Rachel Bramson

Psychometric evaluation of the Beck Depression Inventory-II with primary care medical patients.

This study evaluated the psychometric characteristics of the Beck Depression Inventory-II (BDI-II; A. T. Beck, R. A. Steer, & G. K. Brown, 1996) in a primary care medical setting. A principal-components analysis with Promax rotation indicated the presence of 2 correlated factors, Somatic-Affective and Cognitive, which explained 53.5% of the variance. A hierarchical, second-order analysis indicated that all items tap into a second-order construct of depression. Evidence for convergent validity was provided by predicted relationships with subscales from the Short-Form General Health Survey (SF-20; A. L. Stewart, R. D. Hayes, & J. E. Ware, 1988). A receiver operating characteristic analysis demonstrated criterion-related validity: BDI-II scores predicted a diagnosis of major depressive disorder (MDD), as determined by the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ). This study demonstrated that the BDI-II yields reliable, internally consistent, and valid scores in a primary care medical setting, suggesting that use of the BDI-II in this setting may improve detection and treatment of depression in these medical patients.

Understanding Primary Care Physicians' Propensity to Assess Elderly Patients for Depression Using Interaction and Survey Data.

Objective:The objective of this study was to examine primary care physicians’ propensity to assess their elderly patients for depression using data from videotapes and patient and physician surveys. Study Design:An observational study was informed by surveys of 389 patients and 33 physicians, and 389 videotapes of their clinical interactions. Secondary quantitative analyses used video data scored by the Assessment of Doctor–Elderly Patient Transactions system regarding depression assessment. A random-effects logit model was used to analyze the effects of patient health, competing demands, and racial and gender concordance on physicians’ propensity to assess elderly patients for depression. Results:Physicians assessed depression in only 14% of the visits. The use of formal depression assessment tools occurred only 3 times. White patients were almost 7 times more likely than nonwhite patients to be assessed for depression (odds ratio [OR], 6.9; P < 0.01). Depression assessment was less likely if the patient functioned better emotionally (OR, 0.95; P < 0.01). The propensity of depression assessment was higher in visits that covered multiple topics (OR, 1.3; P < 0.01) contrary to the notion of competing demands crowding out mental health services. Unexpectedly, depression assessment was less likely to occur in gender and racially concordant patient–physician dyads. Conclusions:Primary care physicians assessed their elderly patients for depression infrequently. Reducing the number of topics covered in visits and matching patients and physicians based on race and gender may be counterproductive to depression detection. Informed by videotapes and surveys, our findings offer new insights on the actual care process and present conclusions that are different from studies based on administrative or survey data alone.

Learning basic surgical skills with mental imagery: using the simulation centre in the mind

Context  Although surgeons and athletes frequently use mental imagery in preparing to perform, mental imagery has not been extensively researched as a learning technique in medical education.

An Efficient Method of Identifying Major Depression and Panic Disorder In Primary Care

The research literature is replete with evidence of and concerns about the prevalence and undertreatment of mental disorders in primary care. Although screening, on its own, may not directly affect clinical outcomes, it is still the most efficient and effective way to identify psychologically distressed patients for either research purposes or to provide patients with or refer patients to appropriate care. The current study sought to establish the utility of the MHI-5 for the detection of patients suffering from major depression or panic disorder, two of the most common psychiatric conditions seen in primary care settings. This study was conducted in a family medicine clinic and 246 adult outpatients participated. Patients completed the Mental Health Index-5 (MHI-5) as the screening measure and the PRIME-MD Patient Health Questionnaire (PHQ) as the diagnostic instrument. ROC analyses indicated that a cut-off score of 23 on the MHI-5 yielded a sensitivity of 91% and a specificity of 58% for predicting provisional diagnoses of major depression or panic disorder from the PHQ. Using a single item to screen for a PHQ diagnosis of major depression yielded a sensitivity of 88% and a specificity of 62% and a second question had a sensitivity of 100% and specificity of 63% for PHQ diagnosis of panic disorder. These results indicate that it is possible to use a small number of items to efficiently and effectively screen for mental disorders affecting a significant portion of primary care patients.

The Efficacy of Somatic Symptoms in Assessing Depression in Older Primary Care Patients

Abstract This investigation tested the hypothesis that somatic symptoms such as reduced energy, loss of interest, and sleep disturbance are accurate indices of depression in older medical patients. The Beck Depression Inventory-II (BDI-II) and the Medical Outcomes Study Short-Form General Health Survey (SF-20) were administered to 90 primary care older patients of a large HMO. Exploratory factor analysis of the BDI-II identified three factors (Cognitive/Distress, Depressed Mood, and Somatic). A second-order factor analysis confirmed that all somatic items contributed to the second-order factor of depression. Item analyses also supported the consistency, severity discrimination, and classification efficiency of somatic items. These findings suggest that somatic symptoms, including fatigue, anhedonia, loss of interest, sleep disturbance, and concentration problems should be included when assessing older primary care patients for depression. Although these symptoms may be signs of physical decline, presentation of these symptoms warrants a more complete evaluation of depression in elderly medical patients.

The Symbolic and Material Nature of Physician Identity: Implications for Physician–Patient Communication

This field study considers the implications of the symbolic and material nature of physician identity for communication with patients. In-depth interviews of physicians across multiple organizational contexts reveal that physician identity is a discursive process of situated meaning in which particular configurations of beliefs, values, and actions are constructed within specific contexts. The content of individual physician identity was related to the general environment of medicine and its local medical context. The identities of physicians working in private practice were linked to the economic, legal, and social environment of medicine, whereas physicians working as employees had identities related to working in a setting that buffered the effects of the environment. Specific implications of the symbolic and material nature of physician identity for physician–patient communication are examined. Understanding physician identity is important to health communication scholarship because of the ongoing and central nature of physicians in health-care decision making and delivery.

A reliable and valid instrument to assess competency in basic surgical skills in second-year medical students

Background: Despite calls for competency based education, a dearth of validated instruments for measuring basic skills currently exists. We developed an instrument to assess competency in basic surgical skills in second-year medical students and tested it for psychometric reliability and validity. Methods: From a review of the literature, an instrument comprised of numerically scaled items was constructed. After initial tests, several items were divided to produce a final instrument more specific and more appropriate for providing feedback to students. The final instrument was empirically tested for reliability and validity. Results: The final 10-item instrument is presented here along with all of the empirical evidence including internal consistency reliability and interrater reliability, and content, criterion-related, and construct validity. Overall alpha reliability was 0.84 and interrater reliability was r = 0.83, P < 0.01 for the total scores. Factor analysis provided evidence of construct validity. Conclusions: The instrument has psychometric properties adequate for use as one criterion for summative evaluation and is educationally practical enough to provide focused and detailed feedback for student improvement.

Physician Discussion About Social Activities in Primary Care Encounters With Older Adults

Objective: Involvement in social activities is linked to positive health outcomes. This study focused on the prevalence of social activity discussions during the primary care medical encounter, and examined how patient, physician, and contextual factors were associated with discussions between physicians and older patients. Methods: The research was a secondary analysis of 434 videotapes recorded during primary care medical visits between 1998 and 2000 in outpatient clinics. Recordings were coded to identify a number of variables related to patient, physician, and companion characteristics, physician discussion on various topics, and quality of the physician’s interaction with the patient. Results: Physicians discussed social activity in only 31% of medical encounters. Variables significantly associated with social activity discussions included patient and physician race/ethnicity, physician age group, physician supportiveness, and the geographical site of the visit. Conclusion: Results support the inclusion of discussion and counseling about social activities in medical encounters with older patients. Family physicians will likely experience improved patient satisfaction, and geriatric patients can potentially reap health benefits that improve both quality of life and medical outcomes. Additional research is needed to understand more fully the correlates and benefits of social activity discussion during the medical encounter.

Comparing the Effects of Physical Practice and Mental Imagery Rehearsal on Learning Basic Venipuncture by Medical Students

Effective and efficient techniques to teach basic clinical skills are much needed in medical education. Many of these skills are psychomotor, and mental imagery rehearsal has been effective in learning psychomotor skills in many fields. We conducted a fully randomized experiment to determine if mental imagery rehearsal was effective compared with physical practice in learning venipuncture (blood drawing) skills by medical students. All participants first received a lecture-demonstration on venipuncture and 30 minutes of guided physical practice on artificial plastic arms. One treatment group received an additional 30 minutes of such practice. Another treatment group received a 30-minute session of guided imagery. A control group received no additional training. Both treatment groups demonstrated improved performance on a live venipuncture compared to the control group and did not significantly differ from each other. Hence, imagery rehearsal offers a very cost-effective method of learning this basic clinical skill.

Comparing the Effects of Mental Imagery Rehearsal and Physical Practice on Learning Lumbar Puncture by Medical Students

Using mental imagery in clinical skills instruction can be a valuable teaching strategy. Prior studies have supported its use in the teaching of a variety of clinical skills including basic surgery and venipuncture. We extended this research to lumbar puncture. After viewing an instructional video, medical students received instruction on how to perform a lumbar puncture on simulators. The students were then randomized into two groups with one group receiving additional practice on the simulators and the other group receiving guided mental imagery practice. Students then performed a lumbar puncture as part of an Objective Structured Clinical Examination (OSCE) and were graded on a reliable rating instrument developed for this study. Consistent with prior studies, there was no statistically significant difference in performance between the group receiving additional physical practice and the group receiving guided mental imagery practice. Mental imagery practice appears to be an effective and cost-efficient method to teach lumbar puncture as well as a lifelong learning skill.