Communication skills of medical students: survey of self- and external perception in a longitudinally based trend study.

BACKGROUND: As good communication skills are crucial for doctor-patient interactions, it is recommended to incorporate them in medical school programs from the very beginning. On this basis medical schools in Germany introduced the OSCE (objective structured clinical examination) to examine and by this foster learning of communication skills as assessment drives learning. The aim of the study was to examine the development of the communication skills of medical students during an OSCE to investigate how communication competence has developed between different student cohorts. METHODS: This study is a longitudinal trend study based on seven semester-cohorts, examining the communication skills of medical students in the OSCE both from the perspective of students and from the viewpoint of standardized patients (SP). Altogether, 1027 students from seven semester cohorts were asked to rate their own communication skills (self-perception) before the OSCE exam started. Here, sub-analyses were performed to outline a potential influence of previous history-taking group participation. The SP evaluated the students' communication skills in external perception during the OSCE exam at each station with history-taking or physical examinations. The communication skills in both groups were ascertained in the dimensions of empathy, content structure, verbal expression, and non-verbal expression. RESULTS: Only in the dimension of non-verbal expression could a statistically significant change be found in students' self-perception over the years. Notably, the rating of communication skills as self-rated by the students has risen constantly, whereas they deteriorated from the perspective of standardized patients (SP). It has also been found that previous history-taking courses have a positive influence on the structural dimension of communication skills in particular. CONCLUSIONS: The results of this study support conclusions of other studies which also suggest differences between self- and external perception of medical students' communication skills. Nevertheless, students showed good overall communication skills in the four dimensions of empathy, content structure, verbal expression, and non-verbal expression, as demonstrated in a longitudinal trend study over seven semesters. However, we noted that externally rated empathy levels declined over the semester cohorts, suggesting the need for new priorities to be set in student teaching.

Development of a competency-based formative progress test with student-generated MCQs: Results from a multi-centre pilot study.

INTRODUCTION: Progress tests provide students feedback on their level of proficiency over the course of their medical studies. Peer-assisted learning and competency-based education have become increasingly important in medical education. Although progress tests have been proven to be useful as a longitudinal feedback instrument, there are currently no progress tests that have been created in cooperation with students or that focus on competency in medical education. In this study, we investigated the extent to which students can be included in the development of a progress test and demonstrated that aspects of knowledge related to competency can be represented on a competency-based progress test. METHODS: A two-dimensional blueprint for 144 multiple-choice questions (MCQs) covering groups of medical subjects and groups of competency areas was generated by three expert groups for developing the competency-based progress test. A total of 31 students from seven medical schools in Germany actively participated in this exercise. After completing an intensive and comprehensive training programme, the students generated and reviewed the test questions for the competency-based progress test using a separate platform of the ItemManagementSystem (IMS). This test was administered as a formative test to 469 students in a pilot study in November 2013 at eight medical schools in Germany. The scores were analysed for the overall test and differentiated according to the subject groups and competency areas. RESULTS: A pool of more than 200 MCQs was compiled by the students for pilot use, of which 118 student-generated MCQs were used in the progress test. University instructors supplemented this pool with 26 MCQs, which primarily addressed the area of scientific skills. The post-review showed that student-generated MCQs were of high quality with regard to test statistic criteria and content. Overall, the progress test displayed a very high reliability. When the academic years were compared, the progress test mapped out over the course of study not only by the overall test but also in terms of the subject groups and competency areas. OUTLOOK: Further development in cooperation with students will be continued. Focus will be on compiling additional questions and test formats that can represent competency at a higher skill level, such as key feature questions, situational judgement test questions and OSCE. In addition, the feedback formats will be successively expanded. The intention is also to offer the formative competency-based progress test online.

Morphine hyperalgesia gated through microglia-mediated disruption of neuronal Cl⁻ homeostasis.

A major unresolved issue in treating pain is the paradoxical hyperalgesia produced by the gold-standard analgesic morphine and other opiates. We found that hyperalgesia-inducing treatment with morphine resulted in downregulation of the K(+)-Cl(-) co-transporter KCC2, impairing Cl(-) homeostasis in rat spinal lamina l neurons. Restoring the anion equilibrium potential reversed the morphine-induced hyperalgesia without affecting tolerance. The hyperalgesia was also reversed by ablating spinal microglia. Morphine hyperalgesia, but not tolerance, required µ opioid receptor-dependent expression of P2X4 receptors (P2X4Rs) in microglia and µ-independent gating of the release of brain-derived neurotrophic factor (BDNF) by P2X4Rs. Blocking BDNF-TrkB signaling preserved Cl(-) homeostasis and reversed the hyperalgesia. Gene-targeted mice in which Bdnf was deleted from microglia did not develop hyperalgesia to morphine. However, neither morphine antinociception nor tolerance was affected in these mice. Our findings dissociate morphine-induced hyperalgesia from tolerance and suggest the microglia-to-neuron P2X4-BDNF-KCC2 pathway as a therapeutic target for preventing hyperalgesia without affecting morphine analgesia.

5,7-dihydroxytryptamine injections into the prefrontal cortex and nucleus accumbens differently affect prepulse inhibition and baseline startle magnitude in rats.

The prefrontal cortex and the nucleus accumbens are two brain sites which are known to be involved in the modulation of the acoustic startle response. In particular, the release of monoaminergic transmitters within these brain sites plays an important role in prepulse inhibition of the startle response which serves as an operational measure of sensorimotor gating. Like for dopamine, it is well established that serotonin transmission plays an important role in prepulse inhibition. However, there are only few studies investigating the effects of local manipulation of serotonin transmission on prepulse inhibition. The aim of the present study was to test whether prepulse inhibition or the startle response itself was affected by serotonergic depletion of either the prefrontal cortex or the nucleus accumbens. Serotonergic depletion was induced by local injections of 5,7-dihydroxytryptamine and verified by ex vivo analysis of transmitter levels by high pressure liquid chromatography. In our behavioural tests, we found that 5,7-dihydroxytryptamine into the prefrontal cortex decreased prepulse inhibition, whereas injections into the nucleus accumbens facilitated prepulse inhibition. The time course of these behavioural effects, as well as the transmitter level changes within the different brain sites was very different. Most interestingly, 5,7-dihydroxytryptamine injections into the nucleus accumbens affect serotonin and dopamine levels in both, nucleus accumbens and prefrontal cortex. Taken together, the present study supports an important role of serotonin in the modulation of prepulse inhibition and baseline startle magnitude. However, the observed changes cannot be attributed to a specific brain site since our data clearly show that local 5,7-dihydroxytryptamine injections also affect transmitter levels in brain sites away from the injection site.

Accumbal dopamine D2 receptors are important for sensorimotor gating in C3H mice.

One operational measure of sensorimotor gating that is deficient in many psychiatric disorders is prepulse inhibition (PPI) of the startle response. To investigate the role of dopamine D1 and D2 receptors within the nucleus accumbens (NAC) in sensorimotor gating in mice, we infused dopamine D1 and D2 receptor agonists (dihydrexidine and quinpirole respectively) directly into the NAC and measured the effects on PPI and on prepulse facilitation. Quinpirole infusions increased PPI and attenuated prepulse facilitation, whereas dihydrexidine had no effects. These results stand in contrast to data after systemic injections in mice and rats and intra-accumbal infusions in rats, suggesting that the role of dopamine D2 receptors within the NAC in mice differs from their role in rats.