Timothy R. Dresselhaus

Sensitivity and specificity of the PTSD checklist in detecting PTSD in female veterans in primary care

PTSD affects a substantial number of women in medical settings and is associated with significant distress and impairment. There are effective methods of treating trauma-related distress, but a minority seek such care. Thus, primary care is an important setting in which to identify individuals with PTSD. We sent questionnaires, including the PTSD Checklist—Civilian Version (PCL-C), to 419 female veterans who were seen in our primary care clinic in 1998; 56% (N = 221) returned the measures. A random subset (n = 49) was interviewed to establish psychiatric diagnoses. The results provide qualified support for the use of the PCL-C total score with a lowered cutoff score as a screening measure for PTSD in female veterans in primary care.

Sexual Trauma, Posttraumatic Stress Disorder, and Health Behavior

Abstract The authors tested whether sexual traumatization is associated with poorer health behavior and also evaluated the role of posttraumatic stress disorder (PTSD) in this relationship. They mailed questionnaires to 419 women who had visited a San Diego Veterans Administration primary care clinic in 1998 and received 221 responses, a 56% return rate. They found that a history of sexual assault was associated with increased substance use, risky sexual behaviors, less vigorous exercise, and increased preventive healthcare. They then used regression-based techniques to test whether PTSD mediates the relationship between a history of sexual assault and health behaviors and discovered support for this hypothesis in relation to substance use. PTSD symptoms were also associated with less likelihood of conducting regular breast self-examinations. Findings from the study highlight the value of programs designed to (1) identify trauma victims, (2) screen for problematic behaviors, and (3) intervene to improve long-term health outcomes.

An Evaluation of Vignettes for Predicting Variation in the Quality of Preventive Care

OBJECTIVE: Clinical vignettes offer an inexpensive and convenient alternative to the benchmark method of chart audits for assessing quality of care. We examined whether vignettes accurately measure and predict variation in the quality of preventive care. DESIGN: We developed scoring criteria based on national guidelines for 11 prevention items, categorized as vaccine, vascular-related, cancer screening, and personal behaviors. Three measurement methods were used to ascertain the quality of care provided by clinicians seeing trained actors (standardized patients; SPs) presenting with common outpatient conditions: 1) the abstracted medical record from an SP visit; 2) SP reports of physician practice during those visits; and 3) physician responses to matching computerized case scenarios (clinical vignettes). SETTING: Three university-affiliated (including 2 VA) and one community general internal medicine clinics. PATIENTS/PARTICIPANTS: Seventy-one randomly selected physicians from among eligible general internal medicine residents and attending physicians. MEASUREMENTS AND MAIN RESULTS: Physicians saw 480 SPs (120 at each site) and completed 480 vignettes. We calculated the proportion of prevention items for each visit reported or recorded by the 3 measurement methods. We developed a multiple regression model to determine whether site, training level, or clinical condition predicted prevention performance for each measurement method. We found that overall prevention scores ranged from 57% (SP) to 54% (vignettes) to 46% (chart abstraction). Vignettes matched or exceeded SP scores for 3 prevention categories (vaccine, vascular-related, and personal behavior). Prevention quality varied by site (from 40% to 67%) and was predicted similarly by vignettes and SPs. CONCLUSIONS: Vignettes can measure and predict prevention performance. Vignettes may be a less costly way to assess prevention performance that also controls for patient case-mix.

Measuring Compliance with Preventive Care Guidelines

AbstractOBJECTIVE: To determine how accurately preventive care reported in the medical record reflects actual physician practice or competence. DESIGN: Scoring criteria based on national guidelines were developed for 7 separate items of preventive care. The preventive care provided by randomly selected physicians was measured prospectively for each of the 7 items. Three measurement methods were used for comparison: (1) the abstracted medical record from a standardized patient (SP) visit; (2) explicit reports of physician practice during those visits from the SPs, who were actors trained to present undetected as patients; and (3) physician responses to written case scenarios (vignettes) identical to the SP presentations. SETTING: The general medicine primary care clinics of two university-affiliated VA medical centers. PARTICIPANTS: Twenty randomly selected physicians (10 at each site) from among eligible second- and third-year general internal medicine residents and attending physicians. MEASUREMENTS AND MAIN RESULTS: Physicians saw 160 SPs (8 cases × 20 physicians). We calculated the percentage of visits in which each prevention item was recorded in the chart, determined the marginal percentage improvement of SP checklists and vignettes over chart abstraction alone, and compared the three methods using an analysis-of-variance model. We found that chart abstraction underestimated overall prevention compliance by 16% (P < .01) compared with SP checklists. Chart abstraction scores were lower than SP checklists for all seven items and lower than vignettes for four items. The marginal percentage improvement of SP checklists and vignettes to performance as measured by chart abstraction was significant for all seven prevention items and raised the overall prevention scores from 46% to 72% (P < .0001). CONCLUSIONS: These data indicate that physicians perform more preventive care than they report in the medical record. Thus, benchmarks of preventive care by individual physicians and institutions that rely solely on the medical record may be misleading, at best.

Mental health treatment preferences of older and younger primary care patients

Objective: To compare mental health treatment history and preferences in older and younger primary care patients. Method: We surveyed 77 older (60+) and 312 younger adult primary care patients from four outpatient medical clinics about their mental health treatment history and preferences. Results: Older adults were less likely than younger adults to report a history of mental health treatment (29% vs. 51%) or to be currently receiving treatment (11% vs. 23%). They were also less likely to indicate that they currently desire help with emotional problems (25% vs. 50%). Older adults were more likely to hold a belief in self-reliance that could limit their willingness to accept treatment for mental health problems, although they were less likely than younger adults to identify other barriers to treatment. Older adults reported that they were less likely to attend programs in primary care targeting mental health issues (counseling, stress management) than younger adults, although they were as willing as younger adults to attend programs targeting physical health issues (healthy living class, fitness program). Age remained a significant predictor of mental health treatment history and preferences even after controlling for other demographic variables. Conclusion: These results suggest that older adults in the primary care setting may be less willing to accept mental health services than younger adults. Results further suggest that perceived barriers may differ for older and younger patients, which may indicate the need for age-specific educational messages and services targeted to older adults in primary care.

A Real-Time Assessment of Work Stress in Physicians and Nurses

OBJECTIVE This study adapted ecological momentary assessment methods to: (a) examine differences in work stress between nurses and physicians, and (b) to study relationships between work stress, work activity patterns, and sleep. DESIGN A total of 185 physicians and 119 nurses (206 women, 98 men) working in four teaching hospitals participated in an observational study of work stress. MAIN OUTCOME MEASURES Participants carried handheld computers that randomly prompted them for work activity, patient load, and work stress information. RESULTS Participants completed more than 9,500 random interval surveys during the study (an average of 30.8 surveys per person-week). Approximately 85% of all surveys were completed in full (73.3%) or partially (11.6%). Emotional stress scores among physicians were nearly 50% higher (26.9[19.0]) than those of nurses (18.1[14.9], r[302] = .37, p < .001). Direct and indirect care activities were associated with higher stress reports by both clinician groups (rs[159] = .14-.26, ps < .01). Sleep quality and quantity were predictors of work stress scores (ps < .05). Finally, higher work stress and lower sleep quality were also associated with poorer memory performance (r[302] = -.12, .17, ps < 05). CONCLUSIONS The findings identify patterns of work stress in relationship to work activities, sleep habits, and provider differences that may be used to assist ongoing hospital work reform efforts.

Analyzing the time and value of housestaff inpatient work

OBJECTIVE: To determine time allocation and the perceived value to education and patient care of the weekday activities of internal medicine housestaff on inpatient rotations and to compare the work activities of interns and residents.DESIGN: An observational study. We classified activities along five dimensions (association, location, activity, time, and value), developed a computer-assisted self-interview survey, and demonstrated its face and content validity, internal consistency, and interrater reliability. Subjects were assigned survey computers for 5 consecutive weekdays over a 24-week period, into which they entered data when prompted several times a day.SETTING: The medical service of a university-affiliated Veterans Administration Medical Center.PARTICIPANTS: Sixty housestaff (36 interns, 24 residents) rotating on the inpatient wards.MEASUREMENTS AND MAIN RESULTS: We analyzed activities according to content (direct patient care, indirect patient care, education), association, and location. Likert-scale ratings of perceived value to education and patient care were also obtained. Housestaff provided complete responses to 3,812 (95%) of 3,992 prompts by a median of 11 seconds; 93% of responses were logically consistent across the measured dimensions. Housestaff spent more time in indirect patient care (56%) than in direct patient care (14%) or educational activities (45%). Formal educational activities had the highest educational value (66 on 0–100 scale), and direct care had the highest value to patient care (81). Over 30% of time was spent in administrative activities, which had low educational value (40). Compared with residents, interns allocated significantly less time to educational activities (38% vs 57%) and more time to lower-value activities such as documentation (19% vs 12%).CONCLUSIONS: Improved data collection methods demonstrate that housestaff in our program, particularly interns, spend much of their workday in activities that are low in educational and patient care value. Selective elimination or delegation of such activities would preserve higher-value experiences during reductions in overall inpatient training time. Planners can use automated random sampling to guide the rational redesign of housestaff work.

Intern to Attending: Assessing Stress Among Physicians

Purpose Organizations have raised concerns regarding stress in the medical work environment and effects on health care worker performance. This studys objective was to assess workplace stress among interns, residents, and attending physicians using Ecological Momentary Assessment technology, the gold-standard method for real-time measurement of psychological characteristics. Method The authors deployed handheld computers with customized software to 185 physicians on the medicine and pediatric wards of four major teaching hospitals. The physicians contemporaneously recorded multiple dimensions of physician work (e.g., type of call day), emotional stress (e.g., worry, stress, fatigue), and perceived workload (e.g., patient volume). The authors performed descriptive statistics and t test and linear regression analyses. Results Participants completed 5,673 prompts during an 18-month period from 2004 to 2005. Parameters associated with higher emotional stress in linear regression models included male gender (t = −2.5, P = .01), total patient load (t = 4.2, P < .001), and sleep quality (t = −2.8, P = .006). Stress levels reported by attendings (t = −3.3, P = .001) were lower than levels reported by residents (t = −2.6, P = .009), and emotional stress levels of attendings and residents were both lower compared with interns. Conclusions On inpatient wards, after recent resident duty hours changes, physician trainees continue to show wide-ranging evidence of workplace stress and poor sleep quality. This is among the first studies of medical workplace stress in real time. These results can help residency programs target education in stress and sleep and readdress workload distribution by training level. Further research is needed to clarify behavioral factors underlying variability in housestaff stress responses.

Development of a hand-held computer platform for real-time behavioral assessment of physicians and nurses

We developed a hand-held data collection tool to facilitate real-time collection of data on the factors that affect hospital staff performance. To assure high-yield of data from busy clinicians, the design objectives included low response burden, the ability to collect complex real-time data in dynamic work environments, and automated data integration. Iterative user-centered design of custom interfaces resulted in a dynamic intuitive platform where branching logic was applied to present a series of survey questions dependent on the participants responses. Over a 12-month period, 304 inpatient physicians and nurses completed (with minimal initial training) a total of 11,381 survey responses. For randomly timed repeated survey prompts, complete (73%) or partial (12%) responses were obtained in a median time of 96s.

Real‐Time Assessment of Nurse Work Environment and Stress

&NA; Ecological momentary assessment methods were used to examine real–time relationships between work environment factors and stress in a sample of 119 registered nurses (RNs) in acute and critical care settings of three hospitals. The RNs carried handheld computers for 1 week of work shifts and were randomly surveyed within 90–min intervals to self–report work activity, perceived workload, and stress. Mixed effects linear regression analyses were completed to predict the stress score in the sample. The number of patients assigned significantly predicted stress; the greater the number of assigned patients, the higher the reported stress (p<.01). Age, gender, adult versus pediatric facility type, familiarity with patients, and proportion of direct care tasks were not significant predictors of stress. Further research is needed to link work environment factors and stress with errors among nurses.