Miscellaneous

The United Kingdom kicked off its leading mass coronavirus disease-2019 (COVID-19) vaccination programme by vaccinating the first person, Margaret Keenan on 8^th December 2020¹ which was followed by many other countries.² COVID-19 vaccines were developed in less than 12 months after the pandemic began^{3, 4} and have offered hope of bringing normalcy back to many around the globe, but it is not without its challenges.^{5, 6} The infrastructure of coordinating frontline response and the development of confidence among various communities to accept vaccination posed significant challenges. This required input from governments, healthcare professionals, the media, and importantly the public who play a vital role in not only accepting the vaccines and busting the myths but also actively volunteering for this great cause.

After watching my father, a frontline COVID-19 healthcare worker, receive the vaccine and at the same time sensing the reluctance of some family and friends to take the vaccine, despite the pandemic hitting Black, Asian and minority ethnic (BAME) communities disproportionately, I felt energised to play my role. When I saw an exciting opportunity for volunteering for this noble cause coordinated by my school, Bolton School, I promptly put an application forward in February 2021. The whole process was streamlined, and soon afterwards I embarked on volunteering at the Bolton Wanderers Football Club vaccination centre.⁷ There was some initial anxiety about contracting COVID-19, but I discussed it with my mentor and was reassured about the safety standards of the vaccination centres.

I was pleasantly surprised to see a range of roles for a non-clinician volunteer including being the face of the vaccination programme by greeting patients, explaining the vaccination process and allying anxieties, handing out written information, managing patient flow, ensuring maintenance of social distancing, checking temperatures, and liaising with clinical staff. There was also an element of an administrative role and keeping the registers. However, what I found most fulfilling was to talk to some of the patients who said that they had been socially isolating for several months and were excited to talk to someone face to face. One could see a sense of liberation the vaccination was bringing to them. It was a truly humbling experience to go out of my way to support some of the BAME patients, and speaking to them in their native language to make the whole process a memorable experience. I remembered one elderly lady who seemed distressed as she could only communicate in Hindi and I was fortunate that she allowed me to take her through the whole process and later assist with arranging transport.

I am going to continue with my volunteering on weekly basis and I found that it revitalised me for the rest of the week to engage in my full-time academic studies at school. This being my first work experience, I must admit the shifts were well-paced, lasting 4-5 hours and not too demanding. I was made to feel safe, and the senior members of the team would regularly communicate and offer me guidance and support.

Working closely with clinicians helped me gain new insights into the importance of true multidisciplinary teamwork in healthcare. I appraised it as the epitome of how colleagues with a unique set of skills, and driven by a shared desire to bring about a real difference to people’s lives, strived together selflessly as a team. Furthermore, it was inspiring to observe the leadership of the senior volunteers acting as role models with their professionalism, unflinching dedication to their job and willingness to proactively offer support to others. However, the watershed moment that shaped my thinking to take on medicine as a career was the reward I got from the empathic interaction with patients and gratitude in their eyes. It was pleasing to see in practice the Good Medical Practice⁸ attributes of working collaboratively with colleagues, professionalism, communicating effectively, and treating patients with dignity.

I have been feeling proud to be at the frontline working shoulder to shoulder with my clinical colleagues in this battle to end the pandemic. I would highly recommend vaccination volunteering to others as it is truly a once in a lifetime opportunity to make a real difference in the lives of so many.

my identity & fortunes change
like
decadal fashions

the lines in my face extend
like
suburban roadways

my hairline recedes
like
an endless low tide

the pain in my back recurs
like
unwanted phone calls

my childhood cubby house loses integrity
like
an ancient edifice

my heart sporadically breaks & heals
like
brittle bones

my knowledge increases yet decreases
like
money in the bank

my memories accumulate then fade
like
words on medieval leaves

my glassware gradually shatters
like
glaciers calving

lost loved ones remain on my horizons
like
suns in rural night skies

Introduction

Health Education England (HEE) runs the Medical Training Initiative (MTI) scheme on behalf of the Department of Health (the Government Sponsor) and is influenced by the Home Office Tier 5 Government Authorised Exchange Visa Scheme¹. The Academy of Medical Royal Colleges is the national sponsor for visa purposes. Major stakeholders involved in this scheme are the GMC and GMC Approved Sponsors (e.g. Medical Royal Colleges), Postgraduate Deaneries/Local Educational Training Boards (LETBs), and National Health Services (NHS) Trusts, with support from the Department of Health.

The Royal College of Psychiatrists (RCPsych) Medical Training Initiative (MTI) Scheme enables qualified overseas psychiatrists to undertake training posts in the National Health Service (NHS) for a maximum of two years (2). The purpose of the scheme is to provide training opportunities for international psychiatrists in the UK to improve capacity as a professional and return home with broad knowledge and experience. Vacant core training (CT3) posts approved by Deaneries/LETBs are offered to eligible international doctors. Thus, the MTI psychiatry scheme can benefit overseas doctors, the NHS and the countries that trained them.

Although the MTI scheme was first established in 2009, the RCPsych only formally adopted the program in 2014. Some lessons were learned from the experience of the scheme in other specialities and provided an opportunity for the RCPsych to develop its own scheme. It developed a selection process for successful candidates and matches them with relevant placements in NHS trusts across the UK. This process takes into consideration the training needs of the overseas doctor and vacancies available in NHS trusts. The MTI Psychiatry Scheme is now in its sixth year and has gradually grown over the years as evidenced by an increase in annual allocation of the training post to 40 placements, a rise in the number of applicants from different regions of the world and an increase interest from employing NHS trusts. However, there are areas for further development in this scheme and there is a need to ensure that it consistently provides a good training experience to international doctors.

Various researches suggest that there are diverse difficulties faced by overseas doctors during their transition into a new country ^3,4. Lack of information about NHS; clinical, educational and work-culture challenges; language and communication challenges; and discrimination challenges were issues experienced by international doctors while initially working in the UK hospital settings ⁵. The College has recognised these difficulties and wanted to understand how these are impacting on the international doctors and what can be done to help them.

Aims

The aim of this survey was to evaluate the trainee’s experience of the MTI psychiatry training scheme and explore difficulties during the training and what can be done to help. The purpose of this survey was to gather feedback on the current implementation of the MTI scheme.

Methods

An anonymous online survey consisting of 28 questions was sent to doctors using SurveyMonkey as part of the RCPsych Annual MTI survey. All doctors enrolled in MTI Scheme were identified through the RCPsych MTI mailing list. The survey was open in November 2018 for one month.

Results

Out of seventy-six, a total of thirty-one trainees completed the survey with a response rate of 40.78%. Most of them (n= 13) were from the age group 31-35 years. The findings of the survey are summarised in Table 1-3.

Table 1: Description of MTI doctors (n=31)

Table 2: Induction, Supervision and Mentoring (n=31)

Table 3: Work experience in MTI scheme (n=31)

Reasons for choosing MTI Scheme

Training opportunities in the UK were considered by three quarters of the respondents for joining the MTI scheme. However, about half of the respondents reported job prospects, recommendation from senior colleagues and college reputation as pull factors.

Clinical and Educational Supervision

Three-fifths of trainees had weekly supervision with their designated clinical supervisor and three quarters (75%) of them rated the quality of supervision as either good or excellent. The majority (93.54%) of them had an educational supervisor and less than half met the supervisor 1-2 times per year. RCPsych has a mentoring scheme to support MTI doctors but half of the trainees (51%) did not have a mentor.

Out of hour support

Less than one-third of the trainees were never forced to cope with clinical problems beyond their competence. However, three-fifths of trainees reported that they always had access to out of hour support and advice.

Challenges encountered

Lack of knowledge of regulatory framework was reported by three-fifths of trainees while working in the UK settings. In addition to that, half of the trainees reported a lack of knowledge of NHS and cultural differences. One third had difficulty regarding multidisciplinary team settings and varied levels of support and training. About 51.61% felt that their clinical training was secondary to service and few reported feeling unsafe, being bullied and being punished.

Discussion

This is the first evaluation of the training experience of MTI psychiatric doctors. This study showed that most of the trainees had good work experience of psychiatry before coming to the UK. One of the undoubted strengths of the MTI psychiatry scheme is the recruitment of international psychiatrists with skills and experience of working in diverse cultural backgrounds and low resource settings. This is one of the potential benefits that the NHS can draw whilst delivering the health care smoothly. The majority of respondents in the present survey cited training opportunities as the main reason for choosing the MTI scheme. Child and Adolescent Psychiatry, Old Age Psychiatry, Addiction Psychiatry and Forensic Psychiatry were the subspecialties that received the highest interest in the MTI post in a 2017 survey ⁶. It is encouraging that most doctors were keen to gain further experience and training in subspecialties that were not readily available in their respective home countries.. A similar finding has been reported in the Royal College of Anaesthetists’ annual MTI survey where the majority chose subspecialties that were poorly developed in their respective countries, e.g. ICU and pain⁷.

Transition to the UK is not a smooth process for overseas doctors and must be supported during this transition phase (5). Lack of knowledge of the NHS, regulatory framework and cultural differences were the challenges faced by most MTI doctors in this study. The RCPsych International Medical Graduates (IMG) conference acknowledged that IMGs face more problems than British counterparts in succeeding in the system and recognised the importance of trainers, the role of employers in developing meaningful induction programmes and giving IMGs additional support and remediation if required⁸. This study showed that most of the trainees had attended local induction in the workplace before starting a job. Induction course content must be relevant and reflect issues concerning overseas doctors ⁹. It is particularly important to remember the specific needs of overseas doctors as they were trained in culturally diverse and low resource clinical settings. Several studies have shown that a structured induction program is a useful way to integrate doctors during the transition to the NHS^10-12. Few trainees missed the local hospital induction as they arrived in the UK months later than expected and the trust could not arrange the training. With this hindsight, RCPsych organises the annual national MTI induction program to the new doctor in this scheme to complement and compensate for any shortcomings in the local hospital induction.

MTI posts should provide the trainee with an opportunity to train in a highly supported environment. Supervisors provide regular support and ongoing feedback during the training. Trainees value the support they receive through supervision, senior and peer support, and the opportunity to work in multidisciplinary team ¹³. It was reassuring to find that three-fifths of trainees had weekly clinical supervision as recommended by the Royal College of Psychiatrists.The quality of clinical supervision was rated as good by 51.61% of trainees and 22.58 % reported as excellent. Most of them had access to out-of-hour support/advice. Supervision is important for continued professional development as international doctors need more support than UK trained doctors ⁹. Unfortunately, few reported serious issues such as being bullied at the workplace and feeling unsafe. A survey of bullying of psychiatric trainees in the workplace reported that it was experienced equally by both IMGs and UK graduates, but IMGs were less likely to report the incident to the organisation¹⁴. It is important to educate IMGs about the mechanisms to escalate this concern for proper action. Besides that, it would also be prudent to include these pertinent issues during the annual MTI induction program to raise awareness among IMGs.

The MTI doctors had identified areas for additional support from the College, trusts, local deaneries, and senior colleagues in the 2017 annual survey⁶. The College took the following steps:

1. Annual MTI Induction Program: Full day induction program is held annually in the Royal College of Psychiatrists’ for new doctors in the scheme. The program is specifically tailored for doctors who are working in the UK for the first time. Highlights of the program include an introduction to the NHS, Good Medical Practice, Psychiatric training in the UK, ‘Person-Centred Care’, resources and support available for trainees and most importantly, communication skills workshop. It also provides an opportunity to meet with other MTI fellows and share experiences and set up informal support networks such as WhatsApp group. Twenty-three doctors attended the MTI induction program in 2019. Not all doctors recruited in the MTI scheme were able to attend the annual induction program because of the variable start date resulting from delay in visa processing. RCPsych could provide support to these IMGs by organizing the induction program two times a year.

2. MTI Mentoring Scheme: RCPsych runs a mentoring scheme and has been offering mentorship to MTI doctors for the past three years (15). Mentors are usually experienced RCPsych members who have volunteered in the mentoring scheme. RCPsych MTI team matches the mentor and mentee who will stay together for the duration of the placement. The current study shows that 50% do not have a mentor. We did not explore the reason for this, but we speculate that as doctors must actively express their interest in participating in this mentoring scheme and this might have shown less engagement.

3. Annual MTI Scheme Survey: Feedback is collected from MTI doctors each year as part of ongoing efforts to improve the RCPsych MTI scheme.

4. Sharing of experiences about the scheme between the trusts: Trust has varying levels of experience regarding the training scheme and the College has been facilitating the exchange of shared experience by the experienced trust to a new host trust.

This survey explored the experiences of doctors involved in the MTI scheme and it would be interesting to know findings from longer-term studies. Longer-term follow-up studies are needed to evaluate the positive impact of the scheme after the doctors return home on completion of the training. It is hoped that invaluable insight gained from the survey can be used to strengthen the scheme as well as provide learning points to other specialities with similar training scheme for international doctors.

Conclusions

This survey provides useful information regarding training experiences in the MTI psychiatry scheme. The first step in making the difference is getting feedback directly from those involved in the scheme. RCPsych MTI Scheme is an evolving program and measures were put in place to address the needs/concerns that emerged from the survey to enhance the training experience of the MTI doctors.

Introduction

The way a doctor dresses is a fundamental part of establishing therapeutic alliance with patients.^1,2 It has been shown that doctor’s dress can influence patient confidence, offer greater reassurance, higher levels of trust, better adherence to prescribed medication regimens, enhanced willingness to complete return visits, and discuss sensitive issues.^3,4 The literature outcomes in this field are mixed; for example, some studies suggest a non-correlation with perceived courteousness or professionalism,^5,6 but we believe there is enough evidence to suggest that the manner in which a doctor dresses forms an important part of non-verbal communication, which is important for their interaction with patients, carers and with other staff members.

Various studies have examined patient preferences towards doctors’ dress. Formal dress or a white coat have been cited as favoured due to their perceived association with empathy, competence and trust.^2,4,7,8 This is in contrast to other studies which found semiformal dress as preferred.⁹

In psychiatry, studies of inpatients have indicated a preference for smart attire and white coats as part of their doctors' dress code.^10,11 Mcguire et al also found that community patients preferred their psychiatrists to be dressed as “smart/formal”.¹²

In recent years, dress code policy for doctors in the UK has become more informal, and white coats have been abolished for a number of reasons.¹³ In this study, we sought to determine the attitudes of multiple stakeholders towards doctors’ dress in both general and psychiatric hospital settings.

Methods

We surveyed healthcare staff, patients, and carers in an emergency department at a district general hospital (“medical setting”), and in a psychiatric hospital (“psychiatric setting”) in the South East of England. The data was collected on a week day between 09.00 and 17.00 at both settings, using a questionnaire based on Rehman et al.¹⁴ There were no exclusion criteria.

The survey questionnaire sampled demographic details, and used nine questions and two sets of images (a male doctor & a female doctor) depicting three styles of dress; white coat, formal (tie & trousers for male; dark skirt and white shirt for female) and smart casual (“bare below the elbows”). The survey questionnaire was piloted amongst volunteer staff and assessed for their user-friendliness and ease of comprehension before use. It was amended in line with the feedback received.

Results

337 individuals responded to the questionnaire, giving a response rate of 94%. Our sample was predominantly white (72%), female (62%) and married (43%). Respondent age, ethnicity and employment status were broadly representative of the local population.

Overall (Table 1), we found that the majority of respondents felt that the way that doctors dress was important to them, and that the location of respondents significantly affected their preferences (p <0.001). Although in these overall results there was no majority preference for one dress code over another in either location, preferences within each varied significantly (medical: p<0.01 and psychiatric: p<0.001). This numerical preference appeared to be for formal dress in both settings, capturing 35% and 45% of respondent vote respectively.

Within the three stakeholder-specific breakdowns (Tables 2-4), differences in preference reached significance for medical staff (p<0.001), psychiatric staff (p<0.001), psychiatric patients (p<0.05), and psychiatric carers (p<0.01). Like the overall results, there was no majority preference in any of these groups, but formal dress captured the highest numerical vote in medical staff (41%), psychiatric staff (55%), and in psychiatric patients (41%). Psychiatric carers preferred formal and smart casual dress broadly equally, which captured 36% and 40% of the vote respectively. Carers were the only stakeholder whose preferences were significantly influenced by their location (p< 0.01).

Dress code statistically significantly influenced the attributes associated with the doctor wearing them (p< 0.0001), as shown in Table 5. Formal dress captured the greatest proportion of every attribute tested, and considering total responses, formally dressed doctors were almost twice as likely to be associated with these attributes as those dressed in smart causal or a white coat.

52% of respondents were not aware that a doctors’ dress code policy existed, and while 53% of respondents felt they should not be consulted when considering dress code, 41% believed they should. 59% of respondents believed doctors adhered to their sites’ dress code policies, while 27% did not think so.

Discussion

To our knowledge, this is the first study in the world to compare preferences in doctors’ dress code between a psychiatric hospital and a medical hospital. Also, no other study to our knowledge has simultaneously explored the attitudes of different key stakeholders in both medical and psychiatric settings regarding this important issue.

In this study, we have successfully captured the attitudes and perceptions of key stakeholders regarding doctors’ dress code. We found that overall, doctors’ dress code was felt to be important, and that in medical and psychiatric locations a formal dress code is preferred. Looking at staff, patients and carers specifically, we found a preference for formal dress among medical staff, psychiatric staff, and in psychiatric patients. Among psychiatric carers, formal dress was preferred equally to smart casual. There were no significant preferences among the other stakeholders surveyed.

This preference for formal dress is easily explained by the results shown in Table 5. Seeing a doctor in formal dress made it almost twice as likely that that doctor would be seen as possessing any of the eight positive attributes included. Clearly, in the eyes of the respondents to our survey, a formally dressed doctor was most likely to provide good care. 

Table 1. Dress code preferences among all stakeholders. P values were calculated using Chi-squared test. NS = not significant (p=>0.05).

Table 2. Dress code preferences among staff. P values were calculated using Chi-squared test. NS = not significant (p=>0.05).

Table 3. Dress code preferences among patients. P values were calculated using Chi-squared test. NS = not significant (p=>0.05).

Table 4. Dress code preferences among carers. P values were calculated using Chi-squared test. NS = not significant (p=>0.05).

Table 5. Doctor attributes associated with different dress codes.Respondents were shown images of each dress code asked “Which doctor would you…”: Trust the most (trust), Follow the advice of (advice), Have confidence in their diagnosis and treatment (conf.), Return to for follow-up care (return), Regard as knowledgeable & competent (knowl.), Regard as caring & compassionate (caring), Regard as responsible (resp.), Regard as authoritative & in control (auth.). P <0.0001.(calculated using Chi-squared test). Results were excluded for where more than one dress code was selected for an attribute, or where no choice was made.

Discussion (continued)

Interestingly, we also found that the location of healthcare influenced the preferences of carers to such an extent that it offset the non-significant results among staff and patients; such that this significance was carried through to the overall results. Exploring this in more detail, we see a marked preference for smart casual in the psychiatric setting over the medical setting (40% vs. 13%), for a white coat in the medical setting over the psychiatric setting (33% vs. 11%), and an almost equal preference for formal dress in both. This starkness in difference in preference between care locations indicates differences in the cultural perceptions of doctors by carers, but not by staff or patients. Perhaps an explanation for this difference is that historically, carers have been more involved and influential in the psychiatric setting, being an essential component to care, whereas in the medical setting they have tended to be more passive partners in care. A negative perception of mental health care portrayed to the public through film and media may have driven preferences away from white coat in the psychiatric setting, whereas in the medical setting perhaps a positive association with the white coat and physical health may have done the opposite.

Conclusion

We have identified a clear preference for a formal dress code for doctors from all stakeholders at medical and psychiatric care locations studied. However, we identified several interesting variations in preferences among individual stakeholders, and found that the location of care significantly impacted the preferences of carers. We believe these findings could be harnessed in the future development of dress code policies for doctors in order to enhance the doctor-patient relationship, and to improve the quality of doctors’ relationships with both carers and with other staff members. Additionally, there may be merit in involving these stakeholders during the policy development process.

Introduction

The continuous growth in patient numbers and needs poses several challenges for medical professionals and support staff within the National Health Service (NHS).¹ Health care services are under financial strain in the light of the changing demographic structure of the UK population that requires improved access to health services. Managing patient satisfaction represents another major challenge. Evidence from a recent national survey in the UK shoes that dissatisfaction with the NHS has increased by seven percentage points in 2017, reaching 29 percent, its highest level since 2007.² Staff shortages, long waiting times for surgical operations and access to care, inadequate funding, and slow-paced government reforms are among the reasons for dissatisfaction. For hospitals, long waiting times at the A&E department, and delays for patients in need of critical care represent major concerns.³

Unsatisfactory health care service experiences generate negative outcomes for health service providers in terms of managing patients’ experience of care, and meeting performance targets. As patients are ultimately the receivers of health care provision, understanding their experiences of care is pivotal.⁴ The psychological processes underlying patients’ perceptions and evaluations of service provided by the health care professionals, play a crucial role in patient satisfaction. The cognitive processes of patients and their support network, such as friends and relatives, influence perceptions and attitudes towards health care treatment and service. Research underpinned by knowledge from social psychology can shed light on such cognitive processes and generate insights for effective management of patient satisfaction.

The concept of psychological threat in health care service experiences can be explained through the notion of ‘lock-in situations’⁵ perceived by the patients. For instance, when visiting a hospital or a GP surgery, patients often undertake externally-imposed activities, such as long waiting time for a doctor’s appointment, ease of self-service check-in, lack of acuity in self-care and monitoring, and/or unsatisfactory interactions with support staff – all parts of the service provision. Such situations can be perceived as a threat to the self-determination needs, such as the need for autonomy. Patients who regularly use health care services in the UK associate four main types of threat to health care service experiences, in response to which coping strategies are activated. We discuss these below.

Perceived threats associated with health care services

Patients who use health care services in the UK often report situations they find threatening or questioning their astuteness and sense of control. Interactions with health care staff can make patients feel unintelligent and/or incompetent and restricted in personal control. This is typical of encounters where healthcare support staff are unable to address patients’ queries accurately, and their attempt at resolving the issue is perceived subconsciously as unnecessary and inappropriate by the patients. The above seems to be due to a general lack of trust in the competence of health care personnel, and more conspicuously the perception that they were not willing to act in the interest of patients. Poor health status at the time of accessing health care services might also hinder patients’ willingness to accept advice from health care professionals. Such experiences of threat to self-competence are often associated with negative or even vengeful behavior towards the health service provider, which is the party perceived as threatening. The psychological mechanism behind such behavior is that retaliation alleviates the emotional discomfort caused by threat perceptions⁶.

Threats to personal control are often reported when processes in the health care service provision are perceived as inadequate and lead to, for instance, long waiting times for appointment booking and/or rescheduling. Our qualitative research show that patients perceive the process of booking a doctor’s appointment as ‘a nightmare’, ‘particularly time-consuming’ and ‘complicated’. They perceive a loss of control when seeking to book or reschedule an appointment. When appointments are not scheduled around their commitments, patients perceive that they are not being heard.

Furthermore, health care service experiences are perceived as threatening to the individual’s self-esteem; especially in situations where patients feel ignored by the health care personnel, and their own self-esteem and social identity are being undermined. A key reason is the perceived lack of empathy and concern of health care personnel during interactions with patients.

How patients activate coping strategies

The lock-in situations discussed above can affect satisfaction and well-being, despite patients’ general compliance with requests from health care personnel.⁵ Social psychology research shows that perceived threats, such as those reported in health care service experiences, increase feelings of anxiety, averseness, lack of control, and aggressiveness.⁶ Crucially, in response to threats and consequent negative feelings, patients activate coping strategyas a mechanism of self-defense. We postulate that coping strategies, in turn, influence their behavior, aimed at compensating for the unsatisfactory experience⁷. Such behaviour can be negative, and at times even vindictive towards the health care service provider.

Social psychology research distinguishes between individual’s coping strategies⁸ aimed at addressing the source of the threat (i.e. problem-focused coping), and those focused on re-establishing positive emotions, for instance through the act of venting dissatisfaction caused by the threat (i.e. emotion-focused coping). In health care services, patients often seek to proactively react to threats, thereby engaging in problem-solving. This is especially the case when unsatisfactory health care service experiences are aggravated by a serious illness. Severity of the illness markedly influences patients’ willingness to take actions in response to threats. Crucially, the decision to act seems to benefit patients, as they report feeling ‘back in control of the situation’ – a form of compensatory behaviour⁹. Cerebral activities, such as rational and positive thinking, influence the extent to which patients confront threats. Rational thinkingcan induce patients to take a step back from the experience, reconsider the factors at play, and plan their next actions.

Crucially, in the process of coping with threats imposed by health service experiences, patients often feel overwhelmed. Negative emotions in such threatening circumstances are heightened, and the support from their network of friends and family appears to be fundamental. Intriguingly, for some patients, social media is increasingly seen as a useful source of emotional support, which appears to be gradually replacing conventional forms of verbal, face-to-face support.

Final remarks

We offer an overview on how insights from social science research can be valuable for informing decision-making of health care service providers. This is especially the case in decisions related to staff hiring, training and development, service process improvement and supporting systems design. Lack of empathy and concern from frontline health care staff, outdated service processes and systems represent threats to patients. An implication is that innovative training of frontline staff is necessary for the development of soft skills, which are highly valued by patients. Developing caring and supportive relationships between health care personnel and patients is necessary, as these have considerable bearing on the outcome of healthcare service experiences. Similarly, introducing the practice of simulating patients’ care experience can help to identify threats whilst introducing service improvements and innovations. There is also need for health care service providers to be aware of the fact that patients’ health status at the time of seeking access to and experiencing health services influences their evaluations of the quality of care and of the service experience. It follows that the service provision needs to be adapted to account for patients’ health status and vary according to different patients’ groups. Insights from social science research can inform practice for enhanced provision of health care services. Further survey-based research focusing on the causal links between psychological threat, coping and patient well-being¹⁰ is on hand.

Introduction

Medical Student Syndrome (MSS) is a unique type of hypochondriasis which specifically causes health anxiety related to the diseases medical students study during their medical training.¹ However, this phenomenon does not translate into an increased number of consultations differentiating it from hypochondriasis.² Nevertheless, the common denominator in both conditions is that the affected person persistently experiences the belief or fear of having severe disease, due to the misinterpretation of physical symptoms.³ The medical examination on multiple occasions does not identify medical conditions that fully account for the physical symptoms or the person’s concerns about the disease, making it a diagnosis of exclusion. Unfortunately, the fears frequently persist among medical students despite medical reassurance, affecting their concentration during their training.⁴

Earlier studies have shown a higher prevalence of MSS in various medical schools, but recent studies show a declining trend. While Howes et al⁵ demonstrated that 70% of medical students have groundless medical fears during their studies, Weck et al,⁶ on the contrary, recorded the prevalence of health anxiety only among 5-30 % of study participants. One of the reasons ascribed to this could be that earlier studies, showing a high prevalence of MSS, were uncontrolled. Also, age-matched peers were not used as controls in some studies, and no direct interviews had been conducted.^7,8 Methodological issues in previous data have led to inaccurate interpretations and over-generalization of findings. For example, the high emotional disturbance in medical students resulted from comparisons made with the general population, rather than with other students of their age. ^9-11

We were prompted to conduct this study because the magnitude of MSS is variable from region to region, and in this study we compared medical students with their peers, studying in different colleges of Taif University to avoid observational bias.

Methods

This study was carried out from September 2017 to June 2018 at the female campus of Taif University, Kingdom of Saudi Arabia (KSA) in medical (pre-clinical and clinical years) and non-medical colleges in accordance with research guidelines of the College of Medicine, Taif University, KSA.

Inclusion criteria

Age and gender-matched students were selected for inclusion in the study. These included:

1. Female medical students from the second to the sixth grades enrolled in the College of Medicine, Taif University, KSA.

2. Female non-medical students from first to fourth grades enrolled in colleges of Arts, Admin and Financial Sciences, Computer and Information Technology, Science and Islamic Law.

Exclusion criteria

Biology students were excluded due to the medical content of their courses. At the time of enrolment, permission for participant recruitment was obtained from the concerned faculty administrators.

The participants were approached in the common/study rooms or lecture halls. The students were informed of the voluntary nature of the participation and were randomly selected. They were not required to provide their names during completion of the questionnaire and were assured of confidentiality. The Hypochondria/Health Anxiety Questionnaire (HAQ), developed by the Obsessive Compulsive Centre of Los Angeles (http://ocdla.com/hypochondria-test), was used to collect the data. The questionnaire was translated into Arabic and underwent a revision in order to ensure compatibility with the original one. The questionnaire was not designed to provide a formal diagnosis but provided an indication as to whether or not the persons were exhibiting significant signs of the disease.

Results of this questionnaire were analyzed as under:

A) 1 to 3 test items checked: there is a low probability that the student has health anxiety, and it is unlikely that her concerns significantly impact his life.

B) 4 to 7 test items checked: there is a medium probability that she has health anxiety, and a moderately high amount of distress related to specific health-related thoughts. She spends more time than most people doing unnecessary behaviours related to these thoughts.

C) More than 7 test items checked: there is a high probability that she has health anxiety. She most likely has a significant amount of distress related to certain health-related obsessions, and likely spends a significant amount of time doing unnecessary compulsive and avoidant behaviours directly related to these obsessions.

Statistical methods

Data were statistically described regarding frequencies (number of cases) and valid percentages for categorical variables. The response of the two groups was analyzed by student t-test. P values less than 0.05 were considered to be statistically significant. All statistical calculations were done using computer program IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 21 for Microsoft Windows.

Results

400 students were included in the study. There were 200 medical students, and the other 200 students were from various non-medical colleges of Taif University (Colleges of Arts, Admin and Financial Sciences, Computer and Information Technology, Science and Islamic Law).

All participating students were females (100%), and the mean age of the medical students was 21 years (ranged from 19-22years). The mean age in the non-medical group was 20.5 years (ranged from 19-23 years).

All students in the non-medical colleges completed the HAQ while five students in the medical college (clinical years) did not complete it, so the data on 395 participants were finally analyzed.

According to the scaling criteria, this study showed that the overall prevalence of MSS among the total sample (medical and non-medical female students) was 16.2% (64 out 395 students). However, it was higher in the medical students (34 out of 195 students; 17.4%) than in the non-medical students (30 students out of 200; 15%) – see Table 1.

Table 1. The frequency of Medical Student Syndrome (MSS) among medical and non-medical students.

Figure 1. The difference of Medical Student Syndrome (MSS) between pre-clinical and clinical years (p=0.028).

Figure 2. Fears related to diseases in the study cohort.

While comparing the response of the two groups by student t-test, there was no statistically significant difference between the responses obtained from medical and non-medical colleges (p=0.31). However, from the MSS diagnosed cases in the medical college, there was a significant difference between pre-clinical and clinical years – 21.1% vs 14% (p= 0.028) – see Figure 1.

Regarding the percentage of students who visited the doctors during the last year due to fears from disease, or medical condition, it was higher in the non-medical student's group than in the medical student's group with a significant difference observed (p=0.043).

The medical conditions that caused worry among medical and non-medical students were, diabetes mellitus followed by cancers especially breast cancer. The least worried diseases were headache and heart diseases – see Figure 2.

Regarding the percentage of students who consulted more than one doctor for the same medical concern, because of doubt about the previous doctor’s diagnosis and laboratory results, it was higher in the non-medical student's group compared to the medical student's group. The difference was significant (p=0.001).

The students with MSS in the total sample (of 395 students) were categorized according to the degree of probability into low, medium and high as shown in Figure 3.

Figure 3. The probability of Medical Student Syndrome (MSS) among all groups compared to their non-medical peers.

Discussion

The unrealistic fears about illnesses recorded in this study among medical students were higher than their peers studying various non-medical courses at Taif University; however, the difference was not significant. The subgroup analysis revealed a correspondingly higher prevalence of health anxiety during pre-clinical years than clinical years as shown in Figure 1. Possibly during the pre-clinical years, students have an increased sense of body awareness and stress as demonstrated by Moss-Morris et al.⁷ The authors in the above study described this syndrome as a normal perceptual process and differentiated it from common hypochondriasis. Other researchers ^8,12 as well affirmed this. Our results are in parallel with the finding of Azuri et al¹³ who recorded that first-year students visited a general practitioner (GP) or specialist more often than in other years. The authors in the above study suggested that the pre-clinical students` visits may be due to registering with a new doctor closer to university or due to necessary health checks before the beginning of their medical school. The dream content of pre-clinical medical students frequently involved a preoccupation with a personal illness of the heart, the eyes and the bowels in the above study.

Additionally, the fear of acquiring a future disease is a core feature of health anxiety, while fear of already having a disease is considered more central to the MSS.¹⁴ There is a number of instances where this syndrome manifests among students from time to time during their training. The students are even known to change their diagnosis depending upon their clinical rotation. For example, in a psychiatry rotation the student conceptualizes having schizophrenia and later shifts his or her diagnosis to Meniere's disease during an ear, nose and throat (ENT) rotation. The symptoms are thought to occur due to intensive exposure to knowledge affecting symptom perception and interpretation.¹⁵ The fact remains that the affected student is devoid of either. At times, the simple knowledge of the location of the appendix transforms the most harmless sensations in that region into symptoms of a serious threat.¹⁶ The students who study "frightening diseases" for the first time routinely experience intense delusions of having the disease, reflecting a temporary kind of hypochondriasis.¹⁷

In a study by Waterman et al¹⁸ it was observed that 80% of medical students conceptualize diagnoses ranging from tuberculosis to cancer while studying these diseases during training. This caused emotional distress and conflict in them. It was suggested that this phenomenon was present in approximately 70-80% of students in the study mentioned above. There may be multiple reasons for precipitation of this condition among medical students. The vastness of medical studies are undebatable, and medical schools cause students to experience a large amount of psychological pressure due to work required to grasp the subject matter, the stress of examinations, and the competitive environment.¹⁹

In this study, we compared medical students with the students of the same age and gender with the same cultural background in order to avoid any bias. Our results are in parallel with a more recent study, which compared three groups, medical students, non-medical students, and their peers who were not undergoing any academic course. The authors in the study mentioned above observed no significant differences between the groups on total scores in the questionnaires. However, when considering the individual components of the questionnaires, it was found that medical students were less aware of bodily changes and sensations than the other groups; nevertheless, they did not avoid seeking medical advice for any health-related fears.²⁰

Regarding the percentage of students who visited doctors in the past 12 months due to fear of disease, it was observed in this study that the non-medical group had significantly higher visits to doctors compared to their peers studying in the medical college of the university. It is entirely possible that they had increased access to personal advice from peers, relatives, and various mentors. Of the various diseases, fear of diabetes mellitus was the highest, possibly due to a high prevalence of the disease in Saudi Arabia.²¹ Further, it is entirely possible that medical students subconsciously conceive these metabolic disorders as these are discussed in greater details during their courses.

MSS may lead to cyberchondria, a phenomenon of the public, seeking to diagnose themselves via the internet,¹¹ which in turn may lead to hypochondriasis in any given student. Thus, it becomes imperative that students suffering from this disorder must be dealt with an empathetic approach and counselled properly after ruling out an organic cause of their illness. A step to circumvent it further would be that MSS must be thoroughly discussed among medical students during their training.

Limitation of the study

The drawback of this study is that that the questionnaire was translated from English into Arabic, and although it underwent a revision, there were no other formal tests such as linguistic and cultural validation to validate the translated version. Further, we believe that our focus was only on female students, and it is well known that females have better ability to cope up with anxiety and depression compared to males^22,23 so the figures of MSS among male medical students needs to be studied as it may be different from what we reported in this female cohort.

Conclusion

In conclusion, the students who are suffering from MSS often overuse medical resources and outpatient’s services compared to others. Therefore, clinicians should be aware of these students, to avoid unnecessary procedures and treatments. However, it is vital that a proper evaluation is done before labelling a given student with MSS.

My countryside

home is where the heart is

at its gladdest and lightest,

like a hot air balloon

floating gently over

emerald green fields

and golden dirt tracks.

My rustic

home is where the heart is

far from health services,

far from those specialists –

like cardiologists –

who can stop diseases in

their concrete-covered tracks.

My bucolic

home is where the heart is

more likely to fail –

liable to stop beating

earlier than all those

hearts that thump out their

rhythms in the city.

My rural

home is where the heart is

woven into the patterned fabric

of a vibrant community,

whose median age

keeps rising and rising

as fond memories fade.

My countryside

home is where the heart is

destined to be

till its last beat.

Stale and stilted inhales and exhales:
a striking absence of contentedness.

This neuroplastic beast of a brain-
wired with the wonder and wisdom to thrive

and yet, too, the demons
clinging to dendritic branches
choking cellular expression.

I can hear myself screaming
for a serotonergic surge
then goading the glia:

start pruning any circuitry that has died from shame
and find a neurogenesis waiting to be unearthed.

Sometimes, layers upon layers have to be excavated
before the brain’s resuscitation allows for easier breaths.

Introduction

Within the United Kingdom, all doctors are expected to teach.¹ It is assessed throughout their professional career, during annual appraisals for doctors in training and during consultant revalidation. But how are those just embarking on their medical career expected to develop the necessary teaching skills? As three educators at various stages in our clinical careers, we developed and delivered a small course with the aim of addressing this issue.

The General Medical Council within the United Kingdom, suggest that a basic comprehension of teaching should be gained during the undergraduate and postgraduate training of doctors.² Dandavino et al. further suggest that early development of these teaching skills may have additional benefits for the clinician; such as improving communication and assisting undergraduates to develop their own ability to learn.³ Our local training region, Yorkshire and the Humber Deanery (HEYH), have a mandatory post-graduate training day in teaching skills which focuses on generic and clinical teaching skills. This is delivered towards the end of the first foundation year. It is delivered by doctors who have various roles in medical education. Whilst useful in its content, for many it comes late. Doctors have often already been involved in providing teaching to medical students on placement at this time.

AMC recalls from her first postgraduate (foundation) year. One peer was thrilled to have ‘shaken-off’ a final year medical student who was supposed to accompany them on a shift as a learning experience; stating that they were now able to ‘do some work’. She couldn’t understand the desperation to escape one-to-one teaching. On reflection, it was probable that her colleague found it overwhelming to incorporate the additional responsibility of teaching alongside an already stressful clinical workload. Many share these feelings, with new doctors finding time pressures along with competing clinical demands a challenge to implementing clinical teaching.⁴

We thought that giving our graduates simple tools to understand and overcome these challenges may empower them as teachers. It may also improve their confidence in other areas, such as in their own learning and presentation skills.^5-6 This paper proposes a solution; after creating a short course to be delivered immediately following graduation, to empower new doctors as teachers by providing some basic training in clinical teaching. These doctors are then able to use this training as soon as they begin their foundation training, which is ultimately the beginning of their teaching career.

Methods

Two versions of a half-day course, titled ‘Teach the Medic’ were developed in HEYH which ran in successive years. The original course was designed by a surgical trainee (AMC) and a general practitioner running the undergraduate education curriculum (MS). Initial topics were chosen based on experiences of the authors and colleagues. The optional course (see figure 1), was offered to the cohort of Leeds medical students who were in the transition period between finishing their final examinations and commencing their first post as a doctor.

Figure 1: A representation of the initial course structure. Stations were developed as interactive lectures and delivered to participants by doctors of various training levels.

The initial course received encouraging verbal and written feedback from the participants, which was collected on the day of the course. Further feedback was collected a few months into foundation training, allowing enough time to pass for delegates to use this knowledge. This feedback, whilst encouraging, included that delegates were keen for additional workshop style sessions. Subsequently, a modified half-day course ran the following year, with the recruitment of additional postgraduate teachers (including LES). A further 17 newly qualified doctors from various medical schools completed the course, prior to commencing their HEYH foundation post. This modified course (see figure 2) included scenario based sessions around potentially difficult situations for the clinical teacher, and also explored alternative styles of teaching that could be adopted successfully in the workplace.

Figure 2: A representation of the modified course structure. Building on feedback from the initial course, the three co-authors incorporated new small group scenario based discussions, alongside the interactive lectures.

Results

Initial feedback received from evaluation of the day was positive for both courses. For the second course, initial feedback found that all participants found every session very good (71%) or good (29%) overall. 12/17 (71%) thought that the course should be made compulsory to medical students. We also sent a follow-up survey, distributed six months after the course which generated 14 responses. All respondents felt that the course should be run again. All participants either strongly agreed (n=2, 14%) or agreed (n=12, 86%) that they felt more confident in teaching compared with their peers. Regarding individual sessions, 10 participants (71%) had directly incorporated learning from the ‘Teaching Theory’ session, 12 (86%) from the ‘Teaching for your Learning and Portfolio’ session, 11 (79%) from the ‘Teaching your Peers’ session, and 10 (71%) from the ‘Scenarios’ workshop. All participants stated they would still recommend this course to colleagues. They also reported directly incorporating their learning from the sessions into their teaching practice. The responses gathered from the second course implied that participants felt more confident in teaching when compared to their peers.

Discussion

We feel the course content in ‘Teach the Medic’ complements other courses available later in one’s career, such as the Royal College of Surgeons’ ‘Train the Trainer’ course. We propose this course could be run by a junior doctor who has a strong interest in clinical teaching with involvement of a senior colleague with extensive medical education experience. We felt the course was especially beneficial as participants had continued to find it useful long after its delivery.

To expand this project to include a whole year group as a compulsory course is ambitious. It would require development and the use of more resources, but initial feedback suggested participants will find it extremely useful. Bing-You et al.⁶ agree, having found that undergraduate students would be willing to undertake formal instruction in clinical teaching prior to graduation.

As our short course gains momentum within HEYH, this prospect becomes more achievable. When considering a wider delivered course, one must remember that attendance to ‘Teach the Medic’ was optional; suggesting that those who attended had already identified an interest in teaching. This has the potential to bias our data to some degree. However, we still believe that making the session compulsory would allow skill development and empowerment for those who may not consider themselves aspiring medical educators, but who are still in positions to deliver teaching.

Conclusion

Our evolving teaching skills course suggests that close work with both local medical schools and deaneries is important to allow this course to be incorporated into the training of newly qualified doctors. This may be included as a compulsory part of the final year medical school curriculum, an option for a SSC, or as an integrated part of the new starter induction programme delivered by individual hospitals.

Introduction

Postgraduate medical training should equip trainees with the skills, knowledge and attributes for independent practice¹. They need to be equipped with the skills to become lifelong learners and continually develop their abilities throughout their careers by learning from colleagues, mentors, patients and disease. The challenge for clinical teaching is how to provide an optimal learning environment in which trainees can achieve their competencies for practice within a defined training rotation; both the limitations in the number of hours within a working week and the balance between learning and service commitments all can negatively impact on the educational experience of trainees². Moreover, trainees need to balance their own development of skills, knowledge and attributes for independent practice against the requirement to provide high quality and safe healthcare³. The appropriate level of supervision must be provided to trainees performing any patient interaction and this is gauged by the trainer-trainee relationship, regular assessment and feedback. The clinical workload of a trainee needs to be finely balanced between overstretching them with tasks outside their competencies and being left with all the routine and menial tasks⁴. Thus whilst trainees should work within their competencies, they must be given the opportunities to expand their repertoire of skills, which may result in errors (and potentially patient harm) – supervision should limit these errors, which should be reflected on to provide a learning opportunity within a ‘no-blame’ culture⁵. As a trainee gains competence of their necessary skills, the amount of supervision required can be stepped down, until distant supervision (i.e. advice via a telephone) may be all that is required.

An understanding of how each learning environment within the hospital setting can be maximized may enhance the learning opportunities conferred upon trainees. Both technical skills and the professional attributes of being a clinician can be learnt in clinical and non-clinical environments. These learning environments will be explored in the subsections below.

Bedside Teaching and Ward Rounds

Bedside teaching is a stalwart of medical education, allowing clinical history and examination to be performed under guidance, in an appropriate setting and with relevant clues (observation charts, oxygen, etc.) present. This patient-trainee interaction provides an opportunity to develop professionalism and communication, and can also be the source of training of diagnostic techniques ranging from venesection and cannulation to more invasive techniques (e.g., pleural aspiration, drainage of ascitic fluid)¹.

Presentation of patients during ward rounds allows a professional conversation between trainees and trainers to occur, which justifies their role in management and provides an insight into understanding and thought processes⁶. The multidisciplinary nature of rounds creates a community of practice⁷, allowing social learning to occur, and an opportunity to voice differing perspectives on patient care³. In order to maximize these learning opportunities, learning objectives can be discussed prior to commencement and reflection undertaken once they it has been completed⁶. Teaching rounds should be carried out when the ward is quiet, at a suitable pace, with regular questioning and opportunities for trainees to ‘lead’ the process⁸. Factors that hinder this educational process include time pressures, patients not being available, and the availability of trainees⁸.

Outpatient Clinics

Outpatients provides a mixture of new and follow-up patients that enables a trainee to learn management of patients in an ambulatory setting. Trainees may be in the same room as their supervisor (learning the basics of the consultation), or can practice semi-autonomously as their experience increases (with discussion with their supervisor as required); they must select an appropriate investigation and treatment plan, with a time frame for review, once the investigation or intervention has been performed³. Outpatient teaching is more highly valued by trainees and students compared to ward based tuition⁹. Factors that hinder this educational opportunity include room availability, time constraints, staffing levels and attitudes to teaching⁹.

Operating Theatre and Interventional Suites

Invasive procedures should be performed by adequately trained (or supervised) personal in the relevant area of the hospital (e.g. endoscopy, interventional radiology suites, theatre), with the necessary equipment and monitoring for the technique to be performed. Even before patients enter these environments, trainees have an opportunity to review the patient and their relevant investigations, discuss the procedure with the patient and obtain consent for the intervention¹. Trainees can learn a wide spectrum of skills within these environments including both technical (both procedural related and anesthetic related) and non-technical skills, including Human Factors, anatomy, identification of instruments, aseptic technique, effective hand-washing and donning of surgical gowns¹⁰. Teaching invasive procedures represents a dichotomy for clinicians, not only do trainees need to gain exposure and experience in the relevant technique, but patients need to be prevented from undue harm. Prior to undertaking an intervention, trainees should be familiar with the relevant anatomy and physiology of the system they are about to operate upon, will have watched the procedure being performed and may have learnt the basics of the procedure in a simulated setting.

Trainees must to be able to self-reflect on their own skills and record of the number of procedures they have performed (which can act as a proxy for ability) to ensure that the correct level of supervision is provided alongside an intervention of suitable difficulty. Trainers need to be sure that their trainees have the necessary skills and knowledge to perform a technique, with experience often being gained in a stepwise reflecting both the difficulty of intervention and the gaining of skills, competence and confidence by the trainee¹¹. This skills acquisition should be accompanied by regular discussion and feedback to maximise learning opportunities; when no supervision is available, trainees should consider video-recording the procedure as this allows reflection and review at a later date. A video diary can also be used as a portfolio of a trainee’s repertoire from beginner to expert during their training rotation. The challenge for trainees is to achieve competence in the relevant invasive technique within their training rotation; the number of interventions required to gain competence will vary between each trainee and technique¹¹.

Handover

Handover allows the care of patients to be transferred from one group of individuals to another on a temporary or permanent basis. Handover confers an opportunity to present a clinical synopsis of patients with key information to ensure continuity of care and patient safety is maintained³. Most handovers are trainee led which provides an opportunity for peer learning to occur, checking comprehension and sharing interesting cases or tips for practice¹². Handovers should be considered to be a high risk procedure, as communication errors can result in vital information being omitted; as such the process should be undertaken in suitable environment away from distractions, in a structured written and oral manner supported by an electronic format¹². A further review at the patient’s bedside can be performed if required, which can highlight high risk patients.

Multidisciplinary Team Meetings

Multidisciplinary team (MDT) meetings are small formal meetings focused on all aspects of a patient’s care that involve a wide range of medical personal, nursing staff and allied health care professionals¹. Meetings ensure that evidence-based guidelines are followed, and help to streamline management, removing unnecessary delays in treatment and improving cost effectiveness. MDTs represent a Community of Practice⁷ allowing social learning to occur as each individual can share their relevant expertise; MDTs enable best practice to be shared and help break down barriers between different specialties.  Trainees can learn from the didactic teaching that occurs within the MDT (in relation to clinical details, investigation and management), but can also contribute to the meetings and practice their presentation skills.

Morbidity and Mortality Meetings

Morbidity and Mortality (M&M) meetings can help ascribe accountability and be used to highlight improvements in patient safety. They provide an opportunity for professional education, especially if the discussion can be held within a no-blame culture, and the meeting can voice discrepancies in how to manage patients, especially in ambiguous situations¹³. Trainees may be tasked with presenting a case and the potential learning aspects associated with patient care.

Grand Rounds/Formal Teaching

Grand rounds are traditional formal teaching opportunities that typically revolve around a case, whereby salient findings are presented prior to a discussion of management. These meetings allow opportunities for trainees to present cases and learn management, but their educational benefit may be decreasing as they are being replaced with lectures with limited clinical relevance¹⁴. However “audience apathy, deteriorating decorum and shrinking attendance” have diminished these learning opportunities¹⁴. Targeted teaching and the establishment of learning objectives for trainees can improve the educational content and the provision of feedback to the speakers can also enhance these meetings.

Journal Club

Journal clubs confer an opportunity for current scientific research and developments to be presented, critiqued and discussed by trainees. These clubs confer an opportunity to appraise the current literature and how that can be translated into evidence based patient care¹⁵. Journal clubs tend to be both voluntary and occur outside of working hours, resulting in highly motivated groups of participants whom are protected from interruptions.

eLearning and mLearning

Electronic learning (eLearning) and multimedia learning (mLearning) enable trainees to work informally, away from desks and computers, and at their own pace through a series of educational modules. Any intervention that engages trainees and promotes learning should be encouraged and these online learning platforms can be combined traditional learning resources should be promoted to ensure that all aspects of the curriculum are covered. mLearning in particular  can be ‘dipped into’ allowing the learner optimal flexibility of how and when they want to use it. elearning can be referred to during point-of-care patient interactions when a trainee is unsure of how to proceed with patient management¹. These increasingly important and under-utilized resources should be supported by educational institutions that support both undergraduate and post graduate trainees. By developing a virtual learning environment, individual tailored learning programs can be created that allow a trainee to develop and control their own online learning¹⁶.

Simulation

Simulation is becoming increasingly important for medical training. , anything can be simulated from learning clinical skills to human factors training, for both individuals and teams, focused on patient care and current medical practice in both the undergraduate and postgraduate setting. The availability of simulators coupled with competency based training and a decreased amount of training within the workplace has led to an increase use of this teaching format¹. In addition, trainees need to understand how to use certain pieces of equipment prior to employing them on patients and this familiarity can only be gained in a simulated setting. Simulation can either occur within the workplace (allowing point-of-care simulation to see how teams react in a situation) or on formal taught courses; it can be low-technology and cheap (e.g., tying surgical knots on the back of a chair), but can also be high-fidelity and expensive (e.g., a virtual reality training simulator for laparoscopic operations), or use animal or cadaveric tissue. Simulation that increases trainee’s familiarity with certain techniques is likely to improve their clinical performance, decreasing potential patient harm and shorten the time taken for trainees to achieve competence¹. A simulation should be completed with feedback from the supervisor to ensure that trainees gain the most from the session and clarify any facts or concerns about the simulation; a video recording of the session can also enable participants to reflect on their performance in a manner that is almost impossible in everyday clinical practice.

Introduction

Bed bugs belong to the family Cimicidae and there are two species involved in the modern resurgence; the Common bed bug, Cimex lectularius and the Tropical bed bug, Cimex hemipterus. They are wingless insects with an oval-flat shape that allows them to hide in narrow cracks and crevices. The adults are dark brown, 4-5mm long, becoming to around 10mm when fully blood-engorged. There are five smaller juvenile stages (nymphs) that are similar in appearance, although lighter in colour. All nymphs require a blood meal to moult to the next stage, and both adults also bloodfeed for nutrition, and egg development in the case of the female. Bed bugs are solely haematophagous ectoparasites. After feeding they return to a harbourage and do not remain on the host. The main hosts are humans, but pets, bats, and birds may act as secondary hosts.

Epidemiology

In the past, bed bugs were particularly an affliction of the poor. However, in the early part of the modern resurgence it was the tourist areas and the hospitality sector that were initially impacted.^1-3 Today, bed bugs have conquered quite diverse locations, ranging from hospitals, hotels and homes, to trains, cruise ships, and even airplanes. Most commonly, bed bugs travel in comfort as stowaways in luggage, although they can be transferred via furnishing and other belongings, as well by spreading to adjoining properties. Unfortunately, exact figures on the occurrence of bed bugs are unknown, as there are no mandatory reporting requirements. Additionally, due to the stigma associated with bed bugs, many infestations are simply not reported.

During the day, the largely nocturnal bed bugs will crawl deep into crevices of bed frames and mattresses (Fig.1), or behind wallpaper, and floor moldings. Here they tend to lay their eggs, often several hundred during the female lifetime. Live bed bugs, shed nymphal skins, and dark excrement spots indicate an active infestation. At night they are attracted by carbon dioxide, heat and other host odours to a victim, from which they may take a blood meal every 3-5 days. The adult bugs can survive long periods of starvation, up to five months at 22^oC or even longer at cooler temperatures. When a host is found, they insert their mouthparts into the skin, blood feeding for 5-10 minutes. When bed bugs are in large numbers, often lines of bites occur on the unfortunate victim and this sign is almost a sure indication of the presence of the insect. The bites tend to occur along the arms and legs, down the back and across the shoulders.^4,5

There has been long speculation whether bed bugs can transmit diseases, and in fact more than 40 different pathogens have been implicated. This has included Hepatitis B and C viruses, Human Immunodeficiency Virus (HIV), and Coxiella burnetii (Q fever). Recently, research has indicated that bed bugs are capable of transmitting the agent of Chagas Disease, Trypanosoma cruzi,in the laboratory. However, to date there is not one piece of evidence that bed bugs have transmitted any pathogen to humans.^4,6

Clinical Features

During the act of feeding, saliva is injected which contains a variety of anticoagulants as well as other proteins whose function has yet to be determined. Contrary to popular belief, there is no evidence that bed bugs inject an anaesthetic. One protein, Nitrophorin, is involved in the transport of nitric oxide into the wound. This results in local vasodilation that increases blood supply to the feeding insect. The same protein can also induce a sensitivity to the bite.⁶

The diagnosis of Cimicosis is via the clinical appearance of the bite reaction and confirmation of an actual bed bug infestation (Table 1).^3,5 The most commonly affected body parts are those that are left uncovered during sleep (Fig. 2,3,4), notably the arms, shoulders and legs. In young children, the face and even the eyelids can be bitten. Rarely, however, armpits are bitten, which are often preferred by other insects and ticks (Table 2).

Figure 1: Typical appearance of bed bugs

Figure 2: Bites on the back, note the lines of bites common in moderate to large infestations

Figure 3: Bed bug bites on the arm, typical formation

Figure 4: Bed bug bites on the torso and arm

Figure 5: Bullae due to bed bug bites

Figure 6: Bed bugs, their droppings and eggs underneath a mattress

The degree of the bite reaction often depends on the level of prior exposure. With low level sensitization, individuals may develop a 1-2 cm wheal, with a small central haemorrhagic point. This haemorrhagic point can be recognized easily by diascopy. In contrast, a highly sensitized person will react immediately and may develop a wheal up to 15cm across (6 inches). If many bed bugs are present, an urticarial rash may develop as a result of the large number of bites and subsequent trauma to the area from scratching. On rare occasions, vesicles and bullae (Fig. 5) may form on the arms and legs. In the course of Cimicosis, papules that are extremely itchy may develop and can persist for several days to weeks. Due to the strong pruritus eczematous lesions, bacterial infections may occur, although this is extremely rare. There are case reports of systemic reactions such as anaphylaxis and asthma, although these are uncommon.

Through repeated exposure, some individuals may develop a tolerance to the bites. The clinical symptoms are then largely inapparent with small punctures at the bite site. Small blood spots are then the only clues that an infestation may be present.

Differential Diagnosis

Since reactions to stings and bites of various arthropods are non-specific, bed bug bites are commonly misdiagnosed. Single bites, notably that of other insects such as mosquitoes, fleas and biting midges may appear very similar morphologically (Table 2).

Consideration of where the bites are on the body can assist in the differential diagnosis. For bed bugs, lines of bites are very common in moderate to large infestations and this clinical picture is virtually unique amongst blood sucking arthropods. For the most part, the identification of the actual pest is required to confirm the diagnosis. Histologically, bed bug bites resemble perivascular eosinophilic infiltrates through the superficial and deep dermis, with minimal spongiosis.

Other possible diagnostic confounders can be various allergic reactions and other medical conditions such as urticaria, chickenpox, prurigo subacuta, and erythema multiforme.^7,8 These do not show a central haemorrhagic point in the lesion which allows a correct diagnosis. However, in young children the diagnosis can sometimes be difficult. 

Treatment

The treatment of Cimicosis is symptomatic. Local lesions can be treated with antipruritics e.g. Polidocanol 2-4% in Lotio alba (aqueous lotion) and topical antiseptic. Spirit of menthol may also be helpful. Local treatment with antihistamines is controversial. In severe reactions topical glucocorticoids such as Betamethasone may be required. In severe itching, the use of oral antihistamines is recommended. With infected bites, antibiotic therapy may be required. Uncomplicated bed bug bites tend to stop itching within 1-2 weeks, although temporary scarring from the bite may remain for several months.

Management

Treatment of patients with bed bug bites ultimately comes down to removing the source of the irritant, namely the eradication of the active infestation. Bed bugs have a typical pungent odor. This can be used to detect bed bugs through specially trained sniffer dogs that can rapidly locate the insects.⁹ Due to insecticide resistance, bed bugs are very difficult to control with traditional insecticides alone, and non-chemical means of eradication must be employed to reduce the overall insect biomass. Bed bug control should be undertaken by professionals trained in bed bug management, and the process may take some weeks to achieve.

Prevention

When travelling (1) always inspect the bed and surrounds for bed bugs hiding beneath the mattress and/or in seams of the bedding. Also, look for blood stains or small black dots (Figure 6, Table 1). (2) If present, request another room. (3) Always keep your luggage on the desktop or the luggage rack. A good preventative is to seal luggage in plastic or garbage bags during travelling, even when in transit. (4) When returning home, all clothing should be washed in at temperatures exceeding 60°C or frozen for one week with delicate fabrics. If there is no choice, then repellents containing N, N-Diethyl-meta-toluamide (DEET) should reduce the biting rate, but will not completely prevent all bed bug bites.^10,11

Bed bugs can enter homes via an array of additional ways, particularly from objects bought second hand at flea markets or thrift stores, for example wooden frames, vintage clothes, furniture and the like. These should be heat-treated for a minimum of 10-20 minutes to kill bugs and their eggs.

INTRODUCTION

Like doctors in other specialties, general medical practitioners (GPs) are exposed daily to human suffering which most of society try to avoid.¹ The World Health Organisation (WHO) predicts that by 2030 depression will be ‘the leading cause of disease burden globally.’ And that 1 in 4 individuals seeking health care are ‘troubled by mental or behavioural disorders, not often correctly diagnosed and/or treated.’^{2, 3} Doctors suffer from stress, anxiety and depression (as well as vascular disease, cirrhosis of the liver and road traffic accidents) more than the general population.^4-10 Help for doctors is inadequate and doctors are reluctant to seek help.^{1, 4, 11} Where improvement is suggested, it is usually as counselling and general support.¹¹ Instead of ‘more of the same’, we suggest a radically different approach: Adaptation Practice, which Clive Sherlock pioneered and has taught since 1975. It is pragmatic and safe. This study tests its acceptability to a group of working doctors.

Doctors bear the responsibility for fellow human beings’ health, well-being and, often, for their very survival. Added to this, GPs are under increasing pressure from more patients who want more cures and from health service managers who demand clinical excellence and more administration and more managerial skills of them. GPs’ stress is related to increasing workloads, changes to meet requirements of external bodies, insufficient time to do the job justice, paperwork, long hours, dealing with problem patients, budget restraints, eroding of clinical autonomy, and interpersonal problems.^{6, 10, 12} The recent rise in the GMC’s Fitness to Practice complaints related to patients’ expectations of doctors is yet another stress making them feel threatened.¹³

Job satisfaction for GPs is at its lowest level since a major survey started ten years ago, while levels of stress are at their highest. In 2015 there had been a year on year increase in the number of GPs reporting a slight to strong likelihood of their leaving ‘direct patient care’ within five years, with 53% of those under 50 and 87% of those over 50.⁶

By nature and vocation, GPs want to help but too much pressure is unbearable and takes its toll. They work, not with numbers, data or profits, but with human suffering, which, inevitably, is an emotional burden because of compassion and because it makes them aware of their own vulnerabilities and mortality. ^{3, 14} When combined with heavy workloads and low morale, doctors themselves inevitably suffer emotionally and psychologically.^{7, 10, 14} At the same time they and others feel they should be invincible.^{1, 15-17} What professional help is available for them is inadequate.^{3, 4, 18, 19} Existing support services in the UK are underfunded and sporadic.⁴ Some are outsourced to counselling services, and some of these are by telephone. Doctors do not like to be counselled and are reluctant to use these services.^{4, 15, 17}

Doctors themselves are the mainstay for diagnosis and treatment of mental illnesses but are not adequately trained.^{3, 20} Mental illness is not well understood and conventional treatments are insufficient and often harmful. ^{15, 20-23} Consequently, doctors do not have the wherewithal to deal with the emotional and psychological problems they face every day in their patients and often in themselves, their colleagues and their families.^{4, 12, 18}

There is significant prejudice, stigmatisation and intolerance of mental ill health within the medical profession due to lack of understanding and fear.^{3, 4, 9, 15, 17, 20, 21, 22, 24} This not only affects how doctors treat their patients, it also exacerbates their own difficulties when they suffer with emotional and psychological problems themselves, and dissuades them from self-disclosure and from seeking professional help.^{3, 4, 8, 10, 18, 20, 25, 26} To succumb to stress, anxiety and depression is seen as being weak and inadequate as a person and in particular as a doctor. ^{3, 4, 15} Doctors think they should know the answers and should be able to cope.^{1, 4}

However, doctors are willing to learn work-related skills as this present study set out to show.¹¹ Adaptation Practice is training; not treatment or therapy. The course in this study was presented as a postgraduate programme for doctors to learn how to cope with stress, anxiety and depression.

METHOD

Recruitment

We asked by letter all 314 GPs registered in one UK urban and semi-rural Health Authority Area if they would be interested in a course of twelve fortnightly seminars to learn the basics of Adaptation Practice: a programme of self-discipline to cope with stress, anxiety and depression. Included, was the Hospital Anxiety and Depression Scale (HADS). Those who responded and whose HADS scores were ≥ 8 (the threshold for anxiety and depression) were invited to the course.

Stress, anxiety and depression

Anxiety and depression were assessed by the HADS and stress by a simple stress scale (SSS – see Table 1) one month before training started, immediately prior to training, at three months (mid-way through the training) and at six months (at the end of training).

Evaluation of Adaptation Practice

Half of those GPs who applied for the course were unable to attend because of prior commitments on the days planned for the course. These acted as a control group. Those who attended the course were the study group. All those who attended were also assessed in private by the authors immediately before and throughout the course. At the end of the course the doctors wrote anonymous self-assessments.

Training in Adaptation Practice

Those attending the course were taught not to express and suppress upsetting and disturbing emotion, not to distract their attention from it (including not to think about it and not to analyse it) and not to numb themselves to it with chemicals (alcohol, recreational drugs or prescribed medication). Instead, they learned how to engage with their moods and feelings physically, not cognitively, and how not to engage with thoughts about them. They were instructed to practise this six days a week with whatever they were doing, wherever they were. They were all offered unrestricted confidential telephone and e-mail support from the authors between training sessions and after the course had finished.

Statistical Analyses

The results are reported as means ± standard errors of the means. The scores were normally distributed and the data were analysed by analysis of variance with additional paired comparisons within periods, using the LSD method. Correlations were determined using Pearson’s correlation. The analyses were carried out using the statistical software programme SPSS 17.0 for Windows.

RESULTS

Recruitment

Of 314 registered GPs, 225 (72%) responded to our initial contact, and of these 152 (68%) said they would be interested in participating in the training course. Recruitment was restricted to those with HADS scores ≥ 8. Of the 225 who responded there were 71 (32%) for anxiety, 35 (16%) for depression, and 79 (35%) for both. 29 (13%) applied to attend the course. All were experienced GPs. 15 of these attended and 14 were not able to attend because of pre-existing commitments on the course dates. They asked for alternative dates but these were not available.

At the initial assessment (one month before the course started) there were significant correlations between the scores for anxiety and depression (P < 0.001), anxiety and stress (P < 0.001) and depression and stress (P < 0.001). At the second assessment immediately before the course started these correlations remained highly significant.

Effects of Adaptation Practice

All those who attended the course reported a subjective improvement in their abilities to cope with their own stress, anxiety and depression, and in their sense of well-being.

Anxiety

There were no significant differences between the control and study groups either one month before the start (P=0.949) or immediately before the first session (P=0.914). The anxiety scores in both groups remained greater than 8 at both assessments (Figure 1). At the mid-point of the course the mean score had fallen slightly in the study group (Figure 1) but the difference was not significant (P=0.652) By the end of the course the mean anxiety score in the study group was significantly lower (P=0.008) than that of the control group (Figure 1). The mean scores for anxiety decreased over the 4 assessments. This tendency was significant in the study group (P=0.002) but not in the control group (P=0.567).

Figure 1: The mean anxiety scores and standard errors of the means (SEM) for a control group and a study group of doctors with pre-existing signs of anxiety, assessed twice before, once during and once at the end of a six-month course in Adaptation Practice.

Depression

There were no significant differences between the control and the study groups either one month before the start (P=0.310) or immediately before the first session (P=0.880). The mean HADS scores for depression before training were all greater than 8 (Figure 2). At three months (the mid-point of the course) the difference between the mean scores in the two groups was not significant (P=0.631). At the end of the course the mean depression score in the study group was significantly lower (P=0.046) than the control group (Figure 2). The mean scores for depression decreased over the 4 assessments. This tendency was significant in the assessment group (P=0.003) but not in control group (P=0.689).

Figure 2: The mean depression scores and standard errors of the means (SEM) for a control group and a study group of doctors with pre-existing signs of depression, assessed twice before, once during and once at the end of a six-month course in Adaptation Practice.

Stress

There were no significant differences between the control group and the study group either one month before the course started (P=0.234) or immediately before it started (P=0.505). The stress scores were all greater than 8 (Figure 3). At three months (the mid-point of the course) the difference between the mean scores between the two groups was not significant (P=0.621). At the end of the course the mean stress score in the study group was lower (P=0.077) than that of the control group (Figure 3). The mean assessment scores for stress decreased over the 4 assessments. This decrease was significant for the assessment group (P=0.001) but not for the control group (P=0.425).

Figure 3: The mean stress scores and standard errors of the means (SEM) for a control group and a study group of doctors with pre-existing signs of stress, assessed twice before, once during and once at the end of a six-month course in Adaptation Practice.

Correlations

At all four assessments there were correlations among all three psychological parameters. At the initial assessment the correlation between anxiety and depression (r2= 0.405; P = 0.029) and between depression and stress (r2= 0.800; P < 0.0001) were significant but the correlation between anxiety and stress was not (r2= 0.253; P = 0.185). At the commencement of the course the correlation between anxiety and depression (r2= 0.479; P = 0.009), between depression and stress (r2= 0.765; P < 0.0001) and between anxiety and stress (r2= 0.486; P = 0.007) were all significant.

At three months (the mid-point) the correlation between anxiety and depression (r2= 0.526; P = 0.003), between depression and stress (r2= 0.622; P < 0.0001) and between anxiety and stress (r2= 0.790; P < 0.0001) were all significant and similarly at the and of the course: the correlation between anxiety and depression (r2= 0.604; P = 0.001), between depression and stress (r2= 0.577; P =0.001) and between anxiety and stress (r2= 0.740; P < 0.0001) were also all significant.

Assessments of the doctors’ psychological states and methods of coping

The doctors attending the course were assessed individually in private. They variously complained of stress, anxiety and depression. Notable findings included suicidal thoughts, plans for suicide, self-medication, excessive consumption of alcohol and an intention to leave the medical profession because of the unbearable pressures involved.

By the end of the course all these signs and symptoms had improved and the doctors felt confident in their ability to cope not only with pressures from outside but also with emotion, moods and feelings inside. One doctor still wanted to leave the profession but less adamantly than before, and stayed.

There was no qualitative assessment of the control group.

Qualitative Self-assessments

The anonymous self-assessment reports give meaningful, subjective accounts of what the doctors experienced individually. They fall into four main themes. There were no negative comments.

Connecting with emotion physically in the body

The following comments indicate contact with emotion:

‘I am more aware of my feelings.’

‘It is difficult to say “Yes” to unpleasant or upsetting feelings and situations. I have always preferred to avoid them and I have had a lifetime of suppressing emotions, so it is very difficult to say “Yes” to them, but this is what I am now doing.’

‘Since I’ve been more aware of my feelings there has been an enormous improvement in concentration.’

Developing inner emotional strength and coping.

A number of comments indicate the need to develop the strength to contain emotion physically in the body:

‘I am more accepting of daily stresses at work.’

‘I try to deal with problems instead of feeling so desperate and so wronged by them.’

‘I am calmer, and I lose my temper less often and less dramatically.’

‘The Practice was difficult initially because of my own resistances to it.’

‘I’ve always avoided seeking help for myself. I often feel worse than the patients I prescribe antidepressants for. I can now cope and I feel stronger but I don’t feel I’ve been treated and I now realise I didn’t need treatment: I needed to learn what to do and how to do it.’

Dealing with unpleasant, unwanted thoughts.

These comments illustrate the doctors’ new reactions to thoughts as they started to address the underlying emotion that normally drives worrying thoughts:

‘I now have less ruminations.’

‘As a long-standing ruminator I now realise these thoughts are the source of many anxieties. Thoughts were the main problem for me.’

‘I have learned to deal with obsessional thoughts by not giving time to them.’

General well-being.

The doctors commented on their sense of general well-being and ability to cope:

‘I am less tense and less anxious.’

‘I am now coping with episodes of work overload much better.’

‘I am feeling better generally.’

‘This has given me confidence to pursue the course of action I knew was correct.’

‘There are all-round improvements because of adapting myself to work and other people.’

‘I am happier and more content, optimistic and much less negative.’

DISCUSSION

Varying degrees of stress, anxiety or depression are universal.^{16, 26} Only about half of those thought to be clinically affected by these conditions seek help for them.²⁶ If put into practice, sound medical knowledge and training can be beneficial to doctors’ own health.^{1, 11, 15} This does not seem to be true for stress, anxiety and depression.²² Too little is known about emotional and psychological problems, and treatment for them is inadequate.^{2, 9, 15, 17, 19, 21, 23, 28, 29}

In this study, there was a high level of interest in how to deal with stress, anxiety and depression. Almost one third of respondents had scores on the HADS and SSS that suggested worrying levels of emotional and psychological problems amongst these working GPs. The fact that 152 doctors (68% of respondents) declared an interest in a six-month evening course (90 minute sessions after work on Thursday evenings) to learn how to deal with these conditions, suggests that:

• stress, anxiety and depression are significant problems either amongst their patients or for the GPs themselves, or both
• GPs are not confident in their ability to deal with them and want to learn more
• although they have a strong tendency not to admit that they cannot cope and not to seek help, doctors are willing to attend a course to train and to learn.¹¹

Most doctors tell their patients to seek professional help and to talk about their feelings but do not do so themselves.^{3, 5} They prescribe drugs for their patients that either the doctors will not take themselves or that they take but find ineffective. Of the 15 GPs on the course only one had mentioned psychological difficulties to a colleague and one to a partner and both only reticently. ¹⁶

ADAPTATION PRACTICE

Adaptation Practice strongly discourages self-disclosure, except in private to the Adaptation Practice teacher, which is necessary in order to assess the nature and severity of any problems and to lay the foundations for a rapport. Adaptation Practice sessions involve detailed discussion of moods and feelings as physical sensations and powerful forces that affect behaviour in all human beings. The ethos in Adaptation Practice is for participants to learn from their own experience how they are affected by emotion and how they can change this by containing themselves and not letting the emotion control them. It is not to criticise, judge, blame or condemn. Consequently, without the causes of stigmatisation, there is no prejudice and no stigma; instead there is respect and dignity and a pragmatic attitude to change.¹⁶

Adaptation Practice trains individuals to bear and endure upsetting, disturbing emotion by not expressing it, not suppressing it, not distracting themselves from it and not numbing themselves to it with drugs (alcohol, recreational drugs or prescribed medication). Bearing it this way develops emotional strength and resilience.

The high level of interest, the willingness to attend in groups and the positive results from this study indicate that Adaptation Practice is an acceptable way of teaching doctors how to cope with their own stress, anxiety and depression, that makes sense intellectually and emotionally. This, as well as the pragmatic approach mentioned above, makes Adaptation Practice radically different from other approaches.

GENERAL COMMENTS

Given that those who could not attend asked for an alternative day to attend, gave us reason to assume that the manner in which the study group and the control group were selected – individual availability on a given week night – would not have biased the sampling procedures and it seems reasonable to assume that the two groups did not differ in any meaningful way that would have biased the outcome.

Not surprisingly, there were strong positive correlations between anxiety and depression and between depression and stress on all assessments and between anxiety and stress on all but the first assessment, suggesting a strong association among these parameters of psychological states.

The mean scores for anxiety, depression and stress fell significantly in the participating GPs compared with the control group. The subjective reports from both the medical assessments and the self-assessments support these changes in the study group.

This study begs a number of important questions:

• if doctors are prejudiced and stigmatise mental illness amongst themselves then what are their conscious, or unconscious, attitudes to mental illness in their patients? ^{3, 5, 9, 24}
• if doctors cannot cope with emotional problems themselves then whom are they and their patients to turn to for help? This is not the same as doctors suffering from physical conditions requiring surgery, or medications such as insulin or antibiotics.^{3, 5} Doctors expect, and are expected, to be able to cope with their emotions and, if necessary, that the treatment they give their patients will also work effectively for themselves
• what are doctors to do and what are their patients to do, when doctors succumb to their own moods and feelings?

Adaptation Practice could be integrated in the medical curriculum at undergraduate and postgraduate levels, including Continuing Professional Development (CPD). Not only GPs but all doctors and other healthcare staff (nurses, physiotherapists, occupational therapists, social workers, etc.) could develop emotional resilience – which the GMC have proposed in recent years – and a better understanding of emotional and psychological problems and mental illnesses.

It is hoped that this preliminary study will stimulate and encourage a new way of looking at and investigating emotional and psychological problems and lead to further evaluation of Adaptation Practice.^{29, 30}

With adequate training doctors and psychologists could teach Adaptation Practice.

Introduction

Communicating effectively with patients and families is a vital component of high quality care. Studies have shown that patients feel excellent communication in consultations is vital for instilling confidence in the medical practitioner.^1,2 There is evidence that doctors are not meeting this fundamental need.³

Some consider it an ethical obligation of doctors to balance their training needs against providing optimal care for patients. It is well known that junior trainees have significant level of performance anxiety that translates through to their consultations.⁴

Simulation based training is now an integral part of postgraduate curriculum in training a variety of medical specialties in managing acute scenarios. As an education method it provides a controlled environment in which it is safe to learn from errors,⁵ and improves learner outcomes.⁶ Simulation has been shown to be a valid approximation of true clinical practice.⁷ It therefore allows trainees to reach higher levels of proficiency prior to embarking on real patient encounters.

Current Core Medical Trainees (i.e. junior doctors who have embarked on the first stage of physician training within England) in the London deanery are expected to be able to manage complex communication scenarios effectively prior to entering specialty training. This is demonstrated by requirements set out in the Core Medical Curriculum, as detailed in Box 1. Whilst significant emphasis is placed on communication skills training in basic scenarios at a medical student level, there is very little formal postgraduate communication skills training within this deanery and others.

Box 1: Excerpts from Core Medical Trainee curriculum

This deficit in training led us to conduct a survey exploring Core Trainees’ views regarding communication skills training in the London deanery. Findings from the survey are detailed in Box 2.

Box 2: Results from Core Trainee Survey

Method

We devised a pilot project using simulation to develop trainees’ competencies in advanced communication skills. After application to our local training board, we secured funding to run a number of sessions for core medical trainees within the London area.

The objectives of our pilot project were to provide experience of realistic communication based scenarios in a structured and safe environment to core trainees; provide feedback on trainees’ communication styles and offer suggestions for improvement; improve confidence of trainees in difficult communication situations.

Each session was conducted in an afternoon session and candidates were divided into three groups of three trainees who would remain together for the entire session. We ran four sessions, with a total of 36 trainees. Each group was facilitated by a consultant or a higher trainee in either elderly or palliative care medicine, given our focus on resuscitation/end of life discussions and assessment of capacity. We employed three actors to rotate around each group performing a variety of roles including patients and relatives. With a total of six scenarios, each trainee had the opportunity to participate in at least two scenarios lasting approximately 15 minutes, with feedback thereafter for approximately 10 minutes.

The scenarios employed were based on personal experience of regularly occurring, challenging communication situations encountered in our own clinical practice. We created detailed scripts for the actors as well as corresponding clinical vignettes for the candidates.

The scenarios were:

• End-of-life discussion with a challenging family regarding a patient with end-stage dementia.
• Discussing resuscitation with a family opposed to do not attempt resuscitation (DNAR) regarding an acutely unwell patient with poor functional baseline.
• Discussing resuscitation with a young patient with metastatic cancer undergoing palliative chemotherapy who has little understanding of the terminal nature of the disease.
• Assessing mental capacity regarding discharge planning in a patient with mild to moderate dementia.
• Assessing mental capacity regarding treatment in a patient with moderate learning difficulties.
• Assessing mental capacity in a medically unwell patient with mental health issues who wishes to self discharge from the ward.

Box 3 outlines the session structure.

Box 3: Timetable for the session

Results

Written feedback was obtained from all participants by distributing a post-course evaluation form, with a 100% response rate. A number of areas were assessed via a Likert scale of 1 – 5, with 1 being ‘not at all’ and 5 being ‘very much’. 100% of trainees felt the content was useful and their knowledge/skills had increased. 100% felt more confident after the session and all trainees and facilitators felt this would be beneficial for medical trainees. A full breakdown of results is detailed in Table 1.

Table 1: Results from post-course feedback

The post-course feedback form allowed for free text feedback from participants, with some individual examples given below:

— “Realistic scenarios - good opportunity to experience them and get feedback in a safe environment, good practice of common communication problems”

— “It builds confidence in dealing with these situations and provides basis for building up ”

— “This work dealt with complicated cases and actors were not too easy which I liked. Good and unforgettable”

Discussion

With the European Working Timing Directive and resulting shorter working hours, gaining proficiency in a number of key skill areas is limited due to reduced patient encounters. A recurrent complaint among core medical trainees is the lack of observed clinical encounters that leads to individualised feedback.

Feedback from more experienced speciality practitioners was only one component of our attendees learning experience. They also benefited from personal practise in a non-threatening environment, observation of their colleagues communication styles and finally learning through reflection with their colleagues

This innovation has shown a clear benefit in amplifying the confidence and preparedness of our core medical trainees in approaching these higher level communication scenarios. Future directions include introducing quantitative assessments pre- and post- course to objectively demonstrate improved confidence and performance. Providing the course to trainees in other specialties as well as across the multidisciplinary team would also be beneficial given the universal requirement of healthcare professionals to communicate skilfully.

Poetry is a way of expressing the subjective experiences that spill over the rational mind and it permits spontaneous overflow of subjective feelings. The ability to express oneself through poetry, and share that experience, is one of the unique human experiences that distinguish us from lower biological forms. The strife and struggle of modern men have made them miserable wretches on the face of this beautiful cosmos, and the technological revolution has taken the poetic sense from them; a time old coping mechanism. Those not capable of expressing their own sorrows and joys of everyday life in poetic words could find a surrogate writer in The Gushing Fountain.

In his collection of poetry, Dr Latoo (who is currently working as a Consultant Psychiatrist in United Kingdom) has catered poems for every mood and occasion: love, parting and sorrow, inspiration, rapture, memory, nature, solitude, and contemplation. Some of them are deeply personal and the author is trying to unearth a time capsule he had left in his native country of Kashmir. Dr Latoo appears to be searching for inner truths and making a self exploratory pilgrimage in his collection of poetry. Poetry has the power to describe and dramatize one’s own life, and Dr Latoo has done it well. The themes generally move from childhood to old age, love to grief, sorrow to joyfulness, aggressive nationalism to corrupted politicians, and depression to psychosis. There are pearls of mystical wisdom embedded in the poetry:

“Be choreographed by a great master for our sustenance
Rather than just be a part of random unplanned accident?”

There are wise statements in “Divine Justice”:

“Anything like fatalism shall be a contradiction
Of the Divine justice, free will and Lord’s will.”

All poetries have some hidden messages, and the book as a whole stands for immense moral values. “Woman” stands for women’s rights and dignity. The thoughts about the forgotten orphans are heart touching. “Behold a Man - Judging others” points towards the fallacy of judging other people without correcting oneself. Mental health professionals are particularly prone to this error because they are often professionally bound to assess their clients; we are only supposed to assess others and not judge others. We should not even judge ourselves, but only do self-assessment - God is the only Judge. The author writes about very ordinary humble human beings like the barber, Rupa, Ayesha, Ahmed, Puja etc. “Marriage” highlights the sanctity of wedlock. These poetries reflect the world view of the author. “Hold fast to thy dreams” may be inspired by Langston Hughes (1902 - 1967) and reminded me of my father who liked the verses of Hughes on dreams. “A raven who wants to be a dove” refers to people who pretend to be what they are not - wearing borrowed garments.

There are also poems about the author’s travelling experiences. A century ago, if a poet wrote about airport, he would have been frowned upon by the peer group, but in the 21^st century it is appropriate to write such poetry. “Noisy airport and my mind” illustrates the hustle and bustle of contemporary life and gives the book a modern flavour. “By the Dal Lake” is nostalgic and the author is trying to recapture and share his lost Kashmiri literary Empire with the readers. Born in Kashmir, there is no surprise that the author renders beautiful nature in his poems. One wonders, if William Wordsworth were born in Kashmir, what would have been the content of his writings. Dr Latoo’s dual identity is evident when he writes about Kashmir and London.

In these days of global union through mere technology, poetry may have a serious role in the “international soul-union.” The days of regional poetry are over. Poets like Dr Latoo may be able to contribute to the formation of a healthier global village; poetry penetrates beyond the psychic realm into the spiritual dimension. There is a mission of peace and love in the Gushing Fountain, and the author is not enforcing any strong convictions on the readers. There is a poet-philosopher in the author of the Gushing Fountain.

The author has used rhyming and free verse styles of poetry. Metaphors and similes are appropriately embedded in various situations:

“A smile on our face blooms the gardens of her innocent soul
A tear in our eyes arises from the blood of her bruised heart.” (From the poem, “Mother”)

Lyrical poetries are ravishingly harmonious and there are no repetitions. The thoughts are clear and there is an exotic element in all the poetry. On the whole, all the poems are cerebral and riveting. The works are relevant to the present century and can be appreciated by scholar and casual readers alike. Every poem is an experience to be savoured and memorised. Let these pieces of poetry echo and reverberate not only in the conflict-ridden valleys of Kashmir, but all around the world until they find rest in the minds of the waiting millions.

Psychiatry is going through an identity crisis because the newer medications are not as effective as expected to be and clinicians are turning to different forms of psychotherapy. Poetry/lyric therapy could be another form of psychotherapy that needs attention in the field of soft psychiatry. Dr Latoo’s book could be an inspiration and encouragement in this line of treatment. Hypnotherapists readily recognize that words are like loaded bullets and are highly potent. To an extent, poetry therapy involves the principles of both hetero- and self- hypnotherapy. Primitive and modern religions take advantage of the potentials of different forms of poetry in religious rituals for healing and promoting health.

A study of the mechanism of poetry writing is helpful in developing better conceptual models of creativity and deeper understanding of mental process. Sudden flashes of creative insight and other intuitive leaps, which arise from states of mind through intermediate steps that remain hidden beneath consciousness, and such ultrafast processing involving a concealed intermediate step, is consistent with quantum computations. A poet who enjoys superior mental health is capable of swinging from the unconscious quantum logic to the classical logic of consensus consciousness with an ultrafast speed. In psychotic states, “the quantum gates” do not shut swiftly as in normal mental states and the sufferers get trapped in the quantum logic. The usefulness of poetry therapy in psychotic patients, who get stuck in the quantum logic of the unconscious mind back to the classical logic of ordinary consciousness, needs further analytical studies. The primary aetiology of psychotic disorders may be biological, but secondary symptoms are quantum-linked and the new generation of psychotherapists have to learn the quantum meta-languages to communicate with psychotic and depressed patients. Poetry is such a source of quantum meta-language.

Poetry therapy promotes abstract thinking and develops imaginative powers. It is also a means of relieving and revealing innermost sentiments; it helps to ventilate overpowering emotions and hidden tensions. It is a form of self-expression and aids to build greater self-esteem; useful in strengthening interpersonal skills and communication skills. It would be valuable in repairing the assault of psychosis on the personalities of the sufferers. Quoting from my own memory lane, I became interested in poetry therapy when I comprehended the core problem of a patient who wrote:

“Moon, you shine at the centre of the sky,
Catching attention from all over the world,
Don’t you know that I am lonely?”

Poetry is of the heart and imagination whereas science is about reason and logic and may be grounded on contradictory principles. If science is about objectivity, poetry is essentially about subjectivity and to blend those human experiences harmoniously is a hard task; Dr Latoo has successfully achieved this goal. A man of science, when he writes poetry, has to liberate himself from the shackles of rationalism so that he can be a wholly free human: to be a poet one has to be a natural human being. To quote from Jean-Jacques Rousseau: “Man is born free and everywhere he is in chains.” Let us hope that the Gushing Fountain will have a part two and even more!

All sciences end as poetry!

Introduction

Population studies in Norway are showing that taking part of (creative) or receiving (receptive) cultural activities, i.e. arts, is associated with good health and good satisfaction with life among other things,¹. Cultural activities have the potential to affect individuals beneficially: physiologically, biologically and emotionally, and several studies show that cultural activities can stimulate emotions and behaviors that make life easier, ^2–5. Cultural activities can enrich and enhance our memory, stimulate connections among brain networks and enable us to accelerate learning and differentiate feelings of meaning and context,^6,7 Cultural activities have also improved both physical health, social function and vitality among health care staff,⁸.

In an analysis of data from a large longitudinal cohort-study of a working population (called the SLOSH study = Swedish longitudinal occupational survey of health), some interesting associations were revealed between access to cultural activities in the workplace and health. Participants reporting many cultural activities at work had a more favorable improvement of emotional exhaustion during a follow-up period of two years than those whose workplaces did not offer these amenities,⁹. Other studies in which cultural activities have been offered to patients on long-term sick leave confirm that cultural activities have beneficial effects on both self-confidence and pain,^10,11.

In a new approach, an artistic leadership program, called “Shibboleth”, affects not only managers included in the study, but also their employees (who did not participate in the artistic program). This one year art-based program showed statistically significantly more improvement of mental health, covert coping and performance-based self-esteem than the comparison group (who participated in an ordinary leadership program). They also experienced less winter/fall deterioration in the serum concentration of DHEA-S (dehydroepiandrostereone-sulfate), a regenerative/anabolic hormone,¹².

Studies on singers, both amateur and professional singers and choir singers, show positive effects on different biological markers such as oxytocin and testosterone,^13–15. On the basis of results from another Swedish project, ”Prescribed Culture”, which aimed to evaluate the effects of prescribed cultural experiences in the treatment of patients on long term sick leave, it was claimed that cultural experiences have their best effects when used in health promotion and prevention , rather than when the individual is already sick,¹⁶. Multimodal stimulation seems to have particularly strong effects. For instance, concomitant visual and auditory stimulation gives rise to stronger activation of “visual” and “auditory” parts of the brain than separate visual and auditory stimulation,¹⁷.

A mixture of different cultural activities seems to optimize influence on the limbic system since a broader emotional perception is activated,⁷. Cultural activities offered to participants that would not have chosen them spontaneously, could enhance already existing pathways in the brain enabling deeper cognitive behavioral change,^17–20.

Despite this knowledge regarding the potential benefit of cultural activities in different contexts on both individuals and groups there is still a missing accessible practical functioning link between producers of culture and different groups of practitioners within health-care.

Burnout is characterized by emotional exhaustion, detachment from work and decreased effectiveness at work. This can develop in situations with excessive workload and insufficient resources as well as lack of control and support,²¹. If the process of burnout is a reaction to long-term stress, without enough recovery, this can lead to the more severe exhaustion syndrome,²². Symptoms include fatigue, impaired emotional regulation, cognitive problems and sleeping disorders. Most of these patients have an increased sensitivity for stress even after recovery,²². In recent years, Swedish rates of sick leave due to minor psychiatric morbidity , and burnout symptoms, have increased dramatically,^23-24 . Complaints usually include physical, emotional and cognitive exhaustion, which in most cases appear to be related to chronic stress without restitution,^25–28. Today many women in Sweden have stress related symptoms, and some are diagnosed with exhaustion syndrome. If these women are detected at an early stage, the prognosis is good,²².

Alexithymia, (the difficulty to differentiate your own and others feelings), can be a silent but severe problem for persons suffering from this personality trait. Grabe et al.,²⁹ conducted a study in which the questionnaire TAS-20 was used for the assessment of alexithymia. Medical examination was also performed. In this study alexithymia was related to hypertension and arteriosclerotic plaques. Alexithymic personality traits may increase the risk for CVD (cardio vascular disease).

The rationale behind choosing symptoms of exhaustion, SOC and alexithymia as main outcome variables was the intention to examine whether cultural activities in this form can change pattern of thought, feelings and behavior in participants with burnout symptoms. If cultural activities prove effective for this participant group, they could have considerable benefits both financially in terms of reducing sick leave and health care consumption and of reduced individual suffering.

Aim

The aim of the study was to assess to what extent symptoms of exhaustion, sense of coherence, alexithymia and self-rated health among women with burnout symptoms can be beneficially influenced by cultural activities organized in health care centers.

Method

Participants

Four health care centers in Stockholm County hosted the cultural activities. Medical doctors and social workers distributed information about the study to women diagnosed with exhaustion disorder or exhaustion symptoms. Women, native and foreign born, with burnout/exhaustion symptoms (fatigue syndrome or stress-related fatigue) who were curious about new clinical approaches were asked by the doctor to participate in the study and screened for inclusion and exclusion criteria. Participants (women age > 18) with burnout/exhaustion symptoms such as strong fatigue, cognitive problems, and sleep disturbances were enrolled. There was an inclusion criterion with a score above 2 on the KEDS scale. The diagnosis was made by the doctor.

Exclusion criteria: Participants with difficulty in speaking and understanding Swedish, participants with alcohol or drug abuse problems, or/and participants with severe depression or psychiatric borderline. Also excluded were participants with severe somatic diseases (such as serious angina pectoris or participants who had had a stroke). Randomization was done using a 3:1 allocation to intervention or control groups.

The randomization was done using a stratified randomization by center. Randomization was done by the statistician. The group allocations were sent in individual envelopes which were distributed to centers and blinded to the site staff. Envelopes were further drawn in a consecutive order with regard to recruitment of subjects at each of the four health care centers. Thirty-six participants were allocated to the intervention group (nine patients in each group) and twelve participants to the control group. The standard care that each participant received included physiotherapy such as relaxation and physical light training.

All randomized participants gave their written consent to participation in the study. Data were collected over a period of 6 months. The project includes evaluation of six different culture activities. In the selection of the health care centers socio- economic diversity and employment status were considered. We used regularly occurring structured cultural activities in cooperation with culture producers, i.e. actors, musicians, dance teachers. The Regional Research Ethics Committee of Uppsala has approved the study (Dnr. 2012/359).

The culture palette: six different cultural packages

The following cultural activities were included in the study; five of them have previously been presented in the literature with good evidence on other groups of patients. One package (the musical show), which has not been presented previously on groups of patients, was chosen as it represents a combination of different modalities of activities at the same time. The active mechanism of all six cultural activities was to stimulate different modalities of the senses such as the visual, motor, verbal, auditory, emotional and sensational, according to Downing’s levels of perception, ³⁰. All participants were offered six cultural packages:

1. Interactive theater: An experienced actor introduced poetical lyrics and poems and then initiated and participated in discussions with the participants regarding thoughts, emotions, and experiences evoked by the texts.

2. Movie: After showing a movie, a film expert initiated discussions among the participants about experiences and thoughts evoked by the movie.

3. Vocal improvisation and drawing: After participating in a vocal improvisation session with an experienced performance artist and pianist, the participants painted a picture representing emotions, thoughts and pictures evoked during the improvisation

4. Exploring Dance: The participants improvised dance movements under the guidance of a dance movement pedagogue/music teacher. The dance movements were staged according to the situation in the room and with focus on bodily awareness. Afterwards the group discussed their experiences during the dance session.

5. Mindfulness and contemplation: The participants contemplated and practiced mindfulness together with an experienced mindfulness instructor. Attention was on breathing and body awareness. Thoughts, feelings, images and sensations were in focus and experiences were reflected in the group after the contemplation.

6. Musical show: after a musical show including music, song and dance focusing on bodily awareness, the participants discussed thoughts regarding the body with the actor.

Every session in each one of the six different cultural packages lasted for 90 minutes.

Evaluations

Three different standardized scales, and also self-rated health and self-figure drawing, were used.

KEDS - Karolinska Exhaustion Disorder Scale,³¹. Questions about concentration, memory, physical fatigue, endurance, recovery, sleep, hypersensitivity to sensory input, experience requirements and irritation and anger. Higher scores indicate worse disease activity/performance.

SOC - Sense of coherence,³². A key factor in being able to feel well-being and health. This factor has been shown to be crucial to helping individuals mobilize their self-healing systems. Higher scores indicate better performance.

TAS - Toronto Alexithymia Scale,³³. Estimation of ability to recognize and interpret feelings in oneself and others. TAS contains three subscales; the inability to handle emotions due to emotions being poorly recognized (difficulty recognizing), the inability to describe feelings (difficulty describing), and mismatch between coping behavioral emotions (externally oriented thinking). This study used the full scale score, i.e. the summary of the three sub scores. Higher scores indicate worse performance.

Self-rated health (SRH) consists of a single item measure.

Procedures/implementation

The four different health care centers presented each activity on two consecutive occasions. After two weeks of one program, there was a new program on two consecutive occasions etc. Each participant has thus been offered 12 cultural packages during a three-month period, i.e. once a week. During the monitoring period between month 3 and month 6, there was no culture activity offered. The control group was monitored in parallel during the entire period monthly at 0, 3 and 6 months.

The participants evaluated the project individually with questionnaires prior to the sessions, after completion of the intervention at month 3, and at follow-up after 3 months i.e. month 6 (both intervention and control group). In-depth interviews with both participants and producers of culture, i.e. representatives for the various cultural activities and health care staff were conducted during the monitoring period (this data is not presented in this article).

Data analysis

The primary outcome efficacy end point/measure was mean change from baseline to three and six months in the KEDS summary score. The secondary outcome measures were mean change from baseline in the SOC summary score, the TAS summary score and the self-rated health, from baseline to three to six months.

All data were presented using descriptive statistics, i.e. mean and standard deviation for continuous variables and frequency and percentage for categorical variables. For all main outcome variables, data were further analyzed using the Linear Mixed Models, including group (intervention and control) and time (baseline, 3 month and 6 months) as fixed factors. Results were presented as marginal means, the estimated mean value adjusted for the factors included in the analyses model. The difference between intervention and control group with regard to the estimated and adjusted means are defined as the effect size, i.e. the mean difference between the intervention groups for each of the primary and secondary outcomes measures divided by the standard deviation. All tests were two-tailed and p<0.05 was regarded as statistically significant.

IBM SPSS version 22 was used for statistical calculations. In the presentation of the results from the statistical analyses, the measured effect size was used and derived as the absolute difference between active intervention and controls with regard to each of the outcome variables/endpoints used,³⁴.

Results

There were 55 participants screened in this study, however seven participants who met the exclusion criteria of too serious/severe depression was not included into the study. In total, there were 48 participants randomized into the study, age between 41 and 70 years, mean 53.8 (SD= 8.15).

The results showed that for KEDS (exhaustion) there was a statistically significant two-way interaction (P<0.001) with a decreased mean from baseline to three and six month respectively in the intervention group whereas in the control group there was no change. The mean treatment effect size, i.e. the mean difference between groups, in favor of the intervention group was 9.9 (SE=3.0) at 6 months. See table 1 and figure 1a.

There was no difference in mean SOC - Sense of Coherence – scores between the groups. See figure 1b. Further, the results revealed a statistically significantly more pronounced decrease in the intervention group compared to the control group in the alexithymia items of total score, (P=0.007, mean treatment effect size=5.4 (SE=2.2) at 6 months in favor of the intervention group), difficulty describing (P=0.004, 2.4 (0.9)), difficulty identifying (P=0.051, 2.6 (1.3)) but not for external orientation (P=0.334 0.5 (0.8)). See table 1 and figure 1c. There was also a statistically significant difference between the groups with regard to self-rated health (P<0.001) where mean scores increased over time in the intervention group but decreased in the control group. See figure 1d.

Table 1

KEDS (Karolinska Exhaustion Disorder Scale) and TAS (Toronto Alexithymia Scale) and SRH (self-rated health) at baseline, month 3 and month 6.

Figure 1a

Marginal means and 95 % confidence intervals for the KEDS (exhaustion) scale by group and time. Results were based on the linear mixed models analysis adjusted for baseline.

Figure 1b

Marginal means and 95 % confidence intervals for the sense of coherence (SOC) scale by group and time. Results were based on the linear mixed models analysis adjusted for baseline.

Figure 1c

Marginal means and 95 % confidence intervals for the Toronto Alexithymia Scale (TAS) by group and time. Results were based on the linear mixed models analysis adjusted for baseline.

Figure 1d

Marginal means and 95 % confidence intervals for the self-rated health scale (SRH) by group and time. Results were based on the linear mixed models analysis adjusted for baseline.

Discussion

The results show that the different exhaustion factors measured by means of KEDS (Karolinska Exhaustion Disorder Scale) decreased in the intervention group compared to the control group. With regard to the total score of TAS (Toronto Alexithymic Scale) there was a statistically significant decrease in the intervention group compared to the controls, i.e. the participants started to improve their differentiation of feelings and emotions after three months with cultural activities. The same pattern was seen with regard to self-rated health, which improved in the intervention group. However, there was no significant difference between the groups with regard to the development of sense of coherence.

It seems that the different cultural activities have helped the participants become more aware of their feelings and sensations; to describe and to identify feelings. It is not easy to explain the positive results based on one clear paradigm. It is likely a mixture of psychological, neurological and social factors or changes that interact in a complex manner.

Previous studies have discussed the theory of the emotional brain - cultural modalities can “surprise” the cognitive brain unconsciously. LeDoux,²⁰ discusses the upper/slower and the lower/faster pathway in the brain. Emotionally loaded visual and auditory stimuli are transmitted on both types of pathways. Music impulses are for example evoking activities in the emotional brain much more rapidly than in the cognitive brain. However, impulses spread secondarily from the emotional to the cognitive brain. This can trigger the participants awareness of different emotions and may start a process of differentiation, possibly initiating a change of life course. By using different cultural activities, that the participants normally would not try, the differentiation process may be amplified. This suggests that cultural activities can surpass automated thinking and create new "pathways '' with changes in behavior and increased well-being.

In other studies we have observed that a mixture of different cultural activities can increase the amount of stimuli affecting a broader network of emotional correlates, ^14,16,18 . A very interesting long-term decrease in alexithymia, ³⁵ was associated with lowered blood pressure and a decrease in sick leave. By allowing the participants to try new cultural stimuli we may have helped the participants change old habits. A hypothesis is that this may also have contributed to the observed decrease in exhaustion.

Why did we not see any increase in the sense of coherence in the intervention group? It is very difficult to change patterns of thought and behavior although we can argue that the participants in the control group also found a new sense of coherence just by being invited to answer questions about themselves and being focused upon. Many of the participants did not go out spontaneously because of their fear of socializing. Some of them described their situation as black or white, not wanting to change routines that made them feel less safe,³⁶.

Despite the fact that the health care staff did not participate in the culture palette, they were also affected by the cultural activities ³⁶. This may be a mirroring effect, or emotional contagiousness on health care staff, which may also play a role between the participants and their staff. The passive cultural activation phenomenon has previously been presented in the literature,³⁷ and there seem to be possible well-being effects of just watching dance or visiting a theatre, ^6,10 which may explain the positive health care staff response to the culture palette. The results of this study underscore the importance of regarding the health care system as a whole, where patients, health care staff and visiting relatives affect each other. Empathic behaviors contaminate in all directions and we need to be aware of how we project ourselves when working in a caring context.

Modified “culture palettes” and “train the trainer” programs and workshops are now in use in Sweden, inspiring cultural producers to further develop the health care system and a cultural health box - a box with six different books about cultural activities and the research behind this - have been distributed to all health care centers in Sweden, ³⁸.

Developing and adapting cultural programs to fit other kind of groups of participants could cross-fertilize health care thru culture production.

Limitations

This study was limited to women with exhaustion symptoms and therefore further research on implementation of cultural activities within different groups of participants and sexes is needed before we can generalize the results to other groups of participants. Another limitation is that we did not control for outside activities, such as doing walks in nature. In this study we only presented indoor cultural activities.

Conclusion

The cultural activities in this study made exhausted women understand what makes them vital, confirmed, curious, healthy and creative. The study also illustrated that there could be synergistic effects when bringing cultural activities into the health care system³⁶.

When our beautiful mind feels all muddled up

   With a tendency to draw bizarre conclusions;

When the difference between a reality 

   And an imagination becomes all blurred. 

When one hears people, hears things, hears a god,

     That can't be explained. When one sees images, 

Sees aliens, sees prophets, that can't be accounted for. 

       When one smells, tastes, feels things that can't be untangled.

When one worries about other's intentions,

   Their innocent words, their innocent actions; 

When one is preoccupied with a belief 

   That they are not driving their body or their mind.

When one holds an inflated view

    Of being able to communicate with aliens, 

Of possessing powers to heal, 

   Of being a royal, of being able to control the weather.

When the energy of youth is replaced by 

    A lack of motivation, an idleness, an apathy.

When one ignores daily personnel cleanliness, 

   Daily chores, daily social interactions.

When you are in this perplexed state of mind 

    Remember it is an illness called psychosis, 

 Not a curse or black magic or witchcraft.

    Remember, treatment is available, from the experts who care.