Sleep education for medical students: A study exploring gaps and opportunities.

PURPOSE: To explore final-year medical students' perceptions of sleep education during medical school to inform the development of a sleep curriculum. METHODS: Year 6 medical students on their final general practice placement in 2020 were invited to complete an online survey including questions regarding sleep education recalled during the medical programme. RESULTS: Responses were received from 51/71 (72 %) students. Main learning topics recalled by participants were sleep apnoea (83 %), sleep physiology (71 %), and snoring (69 %). Education in other topics was reported by <65 % of students. Priority topics for students were treating common sleep disorders, taking a sleep history, and navigating shift work. CONCLUSIONS: Whilst the majority of students recalled education on specific topics, many had little awareness of education relating to sleep assessment, insomnia, or shift work. Sleep education in the curriculum needs more emphasis and reinforcement given sleep's relevance across many domains of health and morbidity. We propose that an identifiable sleep curriculum is required to ensure medical students have the necessary core education regarding sleep and sleep disorders both for patients and themselves. Further, we believe this is possible to achieve in a short timeframe within the constraints of an existing curriculum and propose some creative solutions.

Sleep well to perform well: the association between sleep quality and medical student performance in a high-stakes clinical assessment.

Study Objectives: To investigate medical students' sleep quality and duration prior to a major clinical assessment, and their association with clinical performance. Methods: Third year medical students were surveyed following the end of year Observed Structured Clinical Examination (OSCE) using a self-completed questionnaire. The questionnaire focussed on sleep in the month and night before the assessment. OSCE scores were linked to questionnaire data for analysis. Results: The response rate was 76.6% (216/282). Poor sleep quality (Pittsburgh Sleep Quality Index > 5) was reported by 56.9% (123/216) and 34.7% (75/216) of students the month and night before the OSCE, respectively. Sleep quality the night before the OSCE was significantly associated with OSCE score (p = .038), but not sleep quality in the preceding month. The night before the OSCE, students obtained an average of 6.8 h sleep (median 7, SD 1.5, range 2-12 h). Short sleep duration (≤6 h) was reported by 22.7% (49/216) and 38.4% (83/216) of students in the month and the night before the OSCE, respectively. Sleep duration the night before the OSCE was significantly associated with OSCE score (p = .026), but no significant association was found between OSCE score and sleep duration in the preceding month. Use of medication to help with sleep was reported by 18.1% (39/216) of students in the preceding month and by 10.6% (23/216) in the night before the OSCE. Conclusions: Medical students' sleep quality and duration the night before a clinical assessment were correlated with their performance in that assessment.

Modification of maternal late pregnancy sleep position: a survey evaluation of a New Zealand public health campaign.

INTRODUCTION: A 'Sleep-On-Side When Baby's Inside' public health campaign was initiated in New Zealand in 2018. This was in response to evidence that maternal supine going-to-sleep position was an independent risk factor for stillbirth from 28 weeks' gestation. We evaluated the success of the campaign on awareness and modification of late pregnancy going-to-sleep position through nationwide surveys. METHODS AND ANALYSIS: Two web-based cross-sectional surveys were conducted over 12 weeks in 2019-2020 in a sample of (1) pregnant women ≥28 weeks, primary outcome of going-to-sleep position; and (2) health professionals providing pregnancy care, primary outcome of knowledge of going-to-sleep position and late stillbirth risk. Univariable logistic regression was performed to identify factors associated with supine going-to-sleep position. DISCUSSION: The survey of pregnant women comprised 1633 eligible participants. Going-to-sleep position last night was supine (30, 1.8%), non-supine (1597, 97.2%) and no recall (16, 1.0%). Supine position had decreased from 3.9% in our previous New Zealand-wide study (2012-2015). Most women (1412, 86.5%) had received sleep-on-side advice with no major resultant worry (1276, 90.4%). Two-thirds (918, 65.0%) had changed their going-to-sleep position based on advice, with most (611 of 918, 66.5%) reporting little difficulty. Supine position was associated with Maori (OR 5.05, 95% CI 2.10 to 12.1) and Asian-non-Indian (OR 4.20, 95% CI 1.27 to 13.90) ethnicity; single (OR 10.98, 95% CI 4.25 to 28.42) and cohabitating relationship status (OR 2.69, 95% CI 1.09 to 6.61); hospital-based maternity provider (OR 2.55, 95% CI 1.07 to 6.10); education overseas (OR 3.92, 95% CI 1.09 to 14.09) and primary-secondary level (OR 2.80, 95% CI 1.32 to 6.08); and not receiving sleep-on-side advice (OR 6.70, 95% CI 3.23 to 13.92). The majority of health professionals (709 eligible participants) reported awareness of supine going-to-sleep position and late stillbirth risk (543, 76.6%). CONCLUSION: Most pregnant women had received and implemented sleep-on-side advice without major difficulty or concern. Some groups of women may need a tailored approach to acquisition of going-to-sleep position information.

Sleep education for healthcare providers: Addressing deficient sleep in Australia and New Zealand.

Deficient sleep has been recognized as a current health crisis in Australia and New Zealand, contributing to the increased prevalence and severity of chronic diseases and mental health issues. However, all healthcare disciplines currently receive limited training in addressing deficient sleep, which is contributing to the current health crisis. This narrative review considers the following: (1) the prevalence and burden of deficient sleep in Australia and New Zealand; (2) the limited sleep education in healthcare training programs; (3) healthcare providers' lack of knowledge and evidence-based clinical practice in sleep disorders; (4) sleep-focused education initiatives for healthcare providers; (5) an action agenda for improved sleep education for healthcare providers. Both domestic and international sleep initiatives are considered, as is the role of general practitioners (primary care physicians), pediatricians, psychologists, pharmacists, and nurses. Three key themes emerge and guide action: (1) relevant training for students from all healthcare disciplines; (2) continuing professional development for practicing healthcare providers; and (3) translation of evidence-driven best practice into clinical practice. To achieve this sleep education agenda, the sleep community must form and strengthen partnerships across professional associations, public health agencies, and education providers. By improving education and clinical practice in sleep, we will equip healthcare providers with the knowledge and skills needed to address deficient sleep in Australia and New Zealand.

Reliability of Mini-CEX Assessment of Medical Students in General Practice Clinical Attachments.

BACKGROUND AND OBJECTIVES: Mini Clinical Evaluation eXercise (mini-CEX) involves observation of routine clinical encounters, initially developed to assess clinical competencies of postgraduate doctors. This study aimed to measure its inter-rater reliability in assessment of medical students in general practice settings. METHODS: General practitioners (GPs) supervising medical students were invited to complete online teaching on how to conduct a mini-CEX. This included three randomly presented scripted films of clinical scenarios representing different levels of student performance. Consenting participants completed an online mini-CEX. Mean marks were calculated for each case, Intraclass Correlation Coefficients (ICC) for overall clinical and four individual competencies, one-way analysis of variance to compare scores, and internal consistency measured by Cronbach's alpha. RESULTS: RESULTS were collated for the first 100 completing GPs, majority aged 40-59 years (71%), male (59%), New Zealand European (58%). Forty-four percent were in rural practice, with 21 mean years in practice. Mean mini-CEX grades increased as standardized performance increased, indicating that GPs reliably agreed about ranking of student performance from poor to very good. The intraclass correlation coefficient (ICC) for overall clinical competency was 0.78 (95% confidence interval 0.48-0.99), indicating good reliability regarding their agreement with each other. A Cronbach's alpha calculated with the overall scores was 0.85, indicating good internal consistency. CONCLUSIONS: Mini-CEXs in undergraduate general practice attachments provide a reliable measure of assessing performance. However, they may be less useful in identifying exceptional performance or weaknesses in key competencies. In addition, caution must be applied in relying upon mini-CEXs to supply a summative assessment.

Simplified sleep restriction for insomnia in general practice: a randomised controlled trial.

BACKGROUND: Insomnia is common in primary care. Cognitive behavioural therapy for insomnia (CBT-I) is effective but requires more time than is available in the general practice consultation. Sleep restriction is one behavioural component of CBT-I. AIM: To assess whether simplified sleep restriction (SSR) can be effective in improving sleep in primary insomnia. DESIGN AND SETTING: Randomised controlled trial of patients in urban general practice settings in Auckland, New Zealand. METHOD: Adults with persistent primary insomnia and no mental health or significant comorbidity were eligible. Intervention patients received SSR instructions and sleep hygiene advice. Control patients received sleep hygiene advice alone. Primary outcomes included change in sleep quality at 6 months measured by the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and sleep efficiency (SE%). The proportion of participants reaching a predefined 'insomnia remission' treatment response was calculated. RESULTS: Ninety-seven patients were randomised and 94 (97%) completed the study. At 6-month follow-up, SSR participants had improved PSQI scores (6.2 versus 8.4, P<0.001), ISI scores (8.6 versus 11.1, P = 0.001), actigraphy-assessed SE% (difference 2.2%, P = 0.006), and reduced fatigue (difference -2.3 units, P = 0.04), compared with controls. SSR produced higher rates of treatment response (67% [28 out of 42] versus 41% [20 out of 49]); number needed to treat = 4 (95% CI = 2.0 to 19.0). Controlling for age, sex, and severity of insomnia, the adjusted odds ratio for insomnia remission was 2.7 (95% CI = 1.1 to 6.5). There were no significant differences in other outcomes or adverse effects. CONCLUSION: SSR is an effective brief intervention in adults with primary insomnia and no comorbidities, suitable for use in general practice.

A double-blind randomised controlled study of a brief intervention of bedtime restriction for adult patients with primary insomnia.

INTRODUCTION: Bedtime restriction is effective for volunteer patients with primary insomnia. AIM: To determine the effectiveness of bedtime restriction in adult volunteers with primary insomnia. METHODS: Patients were recruited in response to articles in local newspapers. The study hypothesis was not given in the articles. Patients were assessed as to whether or not they had primary insomnia. They completed a two-week sleep diary after which they met the investigators and were randomised to either bedtime restriction and basic sleep hygiene or the control group with basic sleep hygiene only. A total of 224 potential participants applied to be in the study. Of the 52 who had primary insomnia, 45 were randomly allocated to either control or intervention group and only two did not complete the study. Randomisation was concealed and participants were blinded regarding the treatment. The primary outcome was also measured in a blinded fashion. RESULTS: The outcome evaluated was patient description of 'better' or 'much better' quality of sleep versus the 'same', 'worse' or 'much worse' quality of sleep at six weeks. Overall, 73% (16/22) of those in the intervention group were either having better or much better quality of sleep after treatment, while in the control group this was 35% (8/23). The number needed to treat was 3 [95% CI 2-11] for bedtime restriction and sleep hygiene versus sleep hygiene alone. DISCUSSION: This is the first study using bedtime restriction designed to be feasible in primary care by using a brief intervention and a patient-oriented outcome.

Prevalence of causes of insomnia in primary care: a cross-sectional study.

BACKGROUND: As a result of a research interest in primary insomnia, the prevalence of other causes of insomnia in primary care must be ascertained. No source was found in the literature. It is also essential to know the epidemiology of the common causes of a condition to make an accurate diagnosis in primary care. AIM: To determine the prevalence of causes of insomnia in primary care, as part of a method of identifying patients with primary insomnia. DESIGN AND SETTING: Cross-sectional study in three general practices in Auckland, New Zealand. METHOD: Consecutive patients from the waiting room were asked to complete a nine-page questionnaire on possible causes of insomnia. RESULTS: In total, 1517 patients were approached and 955 completed the nine-page questionnaire (63%). Of the 41% (388) who reported difficulty with sleeping, primary insomnia occurred in 12% (45) of the population (95% confidence interval = 9% to 15%); 50% (195) had depression, 48% (185) had anxiety and 43% (165) had general (physical) health problems. Obstructive sleep apnoea occurred in 9% (34) and delayed sleep phase disorder in 2% (7). Only primary insomnia and delayed sleep phase disorder are mutually exclusive; the others can co-exist. CONCLUSION: This is the first description of the prevalence of causes of insomnia in primary care. It is hoped that the focus on primary insomnia will result in more behavioural treatments and lower the use of hypnotics in primary care; it should also assist in the appropriate detection and treatment of other causes of insomnia in primary care.

Development, validation (diagnostic accuracy) and audit of the Auckland Sleep Questionnaire: a new tool for diagnosing causes of sleep disorders in primary care.

INTRODUCTION: Sleep disorders are common in the community and in primary care populations. Epidemiological surveys generally report insomnia rather than specific diagnoses. AIM: Our aim was to develop a questionnaire that could diagnose common sleep disorders in primary care in order to be able to make a diagnosis of primary insomnia by excluding other causes. Having created such a questionnaire, we then validated it (assessed the diagnostic accuracy). METHODS: The questionnaire was developed from the International Classification of Sleep Disorders using the criteria to create operational criteria. This was used in a primary care survey. A sub-sample of 36 primary care patients (aged over 15 years) was chosen to give a spectrum of disorders. A second sample of 85 patients was taken from a sleep disorder private practice to act as an extra test of validity. RESULTS: The response rate was 73% (36/49) for the primary care validation. The sensitivity and specificity of primary insomnia was 0.78 and 0.77, mood disorders 0.67 and 0.97, obstructive sleep apnoea 0.8 and 0.94, delayed sleep phase disorder was 0.8 and 0.97 and for health problems affecting sleep 0.92 and 0.76. There were a wider range of findings in the private practice audit. DISCUSSION: The validity of the Auckland Sleep Questionnaire is promising. The second version of the questionnaire will use this study to improve its functionality.

Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population.

PURPOSE: Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen. Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9. METHODS: Consecutive adult patients attending Auckland family practices completed the PHQ-9, after which they completed the Composite International Diagnostic Interview (CIDI) depression reference standard. Sensitivities and specificities for PHQ-2 and PHQ-9 were analyzed. RESULTS: There were 2,642 patients who completed both the PHQ-9 and the CIDI. Sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86% and 78%, respectively, with a score of 2 or higher and 61% and 92% with a score 3 or higher; for the PHQ-9, they were 74% and 91%, respectively, with a score of 10 or higher. For the PHQ-2 a score of 2 or higher detected more cases of depression than a score of 3 or higher. For the PHQ-9 a score of 10 or higher detected more cases of major depression than the PHQ determination of major depression originally described by Spitzer et al in 1999. CONCLUSIONS: We report the largest validation study of the PHQ-2 and PHQ-9, compared with a reference standard interview, undertaken in an exclusively primary care population. The PHQ-2 score or 2 or higher had good sensitivity but poor specificity in detecting major depression. Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression.

Are antibiotics indicated as an initial treatment for patients with acute upper respiratory tract infections? A review.

AIM: To determine the effect of antibiotic treatment versus placebo in patients with acute upper respiratory tract infections. METHODS: A systematic review and meta-analysis examined the effect of antibiotics versus placebo in randomised controlled trials to initially treat acute upper respiratory tract infections. RESULTS: Eight studies of children from age 6 months and adults up to the age of 49 years were found. The main outcome measures were general improvement and adverse effects. No benefit was demonstrated in terms of overall improvement from the use of antibiotics compared to placebo for patients with acute upper respiratory tract infections RR=0.89 (95%CI 0.77-1.04). There was also a significant increase in adverse effects (mainly gastrointestinal) using a random effects model with a relative risk RR=2.71 (95%CI 1.08-6.83). CONCLUSIONS: Initial use of antibiotics do not benefit patients with acute upper respiratory tract infections and are associated with an increase in adverse effects.

DeLLITE depression in late life: an intervention trial of exercise. Design and recruitment of a randomised controlled trial.

BACKGROUND: Physical activity shows potential in combating the poor outcomes associated with depression in older people. Meta-analyses show gaps in the research with poor trial design compromising certainty in conclusions and few programmes showing sustained effects. METHODS/DESIGN: The Depression in Late Life: an Intervention Trial of Exercise (DeLLITE) is a 12 month randomised controlled trial of a physical activity intervention to increase functional status in people aged 75 years and older with depressive symptoms. The intervention involves an individualised activity programme based on goal setting and progression of difficulty of activities delivered by a trained nurse during 8 home visits over 6 months. The control group received time matched home visits to discuss social contacts and networks. Baseline, 6 and 12 months measures were assessed in face to face visits with the primary outcome being functional status (SPPB, NEADL). Secondary outcomes include depressive symptoms (Geriatric Depression Scale), quality of life (SF-36), physical activity (AHS Physical Activity Questionnaire) and falls (self report). DISCUSSION: Due to report in 2008 the DeLLITE study has recruited 70% of those eligible and tests the efficacy of a home based, goal setting physical activity programme in improving function, mood and quality of life in older people with depressive symptomatology. If successful in improving function and mood this trial could prove for the first time that there are long term health benefit of physical activity, independent of social activity, in this high risk group who consume excess health related costs. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Register ACTRN12605000475640.