Medical students and AIDS: knowledge, attitudes and implications for education.

Second year medical students at a large midwestern university were surveyed about their attitudes regarding AIDS. Results indicated: (1) students with homosexual and/or HIV-positive friends were significantly more tolerant toward AIDS patients, (2) over half the students believed that treating AIDS patients may be hazardous and that their education had not prepared them to treat these patients safely, (3) one-third believed they had the right to refuse to treat AIDS patients, and (4) AIDS-phobia was significantly associated with homophobia. These data suggest that medical educators may need to help students overcome AIDS-phobia before some students will be able to incorporate instruction about AIDS since AIDS-phobia may inhibit this learning. Didactic instruction must be coupled with modeling by educators of non-prejudicial attitudes and strict adherence to medical professionalism.

Education and training in addictive diseases.

Addiction to alcohol and other drugs is a serious public health problem that is one of the most common disorders seen in medical practice. Although it is an extremely common disorder, it is poorly diagnosed and treated by physicians. Training about addictions must begin early in the medical student's career and continue in a vertically integrated way throughout medical school and residency. The notion of addiction as a disease process must be introduced and integrated into course materials in the preclinical years. Careful attention to the development of positive views toward working with addicted patients must be paid, and students must be indoctrinated early with the idea that physicians have a responsibility to diagnose and manage addicted patients.

Medical student homophobia.

OBJECTIVE: To determine whether homophobia existed in a sample of the second-year medical school class before beginning a course on Human Sexuality. METHOD: We administered a questionnaire to a sample of the second-year class at an introductory lecture to the course on Human Sexuality. This questionnaire asked twelve questions regarding attitudes about homosexuality, and incorporated questions from other surveys used previously. RESULTS: The data indicated significant homophobia. One-quarter of the students reported believing homosexuality is immoral and dangerous to the institution of the family, and expressed aversion to socializing with homosexuals. Nine percent believed homosexuality to be a mental disorder and 14% felt more homophobia since AIDS. CONCLUSIONS: Medical student homophobia, if left unchallenged, will hinder care provided to homosexual patients. Physician homophobia may disallow a healthy doctor-patient relationship and may cause a decrease in patients' ability to disclose sensitive issues.

The ability of first-year medical students to correctly identify and directly respond to patients' observed behaviors.

PURPOSE: To determine whether first-year medical students could correctly identify and directly respond to patients' observed behaviors. METHOD: In January 1995, 166 first-year students at the University of Illinois College of Medicine were shown a videotape of six patients vignettes illustrating three types of patient behaviors (anger, seduction, and hypochondriasis) by pairs of men and women. After each vignette the tape was stopped, and in an open-ended format the students were asked to identify each patient's behavior and to write their verbal response to that patient. The students were prompted with the question, "What would you say now?" They were then asked to select their comfort level with each patient on a scale ranging from 1 (very comfortable) to 5 (very uncomfortable). The students' responses were analyzed with several statistical tools. RESULTS: The students correctly identified anger in both the man and the woman over 90% of the time. Forty percent of the students identified seductive behavior from the woman, but only 5% identified it from the man. Hypochondriacal behavior was identified 65% of the time in the woman and 49% of the time in the man. Identification of behavior did not correlate with the formation of a direct response. The students' gender did not predict the ability to correctly identify or directly respond to patients. However, student responses as a whole differed significantly based on the patient's gender. CONCLUSION: These findings underscore the complexity of physician-patient communications and the need to address the subtleties of these interactions as part of the medical school curriculum.

Integration of treatment and posttreatment variables in predicting results of abstinence-based outpatient treatment after one year.

A multi-site, longitudinal study of patients undergoing outpatient alcohol and drug dependence treatment was conducted in private outpatient facilities, consisting of 2,029 subjects from 33 independent programs enrolled in a national addiction treatment outcomes registry. Pretreatment demographic and substance variables, treatment utilization variables, and post-treatment continuum of care variables were examined simultaneously in a multivariate prediction context for association with outcome. Upon admission patients provided history information to treatment staff trained in the collection of data for the evaluation efforts. Trained interviewers conducted consecutive structured interviews prospectively for treatment outcome at six- and 12-month follow-up periods. Multivariate analysis with stepwise multiple regression indicated that, relatively speaking, the most powerful predictors of treatment outcome were posttreatment variables: namely, support group attendance and involvement in a continuing care program. Pretreatment and treatment variables contributed proportionately little to the prediction of outcome. Additional sequential-stage analysis showed that the incremental contribution to prediction by posttreatment attendance at Alcoholics Anonymous and involvement in a treatment program following discharge far exceeded the initial predictive validity of the 14 pretreatment and treatment variables examined. Participation in posttreatment continuing care correlated with statistically significant reductions in job absenteeism, inpatient hospitalizations, and arrest rates. Posttreatment more than pretreatment factors may be decisive in influencing risk for relapse.

Integration in education for addiction medicine.

Addiction to alcohol and other drugs is a serious public health problem that is one of the most common disorders seen in medical practice. Although it is an extremely common disorder, it is poorly diagnosed and treated by physicians. In order to begin to develop an integrated approach to education and addiction, one must define the many roles of the physician working with addicted patients. Training about addictions must begin early in the medical student's career, and continue in a vertically integrated way throughout medical school. The notion of addiction as a disease process must be introduced and integrated into course materials in the preclinical years. Careful attention must be paid to the development of positive views toward working with addicted patients, and students must be indoctrinated early with the idea that physicians have a responsibility to diagnose and manage addicted patients. Students should be given multiple opportunities to learn and use screening interviews for addiction in preclinical interviewing courses, and while on the clerkships. Residency education and continuing medical education in addictions are also important, so that faculty may become good role models for students in this critical area.

The effect of medical education on students' patient-satisfaction ratings.

PURPOSE: To determine whether medical students' interpersonal and communication skills, as measured by satisfaction ratings given by standardized patients (SPs), improves or deteriorates with additional training and experience. METHOD: A longitudinal study was made of a single cohort of 133 medical students scheduled to graduate in 1994 from the University of Illinois College of Medicine at Chicago. Clinical performance examinations employing clinical encounters with SPs were given at the end of the students' second year at the end of the first quarter of their fourth year. The second-year examination consisted of four student-SP encounters for each student; the fourth-year examination consisted of 16 such encounters. For each examination, SP perceptions of interpersonal and communication skills were measured using six items from the American Board of Internal Medicine Patient Satisfaction Questionnaire; the items employed five ordinal-scale descriptors (from 1 = poor to 5 = excellent). The unit of analysis was the student-SP encounter. For each year, ratings on each item were averaged across encounters to produce a mean rating for each item; in addition, ratings across all the encounters and items were averaged to produce a mean total patient satisfaction rating. The percentage of fail or poor ratings given for each item was calculated, as was the average of these percentages across the items. All rating calculations were done between years and between genders. Two-tailed, paired t-tests and F-ratios were used for comparisons between years and between genders, respectively. Finally, ratings for a comparison group of first-, second-, and third-year internal medicine residents were gathered under similar testing conditions. RESULTS: Mean total patient satisfaction with the students' clinical performances improved from the first examination (3.51, SD, .84) to the second (3.60, SD, .86). The percentage of student encounters receiving fair or poor ratings decreased from 14.5% in the second year to 12% in the fourth year; resident encounters received a fair or poor rating 7.8% of the time. The female students received fewer fair or poor ratings than did the male students both in their second year (11.7% vs 16%) and in their fourth year (9.3% vs 12.8%). Of the six patient-satisfaction items, both the students and the residents consistently were ranked lowest in encouraging patients to ask questions and answering patient questions. CONCLUSION: Contrary to the stated beliefs of some physician-educators that students' skills deteriorate during the course of training, these medical students' interpersonal and communication skills improved with additional training and experience.

Interpretive psychotherapy in the inpatient community meeting on a short-term unit.

The authors present a model of inpatient community meetings conducted as large-group interpretive psychotherapy. The model focuses on the examination of relationships between patients and staff in the here-and-now and the patient group's maladaptive ways of interpreting staff members' behavior. The group leader and other staff members listen to patients' comments and questions and identify underlying group themes that reflect how patients are experiencing their relationship to staff. This model is useful even on short-term, acute inpatient units because it can provide an up-to-date monitor of the milieu, illuminate undesirable patient and staff behavior, uncover nontherapeutic activities or attitudes of staff, help improve patients' compliance with treatment, and reduce tension on the unit.

Psychotherapy supervision : a current method.

Psychotherapy supervision remains a crucial element in psychiatric residency training. The rapidly changing health care system is forcing supervisors to explore new methods of psychotherapy training. Supervisors must contend with decreased time for supervision, increased numbers of patients per resident, and patient cases that turn over more quickly. All of these changes require a more efficient and effective method of psychotherapy supervision. The authors propose a method that provides the psychiatry resident two supervisors for the price of one, that is, the psychotherapy supervisor and the resident himself or herself The authors detail the use of this method and present its potential advantages and difficulties.

Prevalence of depression and alcohol and other drug dependence in addictions treatment populations.

The diagnosis of depression has been viewed as an important factor in the treatment response for those who have alcohol and other drug dependence. The objective of the study was to examine the prevalence of a lifetime history of major depression in inpatients with a substance use disorder in addictions treatment. An evaluation study of 6,355 patients was conducted in inpatient and outpatient addictions treatment programs from 41 sites. Subjects were required to have a substance use disorder and to be evaluated for a lifetime diagnosis of major depression according to DSM-III-R criteria. The rate of a lifetime diagnosis of major depression was 43.7%. The most common diagnosis was alcohol dependence, followed by cocaine dependence, and cannabis dependence). Depression was associated in significantly greater numbers with diagnoses involving drugs other than alcohol, in females greater than in males, with number and frequency of use, and in inpatient programs more than outpatient programs. The rates for continuous abstinence at one year did not differ between those with and without a lifetime history of depression.

Posttraumatic stress disorder symptoms in resident physicians related to their internship.

To evaluate whether stresses experienced by physicians during internship are associated with posttraumatic stress disorder (PTSD) symptoms, the authors administered a standardized questionnaire to assess PTSD symptoms, depressive and anxiety symptoms, and social supports to 212 residents. Thirteen percent of residents met diagnostic criteria for PTSD, including 20% of the women and 9% of the men. PTSD symptoms were significantly more frequent in residents who were single or divorced at the time the questionnaire was administered. There were significant positive correlations between PTSD symptoms and symptoms of both current anxiety and depression, and a significant negative correlation existed between social support and PTSD symptoms. PTSD symptoms attributed to stresses associated with internship, which may be deleterious to physician well-being and potentially to patient care, and suggest the importance of making major changes in postgraduate medical training.