Importance of communication in medical practice and medical education: An emphasis on empathy and attitudes and their possible influences.

BACKGROUND: Healthcare professionals need to be prepared to promote healthy lifestyles and care for patients. By focusing on what students should be able to perform one day as clinicians, we can bridge the gap between mere theoretical knowledge and its practical application. Gender aspects in clinical medicine also have to be considered when speaking of personalized medicine and learning curricula. AIM: To determine sets of intellectual, personal, social, and emotional abilities that comprise core qualifications in medicine for performing well in anamnesis-taking, in order to identify training needs. METHODS: An analysis of training clinicians' conceptions with respect to optimal medical history taking was performed. The chosen study design also aimed to assess gender effects. Structured interviews with supervising clinicians were carried out in a descriptive study at the Medical University of Vienna. Results were analyzed by conducting a qualitative computer-assisted content analysis of the interviews. Inductive category formation was applied. The main questions posed to the supervisors dealt with (1) Observed competencies of students in medical history taking; and (2) The supervisor's own conceptions of "ideal medical history taking". RESULTS: A total of 33 training clinicians (n = 33), engaged in supervising medical students according to the MedUni Vienna's curriculum standards, agreed to be enrolled in the study and met inclusion criteria. The qualitative content analysis revealed the following themes relevant to taking an anamnesis: (1) Knowledge; (2) Soft skills (relationship-building abilities, trust, and attitude); (3) Methodical skills (structuring, precision, and completeness of information gathering); and (4) Environmental/contextual factors (language barrier, time pressure, interruptions). Overall, health care professionals consider empathy and attitude as critical features concerning the quality of medical history taking. When looking at physicians' theoretical conceptions, more general practitioners and psychiatrists mentioned attitude and empathy in the context of "ideal medical history taking", with a higher percentage of females. With respect to observations of students' history taking, a positive impact from attitude and empathy was mainly described by male health care professionals, whereas no predominance of specialty was found. Representatives of general medicine and internal medicine, when observing medical students, more often emphasized a negative impact on history taking when students lacked attitude or showed non-empathetic behavior; no gender-specific difference was detected for this finding. CONCLUSION: The analysis reveals that for clinicians engaged in medical student education, only a combination of skills, including adequate knowledge and methodical implementations, is supposed to guarantee acceptable performance. This study's findings support the importance of concepts like relationship building, attitude, and empathy. However, there may be contextual factors in play as well, and transference of theoretical concepts into the clinical setting might prove challenging.

Mind reading improvements in mentalization-based therapy training.

The psychological strain of many psychiatric disorders arises from difficulties encountered in social interactions. Social withdrawal is often the first symptom of neuropsychiatric disorders. The authors explore the various options for training social cognition skills. Social cognition was assessed using the Movie for the Assessment of Social Cognition (MASC). After completion of mentalization-based therapy (MBT) training, MASC scores improved significantly in health care providers (p = .006, r = .57). Mentalizing (operationalized with reflective functioning [RF]) was assessed in the MBT group (Group A) and compared with RF in a control group (Group B). RF was significantly higher in Group A (RF = 4.35, SD = 1.19) than in Group B (RF = 3.43, SD = 1.70) (p = .0385; Cohen's d = 0.65). MBT might be a promising intervention in social cognition training. Mentalizing skills might be associated with attitude.

Affect regulation in psychoanalytic treatments of patients with a borderline personality disorder-psychoanalysis and psychodynamic psychotherapy-a comparison.

BACKGROUND: A recent meta-analysis has confirmed that the effects of psychotherapy on patients with borderline personality disorders (BPD) are still insufficiently understood. Evidence of differences between different types of therapies has been questioned. AIM: To study repetitive interaction patterns in patients with BPD undergoing either psychoanalysis or psychodynamic therapy. METHODS: Psychoanalysis (PSA) or psychodynamic psychotherapy (PDT) was administered to 10 patients each, the two groups were matched. Therapy regimens were applied according to care as usual/manualized including quality control and supervision as usual. Randomization to one of the groups was done after baseline assessment. During classical PSA (n = 10) and PDT (n = 10), semiannually, recordings (audio or video) of five consecutive therapy sessions were taken over three years for an ex-post analysis. The patients' characteristics, such as affect parameters [Affect regulation and experience Q-sort (AREQ)], quality of object relations (quality of object relations scale) and personality traits [Shedler-Westen Assessment Procedure (SWAP-200)] were analyzed retrospectively by independent raters. Therapeutic action (psychotherapy process Q-sort) and affective (re)actions of the patients (AREQ) were then analyzed in relation to changes found in the patients' characteristics. RESULTS: During the first year of therapy (PSA: n = 10; PDT: n = 9), the therapeutic method PSA was associated with significant improvements in the variable "SWAP Borderline", while in PDT change was not significantly different to baseline (PSA: P = 0.04; PDT: P = 0.33). Long-term results and follow up was available for seven participants in PSA and for five in PDT after three years; change in SWAP borderline for the whole sample was not significant at this time point when confronting to baseline (P = 0.545). However, differences between PSA and PDT were significant when analyzing the "mean change" in the SWAP Borderline variable after one year of therapy (P = 0.024): PSA led to slightly increased BPD symptoms, while PDT to a decrease; for the long run, variance of observed change was higher in PSA than in PDT (SDPSA ± 9.29 vs SDPDT ± 7.94). Our assumption that transference interpretations, closely followed by affective changes in the patient, could be useful modes of interaction was reproducible in our findings, especially when looking at the descriptive findings in the long-term data. The analysis of repetitive interaction structures demonstrated a very specific "time-lag" between therapeutic intervention and a corresponding increase in positive affect in successful therapy cases. CONCLUSION: Exploring the change processes in the patients' characteristics and linking these changes to specific treatment strategies is of clinical importance when starting treatment and for its long-term progress.

Interpretation and Working through Contemptuous Facial Micro-Expressions Benefits the Patient-Therapist Relationship.

INTRODUCTION: The significance of psychotherapeutic micro-processes, such as nonverbal facial expressions and relationship quality, is widely known, yet hitherto has not been investigated satisfactorily. In this exploratory study, we aim to examine the occurrence of micro-processes during psychotherapeutic treatment sessions, specifically facial micro-expressions, in order to shed light on their impact on psychotherapeutic interactions and patient-clinician relationships. METHODS: In analyzing 22 video recordings of psychiatric interviews in a routine/acute psychiatric care unit of Vienna General Hospital, we were able to investigate clinicians' and patients' facial micro-expressions in conjunction with verbal interactions and types. To this end, we employed the Emotion Facial Action Coding System (EmFACS)-assessing the action units and microexpressions-and the Psychodynamic Intervention List (PIL). Also, the Working Alliance Inventory (WAI), assessed after each session by both patients and clinicians, provided information on the subjective quality of the clinician-patient relationship. RESULTS: We found that interpretative/confrontative interventions are associated with displays of contempt from both therapists and patients. Interestingly, displays of contempt also correlated with higher WAI scores. We propose that these seemingly contradictory results may be a consequence of the complexity of affects and the interplay of primary and secondary emotions with intervention type. CONCLUSION: Interpretation, confrontation, and working through contemptuous microexpressions are major elements to the adequate control major pathoplastic elements. Affect-cognitive interplay is an important mediator in the working alliance.

Does case-based blended-learning expedite the transfer of declarative knowledge to procedural knowledge in practice?

BACKGROUND: Case-Based Learning (CBL) has seen widespread implementation in undergraduate education since the early 1920s. Ample data has shown CBL to be an enjoyable and motivational didactic tool, and effective in assisting the expansion of declarative and procedural knowledge in academia. Although a plethora of studies apply multiple choice questions (MCQs) in their investigation, few studies measure CBL or case-based blended learning (CBBL)-mediated changes in students' procedural knowledge in practice or employ comparison or control groups in isolating causal relationships. METHODS: Utilizing the flexibilities of an e-learning platform, a CBBL framework consisting of a) anonymized patient cases, b) case-related textbook material and online e-CBL modules, and c) simulated patient (SP) contact seminars, was developed and implemented in multiple medical fields for undergraduate medical education. Additionally, other fields saw a solo implementation of e-CBL in the same format. E- cases were constructed according to the criteria of Bloom's taxonomy. In this study, Objective Structured Clinical Examination (OSCE) results from 1886 medical students were analyzed in total, stratified into the following groups: medical students in 2013 (n = 619) before CBBL implementation, and after CBBL implementation in 2015 (n = 624) and 2016 (n = 643). RESULTS: A significant improvement (adjusted p = .002) of the mean OSCE score by 1.02 points was seen between 2013 and 2015 (min = 0, max = 25). CONCLUSION: E-Case-Based Learning is an effective tool in improving performance outcomes and may provide a sustainable learning platform for many fields of medicine in future.

Association of neonatal hypoxia with lasting changes in left ventricular gene expression: an animal model.

OBJECTIVE: Innovations in pediatric cardiovascular surgery have resulted in significant improvements in survival for children with congenital heart disease. In adults with such disease, however, surgical morbidity and mortality remain significant. We hypothesized that hypoxemia in early life causes lasting changes in gene expression in the developing heart and that such changes may persist into later life, affecting the physiology of the adult myocardium. METHODS: Microarray expression analyses were performed with left ventricular tissue from 10- and 90-day-old rats exposed to hypoxia (inspired oxygen fraction 0.12) for the first 10 days after birth then subsequently reared in ambient air and with tissue from age-matched rats reared entirely in ambient air. Changes in expression of selected genes were confirmed with real-time reverse transcriptase polymerase chain reaction. Left ventricular cardiomyocytes were isolated from adult animals in both groups, and cellular morphology and viability were compared. RESULTS: Microarray analyses revealed significant changes in 1945 and 422 genes in neonates and adults, respectively. Changes in genes associated with adaptive vascular remodeling and energy homeostasis, as well as regulation of apoptosis, were confirmed by real-time reverse transcriptase polymerase chain reaction. The viability of cardiomyocytes isolated from hypoxic animals was significantly lower than in those from control animals (36.7% +/- 13.3% vs 85.0% +/- 2.9%, P = .024). CONCLUSIONS: Neonatal hypoxia is associated with significant changes in left ventricular gene expression in both neonatal and adult rats. This may have physiologic implications for the adult myocardium.