Experiences of Clinical Clerkship Students With Mindfulness-Based Stress Reduction: A Qualitative Study on Long-Term Effects.

Purpose: To explore the mindfulness practice, its long-term effects, facilitators and barriers, in clinical clerkship students 2 years after participation in an 8-week mindfulness-based stress reduction (MBSR) training. Method: A qualitative study was performed by semi-structured in-depth interviews with 16 clinical clerkship students selected by purposive sampling. Students had participated in a MBSR training 2 years before and were asked about their current mindfulness practice, and the long-term effects of the MBSR training. Thematic analysis was conducted using the constant comparison method. Data saturation was reached after 16 interviews. Results: Most interviewees were still engaged in regular, predominantly informal, mindfulness practice, although some discontinued mindfulness practice and reported an "unchanged lifestyle." Three main themes came forward; (1) "focused attention and open awareness" during daily activities as core elements of long-term mindfulness practice; (2) "changes in behavior and coping" that resulted from taking a pause, reflecting, recognizing automatic behavioral patterns and making space for a conscious response; (3) "integration in personal and professional life" by enhanced enjoyment of daily activities, improved work-life-balance and making different career choices. Barriers and facilitators in starting and maintaining mindfulness practice were (1) understanding and intention as "pre-conditions"; (2) practical, personal, and professional factors of students in maintaining practice. Conclusion: Two years after participation in a MBSR training, many interviewees were still engaged in (mostly informal) mindfulness practice contributing to both personal and professional changes. In light of the high clerkship demands, MBSR training could be a valuable addition to medical curricula, supporting medical students in developing necessary competencies to become well-balanced professionals.

A cross-sectional examination of psychological distress, positive mental health and their predictors in medical students in their clinical clerkships.

BACKGROUND: Medical students can experience the transition from theory to clinical clerkships as stressful. Scientific literature on the mental health of clinical clerkship students is scarce and mental health is usually defined as absence of psychological distress without assessing psychological, emotional and social wellbeing, together called 'positive mental health'. This cross-sectional study examines the prevalence of psychological distress and positive mental health and explores possible predictors in a Dutch sample of clinical clerkship students. METHODS: Fourth-year medical students in their first year of clinical clerkships were invited to complete an online questionnaire assessing demographics, psychological distress (Brief Symptom Inventory), positive mental health (Mental Health Continuum- SF), dysfunctional cognitions (Irrational Beliefs Inventory) and dispositional mindfulness skills (Five Facet Mindfulness Questionnaire). Multiple linear regression analysis was used to explore relationships between psychological distress, positive mental health (dependent variables) and demographics, dysfunctional cognitions and dispositional mindfulness skills (predictors). RESULTS: Of 454 eligible students, 406 (89%) completed the assessment of whom 21% scored in the clinical range of psychological distress and 41% reported a flourishing mental health. These proportions partially overlap each other. Female students reported a significantly higher mean level of psychological distress than males. In the regression analysis the strongest predictors of psychological distress were 'acting with awareness' (negative) and 'worrying' (positive). Strongest predictors of positive mental health were 'problem avoidance' (negative) and 'emotional irresponsibility' (negative). CONCLUSIONS: The prevalence of psychopathology in our sample of Dutch clinical clerkship students is slightly higher than in the general population. Our results support conclusions of previous research that psychological distress and positive mental health are not two ends of one continuum but partially overlap. Although no conclusion on causality can be drawn, this study supports the idea that self-awareness and active, nonavoidant coping strategies are related to lower distress and higher positive mental health.

Effects of Mindfulness-Based Stress Reduction on the Mental Health of Clinical Clerkship Students: A Cluster-Randomized Controlled Trial.

PURPOSE: To examine the effect of mindfulness-based stress reduction training (MBSR) on the mental health of medical students during clinical clerkships. METHOD: Between February 2011 and May 2014, the authors conducted a cluster-randomized controlled trial of clerkships as usual (CAU) and clerkships with additional MBSR in medical students during their first year of clinical clerkships at a Dutch university medical center. MBSR consisted of eight weekly two-hour sessions, comprising didactic teaching, meditation exercises, and group dialogues. Students completed online assessments at baseline and after 3, 7, 12, 15, and 20 months. Outcome measures were psychological distress, positive mental health, life satisfaction, physician empathy, mindfulness skills, and dysfunctional cognitions as measured by validated tools. RESULTS: Of 232 eligible students, 167 students (72%) participated and were randomized by clerkship group into MBSR (n = 83) or CAU (n = 84). The MBSR group reported a small reduction of psychological distress (P = .03, Cohen's d = 0.20) and dysfunctional cognitions (P = .05, Cohen's d = 0.18) and a moderate increase of positive mental health (P = .002, Cohen's d = 0.44), life satisfaction (P = .01, Cohen's d = 0.51), and mindfulness skills (P = .05, Cohen's d = 0.35) compared with CAU during the 20-month follow-up. The authors detected no significant effect on physician empathy (P = .18, Cohen's d = 0.27). CONCLUSIONS: MBSR appeared feasible and acceptable to medical clerkship students and resulted in a small to moderate improvement of mental health compared with CAU over the 20-month follow-up.

Reliability and validity of the Dutch version of the Consultation and Relational Empathy Measure in primary care.

BACKGROUND: Empathy is an essential skill in doctor-patient communication with positive effects on compliance, patient satisfaction and symptom duration. There are no validated patient-rated empathy measures available in Dutch. OBJECTIVE: To investigate the validity and reliability of a Dutch version of the Consultation and Relational Empathy (CARE) Measure, a widely used 10-item patient-rated questionnaire of physician empathy. METHODS: After translation and back translation, the Dutch CARE Measure was distributed among patients from 19 general practitioners in 5 primary care centers. Tests of internal reliability and validity included Cronbach's alpha, item total correlations and factor analysis. Seven items of the QUality Of care Through the patient's Eyes (QUOTE) questionnaire assessing 'affective performance' of the physician were included in factor analysis and used to investigate convergent validity. RESULTS: Of the 800 distributed questionnaires, 655 (82%) were returned. Acceptability and face validity were supported by a low number of 'does not apply' responses (range 0.2%-11.9%). Internal reliability was high (Cronbach's alpha 0.974). Corrected item total correlations were at a minimum of 0.837. Factor analysis on the 10 items of the CARE Measure and 7 QUOTE items resulted in two factors (Eigenvalue > 1), the first containing the CARE Measure items and the second containing the QUOTE items. Convergent construct validity between the CARE Measure and QUOTE was confirmed with a modest positive correlation (r = 0.34, n = 654, P < 0.001). CONCLUSION: The findings support the preliminary validity and reliability of the Dutch CARE Measure. Future research is required to investigate divergent validity and discriminant ability between doctors.

Mindfulness training for medical students in their clinical clerkships: two cross-sectional studies exploring interest and participation.

BACKGROUND: So far, studies investigating Mindfulness Based Stress Reduction (MBSR) training in medical students are conducted in self-selected, pre-clinical samples, with modest response rates without collecting data on non-participants. This study first examines interest and participation rates of students starting their clinical clerkships. Second, it compares students interested in a mindfulness training with non-interested students and students participating in a trial on the effect of MBSR with non-participating students on levels of psychological distress, personality traits, cognitive styles and mindfulness skills. METHODS: We examined two student samples from the Radboud University Medical Center, Nijmegen: Study 1 From March to December 2010 we performed a cross-sectional pilot-study among 4th year medical students starting their clinical clerkships, assessing interest in a MBSR training. We compared scores on the Brief Symptom Inventory, the Neo Five Factor Inventory and the Five Facet Mindfulness Questionnaire of interested students with those of non-interested students using t-tests with Bonferroni correction. Study 2 From February 2011 to August 2012 we invited 4th year medical students starting their clinical clerkships to participate in a randomized controlled trial (RCT) on the effectiveness of MBSR. We compared scores on the Brief Symptom Inventory, the Irrational Beliefs Inventory and the Five Facet Mindfulness Questionnaire of participating students with those of non-participants using t-tests with Bonferroni correction. RESULTS: Study 1: Ninety-five out of 179 participating students (53%) were interested in a MBSR training. Interested students scored significantly higher on psychological distress (p = .004) and neuroticism (p < .001), than 84 non-interested students. Study 2: Of 232 eligible students, 167 (72%) participated in our RCT. Participants scored significantly higher on psychological distress (p = .001), worrying (p = .002), problem avoidance (p = .005) and lower on mindfulness skills (p = .002) than 41 non-participants. CONCLUSIONS: Interest in mindfulness training and response rates in a RCT on the effectiveness of MBSR among clinical clerkship students are equal to (study 1) or higher (study 2) than in studies on pre-clinical students. Interested students and participants in a RCT reported more psychological distress and psychopathology related character traits. Participants scored lower on mindfulness skills.

An overview of 19 instruments assessing the doctor-patient relationship: different models or concepts are used.

OBJECTIVES: The doctor-patient relationship has been linked to patient satisfaction, treatment adherence, and treatment outcome. Many different instruments have been developed to assess this relationship. The large variety makes it difficult to compare results of different studies and choose an instrument for future research. This review aims to provide an overview of the existing instruments assessing the doctor-patient relationship. STUDY DESIGN AND SETTING: We performed a systematic search in PubMed, PsychInfo, EMBASE, and Web of Science for questionnaires measuring the doctor-patient relationship. We appraised each instrument ascertaining the questionnaires focused on the doctor-patient relationship. We compared the content and psychometric characteristics of the instruments. RESULTS: We found 19 instruments assessing the doctor-patient relationship. The instruments assess a variety of dimensions and use diverse conceptual models for the doctor-patient relationship. The instruments found also vary in terms to which they have been psychometrically tested. CONCLUSION: We have provided an overview of 19 instruments assessing the doctor-patient relationship. The selection of an instrument for future research should be based on the model or conceptual basis of the doctor-patient relationship that is most applicable to the study objectives and the health care field in which it will be applied.

The reassuring value of diagnostic tests: a systematic review.

OBJECTIVE: This review is a narrative synthesis of the RCTs which studied the efficacy of using diagnostic tests to reassure patients. METHODS: We searched for RCTs that examined the level of reassurance after diagnostic testing in outpatients. We used PubMed, Psychinfo, Cochrane Central, Ongoing Trials Database and Scopus. RESULTS: We found 5 randomized controlled trials that included 1544 patients. The trials used different diagnostic tests (ECG, radiography of lumbar spine, MR brain scan, laboratory tests, MR of lumbar spine) for different complaints (e.g. chest pain, low back pain and headache). Four out of 5 RCTs did not find a significant reassuring value of the diagnostic tests. One study reported a reassuring effect at 3 months which had disappeared after one year. CONCLUSION: Despite the sparse and heterogeneous studies, the results point in the direction of diagnostic tests making hardly any contribution to the level of reassurance. We recommend further studies on the use of diagnostic tests and other strategies to reassure the patient. PRACTICE IMPLICATIONS: A clear explanation and watchful waiting can make additional diagnostic testing unnecessary. If diagnostic tests are used, it is important to provide adequate pre-test information about normal test results.