Theory in Practice: Increasing Professional Effectiveness

Importance Medical students are at high risk for depression and suicidal ideation. However, the prevalence estimates of these disorders vary between studies. Objective To estimate the prevalence of depression, depressive symptoms, and suicidal ideation in medical students. Data Sources and Study Selection Systematic search of EMBASE, ERIC, MEDLINE, psycARTICLES, and psycINFO without language restriction for studies on the prevalence of depression, depressive symptoms, or suicidal ideation in medical students published before September 17, 2016. Studies that were published in the peer-reviewed literature and used validated assessment methods were included. Data Extraction and Synthesis Information on study characteristics; prevalence of depression or depressive symptoms and suicidal ideation; and whether students who screened positive for depression sought treatment was extracted independently by 3 investigators. Estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were estimated using stratified meta-analysis and meta-regression. Main Outcomes and Measures Point or period prevalence of depression, depressive symptoms, or suicidal ideation as assessed by validated questionnaire or structured interview. Results Depression or depressive symptom prevalence data were extracted from 167 cross-sectional studies (n = 116 628) and 16 longitudinal studies (n = 5728) from 43 countries. All but 1 study used self-report instruments. The overall pooled crude prevalence of depression or depressive symptoms was 27.2% (37 933/122 356 individuals; 95% CI, 24.7% to 29.9%, I2  = 98.9%). Summary prevalence estimates ranged across assessment modalities from 9.3% to 55.9%. Depressive symptom prevalence remained relatively constant over the period studied (baseline survey year range of 1982-2015; slope, 0.2% increase per year [95% CI, −0.2% to 0.7%]). In the 9 longitudinal studies that assessed depressive symptoms before and during medical school (n = 2432), the median absolute increase in symptoms was 13.5% (range, 0.6% to 35.3%). Prevalence estimates did not significantly differ between studies of only preclinical students and studies of only clinical students (23.7% [95% CI, 19.5% to 28.5%] vs 22.4% [95% CI, 17.6% to 28.2%]; P  = .72). The percentage of medical students screening positive for depression who sought psychiatric treatment was 15.7% (110/954 individuals; 95% CI, 10.2% to 23.4%, I2  = 70.1%). Suicidal ideation prevalence data were extracted from 24 cross-sectional studies (n = 21 002) from 15 countries. All but 1 study used self-report instruments. The overall pooled crude prevalence of suicidal ideation was 11.1% (2043/21 002 individuals; 95% CI, 9.0% to 13.7%, I2  = 95.8%). Summary prevalence estimates ranged across assessment modalities from 7.4% to 24.2%. Conclusions and Relevance In this systematic review, the summary estimate of the prevalence of depression or depressive symptoms among medical students was 27.2% and that of suicidal ideation was 11.1%. Further research is needed to identify strategies for preventing and treating these disorders in this population.

https://jamanetwork.com/journals/jama/articlepdf/2589340/joi160133.pdf

Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis.

For the past several years the author has been reviewing instructional design theories in an attempt to identify prescriptive principles that are common to the various theries. This paper is a preliminary report of the principles that have been identified by this search. Five first principles are elaborated: (a) Learning is promoted when learners are engaged in solving real-world problems. (b) Learning is promoted when existing knowledge is activated as a foundation for new knowledge. (c) Learning is promoted when new knowledge is demonstrated to the learner. (d) Learning is promoted when new knowledge is applied by the learner. (e) Learning is promoted when new knowledge is integrated into the learner's world. Representative instructional design theories are briefly examined to illustrate how they include these principles. These include: Star Legacy by the Vanderbilt Learning Technology Center, 4-Mat by McCarthy, instructional episodes by Andre, multiple approaches to understanding by Gardner, collaborative problem solving by Nelson, constructivist learning environments by Jonassen, and learning by doing by Schank. It is concluded that, although they use a wide variety of terms, these theories and models do include fundamentally similar principles.

/pdf/first-principles-of-instruction-55wbugvwji.pdf

First Principles of Instruction

by J. Biggs and C. Tang, Maidenhead, England,
Open University Press, 2007, 360 pp., £29.99, ISBN-13: 978-0-335-22126-4

Teaching for quality learning at university

Problem-based learning (PBL) has been utilized for over 40 years in a variety of diff erent disciplines. Although extensively researched, there is heated debate about the eff ectiveness of PBL. Several meta-analyses have been conducted that provide a synthesis of the eff ects of PBL in comparison to traditional forms of instruction. This study used a qualitative meta-synthesis approach to compare and contrast the assumptions and fi ndings of the meta-analytical research on the eff ectiveness of PBL. Findings indicated that PBL was superior when it comes to long-term retention, skill development and satisfaction of students and teachers, while traditional approaches were more eff ective for short-term retention as measured by standardized board exams. Implications are discussed.

/pdf/when-is-pbl-more-effective-a-meta-synthesis-of-meta-analyses-4gvnas3g51.pdf

When is PBL More Effective? A Meta-synthesis of Meta-analyses Comparing PBL to Conventional Classrooms

Problem based learning is used in many medical schools in the United Kingdom and worldwide. This article describes this method of learning and teaching in small groups and explains why it has had an important impact on medical education.

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The group learning process: acquiring desirable learning skills

In problem based learning (PBL) students use “triggers” from the problem case or scenario to define their own learning objectives. Subsequently they do independent, self directed study before returning to the group to discuss and refine their acquired knowledge. Thus, PBL is not about problem solving per se, but rather it uses appropriate problems to increase knowledge and understanding. The process is clearly defined, and the several variations that exist all follow a similar series of steps.

#### Generic skills and attitudes

Group learning facilitates not only the acquisition of knowledge but also several other desirable attributes, such as communication skills, teamwork, problem solving, independent responsibility for learning, sharing information, and respect for others. PBL can therefore be thought of as a small group teaching method that combines the acquisition of knowledge with the development of generic skills and attitudes. Presentation of clinical material as the stimulus for learning enables students to understand the relevance of underlying scientific knowledge and principles in clinical practice.

However, when PBL is introduced into a curriculum, several other issues for curriculum design and implementation need to be tackled. PBL is generally introduced in the context of a defined core curriculum and integration of basic and clinical sciences. It has implications for staffing and learning resources and demands a different approach to timetabling, workload, and assessment. PBL is often used to deliver core material in non-clinical parts of the …

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https://www.cc-seas.columbia.edu/sites/dsa/files/what_is_PBL.pdf

Problem based learning

Background
Empathy is important to patient care. The prevailing view is that empathy declines during university medical education. The significance of that decline has been debated.

This paper reports the findings in respect of two questions relating to university medical education:

1. Do men and women medical students differ in empathy?

2. Does empathy change amongst men and women over time?

/pdf/stability-of-empathy-among-undergraduate-medical-students-a-5g43smaaxz.pdf

Stability of empathy among undergraduate medical students: a longitudinal study at one UK medical school.

There is a growing acknowledgement that doctors need to develop leadership and management competences to become more actively involved in the planning, delivery and transformation of patient services. We undertook a systematic review of what is known concerning the knowledge, skills and attitudes of medical students regarding leadership and management. Here we report the results pertaining to the attitudes of students to provide evidence to inform curriculum development in this developing field of medical education. We searched major electronic databases and citation indexes within the disciplines of medicine, education, social science and management. We undertook hand searching of major journals, and reference and citation tracking. We accessed websites of UK medical institutions and contacted individuals working within the field. 26 studies were included. Most were conducted in the USA, using mainly quantitative methods. We used inductive analysis of the topics addressed by each study to identity five main content areas: Quality Improvement; Managed Care, Use of Resources and Costs; General Leadership and Management; Role of the Doctor, and Patient Safety. Students have positive attitudes to clinical practice guidelines, quality improvement techniques and multidisciplinary teamwork, but mixed attitudes to managed care, cost containment and medical error. Education interventions had variable effects on students' attitudes. Medical students perceive a need for leadership and management education but identified lack of curriculum time and disinterest in some activities as potential barriers to implementation. The findings from our review may reflect the relatively little emphasis given to leadership and management in medical curricula. However, students recognise a need to develop leadership and management competences. Although further work needs to be undertaken, using rigorous methods, to identify the most effective and cost-effective curriculum innovations, this review offers the only currently available summary of work examining the attitudes of students to this important area of development for future doctors.

/pdf/attitudes-of-medical-students-to-medical-leadership-and-2c82fzlnvq.pdf

Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development

Objectives To determine the prevalence of depression among male and female medical students, its change over time and whether depression persists for affected students. Design Longitudinal study comprising annual questionnaire surveys which included the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D). Participants Between 2007 and 2010 all 1112 students entering the Core Science component (Year 1) and all 542 students entering the Clinical component (Year 4) of the Cambridge (UK) medical course were followed-up annually. Methods We analysed, separately for men and women, mean HADS-D scores, the proportions whose scores indicated depression at different time-points and for students maintaining participation, the number of occasions on which their HADS-D scores indicated depression. Results 725 Core Science and 364 Clinical students participated. Mean HADS-D scores ranged between 3.34 and 3.49 among all Core Science students and between 2.16 and 2.91 among all Clinical students. There was no difference between men and women in median HADS-D scores. Prevalence of depression ranged between 5.7% and 10.6% among all Core Science students and between 2.7% and 8.2% among all Clinical students. Over time Core Science students displayed no increase in mean HADS-D score. Among Clinical students only men displayed a small increase (time coefficient 0.33 (95% CI 0.11 to 0.55)). Prevalence did not increase over time. 220 Core Science and 150 Clinical students participated throughout the study. Of these, 18.2% and 10.6%, respectively, recorded HADS-D scores indicating depression on at least one occasion. Of 56 students recording depression at some point, 37 did so only once. Conclusions Prevalence of depression among participants was similar to that reported for comparable groups. Among men approaching the end of clinical studies depression scores increased. In all years a minority of students displayed depression; for some this persisted. Mechanisms are needed to identify and support students suffering from depression, particularly when persistent.

https://bmjopen.bmj.com/content/bmjopen/2/4/e001519.full.pdf

Prevalence and persistence of depression among undergraduate medical students: a longitudinal study at one UK medical school

Although a core element in patient care the trajectory of empathy during undergraduate medical education remains unclear. Empathy is generally regarded as comprising an affective capacity: the ability to be sensitive to and concerned for, another and a cognitive capacity: the ability to understand and appreciate the other person’s perspective. The authors investigated whether final year undergraduate students recorded lower levels of empathy than their first year counterparts, and whether male and female students differed in this respect. Between September 2013 and June 2014 an online questionnaire survey was administered to 15 UK, and 2 international medical schools. Participating schools provided both 5–6 year standard courses and 4 year accelerated graduate entry courses. The survey incorporated the Jefferson Scale of Empathy-Student Version (JSE-S) and Davis’s Interpersonal Reactivity Index (IRI), both widely used to measure medical student empathy. Participation was voluntary. Chi squared tests were used to test for differences in biographical characteristics of student groups. Multiple linear regression analyses, in which predictor variables were year of course (first/final); sex; type of course and broad socio-economic group were used to compare empathy scores. Five medical schools (4 in the UK, 1 in New Zealand) achieved average response rates of 55 % (n = 652) among students starting their course and 48 % (n = 487) among final year students. These schools formed the High Response Rate Group. The remaining 12 medical schools recorded lower response rates of 24.0 % and 15.2 % among first and final year students respectively. These schools formed the Lower Response Rate Group. For both male and female students in both groups of schools no significant differences in any empathy scores were found between students starting and approaching the end of their course. Gender was found to significantly predict empathy scores, with females scoring higher than males. Participant male and female medical students approaching the end of their undergraduate education, did not record lower levels of empathy, compared to those at the beginning of their course. Questions remain concerning the trajectory of empathy after qualification and how best to support it through the pressures of starting out in medical practice.

/pdf/empathy-among-undergraduate-medical-students-a-multi-centre-ise5b61w7o.pdf

Diana Wood

Papers

Problem based learning

Stability of empathy among undergraduate medical students: a longitudinal study at one UK medical school.

Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development

Prevalence and persistence of depression among undergraduate medical students: a longitudinal study at one UK medical school

Empathy among undergraduate medical students: A multi-centre cross-sectional comparison of students beginning and approaching the end of their course.