Validating relationships among attachment, emotional intelligence and clinical communication.

CONTEXT: In a previous study, we found that emotional intelligence (EI) mediates the negative influences of Year 1 medical students' attachment styles on their provider-patient communication (PPC). However, in that study, students were examined on a relatively straightforward PPC skill set and were not assessed on their abilities to elicit relevant clinical information from standardised patients. The influence of these psychological variables in more demanding and realistic clinical scenarios warrants investigation. OBJECTIVES: This study aimed to validate previous research findings by exploring the mediating effect of EI on the relationship between medical students' attachment styles and their PPC across an ecologically valid PPC objective structured clinical examination (OSCE). METHODS: Year 2 medical students completed measures of attachment (the Experiences in Close Relationships-Short Form [ECR-SF], a 12-item measure which provides attachment avoidance and attachment anxiety dimensional scores) and EI (the Mayer-Salovey-Caruso Emotional Intelligence Test [MSCEIT], a 141-item measure on the perception, use, understanding and management of emotions), prior to their summative PPC OSCE. Provider-patient communication was assessed using OSCE scores. Structural equation modelling (SEM) was used to validate our earlier model of the relationships between attachment style, EI and PPC. RESULTS: A total of 296 of 382 (77.5%) students participated. Attachment avoidance was significantly negatively correlated with total EI scores (r = -0.23, p < 0.01); total EI was significantly positively correlated with OSCE scores (r = 0.32, p < 0.01). Parsimonious SEM confirmed that EI mediated the negative influence of attachment avoidance on OSCE scores. It significantly predicted 14% of the variance in OSCE scores, twice as much as the 7% observed in the previous study. CONCLUSIONS: In more demanding and realistic clinical scenarios, EI makes a greater contribution towards effective PPC. Attachment is perceived to be stable from early adulthood, whereas EI can be developed using targeted educational interventions. The validation of this theoretical model of PPC in Year 2 medical students strengthens the potential educational implications of EI.

Emotional intelligence in medical education: a critical review.

CONTEXT: Emotional intelligence (EI) is a term used to describe people's awareness of, and ability to respond to, emotions in themselves and other people. There is increasing research evidence that doctors' EI influences their ability to deliver safe and compassionate health care, a particularly pertinent issue in the current health care climate. OBJECTIVES: This review set out to examine the value of EI as a theoretical platform on which to base selection for medicine, communication skills education and professionalism. METHODS: We conducted a critical review with the aim of answering questions that clinical educators wishing to increase the focus on emotions in their curriculum might ask. RESULTS: Although EI seems, intuitively, to be a construct that is relevant to educating safe and compassionate doctors, important questions about it remain to be answered. Research to date has not established whether EI is a trait, a learned ability or a combination of the two. Furthermore, there are methodological difficulties associated with measuring EI in a medical arena. If, as has been suggested, EI were to be used to select for medical school, there would be a real risk of including and excluding the wrong people. CONCLUSIONS: Emotional intelligence-based education may be able to contribute to the teaching of professionalism and communication skills in medicine, but further research is needed before its wholesale adoption in any curriculum can be recommended.

Exploring the relationships among attachment, emotional intelligence and communication.

OBJECTIVES: Attachment style has been shown to influence both emotional intelligence (EI) and the clinical communication of medical students and doctors. No research has assessed the relationships among attachment, EI and clinical communication in medical students. This study was conducted to evaluate the effect of EI on the relationship between medical students' attachment style and clinical communication. METHODS: Medical students were invited to complete measures of attachment (using the Experiences in Close Relationships-Short Form [ECR-SF], a 12-item measure that provides attachment avoidance and attachment anxiety dimensional scores) and EI (using the Mayer-Salovey-Caruso Emotional Intelligence Test [MSCEIT], a 141-item measure of the perception, use, understanding and management of emotions) at the end of Year 1, prior to a summative objective structured clinical examination (OSCE). Clinical communication was assessed using OSCE scores. Structural equation modelling (SEM) was used to analyse a hypothetical model of the relationships among attachment style, EI and clinical communication. RESULTS: A total of 200 of 358 (55.9%) students participated. Attachment avoidance was significantly negatively correlated with total EI scores (r=-0.28, p<0.01); total EI was significantly positively correlated with OSCE scores (r = 0.23, p < 0.01). A parsimonious SEM revealed that attachment avoidance accounted for 13% of the variance in students' total EI scores but did not directly predict OSCE scores, whereas total EI significantly predicted 7% of the variance in OSCE scores. CONCLUSIONS: Attachment is perceived to be stable from early adulthood, whereas the literature suggests that EI can be developed through the use of targeted interventions. This has potential implications for the training of medical students in clinical communication.

A comparison of self-perceived competencies of traditional and reformed curriculum graduates 6 years after graduation.

BACKGROUND: In 1996, the University of Liverpool reformed its medical course from a traditional lecture-based programme to an integrated, community based PBL curriculum based on the recommendations in Tomorrow's Doctors (General Medical Council, 1993). AIM: A project has been underway since 2000 to evaluate this change. METHODS: This article will summarize questionnaires which were distributed to the final two cohorts to graduate from the traditional curriculum with the first two cohorts to graduate from the reformed curriculum 6 years after graduation. The questionnaires asked the graduates about their preparation for the key skills required to work as doctors. RESULTS: There were significant differences between reformed and traditional curriculum graduates on nearly all the questionnaire variables. Reformed curriculum graduates felt significantly better prepared for undertaking practical procedures, working in a team, understanding evidence-based medicine. The traditional graduates felt better prepared in variables relating to basic sciences such as understanding disease processes. CONCLUSION: Reforming the curriculum can change the way graduates from the same medical school view their undergraduate education.

What impact do structured educational sessions to increase emotional intelligence have on medical students? BEME Guide No. 17.

BACKGROUND: Emotional intelligence (EI) is a type of social intelligence that involves monitoring, discriminating between and using emotions to guide thinking and actions. EI is related to interpersonal and communication skills, and is important in the assessment and training of medical undergraduates. AIM: This review aimed to determine the impact of structured educational interventions on the EI of medical students. METHODS: We systematically searched 14 electronic databases and hand searched high yield journals. We looked at changes in EI and related behaviour of medical students, assessed using Kirkpatrick's hierarchy, provided they could be directly related to the content of the educational intervention. RESULTS: A total of 1947 articles were reviewed, of which 14 articles met the inclusion criteria. CONCLUSIONS: The use of simulated patients is beneficial in improving EI when introduced in interventions later rather than earlier in undergraduate medical education. Regardless of duration of intervention, interventions have the best effects when delivered: (1) over a short space of time; (2) to students later in their undergraduate education and; (3) to female students. This should be taken into account when designing and delivering interventions. Emphasising the importance of empathetic qualities, such as empathetic communication style should be made explicit during teaching.

Integrating professionalism into the curriculum.

Professional values and behaviours are intrinsic to all medical practice yet remain one of the most difficult subjects to integrate explicitly into a curriculum. Professionalism in the twenty-first century raises challenges not only for the adaptation of the medical training programme to changing societal values but also for ensuring that trainees gain the skills for self-directed continuous development and future revalidation. This article is an introduction to the AMEE Guide in Medical Education No 61: Integrating Professionalism into the Curriculum ( www.amee.org ), which is based on the extensive contemporary available literature. An evidence-based approach has been taken throughout the Guide as it focuses on instilling professionalism positively into both undergraduate and postgraduate training. It takes a structured, stepwise approach and sequentially addresses: (i) agreeing an institutional definition, (ii) structuring the curriculum to integrate learning across all years, (iii) suggesting learning models, (iv) harnessing the impact of the formal, informal and hidden curricula and (v) assessing the learning of the trainee. A few well-evaluated case studies for both teaching and assessment have been selected to illustrate the recommendations.

Integrating professionalism into the curriculum: AMEE Guide No. 61.

Professional values and behaviours are intrinsic to all medical practice, yet remain one of the most difficult subjects to integrate explicitly into a curriculum. Professionalism for the twenty-first century raises challenges not only to adapting the course to changing societal values but also for instilling skills of ongoing self-directed continuous development in trainees for future revalidation. This Guide is based on the contemporary available literature and focuses on instilling Professionalism positively into both undergraduate and postgraduate training deliberately avoiding the more negative aspects of Fitness to Practise. The literature on Professionalism is extensive. An evidence-based approach has been taken throughout. We have selected only some of the available publications to offer practical advice. Comprehensive reviews are available elsewhere (van Mook et al. 2009a-g). This Guide takes a structured stepwise approach and sequentially addresses: (i) agreeing an institutional definition, (ii) structuring the curriculum to integrate learning across all years, (iii) suggesting learning models, (iv) harnessing the impact of the formal, informal and hidden curricula and (v) assessing the learning. Finally, a few well-evaluated case studies for both teaching and assessment have been selected to illustrate our recommendations.

Graduates from a reformed undergraduate medical curriculum based on Tomorrow's Doctors evaluate the effectiveness of their curriculum 6 years after graduation through interviews.

BACKGROUND: In 1996 Liverpool reformed its medical curriculum from a traditional lecture based course to a curriculum based on the recommendations in Tomorrow's Doctors. A project has been underway since 2000 to evaluate this change. This paper focuses on the views of graduates from that reformed curriculum 6 years after they had graduated. METHODS: Between 2007 and 2009 45 interviews took place with doctors from the first two cohorts to graduate from the reformed curriculum. RESULTS: The interviewees felt like they had been clinically well prepared to work as doctors and in particular had graduated with good clinical and communication skills and had a good knowledge of what the role of doctor entailed. They also felt they had good self directed learning and research skills. They did feel their basic science knowledge level was weaker than traditional graduates and perceived they had to work harder to pass postgraduate exams. Whilst many had enjoyed the curriculum and in particular the clinical skills resource centre and the clinical exposure of the final year including the "shadowing" and A & E attachment they would have liked more "structure" alongside the PBL when learning the basic sciences. CONCLUSION: According to the graduates themselves many of the aims of curriculum reform have been met by the reformed curriculum and they were well prepared clinically to work as doctors. However, further reforms may be needed to give confidence to science knowledge acquisition.

Graduates from a traditional medical curriculum evaluate the effectiveness of their medical curriculum through interviews.

BACKGROUND: In 1996 The University of Liverpool reformed its medical course from a traditional lecture-based course to an integrated PBL curriculum. A project has been underway since 2000 to evaluate this change. Part of this project has involved gathering retrospective views on the relevance of both types of undergraduate education according to graduates. This paper focuses on the views of traditional Liverpool graduates approximately 6 years after graduation. METHODS: From February 2006 to June 2006 interviews took place with 46 graduates from the last 2 cohorts to graduate from the traditional Liverpool curriculum. RESULTS: The graduates were generally happy with their undergraduate education although they did feel there were some flaws in their curriculum. They felt they had picked up good history and examination skills and were content with their exposure to different specialties on clinical attachments. They were also pleased with their basic science teaching as preparation for postgraduate exams, however many complained about the overload and irrelevance of many lectures in the early years of their course, particular in biochemistry. There were many different views about how they integrated this science teaching into understanding disease processes and many didn't feel it was made relevant to them at the time they learned it. Retrospectively, they felt that they hadn't been clinically well prepared for the role of working as junior doctor, particularly the practical aspects of the job nor had enough exposure to research skills. Although there was little communication skills training in their course they didn't feel they would have benefited from this training as they managed to pick up had the required skills on clinical attachments. CONCLUSION: These interviews offer a historical snapshot of the views of graduates from a traditional course before many courses were reformed. There was some conflict in the interviews about the doctors enjoying their undergraduate education but then saying that they didn't feel they received good preparation for working as a junior doctor. Although the graduates were happy with their undergraduate education these interviews do highlight some of the reasons why the traditional curriculum was reformed at Liverpool.

Do doctors' attachment styles and emotional intelligence influence patients' emotional expressions in primary care consultations? An exploratory study using multilevel analysis.

OBJECTIVE: To investigate whether and how doctors' attachment styles and emotional intelligence (EI) might influence patients' emotional expressions in general practice consultations. METHODS: Video recordings of 26 junior doctors consulting with 173 patients were coded using the Verona Coding Definition of Emotional Sequences (VR-CoDES). Doctors' attachment style was scored across two dimensions, avoidance and anxiety, using the Experiences in Close Relationships: Short Form questionnaire. EI was assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test. Multilevel Poisson regressions modelled the probability of patients' expressing emotional distress, considering doctors' attachment styles and EI and demographic and contextual factors. RESULTS: Both attachment styles and EI were significantly associated with frequency of patients' cues, with patient- and doctor-level explanatory variables accounting for 42% of the variance in patients' cues. The relative contribution of attachment styles and EI varied depending on whether patients' presenting complaints were physical or psychosocial in nature. CONCLUSION: Doctors' attachment styles and levels of EI are associated with patients' emotional expressions in primary care consultations. Further research is needed to investigate how these two variables interact and influence provider responses and patient outcomes. PRACTICE IMPLICATIONS: Understanding how doctors' psychological characteristics influence PPC may help to optimise undergraduate and postgraduate medical education.

GrainGenes.

The GrainGenes website hosts a wealth of information for researchers working on Triticeae species, oat and their wild relatives. The website hosts a database encompassing information such as genetic maps, genes, alleles, genetic markers, phenotypic data, quantitative trait loci studies, experimental protocols and publications. The database can be queried by text searches, browsing, Boolean queries, MySQL commands, or by using pre-made queries created by the curators. GrainGenes is not solely a database, but serves as an informative site for researchers and a means to communicate project aims, outcomes and a forum for discussion. This chapter describes the type of information available on the site and database, and the options available to access this data.

Low-dose mycophenolate mofetil is an effective and safe treatment to permit phased reduction in calcineurin inhibitors in chronic allograft nephropathy.

BACKGROUND: Chronic allograft nephropathy (CAN) is the most common cause of long-term renal-allograft dysfunction and the second most common cause of transplant loss. There are concerns that prolonged patient exposure to calcineurin inhibitors (CNIs) exacerbates or promotes the process of CAN. METHODS: In our unit, we carried out an observational study over the period 2000 to 2003 using low-dose mycophenolate mofetil (MMF) to facilitate a phased reduction in the dose of CNI in a group of patients with CAN. Low doses of MMF were chosen to minimize adverse effects and to reduce levels of CNIs without the attendant risks of under-immunosuppression. RESULTS: A step-wise reduction in mean reciprocalised creatinine was evident over the run-in period (mean 1/creatinine before MMF=0.005739-0.000083*month; R=0.77) with a step-wise monthly improvement postintroduction of MMF and dose reduction of CNI (mean 1/creatinine after MMF=0.004609+0.000049*month; R=0.74) (P<0.0001). The mean Cockroft-Gault estimated creatinine clearances were 47.1+/-24.2, 37.2+/-16.3, and 41.6+/-21.1 mL/min at time [t]=-12, t=0 and t=+12 months, respectively. Low-dose MMF therapy was well tolerated (only 7/89 patients stopped MMF because of side-effects in the first 12 months), and acute rejection was noted in only one patient. At latest follow-up, only 17 transplant losses had occurred, of which 6 patients had died with a functioning graft. CONCLUSIONS: Low-dose MMF was well tolerated and resulted in prolonged graft survival.

Leading and working in teams.

This article considers the role of the clinical leader as a team member and leader and explores how an understanding of the purpose and functions of teams can help doctors work more effectively in the various teams with which they are involved.

Followership, clinical leadership and social identity.

This article explores how the concepts of followership, social identity and social influence help clinical leaders and followers better understand how leadership processes function within and between individuals, teams and complex organizations.

Insights from ambulatory blood pressure monitoring: diagnosis of hypertension and diurnal blood pressure in renal transplant recipients.

BACKGROUND: Accurate diagnosis of hypertension is essential in chronic kidney disease patients, as it is linked to increased left ventricular mass, stroke, cardiovascular mortality and morbidity, and progression to end-stage renal disease. Elevated blood pressure (BP) detected by ambulatory BP monitoring (ABPM) has been shown to be predictive of worse outcome in chronic kidney disease patients. Another predictor of worse outcome is diurnal BP variation, measured also by ABPM. In this study, the authors examined the relationship (concordance or discordance) between blood pressure measured by ABPM compared with daytime office BP, and also explored the predictors of diurnal variation in renal transplant recipients. METHODS: All the patients who underwent renal transplantation and follow-up at the authors' institution from January 1998 to January 2003 were involved in this study (n=177) in addition to another randomly selected 64 patients that underwent transplantation before 1998. All patients had their ABPM performed according to previously described protocols at least 2 weeks after discharge from the hospital, dialysis-independent and with a functioning renal allograft. RESULTS: The authors found a positive correlation between systolic BP (SBP) diurnal variation and age (r =0.263, P <0.0001), glomerular filtration rate (GFR) (r =-0.229, P <0.0001), cyclosporine trough (r =0.171, P =0.047), and ABPM-to-transplant interval (r =-0.133, P =0.039). After fitting a regression model, the authors found that only GFR (P <0.0001) and age (P =0.001) were independent predictors of SBP diurnal variation (r =0.357). Concordance rate between casual BP and ABPM was 80%, and by using casual BP, only 15% of hypertensive renal transplant patients would be erroneously diagnosed as normotensive. CONCLUSIONS: The authors found that SBP diurnal variation is predicted independently by age and GFR, although it does correlate with cyclosporine trough and ABPM-to-transplant interval. In addition, the authors showed that ABPM is a more sensitive method for diagnosing hypertension than is sole reliance on office BP in renal transplant recipients.

The influence of medical students' and doctors' attachment style and emotional intelligence on their patient-provider communication.

OBJECTIVE: Attachment style and emotional intelligence (EI) have been highlighted as potential factors influencing the variation in medical students' and doctors' patient-provider communication (PPC), particularly in relation to emotive issues. The objective of this review is to systematically review and synthesise the published literature relating to the influence of medical students' and/or doctors' attachment style and EI on their PPC. METHODS: Electronic and hand searches were conducted to identify all published literature relating to the aim of the review. Data were narratively synthesised. RESULTS: 1597 studies were identified. 14 were included in the review, of which 5 assessed the influence of attachment style and 9 assessed the influence of EI on PPC. No studies assessed the impact of both attachment style and EI on PPC. CONCLUSION: Whilst tentative links were found between both PPC and both attachment style and EI, heterogeneity in study design, predictor variables and outcome measures made drawing conclusions difficult. PRACTICE IMPLICATIONS: More research is needed to assess the influence of both attachment style and EI on PPC.

Medical leadership: an international perspective.

Doctors are increasingly seen as key to embedding health service improvements and there has been much international debate over how best this can be achieved. This article takes an international perspective on medical leadership and leadership development through discussion of case study examples and initiatives from around the world.

Doctor as professional and doctor as leader: same attributes, attitudes and values?

This article examines the links between medical professionalism and medical leadership and discusses how the values that are required to be a 'good doctor' are the same as a 'good leader'. The potential of this overlap to inform the debate on developing and assessing both medical leadership and professionalism is evaluated.

Medical leadership and the medical student.

As leadership and management are increasingly seen as a vital part of the doctor's daily repertoire, medical schools are starting to implement leadership development programmes as a routine part of the curriculum with opportunities for some students to take extended study in leadership.