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1.  The ‘Dark Side’ and ‘Bright Side’ of Personality: When Too Much Conscientiousness and Too Little Anxiety Are Detrimental with Respect to the Acquisition of Medical Knowledge and Skill 
PLoS ONE  2014;9(2):e88606.
Theory suggests that personality traits evolved to have costs and benefits, with the effectiveness of a trait dependent on how these costs and benefits relate to the present circumstances. This suggests that traits that are generally viewed as positive can have a ‘dark side’ and those generally viewed as negative can have a ‘bright side’ depending on changes in context. We test this in a sample of 220 UK medical students with respect to associations between the Big 5 personality traits and learning outcomes across the 5 years of a medical degree. The medical degree offers a changing learning context from pre-clinical years (where a more methodical approach to learning is needed) to the clinical years (where more flexible learning is needed, in a more stressful context). We argue that while trait conscientiousness should enhance pre-clinical learning, it has a ‘dark side’ reducing the acquisition of knowledge in the clinical years. We also suggest that anxiety has a ‘bright side’ enhancing the acquisition of skills in the clinical years. We also explore if intelligence enhances learning across the medical degree. Using confirmatory factor analysis and structural equation modelling we show that medical skills and knowledge assessed in the pre-clinical and clinical years are psychometrically distinguishable, forming a learning ‘backbone’, whereby subsequent learning outcomes are predicted by previous ones. Consistent with our predictions conscientiousness enhanced preclinical knowledge acquisition but reduced the acquisition of clinical knowledge and anxiety enhanced the acquisition of clinical skills. We also identified a curvilinear U shaped association between Surgency (extraversion) and pre-clinical knowledge acquisition. Intelligence predicted initial clinical knowledge, and had a positive total indirect effect on clinical knowledge and clinical skill acquisition. For medical selection, this suggests that selecting students high on conscientiousness may be problematic, as it may be excluding those with some degree of moderate anxiety.
doi:10.1371/journal.pone.0088606
PMCID: PMC3937323  PMID: 24586353
2.  Effects of pretesting implicit self-determined motivation on behavioral engagement: evidence for the mere measurement effect at the implicit level 
Research into individuals’ intended behavior and performance has traditionally adopted explicitly measured, self-report constructs, and outcomes. More recently, research has shown that completing explicit self-report measures of constructs may effect subsequent behavior, termed the “mere measurement” effect. The aim of the present experiment was to investigate whether implicit measures of motivation showed a similar mere measurement effect on subsequent behavior. It may be the case that measuring the implicit systems affects subsequent implicit interventions (e.g., priming), observable on subsequent behavior. Priming manipulations were also given to participants in order to investigate the interaction between measurement and priming of motivation. Initially, a 2 [implicit association test (IAT: present vs. absent) ×2 (Prime: autonomous vs. absent) and a 2 (IAT: present vs. absent) × 2 (Prime: controlled vs. absent)] between participants designs were conducted, these were them combined into a 2 (IAT: present vs. absent) ×3 (Prime: autonomous vs. controlled vs. absent) between participants design, with attempts at a novel task taken as the outcome measure. Implicit measure completion significantly decreased behavioral engagement. Priming autonomous motivation significantly facilitated, and controlled motivation significantly inhibited performance. Finally, there was a significant implicit measurement × priming interaction, such that priming autonomous motivation only improved performance in the absence of the implicit measure. Overall, this research provides an insight into the effects of implicit measurement and priming of motivation and the combined effect of completing both tasks on behavior.
doi:10.3389/fpsyg.2014.00125
PMCID: PMC3923262  PMID: 24592249
implicit measurement; mere measurement effect; self-determination theory; implicit association test; priming
3.  Health specific traits beyond the Five Factor Model, cognitive processes and trait expression: replies to Watson (2012), Matthews (2012) and Haslam, Jetten, Reynolds, and Reicher (2012) 
Health Psychology Review  2013;7(Suppl 1):S85-S103.
In this article we reply to the issues raised by the three commentaries on Ferguson's (2012) article. Watson argues that the four traits identified by Ferguson (2012) – health anxiety, alexithymia, empathy and Type D – do not lie outside the Five Factor Model (FFM). We present factor analytic data showing that health anxiety forms a separate factor from positive and negative affectivity, alexithymia forms a factor outside the FFM and while emotional empathy loads with agreeableness, cognitive empathy forms a separate factor outside the FFM. Across these analyses there was no evidence for a general factor of personality. We also show that health anxiety, empathic facets and alexithymia show incremental validity over FFM traits. However, the evidence that Type D lies outside the FFM is less clear. Matthews (2012) argues that traits have a more distributed influence on cognitions and that attention is not part of Ferguson's framework. We agree; but Ferguson's original statement concerned where traits have their maximal effect. Finally, Haslam et al. suggest that traits should be viewed from a dynamic interactionist perspective. This is in fact what Ferguson (2012) suggested and we go on to highlight that traits can also influence group processes.
doi:10.1080/17437199.2012.701061
PMCID: PMC3678849  PMID: 23772232
personality; health; factor analysis; determinism; empathy
4.  Can the 12-item general health questionnaire be used to identify medical students who might ‘struggle’ on the medical course? A prospective study on two cohorts 
BMC Medical Education  2013;13:48.
Background
Students who fail to thrive on the Nottingham undergraduate medical course frequently suffer from anxiety, depression or other mental health problems. These difficulties may be the cause, or the result of, academic struggling. Early detection of vulnerable students might direct pastoral care and remedial support to where it is needed. We investigated the use of the short-form General Health Questionnaire (GHQ-12) as a possible screening tool.
Methods
Two consecutive cohorts (2006 and 2007) were invited to complete the GHQ-12. The questionnaire was administered online, during the second semester (after semester 1 exams) for the 2006 cohort and during the first semester for the 2007 cohort. All data were held securely and confidentially. At the end of the course, GHQ scores were examined in relation to course progress.
Results
251 students entered the course in 2006 and 254 in 2007; 164 (65%) and 160 (63%), respectively, completed the GHQ-12. In both cohorts, the study and non-study groups were very similar in terms of pre-admission socio-demographic characteristics and overall course marks. In the 2006 study group, the GHQ Likert score obtained part-way through the first year was negatively correlated with exam marks during Years 1 and 2, but the average exam mark in semester 1 was the sole independent predictor of marks in semester 2 and Year 2. No correlations were found for the 2007 study group but the GHQ score was a weak positive predictor of marks in semester 2, with semester 1 average exam mark again being the strongest predictor. A post-hoc moderated-mediation analysis suggested that significant negative associations of GHQ scores with semester 1 and 2 exams applied only to those who completed the GHQ after their semester 1 exams. Students who were identified as GHQ ‘cases’ in the 2006 group were statistically less likely to complete the course on time (OR = 4.74, p 0.002). There was a non-significant trend in the same direction in the 2007 group.
Conclusions
Results from two cohorts provide insufficient evidence to recommend the routine use of the GHQ-12 as a screening tool. The timing of administration could have a critical influence on the results, and the theoretical and practical implications of this finding are discussed. Low marks in semester 1 examinations seem be the best single indicator of students at risk for subsequent poor performance.
doi:10.1186/1472-6920-13-48
PMCID: PMC3616988  PMID: 23548161
6.  Individual differences in behavioural inhibition explain free riding in public good games when punishment is expected but not implemented 
Background
The literature on social dilemmas and punishment focuses on the behaviour of the punisher. However, to fully explain the effect of punishment on cooperation, it is important to understand the psychological mechanisms influencing the behaviour of those who expect to be punished. This paper examines whether the expectation of punishment, rather than the implementation of punishment is sufficient to prevent individuals from free riding. Individual differences in the punishment sensitivity have been linked to both threat responses (flight, fight, fear system, or the FFFS) and to the response to the uncertainty of punishment (BIS-anxiety).The paper, therefore, examines if individual differences in BIS-anxiety and FFFS can explain some of the variability in free riding in the face of implemented and non-implemented punishment.
Methods
Participants took part in a series of one-shot Public Goods Games (PGGs) facing two punishment conditions (implemented and non-implemented) and two standard non-punishment PGGs. The punishment was implemented as a centralized authority punishment (i.e., if one participant contributed less than their group members, they were automatically fined). Individual contribution levels and presence/absence of zero contributions indexed free riding. Individual differences in behavioural inhibition were assessed.
Results
Individuals contributed more under the threat of punishment (both implemented and non-implemented). However, individuals contributed less when the punishment was not implemented compared to when it was. Those scoring high in BIS-anxiety contributed more when the punishment expectations were not implemented. This effect was not observed for FFFS.
Conclusion
Supporting previous research, punishment had a powerful effect in increasing contribution levels in the PGGs. However, when expected punishment was not implemented, individual differences in punishment sensitivity, specifically in BIS-anxiety, were related to fewer contributions (increased free riding) as compared to the situation when punishment was not implemented. This has implications for our understanding of why some people cannot resist the temptation to free ride, even when facing possible punishment for their actions. Our findings suggest that the diminished functioning of mechanisms, associated with trait behavioural inhibition, can partly explain such behaviours.
doi:10.1186/1744-9081-9-3
PMCID: PMC3562176  PMID: 23305116
Cooperation; Free riding; Punishment risk; Behavioural inhibition; Individual differences
7.  Increasing organ donation via anticipated regret (INORDAR): protocol for a randomised controlled trial 
BMC Public Health  2012;12:169.
Background
Throughout the world there is an insufficient supply of donor organs to meet the demand for organ transplantations. This paper presents a protocol for a randomised controlled trial, testing whether a simple, theory-based anticipated regret manipulation leads to a significant increase in posthumous organ donor registrations.
Methods
We will use a between-groups, prospective randomised controlled design. A random sample of 14,520 members of the adult Scottish general public will be contacted via post. These participants will be randomly allocated into 1 of the 4 conditions. The no questionnaire control (NQC) group will simply receive a letter and donor registration form. The questionnaire control (QC) arm will receive a questionnaire measuring their emotions and non-cognitive affective attitudes towards organ donation. The theory of planned behavior (TPB) group will complete the emotions and affective attitudes questionnaire plus additional items assessing their cognitive attitudes towards organ donation, perceived control over registration and how they think significant others view this action. Finally, the anticipated regret (AR) group will complete the same indices as the TPB group, plus two additional anticipated regret items. These items will assess the extent to which the participant anticipates regret for not registering as an organ donor in the near future. The outcome variable will be NHS Blood and Transplant verified registrations as an organ donor within 6 months of receiving our postal intervention.
Discussion
This study will assess whether simply asking people to reflect on the extent to which they may anticipate regret for not registering as an organ donor increases organ donor registration 6 months later. If successful, this simple and easy to administer theory-based intervention has the potential to save lives and money for the NHS by reducing the number of people receiving treatments such as dialysis. This intervention may also be incorporated into future organ donor campaigns.
Trial registration number
ISRCTN: ISRCTN92204897
doi:10.1186/1471-2458-12-169
PMCID: PMC3323431  PMID: 22401534
8.  Graduate entry to medicine: widening psychological diversity 
Background
At Nottingham University more than 95% of entrants to the traditional 5-year medical course are school leavers. Since 2003 we have admitted graduate entrants (GEM) to a shortened (4-year) course to 'widen access to students from more disadvantaged backgrounds'. We have recently shown that the GEM course widens academic and socio-demographic diversity of the medical student population. This study explored whether GEM students also bring psychological diversity and whether this could be beneficial.
Methods
We studied: a) 217 and 96 applicants to the Nottingham 5- and 4-year courses respectively, applying in the 2002-3 UCAS cycle, and, b) 246 school leavers starting the 5-year course and 39 graduate entrants to the 4-year course in October 2003. The psychological profiles of the two groups of applicants and two groups of entrants were compared using their performance in the Goldberg 'Big 5' Personality test, the Personal Qualities Assessment (PQA; measuring interpersonal traits and interpersonal values), and the Lovibond and Lovibond measure of depression, anxiety and stress. For the comparison of the Entrants we excluded the 33 school leavers and seven graduates who took the tests as Applicants.
Statistical analyses were undertaken using SPSS software (version 16.0).
Results
Graduate applicants compared to school leaver applicants were significantly more conscientious, more confident, more self controlled, more communitarian in moral orientation and less anxious. Only one of these differences was preserved in the entrants with graduates being less anxious. However, the graduate entrants were significantly less empathetic and conscientious than the school leavers.
Conclusion
This study has shown that school leaver and graduate entrants to medical school differ in some psychological characteristics. However, if confirmed in other studies and if they were manifest in the extreme, not all the traits brought by graduates would be desirable for someone aiming for a medical career.
doi:10.1186/1472-6920-9-67
PMCID: PMC2784445  PMID: 19912642
9.  Should applicants to Nottingham University Medical School study a non-science A-level? A cohort study 
Background
It has been suggested that studying non-science subjects at A-level should be compulsory for medical students. Our admissions criteria specify only Biology, Chemistry and one or more additional subjects. This study aimed to determine whether studying a non-science subject for A-level is an independent predictor of achievement on the undergraduate medical course.
Methods
The subjects of this retrospective cohort study were 164 students from one entry-year group (October 2000), who progressed normally on the 5-year undergraduate medical course at Nottingham. Pre-admission academic and socio-demographic data and undergraduate course marks were obtained. T-test and hierarchical multiple linear regression analyses were undertaken to identify independent predictors of five course outcomes at different stages throughout the course.
Results
There was no evidence that the choice of science or non-science as the third or fourth A-level subject had any influence on course performance. Demographic variables (age group, sex, and fee status) had some predictive value but ethnicity did not. Pre-clinical course performance was the strongest predictor in the clinical phases (pre-clinical Themes A&B (knowledge) predicted Clinical Knowledge, p < 0.001, and pre-clinical Themes C&D (skills) predicted Clinical Skills, p = < 0.01).
Conclusion
This study of one year group at Nottingham Medical School provided no evidence that the admissions policy on A-level requirements should specify the choice of third or fourth subject.
doi:10.1186/1472-6920-9-5
PMCID: PMC2650695  PMID: 19159444
10.  Intellectual aptitude tests and A levels for selecting UK school leaver entrants for medical school 
BMJ : British Medical Journal  2005;331(7516):555-559.
An extension of A level grades is the most promising alternative to intellectual aptitude tests for selecting students for medical school
PMCID: PMC1200591  PMID: 16150766
11.  A new selection system to recruit general practice registrars: preliminary findings from a validation study 
BMJ : British Medical Journal  2005;330(7493):711-714.
Objective To design and validate a new competency based selection system to recruit general practice registrars, comprising a competency based application form, referees' reports, and an assessment centre.
Design Longitudinal predictive validity study and a matched case comparison.
Setting South Yorkshire and East Midlands region, United Kingdom, comprising three deaneries.
Participants 46 of 167 doctors were followed up in training after three months in practice, and 20 general practice trainers were selected by using traditional recruitment methods.
Main outcome measures Trainer ratings of trainee performance in practice on targeted competencies.
Results Performance ratings of targeted competencies at the assessment centre predicted trainer ratings of performance in the job. Furthermore, those trainees recruited through the new competency based process performed significantly better in the job than those recruited through traditional recruitment processes.
Conclusion A new competency based selection process using assessment centres improves the validity of selection of general practice registrars compared with traditional selection techniques.
PMCID: PMC555635  PMID: 15790641
12.  Pilot study of the roles of personality, references, and personal statements in relation to performance over the five years of a medical degree 
BMJ : British Medical Journal  2003;326(7386):429-432.
Objectives
To compare the power of three traditional selection procedures (A levels, personal statements, and references) and one non-traditional selection procedure (personality) to predict performance over the five years of a medical degree.
Design
Cohort study over five years.
Setting
Nottingham medical school.
Participants
Entrants in 1995.
Main outcome measures
A level grades, amounts of information contained in teacher's reference and the student's personal statement, and personality scores examined in relation to 18 different assessments.
Results
Information in the teacher's reference did not consistently predict performance. Information in the personal statement was predictive of clinical aspects of training, whereas A level grades primarily predicted preclinical performance. The personality domain of conscientiousness was consistently the best predictor across the course. A structural model indicated that conscientiousness was positively related to A level grades and preclinical performance but was negatively related to clinical grades.
Conclusion
A teacher's reference is of no practical use in predicting clinical performance of medical students, in contrast to the amount of information contained in the personal statement. Therefore, simple quantification of the personal statement should aid selection. Personality factors, in particular conscientiousness, need to be considered and integrated into selection procedures.
PMCID: PMC163931  PMID: 12595384
14.  Personality is of central concern to understand health: towards a theoretical model for health psychology 
Health Psychology Review  2013;7(Suppl 1):S32-S70.
This paper sets out the case that personality traits are central to health psychology. To achieve this, three aims need to be addressed. First, it is necessary to show that personality influences a broad range of health outcomes and mechanisms. Second, the simple descriptive account of Aim 1 is not sufficient, and a theoretical specification needs to be developed to explain the personality-health link and allow for future hypothesis generation. Third, once Aims 1 and 2 are met, it is necessary to demonstrate the clinical utility of personality. In this review I make the case that all three Aims are met. I develop a theoretical framework to understand the links between personality and health drawing on current theorising in the biology, evolution, and neuroscience of personality. I identify traits (i.e., alexithymia, Type D, hypochondriasis, and empathy) that are of particular concern to health psychology and set these within evolutionary cost-benefit analysis. The literature is reviewed within a three-level hierarchical model (individual, group, and organisational) and it is argued that health psychology needs to move from its traditional focus on the individual level to engage group and organisational levels.
doi:10.1080/17437199.2010.547985
PMCID: PMC3678852  PMID: 23772230
personality; evolution; diagnosis
15.  Psychological Processes and Repeat Suicidal Behavior: A Four-Year Prospective Study 
Objective: Although suicidal behavior is a major public health concern, understanding of individually sensitive suicide risk mechanisms is limited. In this study, the authors investigated, for the first time, the utility of defeat and entrapment in predicting repeat suicidal behavior in a sample of suicide attempters. Method: Seventy patients hospitalized after a suicide attempt completed a range of clinical and psychological measures (depression, hopelessness, suicidal ideation, defeat, and entrapment) while in hospital. Four years later, a nationally linked database was used to determine who had been hospitalized again after a suicide attempt. Results: Over 4 years, 24.6% of linked participants were readmitted to hospital after a suicidal attempt. In univariate logistic regression analyses, defeat and entrapment as well as depression, hopelessness, past suicide attempts, and suicidal ideation all predicted suicidal behavior over this interval. However, in the multivariate analysis, entrapment and past frequency of suicide attempts were the only significant predictors of suicidal behavior. Conclusions: This longitudinal study supports the utility of a new theoretical model in the prediction of suicidal behavior. Individually sensitive suicide risk processes like entrapment could usefully be targeted in treatment interventions to reduce the risk of repeat suicidal behavior in those who have been previously hospitalized after a suicide attempt.
doi:10.1037/a0033751
PMCID: PMC3933214  PMID: 23855989
suicidal; longitudinal; cognition; defeat; entrapment

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