Target-D: a stratified individually randomized controlled trial of the diamond clinical prediction tool to triage and target treatment for depressive symptoms in general practice: study protocol for a randomized controlled trial.

BackgroundDepression is a highly prevalent and costly disorder. Effective treatments are available but are not always delivered to the right person at the right time, with both under- and over-treatment a problem. Up to half the patients presenting to general practice report symptoms of depression, but general practitioners have no systematic way of efficiently identifying level of need and allocating treatment accordingly. Therefore, our team developed a new clinical prediction tool (CPT) to assist with this task. The CPT predicts depressive symptom severity in three months' time and based on these scores classifies individuals into three groups (minimal/mild, moderate, severe), then provides a matched treatment recommendation. This study aims to test whether using the CPT reduces depressive symptoms at three months compared with usual care.MethodsThe Target-D study is an individually randomized controlled trial. Participants will be 1320 general practice patients with depressive symptoms who will be approached in the practice waiting room by a research assistant and invited to complete eligibility screening on an iPad. Eligible patients will provide informed consent and complete the CPT on a purpose-built website. A computer-generated allocation sequence stratified by practice and depressive symptom severity group, will randomly assign participants to intervention (treatment recommendation matched to predicted depressive symptom severity group) or comparison (usual care plus Target-D attention control) arms. Follow-up assessments will be completed online at three and 12 months. The primary outcome is depressive symptom severity at three months. Secondary outcomes include anxiety, mental health self-efficacy, quality of life, and cost-effectiveness. Intention-to-treat analyses will test for differences in outcome means between study arms overall and by depressive symptom severity group.DiscussionTo our knowledge, this is the first depressive symptom stratification tool designed for primary care which takes a prognosis-based approach to provide a tailored treatment recommendation. If shown to be effective, this tool could be used to assist general practitioners to implement stepped mental-healthcare models and contribute to a more efficient and effective mental health system.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR 12616000537459 ). Retrospectively registered on 27 April 2016. See Additional file 1 for trial registration data

Humanities for medical students? A qualitative study of a medical humanities curriculum in a medical school program

BACKGROUND: Today, there is a trend towards establishing the medical humanities as a component of medical education. However, medical humanities programs that exist within the context of a medical school can be problematic. The aim of this study was to explore problems that can arise with the establishment of a medical humanities curriculum in a medical school program. METHODS: Our theoretical approach in this study is informed by derridean deconstruction and by post-structuralist analysis. We examined the ideology of the Humanities and Medicine program at Lund University, Sweden, the practical implementation of the program, and how ideology and practice corresponded. Examination of the ideology driving the humanities and medicine program was based on a critical reading of all available written material concerning the Humanities and Medicine project. The practice of the program was examined by means of a participatory observation study of one course, and by in-depth interviews with five students who participated in the course. Data was analysed using a hermeneutic editing approach. RESULTS: The ideological language used to describe the program calls it an interdisciplinary learning environment but at the same time shows that the conditions of the program are established by the medical faculty's agenda. In practice, the "humanities" are constructed, defined and used within a medical frame of reference. Medical students have interesting discussions, acquire concepts and enjoy the program. But they come away lacking theoretical structure to understand what they have learned. There is no place for humanities students in the program. CONCLUSION: A challenge facing cross-disciplinary programs is creating an environment where the disciplines have equal standing and contribution

Cultural Discord in a Medical Context: A Challenge for Physicians

Physician and patient do not meet as equals in the consultation. It is the responsibility of the physician to actively work for better communication in order to provide equitable health care for all individuals. Immigrant patients are a vulnerable group, shown in studies all over the world to have less access to care, fewer opportunities for health, and poorer health compared to majority populations. One barrier to equitable care may be cultural discord between patient and physician that hinders communication. The aim of this dissertation was to explore the role of the physician in cultural discord. Two seemingly disparate areas were examined: the primary care sector and the medical school environment. By focusing on the clinical environment of the primary care sector, the first part of this dissertation aims to uncover both what the patient and what the doctor bring to the consultation. In the second part of the dissertation, focus on the doctor was intensified by concentration on the pedagogic environment that forms the doctor. In the clinical environment, patients? health status does depend on background. However, there are variations both within and between groups that make it difficult to generalize on the basis of background for a specific individual patient. Physicians need skills to address cultural background in order to ensure good communication and equity of care for all patients, but their skills are insufficient. While physicians do aim to focus on the individual patient in consultation, they do not address differences in cultural background between themselves and the patient in their consultations. Communication problems based on difference in cultural background are therefore difficult to solve. Insufficiency in skills for addressing cultural background in the consultation was seen to be a structural problem located in the medical school environment. These skills are not a consequent part of the curriculum, and are not subject to examination. Furthermore, when an attempt was made to introduce these skills to medical students they were understood as outside of and lower status than medical knowledge. Students therefore did not come to understand these skills or learn to use them. This dissertation shows that the role of the physician in cultural discord is problematic. Physicians do not address existing cultural discord in the clinical environment, and in the medical school environment they do not learn how to address cultural discord. Cultural discord can hinder to communication between physician and patient. In order to improve possibilities for equitable care, the challenge for physicians is to learn to address cultural discord both in the clinic and in the medical school

A hidden curriculum: mapping cultural competency in a medical programme.

Background Cultural competency can be understood as those learned skills which help us understand cultural differences and ease communication between people who have different ways of understanding health, sickness and the body. Recently, medical schools have begun to recognise a need for cultural competency training. However, few reports have been published that articulate and evaluate cultural competency in medical curricula. Aim This study was performed in order to evaluate the current status of cultural competency training at a medical school in southern Sweden. Methods We used a multimethod approach to curriculum evaluation. We reviewed the published list of learning objectives for the medical programme, interviewed curriculum directors and individual teachers for each term about course content and carried out focus group interviews with students in all stages of the medical programme. Results Cultural competency is a present but mostly hidden part of the curriculum. We found learning objectives about cultural competency. Teachers reported a total of 25 instances of teaching that had culture or cultural competency as the main theme or 1 of many themes. Students reported few specific learning instances where cultural competency was the main theme. Students and teachers considered cultural competency training to be integrated into the medical programme. Cultural competency was not assessed. Conclusion This evaluation showed places in the curriculum where cultural competency is a present, absent or hidden part of the curriculum. The differences between the 3 perspectives on the curriculum lead us to propose curriculum changes. This study illustrates how triangulation with a multifactorial methodology leads to understanding of the current curriculum and changes for the future

Meeting and treating cultural difference in primary care: a qualitative interview study.

Background. Primary care doctors see patients from diverse cultural backgrounds and communication plays an important role in diagnosis and treatment. Communication problems can arise when patient and doctor do not share the same cultural background. Objective. The aim of this study was to examine how consultations with immigrant patients are understood by GPs and how GPs manage these consultations. Methods. Semi-structured interviews with GPs about their experiences with immigrant patients were recorded on audio-tape, transcribed and analysed using a qualitative thematic analysis methodology. A constructivist approach was taken to analysis and interpretation. Results. Culture is not in focus when GPs meet immigrant patients. The consultation is seen as a meeting between individuals, where cultural difference is just one of many individual factors that influence how well doctor and patient understand each other. However, when mutual understanding is poor and the consultation not successful, cultural differences are central. The GPs try to conduct their consultations with immigrant patients in the same way that they conduct all their consultations. There is no specific focus on culture, instead, GPs tend to avoid addressing even pronounced cultural differences. Conclusion. This study indicates that cultural difference is not treated in GPs consultation with immigrant patients. Learning about cultural difference's effect on mutual understanding between doctor and patient could improve GPs cross-cultural communication. Increased awareness of the culture the doctor brings to the consultation could facilitate management of cross-cultural consultations

Are we on the same page? : mental health literacy and access to care : a qualitative study in young Hazara refugees in Melbourne

Hazaras, mostly aged <30 years, constituted the greatest number of people resettled under Australia's migration resettlement between 2009 and 2013. This group is at high risk of mental health issues due to pre- and post-forced migration experiences. This study explored the understanding of mental health and barriers to accessing primary mental health care in young Hazara refugees in Melbourne. Seventeen Hazaras aged 18-30 years were recruited for two sex-segregated focus groups; two individual semistructured interviews were also conducted (with one male and one female participant). Discussions were audiotaped, transcribed and analysed thematically. Participants had varied perspectives on mental health issues stemming from historical and current beliefs. Lack of knowledge and concerns over confidentiality within Hazaras were considered major barriers to seeking help. Community education through existing community groups and through the women could potentially help overcome barriers to mental health access by young Hazaras