ABSTRACT
É fácil constatar em conversas informais com estudantes de Medicina que nos momentos de dificuldades apelam para a ajuda materna. Partindo desta observação os autores fazem uma revisão da literatura sobre a influência materna na educação da pessoa e as consequências que se decorrem na escolha da profissão médica. A incorporação de valores e atitudes, com ênfase na empatia, está de algum modo atrelada ao cenário de aprendizado junto das mães. Melhorar a seleção de candidatos às faculdades de medicina deve contemplar requisitos que vão além dos conhecimentos técnico-científicos, parâmetros que também estão relacionados com a figura materna formadora. As referências variadas que os autores incluem no presente trabalho servem de base para uma reflexão a todos os que estão envolvidos no mundo da educação médica. Caberá à criatividade de cada um encontrar o modo de incorporar o exemplo que as mães proporcionam como elemento de sinergia na formação profissional.
ABSTRACT
The greater the psychosocial health, the greater is the well-being and the capacity for adaptation and overcoming problems and common life frustrations in family, relationships, and work. Medical students and practicing physicians, in comparison with the general population and that of other professions, are exposed to academic and professional stress and therefore are vulnerable to psychosocial health problems and certain specific dysfunctions that may compromise their physical, mental, and social health. In the field of psychosocial research in medical education, the key issue is to find relevant and psychometrically sound measures. The Jefferson Medical College's Psychosocial Questionnaire contains abridged versions of nine personality tests, as well as questions about respondents' relationships with parents in the first five years of life and with classmates in the early schooling. The scales in the questionnaire have shown satisfactory internal consistency reliability and construct validity through factor analysis. To our knowledge, in Mexico, there is not a specific questionnaire that measures psychosocial profile in a non-clinical population such as medical students. The present study adapted and translated the questionnaire from English to Spanish in order to evaluate its validity and reliability in Mexican medical students, to further learn its predictive validity of academic performance. In this study, we compared the factor structure in Mexico to the results obtained in the United States research. Implications for predicting academic and clinical performance of medical students and physicians were discussed. Study participants consisted of 3,603 matriculates at the Escuela de Medicina de la Universidad Autónoma de Nuevo León (Mexico). Psychosocial measures included Loneliness, Test anxiety, General anxiety, Self-esteem, Extroversion, External locus of control, Neuroticism, Depression, Stressful life events, Perceptions of early relationships with mother and father, Peer relationships and Perception of health, used by researchers at Jefferson Medical College in the United States. The items were translated into Spanish and back translated from Spanish to English, following the guidelines for adaptation of instruments for psychological evaluation. The questionnaire was administered in the third month after admission of the students to the Medicine School in the students' usual classrooms, on a schedule and day set aside for it according to the school's administration program. They were assured of the strict confidentiality of the test scores and of the individual data. Dimensionality of 40 items of the eight brief psychosocial scales was assessed with factor analysis using the principal components extraction method and orthogonal rotation; the Depression Scale was not included in the factorial analysis because it was not shortened for the present study. Correlation coefficients and internal consistencies were calculated for all the scales. Unidimensionality and construct validity were confirmed for measures of Loneliness, Test anxiety, General anxiety, Self-esteem, and Extroversion. The pattern and direction of the scale correlations with external criterion measures supported the concurrent validity of some of the measures. Also, the magnitude and direction of the inter-scale correlations supported the convergent and discriminant validities with the exception of the External locus of control and Neuroticism scales. The results supported the psychometric properties of the scales useful for providing information for medical educators and mental health professionals in early detection of psychosocial problems. It is important to mention that in spite of frequent talk about the importance of health among college students, few schools of Medicine in Mexico and in Latin America actually promote empirical research and support detect problems and develop solutions once they are identified. The mental health professionals should be responsible for sharing their understanding. They are capable of helping faculty for optimizing mental health through allocation of educational and remedial resources when designing academic programs in agreement with necessities of their students.
Como la literatura consigna, los estudiantes y profesionales de la Medicina en comparación con la población general y de otras carreras conforman una población que resulta vulnerable frente a los trastornos de salud psicosocial. En la investigación psicosocial de la educación médica un punto clave corresponde a la identificación de medidas relevantes con cualidades psicométricas. En el presente trabajo se analiza la validez y confiabilidad de un conjunto de escalas psicosociales aplicadas a 3.603 alumnos de la Facultad de Medicina de la Universidad Autónoma de Nuevo León (México). Las escalas administradas fueron: Soledad, Ansiedad ante los exámenes, Ansiedad general, Autoestima, Extroversión, Locus de control externo, Neuroticismo, Depresión, Eventos estresantes en la vida, Percepción de relaciones tempranas con los padres y amigos y Percepción de estado de salud general. Estas escalas fueron propuestas por investigadores de la Escuela de Medicina de Jefferson (Estados Unidos). Se confirmó la unidimensionalidad y la validez de constructo de las mediciones de Soledad, Ansiedad ante los exámenes, Ansiedad general, Autoestima y Extroversión. Así también, la magnitud y dirección de las correlaciones interescalas apoyaron la validez convergente y discriminante, con excepción de Locus de control externo y Neuroticismo. Los resultados confirman las propiedades psicométricas de las escalas, las cuales son útiles para proveer información a los educadores médicos y a profesionales de la salud mental en la detección temprana de problemas psicosociales quienes en conjunto pueden coadyuvar en la optimización de la salud mental de los estudiantes de escuelas de Medicina a través de programas académicos acordes a sus necesidades.
ABSTRACT
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Summary Introduction A meaningful doctor-patient relationship is a key factor in medical practice and in the art of curing. In the past, several institutions have recommended the addition of humanistic education among medical doctors not only for enhancing the doctor-patient relationship, but also for improving the quality of medical care. In fact, an empathic physician-patient relationship has been associated with better clinic outcomes. In spite of recommendations, medical empathy is still an unexplored research area in medical education for two reasons. One of these is that theoretical research on empathy is not easy because of a lack of clarity in its conceptualization. Another reason for the dearth of empirical research is the absence of a valid and reliable operational tool by which to measure empathy in patient care situations. A team from the Center for Research in Medical Education and Health Care at the Medical College of Thomas Jefferson University, developed the Jefferson Scale of Physician Empathy (JSPE). The English version factor structure is consistent with conceptual aspects of a multidimensional scale that measures the perspective taking, compassionate care and "standing in the patient's shoes" factors. The JSPE has shown satisfactory psychometric properties; construct, discriminant, and criterion validity has been confirmed among medical students with an internal consistency of 0.89. Empathy may vary among individuals depending on social, educational, and personal experiences, and it corresponds to an interpersonal ability and a clinical competence component. Hence, the availability of a valid and reliable instrument for measuring empathy among medical doctors is a critical issue. However, the instrument should be culturally adapted for the population of interest. Therefore, the present study was designed for evaluating the validity and reliability of the Spanish version of the JPES among Mexican medical students. Material and methods Subjects: 1022 medical students (mean age 21±2.7 years) from the School of Medicine at the Autonomous University of Nuevo Leon, in Monterrey, Mexico (494 women and 528 men). Instrument: The students' version of the JSPE was used to measure the orientation of medical students towards empathy in patient care situations. The JSPE consists of 20 items on a seven-point Likert scale (1=strongly disagree, 7= strongly agree). Procedures: The JSPE was translated into Spanish and back translated following the guidelines to adaptate psychological evaluation instruments. The questionnaire was answered by first (n=687), third (n=183) and fifth grade (n=152) medical students. They were assured of the strict confidentiality of the test and of the individual responses. Plan of analysis: Dimensionality of 20 items was assessed with factors analysis using the principal components extraction method and orthogonal rotation. Cronbach's alpha was calculated for evaluating the internal consistency. Results The exploratory factor analysis allowed the identification of three factors with eigen values greater or equal to one. All the items with coefficients greater than 0.30 of the first factor were positive and corresponded to the perspective taking domain. On the other hand, seven out of ten negative questions loaded to the second factor with coefficients greater than 0.40; all of them were related to compassionate care. Finally, there were other two questions with high loading on the third factor, which matched to "standing in the patient's shoes" domain. The internal consistency was 0.74. The mean of empathy scores was 110 and the standard deviation, 14. The observed range was 44-140 compared to the possible range of 20-140. The mean empathy score was higher for women than men (111.9 ±13.9 vs. 109.08± 14.1, p=.002). Age was not significantly correlated with empathy scores, even after controlling for sex (women: r=-0.01; men: r=0.02). Conclusions The results of study supported the validity of the JSPE among medical students in Mexico. The first factor (perspective taking) corresponded to the main component of empathy. The other two factors, compassionate care and "standing in the patient's shoes", were related to specific components of the doctor-patient relationship. The observed internal consistency was satisfactory for personality tests. The findings showed significantly higher empathy scores for women than men, suggesting that female doctors might render a different type of medical care. These findings are consistent with those reported for U.S.A. medical students. It has been informed that women are more receptive to emotional signs than men and that they devote more time and offer more preventive care to their patients. More scientific evidence is needed to explain these sex differences which represents different implications for the selection of medical training. Interpersonal relationships are especially critical between physicians and patients. Failures in understanding a patient's perspective may result in communication problems, which in turn contribute to the patient's dissatisfaction with care. As soon as the doctor understands what his/her patient thinks and feels, he/she can offer a better care. This is how empathy translates into the vehicle of a meaningful doctor-patient relationship. Finally, empathy measurement is meaningful because it constitutes the first step for examining permanence from the first years of the medical career up to specialty training years. It also allows for the analysis of the impact of educational strategies designed to improve empathy and achieve potential benefits not only for the doctors' professional development but also for their patients' health.