Mark Huthwaite

“Being-in-role”: A teaching innovation to enhance empathic communication skills in medical students

Background: The communication of empathy is key in physician–patient interactions. We introduced drama training in “How to act-in-role” to medical students and evaluated the effect of this. Methods: A quasi-experimental design was employed, with 72 students in the control and 77 students in the intervention group. The students’ empathy scores were obtained using the Jefferson Scale of Physician Empathy (JSPE) during the introductory course. Both groups received tutorials in motivational interviewing and brief intervention skills. The students in the intervention group also received training in “How to act-in-role”. The JSPE was repeated for both groups. The students subsequently undertook observed structured clinical examinations (OSCE). Both tutors and students evaluated the students OSCE performance as well as their motivational interviewing skills using the Behavior Change Counseling Index (BECCI). Results: Our findings show that while the students in both groups did not significantly differ in baseline empathy scores, the intervention group reported significantly higher empathy scores post-intervention. The intervention group also received significantly higher tutor ratings for their motivational interviewing (BECCI score) and overall OSCE performances. In conclusion, the teaching innovation “How to act-in-role” was effective not only in increasing medical students’ self-reported empathy but also their competence in consultation skills.

Clozapine-treated Patients Have Marked Gastrointestinal Hypomotility, the Probable Basis of Life-threatening Gastrointestinal Complications: A Cross Sectional Study.

Background Gastrointestinal side effects are particularly common with clozapine and occur with other antipsychotics, ranging from mild constipation to fatal bowel obstruction and/or ischemia. While this adverse-effect spectrum has been attributed to ‘gastrointestinal hypomotility’, gastrointestinal transit times in antipsychotic-treated patients have not previously been measured, making this mechanism speculative. Methods Using standardized radiopaque marker (‘Metcalf’) methods we established colonic transit times of antipsychotic-treated psychiatric inpatients and compared them with population normative values. We analyzed results by antipsychotic type, antipsychotic dose equivalent, anticholinergic load, duration of treatment, gender, ethnicity, and age. Outcomes For patients not prescribed clozapine, median colonic transit time was 23 h. For patients prescribed clozapine, median transit time was 104.5 h, over four times longer than those on other antipsychotics or normative values (p < 0.0001). Eighty percent of clozapine-treated patients had colonic hypomotility, compared with none of those prescribed other antipsychotics (olanzapine, risperidone, paliperidone aripiprazole, zuclopenthixol or haloperidol). In the clozapine group, right colon, left colon and rectosigmoid transit times were all markedly abnormal suggesting pan-colonic pathology. Hypomotility occurred irrespective of gender, age, ethnicity, or length of clozapine treatment. Transit times were positively correlated with clozapine plasma level (rho = 0.451, p = 0.045), but not with duration of treatment, total antipsychotic load or demographic factors. Interpretation Clozapine, unlike the other antipsychotics examined, causes marked gastrointestinal hypomotility, as previously hypothesized. Pre-emptive laxative treatment is recommended when starting clozapine.

How well do medical students rate and communicate clinical empathy

Background: This article presents findings from a prospective, longitudinal cohort educational study investigating empathy communication in clinical consultations. It reports on changes in students’ self-report empathy during medical undergraduate training, investigates how well peers can assess student competence in motivational interviewing/brief interventions (MI/BI) skills and explores the relationship between students’ self-report empathy and peer- or tutor-assessments of competence. Methods: 72 medical students completed the Jefferson Scale of Physician Empathy at three time points: at the beginning of their fifth year medical training (Time 1), after a specific MI/BI training session during their fifth year medical training (Time 2) and 1 year later during a revision session in year 6. Competence in BI/MI consultation was assessed using the validated tool Behaviour Change Counselling Index. Results: A significant decline in medical students’ empathy scores was observed from year 5 to year 6, consistent with international findings. Peer assessments and tutor ratings of competence in MI/BI skills performance were moderately correlated, but peer assessments were negatively correlated with medical students’ self-rated empathy. Senior medical students who self-rated as more empathic received lower competence evaluations of MI/BI skills from their peers. Interventions to further investigate teaching and learning of empathy are discussed.

Prevalence of abnormal sleep duration and excessive daytime sleepiness in pregnancy and the role of socio-demographic factors: comparing pregnant women with women in the general population.

OBJECTIVES To compare the prevalence of self-reported abnormal sleep duration and excessive daytime sleepiness in pregnancy among Māori (indigenous New Zealanders) and non-Māori women versus the general population, and to examine the influence of socio-demographic factors. METHODS Self-reported total sleep time (TST) in 24-hrs, Epworth Sleepiness Scale scores and socio-demographic information were obtained from nullipara and multipara women aged 20-46 yrs at 35-37 weeks pregnant (358 Māori and 717 non-Māori), and women in the general population (381 Māori and 577 non-Māori). RESULTS After controlling for ethnicity, age, socio-economic status, and employment status, pregnant women average 30 min less TST than women in the general population. The distribution of TST was also greater in pregnant women, who were 3 times more likely to be short sleepers (≤6 h) and 1.9 times more likely to be long sleepers (>9 h). In addition, pregnant women were 1.8 times more likely to report excessive daytime sleepiness (EDS). Pregnant women >30 years of age experienced greater age-related declines in TST. Identifying as Māori, being unemployed, and working at night increased the likelihood of reporting abnormal sleep duration across all women population in this study. EDS also more likely occurred among Māori women and women who worked at night. CONCLUSIONS Pregnancy increases the prevalence of abnormal sleep duration and EDS, which are also higher among Māori than non-Māori women and those who do night work. Health professionals responsible for the care of pregnant women need to be well-educated about the importance of sleep and discuss sleep issues with the women they care for.

Infection-associated clozapine toxicity.

Three case vignettes are presented documenting the rise in serum clozapine that occurred at a time of acute infection in these patients. The literature on this phenomenon is scant. The physiological processes that occur in the acute phase of the inflammatory response are summarized and provide an explanation of how clozapine levels may rise in response to infection. The risk of clozapine toxicity occurring in association with infections is highlighted.

Lithium in drinking water

In their short report, Ohgami et al [1][1] reported lithium levels in drinking water and linked them to the risk of suicide. Despite the report highlighting the pitfalls of drawing simple conclusions from large-scale ecological studies, a Google search shows that these findings have been widely

Self-reported sleep in late pregnancy in relation to birth size and fetal distress: the E Moe, Māmā prospective cohort study.

Objectives To explore associations between features of sleep during pregnancy and adverse outcomes for the infant. Setting E Moe, Māmā is a cohort study in Aotearoa/New Zealand that investigates self-reported sleep and maternal health in late pregnancy and the postpartum period. Participants Women (N=633; 194 Māori) reported detailed information on their sleep duration, quality, disturbances, disorders (snoring, breathing pauses, twitching legs, restless legs) and daytime sleepiness between 35 and 37 weeks gestation. Outcome measures Birthweight and fetal distress during labour were extracted from medical records. Associations between each sleep variable and small or large for gestational age (SGA/LGA) using customised birthweight centile or fetal distress were estimated using multinomial/logistic regression, controlling for potential confounders. Secondary analyses considered differences in associations between Māori and non-Māori women. Results There was some indication that breathing pauses (a measure of sleep apnoea) were associated with both SGA (OR 2.8, 95% CI 0.9 to 9.0, p=0.08) and LGA (OR 2.0, 95% CI 0.7 to 5.7, p=0.20), with the association for LGA being stronger when only pregnancy-onset breathing pauses were considered (OR 3.5, 95% CI 1.3 to 9.6, p=0.01). There was also some evidence that pregnancy-onset leg twitching (OR 3.3, 95% CI 1.1 to 10.0, p=0.03) and frequent sleep disturbance due to feeling too hot or too cold (OR 1.7, 95% CI 0.9 to 3.6, p=0.13) were associated with higher risk of fetal distress. Other sleep measures, including snoring, were not associated with SGA, LGA or fetal distress. Many of the associations we observed were considerably stronger in Māori compared with non-Māori women. Conclusions We did not find evidence of previously reported associations between snoring and SGA. Our findings tentatively suggest that self-reported breathing pauses and leg twitching in late pregnancy are associated with infant outcomes, and highlight ethnic inequalities.

Dysfunctional cognitions about sleep in psychiatric patients.

The optimal management of sleep problems is a significant challenge, particularly in patients with psychiatric illness, because disturbed sleep is a known risk factor for relapse. This study used the short Dysfunctional Beliefs and Attitudes Scale to assess beliefs about sleep in adults with acute psychiatric disorders (N=100) recruited from inpatient and outpatient clinics. The subjects showed highly dysfunctional beliefs and attitudes about sleep and held diverse opinions about, but had low confidence in, their own capacity for optimal sleep management. They did not report excessive daytime sleepiness. We conclude that individuals with acute psychiatric illness worry significantly about their sleep and hold more dysfunctional beliefs about sleep than people without psychiatric illness. The absence of excessive daytime sleepiness in this sample, although counterintuitive, is consistent with findings in other studies. Given that two thirds of the sample expressed interest in non-pharmacological strategies to better manage their sleep problems, cognitive reshaping therapies appear to have clinical potential as alternatives to hypnosedative medication once a comprehensive sleep workup has excluded a physical sleep disorder such as obstructive sleep apnea. Dysfunctional beliefs and high concern about sleep offer potential targets for psychotherapy. (Journal of Psychiatric Practice 2014;20:188–195)

Sleep medication in acute psychiatric illness: patient's knowledge and prescription patterns in New Zealand.

Abstract Adult patients (N = 100) being treated for acute psychiatric illness were interviewed about their sleep problems and attitudes toward available treatments. Most (74%) were using at least one prescribed psychotropic drug with hypnotic or sedative effects. Participants prescribed three or more drugs were less likely to name them correctly compared with those prescribed less. One quarter (24%) did not know that they were on a hypnosedative; more than half of those not prescribed a hypnosedative thought they were. Most participants found their medication effective; however, 54% wished to discontinue it. Two fifths of zopiclone users had been using it for more than 12 months. Although subjective sleep problems are very common in this patient group, they have limited accurate knowledge about their medication treatments. Many want to try alternative nonpharmacological ways to manage their sleep problems.

Hypnosedative prescribing in outpatient psychiatry.

The objective of this study was to describe hypnosedative (HS) prescribing patterns in a typical sample of psychiatric outpatients. Prescription information was extracted from the clinical records of all current outpatients at two New Zealand public mental health centres. This included the type and duration of HS use and documentation of a clinical review of longstanding (>3 months) use, patient sex, age and ICD10 diagnoses. One-third of the patients (35.2%) were prescribed at least one HS; this was longstanding in two-thirds (69%). One in 10 had a coprescription of more than one HS drug. HS use was related to female sex and diagnosis, being more common among patients with nonpsychotic than psychotic disorders and very infrequent in patients on clozapine. In most longstanding cases, a clinical review had been documented. The logistic regression confirmed female sex, diagnosis and clozapine all as independent predictors of HS prescription. HS prescribing in psychiatric illness is more common than in the general population, often longstanding, with polypharmacy being common. The frequent use of antipsychotic drugs as HSs is of concern, given their side-effect profile. As there are risks involved with longstanding HS use, a better rationale for the role of medication in the management of sleep problems in psychiatric disorders is needed.