Summary of thesis
Complete mental health exists of the absence of psychological distress and the presence of positive feelings and positive functioning (‘positive mental health’). Psychological distress is prevalent in medical students, but there is little knowledge about positive mental health. High levels of psychological distress and languishing positive mental health are related to worse self-reported functioning and lower self-reported empathy of medical clerkship students. Previous studies showed that mindfulness-based stress reduction (MBSR) decreased distress in medical students, but response rates were modest, follow-up was short and studies in medical clerkship students were underrepresented.
The current thesis examined three main topics:
1. Mental health of medical clerkship students; We assessed prevalence rates and predictors of both psychological distress and positive mental health.
2. Effects of MBSR on mental health of medical clerkship students; We used quantitative and qualitative methods to examine the long-term effects of an MBSR training integrated in the core curriculum.
3. Effects of MBSR on medical clerkship student empathy. We explored the feasibility of using a simulated patient-reported instrument to assess physician empathy and used it to examine effectiveness of MBSR in enhancing student empathy.
1. Mental health of medical clerkship students
In chapter 2 we examined the prevalence of psychological distress and positive mental health and their possible predictors in all 454 fourth-year medical students of the Radboud University Medical Center in their first year of clinical clerkships. Of those eligible, 406 (89%) students completed the assessment, 86 (21%) of whom reported clinical levels of distress. We found a flourishing mental health in 159 (41%) students, meaning that they experienced feelings such as happiness and interest in life and reported positive psychological and social functioning such as selfacceptance and rewarding relationships. As hypothesized, psychological distress and positive mental health did not appear to be two ends of the same continuum: Students without psychological distress did not necessarily have a flourishing positive mental health and vice versa. Out of a number of possible contributing factors, psychological distress appeared to be most related to less ‘acting with awareness’ and more ‘worrying’. Positive mental health, on the other hand, was strongly related to a lack of ‘problem avoidance’ and ‘emotional irresponsibility’ (the feeling that human suffering including your own is beyond your control). Although Summary and general discussion | 139 8 no conclusion on causality can be drawn, this study supports the idea that selfawareness and active, nonavoidant coping strategies are related to lower distress and higher positive mental health. Supporting the development of these skills might contribute to student well-being.
2. Effects of MBSR on mental health of medical clerkship students
As previous studies on MBSR in medical students suffered from a low response rate and offered MBSR as elective, their results could have been distorted by selection bias. Students refusing participation in a study assessing the effect of MBSR could either be those less distressed and more mindful or those more distressed and less mindful. We performed a preliminary study (chapter 3) to examine the characteristics of students willing to participate in a training in terms of demographic information, levels of psychological distress, personality traits and mindfulness skills. Of 179 students included in the study, 97 (53%) indicated they would be interested in participating in a training. Interested students reported significantly higher levels of psychological distress and neuroticism than non-interested students. Subsequently, we compared the 167 (72%) participants in our randomized-controlled trial with 41 non-participants. Again, the participants reported significantly higher levels of psychological distress, worrying and problem avoidance and lower levels of mindfulness skills. Taken together, these results showed that by offering an MBSR training we probably do reach students who can benefit most of it, namely those with the highest distress levels and the lowest mindfulness skills.
In chapter 4 we discussed the results of a cluster-randomized controlled trial investigating the effects of MBSR training on psychological distress and positive mental health of medical clerkship students over the entire duration of their core clerkships. Of the 232 eligible fourth-year students at the beginning of their clerkships, 167 (72%) were randomized in their clerkship cohort to either clerkships as usual (n=83) or clerkships with addition of MBSR training (n=84). The students in the MBSR group reported a small statistically significant reduction of psychological distress (Cohen’s d=0.20) and a moderate statistically significant improvement of positive mental health (Cohen’s d=0.44) throughout the 20 months of clerkships. They reported a reduction in dysfunctional cognitions (Cohen’s d=0.18) and an increase of mindfulness skills (Cohen’s d=0.35) and life satisfaction (Cohen’s d=0.51).
In addition to the randomized controlled trial, we conducted a qualitative study by interviewing 16 students two years after the training about the nature and effects of their current mindfulness practice (if present). We applied purposive sampling based on gender, clerkship group and satisfaction with the course, attempting to maximize diversity of the reported experiences. Chapter 5 summarizes the results of 140 | Chapter 8 8 the constant comparative analysis of the transcribed interviews. The 16 interviews resulted in six main themes related to the nature and effects of students longterm mindfulness practice; (1) the ‘unchanged lifestyle’ reported by the students that discontinued practice; (2) understanding and intention as ‘pre-conditions’ for developing long-term practice; (3) ‘attention regulation and awareness’ during daily activities as core elements of students’ long-term mindfulness practice; (4) practice sometimes resulted in ‘changed ways of coping’ such as taking a pause, reflecting and recognizing automatic behavioral patterns, making room for a conscious response. Students described both conscious internal responses such as taking distance (decentering) from negative thoughts, as well as external responses such as changing behavior towards a clerkship supervisor or patient; (5) ‘quality of life increased’ by enhanced enjoyment of daily activities, improved work-life balance and sometimes even different career choices and; (6) students reported practical, personal and professional ‘barriers and facilitators’ of maintaining mindfulness practice. Overall, changes in attitude (e.g. non-judgment, compassion) seemed less present than changes in attention regulation.
3. Effects of MBSR on medical clerkship student empathy
In addition to using self-report empathy measures, we wanted to explore the effects of MBSR on medical clerkship student empathy as reported by patients after a simulated consultation. As the only patient-rated measure with evidence of reliability and validity was not available in Dutch, we translated it and conducted a preliminary investigation of its psychometric properties (chapter 6). We distributed this 10-item patient-rated Consultation and Relational Empathy Measure (CARE Measure) among patients of 19 general practitioners in 5 primary care centers and compared it to seven items of the QUality trOugh The patient’s Eyes (QUOTE) questionnaire assessing ‘affective performance’ of the physician. Analyses of the 655 questionnaires that were returned showed high internal reliability of the CARE Measure (Cronbach’s alpha 0.974) and a modest positive correlation (r=0.34) with the QUOTE confirming convergent validity.
Chapter 7 describes the exploratory secondary outcome measure of our randomized controlled trial comparing the effects of clerkships as usual (CAU) to clerkships with additional MBSR on simulated patient-rated empathy of medical clerkships students. Of 167 participating students, at least one valid CARE Measure score could be obtained from 75 CAU students and 71 MBSR students. Empathy increase in the MBSR group did not significantly differ from the increase in the CAU group (Cohen’s d=0.19). However, baseline psychological distress moderated the effect of MBSR on student empathy. In students with pathological levels of psychological distress at baseline, simulated patient-reported empathy increased significantly in the MBSR group compared to a decrease in the control group (Cohen’s d=0.71).
van Dijk, I., Lucassen, P., van Weel, C., & Speckens, A. (2017). A cross-sectional examination of psychological distress, positive mental health and their predictors in medical students in their clinical clerkships.
van Dijk, I., Lucassen, P., Akkermans, R., van Engelen, B., van Weel, C., & Speckens, A. (2017). Effects of Mindfulness-Based Stress Reduction on the mental health of clinical clerkship students: A cluster randomized controlled trial.
van Dijk, I., Scholten, N., Lenferink, M., Lucassen, P., Mercer, S., van Weel, C., Hartman, T., & Speckens, A. (2017). Reliability and validity of the Dutch version of the consultation and relational empathy measure in primary care.