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Introduction It is now widely accepted that veterinary graduates should enter their profession with high-quality communication skills. Until recently, however, this has not been reflected in undergraduate training. Recently, the Veterinary Faculty at the University of Liverpool, in collaboration with the profession's indemnity insurers (the Veterinary Defence Society), has developed one of the first specific communication skills training courses for veterinary undergraduates. For the first three years it has been run, the aim of this course has been to increase students’ awareness of the importance of good communication in the veterinary profession. The course is based on best practice as currently defined in medical education, making extensive use of actors as simulated clients. As well as watching acted-out consultations, the students also role-play scenarios designed to expose them to all aspects of the veterinary consultation (including introductions, history taking, breaking bad news, fee issues, and dealing with anger). Feedback on the role plays is facilitated by members of stbio. Evaluation of the first year of this course has been published and has shown it achieves its aims of increasing the students’ awareness of the importance of good communication with their clients.1 However, regular facilitators became aware that the students’ learning experience was very variable and, perhaps more importantly, could not be defined. This was felt to be a critical limitation to further development of the course, particularly in the area of student learning and assessment. It was recognized that one of the major obstacles to further development was the lack of a teaching model suitable for the veterinary consultation. Such models are routinely used in medical education. However, their direct application to veterinary education is limited because they do not reflect the diversity of clients with whom the veterinarian/veterinary surgeon communicates (e.g., farmers, companion animal owners), nor do they take into account the two important, and often difficult, areas of euthanasia and finances. The aim of this project was to develop a consultation model for veterinary education based on the Calgary-Cambridge model of the medical consultation. The model was adapted, recognizing both the considerable overlap and also the likely differences between the veterinary and medical consultations. Subsequently, this model has been used to train communication skills facilitators and undergraduates. Here we present the model and provide results of evaluation of its use within the communication skills program for veterinary undergraduates at the University of Liverpool.

BACKGROUND: The management of persistent, unexplained physical symptoms is challenging and often unsatisfactory for patients and doctors. Aerobic exercise training has benefited patients referred to secondary care with symptoms of chronic fatigue and fibromyalgia. It is not known if this approach is either possible or beneficial for patients with the broader range of persistent, unexplained symptoms found in primary care. OBJECTIVES: To examine the feasibility and effects of aerobic exercise training in primary care patients with unexplained physical symptoms persisting more than 12 months. METHODS: Randomized comparison (n = 228) of aerobic exercise with stretching as control among patients recruited from primary care. Training comprised 20, one-hour, sessions led by NHS physiotherapists. Adherence to training was recorded along with two groups of outcome measures: (i) documented symptoms and health care use, monitored from six months before to six months after training; and (ii) self-reported measures including emotional state and perceived disability, assessed before, during and six months after training. RESULTS: Exercise training proved feasible: more than 70% of referred patients attended for assessment and were randomized to aerobic or control exercise; 78% of eligible patients attended the first session; and median attendance was 11 sessions for both programmes. Primary care consultations and prescriptions were significantly reduced in the 6 months after training; extent of reduction was related to attendance at training sessions, irrespective of type. Whilst self-reported measures improved similarly during both training programmes, improvements were unrelated to level of attendance. CONCLUSION: For primary care patients with persistent, unexplained physical symptoms willing to be involved in exercise training, aerobic exercise offers no benefits over non-aerobic exercise. Whilst the observed reduction in primary health care use following exercise training is potentially of practical importance in a group of patients characterized by high consultation rates, improvement in patients' subjective state was not clearly attributable to exercise training.

To compare the health status of groups of Primary Sjögren's and Xerostomia patients, using the Medical Outcomes Short Form 36 (SF-36). The SF-36 is a generic measure, divided into eight domains, used in the assessment of health-related quality of life.The SF-36 was given to 2 groups: Group 1 comprised 43 patients diagnosed with Primary Sjögren's Syndrome (1 degrees SS) and an unstimulated whole salivary flow rate (UFR) of0.1 ml/min). Group 2 (n = 40) reported Xerostomia but had an UFR0.2 ml/min. Sub groups of patients in Groups 1 and 2 were compared with community normative data, for the SF-36.There were trends to suggest lower SF36 scores for 1 degrees SS patients but there were no significant differences between the mean domain scores of Groups 1 and 2. 1 degrees SS and Xerostomia patients registered lower mean scores across all 8 domains, compared with normative community data.The SF-36 was unable to detect significant differences between subjects with 1 degrees SS and Xerostomia but a larger sample size is required to confirm these findings. The results of this limited study suggest that a disease-specific measure is required to assess the impact 1 degrees SS on health-related Quality of life (QOL).

Objectives. To investigate the influence of current media events on hallucinatory content in ICU patients. Design and methods. Patients were interviewed over a one-year period, and their descriptions of hallucinatory experiences, together with weekly media stories, were assessed for themes of war. Results. Media coverage for war-related stories rose significantly during the period of war in Kosovo (24/3/99-20/6/99). Patients whose ICU stays coincided with this conflict were more likely to have hallucinatory experiences involving themes of war or the military. Older adults (> 70) were also more susceptible to this effect. Conclusions. Contextual variables such as current media events can have a significant impact upon the contents of hallucinatory experiences.

Context The teaching of clinical communication skills’ teaching has become an important part of medical school curricula. Many undergraduate medical courses include communication skills training at various points in their curriculum. Very few reports have been published on the development of communication skills over the duration of a medical undergraduate training. Aims To determine the change in communication skills between early and mid-stages of the students’ 5-year curriculum, and to investigate the predictive and theoretical significance of knowledge and understanding of communication skills in relation to

Objectives (i) To design a new, quick and efficient method of assessing specific cognitive aspects of trainee clinical communication skills, to be known as the Objective Structured Video Exam (OSVE) (Study 1); (ii) to prepare a scoring scheme for markers (Study 2); and (iii) to determine reliability and evidence for validity of the OSVE (Study 3). Methods Study 1 describes how the exam was designed. The OSVE assesses the student’s recognition and understanding of the consequences of various communication skills. In addition, the assessment taps the number of alternative skills that the student believes will be of assistance in improving the patient–doctor interaction. Study 2 outlines the scoring system that is based on a range of 50 marks. Study 3 reports inter-rater consistency and presents evidence to support the validity of the new assessment by associating the marks from 607 1st year undergraduate medical students with their performance ratings in a communication skills OSCE. Setting Medical school, The University of Liverpool. Results Preparation of a scoring scheme for the OSVE produced consistent marking. The reliability of the marking scheme was high (ICC=0·94). Evidence for the construct validity of the OSVE was found when a moderate predicted relationship of the OSVE to interviewing behaviour in the communication skills OSCE was shown (r=0·17, P

Objectives. It was hypothesized that people with persecutory delusions, such as depressed people, would experience difficulty when attempting to generate specific autobiographical memories. Design. 20 deluded participants, 20 depressed patients and 20 normal controls were compared on an autobiographical memory test. Methods. Participants attempted to recall memories to positive and negative cue words. Independent raters classified responses as specific, general, imaginary or unscorable. Over-general memories were further classified as extended or categorical. Results. Deluded participants recalled significantly more general (especially categorical) memories and fewer specific memories than the normal control subjects. Depressed participants showed little evidence of over-general memories, although they showed faster recall latencies to negative than to positive cues. Conclusions. People with paranoid delusions show information processing features similar to those previously reported in people with depression. The possible contribution of adverse experiences to over-general autobiographical recall is discussed.

Examines the issues of work-related stress in the healthcare professions, focusing on junior medical and dental staff. Identifies the stressors, and reports on an interview survey conducted as part of a larger study funded by the National Health Service Management Executive to identify the levels of stress. Concludes that outsourcing to an independent counselling service could prove to be an effective stress-management strategy.

An experiment was conducted to examine recall bias in patients suffering from persecutory delusions, depressed controls, and normal subjects. Subjects were given a mixed list of threat-related, depression-related, and emotionally neutral words which they were asked to recall immediately afterwards. Deluded patients recalled fewer words overall than the normal subjects, and showed a recall bias toward both threat-related and depression-related words. The deluded subjects also showed a significant tendency to repeat threat-related words during recall. These biases were not significantly related to levels of depressive symptomatology or magical ideation in the deluded patients. Depressed patients showed a recall bias toward depression-related words only, and showed no significant tendency to repeat either depression-related or threat-related words. The findings are interpreted in the light of cognitive accounts of persecutory delusions.

A data set of Attributional Style Questionnaire responses collected by Kaney & Bentall (1989) from persecutory deluded, normal and depressed subjects was added to a similar data set collected by the first author. The attributions made for hypothetical positive and negative events by the combined pool of subjects were then blind rated for internality by five independent judges. Whereas the internality ratings made by the subjects for their own attributions showed evidence of an exaggerated self-serving bias in the case of the deluded subjects, and an absence of such a bias in the case of the depressed subjects, the independent ratings showed no such group differences. These findings suggest that the differences in internality for positive and negative events observed on the ASQ between deluded, normal and depressed subjects may not reflect differences in the types of causal statements made by these subjects but differences in their attributions about their attributions. The relevance of this observation for attribution theory in general and attributional accounts of psychopathology in particular are discussed.

Background. Current guidelines for surgeons' decisions about whether to offer cosmetic surgery are ineffective. Therefore, surgeons have to make difficult decisions on a case-by-case basis. The authors sought to identify the patient variables that influence surgeons' decisions in practice. Design. A qualitative study first delineated, from observation of consultations and interviews with surgeons and other staff, variables that might influence their decisions. Then, in a cross-sectional survey of patients seeking cosmetic surgery, the authors measured these variables and tested whether they predicted the surgeons' decisions to offer surgery. Participants. Participants were 6 consultant plastic surgeons who assess cosmetic surgery referrals and 276 new patients aged 16 years or older referred to these surgeons. Results. The qualitative study suggested that, as well as clinical factors (the probability of a satisfactory surgical outcome and the risks v. benefits of surgery), surgery was more likely to be offered where it was of low cost (i.e., minor skin surgery), physical symptoms or dysfunction were present, and abnormality of appearance was extreme. The role of patients' quality of life was unclear. The quantitative study confirmed that the probability of surgery was increased where requests were for minor skin procedures and by abnormality of patients' appearance. In patients seeking major body procedures, surgery was less likely when patients reported poor quality of life. Conclusion. Surgeons' decisions about whether to offer elective cosmetic surgery follow systematic rules. By incorporating the factors that surgeons use in their decision making, more effective guidelines about elective cosmetic surgery provision than are presently available could be developed.

Background. Attributions play an important role in depression and paranoia. However, contrary to most attributional models of psychopathology, there is evidence that attributional style is not a stable trait but is affected by recent experiences. Method. Paranoid, depressed, and healthy participants were exposed to a mild stressor in the form of the requirement to complete an anagram task, which included insoluble items. Before and afterwards, they completed measures of attributional style for negative events and a contingency judgment task. Results. Replicating previous findings, paranoid patients initially showed low internality scores for negative events and high judgments of control on the contingency judgment task, whereas the depressed participants showed high internality for negative events and low judgments of control. Following the anagram task, both clinical groups showed increased internality for hypothetical negative events. The paranoid participants also gave increased estimates of control on the contingency judgment task. Conclusions. Attributional style is more labile in paranoid and depressed patients than in healthy individuals. Implications for attributional theories of psychopathology are discussed.

Context The assessment of undergraduates’ communication skills by means of objective structured clinical examinations (OSCEs) is a demanding task for examiners. Tiredness over the course of an examining session may introduce systematic error. In addition, unsystematic error may also be present which changes over the duration of the OSCE session. Aim To determine the strength of some sources of systematic and unsystematic error in the assessment of communication skills over the duration of an examination schedule. Methods Undergraduate first-year medical students completing their initial summative assessment of communication skills (a four-station OSCE) comprised the study population. Students from three cohorts were included (1996–98 intake). In all 3 years the OSCE was carried out identically. All stations lasted 5 minutes with a simulated patient. Students were assessed using an examiner (content expert) and a simulated-patient evaluation tool, the Liverpool Communication Skills Assessment Scale (LCSAS) and the Global Simulated-patient Rating Scale (GSPRS), respectively. Each student was assigned a time slot ranging from 1 to 24, where 1, for example, would denote that the student entered the exam first and 24 indicates the final slot for entry into the examination. The number of students who failed this exam was noted for each of the 24 time slots. A control set of marks from a communication skills written exam was also adopted for exploring a possible link with the time slot. Analysis was conducted using graphical display, covariate analysis and logistic regression. Results No significant relationship was found between the schedule point that the student entered the OSCE exam and their performance. The reliability of the content expert and simulated-patient assessments was stable throughout the session. Conclusion No evidence could be found that duration of examining in a communication OSCE influenced examiners and the marks they awarded. Checks of this nature are recommended for routine inspection to confirm a lack of bias.

Two groups of patients suffering from persecutory delusions, one consisting of patients also suffering from depression and a non-depressed group, together with clinically depressed and normal controls matched with the deluded patients for age and intelligence, were asked to rate the frequency with which selected positive, negative and neutral events had happened to themselves and to an average other person in the past, and the frequency with which these events were likely to happen to themselves and to an average other person in the future. Results were similar for both past and expected future events. Non-depressed-deluded, depressed-deluded and depressed patients rated negative events as occurring relatively more frequently in comparison to the normal controls. Depressed participants rated positive events as occurring more frequently to others, whereas the normal participants rated negative events as occurring more often to others. Correlational analyses indicated that depression scores were associated with low estimates of the frequency with which positive events happen to self and high estimates of the frequency with which negative events happen to self. Magical ideation scores, an index of psychosis, were associated with high estimates of the frequency of negative events for both self and others. These findings are interpreted in the context of previous evidence on cognitive biases in deluded patients.

Abnormalities of ‘social’ reasoning were investigated in patients suffering from persecutory delusions and in matched depressed and normal controls using transparent (obvious) and opaque (unobvious) tests of attributional style. Whereas depressed and normal subjects yielded similar causal inferences for both attributional measures, the deluded subjects showed a marked shift in internality, attributing negative outcomes to external causes on the transparent Attributional Style Questionnaire but, on the more opaque Pragmatic Inference Task, attributing negative outcomes to internal causes and thus showing a cognitive style resembling that of the depressed group. This finding, interpreted in terms of explicit versus implicit judgements, supports the hypothesis that delusions function as a defence against underlying feelings of low self-esteem.

In this paper we review a series of recent investigations into cognitive abnormalities associated with persecutory delusions. Studies indicate that persecutory delusions are associated with abnormal attention to threat-related stimuli, an explanatory bias towards attributing negative outcomes to external causes and biases in information processing relating to the self-concept. We propose an integrative model to account for these findings in which it is hypothesized that, in deluded patients, activation of self/ideal discrepancies by threat-related information triggers defensive explanatory biases, which have the function of reducing the self/ideal discrepancies but result in persecutory ideation. We conclude by discussing the implications of this model for the cognitive-behavioural treatment of paranoid delusions.

The self-serving attributional bias was studied in matched groups of patients with persecutory delusions, patients with major affective disorder, and normal controls, (N = 14 in each group). On a preprogrammed computer task, subjects mainly won points in one condition and mainly lost points in the other. Subjects were asked to estimate the degree of control they thought they had over winning or losing in the two conditions. In comparison with the normal subjects and the psychiatric controls, the deluded subjects showed a greater self-serving bias, as evidenced by their perceived greater control over outcomes in the win condition. These findings are interpreted as consistent with the hypothesis that persecutory delusions function as a defense against low self-esteem.

Subjects suffering from persecutory delusions, psychiatric controls and normal subjects were required to recall immediately six passages of prose, half of which contained mildly threatening propositions. Deluded subjects recalled fewer propositions overall but more propositions of specifically threatening content. These findings suggest that the role of recall bias in persecutory delusions merits further study.

The social reasoning of patients suffering from persecutory delusions and matched groups of depressed and normal controls was investigated using the framework of Kelley's (1967) theory of social attribution. Subjects were required to choose between person, circumstances and stimulus attributions for a series of social vignettes describing interactions between two persons. The vignettes varied in terms of the distinctiveness, consistency and consensus information supplied, as well as in respect of whether the actions described were positively or negatively valued. It was found that the deluded patients made excessive person attributions for negative events. It was also found that the deluded patients were excessively certain about their judgements compared to the depressed controls. Normal subjects tended to rate their certainty in their own judgements midway between the deluded and depressed patients.

This paper aims to examine and highlight the difference between sources of stress and burn-out. The first part of the paper examines stress and the second part looks at the concept of burn-out with reference to how orthodontists compare with other dental professionals.

Seventeen psychotic patients with persecutory delusions were matched against depressed and normal controls and assessed for magical ideation, locus of control and attributional style. The deluded and depressed patients were found to make global and stable attributions when compared to the normal subjects. However, the deluded patients, in contrast with both control groups, made excessively external attributions for negative events and internal attributions for positive events. Highly significant differences were observed between the deluded group and the two control groups on magical ideation and on the 'powerful others' subscale of the locus of control questionnaire. Both psychiatric groups differed from the normal control group on 'chance' locus of control and a significant difference was observed between the persecuted and normal subjects on the 'internality' subscale of the questionnaire. The implications of these findings for the understanding and treatment of paranoid delusions are discussed.

Attentional bias was investigated in patients suffering from persecutory delusions and matched psychiatric and normal controls, using the emotional Stroop task. Subjects were required to colour name words which were either meaningless strings of Os, neutral words, words indicating negative affect, or words judged to be of paranoid content. In comparison with the control subjects the deluded patients demonstrated a selective increase of response time for the paranoid words. A second analysis using indices of interference produced even more marked results. The relevance of these findings for the understanding of delusional thinking is discussed.