Quelles interventions pour améliorer le bien-être des étudiants en médecine ? Une revue de la littérature

Physician's psychological distress has been known for more than a century. A meta-analysis found an increase in the suicide rate among physicians, compared to the general population, with a relative risk of 1.41 for men and 2.27 for women. Among interns, the prevalence of depression or depressive symptoms is estimated at 28.8% (IC 95% = 25.3%–32.5%). The suffering of medical students prior to internship has been recognized more recently. But now there are many studies, and a few meta-analyses, which have evaluated the prevalence of anxiety, depression, burnout and, more generally, the lack of well-being. Among medical students, the prevalence of depression or depressive symptoms is estimated at 27.2% (IC 95% = 24.7–29.9) and that of suicidal ideation of 11.2% (CI at 95% = 9.0–13.7). Another meta-analysis found a prevalence of burnout of 44.2 % (IC 95% = 33.4–55.0). Since the problem has been known researchers have tested interventions to improve the well-being of students. Our work aims to review interventions to help medical students and use validated scales. A review was published in 2016 about interventions on the learning environment, and the well-being of medical students was published; 28 studies were identified. But they did not systematically use validated questionnaires allowing a quantitative approach. Interventions included: pass/fail scoring systems (n = 3), mental health programs (n = 4), psycho-corporal skills programs (n = 7), curriculum structure (n = 3), multi-component program reform (n = 5), wellness programs (n = 4), and counseling/mentoring programs (n = 3). We chose to focus only on studies using validated questionnaires. A search was performed in the MEDLINE biomedical electronic database until July 31, 2018. The inclusion criteria were: original study, in French or English, concerning medical students prior to internship involving an intervention to improve the well-being of medical students by measuring at least one criterion of psychological distress (anxiety, burnout, depression…) using a validated scale. Thirty-six studies were included in this review. The quality of the studies is very heterogeneous. We can distinguish three types of intervention: institutional (modification of the system of notation, classification…), in-group (management of the stress, therapy full of conscience, relaxation, psychoeducation…) or individual (screening and support custom). These interventions encompass all levels of prevention (primary, secondary and tertiary). There is limited effectiveness of group interventions. This effectiveness disappeared after SIX months with the exception of institutional interventions. The data set encourages us not to favor a single type of intervention but to promote a global intervention acting at all levels. In particular, researchers can draw on studies of doctors and interns. France is late to come to the issue with few published studies on interventions to improve the well-being of students, but recent awareness seems to have taken place. Our study has some limitations: restriction to French and English, the choice to select only comparative studies using validated scales which limited the number of studies selected but also the type of interventions not all of which allow a quantitative evaluation. In the interventions not taken into account in this review, several seem promising. They mainly involve secondary prevention: improving the training of staff and students in the detection of symptoms of depression, burnout and psychological stress, screening at-risk populations, and communication campaigns to combat the stigma of psychiatric disorders and encourage students to consult. But tertiary prevention is also of interest: have psychologists and psychiatrists in the faculties accessible to students who feel the need and can also accommodate. Finally, a certain number of faculties have set up vocational guidance and selection aids that are appreciated by students but have not been evaluated for their impact on students’ health. Recent studies and meta-analyses indicate a significant prevalence of outstanding medical students, however, there is reason to be optimistic. Many health professionals and researchers are interested in the problem as well as the means to remedy it. Most studies are effective in the short term. However, the methodological limitations (low number of subjects, limited follow-up time…) and the heterogeneity of studies concerning interventions (mindfulness, psychoeducation…) on students do not allow us to conclude that they are effective in the long term. It should therefore rather move towards comprehensive care acting on the three levels of prevention: primary (institutional interventions/speech groups/psycho education), secondary (screening of subjects at risk, speech groups/psycho education/others) and tertiary (individual interventions).     

Adolescent social withdrawal,parental psychological control,and parental knowledge across seven years: A developmental cascade model

IntroductionSocial withdrawal can be problematic for adolescents, increasing the risk of poor self-efficacy, self-esteem, and academic achievement, and increased levels of depression and anxiety. This prospective study follows students across adolescence, investigating links between social withdrawal and two types of parenting hypothesized to impact or be reactive to changes in social withdrawal.MethodsAdolescent social withdrawal and parenting were assessed across seven years in a U.S. sample, beginning when students were in 6th grade and ending in 12th grade. The sample consisted of 534 adolescents (260 girls and 274 boys, 82% Euro- and 16% African-American). Social withdrawal was assessed in four grades using at least two informants (teachers, mothers, and/or adolescents). Mothers' and fathers' psychological control and monitoring-related knowledge were assessed by adolescents at two time points. A developmental cascade analysis was conducted using structural equation modeling to assess how withdrawal and control-related parenting impact each other transactionally over time. Analyses included a test for gender differences in the model.ResultsThe cascade model revealed that, controlling for previous levels of social withdrawal and parenting, earlier social withdrawal positively predicted psychological control and negatively predicted monitoring knowledge, and earlier parental psychological control—but not monitoring knowledge—predicted later social withdrawal. No adolescent gender differences were identified in the associations between social withdrawal and parental knowledge.ConclusionsThis study offers insight into the mechanisms by which adolescents become more or less withdrawn over time, and suggests psychological control as a point of psychoeducation or intervention for parents.     

Quality of life after fracture-related infection of the foot

BackgroundFracture related infection (FRI) of the foot is a serious hazard. Despite successful therapy, the physiological and psychological involvement seems to be high. Therefore, we aim to analyze the impact of an FRI of the foot on the quality of life after successful surgical therapy and infect eradication.MethodsIn total, 25 patients from two German hospitals treated for FRI of the foot between March 2011 to January 2020 were retrospectively included. Quality of life was assessed by the German Short Form 36 (SF-36) and the EuroQol five-dimension three-level questionnaire (EQ-5D) as well as the ICD-10 based psychological symptom rating (ISR), and compared to a norm obtained from the general population of Germany.Results3.0 years (range 0.7–7.9 years) following final surgery after fracture-related infection of the foot, the mean physical health component score (PCS) of the SF-36 was 35.6 ± 12.3, and the mean mental health component score (MCS) of the SF-36 reached a value of 41.3 ± 12.9. Both values were significantly lower than in the general population of Germany (p< .019). The mean scores of the ISR of the cohort crossed the threshold of mild symptom burden in total, as well as for the subscales depression and somatization. The mean EQ-5D VAS rating (62.1 ± 18.6) and the EQ-5D index value (0.66 ± 0.27) were significantly lower in comparison to a score of 72.9 ± 1.0 and 0.88 obtained from an age-matched reference population (p < .01).ConclusionFRI of the foot represents a major burden for the patient. Physical and mental well-being of affected patients is restricted albeit successful treatment in terms of infect eradication and bone union has been achieved after a mean follow-up of 3.0 years. A patient-centered treatment approach focusing on improvement of quality of life during and after treatment is therefore warranted.     

Inflexibilidad psicológica e impacto clínico: adaptación del Cuestionario de Aceptación y Acción-II en una muestra de pacientes en tratamiento de hemodiálisis

Background and objectivesFew studies have investigated the role psychological inflexibility (PI) could have in the context of chronic renal failure. The primary objective of this study was to analyse the psychometric features, the reliability and the validity of the Spanish version of the Acceptance and Action Questionnaire-II (AAQ-II) adapted to the context of patients undergoing haemodialysis (HD). The secondary objective was to assess the relationship between PI and parameters related to the adherence to treatment and quality of life in these types of patients.Materials and methodsProspective cross-sectional study with patients on haemodialysis (n = 186).ResultsThe fat tissue index (15.56 ± 5.72 vs. 18.99 ± 8.91, P = .033), phosphorus levels (3.92 ± 1.24 vs. 4.66 ± 1.38; P = .001) and interdialytic weight gain (1.56 ± 0.69 vs. 1.89 ± 0.93, P = .016) were higher in patients with a higher PI score. Phosphorus levels (P = .013) significantly explained the variability of PI levels. PI was also shown as a significant predictor (P = .026) of the variability of phosphorus levels.ConclusionsThe adaptation of the AAQ-II questionnaire to the HD context led to a valid and reliable measurement of PI in these types of patients and our results also seem to support the relationship between PI and health and quality of life parameters in patients with chronic conditions.     

Relación entre estrés y malestar psicológico de los padres y problemas emocionales y conductuales en niños preescolares con trastorno del espectro autista

IntroductionThe Autistic Spectrum Disorders (ASD) are characterised by general deficits in social communication, stereotypes, and restricted interests. The ASD have a high prevalence of additional psychiatric disorders that make their daily functioning worse, and reduces the quality of life of them and their families.Material and methodsIn an effort to identify family environmental characteristics that may influence in the course of additional psychiatric disorders, this study has focused on the symptoms of parental stress and psychological distress as possible risk factors. A cross-section study was carried out on the relationship between the stress and psychological distress of the parents and its relationship with co-existing psychopathology in a population of pre-school children with ASD (2-6 years).Results and conclusionsHigh levels of stress and psychological distress of the parents arealready associated, since early childhood, with co-existing psychiatric symptoms, specifically with emotional and behavioural problems (p < 0.05). However, further longitudinal studies are needed for a better understanding of the causal relationship between these variables and their possible bidirectional relationship.     

Communicating polygenic risk scores in the familial breast cancer clinic

ObjectiveTo describe the communication of polygenic risk scores (PRS) in the familial breast cancer setting.MethodsConsultations between genetic healthcare providers (GHP) and female patients who received their PRS for breast cancer risk were recorded (n = 65). GHPs included genetic counselors (n = 8) and medical practitioners (n = 5) (i.e. clinical geneticists and oncologists). A content analysis was conducted and logistic regression was used to assess differences in communication behaviors between genetic counselors (n = 8) and medical practitioners (n = 5).ResultsOf the 65 patients, 31 (47.7 %) had a personal history of breast cancer, 18 of whom received an increased PRS (relative risk >1.2). 25/34 unaffected patients received an increased PRS. Consultations were primarily clinician-driven and focused on biomedical information. There was little difference between the biomedical information provided by genetic counselors and medical practitioners. However, genetic counselors were significantly more likely to utilize strategies to build patient rapport and counseling techniques.ConclusionsOur findings provide one of the earliest reports on how breast cancer PRSs are communicated to women.Practice implicationsKey messages for communicating PRSs were identified, namely: discussing differences between polygenic and monogenic testing, the multifactorial nature of breast cancer risk, polygenic inheritance and current limitation of PRSs.     

ICU患者家属创伤后成长体验的质性研究

目的 深入了解神经外科ICU患者家属创伤后成长的真实体验。方法 采用质性研究中描述性现象学研究法,于2019年4月—8月对12名上海市某三级甲等综合医院神经外科ICU患者家属进行深入访谈,借助Nvivo 11软件管理访谈资料,采用Colaizzi 7步分析法进行归纳分析并提炼主题。 结果 共提炼出4个主题：人生哲学的改变,包括对生命的欣赏、关注自身健康、确立生活的优先次序、不确定的未来;个人力量增强,包括挖掘优势潜能、责任感增强、自我依靠感增强;与他人关系改善,包括“为己利他”行为、人际交往中获益;有效应对,包括设定希望、向下比较、学会自我调适。 结论 神经外科ICU患者家属在对抗逆境的过程中能体验到创伤后成长,呈现积极的自我变化现象,临床医护人员应关注患者家属的积极体验,将创伤后成长与临床心理护理整合,促成临床干预向以激发潜能、培养积极力量、促进成长为主题的范式转变。     

Psychological immune competency predicts burnout syndrome among the high-risk healthcare staff: A cross-sectional study

BackgroundBurnout and psychological immune competency have not been investigated together among employees of high-risk specializations such as emergency medicine, intensive care or surgery.AimIn this study we aim to examine the prevalence of burnout among high-risk clinical staff and explore whether the strength of psychological immune competency predict burnout.DesignA cross-sectional design utilizing a self-administrated questionnaire was used to collect data from the participants (n = 216). Nurses (n = 145) and physicians (n = 71) from emergency medicine, intensive care and surgery departments participated in the study.MethodBurnout syndrome was measured using the Maslach Burnout Inventory, while psychological immune competency was measured using the Psychological Immune Competency Questionnaire. The data collection started in June of 2018 and was finished in March of 2019.ResultsParticipants with higher psychological immune competency reported lower levels of burnout: emotional exhaustion (r = −0.478; p < 0.001), depersonalization (r = −0.459; p < 0.001) and personal accomplishment (r = 0.543; p < 0.001). Multiple linear stepwise regression analysis revealed the psychological immune competency to be a stable predictor of burnout on all three scales.ConclusionPsychological immune competency shows a strong relationship with scales of burnout syndrome and as such should be further examined due to development of successful intervention and prevention programs.