George C. Sisler

A study of the reliability of the clinical oral examination in psychiatry.

A study of the variability between raters in scoring an oral clinical examination in psychiatry in the format of the certification by the Royal College of Physicians and Surgeons of Canada is reported. A video-taped examination from another centre was rated independently by academic psychiatrists, nonacademic psychiatrists and residents. Considerable inter-rater differences between and within these groups were found. In particular, the averaging of the marks of pairs of raters as occurs in the actual certification resulted in the outcome depending to a considerable degree on the chance pairings of raters. These findings support a number of previous studies and emphasize the need to train examiners and to develop clearer rating criteria.

Amnesia Following Severe Head Injury

This report concerns some aspects of the problem of establishing valid and reliable criteria for post-traumatic amnesia, and of relating this to other cognitive functions in the post-injury period. Of specific interest are the variability of the duration of retrograde and anterograde amnesia on attempts at repeated assessment, and the relationship between the time of return of full orientation and the end of the period of anterograde amnesia. A prospective study was undertaken of sixty consecutive patients who had suffered severe head injuries and had been admitted to the neurosurgical service of the Winnipeg General Hospital. The object of this study was to obtain information regarding organic, psychological and social indices of the future clinical course.

The measurement of retrograde post-traumatic amnesia

Retrograde amnesia is the inability to recall events which occurred immediately before head trauma or other acute brain insult. It is one aspect of a larger entity — posttraumatic amnesia — seen in some head injuries, and represents a defect in the consolidation of memories. Previous studies of retrograde amnesia have produced conflicting findings regarding its characteristics. A study was undertaken to identify the characteristics of retrograde amnesia, its relationship to anterograde amnesia, and the problems of its measurement. Forty-eight patients with head injuries admitted to the Emergency Department of the Winnipeg General Hospital were interviewed to identify all subjects meeting certain criteria regarding age, education, and so on, and twenty-five met the criteria and were included in the sample. Each subject was interviewed at least twice until the retrograde amnesia had reached a stable minimum. The duration of retrograde and anterograde amnesia as well as immediate and short-term memory were assessed. It was found that the duration of retrograde amnesia was directly related to the duration of the anterograde amnesia and to the duration of hospitalization. Some problems involved in measurement are discussed.

The clinical oral examination in psychiatry: association between subscoring and global marks

Fifteen academic psychiatrists rated a videotaped clinical oral examination done in the Royal College format. In addition to assigning an overall mark, the raters completed a detailed scoring form. The ratings of the case presentation and discussion accounted for most of the variance in the overall mark. The rating of the interview difficulty and establishment of rapport were weaker predictors. Implication of these findings for the trainees and the examiners are discussed.

A clinical study of post-traumatic amnesia

Fifteen consecutive patients with head injuries, admitted to the neurosurgical services of the Winnipeg General and St. Boniface hospitals, were given two memory tests within 24 hours following recovery of consciousness. The first test concerned immediate recall of a series of digits, presented orally. The second was a paired-associates test which involved learning and retaining pairs of stimuli and also required that when one stimulus of the pair is given the subjects correctly respond with the other associated stimulus. Fifteen control subjects admitted to hospital for acute episodes other than head injury were tested. The controls were matched with the head-injured subjects for age and education. During the eight-minute retention interval a distraction stimulus was administered randomly to six of the head-injured subjects and to six matched controls. No defect was found in immediate (a few seconds) memory of the head-injured group. The distracting stimulus had no significant influence on retention. Verbal learning, as defined by the number of trials to reach a criterion score on a memory test, was impaired and verbal retention, tested by recall at one hour after the initial learning period, was also impaired. These findings suggest that head-injured patients have at least a temporarily decreased ability to form lasting memory traces.

Psychiatric aspects of the long-term course of severe diffuse non-progressive cerebral disease in adults.

Though there are major limitations in present knowledge regarding the psycho- and physio-pathology and prognostic indices of the syndromes produced by the after effects of severe non-progressive cerebral disease in adults, an early poor prognosis on the basis of prolonged coma, a picture of dementia, or relapse following improvement, is often proven wrong. Treatable decompensation may temporarily interrupt the course of improvement. The patient and family require the hopeful co-operative efforts of family physicians, psychiatrist and other specialists, psychologists, and paramedical remedial therapists to achieve maximum freedom from disabling symptoms and social adaption.