Teachers' mindsets in medical education: A pilot survey of clinical supervisors.

Purpose: Current medical education models maintain that competencies such as professionalism and communication can be taught; however, some argue that certain attributes that make up these competencies, such as empathy, are fixed. Teachers' implicit theories, or mindsets (beliefs about the fixed versus learnable nature of human attributes) have been shown to impact their teaching and assessment practices; but little work has explored mindsets in medical education. We examined clinical supervisors' mindsets of two cognitive attributes (intelligence and clinical reasoning) and two affective attributes (moral character and empathy).Methods: Clinical supervisors (n = 40) from three specialities completed a survey designed to measure mindsets using two existing instruments for intelligence and moral character and 18 new items for clinical reasoning and empathy. Participants completed the survey twice for test-retest reliability (n = 25).Results: New items had satisfactory psychometric properties. Clinical supervisors' mindsets were mixed. Only 8% of participants saw clinical reasoning as fixed while more saw empathy (45%), intelligence (53%), and moral character (53%) as fixed - running counter to current educational models that characterize these attributes as learnable.Conclusion: This study provides evidence supporting the use of these new tools to measure mindsets that may help to better understand the impact of mindsets on medical education.

Clinical pharmacology education: looking into the future.

The numbers of specialists who are practicing Clinical Pharmacology is declining. This raises questions about the nature of the discipline and the roles of those who practice Clinical Pharmacology. Numbers and qualifications of successful trainees in North American accredited Clinical Pharmacology training programs are presented. Questions are posed that require discussion by a forum of academic, regulatory, and industry-based scientists to enable Clinical Pharmacology training programs to meet the clinical care, drug development, and drug policy needs in Western countries in the next decade.

The role of stress in functional disability among women with systemic lupus erythematosus: a prospective study.

OBJECTIVE: In the last decade, the biopsychosocial approach has been applied to systemic lupus erythematosus (SLE) to understand the multiple factors involved in the disease course. This study examined the link between stress and changes in functional disability as assessed by the Stanford Health Assessment Questionnaire (HAQ) in women with SLE. METHODS: Forty-two women with SLE were assessed at baseline and 8 months later. Major stress (Life Events), minor stressors (Hassles), depression (Beck Depression Inventory), disease activity (Systemic Lupus Activity Measure), and functional disability were collected at both time points, while demographic and disease damage variables (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index) were collected once at baseline. RESULTS: Mean HAQ scores at baseline (0.52) and followup (0.46) indicated mild disability and remained fairly stable, although individual variation was observed (mean change -0.07; range -1.25-0.5). Demographic (age, education) and disease (duration, activity, damage) variables were not related to 8-month changes on the HAQ. Of the baseline stress measures, greater negative life events in the preceding 6 months was correlated with reduced functional ability (r = 0.42) 8 months later. Individual changes in depressed mood over the 8-month period were correlated (r = 0.33) with changes in functional ability. Hierarchical multiple regression revealed that after controlling for baseline HAQ scores and changes in depressed mood, baseline negative life events remained a significant predictor of changes in functional ability. CONCLUSION: We found that the major short-term determinants of functional disability were not demographic- or disease-related factors, but rather stress caused by negative life events. Comprehensive treatment of SLE requires management of life stress.

Recommendations for incorporating palliative care education into the acute care hospital setting.

This article presents recommendations for improving the education of physicians about end-of-life care in the acute care hospital setting. The authors, who have a variety of backgrounds and represent several types of institutions, formulated and reached consensus on these recommendations as members of the Acute Care Hospital Working Group, one of eight working groups convened at the National Consensus Conference on Medical Education for Care Near the End of Life in May 1997. A recently published literature review on the status of palliative care education, a summary of recent research on education about end-of-life care, and expert opinion were helpful in developing the recommendations. The authors emphasize that the acute care setting offers many opportunities for education about care at the end of life. Faculty should support learners' appreciation of the importance of end-of-life care, and convey the meaning and privilege of attending to patients and families at this difficult time. Faculty should teach students and residents to provide care that embodies attention to the control of distressing physical, physiologic, and spiritual symptoms, appropriate awareness of patients' differing cultural backgrounds and their impact upon the experience of dying, excellent communication skills, the application of bioethical principles, timely referral and smooth transition to other care settings that meet patient and family goals, and the role of the interdisciplinary team in meeting the diverse needs of dying patients and their families.

Teaching professionalism in undergraduate medical education.

CONTEXT: There is a growing consensus among medical educators that to promote the professional development of medical students, schools of medicine should provide explicit learning experiences in professionalism. OBJECTIVE: To determine whether and how schools of medicine were teaching professionalism in the 1998-1999 academic year. DESIGN, SETTING, AND PARTICIPANTS: A 2-stage survey was sent to 125 US medical schools in the fall of 1998. A total of 116 (92.3%) responded to the first stage of the survey. The second survey led to a qualitative analysis of curriculum materials submitted by 41 schools. MAIN OUTCOME MEASURES: Presence or absence of learning experiences (didactic or experiential) in undergraduate medical curriculum explicitly intended to promote professionalism in medical students, with curriculum evaluation based on 4 attributes commonly recognized as essential to professionalism: subordination of one's self-interests, adherence to high ethical and moral standards, response to societal needs, and demonstration of evincible core humanistic values. RESULTS: Of the 116 responding medical schools, 104 (89.7%) reported that they offer some formal instruction related to professionalism. Fewer schools have explicit methods for assessing professional behaviors (n = 64 [55.2%]) or conduct targeted faculty development programs (n = 39 [33.6%]). Schools use diverse strategies to promote professionalism, ranging from an isolated white-coat ceremony or other orientation experience (n = 71 [78.9%]) to an integrated sequence of courses over multiple years of the curriculum (n = 25 [27.8%]). Of the 41 schools that provided curriculum materials, 27 (65.9%) addressed subordinating self-interests; 31 (75.6%), adhering to high ethical and moral standards; 17 (41.5%), responding to societal needs; and 22 (53.7%), evincing core humanistic values. CONCLUSIONS: Our results suggest that the teaching of professionalism in undergraduate medical education varies widely. Although most medical schools in the United States now address this important topic in some manner, the strategies used to teach professionalism may not always be adequate.

The relationship between health status, social support and satisfaction with medical care among patients with systemic lupus erythematosus.

OBJECTIVE: To examine the effect of physical and mental health status and social support on patient satisfaction with health care in patients with systemic lupus erythematosus (SLE). STUDY DESIGN: Using a cross-sectional design, 220 SLE patients were recruited from rheumatology departments in two hospitals in the Montreal (Canada) area. Data comprised physician-rated indices of health status and patient-completed questionnaires. MEASURES: Independent variables included demographics, disease duration, physician-rated indices of disease activity (SLAM-R) and disease damage (SLICC/ACR), patient self-reported health status (SF-36), and perceived social support (ISEL). Patient satisfaction with medical care (PSQ-IV) was the dependent variable. ANALYSES: Univariate analyses were performed to describe the sample and examine univariate associations between the independent variables and patient satisfaction with medical care. A hierarchical multiple linear regression analysis was computed to determine the relative importance of physician-rated indices of health status, self-reported physical and mental health status and social support on patient satisfaction after controlling for demographic variables. RESULTS: A multivariate hierarchical regression computed to predict patient satisfaction included the following variables in the equation: age, education, income (step 1), disease duration, SLAM-R, SLICC/ACR (step 2), mental and physical health status (step 3), and perceived social support (step 4). Less education (P< 0.01), better self-reported mental (P< 0.05) and physical health status (P< 0.005) and higher perceived social support (P< 0.005) were significant predictors of patient satisfaction (R2 = 0.15, P< 0.0001). CONCLUSION: The findings suggest that self-reported physical and mental health status and social support are more important than clinical status variables in understanding patient satisfaction with medical care.

An international perspective on the well being and health care costs for patients with systemic lupus erythematosus. Tri-Nation Study Group.

OBJECTIVE: To compare health care expenditure and health status for patients with systemic lupus erythematosus (SLE) between nations with distinct mechanisms for funding and delivering health care services. METHODS: Seven hundred eight patients with SLE from 2 centers in each of 3 countries (Canada 229, United States 268, United Kingdom 211) underwent physician assessment of disease activity and damage and reported on physical and psychosocial well being, satisfaction, social support, and health resource utilization. To compare overall utilization, constant prices (1997 Canadian dollars) were applied across countries for each service, enabling diverse resources to be collapsed into a single expression. RESULTS: After adjusting for important patient covariates, Canadian, compared to American and British patients, reported significantly superior health status in 3 of 8 Medical Outcome Survey Short Form-36 (SF-36) subscales, the SF-36 physical component summary score, and the visual analog scale of general health status. There was no consistent trend in patient satisfaction. Overall annual resource utilization did not vary significantly, with mean annual per patient expenditures (adjusted for demographics, disease duration, activity, damage, social support, health status, patient satisfaction, and age and sex adjusted country-specific SF-36 general population norms) totalling $4853, $5285, and $4760 for Canada, US, and the UK, respectively. However, within each resource category, differences were observed. Canadians saw more specialists than the British, the British more generalists. Canadians and Americans were more frequent users of the emergency room; Americans of laboratory/imaging procedures. Canadians had higher hospital costs than Americans. CONCLUSION: After adjustment, Canadian patients reported better well being than their counterparts. Despite considerable differences in the mechanisms of health care funding and service mixture, overall resource utilization did not vary significantly between the countries, although there was a trend towards more intense use of inpatient services in Canada and outpatient services in the United States.

Can health utility measures be used in lupus research? A comparative validation and reliability study of 4 utility indices.

OBJECTIVE: To assess validity and reliability of 4 utility indices in patients with systemic lupus erythematosus (SLE). METHODS: Twenty-five patients with stable SLE underwent assessment of disease activity [Systemic Lupus Disease Activity Measure (SLAM-R) and SLE Disease Activity Index (SLEDAI)] and damage [Systemic Lupus Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR DI)] and completed a health survey [Medical Outcome Survey Short Form-36 (SF-36)] and 4 utility measures: the visual analog scale (VAS), the time trade-off (TTO), the standard gamble (SG), and the McMaster Health Utilities Index Mark 2 (HUI2). To assess validity, Pearson's correlations were calculated between the SF-36 subscales and the utility measures. To assess reliability, intraclass correlations or kappa coefficients were calculated between first and second assessments, performed from 2 to 4 weeks apart, in patients without important clinical change in disease activity. RESULTS: Disease activity from a SLAM-R varied from 0 to 14 (median = 4) and SLEDAI from 0 to 18 (median = 0). All subscales of the SF-36 correlated well with the VAS [lowest r = 0.56, 95% confidence interval (CI) (0.17, 0.80)] and poorly with the SG [maximum r = 0.41, CI (-0.01, 0.70); minimum r = 0.10, CI (-0.32, 0.50)]. The subscales of bodily pain (r = 0.56), mental health (r = 0.45), physical functioning (r = 0.62), role-emotional (r = 0.47), social functioning (r = 0.49) and vitality (r = 0.44) correlated significantly with TTO. All subscales correlated significantly [lowest r = 0.48, CI (0.09, 0.75)] with the HUI2 index of pain. Intraclass correlations for the VAS (ICC = 0.67) and TTO (ICC = 0.60) were good. They were fair for the SG (ICC = 0.45). The kappa coefficient was poor (0.32) for the HUI attribute of pain, but varied from fair (0.46) to excellent (0.88) for the remaining attributes. Regression analysis showed that a model incorporating the SLAM-R value and SF-36 subset of mental health was a good predictor of VAS and TTO utility measures. CONCLUSION: The VAS, TTO, and to some extent, the HUI2, when compared with the SF-36 health survey, are valid and reliable measures to assess health related quality of life in a group of patients with SLE and may be useful for future research in this population. On the basis of these results the usefulness of the SG is questionable in these patients.

Systemic immune reactions to HMG-CoA reductase inhibitors. Report of 4 cases and review of the literature.

Four patients with systemic autoimmune disorders, 3 of a serious nature, presented to 1 cardiologist over a 20-month span. In 3 of these cases, an HMG-CoA reductase inhibitor was presumably etiologic, while in the fourth case, the HMG-CoA reductase inhibitor might have unmasked the disorder. It would be useful to determine the true frequency of this complication, particularly in older patients not included in most of the statin trials to date. It is well established that autoimmune phenomena and particularly the development of autoantibodies increase with age. The data presented in this report that the group of HMG-CoA reductase inhibitors could be a heretofore poorly recognized etiologic agent. This issue might be addressed by a case-control study looking at the prevalence of statin use in elderly patients with systemic autoimmune disorders and in controls. Until then, the authors advise caution in the use of this class of medications in patient subgroups for whom no clear-cut clinical benefit has yet been proven.

A long-term study of hydroxychloroquine withdrawal on exacerbations in systemic lupus erythematosus. The Canadian Hydroxychloroquine Study Group.

The ability of antimalarials to moderate severe disease activity in systemic lupus erythematosus (SLE) is plausible but undemonstrated. We evaluated the long-term effectiveness of maintaining treatment with hydroxychloroquine sulphate (HCQ) to prevent major flares in quiescent SLE. Forty-seven patients with quiescent SLE who had been randomized to take HCQ (n = 25) or placebo (n = 22) as part of a 24-week withdrawal trial were evaluated for an additional 3 years. The primary outcome was time to a major flare of SLE which resulted in either the institution of or an increase in the current dosage of prednisone of 10 mg/day or more, or institution of therapy with immunosuppressive agents. Secondary outcomes included the specific subtype of these major flares (glomerulonephritis, vasculitis or other) and hospitalization for an exacerbation of SLE. An intent-to-treat analysis was conducted. Over the 42 months of study, 11 of 22 (50%) patients randomized initially to placebo, and seven of 25 (28%) patients randomized to continue treatment experienced a major flare. The relative risk of major flare for those randomized to continue HCQ compared with controls was 0.43 (95% CI: 0.17, 1.12). The relative risks for subtypes of flares were 0.26 (95% CI: 0.03, 2.54) for nephritis, 0.51 (95% CI: 0.09, 3.08) for vasculitis and 0.65 (95% CI: 0.17, 2.41) for flares characterized by other symptoms. The relative risk of hospitalization for major flare for patients randomized to continue hydroxychloroquine was 0.58 (95% CI: 0.13, 2.60). While the results are not statistically significant, they are compatible with the clinical belief that HCQ has a long-term protective effect against major disease flares in SLE and suggest that on average, HCQ use reduces major flares by 57% (95% CI: 83% reduction to 12% increase).

Impact of disease activity and cumulative damage on the health of lupus patients.

To test if lupus activity and damage predict physical function and general health in lupus was the objective of this study. Ninety-six patients with lupus were seen at baseline and monthly for 4 months. Sociodemographic characteristics and lupus damage (SLICC/ACR DI), were collected at baseline while lupus activity (SLAM-R, SLEDAI), health status measures (HAQ, SF-36) and immunological tests were collected at each visit. Associations of lupus activity and damage with general health and physical function were evaluated. Baseline health status measures were greatly impaired and comparable to those of severe medical illnesses. In cross-sectional analyses, baseline activity score measured by SLAM-R, but not by SLEDAI, correlated with most subscales of SF-36. Baseline damage score SLICC/ACR DI correlated only with the HAQ and the physical function subscale of SF-36. Differences in both activity measures (SLAM-R and SLEDAI) over time correlated with change in health status measures while baseline cumulative damage (SLICC/ACR DI) correlated with the average level of physical function only. Lupus activity measures, SLAM-R and SLEDAI, although differing cross-sectionally, both reflected patients' health status performance over time and lupus damage measure, SLICC/ACR DI, performed well in assessing physical function. Lupus patients scores for health are poor and comparable to those found in severe medical illnesses.

Psychosocial contributors to mental and physical health in patients with systemic lupus erythematosus.

OBJECTIVE: To delineate psychosocial and systemic lupus erythematosus (SLE)-related medical factors that contribute to the mental and physical health of SLE patients. METHODS: In a cross-sectional study, 44 women completed standardized instruments assessing daily hassles, social support, psychologic distress, and quality of life and underwent a physician examination to assess disease activity and disease damage. Four multiple linear regression analyses were computed to identify factors associated with the following outcomes: patient-perceived psychologic distress and global physical health and physician-assessed disease activity and damage. Variables entered into the regression analyses were: hassles severity, types of social support, SLE disease activity and damage, age, disease duration, education, ethnicity, and global psychologic distress (for the outcomes of self-perceived global physical health and disease activity and damage). RESULTS: The best model explaining global psychologic distress included hassles severity and self-esteem social support. The best model explaining patients' perceptions of their global physical health included hassles severity and tangible social support. Psychologic distress accounted for a significant proportion of variance in both disease activity and damage. CONCLUSION: High stress (assessed by hassles severity), poor social support, and psychologic distress--potentially modifiable variables--are associated with the mental and physical health of SLE patients.

Stress and depressed mood in medical students, law students, and graduate students at McGill University.

PURPOSE: To investigate stress in medical students, law students, and graduate students at McGill University using a well-validated measure, the Derogatis Stress Profile (DSP). METHOD: The DSP was administered to the medical students in November and December 1994. For comparison, the DSP was also administered to the undergraduate law students and the graduate students. In November 1995 the DSP was administered to the first- and second-year medical students. Results were analyzed with a number of statistical methods. RESULTS: The response rates for the medical students, the law students, and the graduate students in 1994-95 were 70%, 96%, and 43%, respectively. The response rate for the first- and second-year medical students in 1995-96 was 57%. The medical students had subjective feelings of stress that are marginally above population norms, but their total-stress scores (related to environmental factors, personality mediators, and emotional responses) were below those of the general population, the law students, and the graduate students. Elevated depression scores in a minority of the students did not seem to be related directly to the stresses associated with medical school. The transition from basic science training to clinical training was associated with an increase in stress and depressed mood. CONCLUSION: Medical students are not greatly stressed relative to other groups, hence other explanations must be sought for the elevated levels of depression in some students. One situation in which stress appears to be particularly important is in the transition from basic science training to clinical training. Targeted interventions may be an effective way of dealing with this problem.