Medical education can have significant negative effects on the well-being of medical students. To date, efforts to improve student mental health have focused largely on improving access to mental ...health providers, reducing the stigma and other barriers to mental health treatment, and implementing ancillary wellness programs. Still, new and innovative models that build on these efforts by directly addressing the root causes of stress that lie within the curriculum itself are needed to properly promote student wellness. In this article, the authors present a new paradigm for improving medical student mental health, by describing an integrated, multifaceted, preclinical curricular change program implemented through the Office of Curricular Affairs at the Saint Louis University School of Medicine starting in the 2009–2010 academic year. The authors found that significant but efficient changes to course content, contact hours, scheduling, grading, electives, learning communities, and required resilience/mindfulness experiences were associated with significantly lower levels of depression symptoms, anxiety symptoms, and stress, and significantly higher levels of community cohesion, in medical students who participated in the expanded wellness program compared with those who preceded its implementation. The authors discuss the utility and relevance of such curricular changes as an overlooked component of change models for improving medical student mental health.
Racial/ethnic disparities not only are prevalent throughout the U.S. health care system but also have proved refractory to change. Such disparities are evident and similarly persistent in the ...treatment of patients with chronic pain conditions, exacting high personal and societal costs. While psychosocial factors contribute significantly to this intractable problem, an integrated examination of the literature is lacking. This article provides an overview of psychosocial factors that contribute to disparities in the treatment of chronic pain patients and in their adjustment to pain. It focuses initially on aspects of pain assessment that can occasion disparate care. Because pain is a subjective phenomenon that often defies objective medical assessment, it is particularly susceptible to social psychological influences, such as stereotypes. We pay particular attention to negative racial/ethnic stereotypes as well as to the circumstances that are likely to trigger stereotype-driven judgments. Subsequent sections review psychosocial factors that can influence a patient's experience of pain, those that can influence the patient-provider interaction, and those that operate in the public health environment. After each section, we suggest actions that could address identified issues related to clinical care, research, and policy. Policy recommendations generally are linked to provisions of the Affordable Care Act. We conclude with a discussion of the role that psychology should play in future efforts to address the persistent problem of racial/ethnic disparities in pain care.
Objective
While medical student wellness has been a subject of recent study and discussion, current efforts may fail to address possible underlying, harmful cognitive distortions regarding academic ...performance. The authors sought to examine dysfunctional thoughts (maladaptive perfectionism, impostor phenomenon) and negative feelings (shame, embarrassment, inadequacy) that may contribute to poor mental health in pre-clinical medical students.
Methods
A survey was administered to first-year medical students at Saint Louis University that included assessments for maladaptive perfectionism, impostor phenomenon, depression, and anxiety, as well as questions about feelings of shame, embarrassment, inadequacy, comparison, and self-worth.
Results
A total of 169 students (93%) participated. Students who met criteria for maladaptive perfectionism were significantly more likely to report greater feelings of shame/embarrassment and inadequacy (
P
< 0.001) than their peers who did not; similar associations were observed in students who reported high/intense levels of impostor phenomenon (
P
< 0.001). Furthermore, students who reported feelings of shame/embarrassment or inadequacy were significantly more likely to report moderate/severe levels of depression symptoms (
P
< 0.001) and moderate/high levels of anxiety symptoms (
P
= 0.001) relative to students who did not report these negative feelings.
Conclusions
These preliminary data support a model for how negative thoughts may lead to negative emotions, and depression and anxiety in medical students. The authors propose strategies for preventive interventions in medical school beginning in orientation. Further research is needed to develop targeted interventions to promote student mental health through reduction of cognitive distortions and negative feelings of shame, embarrassment, and inadequacy.
The poor mental health of residents, characterized by high rates of burnout, depression, and suicidal ideation, is a growing concern in graduate medical education. Research is needed to gain a deeper ...understanding of the sources of distress as well as the sources of sustenance in residency training. The study by Mata and colleagues contributes significantly to this understanding. In addition to this line of research, however, studies are needed that assess the impact of interventions to help residents deal more effectively with the stress of training and find meaning in their work. Given the stresses of residency training, this approach may not make a dramatic difference in mental health outcomes. Efforts directed at changing the educational and clinical environments are also needed to reduce unnecessary stressors and create more positive settings for learning and clinical care. Since 2011, Saint Louis University School of Medicine has been pursuing a multipronged strategy to address these issues in the preclinical years. These efforts have led to dramatic decreases in depression and anxiety symptoms in students. An essential component of these interventions is the ongoing measurement of mental health outcomes across all four years of the curriculum. Leaders of residency programs, medical schools, and hospitals need to have the courage to measure these kinds of outcomes to spur change and track the efficacy of programs.
IMPORTANCE Implantable cardioverter-defibrillators (ICDs) have changed the way in which patients with chronic ventricular dysfunction are evaluated and treated. OBJECTIVE To examine patient-physician ...communication at the time the decision is made to implant an ICD. DESIGN, SETTING, AND PARTICIPANTS Forty-one patients with ICDs and 11 cardiologists were recruited by a national marketing research company for a study comprising patient focus groups and standardized patient interviews in 3 different metropolitan areas. INTERVENTIONS Eight patient focus groups and (separately) 22 standardized patient interviews with cardiologists. MAIN OUTCOME MEASURES Patient focus group findings and the results of standardized patient interviews (each cardiologist interviewed 2 patients). RESULTS The mean (SD) patient age was 61.4 (14.7) years; 21 were female. Thirty-three patients could not recall a discussion about periprocedural or long-term complications. On a scale of 1 to 10, the mean (SD) rating of the degree to which patients felt informed before the implant procedure was 5.7 (3.2) (1 indicates “not at all informed,” and 10 indicates “I had all the information I needed or wanted”). The mean (SD) estimated number of patients out of 100 who would be saved by the ICD was 87.9 (20.1). A negative perception on body image and lifestyle was prevalent. Across 22 standardized patient interviews, cardiologists frequently (in >17 of 22 of interviews) did not address or minimized or denied quality-of-life issues and long-term consequences of ICD placement, including the risk for depression, anxiety, and inappropriate delivery of shock or device advisory. In 15 of 22 of the standardized patient interviews, cardiologists used unexplained medical terms or jargon. CONCLUSIONS AND RELEVANCE Patient-physician communication about ICDs is characterized by unclear representation and omission of information to patients, with notable lack of attention to psychological and long-term risks. Training of cardiologists on information exchange with patients may promote informed decision making and preempt threats to patient quality of life.
Abstract
Objective
This study examined factors influencing lay perceptions of a provider’s clinical burden in providing care to a person with chronic pain.
Design
In a between-subjects design that ...varied three levels of pain severity (4, 6, or 8 out of 10) with two levels of medical evidence (low/high), participants rated the credibility of pain reported by a hypothetical patient and the psychosocial factors expected to mediate the effects of evidence and severity on a provider’s burden of care.
Setting
A randomized vignette study in which community participants were recruited via Amazon Mechanical Turk.
Subjects
337 community participants.
Methods
Using a Qualtrics platform, participants read one of six vignettes describing a hypothetical patient with varying levels of medical evidence and pain severity and then rated perceived pain severity, pain credibility, psychosocial variables, and burden.
Results
Serial mediation models accounted for all effects of medical evidence and pain severity on burden. Low medical evidence was associated with increased burden, as mediated through lower pain credibility and greater concerns about patient depression, opioid abuse, and learning pain management. Higher levels of reported pain severity were associated with increased burden, as mediated through greater pain discounting and concerns about opioid abuse.
Conclusions
The lay public is skeptical of chronic pain that is not supported by medical evidence or is reported at high levels of severity, raising concerns about psychosocial complications and drug seeking and expectations of higher burden of care. Such negative stereotypes can pose obstacles to people seeking necessary care if they or others develop a chronic pain condition.
The Mini-Mental State Examination (MMSE) is commonly used as a screening tool to detect dementia. However, it performs poorly in identifying persons with mild neurocognitive disorder. The Saint Louis ...University Mental Status (SLUMS) examination is a 30-point screening questionnaire that tests for orientation, memory, attention, and executive functions.
The objective of this study was to compare SLUMS and the MMSE for detecting dementia and mild neurocognitive disorder (MNCD) using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) criteria.
Patients at the Veterans' Affairs Geriatric Research, Education and Clinical Center, St. Louis, MO (N = 702) were clinically classified as having normal cognitive functioning, MNCD, or dementia based on DSM–IV criteria. The SLUMS and MMSE were administered for comparison.
Mean age was 75.3 years (standard deviation: 5.5). Regarding education, 62.4% of the sample had at least completed high school and 30.6% had not. Sensitivity and specificity were calculated and receiver operator curves (ROCs) generated for SLUMS and MMSE as a function of diagnosis (MCND versus dementia) and education. Both the SLUMS and MMSE produced acceptable ROCs for the diagnosis of dementia, but the ROCs for SLUMS were better than the MMSE for the diagnosis of MNCD in both education groups.
These results suggest that the SLUMS and MMSE have comparable sensitivities, specificities, and area under the curve in detecting dementia. Although the definition of MNCD is controversial, the authors believe that the SLUMS is possibly better at detecting mild neurocognitive disorder, which the MMSE failed to detect, but this needs to be further investigated.
This study compared perceptions of the burden of patient care and associated clinical judgments between physicians and people with chronic pain (PWCP) in a 2 × 3 × 2 between-subjects design that ...varied participant type, patient-reported pain severity (4/6-8/10), and supporting medical evidence (low/high). One hundred and nine physicians and 476 American Chronic Pain Association members were randomly assigned to 1 of 6 conditions. Respondents estimated the clinical burden they would assume as the treating physician of a hypothetical patient with chronic low back pain, and made clinical judgments regarding that patient. Physician burden ratings were significantly higher than PWCP ratings, and clinical impressions (eg, trust in pain report, medical attribution) and management concerns (eg, opioid abuse risk) were relatively less favorable. Neither pain severity nor medical evidence affected burden ratings significantly. High medical evidence was associated with more favorable clinical impressions; higher pain severity led to more discounting of patient pain reports. Burden was significantly correlated with a range of clinical judgments. Results indicate that physicians and PWCP differ in their perceptions of provider burden and related clinical judgments in ways that could impact treatment collaboration. Further research is needed that examines provider burden in actual clinical practice. PERSPECTIVE: Physicians and people with chronic pain (PWCP) estimated the clinical burden of patient care and made judgments about a hypothetical patient with chronic pain. Physician burden ratings were higher and clinical judgments less favorable, relative to PWCP respondents. These differences could impact treatment collaboration and merit study in clinical practice.
While patient perceptions of burden to caregivers is of recognized clinical significance among people with chronic pain, perceived burden to treating physicians has not been studied. This study ...examined how people with chronic pain perceived levels of medical evidence (low vs high) and pain severity (4,6,8/10) to influence physician burden and how burden then mediated expected clinical judgments. 476 people with chronic pain read vignettes describing a hypothetical patient with varying levels of medical evidence and pain severity from the perspective of a treating physician, rated the burden that patient care would pose, and made a range of clinical judgments. The effect of pain severity on clinical judgments was expected to interact with medical evidence and be conditionally mediated by burden. Although no associations with burden were found for the pain severity x medical evidence interaction or for pain severity alone, low levels of supporting medical evidence yielded higher burden ratings. Burden significantly mediated medical evidence effects on judgments of symptom credibility, clinical improvement, and psychosocial dysfunction. Results indicate that perceived physician burden negatively influenced judgments of patients with chronic pain, beyond the direct effects of medical evidence. Implications are discussed for clinical practice, as well as future research. PERSPECTIVE: : People with chronic pain expect physicians to view the care of patients without supporting medical evidence as burdensome. Higher burden is associated with less symptom credibility, more psychosocial dysfunction, and less treatment benefit. Perceived physician burden appears to impact how patients approach treatment, with potentially adverse implications for clinical practice.
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