Miguel Julião

Is the OSCE a feasible tool to assess competencies in undergraduate medical education

Background: The Objective Structured Clinical Examination (OSCE) was introduced by Harden et al. (1975) trying to answer the problems regarding the assessment of clinical competencies. Despite increasingly widespread use of OSCEs, debate continues with arguments as ‘why using such a demanding format if other methods are available?’ Aim: To review and synthesize evidence on technical and economic feasibility of OSCE in undergraduate medical studies. Methods: Best Evidence Medical Education methodology was applied by two independent coders to 1083 studies identified by literature search from 1975 until the end of 2008. Key findings: The OSCE is a feasible approach to the assessment of clinical competence for use in different cultural and geographical contexts; to assess a wide range of learning outcomes; in different specialties and disciplines; for formative and summative purposes; to assess students a curriculum or an educational intervention; in the different phases of education including the early and later years of the undergraduate curriculum; and in different health care professions. Conclusion: Despite being an expensive test format, evidence suggests that the use of OSCE produces reliable results. The study also suggests that one reason for the wide-scale adoption of the OSCE and the feasibility of its use in different contexts and situations is its inherent flexibility in terms of the number of students that can be assessed, the number of examiners included, the type of patients represented and the format of the examination itself, including the length of the examination, the number and duration of stations.

A comprehensive checklist for reporting the use of OSCEs.

Background: The Objective Structured Clinical Examination (OSCE) has experienced an explosion of use which has rarely been accompanied by systematic investigations on its validity, reliability and feasibility. A systematic review of OSCE was undertaken as part of Best Evidence Medical Education at the Centre for Evidence Based Medicine of the Faculty of Medicine of the University of Lisbon. Several problems were identified with published papers relating to completeness of information presented, methodological issues or the use of terminology. Aim: To identify a need for standardization within the reporting of OSCE studies in medical education based in the first 104 papers of the aforementioned review. Method: Two independent reviewers coded each paper. Results: The most important problem identified was the lack of information, followed by the degree of inconsistency when reporting on OSCEs (papers with missing data and papers where data was given in a way that interpretation is difficult or impossible in terms of evidence; heterogeneity in reporting, lack of a standardized vocabulary, statistical errors and lack of structure within reporting). Conclusions: The authors present a ‘Comprehensive Checklist for those describing the use of OSCEs in the report of educational literature’ as an attempt to encourage better report standards.

Efficacy of dignity therapy for depression and anxiety in terminally ill patients: early results of a randomized controlled trial.

OBJECTIVE Dignity therapy (DT) is a short-term psychotherapy developed for patients living with a life-limiting illness. Our aim was to determine the influence of DT on symptoms of depression and anxiety in people with a life-threatening disease with high level of distress, referred to an inpatient palliative care unit. METHOD This was an open-label randomized controlled trial. Sixty terminally ill patients were randomly assigned to one of two groups: intervention group (DT+ standard palliative care [SPC]) or control group (SPC alone). The main outcomes were symptoms of depression and anxiety, measured with the Hospital Anxiety and Depression Scale, assessed at baseline, day 4, day 15, and day 30 of follow-up. RESULTS Of the 60 participants, 29 were randomized to DT and 31 to SPC. Baseline characteristics were similar between the two groups. DT was associated with a significant decrease in depressive symptoms at day 4 and day 15 (mean = -4.46, 95% CI, -6.91-2.02, p = 0.001; mean= -3.96, 95% CI, -7.33 to -0.61; p = 0.022, respectively), but not at day 30 (mean = -3.33, 95% CI, -7.32-0.65, p = 0.097). DT was also associated with a significant decrease in anxiety symptoms at each follow-up (mean= -3.96, 95% CI, -6.66 to -1.25, p = 0.005; mean= -6.19, 95% CI, -10.49 to -1.88, p = 0.006; mean = -5.07, 95% CI, -10.22 to -0.09, p = 0.054, respectively). SIGNIFICANCE OF RESULTS DT appears to have a short-term beneficial effect on the depression and anxiety symptoms that often accompany patients at the end of their lives. Future research with larger samples compared with other treatments is needed to better understand the potential benefits of this psychotherapy.

Prevalence and factors associated with desire for death in patients with advanced disease: results from a Portuguese cross-sectional study

BACKGROUND Desire for death (DFD) within the context of palliative care has become a prominent medical issue and remains the subject of much controversy. METHODS Cross-sectional study designed to assess the prevalence and associated demographic, physical, psychiatric, and psychosocial factors for DFD in patients with advanced disease. RESULTS Seventy-five terminally ill patients were included in the analyses in a 28-month period. The prevalence of DFD was 20% (95% CI [11.7-30.8]). No statistical differences were observed between patients with and without DFD with respect to sex, age, race, education, religion, type of family, medical diagnosis, and medication. There were associations between DFD and being married/cohabitating (OR = 4.0; 95% CI [1.21-13.29]) and being socially isolated (OR = 0.3; 95% CI [0.06-0.98]). Significant positive correlations were found between moderate to severe Edmonton Symptom Assessment Scale (ESAS) scores and DFD for tiredness (OR = 10.1; 95% CI [1.57 ± inf]) and drowsiness (OR = 6.0; 95% CI [1.77-20.37]). DFD was also correlated with depression (DSM-IV criteria: OR = 5.5; 95% CI [1.56-19.47]; Hospital and Anxiety Depression Scale (HADS) depression subscale ≥11: OR = 8.6; 95% CI [1.33 ± inf]). In exact multivariate regression analyses predicting DFD, three independent factors emerged: marital status (OR = 5.3; 95% CI [1.16-29.89]); HADS depression sub-scale score ≥11 (OR = 8.3; 95% CI [1.11 ± inf]); drowsiness (OR = 5.8; 95% CI [1.29-32.85]). DISCUSSION Prevalence of DFD was high in this sample of patients. Identifying factors associated with DFD could help provide medical and social interventions capable of diminishing suffering in terminal ill patients.

Prevalence and factors associated with demoralization syndrome in patients with advanced disease: Results from a cross-sectional Portuguese study.

BACKGROUND Demoralization syndrome (DS) within the context of the psychological experience at the end of life is an important and relevant medical issue and remains the subject of a growing area of research. METHOD Ours was a cross-sectional study designed to assess the prevalence and associated demographic, physical, psychiatric, and psychosocial factors for demoralization syndrome in Portuguese patients with advanced disease. RESULTS Some 80 terminally ill patients were included in the analyses over a 28-month period of time. The prevalence of DS was found to be 52.5%. No statistical differences were observed among prevalence of DS within categories of all studied variables, with the exception of depression using DSM-IV criteria (prevalence ratio PR = 1.8, CI 95% = [1.18-2.74]) and desire for death (PR = 1.8, CI 95% = [1.25-2.56]). In the Poisson regression analyses predicting DS, none of the latter factors emerged as significant (DSM-IV criteria: PR = 1.6, CI 95% = [0.84-3.08]; and desire for death: PR = 1.5, CI 95% = [0.74-2.99]). Thirty percent of participants met both criteria for demoralization syndrome and depression using the DSM-IV. SIGNIFICANCE OF RESULTS Prevalence of demoralization syndrome was high in this patient sample. Based on our results, we cannot determine if DS and depression are two distinct psychological entities. Identifying factors associated with DS could help provide efficacious interventions capable of diminishing suffering in terminally ill patients.

Dignity therapy and its effect on the survival of terminally ill Portuguese patients

The aim of this study was to determine whether those patients randomized to DT along with SPC had a survival advantage over those randomized to SPC alone. Ninety-two patients were assessed for eligibility, 80 of whom were randomized (39 to DT and 41 to SPC). All participants were ≥ 18 years old, had a prognosis ≤ 6 months, showed no evidence of dementia or delirium, had a MiniMental State score ≥ 20, were able to read and speak Portuguese and provided written informed consent. There were no differences between the two groups regarding baseline characteristics ( table 1 ). The estimated median survival time (measured as the time from first contact to death) was 23.2 days (95% CI 20.9–25.6) for the total sample (80 participants), 26.1 days (95% CI 23.2–20.0) for the DT group (39 participants) and 20.8 days (95% CI 17.4–24.2) for the control group (41 participants; p = 0.025). After adjustment by Cox regression for sex, age, educational level, occupation, tumor type, metastasis, performance status, previous treatment and follow-up in palliative care, group allocation remained a significant predictor of survival [hazard ratio of death for the DT group was 0.35 (95% CI 0.13–0.92)] (fig. 1). This is the first RCT studying the effect of DT on the survival of terminally ill patients. The increased survival of patients allocated to the DT, although modest, begs some explanation. Being engaged in a psychotherapeutic intervention may enhance a sense of meaning and purpose. Our RCT previously demonstrated the efficacy of DT compared to SPC on several psychosocial The empirical literature regarding the effect of psychotherapy on the survival of cancer patients is highly contested [1, 2] . Dignity therapy (DT) is a brief, individualized intervention, which gives terminally ill patients the opportunity to convey memories and important disclosures and to prepare a legacy document [3] . We conducted a 36-month phase II, nonblinded randomized controlled trial (RCT), comprised of two study arms: (1) DT and standard palliative care (SPC) and (2) SPC alone. Results demonstrating the significant benefits of DT on depressive and anxiety symptoms have been previously reported [4] . Received: April 13, 2014 Accepted after revision: July 24, 2014 Published online: December 24, 2014

Effect of dignity therapy on end-of-life psychological distress in terminally ill Portuguese patients: A randomized controlled trial

OBJECTIVE Dignity therapy (DT) is a brief form of psychotherapy developed for patients living with a life-limiting illness that has demonstrated efficacy in treating several dimensions of end-of-life psychological distress. Our aim was to determine the influence of DT on demoralization syndrome (DS), the desire for death (DfD), and a sense of dignity (SoD) in terminally ill inpatients experiencing a high level of distress in a palliative care unit. METHOD A nonblinded phase II randomized controlled trial was conducted with 80 patients who were randomly assigned to one of two groups: the intervention group (DT + standard palliative care [SPC]) or the control group (SPC alone). The main outcomes were DS, DfD, and SoD, as measured according to DS criteria, the Desire for Death Rating Scale, and the Patient Dignity Inventory (PDI), respectively. All scales were assessed at baseline (day 1) and at day 4 of follow-up. This study is registered with http://www.controlled-trials.com/ISRCTN34354086. RESULTS Of the 80 participants, 41 were randomized to DT and 39 to SPC. Baseline characteristics were similar between the two groups. DT was associated with a significant decrease in DS compared with SPC (DT DS prevalence = 12.1%; SPC DS prevalence = 60.0%; p < 0.001). Similarly, DT was associated with a significant decrease in DfD prevalence (DT DfD prevalence = 0%; SPC DfD prevalence = 14.3%; p = 0.054). Compared with participants allocated to the control group, those who received DT showed a statistically significant reduction in 19 of 25 PDI items. SIGNIFICANCE OF RESULTS Dignity therapy had a beneficial effect on the psychological distress encountered by patients near the end of life. Our research suggests that DT is an important psychotherapeutic approach that should be included in clinical care programs, and it could help more patients to cope with their end-of-life experiences.

Time and life perception in the terminally ill: its utility in screening for depression

OBJECTIVE The objective was to explore the utility of a new three-item depression screening tool concerning time and life perception (TLP-3), compared with the DSM-IV criteria. METHODS This was a cross-sectional study of 63 Portuguese terminally ill patients, from May 2010 to November 2012. Patients were eligible if they fulfilled the following inclusion criteria: age ≥18 years old; having a life-threatening disease with prognosis of 6 months or less; no evidence of dementia or delirium, based on documentation within the medical chart or by clinical consensus; Mini Mental State score ≥20; being able to read and speak Portuguese; and provision of written informed consent. Participants were assessed for depression using DSM-IV criteria and the newly developed TLP-3. Screening performance for depression using the TLP-3 compared with DSM-IV was calculated using measures of sensitivity, specificity, positive and negative predictive values. Logistic regression was calculated with the aim of identifying variables with the best predictive ability for diagnosing depression. RESULTS After logistic regression analysis was made to all three items composing TLP-3, only two items were maintained (OR=2.9, 95% CI [0.9-8.7]; OR=7.6, 95% CI [0.9-65.3], respectively). This final regression model composed of two questions (TLP-2) was able to diagnose correctly 70% of the depressed patients with a sensitivity of 63% and a specificity of 74%. The area under the ROC curve was 72% (95% CI [59-85]). CONCLUSION TLP-3 is a novel and clinically applicable approach to assessing depression among palliative care patients. Further investigation is needed on the psychological significance of time and life perception distortions, and its possible application to screen for depression among patients nearing end of life.

Letter to the Editor: The Concept of Dignity in Non-institutionalized Elderly People Cared for in Primary Health Care: A Preliminary Empirical Model

Dignidade é definida como “a qualidade ou estado de ter valor, ser honrado ou estimado”,1 sendo um conceito complexo e abusivamente utilizado na sociedade, particularmente no âmbito da Medicina.2 Estudos anteriores realizados em grupos sociais vulneráveis clarificaram o seu significado, criando modelos mais inteligíveis.3,4 Em Portugal, e até à data, nenhuma investigação olhou para o conceito de dignidade na perspetiva de idosos não institucionalizados, seguidos em cuidados de saúde primários. Nesse sentido, desenvolvemos um estudo transversal qualitativo, recorrendo a entrevistas semiestruturadas a uma amostra de 30 idosos não institucionalizados utilizadores de uma consulta de medicina geral e familiar com o objetivo de compreender a sua perspetiva sobre o conceito de dignidade, construindo posteriormente um modelo empírico preliminar de dignidade. Critérios de inclusão: idade ≥ 65 anos; não estar institucionalizado; utilizadores de consulta de medicina geral e familiar; capacidade de ler e escrever português; dar consentimento informado; Mini Mental Scale Examination ≥ 20. Dos participantes, 53% eram mulheres, com idade média de 74 anos (desvio padrão: 5,7; mín. 65, máx. 93), 73% casados, 53% com quatro anos de escolaridade e 100% reformados. Foram obtidas as autorizações éticas e de proteção de dados. Foi realizada uma análise de conteúdo com recurso a técnicas de processamento de linguagem natural e Latent Dirichlet Allocation da qual resultou um modelo de dignidade formado por três categorias principais: Social; Autonomia; Integridade. Cada categoria inclui temas que dizem respeito a áreas que reforçam ou ameaçam o sentido de dignidade (Tabela 1). O Modelo de Dignidade preliminar apresentado encontra pontos similares com outros modelos de dignidade,3,4 nomeadamente na dignidade intrínseca (categoria Integridade) e contingente/relacional (categorias Social e Autonomia), reforçando a dignidade como um valor inerente a cada ser humano com características universais apesar do contexto, do tempo e do espaço em que é avaliado. O conhecimento do atual modelo poderá ser útil aos profissionais envolvidos nos cuidados a idosos, assim como aos decisores político-sociais, no melhoramento de ações face aos cuidados prestados a esta população, indo ao encontro das recomendações da Organização Mundial de Saúde para um envelhecimento que tenha em conta um sistema compreensivo que dê importância ao valor da vida e a sua vivência digna.5 Esta investigação representa apenas um interesse inicial acerca do relevante tema da dignidade em idosos. Assim, consideramos que devem ser desenvolvidos estudos futuros numa amostra portuguesa representativa por forma a corrigir as limitações da investigação atual e a compreender melhor o conceito de dignidade.

The Efficacy of Dignity Therapy on the Psychological Well-Being in Loved Ones of Terminally Ill Patients

Dear Editor: Dignity therapy (DT) is a novel, brief, individualized intervention, which gives terminally ill patients the opportunity to convey memories and important disclosures and to prepare a legacy document that can be given to patients for them to share or bequeath to individuals of their choice. A previously published DT study showed that family members found DT helpful in terms of enhanced patient dignity (78%), 72% reported that it heightened meaning of life for the patient (72%), the document produced from DT was a comfort to them in their time of grief (78%), and most would recommend DT for other patients and families (95%). In view of these data, we recently conducted a study that randomized patients to either DT and standard palliative care (SPC) or SPC alone to evaluate DT’s effect on psychological well-being of both terminally ill patients and their loved ones (family members, friends, other significant, and close caregivers). In this letter, we present data evaluating the effects of DT on the loved ones of terminally ill patients. In this study, psychological well-being was assessed using the Mental Health Inventory (Mental Health Index [MHI]: minimum 38; maximum 226) at baseline and four days after the intervention. Of the 80 terminally ill patients enrolled, 45 (56%) had someone in their lives they wished to bequeath a legacy document to. Of these 45 patients, 25 (55%) agreed to participate in the study and provided written informed consent; 52% were male. In these 25 participants, 15 were randomized to DT and 10 to the SPC group. Overall baseline mean MHI in the loved ones was 131 (range: 38–226), indicating a moderate-to-high level of psychological well-being. Legacy documents were given to family members in 67% of the cases, 30% of the terminally ill patients did not want to deliver the legacy document, and 3% of patients gave it to friends. The results showed no significant difference between baseline and post-intervention MHI scores within each study group (Table 1). Similarly, no significant differences between subjects in the two study arms were observed in MHI between baseline and post-intervention (baseline: mean’s difference = 1.54; 95% CI [-24.43 to 27.51]; p = 0.9041; post-intervention: mean’s difference = -12.68; 95% CI [-43.52 to 18.16]; p = 0.4046). Although this study appeared to show no effect of DT, there are important study limitations. First, the study was small because of the low percentage of patients who had a loved one they wanted to leave legacy documents to. Second, the fact that only 55% of these loved ones agreed to participate. Another factor is the high baseline MHI scores in both the DT and SPC groups. These scores would suggest that these loved ones already had a moderate-to-high level of psychological well-being and it would be challenging for an intervention to show a further increase or effect. This study has tried to answer some of the unanswered questions still remaining about DT’s effect on caregivers’ well-being. As ultimately although DT did not improve the psychological well-being of loved ones in our study—likely because of the high baseline MHI scores—DT may ultimately prove itself to be an important tool within the setting of any multidisciplinary palliative care setting. Thus, even though this study is ‘‘negative,’’ we realized that it is important to publish these data so that future researchers in this area can learn from our experience.