Can we rely on simulated patients' satisfaction with their consultation for assessing medical students' communication skills? A cross-sectional study.

BACKGROUND: In medical education, teaching methods offering intensive practice without high utilization of faculty resources are needed. We investigated whether simulated patients' (SPs') satisfaction with a consultation could predict professional observers' assessment of young doctors' communication skills. METHODS: This was a comparative cross-sectional study of 62 videotaped consultations in a general practice setting with young doctors who were finishing their internship. The SPs played a female patient who had observed blood when using the toilet, which had prompted a fear of cancer. Immediately afterwards, the SP rated her level of satisfaction with the consultation, and the scores were dichotomized into satisfaction or dissatisfaction. Professional observers viewed the videotapes and assessed the doctors' communication skills using the Arizona Communication Interview Rating Scale (ACIR). Their ratings of communication skills were dichotomized into acceptable versus unacceptable levels of competence. RESULTS: The SPs' satisfaction showed a predictive power of 0.74 for the observers' assessment of the young doctors and whether they reached an acceptable level of communication skills. The SPs' dissatisfaction had a predictive power of 0.71 for the observers' assessment of an unacceptable communication level. The two assessment methods differed in 26% of the consultations. When SPs felt relief about their cancer concern after the consultation, they assessed the doctors' skills as satisfactory independent of the observers' assessment. CONCLUSIONS: Accordance between the dichotomized SPs' satisfaction score and communication skills assessed by observers (using the ACIR) was in the acceptable range. These findings suggest that SPs' satisfaction scores may provide a reliable source for assessing communication skills in educational programs for medical trainees (students and young doctors). Awareness of the patient's concerns seems to be of vital importance to patient satisfaction.

Tx-discs--no effect against subjective health complaints: a randomised controlled study.

BACKGROUND: Dowsers claim unhealthy effects of 'earth rays', and the producer of TX-discs claims that these discs may shield a person from the influence of 'earth rays', thereby relieving most illness in the person shielded. OBJECTIVES: To compare the effects of the TX-disc versus a placebo disc in patients with longstanding muscular-skeletal complaints. SETTING: Self-recruited community living persons in the Bergen area, Western Norway. PATIENTS: 67 women and 13 men with longstanding muscular-skeletal complaints, recruited by advertisements in local newspapers. DESIGN: A randomised and double-blinded controlled trial with a 6 months follow-up period. MAIN OUTCOME MEASUREMENT: The Subjective Health Complaints (SHC) questionnaire. RESULTS: We found a substantial reduction on the mean SHC sub-scale scores of muscular-skeletal, pseudo-neurological, gastro-intestinal, and allergic complaints, mainly occurring from baseline to 6 weeks (28-45%, P < 0.05-0.001). There were however no statistically significant differences for these variables between the TX group and the placebo group at any time point. IMPLICATIONS: TX-discs used in accordance with the instructions had no clinically or statistically significant effect on muscular-skeletal pain, pseudo-neurological complaints, gastro-intestinal, or allergic complaints during this study.

Duration of antibacterial treatment for uncomplicated urinary tract infection in women.

BACKGROUND: Uncomplicated urinary tract infection (UTI) is a common disease, occurring frequently in young sexually active women. In the past, seven day antibiotic therapy was recommended while the current practice is to treat uncomplicated UTI for three days. OBJECTIVES: TO compare the efficacy and safety of three-day antibiotic therapy to multi-day therapy (five days or longer) on relief of symptoms and bacteriuria at short-term and long-term follow-up. SEARCH STRATEGY: The Cochrane Library (Issue 1, 2004), the Cochrane Renal Group's Register of trials (July 2003), EMBASE (January 1980 to August 2003), and MEDLINE (January 1966 to August 2003) were searched. We scanned references of all included studies and contacted the first or corresponding author of included trials and the pharmaceutical companies. SELECTION CRITERIA: Randomised controlled trials comparing three-days oral antibiotic therapy with multi-day therapy (five days and longer) for uncomplicated cystitis in 18 to 65 years old non-pregnant women without signs of upper UTI. DATA COLLECTION AND ANALYSIS: Data concerning bacteriological and symptomatic failure rates, occurrence of pyelonephritis and adverse effects were extracted independently by two reviewers. Relative risk (RR) and their 95% confidence intervals (CI) were estimated. Outcomes were also extracted by intention-to-treat analysis whenever possible. MAIN RESULTS: Thirty-two trials (9605 patients) were included. For symptomatic failure rates, no difference between three-day and 5-10 day antibiotic regimen was seen short-term (RR 1.06, 95% CI 0.88 to 1.28) and long-term follow-up (RR 1.09, 95% CI 0.94 to 1.27). Comparison of the bacteriological failure rates showed that three-day therapy was less effective than 5-10 day therapy for the short-term follow-up, however this difference was observed only in the subgroup of trials that used the same antibiotic in the two treatment arms (RR 1.37, 95% CI 1.07 to 1.74, P = 0.01). This difference was more significant at long-term follow-up (RR 1.43, 95% CI 1.19 to 1.73, P = 0.0002). Adverse effects were significantly more common in the 5-10 day treatment group (RR 0.83, 95% CI 0.74 to 0.93, P = 0.0010). Results were consistent for subgroup and sensitivity analyses. AUTHORS' CONCLUSIONS: Three days of antibiotic therapy is similar to 5-10 days in achieving symptomatic cure during uncomplicated UTI treatment, while the longer treatment is more effective in obtaining bacteriological cure. In spite of the higher rate of adverse effects, treatment for 5-10 days could be considered for treatment of women in whom eradication of bacteriuria is important.

[What happens when medical students set their own exam papers?]. / Hva om medisinstudenter lager oppgaver til egen eksamen?

BACKGROUND: In the section for general practice at the University of Bergen, Norway, we want to emphasise learning more than control in our work with students. As a step in this direction we invited students to come up with proposals for exam papers, papers that usually include six to nine multiple steps for clinical reasoning. We guaranteed that one out of three proposals would be included as a paper in the written examination, possibly slightly modified. This article is an evaluation of the consequences of letting medical students set some of their own exam papers. MATERIAL AND METHODS: The process was evaluated using 1) grades given, 2) students' assessment of whether this mode of setting papers influenced their exam preparations, and 3) students' free-text comments on the process. RESULTS: 57 out of 64 students (89%) took part in the evaluation. All knew that their fellow students had set one of the exam papers, but only 34 (60%) reported that this knowledge had changed the way they prepared for the exam. The mean grade was 9.9 (range 5-12, on a scale from 1 to 12, 6 being the lowest pass grade) for the paper set by students, and 9.5 (range 5-11) for all papers combined. Mean difference in score was 0.32 (95% confidence interval 0.08-0.64). Students' free-text comments showed that they specifically prepared for the three known paper topics. They drew comfort from knowing at least one of the papers set, and the student-set papers were found relevant for general practice. INTERPRETATION: Letting medical students set one of the exam papers makes them feel more confident. Student-set papers were seen as relevant for clinical practice. The control function of the exam seemed to have been preserved.

[Acupuncture contra antiphlogistics in acute lumbago]. / Akupunktur kontra antiflogistika ved akutt lumbago.

BACKGROUND: Acute low back pain is one of the most frequent complaints presented in general practice. This study compares acupuncture and antiphlogistica in the treatment of acute low back pain in general practice. MATERIAL AND METHODS: Among 60 consecutively included patients with acute low back pain, 30 patients were randomized to standardised acupuncture treatment for two weeks, and 30 patients to entero-soluble naproxen 500 mg twice daily for ten days. Effects were observed over six months, and observed for a further 12 months with regard to relapse of low back pain and number of days on sickness leave. RESULTS: There were no differences in pain or stiffness (VAS, physical tests) at inclusion, nor in the reduction of pain or stiffness over a six month evaluation. However, patients receiving acupuncture used significantly less analgetic drugs during the first week after start of treatment than those receiving naproxen (2/28 versus 11/29, p < 0.01). Patients receiving acupuncture also reported fewer new episodes of low back pain (11/28 versus 30/29, p < 0.05) during the 6 + 12 month follow-up. Side effects were frequent in the naproxen group, especially gastro-enteric side effects (0/28 versus 15/29, p < 0.01). INTERPRETATION: Standardised acupuncture treatment seems to be safe and effective in the treatment of acute low back pain in general practice.

Patients' views on importance and usefulness of plain radiography for low back pain.

STUDY DESIGN: Quantitative and qualitative cross-sectional interview study. OBJECTIVES: To investigate how patients who are referred for plain radiography because of low back pain perceive the importance and usefulness of the examination. SUMMARY OF BACKGROUND DATA: Up to 50% of plain radiography examinations for low back pain may be unnecessary based on clinical criteria. However, many patients have great confidence in these examinations. A further exploration of the patients' views may indicate how their needs can be met without unnecessary use of radiography. METHODS: Ninety-nine patients (65 women, 34 men) 14-91 years of age who were referred from Norwegian general practitioners for plain radiography of the lumbosacral spine were asked to rate the examination as slightly/fairly or very important (93 responded). Chi-squared tests were used to evaluate differences in rating according to age, gender, clinical history, and clinical appropriateness of the examination, as determined by comparing information in the referral form with Norwegian (NR) and British (BR) recommendations for use of radiography. Each of the 99 patients also underwent a semistructured interview that was based on questions about importance, usefulness, and reasons for the radiography referral. Answers were categorized and described using a qualitative method (template analysis). RESULTS: Seventy-two percent (68 of 93) of patients rated radiography as very important. The proportion was higher for men than women (85% vs. 65%, P = 0.04), higher for those with worsening than those with improving/unchanged symptoms (86% vs. 65%, P = 0.03), and higher for inappropriately than appropriately referred patients (NR: 76% vs. 61%, P = 0.17; BR: 81% vs. 56%, P = 0.01). The qualitative analysis showed that the patients related their views on the importance and usefulness of receiving radiography to seven different issues: symptoms and clinical history, information and advice (especially from health care providers), need for emotional support from the physician, need for certainty and reassurance, need for symptom explanation and diagnosis, reliability of radiography compared with clinical evaluation, and expected practical consequences of the radiologic examination. CONCLUSIONS: The finding that inappropriately referred patients tended to rate their radiography referral as more important than appropriately referred patients indicates that the patient's view may be a substantial barrier to appropriate use of radiography. The study identified seven issues underlying the patients' views on importance and usefulness of receiving radiography. Strategies to prevent unnecessary use of plain radiography for low back pain that address these issues are suggested.

'An empty and happy feeling in the bladder.. .': health changes experienced by women after acupuncture for recurrent cystitis.

OBJECTIVE: The aim of this study was to explore changes in health as reported by cystitis-prone females after having received prophylactic acupuncture treatment for recurrent cystitis. DESIGN: A qualitative study based on written free text answers on the women's own experience of changes related to health after completion of TCM acupuncture treatment. Data were analyzed using Giorgi's phenomenological approach. SETTING: Subjects living in the Bergen area, Norway, were recruited by advertisement in local newspapers and included provided they had had three or more episodes of lower UTI during the previous 12 months. RESULTS: The main topics reported were related to improved pressure during micturition and more complete bladder emptying; more normal bowel movement and less abdominal discomfort; more energy, reduced stress level, and better sleep. Only a few reported feeling worse. CONCLUSION: The symptoms described as relieved by the women in our study seem to fit TCM theory for diagnoses of their vulnerability to cystitis. Qualitative methods have a role in TCM research that may enrich our knowledge in other ways than traditional quantitative methods may.

Traditional Chinese medicine syndromes in women with frequently recurring cystitis: frequencies of syndromes and symptoms.

BACKGROUND: Frequently recurrent acute cystitis in adult women is common in Western medicine. In prophylactic treatment, women are treated between attacks of acute cystitis to prevent recurrences. A recent study has shown that acupuncture seems effective for prophylaxis. OBJECTIVES: To describe the frequency of traditional Chinese medicine (TCM) syndromes found in females vulnerable to recurrent cystitis, and which symptoms most often form the basis for TCM diagnoses made in this condition. METHODS: A descriptive study based on TCM diagnostic methods as used by experienced acupuncturists, and a questionnaire of symptoms used in TCM diagnostics. RESULTS: Of 61 women with frequently recurring cystitis, 90% were diagnosed as having either a Spleen/Kidney yang xu/qi xu (54%), or a Liver qi stagnation (36%). Only 10% fell in other diagnostic groups. Of all symptoms noted, only three differed in frequency between the two main diagnostic groups: feeling cold (29/33 vs. 13/22, P<0.05), feeling tired (25/33 vs. 4/22, P<0.001), and having a preference for sweets (10/33 vs. 2/22, P<0.05). CONCLUSION: Our findings have implications for TCM-based diagnostic work in females with recurrent cystitis, and also indicate that recurrent cystitis may be used as a case for further TCM research.

The diagnosis of urinary tract infections among pregnant women in rural Tanzania; prevalences and correspondence between different diagnostic methods.

BACKGROUND: To assess the prevalence of dysuria, dipsticks positive on nitrite and leukocyte esterase and positive Uricult dip slides among pregnant women in rural Tanzania. METHODS: 3,715 pregnant women were examined for dysuria and had their urine tested with nitrite and leukocyte esterase dipsticks and Uricult dipslides, at their first antenatal visit in 1995-96. RESULTS: The prevalences of positive symptoms and tests were as follows: dysuria 32%, nitrite 40.3%, leukocyte esterase 65.6%, and Uricult dip slides 16.4%. A general log-linear model where all four variables were analyzed simultaneously showed poor correspondence between the diagnostic methods. Odds ratio with 95% confidence intervals were as follows: dysuria vs. nitrite [1.6 (1.4 1.8)]. dysuria vs. leukocyte esterase [1.2 (1.0-1.4)], nitrite vs. leukocyte esterase [4.2 (3.6-4.9)], and leukocyte esterase vs. Uricult [1.4 (1.1-1.7)]. Dysuria and nitrite were not associated with Uricult dipslide. CONCLUSION: A high prevalence of positive tests, but a poor correspondence between the methods was found, emphasizing the need for more attention to the problem of urinary tract infections among pregnant women in developing countries, and the need for better screening tests for urinary tract infections in these countries.

[Patient centered medicine--a review with emphasis on the background and documentation]. / Pasientsentrert medisin--en oversikt med vekt på bakgrunn og dokumentasjon.

BACKGROUND: In this paper we present the patient centred clinical method from a historical viewpoint with emphasis on its philosophical and ethical foundations. The paper reviews the documentation and discusses the relevance of the method. MATERIAL AND METHODS: Literature review. RESULTS: The patient centred method was introduced in western clinical medicine as a result of a general shift in science and the introduction of systems theory and relational understanding. The ethical basis for the method is humanistic values with emphasis on respect and mutuality in human relations. Observational studies suggest that the method improves outcome for patients. Experimental evidence is sparse and conflicting. The concept of patient centredness is vague with regard to the management phase of consultations. The relationship between doctor-patient communication, the concept of patient centredness, patient satisfaction, empowerment and outcome needs further clarification and research. INTERPRETATION: Clinical medicine has to encompass the personal and relational level of human life in order to help and guide patients. The patient centred method demonstrates how this can be achieved during the diagnostic phase of the consultation. We need, however, firmer knowledge and ethical consideration of how management negotiations may empower patients and improve their outcome.

[Clinical communication--a structured teaching model]. / Klinisk kommunikasjon--et strukturert undervisningsopplegg.

A 16-hour course of patient-centered consultation skills, aimed at senior medical students and clinicians, is presented. The goal is to train participants in communication skills which at the same time stimulate the development of a good therapeutic relationship and allow effective gathering of relevant clinical information. The article describes a consultation model in five consecutive steps--opening, exploration, hypothesis testing, negotiations over management, and closure. Each phase confronts the doctor with typical tasks to be solved through adequate dialogue with the patient. The course is based on active student participation through role play, dialogue, reciprocal observation and group analysis of videotaped consultations between the participants and real patients. The article gives a detailed presentation of structures and techniques applied in the course, and describes how this training in consultation skills was developed.

[Consultation course in medical education--students' evaluation]. / Konsultasjonsundervisning i medisinstudiet--studentenes evaluering.

BACKGROUND: Final-year medical students at the University of Bergen take a 16-hour consultation course. The students are trained in an educational setting focusing on structured elements of the patient-centred consultation method, self evaluation and peer evaluation. The course has a strong emphasis on learning by doing. The objective of this study was to evaluate the learning process and the subjective outcome of the course. We used a focus group technique and a self-administered free text based questionnaire. MATERIAL AND METHODS: Transcriptions from the focus groups and free text from the questionnaires were analysed using qualitative methods. RESULTS: The qualitative analysis revealed three main categories of statements about the learning process: about the process of selfchange in the consultations; about the pain of self evaluation; and about insufficiency faced with clinical uncertainty. INTERPRETATION: We conclude that the course seems to initiate changes in consultation strategies. The students' evaluation also underline the need to take care of the students during a process of change in which they are vulnerable.

Behaviour modification group-treatment of children with recurrent lower urinary tract infections.

It has long been recognized that infrequent micturition and incomplete emptying of the bladder in children represent important factors in the causation of incontinence during the day, and of urinary tract infections (UTI). Behaviour modification is well documented, both as an individual- and a group intervention. The purpose of our study was to develop a programme for group intervention with children, with the aim of improving the children's micturition habits and thereby changing the frequency of wettings, the amount of residual urine, and the UTI frequency. The children responded quickly to the intervention. The amount of residual urine was unaffected, but there are methodological problems in measuring this. There were, however, significant reductions in incontinence and UTI, although there was a tendency to relapse of incontinence over time, probably because of lack of continued follow-up. It is tentatively concluded that the described behavioural intervention seemed effective in improving children's micturition habits, thereby changing the frequency of wettings, and the frequency of urinary tract infections. The treatment seems to be suitable for nursing intervention, either within a hospital setting, or on an outpatient, primary care basis.

[Children exposed to "earth rays" are not more frequently ill than other children]. / Barn utsatt for "jordstråler" er ikke hyppigere syke enn andre barn.

From time to time newspapers bring reports on "earth rays" and their alleged damaging effects on health. There is, however, no objective evidence which suggests the existence of earth rays. In spite of this, dowsers claim that earth rays are a main cause of disease, also in children. In this study we wanted to evaluate, using a double-blind design, the alleged effects of earth rays on young children. A total of 44 children in four nursery schools in the Bergen area were recruited. Two dowsers and one interviewer visited the homes of all the children. The dowsers evaluated the presence of earth rays over the child's bed while the parents were interviewed in an independent procedure about the child's medical history over the past 12 months. Whether or not earth rays where found over the child's bed, there where no differences in the reported health of the child with regard to upper and lower respiratory tract infections, stomach aches, allergies or sleeping habits. Parents' report on restlessness and hyperactivity were also the same. The study failed to find any health effects, adverse or not, of earth rays.