A randomized control trial was designed to assess the impact of two different educational interventions on medical student attitudes towards mental illness: a one-time contact based educational intervention and a 4 week mandatory psychiatry course at the University of Calgary, in Calgary (U of C), Canada. The Psychiatry and Family Violence Course is part of the U of C Medical School’s three-year, year-round program where clinical presentations are the foundation of the curriculum [44
] and the majority of students have an undergraduate or graduate university degree prior to entering medical school. Students completed the course in their second year immediately prior to starting the clerkship component of their education.
The course learning objectives were based on the Medical Council of Canada’s (MCC) Objectives for the Qualifying Examination Part I, which are based on the Royal College of Physicians and Surgeons of Canada’s CanMEDS (Canadian Medical Educations Directives for Specialists) framework for physicians’ roles [45
The course content was organized according to the following topics: Psychiatric interviewing and the Mental Status Examination, addictions, ADHD, anxiety disorders, eating disorders, emergency psychiatry, psychiatry and the law, psychiatry of the elderly, organic causes of mental illnesses, mood disorders, mood disorders in children and adolescents, personality disorders, pharmacology, psychosis, psychosomatic disorders, psychotherapy and the general physician, the sexually concerned patient, suicide, family issues and violence.
Students were taught about mental illness using the biopsychosocial model [46
]. Mental disorders were classified according to criteria established by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) [47
The course has been the highest rated course in the medical school based on student evaluations for the last seven years, and incorporates various teaching methods including didactic teaching (30 hours), case-based teaching with group discussions (12 hours) and an optional movie night with a post-movie discussion about mental illness (3–4 hours). It also includes two teaching methods that involved contact with people who have mental illness: patient presentations (2 hours) and “clinical correlations” sessions (6 hours).
“Clinical correlations” are small group teaching sessions where 5–6 students, paired since the first day of medical school, are mentored by a psychiatrist and directly interact with patients with a mental illness in an inpatient or out-patient setting. They provide students with an opportunity to practice their psychiatric skills and to process their reactions and experiences with the psychiatrist. Anecdotal reports suggest that students value these sessions (6 hours in total) and we hypothesized that students would rank this course component as the most effective teaching method.
The patient presentation component (a one-time contact based educational intervention) consisted of two, one-hour oral presentations given by patients who shared their story of having a mental illness. The first patient had recovered from medication-induced depression with psychotic symptoms and the second patient had narcolepsy and narcissistic personality disorder. Students had an opportunity to ask questions of the presenters and of the psychiatry course chair, who moderated the sessions.
To determine the impact of the entire psychiatry course on the stigma of mental illness and how this compared with the one-time contact-based educational intervention, students were cluster randomized according their clinical correlation groups into either an early intervention group or the late intervention group using a computer generated random sequence. The early group (intervention group) received the patient presentation on the first day of class, prior to the commencement of the regular course curriculum. The late intervention group (control group) received the same presentation at the very end of the course. Apart from the timing of the contact-based sessions, both groups participated in the same curriculum.
Data were collected on-line using the Opening Minds Scale for Health Care Providers (OMS-HC; Additional file 1
), a validated twenty item scale [48
]. Data were collected at four different time points: prior to the beginning of the course (T1), after a randomization step on the first day of class (T2), upon completion of the course (T3), and three months after the course was completed (T4). To assess for the consistency of student responses over time and to place medical student attitudes towards mental illness into a greater context, attitudes towards mental illness were compared with those for Type 2 Diabetes Mellitus (T2DM), a stigmatized but non-mental health related illness [43
], using questions 4, 5, 6 and 7 of the OMS-HC (Additional file 1
). The third survey, upon course completion, included additional questions to assess medical student perceptions of the course and its impact on their attitudes and behaviors.
The study was approved by the U of C Ethics Board and participation was voluntary. Students were assigned a unique identifier to maintain confidentiality and investigators directly involved with the course remained blinded to student participation. The following demographic information was collected to assess its impact on medical student attitudes: age, gender, contact with people with mental illness (family member, close friend, or having treated a patient with mental illness) and a personal history of being treated for a mental illness. Students were also asked if they have completed any psychiatry electives and if they would consider a career in psychiatry.
Data was entered twice and checked for errors and outliers. The analysis used the statistical program STATA version 11.0 [49
]. Authors used frequency distributions to characterize the participants with respect to their responses on each individual questionnaire item. Two-way frequency distributions and cross-tabulations were used in the analysis.
Attitudes towards people with mental illness were measured at baseline (T1) and compared to the ratings after the intervention (T2) and at the end of the course (T3). Attitudes were found to be substantially right skewed, whereas changes in those ratings were approximately normally distributed. The authors therefore examined changes between the various sets of ratings, so that parametric statistical tests could be used. The primary analysis examined the change between the first and second set of ratings to allow for a comparison of changes at a point in time where one half of the sample had received the contact-based intervention (intervention group) and one had not (control group). It was restricted to people who completed the baseline (T1) and post-intervention survey (T2), and linear regression analysis with adjustment for baseline score was used in these comparisons. The null hypothesis that the change score did not depend on group was assessed using a likelihood ratio test. The unit of randomization (clinical correlation groups) was included in the analysis as strata. The three month follow-up provided an opportunity to examine whether changes observed during the course were sustained. The secondary analysis examined the change between the baseline ratings and the post-course ratings.