Assessing medical students' awareness of and sensitivity to diverse health beliefs using a standardized patient station.

PURPOSE: To assess students' performances on a health-beliefs communication OSCE station to determine whether there were differences in cultural competence based on the students' ethnic backgrounds. METHOD: A total of 71 students completed a health-beliefs communication OSCE station in which they were required to address the health beliefs and cultural concerns of a standardized patient (SP) portraying an African American woman with diabetes. The SPs rated students' performances on a ten-item interview assessment checklist. Scores on the station were standardized within SPs to adjust for differences in their use of the rating scale. A factor analysis was performed to determine conceptual constructs on the interview assessment checklist. Subscale means were computed for each student. T-tests of these subscale scores were conducted to investigate gender and ethnic differences between subgroups of students. The underrepresented minority (URM) students (five African Americans and three Mexican Americans) were compared with all other students, and the white students were compared with all others. To assess the magnitudes of the differences between subgroups, effect sizes (ES(m)) were computed for means comparisons. RESULTS: Factor analysis formed two factors: Disease Beliefs and Management, and Cultural Concerns. Two remaining items loaded on a third factor that had reliability too low to support further analysis. Meaningful differences were found in cultural sensitivity based on students' ethnic backgrounds. The URM students performed better than did all other students in addressing the patient's concerns about altering culturally-based dietary behaviors for diabetes self-care [URM students' mean standardized score (SD) = 0.42 (0.15); all others = -0.01 (0.67); ES(m) = 1.05]. White students performed better than did all other students in assessing the patient's concerns about using insulin to control her blood sugar levels [white students' mean standardized score (SD) = 0.13 (0.40); all others = -0.10 (0.64); ES(m) = 0.4]. CONCLUSION: Cultural competency deficits and differences were measurable using a health-beliefs communications station, and these differences were meaningful enough to warrant faculty discussion and research about how to ensure that students master this competency.     

Sleep effects on slow-brain-potential reflections of associative learning

Previous research has indicated that information acquired before sleep gets consolidated during sleep. This process of consolidation might be reflected after sleep in changed extent and topography of cortical activation during retrieval of information. Here, we designed an experiment to measure those changes by means of slow event-related EEG potentials (SPs). Retrieval of newly learnt verbal or spatial associations was tested both immediately after learning and two days later. In the night directly following immediate recall, participants either slept or stayed awake. In line with previous studies, SPs measured during retrieval from memory had parietal or left-frontal foci depending on whether the retrieved associations were spatial or verbal. However, contrary to our expectations, sleep-related consolidation did not further accentuate these content-specific topographic profiles. Rather, sleep modified SPs independently of the spatial or verbal type of learned association: SPs were reduced more after sleep than after waking specifically for those stimulus configurations that had been presented in the same combination at retrieval before sleep. The association-independent stimulus-specific effect might generally form a major component of sleep-related effects on memory.     

Psychological adjustment in caregivers of school-age children infected with HIV: stress, coping, and family factors

OBJECTIVE: To assess for significant differences in psychological functioning between caregivers of HIV-infected children and caregivers of healthy children, and to examine the utility of applying a stress and coping model to caregivers of children with HIV disease. METHODS: Participants included caregivers of HIV-infected children (n = 36) and caregivers of a demographically matched control group of healthy children (n = 32). During their child's pediatric clinic visits, caregivers completed measures of psychological adjustment, stress, coping style, and family resources and support. They also completed a measure of their child's psychological adjustment. RESULTS: Caregiver psychological distress scores did not significantly differ between the HIV and control groups, and clinically significant rates of psychological distress were reported by more than a third of caregivers in both groups. Hierarchical multiple regression analyses revealed that independent of their child's illness status, stress and coping style were significant predictors of caregiver's psychological adjustment. In addition, caregiver psychological distress was a significant predictor of children's maladjustment. CONCLUSIONS: High rates of psychological distress were observed in caregivers of children with HIV disease; however, similarly high rates of psychological adjustment problems were found in caregivers of healthy children. Caregivers who reported high levels of daily stress and emotion-focused coping styles tended to report more psychological distress. Further, caregivers who reported more psychological distress also reported more internalizing and more externalizing behavior problems in their children, regardless of the child's illness status. These findings reflect the impact of poverty and environmental stress on caregivers' adjustment.     

Biofeedback-produced hemispheric asymmetry of slow cortical potentials and its behavioural effects

Two studies served to examine behavioural effects of slow cortical potentials (SPs). SPs were manipulated by means of a biofeedback procedure. The ability of human subjects to alter SPs differentially between the two hemispheres--specifically over the lateral aspects of the central sulcus--was tested by providing feedback of the SP difference between C3 and C4. In Expt. I, 21 of the 45 subjects produced hemispheric asymmetries of more than 2 microV between C3 and C4 on an average after 80 trials of analogue, continuous and immediate feedback. In Expt. II, SP changes were fed back digitally at the end of each trial. Within 120 trials, 20 of the 48 subjects reached the criterion of a minimum 2-microV difference in SPs between C3 and C4 on the average. Average differentiation remained significantly below the SP differentiations achieved for continuous feedback. Trials with feedback were followed by 'task' trials without feedback, during which subjects were still requested to produce SP changes but also had to complete a task: Either sensorimotor tasks (Expt. I) or forced choice handedness tasks (Expt. II) were presented to evaluate behavioural consequences of hemispheric SP differences. In subjects achieving the required SP differentiation it affected the behavioural output in agreement with the known functions of the respective cortical area.     

Patient and provider perceptions of diabetes: measuring and evaluating differences

OBJECTIVE: This study measures diabetes care perceptions of patients and their providers, and examines perceptions differences of patient-provider pairs. METHODS: Patient and provider perceptions were assessed using the Diabetes Semantic Differential Scales (DSDS) which ask respondents to rate diabetes care concepts using contrasting adjective pairs. The DSDS was scored by two methods: using means and using factor analysis. Persons with diabetes 40-years-old or older were recruited. Using a "snowball" sampling strategy, potential provider participants were identified by their patients; 71 providers agreed. These providers represented 51% of the patient participants and created 138 patient-provider pairs. RESULTS: For the mean scores, there were significant differences between patients and providers for 5 of the 18 semantic differentials (28%). Similarly, the factor scores indicated significant differences for 14 of 54 factors (26%). The effect sizes indicated practical differences. CONCLUSION: Significant differences exist between patient and provider perceptions. Generally, patients have the more positive diabetes perceptions. PRACTICE IMPLICATIONS: During patient and provider discussions, participants can perceive diabetes concepts differently. The DSDS can determine perception differences. While it is best to use factor analyses to score the DSDS, mean scores are more easily calculated and indicate the broad conceptual areas where patient and provider differ.     

Initial reliability of the Standardized Orthopedic Assessment Tool (SOAT)

CONTEXT: Orthopaedic assessment skills are critical to the success of athletic therapists and trainers. The Standardized Orthopedic Assessment Tool (SOAT) has been content validated. OBJECTIVE: To establish interrater reliability of the SOAT. PATIENTS OR OTHER PARTICIPANTS: Thirty-two college students, 10 raters, and 2 standardized patients (SPs) from Calgary, Alberta, Canada. DESIGN: Randomized observational study. INTERVENTION(S): Students were allowed 30 minutes to complete a mock orthopaedic assessment of an SP with an injury specific to a region of the body (shoulder, knee, or ankle). Using the region-specific SOAT, raters and SPs evaluated students' orthopaedic assessment skills. MAIN OUTCOME MEASURE(S): The sum totals of the SOAT for 2 raters and 1 SP were used to calculate each student's performance scores for respective scenarios. Scale reliability analysis (Cronbach alpha) was completed on the SOAT for each of the 3 body-region examinations. RESULTS: The mean overall reliability of 3 SOATs (ie, ankle, knee, and shoulder) was positive: alpha = .85 with the SP scores factored into the equation and alpha = .86 without the SP scores factored into the equation. Reliability for the ankle region was highest (alpha = .91), followed by the knee (alpha = .83) and the shoulder (alpha = .82). CONCLUSIONS: The study sample size was small, but the results will enable further study with generalization to a broader audience of athletic therapists and athletic trainers. Because a baseline measure of reliability was established using a robust statistical analysis, future researchers can employ more stringent statistical analysis and focus on the effects of various pedagogical techniques to teach and learn the underlying construct of clinical competence in orthopaedic assessment.     

Can patient-centered attitudes reduce racial and ethnic disparities in care?

PURPOSE: Patient-centeredness has been advocated to reduce racial/ethnic disparities in health care quality, but no empirical data support such a connection. The authors' purpose was to determine whether students with patient-centered attitudes have better performance and are less likely to demonstrate disparities with African American compared with white standardized patients (SPs). METHOD: Third-year medical students were assessed by SPs at the Clinical Educational Center of the Johns Hopkins University School of Medicine in 2002. One African American and one white actor were trained as SPs for each of four case scenarios; students were randomly assigned to interact with either SP for each case. Before the exam, students were surveyed about their attitudes towards patient-centered medicine. Students with and without patient-centered attitudes were compared with regard to their performance with African American and white SPs. Outcome measures were student exam scores in interpersonal skill, history taking, physical exam, and counseling. RESULTS: All 177 of eligible students participated in all four case scenarios. With white SPs, students with patient-centered attitudes performed similarly to students without patient-centered attitudes in all four areas. However, with African American SPs, students with patient-centered attitudes performed significantly better than students without patient-centered attitudes in interpersonal skills (71.4 versus 69.4, P = .010), history taking (63.8 versus 61.1, P = .003), and counseling (92.1 versus 88.7, P = .002) and not significantly different in physical exam performance (73.6 versus 68.6, P = .311). CONCLUSIONS: Patient-centered attitudes may be more important in improving physician behaviors with African American patients than with white patients and may, therefore, play a role in reducing disparities.     

A comparison of global ratings and checklist scores from an undergraduate assessment using an anesthesia simulator.

PURPOSE: To determine the correlation between global ratings and criterion-based checklist scores, and inter-rater reliability of global ratings and criterion-based checklist scores, in a performance assessment using an anesthesia simulator. METHOD: All final-year medical students at the University of Toronto were invited to work through a 15-minute faculty-facilitated scenario using an anesthesia simulator. Students' performances were videotaped and analyzed by two faculty using a 25-point criterion-based checklist and a five-point global rating of competency (1 = clear failure, 5 = superior performance). Correlations between global ratings and checklist scores, as well as specific performance competencies (knowledge, technical skills, and judgment), were determined. Checklist and global scores were converted to percentages; means of the two marks were compared. Mean reliability of a single rater for both checklist and global ratings was determined. RESULTS: The correlation between checklist and global ratings was.74. Mean ratings of both checklist and global scores were low (58.67, SD = 14.96, and 57.08, SD = 24.27, respectively); these differences were not statistically significant. For a single rater, the mean reliability score across rater pairs for checklist scores was.77 (range.58-.93). Mean reliability score across rater pairs for global ratings was.62 (.40-.77). Global ratings correlated more highly with technical skills and judgment (r =.51 and r =.53, respectively) than with knowledge. (r =.24) CONCLUSION: Inter-rater reliability was higher for checklist scores than for global ratings; however, global ratings demonstrated acceptable inter-rater reliability and may be useful for competency assessment in performance assessments using simulators.     

Trait anxiety and reactions to patient-centered and doctor-centered styles of communication: an experimental study

OBJECTIVE: A patient-centered model of communication has often been advocated in preference to a doctor-centered model. The aim of the present study was to assess in an experimental setting how subjects' general level of anxiety affects their reactions to these two communication styles as measured by emotional reactions and satisfaction immediately after consultation. METHODS: Twenty students with low trait anxiety and 21 students with high trait anxiety each had a single consultation with a physician who performed the consultation using either a patient-centered or doctor-centered style of communication. Questionnaires about emotional state were completed by the students before and after the consultation, and a questionnaire about satisfaction was completed after the consultation. RESULTS: Students with low trait anxiety were significantly more satisfied with a patient-centered than a doctor-centered style of communication. There were no significant differences in emotional response to the two styles of communication. Students with high trait anxiety reacted emotionally more positively to a doctor-centered communication style, with significant and nearly significant change scores for the emotions of tension/anxiety and vigor/activity, respectively. No significant difference was found between satisfaction scores. CONCLUSIONS: Data indicate that differences between subjects' emotional traits may be of importance for a differentiated response to patient-centered and doctor-centered communication styles. Subjects' trait anxiety seems to be a significant factor that should be taken into account when assessing the effects of different communication styles.     

Sustaining program effectiveness after implementation: The case of the self-management of well-being group intervention for older adults

ObjectiveThe Self-Management of Well-being (SMW) group intervention for older women was implemented in health and social care. Our aim was to assess whether effects of the SMW intervention were comparable with the original randomized controlled trial (RCT). Furthermore, we investigated threats to effectiveness, such as participant adherence, group reached, and program fidelity.MethodsIn the implementation study (IMP) 287 and RCT 142 women participated. We compared scores on self-management ability and well-being of the IMP and RCT. For adherence, drop-out rates and session attendance were compared. Regarding reach, we compared participants’ baseline characteristics. Professionals completed questions regarding program fidelity.ResultsNo significant differences were found on effect outcomes and adherence between IMP and RCT (all p ≥ 0.135). Intervention effect sizes were equal (0.47–0.59). IMP participants were significantly less lonely and more likely to be married, but had lower well-being. Most professionals followed the protocol, with only minimal deviations.ConclusionThe effectiveness of the SMW group intervention was reproduced after implementation, with similar participant adherence, minimal changes in the group reached, and high program fidelity.Practice implicationsThe SMW group intervention can be transferred to health and social care without loss of effectiveness. Implementation at a larger scale is warranted.     

"Teach 1, do 1 ... better": superior communication skills in senior medical students serving as standardized patient--examiners for their junior peers.

PURPOSE: To see if senior medical students who had served as standardized patients (SP) demonstrated improvement in their own interpersonal communication skills. METHOD: From George Washington School of Medicine's class of 1996, 154 fourth-year students took a clinical practice examination that used professional SPs. Within the preceding six months, 28 of these students had been SP-examiners in similar examinations for first- and second-year medical students. The professional SPs rated the fourth-year examinees using checklists that measured five dimensions of interpersonal communication skills. Four of these five dimensions were identical to those measured on the examinations for which the fourth-year students had served as SPs. Hypothesizing that the SP-experienced seniors would outscore their inexperienced classmates on those four dimensions, but not on the fifth, the authors analyzed the fourth-year students' scores. P values were computed by the F test from a two-way analysis of variance. RESULTS: As predicted, the group with prior SP experience significantly outscored their inexperienced colleagues in each of the four expected dimensions of interpersonal communication skills, with p values ranging from .000 to .023. The score differential in these dimensions ranged from 3.8 to 11.8 percentage points. As further predicted, there was no significant difference between the scores of the two groups on the fifth dimension. CONCLUSION: Compared with their inexperienced peers, senior medical students with prior SP experience consistently demonstrated superior scores when their own communication skills were tested in a similar manner. The U.S. Medical Licensing Examinations propose to incorporate SP clinical examinations; in response, medical schools will use more SP examinations in their own curricula. Such examinations are expensive when using professional standardized patients; the authors believe that an SP program using senior medical students will prove an attractive alternative. Such programs may have the added advantage of making better communicators of senior medical student teachers as well as the students they teach.     

Comparing Repeated Measures Means in Factorial Designs

The effects of violating multisample sphericity were investigated for multiple comparison procedures for pairwise contrasts in nonorthogonal split-plot repeated measures designs. Results indicated that rates of Type I error of the multiple comparison procedures are affected not only by assumption violations but also by the type of nonorthogonal solution. Specifically, if one intends to test contrasts of unweighted means, as would be the case when the unequal group sizes are due to random loss, then all multiple comparison procedures investigated, including the previously recommended Bonferroni procedure, are prone to excessive rates of Type I errors. A satisfactory solution to this bias is to obtain additional data in order to achieve equal group sizes and hence an orthogonal design. For tests of contrasts of weighted repeated measures means, which would be of interest when the unequal group sizes are representative of population group sizes, the Bonferroni approach to Type I error control is satisfactory. In most instances, a Bonferroni critical value will provide a more powerful test than a multivariate critical value.     

Robust fluoroscopic respiratory gating for lung cancer radiotherapy without implanted fiducial markers

For gated lung cancer radiotherapy, it is difficult to generate accurate gating signals due to the large uncertainties when using external surrogates and the risk of pneumothorax when using implanted fiducial markers. We have previously investigated and demonstrated the feasibility of generating gating signals using the correlation scores between the reference template image and the fluoroscopic images acquired during the treatment. In this paper, we present an in-depth study, aiming at the improvement of robustness of the algorithm and its validation using multiple sets of patient data. Three different template generating and matching methods have been developed and evaluated: (1) single template method, (2) multiple template method, and (3) template clustering method. Using the fluoroscopic data acquired during patient setup before each fraction of treatment, reference templates are built that represent the tumour position and shape in the gating window, which is assumed to be at the end-of-exhale phase. For the single template method, all the setup images within the gating window are averaged to generate a composite template. For the multiple template method, each setup image in the gating window is considered as a reference template and used to generate an ensemble of correlation scores. All the scores are then combined to generate the gating signal. For the template clustering method, clustering (grouping of similar objects together) is performed to reduce the large number of reference templates into a few representative ones. Each of these methods has been evaluated against the reference gating signal as manually determined by a radiation oncologist. Five patient datasets were used for evaluation. In each case, gated treatments were simulated at both 35% and 50% duty cycles. False positive, negative and total error rates were computed. Experiments show that the single template method is sensitive to noise; the multiple template and clustering methods are more robust to noise due to the smoothing effect of aggregation of correlation scores; and the clustering method results in the best performance in terms of computational efficiency and accuracy.     

Prevalence of Hyperactivity

This study reports the results of the Conners Teacher RatingScale completed for a random sample of 14,083 elementary schoolchildren. Prevalence estimates of hyperactivity and other problemsshowed marked consistency across age and teachers. As expectedboys tended to be identified as problems more frequently thangirls. Prevalence rates obtained in this study were comparedwith others obtained using the same instrument in other countries.The problems of using arbitrary cutoff scores with such instrumentsare discussed.     

Attributional biases in subclinical depression: A schema‐based account

Non‐depressed individuals exhibit a self‐serving attributional bias, taking more credit for success than for failure. Clinically and subclinically depressed people are less self‐serving, often to the point of making similar attributions (explanations) for successes and failures. The present studies evaluated a schematic account of these distinct attributional biases. Subclinically depressed and non‐depressed participants completed measures of attributional bias (the relative strength of ability attributions for success versus failure), schema‐based optimism (the relative expectedness of success versus failure) and self‐schemas of competence. Two studies evaluated a hypothesis derived from the schematic account: the greater the perceived competence and optimism, the more self‐serving the attributional bias. As predicted, (a) attributional bias scores covaried with optimism and competence scores in both magnitude and valence (or direction), (b) depressed‐non‐depressed differences in attributional biases paralleled differences in competence and optimism and (c) when attributional bias scores were adjusted for the effects of optimism or competence, depressed–non‐depressed differences in attributional biases were eliminated. The schematic account raises questions about the common assumptions that attributional patterns are traits, and that they play a central role in the aetiology and treatment of depression. Copyright © 2007 John Wiley & Sons, Ltd.     

Serrated polyps of the colon: how reproducible is their classification?

For several years, the lack of consensus on definition, nomenclature, natural history, and biology of serrated polyps (SPs) of the colon has created considerable confusion among pathologists. According to the latest WHO classification, the family of SPs comprises hyperplastic polyps (HPs), sessile serrated adenomas/polyps (SSA/Ps), and traditional serrated adenomas (TSAs). The term SSA/P with dysplasia has replaced the category of mixed hyperplastic/adenomatous polyps (MPs). The present study aimed to evaluate the reproducibility of the diagnosis of SPs based on currently available diagnostic criteria and interactive consensus development. In an initial round, H&E slides of 70 cases of SPs were circulated among participating pathologists across Europe. This round was followed by a consensus discussion on diagnostic criteria. A second round was performed on the same 70 cases using the revised criteria and definitions according to the recent WHO classification. Data were evaluated for inter-observer agreement using Kappa statistics. In the initial round, for the total of 70 cases, a fair overall kappa value of 0.318 was reached, while in the second round overall kappa value improved to moderate (kappa?=?0.557; p?<?0.001). Overall kappa values for each diagnostic category also significantly improved in the final round, reaching 0.977 for HP, 0.912 for SSA/P, and 0.845 for TSA (p?<?0.001). The diagnostic reproducibility of SPs improves when strictly defined, standardized diagnostic criteria adopted by consensus are applied.     

Assessing validity of standardized patient ratings of medical students' communication behavior using the Roter interaction analysis system

OBJECTIVE: The primary objective of this study is to examine concurrent validity of standardized patient (SP) ratings of second year medical students' communication skills with the Roter interaction analysis system (RIAS). METHODS: We designed An Integrated Medical Encounter (AIME), to teach second year medical students the link between communication and clinical reasoning with emphasis placed on understanding the connection between biomedical and psychosocial aspects of patient care. We randomized 120 students to intervention (AIME) and control groups (non-AIME). Students completed two post-intervention SP encounters which were videotaped and coded using RIAS. SPs used a 30-item checklist to rate students' communication behaviors. RESULTS: There were no differences between AIME and non-AIME students in age, ethnicity, gender, or college major; however, more AIME students reported prior health professional work. SPs rated AIME students' rapport-building skills higher (mean [S.E.]: 4.1 [0.15] vs. 3.9 [0.15], p=0.05); however, there were no differences in data gathering, patient education/counseling. RIAS demonstrated that AIME students more frequently used rapport-building statements (60.4 [2.7] vs. 52.1 [2.8], p=0.03). CONCLUSION: The RIAS confirmed SP ratings of differences in AIME and non-AIME students' rapport-building skills. PRACTICE IMPLICATIONS: Future studies in medical education should further examine the minimum number of SP ratings needed to effectively evaluate communication skills curricula when resources are limited.     

Predictors of psychological adjustment in school-age children infected with HIV

OBJECTIVE: To assess for significant differences in psychological functioning between HIV-infected children and a demographically matched healthy control group and to examine the utility of applying a stress and coping model to children with HIV disease. METHODS: Participants included HIV-infected children (ages 6-16) and their caregivers (n = 36) and a control group of healthy children and their caregivers (n = 32). During routine clinic visits, children completed measures of psychological adjustment, health locus of control, and coping style, and caregivers completed measures of their own and their child's psychological adjustment. RESULTS: Caregiver-reported and child self-reported psychological adjustment scores did not significantly differ between the HIV and control groups, with the exception of significantly more internalizing behavior problems reported in the control group. Hierarchical multiple regression analyses revealed that the stress and coping model accounted for 36% of the variance in HIV-infected children's self-reported psychological adjustment. In addition, child age and coping style were significant predictors of child self-reported psychological adjustment, but not of caregiver-reported child adjustment. CONCLUSIONS: Approximately 25% of children with HIV disease exhibited clinically significant emotional or behavioral problems; however, even higher rates of psychological adjustment problems were found in healthy children. Children with HIV disease who have not been told their diagnosis and children who endorse more emotion-focused coping strategies tend to exhibit more psychological adjustment problems.     

A dietary study of the elderly in the city of Roskilde 1988/89. Methodological aspects of the relative validity of the dietary history method

In winter 1988/89, 194 elderly adults (96 men and 98 women, aged 70-75 years) were interviewed, using the dietary history method. The relative validity of a dietary history method used in this elderly population was assessed. The record of intake of energy and nutrients from the dietary history method was compared with that obtained in the same group by means of a 3-day food record completed during the same period. For daily intake of energy and nutrients, the differences in mean intake were generally below 15%. But mean differences were significant for energy, fat, dietary fiber, and calcium. The two dietary methods correlated well for energy and nutrients. Pearson's correlation coefficient varied from 0.80 (dietary fiber) to 0.24 (vitamin A). The two methods classified about half of the subjects similarly into tertiles for energy and most nutrients. Gross misclassification occurred for 2-17% of the subject. Agreement between the two methods were poorest for vitamin A. The results suggest that the dietary history method may be inadequate for determining the exact level of mean and distribution of dietary intake in a group or the precise intake of an individual. But the method could be used to test differences in means between groups and to rank subjects as to their dietary intake within the study.