groups (baseline, attachment intervention) are assessed before treatment, after treatment, and at a 6 month follow-up. The study is conducted in a block design: After data collection of the first block (controls) and before as well as during data collection for the second block (treatment group), the health care personnel of the outpatient pain clinic receives training on attachment theory and its use in the therapeutic context. Pain intensity as measured with visual analogue scales and physical functioning will serve as the primary outcome measures. DISCUSSION: The design of our study allows for a continuous exchange of experienced team members, which may help bring about concrete attachment related guidelines for the enhancement of therapeutic outcome. This would be the first attempt at an attachment-oriented improvement of multimodal pain programs. CONCLUSION: An attachment-based approach may be a promising way to enhance long-term treatment outcomes for insecurely attached pain patients. TRIAL REGISTRATION: DRKS00008715 (registered on the 3(rd) of June 2015).

Attachment, symptom severity, and depression in medically unexplained musculoskeletal pain and osteoarthritis: a cross-sectional study.

BACKGROUND: Attachment insecurity relates to the onset and course of chronic pain via dysfunctional reactions to pain. However, few studies have investigated the proportion of insecure attachment styles in different pain conditions, and results regarding associations between attachment, pain severity, and disability in chronic pain are inconsistent. This study aims to clarify the relationships between insecure attachment and occurrence or severity of chronic pain with and without clearly defined organic cause. To detect potential differences in the importance of global and romantic attachment representations, we included both concepts in our study. METHODS: 85 patients with medically unexplained musculoskeletal pain (UMP) and 89 patients with joint pain from osteoarthritis (OA) completed self-report measures of global and romantic attachment, pain intensity, physical functioning, and depression. RESULTS: Patients reporting global insecure attachment representations were more likely to suffer from medically unexplained musculoskeletal pain (OR 3.4), compared to securely attached patients. Romantic attachment did not differ between pain conditions. Pain intensity was associated with romantic attachment anxiety, and this relationship was more pronounced in the OA group compared to the UMP group. Both global and romantic attachment anxiety predicted depression, accounting for 15% and 17% of the variance, respectively. Disability was independent from attachment patterns. CONCLUSIONS: Our results indicate that global insecure attachment is associated with the experience of medically unexplained musculoskeletal pain, but not with osteoarthritis. In contrast, insecure attachment patterns seem to be linked to pain intensity and pain-related depression in unexplained musculoskeletal pain and in osteoarthritis. These findings suggest that relationship-informed focused treatment strategies may alleviate pain severity and psychological distress in chronic pain independent of underlying pathology.