Nonpharmacological labor pain management methods and risk of cesarean birth: A retrospective cohort study.

BACKGROUND: Nonpharmacological labor pain management methods (NPLPMM) are noninvasive, low-cost practices that may play a role in reducing the rates of unnecessary cesarean birth. We aimed to evaluate whether the NPLPMM is associated with the mode of birth. METHODS: We conducted a retrospective cohort study with clinical records of all women admitted for birth from January 2013 to December 2017. Records of women who had spontaneous labor or received induction or augmentation of labor during hospitalization were eligible for the study. We estimated the risk ratios for cesarean birth in general linear models using the Poisson regression with adjustments for the following variables: age, ethnicity, schooling, parity, gestational age, previous cesarean birth, spontaneous labor before admission, or induction/augmentation of labor. RESULTS: Within the total of 3,391 medical records, 40.1% had the use of a nonpharmacological labor pain management method registered. Cesarean rate among the study population was 44.2%. The use of NPLPMM decreased the risk of cesarean birth by 78% (OR = 0.22; 95% CI 0.19-0.26). History of a previous cesarean birth (RR = 2.63; 95% CI 2.35-2.64), the lack of use of NPLPMM (RR = 2.46; 95% CI 2.22-2.72), and primiparity (RR = 2.09; 95% CI 1.86-2.34) were the strongest risk factors for cesarean birth in the cohort. DISCUSSION: The use of NPLPMM may be an effective strategy to reduce unnecessary cesarean birth. Further studies to identify the efficacy of each method may help health professionals to offer more appropriate methods at different stages of labor.

Relationship among Medical Student Resilience, Educational Environment and Quality of Life.

CONTEXT: Resilience is a capacity to face and overcome adversities, with personal transformation and growth. In medical education, it is critical to understand the determinants of a positive, developmental reaction in the face of stressful, emotionally demanding situations. We studied the association among resilience, quality of life (QoL) and educational environment perceptions in medical students. METHODS: We evaluated data from a random sample of 1,350 medical students from 22 Brazilian medical schools. Information from participants included the Wagnild and Young's resilience scale (RS-14), the Dundee Ready Educational Environment Measure (DREEM), the World Health Organization Quality of Life questionnaire - short form (WHOQOL-BREF), the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI). RESULTS: Full multiple linear regression models were adjusted for sex, age, year of medical course, presence of a BDI score ≥ 14 and STAI state or anxiety scores ≥ 50. Compared to those with very high resilience levels, individuals with very low resilience had worse QoL, measured by overall (ß=-0.89; 95% confidence interval =-1.21 to -0.56) and medical-school related (ß=-0.85; 95%CI=-1.25 to -0.45) QoL scores, environment (ß=-6.48; 95%CI=-10.01 to -2.95), psychological (ß=-22.89; 95%CI=-25.70 to -20.07), social relationships (ß=-14.28; 95%CI=-19.07 to -9.49), and physical health (ß=-10.74; 95%CI=-14.07 to -7.42) WHOQOL-BREF domain scores. They also had a worse educational environment perception, measured by global DREEM score (ß=-31.42; 95%CI=-37.86 to -24.98), learning (ß=-7.32; 95%CI=-9.23 to -5.41), teachers (ß=-5.37; 95%CI=-7.16 to -3.58), academic self-perception (ß=-7.33; 95%CI=-8.53 to -6.12), atmosphere (ß=-8.29; 95%CI=-10.13 to -6.44) and social self-perception (ß=-3.12; 95%CI=-4.11 to -2.12) DREEM domain scores. We also observed a dose-response pattern across resilience level groups for most measurements. CONCLUSIONS: Medical students with higher resilience levels had a better quality of life and a better perception of educational environment. Developing resilience may become an important strategy to minimize emotional distress and enhance medical training.

Empathy among medical students: is there a relation with quality of life and burnout?

BACKGROUND: We aimed to assess medical students' empathy and its associations with gender, stage of medical school, quality of life and burnout. METHOD: A cross-sectional, multi-centric (22 medical schools) study that employed online, validated, self-reported questionnaires on empathy (Interpersonal Reactivity Index), quality of life (The World Health Organization Quality of Life Assessment) and burnout (the Maslach Burnout Inventory) in a random sample of medical students. RESULTS: Out of a total of 1,650 randomly selected students, 1,350 (81.8%) completed all of the questionnaires. Female students exhibited higher dispositional empathic concern and experienced more personal distress than their male counterparts (p<0.05; d ≥ 0.5). There were minor differences in the empathic dispositions of students in different stages of their medical training (p<0.05; f<0.25). Female students had slightly lower scores for physical and psychological quality of life than male students (p<0.05; d<0.5). Female students scored higher on emotional exhaustion and lower on depersonalization than male students (p<0.001; d<0.5). Students in their final stage of medical school had slightly higher scores for emotional exhaustion, depersonalization and personal accomplishment (p<0.05; f<0.25). Gender (ß = 0.27; p<0.001) and perspective taking (ß = 0.30; p<0.001) were significant predictors of empathic concern scores. Depersonalization was associated with lower empathic concern (ß =  -0.18) and perspective taking (ß =  -0.14) (p<0.001). Personal accomplishment was associated with higher perspective taking (ß = 0.21; p<0.001) and lower personal distress (ß =  -0.26; p<0.001) scores. CONCLUSIONS: Female students had higher empathic concern and personal distress dispositions. The differences in the empathy scores of students in different stages of medical school were small. Among all of the studied variables, personal accomplishment held the most important association with decreasing personal distress and was also a predicting variable for perspective taking.

Cross-cultural validation of the Patient-Practitioner Orientation Scale (PPOS).

OBJECTIVES: Translate, adapt and validate the Patient-Practitioner Orientation Scale (PPOS) for use in Brazil. METHODS: The PPOS was translated to Portuguese using a modified Delphi technique. The final version was applied to 360 participants. Reliability (test-retest and internal consistency) and construct validity (explanatory and confirmatory factor analysis) were assessed. RESULTS: Only two items did not reach pre-established criteria agreement in Delphi technique. In pre-testing, seven items were modified. Internal consistency (Cronbach's alpha=0.605) and test-retest reliability (intraclass correlation coefficient=0.670) were adequate. In explanatory factor analysis, one item did not achieve a loading factor, one item was considered factorially complex and two items were inconsistent with a priori factors. Confirmatory factor analysis provided an acceptable adjustment for the observed variables (χ(2)/df=2.33; GFI=0.91; AGFI=0.89; CFI=0.84; NFI=0.75; NNFI=0.81; RMSEA=0.062 (p=0.016) and SRMR=0.065). CONCLUSIONS: The Brazilian version PPOS (B-PPOS) showed acceptable validity and adequate reliability. PRACTICE IMPLICATIONS: The use of the B-PPOS in national and cross-cultural studies may contribute to the evaluation and monitoring of the attitudes of doctors, medical students and patients toward their professional relationships in research and practice.

What do medical students think about their quality of life? A qualitative study.

BACKGROUND: Medical education can affect medical students' physical and mental health as well as their quality of life. The aim of this study was to assess medical students' perceptions of their quality of life and its relationship with medical education. METHODS: First- to sixth-year students from six Brazilian medical schools were interviewed using focus groups to explore what medical student's lives are like, factors related to increases and decreases of their quality of life during medical school, and how they deal with the difficulties in their training. RESULTS: Students reported a variety of difficulties and crises during medical school. Factors that were reported to decrease their quality of life included competition, unprepared teachers, excessive activities, and medical school schedules that demanded exclusive dedication. Contact with pain, death and suffering and harsh social realities influence their quality of life, as well as frustrations with the program and insecurity regarding their professional future. The scarcity of time for studying, leisure activities, relationships, and rest was considered the main factor of influence. Among factors that increase quality of life are good teachers, classes with good didactic approaches, active learning methodologies, contact with patients, and efficient time management. Students also reported that meaningful relationships with family members, friends, or teachers increase their quality of life. CONCLUSION: Quality of teachers, curricula, healthy lifestyles related to eating habits, sleep, and physical activity modify medical students' quality of life. Lack of time due to medical school obligations was a major impact factor. Students affirm their quality of life is influenced by their medical school experiences, but they also reframe their difficulties, herein represented by their poor quality of life, understood as necessary and inherent to the process of becoming doctors.

Brazilian version of the Jefferson Scale of Empathy: psychometric properties and factor analysis.

BACKGROUND: Empathy is a central characteristic of medical professionalism and has recently gained attention in medical education research. The Jefferson Scale of Empathy is the most commonly used measure of empathy worldwide, and to date it has been translated in 39 languages. This study aimed to adapt the Jefferson Scale of Empathy to the Brazilian culture and to test its reliability and validity among Brazilian medical students. METHODS: The Portuguese version of the Jefferson Scale of Empathy was adapted to Brazil using back-translation techniques. This version was pretested among 39 fifth-year medical students in September 2010. During the final fifth- and sixth-year Objective Structured Clinical Examination (October 2011), 319 students were invited to respond to the scale anonymously. Cronbach's alpha, exploratory factor analysis, item-total correlation, and gender comparisons were performed to check the reliability and validity of the scale. RESULTS: The student response rate was 93.7% (299 students). Cronbach's coefficient for the scale was 0.84. A principal component analysis confirmed the construct validity of the scale for three main factors: Compassionate Care (first factor), Ability to Stand in the Patient's Shoes (second factor), and Perspective Taking (third factor). Gender comparisons did not reveal differences in the scores between female and male students. CONCLUSIONS: The adapted Brazilian version of the Jefferson Scale of Empathy proved to be a valid, reliable instrument for use in national and cross-cultural studies in medical education.

Health-related quality of life of medical students.

OBJECTIVES: Mental problems such as stress, anxiety and depression have been described among medical students and are associated with poor academic and professional performance. It has been speculated that these problems impair students' quality of life (QoL). The authors aimed to assess the health-related QoL (HRQL) of medical students throughout their 6 years of training at a school with a traditional curriculum. METHODS: Of a total of 490 students attending our institution's medical school, 38 were surveyed in February 2006 (incoming Year 1 group, surveyed when students were in the second week of Year 1 classes) and 352 were surveyed in February 2007 (students in Years 1-6). Students self-reported their HRQL and depressive symptoms using the Short-Form Health Survey (SF-36) and the Beck Depression Inventory (BDI). Comparisons were performed according to year in training, presence of depressive symptoms, gender, living arrangements and correlations with family income. RESULTS: The students' ages ranged from 18 to 31 years (median 22.3 years). Students in Years 2, 3, 4 and 6 had lower scores for mental and physical dimensions of HRQL compared with the incoming Year 1 group (P < 0.01), with the largest difference observed for Year 3 students. Students with depressive symptoms had lower scores in all domains of the SF-36 (P < 0.01). Female students had lower HRQL scores than males (P < 0.01). No differences were observed for students living with versus without family and no correlation with family income was found. CONCLUSIONS: Major impairments in HRQL were observed among Year 3 students, students with depressive symptoms and women. Medical schools should institute efforts to ensure that students' HRQL and emotional support are maintained, particularly during critical phases of medical training.