Use of simulated clients in training veterinary undergraduates in communication skills

A course in communication skills has been developed specifically for veterinary students, based on those delivered at many medical schools, and making extensive use of professional actors as simulated clients. Its aim is to raise awareness of the importance of communication among veterinary undergraduates at all stages of the curriculum, and it allows them to role-play in acted-out scenarios. Facilitated small groups provide an environment in which students can receive feedback on their own performance and also give feedback to their colleagues. An independent evaluation suggests that the opportunity to role-play increased the students' confidence in communicating with others. They were able to identify their personal strengths as communicators and gain insights into the aspects of communication they could improve. Feedback and subsequent discussions were highly valued, with the actors playing a crucial role in providing feedback from the client's perspective. Students were able to use the knowledge they acquired when consulting with real clients. Most of the students suggested that the course should continue in its current format, but with more time provided for it in the curriculum.

Examiner fatigue in communication skills objective structured clinical examinations

CONTEXT

The assessment of undergraduates' communication skills by means of objective structured clinical examinations (OSCEs) is a demanding task for examiners. Tiredness over the course of an examining session may introduce systematic error. In addition, unsystematic error may also be present which changes over the duration of the OSCE session.

AIM

To determine the strength of some sources of systematic and unsystematic error in the assessment of communication skills over the duration of an examination schedule.

METHODS

Undergraduate first-year medical students completing their initial summative assessment of communication skills (a four-station OSCE) comprised the study population. Students from three cohorts were included (1996-98 intake). In all 3 years the OSCE was carried out identically. All stations lasted 5 minutes with a simulated patient. Students were assessed using an examiner (content expert) and a simulated-patient evaluation tool, the Liverpool Communication Skills Assessment Scale (LCSAS) and the Global Simulated-patient Rating Scale (GSPRS), respectively. Each student was assigned a time slot ranging from 1 to 24, where 1, for example, would denote that the student entered the exam first and 24 indicates the final slot for entry into the examination. The number of students who failed this exam was noted for each of the 24 time slots. A control set of marks from a communication skills written exam was also adopted for exploring a possible link with the time slot. Analysis was conducted using graphical display, covariate analysis and logistic regression.

RESULTS

No significant relationship was found between the schedule point that the student entered the OSCE exam and their performance. The reliability of the content expert and simulated-patient assessments was stable throughout the session.

CONCLUSION

No evidence could be found that duration of examining in a communication OSCE influenced examiners and the marks they awarded. Checks of this nature are recommended for routine inspection to confirm a lack of bias.

Assessing the development of communication skills in undergraduate medical students

CONTEXT

The teaching of clinical communication skills' teaching has become an important part of medical school curricula. Many undergraduate medical courses include communication skills training at various points in their curriculum. Very few reports have been published on the development of communication skills over the duration of a medical undergraduate training.

AIMS

To determine the change in communication skills between early and mid-stages of the students' 5-year curriculum, and to investigate the predictive and theoretical significance of knowledge and understanding of communication skills in relation to observed performance.

PARTICIPANTS

Students entering as the first cohort to the new medical curriculum at Liverpool Medical School (n=207). Nine students withdrew leaving 198 students who completed two summative assessments in June 1997 (level 1) and November 1998 (level 2).

STATISTICAL ANALYSIS

Repeated measures multivariate ANOVAS were applied to the main study data to detect any change in performance between levels 1 and 2.

RESULTS AND CONCLUSIONS

An improvement in communication skills was found in medical students over 17 months of their undergraduate teaching: that is from the level 1 to the level 2 assessment. Knowledge and understanding of communication skills at initial assessment did not show the predicted association with performance at level 2.

Assessing the development of communication skills in undergraduate medical students

CONTEXT

The teaching of clinical communication skills' teaching has become an important part of medical school curricula. Many undergraduate medical courses include communication skills training at various points in their curriculum. Very few reports have been published on the development of communication skills over the duration of a medical undergraduate training.

AIMS

To determine the change in communication skills between early and mid-stages of the students' 5-year curriculum, and to investigate the predictive and theoretical significance of knowledge and understanding of communication skills in relation to observed performance.

PARTICIPANTS

Students entering as the first cohort to the new medical curriculum at Liverpool Medical School (n=207). Nine students withdrew leaving 198 students who completed two summative assessments in June 1997 (level 1) and November 1998 (level 2).

STATISTICAL ANALYSIS

Repeated measures multivariate ANOVAS were applied to the main study data to detect any change in performance between levels 1 and 2.

RESULTS AND CONCLUSIONS

An improvement in communication skills was found in medical students over 17 months of their undergraduate teaching: that is from the level 1 to the level 2 assessment. Knowledge and understanding of communication skills at initial assessment did not show the predicted association with performance at level 2.

The Liverpool brief assessment system for communication skills in the making of doctors

The teaching of clinical communication skills is gaining importance in medical schools. There is a need to design feasible assessments that are credible to faculty, students and the profession.

AIM

To design, and assess the reliability and validity of a new communication skills assessment system (the Liverpool Communication Skills Assessment Scale-LCSAS, and the Global Simulated Patient Rating Scale-GSPRS) for employment in OSCEs.

PARTICIPANTS

The first three annual intakes of students to the new medical curriculum at Liverpool Medical School (n = 600). Two further sub samples of 1st year (n = 60) and 2nd year students (n = 80) were included for further validation purposes in separate studies.

STATISTICAL ANALYSIS

Intra class correlation coefficients and generalisability coefficients were employed to assess reliability of the LCSAS and GSPRS. Validity was tested by examining predicted relationships using pearson product moment correlation coefficients.

RESULTS AND CONCLUSIONS

The LCSAS and GSPRS showed reasonable evidence for their reliability and validity although further work is recommended.

The Objective Structured Video Exam for assessment of communication skills

OBJECTIVES

(i) To design a new, quick and efficient method of assessing specific cognitive aspects of trainee clinical communication skills, to be known as the Objective Structured Video Exam (OSVE) (Study 1); (ii) to prepare a scoring scheme for markers (Study 2); and (iii) to determine reliability and evidence for validity of the OSVE (Study 3).

METHODS

Study 1 describes how the exam was designed. The OSVE assesses the student's recognition and understanding of the consequences of various communication skills. In addition, the assessment taps the number of alternative skills that the student believes will be of assistance in improving the patient-doctor interaction. Study 2 outlines the scoring system that is based on a range of 50 marks. Study 3 reports inter-rater consistency and presents evidence to support the validity of the new assessment by associating the marks from 607 1st year undergraduate medical students with their performance ratings in a communication skills OSCE.

SETTING

Medical school, The University of Liverpool.

RESULTS

Preparation of a scoring scheme for the OSVE produced consistent marking. The reliability of the marking scheme was high (ICC=0.94). Evidence for the construct validity of the OSVE was found when a moderate predicted relationship of the OSVE to interviewing behaviour in the communication skills OSCE was shown (r=0.17, P < 0.001).

CONCLUSION

A new video-based written examination (the OSVE) that is efficient and quick to administer was shown to be reliable and to demonstrate some evidence for validity.

Sources of stress for orthodontic practitioners

This paper aims to examine and highlight the difference between sources of stress and burn-out. The first part of the paper examines stress and the second part looks at the concept of burn-out with reference to how orthodontists compare with other dental professionals.

Persecutory delusions and autobiographical memory

OBJECTIVES

It was hypothesized that people with persecutory delusions, such as depressed people, would experience difficulty when attempting to generate specific autobiographical memories.

DESIGN

20 deluded participants, 20 depressed patients and 20 normal controls were compared on an autobiographical memory test.

METHODS

Participants attempted to recall memories to positive and negative cue words. Independent raters classified responses as specific, general, imaginary or unscorable. Over-general memories were further classified as extended or categorical.

RESULTS

Deluded participants recalled significantly more general (especially categorical) memories and fewer specific memories than the normal control subjects. Depressed participants showed little evidence of over-general memories, although they showed faster recall latencies to negative than to positive cues.

CONCLUSIONS

People with paranoid delusions show information processing features similar to those previously reported in people with depression. The possible contribution of adverse experiences to over-general autobiographical recall is discussed.

Two predictions about paranoid ideation: deluded, depressed and normal participants' subjective frequency and consensus judgments for positive, neutral and negative events

Two groups of patients suffering from persecutory delusions, one consisting of patients also suffering from depression and a non-depressed group, together with clinically depressed and normal controls matched with the deluded patients for age and intelligence, were asked to rate the frequency with which selected positive, negative and neutral events had happened to themselves and to an average other person in the past, and the frequency with which these events were likely to happen to themselves and to an average other person in the future. Results were similar for both past and expected future events. Non-depressed-deluded, depressed-deluded and depressed patients rated negative events as occurring relatively more frequently in comparison to the normal controls. Depressed participants rated positive events as occurring more frequently to others, whereas the normal participants rated negative events as occurring more often to others. Correlational analyses indicated that depression scores were associated with low estimates of the frequency with which positive events happen to self and high estimates of the frequency with which negative events happen to self. Magical ideation scores, an index of psychosis, were associated with high estimates of the frequency of negative events for both self and others. These findings are interpreted in the context of previous evidence on cognitive biases in deluded patients.

Burnout and stress-related factors among junior staff of three dental hospital specialties

OBJECTIVE

To determine whether occupational stress, health status, job satisfaction and burnout differed between the three major hospital dental specialties, and to compare this data with previous studies.

DESIGN

A cross-sectional survey.

SETTING

The regional dental teaching hospital and outlying hospital units in Merseyside in 1993.

SUBJECTS AND METHODS

All 52 junior hospital dentists in the Merseyside area were invited to complete a self-report questionnaire to be returned by post. Up to three reminders were sent. 42 staff replied (81% response rate).

MAIN OUTCOME MEASURES

Occupational Stress Indicator, Maslach Burnout Inventory.

RESULTS

The profile of stressors was comparable to a previously reported sample of hospital dentists. Job satisfaction varied significantly across specialties (P < 0.015) whereas personal achievement was reported to be strong regardless of the nature of work. Self-reported health (physical and mental) was similar across specialties. 10% of respondents were suffering burnout. Depersonalisation (a result of extended and demanding contacts with patients) was significantly (P < 0.05) greater in restorative and oral surgery specialties in comparison with orthodontists.

CONCLUSIONS

Although short-term stressors among hospital dental staff were not different between occupational groups, some important longer term effects were identified.

Abnormalities of self-representation and persecutory delusions: a test of a cognitive model of paranoia

Patients suffering from persecutory delusions exhibit information processing and social reasoning biases that have been hypothesized to have a self-protective function. In a test of this hypothesis, patients suffering from persecutory delusions who were also depressed and non-depressed deluded subjects were compared with depressed and normal controls on two indirect assessments of self-schemata: the Dysfunctional Attitudes Scale (DAS) and incidental recall of negative and positive trait words that had previously been judged to be self-descriptive or not self-descriptive. Both the depressed subjects and the deluded subjects, whether or not they were depressed, scored highly on the DAS. Like normals, both depressed and non-depressed deluded subjects endorsed more positive than negative trait words as true of themselves whereas the depressed subjects endorsed as many negative as positive trait works. Like the depressed subjects, both groups of deluded subjects recalled as many of the negative words they had endorsed as positive words, whereas the normals remembered more positive words. No such bias was observed in subjects' recall of unendorsed words. The DAS results are interpreted as clearly consistent with a defensive model of persecutory delusions whereas the incidental recall data were equivocally so.

Stress in junior hospital medical and dental staff: a descriptive account of their concerns and needs

Examines the issues of work-related stress in the healthcare professions, focusing on junior medical and dental staff. Identifies the stressors, and reports on an interview survey conducted as part of a larger study funded by the National Health Service Management Executive to identify the levels of stress. Concludes that outsourcing to an independent counselling service could prove to be an effective stress-management strategy.

The defensive function of persecutory delusions. Evidence from attribution tasks

Abnormalities of 'social' reasoning were investigated in patients suffering from persecutory delusions and in matched depressed and normal controls using transparent (obvious) and opaque (unobvious) tests of attributional style. Whereas depressed and normal subjects yielded similar causal inferences for both attributional measures, the deluded subjects showed a marked shift in internality, attributing negative outcomes to external causes on the transparent Attributional Style Questionnaire but, on the more opaque Pragmatic Inference Task, attributing negative outcomes to internal causes and thus showing a cognitive style resembling that of the depressed group. This finding, interpreted in terms of explicit versus implicit judgements, supports the hypothesis that delusions function as a defence against underlying feelings of low self-esteem.

The self, attributional processes and abnormal beliefs: towards a model of persecutory delusions

In this paper we review a series of recent investigations into cognitive abnormalities associated with persecutory delusions. Studies indicate that persecutory delusions are associated with abnormal attention to threat-related stimuli, an explanatory bias towards attributing negative outcomes to external causes and biases in information processing relating to the self-concept. We propose an integrative model to account for these findings in which it is hypothesized that, in deluded patients, activation of self/ideal discrepancies by threat-related information triggers defensive explanatory biases, which have the function of reducing the self/ideal discrepancies but result in persecutory ideation. We conclude by discussing the implications of this model for the cognitive-behavioural treatment of paranoid delusions.

Paranoia and the defensive attributional style: deluded and depressed patients' attributions about their own attributions

A data set of Attributional Style Questionnaire responses collected by Kaney & Bentall (1989) from persecutory deluded, normal and depressed subjects was added to a similar data set collected by the first author. The attributions made for hypothetical positive and negative events by the combined pool of subjects were then blind rated for internality by five independent judges. Whereas the internality ratings made by the subjects for their own attributions showed evidence of an exaggerated self-serving bias in the case of the deluded subjects, and an absence of such a bias in the case of the depressed subjects, the independent ratings showed no such group differences. These findings suggest that the differences in internality for positive and negative events observed on the ASQ between deluded, normal and depressed subjects may not reflect differences in the types of causal statements made by these subjects but differences in their attributions about their attributions. The relevance of this observation for attribution theory in general and attributional accounts of psychopathology in particular are discussed.

Persecutory delusions and the self-serving bias. Evidence from a contingency judgment task

The self-serving attributional bias was studied in matched groups of patients with persecutory delusions, patients with major affective disorder, and normal controls, (N = 14 in each group). On a preprogrammed computer task, subjects mainly won points in one condition and mainly lost points in the other. Subjects were asked to estimate the degree of control they thought they had over winning or losing in the two conditions. In comparison with the normal subjects and the psychiatric controls, the deluded subjects showed a greater self-serving bias, as evidenced by their perceived greater control over outcomes in the win condition. These findings are interpreted as consistent with the hypothesis that persecutory delusions function as a defense against low self-esteem.

Persecutory delusions and recall of threatening propositions

Subjects suffering from persecutory delusions, psychiatric controls and normal subjects were required to recall immediately six passages of prose, half of which contained mildly threatening propositions. Deluded subjects recalled fewer propositions overall but more propositions of specifically threatening content. These findings suggest that the role of recall bias in persecutory delusions merits further study.

Paranoia and social reasoning: an attribution theory analysis

The social reasoning of patients suffering from persecutory delusions and matched groups of depressed and normal controls was investigated using the framework of Kelley's (1967) theory of social attribution. Subjects were required to choose between person, circumstances and stimulus attributions for a series of social vignettes describing interactions between two persons. The vignettes varied in terms of the distinctiveness, consistency and consensus information supplied, as well as in respect of whether the actions described were positively or negatively valued. It was found that the deluded patients made excessive person attributions for negative events. It was also found that the deluded patients were excessively certain about their judgements compared to the depressed controls. Normal subjects tended to rate their certainty in their own judgements midway between the deluded and depressed patients.

Content specific information processing and persecutory delusions: an investigation using the emotional Stroop test

Attentional bias was investigated in patients suffering from persecutory delusions and matched psychiatric and normal controls, using the emotional Stroop task. Subjects were required to colour name words which were either meaningless strings of Os, neutral words, words indicating negative affect, or words judged to be of paranoid content. In comparison with the control subjects the deluded patients demonstrated a selective increase of response time for the paranoid words. A second analysis using indices of interference produced even more marked results. The relevance of these findings for the understanding of delusional thinking is discussed.

Persecutory delusions and attributional style

Seventeen psychotic patients with persecutory delusions were matched against depressed and normal controls and assessed for magical ideation, locus of control and attributional style. The deluded and depressed patients were found to make global and stable attributions when compared to the normal subjects. However, the deluded patients, in contrast with both control groups, made excessively external attributions for negative events and internal attributions for positive events. Highly significant differences were observed between the deluded group and the two control groups on magical ideation and on the 'powerful others' subscale of the locus of control questionnaire. Both psychiatric groups differed from the normal control group on 'chance' locus of control and a significant difference was observed between the persecuted and normal subjects on the 'internality' subscale of the questionnaire. The implications of these findings for the understanding and treatment of paranoid delusions are discussed.