Psychosocial Health and Physical Activity in People With Major Depression in the Context of COVID-19.

Introduction: Major depression is a psychiatric disease associated with physical inactivity, which in turn affects mental and physical health. A randomized controlled trial is being implemented to facilitate physical activity in people with major depression. In March 2020, Swiss state authorities temporarily legislated a lockdown to contain the Coronavirus disease-19 (COVID-19), which influenced health, behavior and research. The aim of this study was to find out whether data gathered before and during/after the lockdown among in-patients with major depression differ with regard to psychosocial health, physical activity and related attitudes and to establish whether baseline data have been affected by the lockdown. Methods: This is a cross-sectional analysis within a randomized controlled trial. Physically inactive, adult in-patients diagnosed with major depression were recruited from four Swiss psychiatric clinics between January 2019 and December 2020. Psychosocial health was measured with questionnaires pertaining to stress, sleep and health-related quality of life. Physical activity was measured with the Simple Physical Activity Questionnaire. Explicit attitudes were measured with seven questionnaires pertaining to physical activity-related motivation and volition. Implicit attitudes toward physical activity were captured with a single target implicit association test. Results: The sample consisted of 165 participants (n = 119 before lockdown, n = 46 during/after lockdown). No statistically significant differences were found between in-patients with major depression assessed before and during/after the COVID-19 lockdown with regard to psychosocial health (stress, p = 0.51; sleep, p = 0.70; physical component of health-related quality of life, p = 0.55; mental component of health-related quality of life, p = 0.64), self-reported physical activity (p = 0.16) and explicit as well as implicit attitudes toward physical activity (p = 0.94). Hence, the COVID-19-induced lockdown seems not to have led to group differences. Conclusion: Baseline data gathered in in-patients suffering from major depression who are physically inactive upon admission to in-patient treatment in Switzerland seem to be unaffected by the COVID-19-induced lockdown. To assess changes in said population regarding psychosocial health and physical activity patterns over time, longitudinal data are needed.

Variability and dimensionality of students' and supervisors' mini-CEX scores in undergraduate medical clerkships - a multilevel factor analysis.

BACKGROUND: The mini clinical evaluation exercise (mini-CEX)-a tool used to assess student-patient encounters-is increasingly being applied as a learning device to foster clinical competencies. Although the importance of eliciting self-assessment for learning is widely acknowledged, little is known about the validity of self-assessed mini-CEX scores. The aims of this study were (1) to explore the variability of medical students' self-assessed mini-CEX scores, and to compare them with the scores obtained from their clinical supervisors, and (2) to ascertain whether learners' self-assessed mini-CEX scores represent a global dimension of clinical competence or discrete clinical skills. METHODS: In year 4, medical students conducted one to three mini-CEX per clerkship in gynaecology, internal medicine, paediatrics, psychiatry and surgery. Students and clinical supervisors rated the students' performance on a 10-point scale (1 = great need for improvement; 10 = little need for improvement) in the six domains history taking, physical examination, counselling, clinical judgement, organisation/efficiency and professionalism as well as in overall performance. Correlations between students' self-ratings and ratings from clinical supervisors were calculated (Pearson's correlation coefficient) based on averaged scores per domain and overall. To investigate the dimensionality of the mini-CEX domain scores, we performed factor analyses using linear mixed models that accounted for the multilevel structure of the data. RESULTS: A total of 1773 mini-CEX from 164 students were analysed. Mean scores for the six domains ranged from 7.5 to 8.3 (student ratings) and from 8.8 to 9.3 (supervisor ratings). Correlations between the ratings of students and supervisors for the different domains varied between r = 0.29 and 0.51 (all p < 0.0001). Mini-CEX domain scores revealed a single-factor solution for both students' and supervisors' ratings, with high loadings of all six domains between 0.58 and 0.83 (students) and 0.58 and 0.84 (supervisors). CONCLUSIONS: These findings put a question mark on the validity of mini-CEX domain scores for formative purposes, as neither the scores obtained from students nor those obtained from clinical supervisors unravelled specific strengths and weaknesses of individual students' clinical competence.

Outcome of a four-hour smoking cessation counselling workshop for medical students.

BACKGROUND: Lack of smoking cessation education in undergraduate medical training hinders healthcare professionals in providing adequate tobacco cessation counselling. We developed a comprehensive 4-h smoking cessation counselling course for medical students that is easy to incorporate in a medical school curriculum, and assessed its short-term outcome for knowledge, skills, and attitudes. METHODS: Eighty-eight medical students (53f, 35 m) were educated by a doctoral student in five identical 4-h courses. A 45-min theoretical introduction was followed by patient-physician role-playing by student pairs. Knowledge, skills, and attitude were assessed before and 4 weeks after the course by questionnaires, and by blinded analysis of pre- and post-course videos of a five-minute standardized patient situation. RESULTS: Knowledge: Before the course 10.6 (mean, SD: 2.7) questions out of 29 were answered correctly, and increased to 19.2 (3.6) after the course (p < 0.0005). Major features of the students' counselling skills improved. Significant and highly relevant attitude changes reflected increased motivation to counselling smokers. CONCLUSION: Implementing a four-hour smoking intervention workshop into a medical curriculum was highly effective in improving students' knowledge, skills and attitudes towards smoking counselling, as well as providing them with additional clinical competencies.

Sustained impact of a short small group course with systematic feedback in addition to regular clinical clerkship activities on musculoskeletal examination skills--a controlled study.

BACKGROUND: The discrepancy between the extensive impact of musculoskeletal complaints and the common deficiencies in musculoskeletal examination skills lead to increased emphasis on structured teaching and assessment. However, studies of single interventions are scarce and little is known about the time-dependent effect of assisted learning in addition to a standard curriculum. We therefore evaluated the immediate and long-term impact of a small group course on musculoskeletal examination skills. METHODS: All 48 Year 4 medical students of a 6 year curriculum, attending their 8 week clerkship of internal medicine at one University department in Berne, participated in this controlled study. Twenty-seven students were assigned to the intervention of a 6×1 h practical course (4-7 students, interactive hands-on examination of real patients; systematic, detailed feedback to each student by teacher, peers and patients). Twenty-one students took part in the regular clerkship activities only and served as controls. In all students clinical skills (CS, 9 items) were assessed in an Objective Structured Clinical Examination (OSCE) station, including specific musculoskeletal examination skills (MSES, 7 items) and interpersonal skills (IPS, 2 items). Two raters assessed the skills on a 4-point Likert scale at the beginning (T0), the end (T1) and 4-12 months after (T2) the clerkship. Statistical analyses included Friedman test, Wilcoxon rank sum test and Mann-Whitney U test. RESULTS: At T0 there were no significant differences between the intervention and control group. At T1 and T2 the control group showed no significant changes of CS, MSES and IPS compared to T0. In contrast, the intervention group significantly improved CS, MSES and IPS at T1 (p < 0.001). This enhancement was sustained for CS and MSES (p < 0.05), but not for IPS at T2. CONCLUSIONS: Year 4 medical students were incapable of improving their musculoskeletal examination skills during regular clinical clerkship activities. However, an additional small group, interactive clinical skills course with feedback from various sources, improved these essential examination skills immediately after the teaching and several months later. We conclude that supplementary specific teaching activities are needed. Even a single, short-lasting targeted module can have a long lasting effect and is worth the additional effort.

The influence of students' prior clinical skills and context characteristics on mini-CEX scores in clerkships--a multilevel analysis.

BACKGROUND: In contrast to objective structured clinical examinations (OSCEs), mini-clinical evaluation exercises (mini-CEXs) take place at the clinical workplace. As both mini-CEXs and OSCEs assess clinical skills, but within different contexts, this study aims at analyzing to which degree students' mini-CEX scores can be predicted by their recent OSCE scores and/or context characteristics. METHODS: Medical students participated in an end of Year 3 OSCE and in 11 mini-CEXs during 5 different clerkships of Year 4. The students' mean scores of 9 clinical skills OSCE stations and mean 'overall' and 'domain' mini-CEX scores, averaged over all mini-CEXs of each student were computed. Linear regression analyses including random effects were used to predict mini-CEX scores by OSCE performance and characteristics of clinics, trainers, students and assessments. RESULTS: A total of 512 trainers in 45 clinics provided 1783 mini-CEX ratings for 165 students; OSCE results were available for 144 students (87%). Most influential for the prediction of 'overall' mini-CEX scores was the trainers' clinical position with a regression coefficient of 0.55 (95%-CI: 0.26-0.84; p < .001) for residents compared to heads of department. Highly complex tasks and assessments taking place in large clinics significantly enhanced 'overall' mini-CEX scores, too. In contrast, high OSCE performance did not significantly increase 'overall' mini-CEX scores. CONCLUSION: In our study, Mini-CEX scores depended rather on context characteristics than on students' clinical skills as demonstrated in an OSCE. Ways are discussed which focus on either to enhance the scores' validity or to use narrative comments only.

The mini-clinical evaluation exercise during medical clerkships: are learning needs and learning goals aligned?

OBJECTIVES: The generation of learning goals (LGs) that are aligned with learning needs (LNs) is one of the main purposes of formative workplace-based assessment. In this study, we aimed to analyse how often trainer-student pairs identified corresponding LNs in mini-clinical evaluation exercise (mini-CEX) encounters and to what degree these LNs aligned with recorded LGs, taking into account the social environment (e.g. clinic size) in which the mini-CEX was conducted. METHODS: Retrospective analyses of adapted mini-CEX forms (trainers' and students' assessments) completed by all Year 4 medical students during clerkships were performed. Learning needs were defined by the lowest score(s) assigned to one or more of the mini-CEX domains. Learning goals were categorised qualitatively according to their correspondence with the six mini-CEX domains (e.g. history taking, professionalism). Following descriptive analyses of LNs and LGs, multi-level logistic regression models were used to predict LGs by identified LNs and social context variables. RESULTS: A total of 512 trainers and 165 students conducted 1783 mini-CEXs (98% completion rate). Concordantly, trainer-student pairs most often identified LNs in the domains of 'clinical reasoning' (23% of 1167 complete forms), 'organisation/efficiency' (20%) and 'physical examination' (20%). At least one 'defined' LG was noted on 313 student forms (18% of 1710). Of the 446 LGs noted in total, the most frequently noted were 'physical examination' (49%) and 'history taking' (21%). Corresponding LNs as well as social context factors (e.g. clinic size) were found to be predictors of these LGs. CONCLUSIONS: Although trainer-student pairs often agreed in the LNs they identified, many assessments did not result in aligned LGs. The sparseness of LGs, their dependency on social context and their partial non-alignment with students' LNs raise questions about how the full potential of the mini-CEX as not only a 'diagnostic' but also an 'educational' tool can be exploited.

Rarely selected distractors in high stakes medical multiple-choice examinations and their recognition by item authors: a simulation and survey.

BACKGROUND: Many medical exams use 5 options for multiple choice questions (MCQs), although the literature suggests that 3 options are optimal. Previous studies on this topic have often been based on non-medical examinations, so we sought to analyse rarely selected, 'non-functional' distractors (NF-D) in high stakes medical examinations, and their detection by item authors as well as psychometric changes resulting from a reduction in the number of options. METHODS: Based on Swiss Federal MCQ examinations from 2005-2007, the frequency of NF-D (selected by <1% or <5% of the candidates) was calculated. Distractors that were chosen the least or second least were identified and candidates who chose them were allocated to the remaining options using two extreme assumptions about their hypothetical behaviour: In case rarely selected distractors were eliminated, candidates could randomly choose another option--or purposively choose the correct answer, from which they had originally been distracted. In a second step, 37 experts were asked to mark the least plausible options. The consequences of a reduction from 4 to 3 or 2 distractors--based on item statistics or on the experts' ratings--with respect to difficulty, discrimination and reliability were modelled. RESULTS: About 70% of the 5-option-items had at least 1 NF-D selected by <1% of the candidates (97% for NF-Ds selected by <5%). Only a reduction to 2 distractors and assuming that candidates would switch to the correct answer in the absence of a 'non-functional' distractor led to relevant differences in reliability and difficulty (and to a lesser degree discrimination). The experts' ratings resulted in slightly greater changes compared to the statistical approach. CONCLUSIONS: Based on item statistics and/or an expert panel's recommendation, the choice of a varying number of 3-4 (or partly 2) plausible distractors could be performed without marked deteriorations in psychometric characteristics.

Feasibility and acceptance of electronic quality of life assessment in general practice: an implementation study.

BACKGROUND: Patients' health related quality of life (HRQoL) has rarely been systematically monitored in general practice. Electronic tools and practice training might facilitate the routine application of HRQoL questionnaires. Thorough piloting of innovative procedures is strongly recommended before the conduction of large-scale studies. Therefore, we aimed to assess i) the feasibility and acceptance of HRQoL assessment using tablet computers in general practice, ii) the perceived practical utility of HRQoL results and iii) to identify possible barriers hindering wider application of this approach. METHODS: Two HRQoL questionnaires (St. George's Respiratory Questionnaire SGRQ and EORTC QLQ-C30) were electronically presented on portable tablet computers. Wireless network (WLAN) integration into practice computer systems of 14 German general practices with varying infrastructure allowed automatic data exchange and the generation of a printout or a PDF file. General practitioners (GPs) and practice assistants were trained in a 1-hour course, after which they could invite patients with chronic diseases to fill in the electronic questionnaire during their waiting time. We surveyed patients, practice assistants and GPs regarding their acceptance of this tool in semi-structured telephone interviews. The number of assessments, HRQoL results and interview responses were analysed using quantitative and qualitative methods. RESULTS: Over the course of 1 year, 523 patients filled in the electronic questionnaires (1-5 times; 664 total assessments). On average, results showed specific HRQoL impairments, e.g. with respect to fatigue, pain and sleep disturbances. The number of electronic assessments varied substantially between practices. A total of 280 patients, 27 practice assistants and 17 GPs participated in the telephone interviews. Almost all GPs (16/17 = 94%; 95% CI = 73-99%), most practice assistants (19/27 = 70%; 95% CI = 50-86%) and the majority of patients (240/280 = 86%; 95% CI = 82-91%) indicated that they would welcome the use of electronic HRQoL questionnaires in the future. GPs mentioned availability of local health services (e.g. supportive, physiotherapy) (mean: 9.4 +/- 1.0 SD; scale: 1 - 10), sufficient extra time (8.9 +/- 1.5) and easy interpretation of HRQoL results (8.6 +/- 1.6) as the most important prerequisites for their use. They believed HRQoL assessment facilitated both communication and follow up of patients' conditions. Practice assistants emphasised that this process demonstrated an extra commitment to patient centred care; patients viewed it as a tool, which contributed to the physicians' understanding of their personal condition and circumstances. CONCLUSION: This pilot study indicates that electronic HRQoL assessment is technically feasible in general practices. It can provide clinically significant information, which can either be used in the consultation for routine care, or for research purposes. While GPs, practice assistants and patients were generally positive about the electronic procedure, several barriers (e.g. practices' lack of time and routine in HRQoL assessment) need to be overcome to enable broader application of electronic questionnaires in every day medical practice.

[Role of the general practitioner in outpatient care for schizophrenic patients from the patients' perspective]. / Die Rolle des Hausarztes in der ambulanten Schizophreniebehandlung aus Sicht von Patienten.

OBJECTIVE: To explore the view of schizophrenic patients regarding the role of general practitioners (GPs) in outpatient psychiatric care. METHODS: Semi-structured interviews with 20 schizophrenic patients were tape-recorded. Using the software Atlas.ti, the data were analysed according to the model of inductive category development (Mayring, 1995). RESULTS: Nearly all patients regarded the GPs as doctors "for the body" and--in contrast--the psychiatrists as doctors "for the soul". At the same time, an appointment with a GP was perceived as less embarrassing and stigmatising. Patients consulted their GP mainly because of somatic complaints or to receive follow-up prescriptions for their antipsychotic medication. They liked to get a "second opinion" regarding medical decisions by GPs. Some patients wished to have more consultation time with their GP to discuss psychological problems. CONCLUSIONS: Schizophrenic patients appreciate the distinction, and the choice, between different medical specialties. Primary care offers services with an exceptionally low threshold for schizophrenic patients because consultations with a GP are to a lesser degree perceived as embarrassing or stigmatising.

A parametric analysis of ordinal quality-of-life data can lead to erroneous results.

OBJECTIVE: Measurements from health-related quality-of-life (HRQoL) studies, although usually of an ordered categorical nature, are typically treated as continuous variables, allowing the calculation of mean values and the administration of parametric statistics, such as t-tests. We investigated whether parametric, compared to nonparametric, analyses of ordered categorical data may lead to different conclusions. STUDY DESIGN AND SETTING: HRQoL data were obtained from patients with a diagnosis of asthma (n=192) and chronic obstructive pulmonary disease (COPD; n=88) at two time points. The impact of the group factor (asthma vs. COPD) and the time factor (t1 vs. t2) on HRQoL was analyzed with a metric approach (repeated measures ANOVA) and two ordinal approaches (each with a nonparametric repeated measures ANOVA). RESULTS: Using the metric approach, a significant effect of "group" (P=0.0061) and "time" (P=0.0049) on HRQoL was found. The first ordinal approach (ranked total score) still showed a significant effect for "group" (P=0.0033) with a worse HRQoL for patients suffering from COPD. In the second approach (ranks for each HRQoL item and summed ranks), there were no significant effects. CONCLUSION: Applying simple parametric methods to ordered categorical HRQoL scores led to different results from those obtained with nonparametric methods. In these cases, an ordinal approach will prevent inappropriate conclusions.

Association between the BclI glucocorticoid receptor polymorphism and smoking in a sample of patients with obstructive airway disease.

Glucocorticoids seem to mediate the effect of stimulant drugs such as nicotine. Several studies have pointed to an association between the BclI polymorphism in the glucocorticoid receptor gene and increased glucocorticoid effects. We analysed the association of smoking behaviour and the BclI polymorphism using a case-control design within the framework of a larger pharmacogenetic study. A total of 327 Caucasian patients with asthma or chronic obstructive pulmonary disease from 39 German general practices gave informed consent to take part in the study. They filled in questionnaires concerning their smoking behaviour and were genotyped for the BclI polymorphism. The genotype frequencies for non-smokers (n = 251; CC, 0.42; CG, 0.46; GG, 0.12) as well as for smokers (n = 76; CC, 0.29; CG, 0.55; GG, 0.16) were consistent with the Hardy-Weinberg equilibrium. The proportion of smokers was significantly lower among carriers of the CC-genotype (22/127 = 17%) compared with carriers of the G-allele (54/200 = 27%; chi2 = 4.08; P = 0.04). Within the group of smokers, the proportion of heavy smokers (> 19 cigarettes/day; median) was reduced in C-homozygous patients when compared with carriers of the G-allele (7/22 = 32% versus 31/54 = 57%; chi2 = 4.09; P = 0.04). Stepwise logistic regression analysis also pointed to an association between the CC-genotype and a reduced probability of being a smoker (odds ratio = 0.55; 95% confidence interval = 0.30-1.00; P = 0.05) controlling for other predictors. In summary, this study provides evidence that the BclI polymorphism might play a role in the maintenance and severity of nicotine dependence.

Patients' and physicians' perspectives on pharmacogenetic testing.

INTRODUCTION: The integration of pharmacogenetic testing into routine care will, in part, depend upon the patients' and physicians' acceptance of these tests. Empirical data regarding patients' and physicians' views on pharmacogenetic testing are lacking. OBJECTIVES: To explore patients' and physicians' perspectives on the potential implications of pharmacogenetic testing, particularly focusing on asthma, and to analyze the possible determinants of their expectations, hopes and fears. METHODS: We conducted telephone interviews with patients with asthma or chronic obstructive pulmonary disease taking part in a larger pharmacogenetic study, in addition to general practitioners (GPs) from a different region in Germany. A total of 328 patients and 378 GPs were invited to participate. Determinants of their attitudes toward pharmacogenetic testing were assessed using logistic regression analysis. RESULTS: Informed consent to participate in this study was given by 196 patients (60%) and 106 GPs (28%). Most patients (96%) and physicians (52%) appreciated the availability of pharmacogenetic tests for a disease such as asthma. Approximately a third of the patients worried about potential unfavorable test results (35%) and violation of privacy (36%). Female patients were more likely to have a fearful attitude (odds ratio [OR]=2.85; 95% confidence interval [CI]=1.58-5.12). Younger patients were generally more likely to be hopeful about the usefulness of pharmacogenetic testing (OR=2.12; CI=1.01-4.46). The GPs' concerns were mainly related to the possibility that patients might either be put under pressure to be tested (72%) or be disadvantaged at private health insurance agencies (61%). The nature of the responsible institution, the clarity of the research aim and explicit informed consent from patients influenced a physicians' decision regarding whether to support a pharmacogenetic study. CONCLUSION: The concerns of patients and GPs differ somewhat with respect to negative psychosocial consequences, discrimination or violation of privacy. Development of information for physicians and patients would be helpful in preventing unrealistic fears or hopes.

Participation in a quality of care study and consequences for generalizability of general practice research.

BACKGROUND: Non-participation of General Practitioners (GPs) hampers primary care research. Using existing network structures can improve participation, but may introduce sampling effects. OBJECTIVES: To examine the role of network-based recruitment and other determinants of participation, and to estimate effects of sampling and non-participation on generalizability. METHODS: For a study of quality of care assessment, we recruited GPs from a regionally defined population and a GP network. Effects of sampling and non-participation were analysed by comparing characteristics between participants, target samples, and reference data for all German GPs. Factors influencing study participation were assessed in multiple logistic regression. RESULTS: Compared to the regional sample, network GPs were more likely to complete survey questionnaires (92% versus 69%) and to participate in the study (66% versus 23%). Compared to national reference data, study participants from both populations were younger, had a higher level of professional training, and included more men. These differences were already present in the network target sample, but were largely attributable to selective participation in the regional sample. Network membership remained the strongest determinant of participation in multiple logistic regression (odds ratio 5.01; 95% confidence interval 2.53-9.91). A younger age, higher professional training, and membership in the German Society of General Practice were also predictive of participation. CONCLUSIONS: Although network-based recruitment of GPs increases participation rates, sample effects are similar in size and direction as effects of non-participation in the regionally defined population. Careful analysis of participants based on publicly available data is therefore crucial for the assessment of generalizability.

[Documentation of electronic patient records (EPRS) in German general practices: a telephone survey]. / Elektronische Erfassung von medizinischen Daten in deutschen Hausarzt- praxen: Ein Telefon-Survey.

In Germany, use and contents of EPRs are largely unknown and expected to be highly variable, due to missing standards. We conducted a telephone survey to describe and compare computer documentation habits in general practices. Specifically, we were interested in: (1) the type of medical data recorded; and (2) which factors influence the extent to which doctors used the EPR while seeing their patients. The sampling frame consisted of family physicians participating in a general practice research project: 32% (145/452) of family physicians in the district of Göttingen, Lower Saxony, and 63% (52/83) of physicians from a quality assurance network of family practices in the district of Freiburg, Baden-Württemberg. With the exception of two practices in Göttingen, all practices (n = 165 of 167) took part in this survey. Diagnoses, digital codes for service fees, and prescriptions were computerized in nearly all practices, although doctors were significantly more involved in Freiburg than in Göttingen. Clinical symptoms and findings were recorded in 80% of Freiburg and 52% of Göttingen practices (p = 0.008). Overall, in 74% of Freiburg and 51% of Göttingen practices, the physicians opened the EPR while seeing patients (p = 0.022). Nearly half of the Göttingen practices (49%) and 24% of the Freiburg practices (p < 0.05) entered digital codes for service fees and diagnoses on paper before entering them electronically. In multivariate models adjusting for sex, target group and training specialty, internet access in the office was independently predictive of 'EPR-activity' (OR: 2.23; 95%-confidence interval: 1.12-4.43). There seems to be room for improvement in terms of degree and intensity of recording of clinically-relevant data. Technical interest, i.e., internet access in the office, seems to enhance electronic documentation activities.