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.

Medical Students' Self-Perceptions of Harassment During Clinical Placement.

Objectives: Exploring workplace dynamics during clinical placement is crucial to determine whether medical students are encountering safe and meaningful learning experiences. The aim of this original article is to describe medical students' reported harassment experiences whilst on clinical placement. Design: Medical students in years 4 to 6 were invited to participate in the survey. In this mixed-methods study, data collection included demographic information, responses to the Generalized Workplace Harassment Questionnaire, and qualitative commentaries. Results: Two hundred and five students completed the questionnaire. Medical students experienced harassment in areas of verbal aggression, disrespect, isolation/exclusion, threats/bribes, and physical aggression. Concerning levels of occurrence were noted for disrespect, isolation/exclusion, and verbal aggression. Conclusions: Many medical students in this study reported experiencing harassment during their clinical placements indicating that harassment during clinical placement continues to be of concern in medical education. The findings indicate that further initiatives need to be designed to identify and respond to these cases of workplace harassment and that power imbalance and safe reporting appear to be further issues of concern. It was evident that students need to feel safe enough to be able to report harassment experiences to allow managers and educators to address the full extent of the problem.

Validation of the Generalized Workplace Harassment Questionnaire for Use with Medical Students.

The Generalized Workplace Harassment Questionnaire (GWHQ) has not been validated among medical students whilst they are on clinical placements. Therefore, this study aims to validate its use when applied to this cohort. A sample of 205 medical students in their clinical training phase completed the GWHQ. To examine the validity of the proposed factor structure of the validated 25-item GWHQ, which was reduced to from the original 29-item set, a confirmatory factor analysis was conducted. Model fit was appraised by evaluating the comparative fit index (CFI), the root mean square error of approximation (RMSEA), and the standardized root mean squared residual (SRMR). Spearman's rho correlation coefficients were applied to correlations between factors. With the exclusion of Item 19, the resulting fit was improved. In the revised model for a 24-item GWHQ, CFI = 0.995, RMSEA = 0.047, and SRMR = 0.115. Overall, the fit met the criteria for two fit indices and was thus deemed to be acceptable. Factor loadings ranged from 0.49 to 0.96. The Spearman's rho correlation coefficient between Verbal and Covert Hostility was high, although all correlations with Physical Hostility were weak. In conclusion, the amended 24-item version of the GWHQ is a valid instrument for appraising instances of harassment or hostility within clinical placements attended by medical students in New Zealand.

Burns Depression Scale Today (BDST): A validation study of BDST against the reference standard of PHQ-9.

Background: Case finding for low mood is essential in primary care, but it is time-consuming using current depression inventories. The Burns Depression Scale Today (BDST) is a short, simple inventory which assesses mood for today, and we aimed to validate it in this study. Materials and Methods: Consecutive patients with emotional distress seen in a single primary care clinic by one of the authors over 22 months were eligible for this retrospective audit (N = 160). Multiple visits (N = 421) from the same patient were included in the study. The index test was BDST, which assesses the patient's mood for today. The reference standard was the 9-item Patient Health Questionnaire (PHQ-9), which assesses mood over the past 2 weeks. PHQ-9 had a cut-off point of ≥10 and BDST had a cut-off point of ≥6 for a significant mood issue. Results: The median age of patients was 35 years, and 63% of the cohort were women. The median BDST score was 8, indicative of moderately low mood, and the median PHQ-9 score was 15, indicative of moderately severe depression. For patients with a BDST score ≥6, the likelihood ratio of a positive test was 2.67. The sensitivity was 85% (95% confidence interval [CI]: 89%-96%) and the specificity was 68% (95% CI: 60%-76%). The area under the curve was 84% (95% CI: 80%-87%). Conclusion: This audit validates BDST against PHQ-9 and finds it an excellent case-finding tool compared to PHQ-9. This is the first validation study of BDST.

Psychological treatment of adult depression in primary care compared with outpatient mental health care: A meta-analysis.

BACKGROUND: It is not yet known whether psychological treatments of depression in primary care have comparable effects to treatments in specialized mental health care. We conducted a meta-analysis comparing randomized controlled trials in primary and specialized care. METHODS: We selected studies from an existing database of randomized trials of psychological treatments of depression in adults, which was built through searches in PubMed, PsychINFO, Embase and the Cochrane Library. Random effects meta-analyses were conducted to examine the effects of therapies and mixed effects subgroup analyses were used to compare the effects in primary and specialized care. RESULTS: We included 52 trials (7984 patients) in primary care and compared them with 50 trials (3685 patients) in specialized care. The main effect of therapies in primary care was g = 0.43 (95 % CI: 0.32; 0.53; PI: -0.18; 1.03). The overall effects were significantly smaller than those in specialized care (p = 0.006), but this was no longer significant after adjustment for differences between the two settings. The proportion of patients responding to treatment was comparable in primary (0.38; 95 % CI: 0.33; 0.43) and specialized care (0.34; 95 % CI: 0.28; 0.41; p = 0.41), but higher in control conditions in primary care (0.25; 95 % CI: 0.22; 0.28) compared to specialized care (0.16; 95 % CI: 0.12; 0.20; p < 0.001). DISCUSSION: Psychological treatments are effective in primary care, but somewhat less than in specialized care. Response rates in control conditions in primary care are higher than in specialized care, which may point at a transient nature of depression in primary care.

Emoqol-100: Development and validation of a single question for low mood in primary care. A retrospective audit.

BACKGROUND: Patients with depression need to be diagnosed and managed effectively in primary care. However, current inventories for case-finding low mood are time-consuming when considering the limited time available during appointments. AIM: To validate the diagnostic accuracy of a single question on the emotional quality of life (Emoqol-100) as a measure of depression in symptomatic patients. DESIGN & SETTING: A retrospective clinical audit, validating the Emoqol-100 compared with the 9-item Patient Health Questionnaire (PHQ-9) and Burns Depression Scale Today (BDST) in South Auckland, New Zealand. METHOD: Consecutive patients with suspected low mood, seen over 22 months in a single primary care clinic by one of the authors, were eligible for this retrospective audit (n = 160). The index test was the verbally asked Emoqol-100: 'How is your emotional quality of life now, with 100 being perfect and 0 being the worst imaginable?' The reference standard was the PHQ-9 (n = 426 visits) with a cut-off point of ≥10 or BDST (n = 513 visits) with a cut-off point of ≥6. RESULTS: The Emoqol-100 range 0-20 had a likelihood ratio (LR) of 25.2 for low mood compared with the BDST as the reference standard; and for Emoqol-100 scores of 21-40, 41-60, 61-80, and 81-100 the LRs were 3.6, 1.7, 0.35, and 0.09, respectively. For the PHQ-9, these were 10.1, 2.9, 1.3, 0.40, and 0.2, respectively. Any score ≤60 was associated with a low mood. CONCLUSION: The Emoqol-100 appears to have high validity, so when it is low (≤60), it is suggestive of a high PHQ-9 or BDST score, and a mood issue probably exists. Emoqol-100 could be helpful for busy primary care professionals and other clinicians.

Trends in medical students' health over 5 years: Does a wellbeing curriculum make a difference?

BACKGROUND: Trends in New Zealand (NZ) medical students' health and the influence of a wellbeing curricula are unknown. METHODS: The author's collected self-report data from NZ medical students on 'Graduation Day' from 2014 to 2018, using a serial cross-sectional survey design with validated scales assessing psychological health, stigma, coping, and lifestyle. Comparisons were made with NZ general population same-age peers. Analyses examined trends, differences between 'cohorts' of students receiving different exposures to a wellbeing curriculum, and correlations between students' own lifestyle practices and their frequency of talking with patients about those topics. RESULTS: Of 1,062 students, 886 participated. The authors found statistically significant self-reported increases from 2014 to 2018 for negative psychological indices, including scores for distress and burnout, suicidal thoughts in the preceding year, and the likelihood of being diagnosed with an anxiety disorder. There was a significant increase in numbers of students reporting having their own doctor as well as increased healthy coping strategies and a significant decrease in stigma scores. Academic cohorts of students who had completed a wellbeing curriculum were more likely to report high distress levels, having been diagnosed with a mood disorder, and being non-drinkers than students without wellbeing training. When compared to NZ peers, medical students smoked less, exercised more, and were less likely to have diagnosed mood and anxiety disorders, but reported more distress. The authors found a significant correlation between the amount of exercise students undertook and their likelihood to discuss exercise with patients. CONCLUSIONS: NZ medical students have better physical health than general population peers and are more likely to discuss exercise with patients if exercising themselves. However, cohorts of graduating students report increasing distress despite the implementation of a wellbeing curriculum. Research is needed into mechanisms between students' self-awareness, willingness to report distress, stigma, mind-set, coping, and psychological outcomes, to inform curriculum developers.

The first consultation with a depressed patient: A qualitative study of GPs' approaches to diagnosis.

Background: The first consultation with a depressed patient is important because many patients do not return for subsequent visits. Therefore, the first consultation provides a unique opportunity for diagnosis (if required) and treatment, but there are risks of both under and over-diagnosis. Aim: To understand how general practitioners utilize diagnosis when patients present with a new episode of depression. Method: We approached a random selection of twenty-one general practitioners (GPs) in Auckland, New Zealand and asked them to participate in a semi-structured telephone interview. The interviews explored "the first consultation for a depressed/distressed patient" were undertaken to theme saturation. Interviews were hand-written and later transcribed. Results: We identified three major themes in GPs' approach to diagnosis. The issue of diagnosis was underpinned by a complex understanding of depression and the GP role. GPs did not always make a formal diagnosis, but the experience of a patient's distress/depression was understood by drawing on a range of factors and resources. These included time, screening tools, clinician experience, and patient affect. GPs were careful about how they communicated a diagnosis, both in their documentation and in their conversations with patients. Conclusion: At an initial appointment, the distressed/depressed patient can present to their GP with various symptoms and differing degrees of distress. GPs draw upon a variety of skills and resources to negotiate these complexities. The value of a diagnosis was questioned and issues such as impairment may be more useful concepts for GPs. This is the first study to report the findings of the first visit.

Treatment of depression in the first primary care consultation: A qualitative study.

Introduction: The first primary care consultation for patients with depression can have long-term consequences for patients, but little is known about treatment decisions at this visit. The aim of this study was to explore the treatment of patients presenting in primary care with a new episode of depression and the drivers behind GPs' treatment decisions at the initial consultation. Materials and Methods: A random sample of GPs in Auckland was invited to participate. A qualitative study was undertaken using semi-structured interviews. Interview transcripts were analyzed using a general inductive approach. Results: Twenty-one GPs were interviewed. We identified three themes as drivers of treatment decisions at the first visit: characteristics of GPs, characteristics of patients, and characteristics of treatment options. Drivers for prescribing were severe depression and time constraints. A driver for non-pharmacological treatment was a strong doctor-patient relationship. Limited time, skill, and training were associated with low confidence using talking therapies. Access to counseling was reported as poor. There was a very wide range of approaches taken. GPs described preferring antidepressants less and talking therapies more with Maori patients. Behavioral activation was used least despite its ease of use and it being one of the most effective treatments for depression. Conclusion: Treatment of depression at the first visit varies widely between practitioners. GPs report multiple barriers to the provision of talking therapies. A move to a more standardized approach may lead to more equitable care. This is the first study to report findings about the initial primary care consultation for depression.

Medical students' evaluation of a suicide prevention multimedia resource: A focus group study.

AIMS: A series of podcasts and videos was created to assist medical students with learning about suicide prevention. The aim of this research was to explore medical students experiences of using a suicide prevention learning resource. METHODS: A multimedia repository of learning resources for suicide prevention was designed and created for use across all years of the medical programme at The University of Auckland. Emphasis was placed on ensuring that the resource was culturally safe. The impact of the learning resource was evaluated with a qualitative approach using focus group methodology. Two focus groups were audio-recorded, transcribed and a thematic analysis was conducted employing three cycles of coding. RESULTS: Three themes were identified: perceiving that suicide is complex and sensitive; tailoring knowledge to match students' developmental stage and context; and elements that facilitated interaction with the resource. CONCLUSIONS: Suicide is unsurprisingly a challenging topic for medical students. The students in this study actively engaged with this resource on suicide prevention, which supplemented their core learning of the topic. Early access to resources developed in a culturally safe way within a spiral curriculum empowers students to understand that they have an important contribution to make in preventing suicide. This may prepare them for encountering suicide with peers, family members and in clinical practice.

The Role of Online Videos in Teaching Procedural Skills in Postgraduate Medical Education: A Scoping Review.

OBJECTIVE: The purpose of this scoping review was to outline the extent of available literature including the prevalence of video quality appraisal tools, characterize how online videos were used, and identify the gaps in the literature with implications for future research. DESIGN: The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for scoping reviews (PRISMA-ScR). Six databases were searched: (1) MEDLINE (Ovid), (2) EMBASE, (3) Cochrane, (4) ERIC, (5) CINAHL PLUS, and (6) Google Scholar for Medical Subject Headings terms online videos, postgraduate health education, and health professional/s. RESULTS: A total of 6948 articles were identified, of which 78 were included in the review. The articles included were primarily either experimental or observational studies, with most being from North America. Twelve concepts were identified: (1) procedural skills teaching; (2) video assessment; (3) validation of an assessment tool; (4) video feedback; (5) coaching; (6) broadcasting; (7) learner characteristics; (8) video characteristics; (9) video quality; (10) a quality assessment tool; (11) platforms and video library; and (12) health information governance. CONCLUSIONS: While there is a diverse and growing body of literature on this area, information is lacking about the quality appraisal of online videos.

School-based interventions to improve health literacy of senior high school students: a scoping review protocol.

OBJECTIVE: The objective of this review is to map the details of school-based interventions used to improve health literacy of senior high school students. INTRODUCTION: The global prevalence of poor adult health literacy is caused, in part, by limited health education in secondary schools. Enhancing adolescent health literacy could potentially improve adult health literacy, health behavior, and health outcomes. INCLUSION CRITERIA: Studies investigating school-based interventions to improve health literacy of senior high school students, regardless of design, characteristics, and assessment tools, will be eligible for inclusion. Studies that provide combined data (senior high school students mixed with other students) or have a compulsory component outside of school will be excluded. METHODS: MEDLINE, Embase, ProQuest Education Journals, Education Research Complete, SAGE Journals, and Index New Zealand will be searched for journal articles published in English since 1998. Two independent reviewers will screen titles and abstracts for eligibility, retrieve potentially relevant papers in full, and extract data from included studies. A third reviewer will resolve any disagreements. Quantitative analysis (eg, frequency analysis) will indicate geographic region of studies, design and targeted population (school grade of study participants); the mode of delivery (extracurricular or during school hours, implemented by teachers or other professionals), duration, and health literacy model anddomainoftheinterventions. Descriptive qualitative content analysis will be used to summarize, code and classify key characteristics of the interventions (eg, teaching models and strategies, content, and related skills) and main outcomes related to health literacy into meaningful categories.

Medical Students' Quality of Life and Its Association with Harassment and Social Support.

OBJECTIVES: To explore the associations between self-reported quality of life (QoL) and harassment and the potential moderating effect of social support. DESIGN: Senior medical students were invited to participate in a survey consisting of a background section, the World Health Organisation QoL questionnaire (New Zealand version), a version of the generalised workplace harassment questionnaire, and the multidimensional scale of perceived social support. A series of multivariate statistical analyses were conducted. RESULTS: Two hundred and five students completed the online survey (response rate = 25%). The findings indicated a high incidence of verbal (90%) and covert harassment (87%), with relatively low levels of physical harassment (6%) and manipulation (6%). The correlational analyses indicated that low levels of QoL were associated with high levels of verbal and covert harassment and high levels of social support were directly associated with high levels of QoL. The moderation models indicated that social support conditionally influences the impact of verbal and covert harassment on social and psychological QoL. CONCLUSIONS: These findings imply that medical students experiencing harassment in clinical learning environments likely experienced lowered levels of QoL. Social support may moderate, in certain instances, the adverse impact of harassment on QoL.

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.

Medical Students' Experience of Harassment and Its Impact on Quality of Life: a Scoping Review.

OBJECTIVES: Medical students' experiences of harassment and its influence on quality of life were examined. DESIGN: A set of databases were employed in this review, and using ATLAS.ti, a set of emergent themes were identified. RESULTS: The initial search identified 4580 potential articles for review. The inclusion and exclusion criteria reduced the list to 48 articles. Two predominant emergent themes were categorised as 'Antecedents' of 'harassment' and 'Consequences' on quality of life. CONCLUSIONS: Harassment likely has an adverse impact on quality of life, although more empirical research is required to establish more definitive links between the two variables.

Survey protocol for exploring video and phone use in Aotearoa New Zealand general practice: considerations for future telehealth.

INTRODUCTION: Telehealth became the most practical option for general practice consultations in Aotearoa New Zealand (NZ) as a result of the national lockdowns in response to the COVID-19 pandemic. What is the consumer experience of access to telehealth and how do consumers and providers perceive this mode of care delivery going forward? METHODS AND ANALYSIS: A national survey of general practice consumers and providers who used telehealth services since the national lockdowns in 2020 will be distributed. It is based on the Unified Theory of Acceptance and Use of Technology framework of technology acceptance and the access to care framework. The data will be statistically analysed to create a foundation for in-depth research on the use of telehealth services in NZ general practice services, with a specific focus on consumer experiences and health outcomes. ETHICS AND DISSEMINATION: Ethics approval was granted by the Auckland Health Research Ethics Committee on 13/11/2020, reference AH2539. The survey will be disseminated online.

Cultural variations in wellbeing, burnout and substance use amongst medical students in twelve countries.

High levels of stress, burnout, and symptoms of poor mental health have been well known among practicing doctors for a number of years. Indeed, many health systems have formal and informal mechanisms to offer support and treatment where needed, though this varies tremendously across cultures. There is increasing evidence that current medical students, our doctors of the future, also report very high levels of distress, burnout, and substance misuse. We sampled large groups of medical students in 12 countries at the same time and with exactly the same method in order to aid direct comparison. 3766 students responded to our survey across five continents in what we believe is a global first. Our results show that students in all 12 countries report very high levels of 'caseness' on validated measures of psychiatric symptoms and burnout. Rates of substance misuse, often a cause of or coping mechanism for this distress, and identified sources of stress also varied across cultures. Variations are strongly influenced by cultural factors. Further quantitative and qualitative research is required to confirm our results and further delineate the causes for high rates of psychiatric symptoms and burnout. Studies should also focus on the implementation of strategies to safeguard and identify those most at risk.

Psychological wellbeing, burnout and substance use amongst medical students in New Zealand.

Medical students are thought to have increased pressures in study life beyond that of their peers. This could impact their psychological wellbeing, burnout and substance use, impeding a smooth transition into the health workforce. A cross-sectional electronic survey of one of New Zealand's two medical schools was undertaken, and students in all years were invited to participate through email. Two hundred and twenty students completed the survey. Forty-six students (21%) reported that they were currently seeing a GP or Allied Healthcare Professional (AHP) for their mental ill-health. Seventy-seven students (35%) reported having taken cannabis during medical school. The number of respondents reaching the threshold for CAGE, and thus demonstrating problem drinking, was 40 (18%). Additionally, burnout levels were scored, with 150 students (68%) classifying as disengaged and 169 (77%) as suffering from exhaustion on the Oldenburg burnout measure. Going forwards, organizational bodies including governments and medical schools should place emphasis on the importance of optimizing medical student wellbeing, including resilience training and improved workforce wellbeing planning, to positively impact not just medical students as they progress to doctors, but for patients, and the healthcare system as a whole.

Depression in medical students: current insights.

Medical students are exposed to multiple factors during their academic and clinical study that have been shown to contribute to high levels of depression, anxiety, and stress. The purpose of this article was to explore the issue of depression in the medical student population, including prevalence, causes, and key issues, along with suggestions for early identification and support from one medical school in New Zealand. After establishing that the prevalence of depression is higher for medical students than the general population, the key issues explored include assessment used in the program, characteristics of the student population (such as Type A personality and perfectionism), resilience, selection procedures, students' motivation, and the nature of the clinical environment. This review includes several recommendations to improve students' psychological health such as positioning well-being within an overarching comprehensive workplace wellness model and integrating peer and faculty-led support into the day-to-day running of the institution. It also highlights the advantages of the addition of a well-being curriculum, as skills to prevent and manage distress and depression are relevant in supporting the competencies required by medical practitioners. It concludes that medical schools need wide-ranging strategies to address the complexities associated with the particular student population attracted to medicine and calls for educators to act, by noticing opportunities where they can introduce such initiatives into their medical programs.