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Regular Article | September 01, 2001

Medical Students Attend to Case-Based Psychosocial Information: A Prospective Study

Patricia B. Mullan, Ph.D.; Arnold Werner, M.D.; Elizabeth A. Seagull, Ph.D.

Academic Psychiatry 2001;25:162-166. 10.1176/appi.ap.25.3.162

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Case-Based InformationTeaching MethodsProblem-Based Learning

Dr. Mullan is an Associate Professor in the Office of Medical Education Research and Development at Michigan State University's College of Human Medicine. Dr. Werner is a Professor in the Department of Psychiatry, and Dr. Seagull is a Professor in the Department of Pediatrics and Human Development at Michigan State University's College of Human Medicine. Address reprint requests to Arnold Werner, MD, Michigan State University, Department of Psychiatry, West Fee, East Lansing, MI 48824-1316. e-mail: werner@msu.edu

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Abstract

The authors describe a prospective study of medical students' identification of the presence and importance of psychosocial information. They investigated the development of these skills over time in two successive academic cohorts, exploring the potential relationship of students' performance on a cue-identification task to their self-reported interest in patients' psychosocial concerns and to their academic performance in medical school. The absolute number of psychosocial cues students identified varied with the students' training, but the importance that the students attributed to psychosocial cues increased over the time of their training. Their recognition of psychosocial cues as important correlated with academic performance in advanced clerkships and election to Alpha Omega Alpha. The results suggest that students are able to attend to psychosocial issues while performing well on traditional biomedical education measures.

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Medical education reform efforts consistently urge medical schools to better prepare students to recognize and address the psychosocial needs of patients (1). Such proposals can, however, elicit concerns from medical students and faculty that such change might distract or impede students' acquisition of knowledge and skills in traditional biomedical areas. Good's study documented such fears in students and faculty who participated in a medical education program intended to develop caring physicians (2). The professional socialization literature has provided insight into how biomedically focused education narrows the "clinical gaze" of medical students (3), including students who began their training sympathetic to the premise that their responsibilities would include addressing patients' psychosocial needs (4,5).

The intention of this prospective study was to examine medical students' ability to recognize, over time and curriculum exposure, the presence and importance of psychosocial information in descriptions of patient cases. We investigated students' performance in two successive academic cohorts, exploring the relationship of this ability to students' gender, minority status, their interest in patients' psychosocial concerns, and selected measures of their academic performance. In contrast to previous studies, which examined students' interests or beliefs, this study called on students to perform an applied task demonstrating their recognition of psychosocial cues and their importance.

METHODS

Students admitted in 1992 and 1993 identified cues present in written patient cases. Five cases were developed for this assessment, one of which was used as an example in the instructions provided to the students. The sample vignette and a set of cues are contained in a copy of the written instructions for the cue-recognition task in Appendix 1. The brevity of the cases and the simplicity of the cue-identification task were designed to minimize the effort and time required of students to work on the task. The students were told that the purpose of the exercise was to study how they identify cues in patient cases over time. At each administration, students completed two of the test cases, which were controlled for gender and age characteristics of patients. The instructions and the case content avoided suggesting that attention to either biomedical or psychosocial dimensions was expected; the set of cues provided in the example for students included both psychosocial and biomedical cues.

Students were asked to identify up to 10 cues presented in the patient cases and mark with an asterisk the cues that they considered most important. Students completed the assessment three times: during orientation to medical school; at the first class session of the Human Development and Behavior course, which is scheduled during the third trimester of Year I; and immediately before the Disorders of Development and Behavior Domain, which is the second segment of the Problem-Based Learning (PBL) Year II sequence. The PBL curriculum encompasses the biologic science and psychosocial content typically taught in separate courses in traditional curricula. In this medical school, the task-administration's timing (the first session of a course) represented the time in which students routinely completed structured evaluations of the previous course and associated examinations.

The set of stimulus cases included two adult and two child patient cases. Half the entry class (Group I) received the pediatric A-1 case and the adult A-2 case. The remaining students (Group II) received the pediatric B-1 case and the adult B-2 case. At the second assessment, 8 months later, students were given the cases they had not seen previously. At the third assessment, 12 months after the first assessment, students received the cases they had first completed during orientation.

An instrument administered at orientation was used to elicit students' interest in psychosocial concerns in patient care (6). Academic performance included students' course grades on their first-year courses, honors performance in their second-year PBL curriculum, honors performance in required advanced clerkships, and election to Alpha Omega Alpha (AOA).

In the construction of the cases, the authors reviewed the distribution of information contained in the cases that constituted cues representing predominantly psychosocial or traditional biomedical information. In distinguishing between psychosocial and biomedical cues, the authors applied the principles they had developed for construction of the 80 cases that form the basis of the PBL curriculum. Information about personal status, relationships with others, and emotional state are categorized as psychosocial. Descriptors that point to organ systems, bodily functions, and pathophysiologic processes are categorized as biomedical. Examples of predominantly psychosocial cues include items such as: mother died 2 weeks ago; news coverage of proposed layoffs at work; father often away. Examples of case-based information representing predominantly biomedical cues include items such as: gastric pain after eating; headache on the left side; allergies in early spring. The percentage of cues students identified that represented psychosocial cues and the percentage of cues that students asterisked as most significant cues among the 10 cues they identified were then determined.

We used analysis of variance to examine changes over time in the percentage of psychosocial cues identified as a) the total and b) important cues. Potential differences between mean responses of male and female medical students were examined with t-tests. We calculated the correlation of the proportion of cues students marked as important with their rating of the need for physicians to address patients' psychosocial concerns and their academic performance by means of Pearson product-moment correlation coefficients.

RESULTS

The patient cases were initially administered to 221 medical students (110 from the class of 1997, and 111 from the class of 1998). Of these students, 101 (45.7%) were women, and 40 (18%) were underrepresented minority students. Continuous data from the three administrations of the cases were available for 184 (83.4%) of the initial 221 students. Students omitted from the cumulative data set included those affected by course waiver, academic deceleration, and absences. We elicited data from 210 students at the second case administration and 184 students at the third administration.

Cues Identified in Patient Cases

In the initial task administration, the mean number of psychosocial cues included in the 10 cues that students identified was 4.3 in the pediatric case and 2.9 in the adult case. Of the cues asterisked as most important in the case, a mean of 27% in the pediatric case and 29% in the adult case were psychosocial.

At the second administration, the mean number of psychosocial cues identified was 2.5 for the pediatric case and 3 for the adult case. Of those asterisked as most important, a mean of 19% in the pediatric case and 26% in the adult case were psychosocial.

At the final administration, the mean number of cues categorized as psychosocial was 3.2 for the pediatric case and 2.6 for the adult case. Of those identified as most important, a mean of 42% in the pediatric case and 42% in the adult case were psychosocial. The number of items did not change at a statistically significant level over the three administrations of the cases, but the proportion of those characterized as important increased (P=0.03). The description of cues identified in patient cases is summarized in Table 1.

Cues Identified as a Function of Student Characteristics

At the first and second administration, women identified more psychosocial cues (P=0.03), but men more often characterized psychosocial cues among those identified as most important (P=0.04). An interaction of gender of the student with the gender of the patient emerged in which the students were somewhat more likely (but not at a statistically significant level) to identify psychosocial cues as most important in cases in which the student's gender did not match the gender of the patient. Students' interest in patients' psychosocial concerns (6) was correlated with the proportion of cues identified as most important at the initial (P=0.03) and final administration (P=0.04). There were no significant trends from the analysis of cue identification that were associated with the students' minority status.

Correlates with Academic Performance Measures

We used the final administration of the cue-identification exercise to explore relationships to academic performance. Of the pre-clinical academic performance measures, the proportion of psychosocial cues identified as important correlated only with honors performance in the PBL curriculum, albeit not at a statistically significant level (P=0.07). Of the clinical academic performance measures, the proportion of psychosocial cues identified as most important correlated with honors performance in the advanced medicine (P=0.04) and surgery clerkships (P=0.04). Students who were elected to AOA characterized more of the psychosocial cues as important (P=0.03).

DISCUSSION

The curriculum at the study institution has reflected the faculty's efforts to portray the importance of psychosocial science in medical education (7,8). But such educational intentions might well be insufficient to sustain this view in students, given the pervasive cultural model that limits consideration of psychosocial factors in the understanding of disease (9). Another constraint on students' development includes the overwhelming scope of the content to be mastered, which encourages students to limit the responsibility they see for attending to psychosocial concerns (10).

Limitations of this study include its dependence on students' responses obtained from a single medical school and students' written responses to paper-and-pencil depictions of patient cases. The study's design included elements intended to avoid practice effects or communicating to students that the task called their attention to the psychosocial aspects of the case. These efforts might have been insufficient, particularly in a curriculum in which attention to psychosocial concerns is pervasive. A further limitation of the study might exist in the lack of independence among the outcome measures of academic performance and psychosocial cue-recognition ability. Although the election to AOA and honors within the school's advanced clerkships emphasize academic achievement on objective performance measures, the criteria include assessment of the candidate's behavior. Despite these constraints, this prospective study was able to demonstrate that measures of overall high academic performance correlate with the ability to identify psychosocial cues, as measured by students' performance on this task.

Our study's gender-related findings, in which women tended to identify more psychosocial cues as present, whereas men tended to identify a higher proportion of the cues they did recognize as important in the cases, can be considered to elaborate existing gender-related research on the physician—patient relationship (4,5,11). Our study's finding also suggests that these outcomes might reflect women's readiness to perceive themselves as more attuned to the likely presence of psychosocial concerns and then to look for and report them as present, whereas men may more likely be struck with the importance of the psychosocial information that comes to their attention.

In our prospective study, the absolute number of psychosocial cues students identified varied over their training, but the significance that students attached to these cues increased. Skill in recognizing psychosocial concerns as a priority corresponded to subsequent measures of students' successful performance during the clinical training. The finding that this ability occurred to a high degree among students who earned honors in demanding advanced clinical clerkships and received AOA awards suggests that students who learn traditional biomedical material well also enhance their acquisition of skills focusing on recognition and understanding of psychosocial issues. The study suggests that students who perform well on traditional measures sustain a comprehensive clinical vision.

ACKNOWLEDGMENTS

A preliminary version of this article was presented at the meeting of the American Educational Research Association; April 19—23, 1999, in Montreal, Canada.

TABLE 1. Psychosocial cues identified by medical students in patient case descriptions^a

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References

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