An Exploration of Residents' Implicit Biases Towards Depression-a Pilot Study.

BACKGROUND: Implicit attitudes are outside of conscious awareness and are thought to affect automatic responses outside of one's deliberate control, with the potential to impact physician-patient relationships. OBJECTIVE: To measure the nature and extent of implicit biases towards depression in internal medicine and psychiatry residents. DESIGN: Descriptive and comparative study. PARTICIPANTS: Fifty-one residents from three internal medicine programs and 35 residents from three psychiatry programs located in two states. INTERVENTIONS: Participants were sent a link to voluntarily participate in four online implicit association tests. Residents' identities were anonymous. MAIN MEASURES: Four implicit association tests to measure the association of (1) attitude (good/bad), (2) permanence, (3) controllability, and (4) etiology with depression/physical illness. KEY RESULTS: Internal medicine residents demonstrated a significant association between depression and negative attitudes (t(38) = 6.01, p < .001, Cohen's d = .95), uncontrollability (t(35) = 4.80, p < .001, Cohen's d = .79), temporariness (t(37) = 2.94, p = .006, Cohen's d = .48), and a psychologic etiology (t(1) = 6.91, p < .001, Cohen's d = 1.24). Psychiatry residents only demonstrated an association between depression and a psychologic etiology (t(2) = 4.79, p < .001, Cohen's d = 4.5). When comparing the two specialties, internal medicine and psychiatry differed on two of the IATs. Internal medicine residents were more likely to associate negative attitudes with depression than psychiatry residents (t(63) = 4.66, p < .001, Cohen's d = 1.18) and to associate depression with being uncontrollable (t(57) = 3.17, p = .002, Cohen's d = .81). CONCLUSIONS: Internal medicine residents demonstrated biases in their attitudes towards depression and significantly differed in some areas from psychiatry residents. This pilot study needs to be replicated to confirm our findings and further work needs to be done to determine the effect of these attitudes on the provision of clinical care.

Internal Medicine Residents' Attitudes Toward Simulated Depressed Cardiac Patients During an Objective Structured Clinical Examination: A Randomized Study.

BACKGROUND: Physician biases toward mental conditions such as depression have been shown to adversely affect medical outcomes. OBJECTIVE: To explore the relationship between residents' explicit bias toward depressed patients and their clinical skills on a cardiac case during an objective structured clinical exam (OSCE). DESIGN: Prospective parallel randomized controlled study. PARTICIPANTS: One hundred eighty-five internal medicine residents from three residency programs in two states. INTERVENTION: During October-November 2015, residents were randomized to either a depressed or non-depressed standardized patient (SP) presenting with acute chest pain. MAIN MEASURES: The Medical Condition Regard Scale (MCRS) assessed residents' explicit bias toward patients with depression. Their clinical skills (history-taking, physical examination, patient counseling, patient-physician interaction (PPI), differential diagnosis, and workup plan) and facial expressions were rated during an OSCE. KEY RESULTS: No significant relationships were found between resident explicit bias and clinical skill measurements. Residents who examined the depressed SP scored lower, on average, on history-taking (t [183] = -2.77, p < 0.01, Cohen's d = 0.41) and higher on PPI (t [183] = 2.24, p < 0.05, Cohen's d = 0.33) than residents examining the non-depressed SP. There were no differences, on average, between stations on physical examination, counseling, correct diagnosis, workup plan, or overall SP satisfaction. Facial recognition software demonstrated that residents with a non-depressed SP had more neutral expressions than depressed-SP residents (t [133] = -2.46, p < 0.05, Cohen's d = 0.46), and residents with a depressed SP had more disgusted expressions than non-depressed-SP residents (t [83.52] = 2.10, p < 0.05, Cohen's d = 0.28). CONCLUSIONS: Extrinsic bias did not predict OSCE performance in this study. Some differences were noted in the OSCE performance between the two stations. Further study is needed to examine the effects of patient mental health conditions on physician examination procedures, diagnostic behaviors, and patient outcomes.

A comparison of medical students' learning approaches between the first and fourth years.

OBJECTIVES: We hypothesized that medical students exposed to a case-based curriculum in years 1 and 2 and clinical cases in the year 3 clerkship would demonstrate a longitudinal increase in the deep approach to learning and a decrease in the surface apathetic approach. METHODS: A cohort of first-year medical students completed the Approaches and Study Skills Inventory for Students at the beginning of their first term and again at the beginning of their fourth year. Approaches and Study Skills Inventory for Students scores were aggregated into three main learning approach scales: deep, strategic, and surface apathetic. RESULTS: On average, deep and strategic scores did not significantly change between years 1 and 4, but the surface apathetic mean score decreased as a result of lower syllabus boundness and fear of failure subscale scores. Effect sizes were small (d = 0.30, 0.34, respectively). CONCLUSIONS: The deep approach to learning is a complex process and did not change in our students after 3 years of medical school, even though a case-based curriculum was believed to foster deeper learning. By the end of year 3, our students were, on average, less bound to syllabi and feared failure less.

Reducing stigma towards substance users through an educational intervention: harder than it looks.

OBJECTIVE: Stigma towards people with substance use disorders is pervasive and imbedded in our US culture. Prejudicial attitudes that are part of a health care practitioner's value system are a barrier to people accessing health care and substance use treatment. This study aimed to reduce stigmatizing attitudes of graduate health care professional students by implementing an innovative curriculum combining multiple teaching methods. METHODS: Physician assistant students received a 3-h educational intervention that consisted of lecture and discussion sessions, direct interaction with a recovering substance user, viewing a film portrayal of addiction and addiction treatment, and written self-reflection. Changes in student attitudes were measured using a subscale of the Attitudes to Mental Illness Questionnaire (AMIQ) instrument and analysis of coded written reflections. A follow-up focus group resulted in additional qualitative insight into attitudes. RESULTS: Post-intervention scores for the "heroin" AMIQ vignette significantly improved compared to pre-test scores (p<0.007), but the effect was small and the mean post-test scores still reflected very negative attitudes. Students' neutral attitude towards alcohol use did not change as a result of the intervention. Written reflections demonstrated that this sample of students continued to harbor stigma towards people with substance use following the intervention. Focus group data suggested students believed that stigma beliefs about substance use were common among health care professionals, though they believed that their own level and quality of care would not be influenced by these beliefs. CONCLUSIONS: The persistence of negative attitudes following this and others' educational interventions suggests the need for a new approach to changing health care professionals' stigma towards substance users.

A Curriculum to Improve Residents' End-of-Life Communication and Pain Management Skills During Pediatrics Intensive Care Rotation: Pilot Study.

BACKGROUND: Research suggests pediatrics practitioners lack confidence and skills in the end-of-life (EOL) care. OBJECTIVE: This pilot study explored the impact of a curriculum designed to prepare future pediatricians to manage pain and provide comfort for children and infants with life-threatening conditions and to be more confident and competent in their EOL discussions with families. METHODS: Participants included 8 postgraduate year (PGY)-2 residents in the study group and 9 PGY-3 residents in a control group. The EOL curriculum included 4, 1-hour sessions consisting of didactic lectures, videos, and small-group, interactive discussions. Topics included discussing EOL with families, withdrawal of care, and pain assessment and management. Curriculum evaluation used an objective structured clinical examination (OSCE), self-assessment confidence and competency questionnaire, and a follow-up survey 18 months after the intervention. RESULTS: The OSCE showed no statistically significant differences between PGY-2 versus PGY-3 residents in discussing EOL issues with family (mean  =  48.3 [PGY-2] versus 41.0 [PGY-3]), managing withdrawal of care (mean  =  20.9 [PGY-2] versus 18.91 [PGY-3]), and managing adolescent pain (mean  =  30.97 [PGY-2] versus 29.27 [PGY-3]). The self-assessment confidence and competency scores improved significantly after the intervention for both PGY-2 residents (0.62 versus 0.86, P < .01) and PGY-3 residents (0.61 versus 0.85, P < .01). CONCLUSIONS: An EOL curriculum for PGY-2 pediatrics residents delivered during the intensive care unit rotation is feasible and may be effective. Residents reported the curriculum was useful in their practice.

The relationship between medical students' learning approaches and performance on a summative high-stakes clinical performance examination.

BACKGROUND: A learning approach embeds the intention of the student when starting a task and the learning processes and strategies used to carry out a task. Student approaches to learning have been categorized as deep, strategic, and surface. AIM: To explore the relationships among medical students' learning approaches, gender, and performance on a summative high-stakes clinical performance examination (CPX). METHODS: We measured medical students' learning approaches at the beginning of year four using the Approaches and Study Skills Inventory for Students and compared results with CPX scores. RESULTS: Student scores in the top two quartiles of the CPX were significantly higher on the deep approach than student CPX scores in the bottom quartile, and student scores in the bottom quartile of the CPX were significantly higher on the surface approach than scores for the other three CPX quartiles. CPX patient-physician interaction scores showed a significant positive correlation with deep approach scores, and CPX overall patient satisfaction scores showed a significant positive correlation with deep and strategic approach scores. Surface approach scores correlated negatively with all CPX score categories. CONCLUSION: Approach to learning was associated with performance on a high-stakes CPX.

Developing the HIV workforce: a case study of a training model for inexperienced HIV providers.

HIV patients in a rural California community were inconsistently receiving optimum HIV care. A local primary care physician assumed the care of these patients and contacted an experienced HIV provider for assistance. This report describes a three-step onsite training program that was implemented and the ensuing successful patient outcomes.

Integrated Cases Section: a course designed to promote clinical reasoning in year 2 medical students.

BACKGROUND: Medical students often have difficulty applying basic science knowledge within clinical contexts as they transition into clerkships. DESCRIPTION: To enhance clinical reasoning skills in 2nd-year medical students, we developed a 7-week transition course called the Integrated Cases Section. Curricular instruction incorporated analytic and nonanalytic clinical reasoning models. Practice with variable case scenarios enhanced students' application of basic science knowledge to clinical problem solving. EVALUATION: We evaluated curricular design and objectives by measuring student perceptions during the course and following completion of 2 clerkship rotations. To obtain measurement of students' clinical reasoning ability we administered a script concordance test immediately before and after the course. CONCLUSIONS: Students reported increased confidence in their diagnostic reasoning ability during the course and after completion of 2 clerkships. Students' clinical reasoning showed a significant gain after the Integrated Cases Section on a script concordance test. Student support has solidified Integrated Cases Section in the curriculum.

Use of script concordance test to assess pharmaceutical diabetic care: a pilot study in Thailand.

The script concordance (SC) test is an assessment tool designed to probe whether knowledge of examinees is efficiently organized for clinical actions. The aim of this study was to develop an SC test, and determine whether it could be used to differentiate novices from expert pharmacists in their ability to carry out clinical actions in the area of diabetes mellitus. The SC test was developed and validated according to guidelines proposed previously. Data analysis was performed using a post-hoc test and ANOVA. The test developed had 31 items. Participants included 54 students, six new graduates, and 16 clinical pharmacists. Average scores and standard deviations for students, new graduates and clinical pharmacists were 18.54 (2.90), 20.27(1.42) and 21.09(2.89), respectively. The group differences were significant (p < 0.05). It is concluded that the SC test could accurately differentiate examinees according to levels of experience. It could be a useful tool to measure students' progress in the area of diabetes mellitus.

Effects of funding family physicians for advanced research training.

BACKGROUND AND OBJECTIVES: Beginning in 1998, the American Academy of Family Physicians (AAFP) initiated a 4-year funded Advanced Research Training (ART) program to increase the number of family medicine researchers in the United States. This study describes the extent to which ART recipients achieved the objectives they had set for themselves, barriers to achieving their objectives, and changes in their research capacity as reported by themselves and as observed by colleagues. METHODS: We gathered data by examining 28 awardees' applications and semiannual reports, questionnaires sent to awardees, and reports from awardees' colleagues. RESULTS: Only 13 recipients (48%) filed final reports. For awardees in the first two cohorts, the percentage of awardees who achieved their objectives ranged from 50% to 76%. Having only 2 years of funding, lacking sufficient protected time, and inadequate resources were cited as barriers to research productivity. Awardees' colleagues reported that awardees have improved research skills, improved grant and publication writing ability, and greater leadership skills. CONCLUSIONS: Fewer than half of awardees submitted reports at the end of the project to report on their achievements. Of those who did, research capacity was strengthened as a result of receiving an ART award. Barriers may have prevented the majority of awardees from achieving their objectives and completing their reports.