Evaluating clinician experience in value-based health care: the development and validation of the Clinician Experience Measure (CEM).

BACKGROUND: Clinicians' experiences of providing care constitute an important outcome for evaluating care from a value-based healthcare perspective. Yet no currently available instruments have been designed and validated for assessing clinicians' experiences. This research sought to address this important gap by developing and validating a novel instrument in a public health system in Australia. METHODS: A multi-method project was conducted using co-design with 12 clinician leaders from a range of NSW Health Local Health Districts to develop the Clinician Experience Measure (CEM). Validity and reliability analyses were conducted in two stages, first assessing face and content validity with a pool of 25 clinicians and then using psychometric analysis with data from 433 clinicians, including nurses, doctors and allied health and representing all districts within one jurisdiction in Australia. RESULTS: Data gathered from 25 clinicians via the face and content validity process indicated that the initial 31-items were relevant to the range of staff employed in the NSW state health system, with minor edits made to the survey layout and wording within two items. Psychometric analysis led to a rationalised 18-item final instrument, comprising four domains: psychological safety (4-items); quality of care (5-items); clinician engagement (4-items) and interprofessional collaboration (5-items). The 18-item four-factor model produced a good fit to the data and high levels of reliability, with factor loadings ranging from .62 to .94, with Cronbach's alpha (range: .83 to .96) and composite reliability (range: .85 to .97). CONCLUSIONS: The CEM is an instrument to capture clinicians' experiences of providing care across a health system. The CEM provides a useful tool for healthcare leaders and policy makers to benchmark and assess the impact of value-based care initiatives and direct change efforts.

Clinical characteristics and outcomes of COVID-19 in a low-prevalence, well resourced setting, Sydney, Australia.

BACKGROUND: The Northern Sydney Local Health District was one of the first health regions to be affected by COVID-19 in Australia. AIMS: To describe the clinical characteristics, risk factors and outcomes in our low-prevalence Australian population. METHODS: This is a retrospective analysis of 517 laboratory-confirmed COVID-19 cases between January and June 2020. Patient information was collected as part of routine care within the COVID-19 Virtual Hospital system. Outcomes examined were death, recovery at 30 days and intensive care unit (ICU) admission. RESULTS: The case fatality rate was 1.8%. Multivariate analysis showed factors independently associated with death, composite outcome of death/ICU admission or incomplete recovery at 30 days were age >80 years and presence of two or more comorbidities. Most cases acquired COVID-19 through international (50.9%) or cruise ship travel (9.1%). Healthcare workers comprised 12.8% of the cohort and represented a disproportionately high percentage of the 'unknown' source group (27.6%). The median incubation period was 5 days (interquartile range 3-8); one patient had an incubation period of 15 days. Hospitalisation was required in 11.8%, ICU admission in 2.1% and ventilation in 1.4%. A Radiographic Assessment of Lung Oedema score on chest X-ray of >10 was independently associated with death. CONCLUSIONS: In this low prevalence, well resourced Australian setting, we report an overall low mortality. Factors associated with adverse patient outcomes on multivariate analysis were age greater than 80 and the presence of two or more comorbidities. These data can assist in early risk stratification of COVID-19 patients, and in surge capacity planning for hospitals.

Practicing mind-body medicine before Freud: John G. Gehring, the "Wizard of the Androscoggin".

This article describes the psychotherapy practice of physician John G. Gehring and places it in historical context. Forgotten today, Gehring was a highly sought-after therapist from the 1890s to the 1920s by prominent figures in the arts, sciences, business, and law. He practiced a combination of work therapy, suggestion, and autosuggestion that has similarities to Cognitive Behavior Therapy and Behavioral Activation. Using biographies, memoirs, and archival records, the details of Gehring's work are reconstructed and the reasons for its success are analyzed. His invisibility in the history of psychiatry is attributed to the later dominance of Freudianism within the field.

A comparison of the neuropsychological profiles of people living in squalor without hoarding to those living in squalor associated with hoarding.

OBJECTIVE: Squalor affects 1 in 1000 older people and is regarded as a secondary condition to other primary disorders such as dementia, intellectual impairment and alcohol abuse. Squalor frequently is associated with hoarding behaviour. We compared the neuropsychological profile of people living in squalor associated with hoarding to those presenting with squalor only. METHODS: This study is a retrospective case series of hospital inpatient and community healthcare services of 69 people living in squalor (49 from aged care, 16 from aged psychiatry, 3 from acute medical and 1 from a memory clinic). Forty per cent had co-morbid hoarding behaviours. The main outcomes were neuropsychologists' opinions of domain-specific cognitive impairment. RESULTS: The squalor-hoarding group (M age 75.8, SD = 6.9,) was significantly older (p < 0.05) than the squalor-only group (M age 69.9 years, SD = 13.1), significantly more likely to have vascular or Alzheimer's type neurodegeneration (p < 0.05) and significantly less likely to have alcohol-related impairment (p < 0.05). Chi-square analyses revealed significantly greater rates of impairment for the squalor-only group (p < 0.05) in visuospatial reasoning, abstraction, planning, organisation, problem solving and mental flexibility, compared with the squalor-hoarding group. Logistic regression analysis indicated that impaired mental flexibility was a significant predictor and strongly indicated squalor only (odds ratio = 0.07; 95% confidence interval: 0.01-0.82). CONCLUSIONS: Preliminary evidence suggests that squalor associated with hoarding may have distinct neuropsychological features compared against squalor only. Future work should be conducted using a larger sample and a common neuropsychological battery to better understand the deficits associated with hoarding-related squalor. Copyright © 2016 John Wiley & Sons, Ltd.

Phenotypic cognitive impairment in late-onset delusional disorder.

BACKGROUND: Previous use of heterogeneous diagnostic criteria and insensitive cognitive measures has impeded clarification of the extent and type of cognitive impairment specific to late-onset delusional disorder. We examined whether clinical presentations of late-onset delusional disorder are associated with prodromal or established dementia, and whether it might be a discrete clinical syndrome characterized by its own profile of cognitive impairment. METHOD: Nineteen patients with late-onset delusional disorder from a hospital psychiatric service and 20 patients with dementia of the Alzheimer's type (AD) from an outpatient memory clinic were recruited in a consecutive case series. All patients underwent comprehensive neuropsychological assessment that included general intellectual function, executive function, new learning and delayed memory, language, processing speed, and visuo-perceptual skills. RESULTS: Late-onset delusional disorder patients showed moderate impairment to conceptual reasoning, visual object recognition, processing speed, and confrontation naming. Severe impairment appeared in visuo-perceptual planning and organization, and divided attention. Compared with the Alzheimer's disease (AD) group, the late-onset delusional disorder group demonstrated significantly poorer visuo-perceptual skills but a significantly better capacity to consolidate information into delayed memory. CONCLUSIONS: A high rate of marked cognitive impairment occurs in late-onset delusional disorder. There was evidence of a conceptual reasoning deficit, plus the presence of a visuo-perceptual impairment affecting object recognition. This impairment profile can explain the genesis and maintenance of the observed delusions. Understanding late-onset delusional disorder as other than a purely psychiatric phenomenon or a precursor to AD will lead to better assessment and management approaches.

Neuropsychological characteristics of people living in squalor.

BACKGROUND: Squalor is an epiphenomenon associated with a range of medical and psychiatric conditions. People living in squalor are not well described in the literature, and prior work has indicated that up to 50% do not have a psychiatric diagnosis. Squalor appears to be linked with neuropsychological deficits suggestive of the presence of impaired executive function. We present a case series of people living in squalor that examines their neuropsychological assessment and diagnosis. METHODS: Clinicians from local health networks were invited to submit neuropsychological reports of patients living in squalor. These selected reports were screened to ensure the presence of squalor and a comprehensive examination of a set of core neuropsychological domains. Assessments were included if basic attention, visuospatial reasoning, information processing speed, memory function, and executive function were assessed. RESULTS: Sixty-nine neuropsychological reports were included. Sixty-eight per cent of the group underwent neuropsychological assessments during an inpatient admission. For participants where it was available (52/69), the mean Mini-Mental State Examination score was 25.29 (SD = 3.96). Neuropsychological assessment showed a range of cognitive impairment with nearly all the participants (92.75%) found to have frontal executive dysfunction. One person had an unimpaired neuropsychological assessment. Results indicated that dorsolateral prefrontal rather than orbitofrontal functions were more likely to be impaired. Vascular etiology was the most common cause implicated by neuropsychologists. CONCLUSIONS: Frontal executive dysfunction was a prominent finding in the neuropsychological profiles of our sample of squalor patients, regardless of their underlying medical or psychiatric diagnoses. Our study highlights the importance of considering executive dysfunction when assessing patients who live in squalor.

Little Albert's alleged neurological impairment: Watson, Rayner, and historical revision.

In 2012, Fridlund, Beck, Goldie, and Irons (2012) announced that "Little Albert"-the infant that Watson and Rayner used in their 1920 study of conditioned fear (Watson & Rayner, 1920)-was not the healthy child the researchers described him to be, but was neurologically impaired almost from birth. Fridlund et al. also alleged that Watson had committed serious ethical breaches in regard to this research. Our article reexamines the evidentiary bases for these claims and arrives at an alternative interpretation of Albert as a normal infant. In order to set the stage for our interpretation, we first briefly describe the historical context for the Albert study, as well as how the study has been construed and revised since 1920. We then discuss the evidentiary issues in some detail, focusing on Fridlund et al.'s analysis of the film footage of Albert, and on the context within which Watson and Rayner conducted their study. In closing, we return to historical matters to speculate about why historiographical disputes matter and what the story of neurologically impaired Albert might be telling us about the discipline of psychology today.

If the peri-operative patient pathway was right, what would it look like?

BACKGROUND: Patients undergoing surgery deserve the best possible peri-operative outcomes. Each stage of the peri-operative patient journey offers opportunities to improve care delivery, with shorter lengths of stay, less complications, reduced costs and better value. METHODS: These opportunities were identified through narrative review of the literature, with consultation and consensus at the hidden pandemic (of postoperative complications) summit 2, July 2023 in Adelaide, Australia RESULTS: Before surgery: Some patients who receive timely alternative treatments may not need surgery at all. The period of waiting after listing should be a time of preparation. Risk assessment at the time of surgical listing facilitates recognition of need for comorbidity optimisation and identifies those who will most benefit from prehabilitation, particularly frail and deconditioned patients. DURING SURGERY: During the surgical admission, ERAS programs result in less postoperative complications, shorter length of stay and better patient experience but require agreement between clinicians, and coordinated monitoring of delivery of the elements in the ERAS bundle of care. AFTER SURGERY: At-risk patients need to have the appropriate levels of monitoring for cardiovascular instability, renal impairment or respiratory dysfunction, to facilitate timely, proactive management if they develop. Access to allied health in the early postoperative period is also critical for promoting mobility, and earlier discharge, particularly after joint surgery. Where appropriate, provision of rehabilitation services at home improves patient experience and adds value. The peri-operative patient journey begins and ends with primary care so there is a need for clear communication, documentation, around sharing of responsibility between practitioners at each stage. CONCLUSION: Identifying and mitigating risk to reduce complications and length of stay in hospital will improve outcomes for patients and deliver the best value for the health system.

A novel daily QA system for proton therapy.

We describe the design and use of a daily quality assurance (QA) system for proton therapy. The QA system is designed to check the overall readiness of proton therapy system consistently within certain reference tolerances by a home-made QA device (the QA device). The QA device is comprised of a commercially available QA device, rf-Daily QA 3, a home-made acrylic phantom, a set of acrylic compensators with various thicknesses, and a mechanical indexing jig. The indexing jig indexes the rf-Daily QA 3, as well as the acrylic phantom, onto the patient treatment couch. Embedded fiducial markers in the acrylic phantom are used to check X-ray image quality and positioning alignment accuracy of the imaging system. The rf-Daily QA 3 is used to check proton beam output, range and symmetry with one single beam delivery. We developed in-house software to calculate beam range and symmetry, based on various ion chambers' readings inside the rf-Daily QA 3. With a single setup and one beam irradiation, the QA system is employed to check couch movement, laser alignment, image registration, and reference proton beam characteristics. The simplicity and robustness of this QA system allows for a total QA time of less than 20 minutes per room. The system has been in use at three proton therapy centers since June 2009.

"Down with fascism, up with science": Activist psychologists in the U.S., 1932-1941.

At the height of the Depression, more psychologists in the U.S. were awarded degrees than could find jobs. Master's level graduates were particularly affected, holding positions that were tenuous, and they rejected second-class membership offered by the American Psychological Association. In response to this employment crisis, two Columbia University MA graduates created The Psychological Exchange, a journal that offered graduates and established colleagues a forum for news, job ads, and for discussing the expansion of psychology to address problems of the Depression. This article describes the Exchange and its unique window into psychologists debating how to reshape their field. In 1934, it was used by young Marxists to launch The Psychologists' League, which agitated for colleagues who lost their jobs, tried to make research socially relevant, and connected with movements for the "social reconstruction" of society. It raised the consciousness of its members and sympathizers by linking to worldwide antifascist struggles while fighting antisemitism and nativism at home. While previous accounts make the League seem a spontaneous eruption, this article shows how members of the Communist Party created it, then controlled its agenda and activities. During the Stalin-Hitler pact they followed Stalin's anti-war ideology and the League became a shell organization. Its members, nonetheless, creatively mixed psychological concepts and political ideology, drawing in colleagues through discussion groups, demonstrations, and social events. Sources for this work include unpublished correspondence, a diary, and Federal Bureau of Investigation files that reveal more complex lives than previously portrayed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Archival oddities: Rosalie Rayner's application to take graduate classes.

In the history of psychology, Rosalie Rayner is known as a research assistant to behaviorist John B. Watson in the study of a baby named Albert, coauthor of articles describing that research, and coauthor of Psychological Care of Infant and Child. Rayner also wrote two magazine articles about her experience as a mother and the wife of Watson (Harris, 2014). Thanks to archivist James Stimpert, the author discovered that she was never a candidate for a graduate degree. In fall of 1919, she applied to take graduate classes at Hopkins and was accepted (Figure 1). However, she applied 2 weeks after classes had begun and never registered for any courses in the fall or spring semesters. Even more interesting, her application was approved by Watson on the same day she applied, which was a Saturday. The current author agrees with Romano-Lax and suggest that we appreciate Rayner's life and work without claiming her as a psychologist. While she deserves credit for her contributions to the Albert study and coauthored book on child care, her own voice is best heard when she looked beyond the field of psychology. In her 1932 article, "what future has motherhood?" she addressed the broader question of how the family could be restructured, which was being debated by feminists and other social reformers. While not consistently feminist, her perspective was dramatically different from her husband's. In Rayner Watson's view of the future, child care and other domestic work would be collectivized, as was being tried in the Soviet Union, freeing women for any activities they choose (Harris, 2014; R. R. Watson, 1932). Clearly, she had long left the laboratory, and her contributions should not be reduced to the "study of behavioral psychology" (Smirle, 2013). (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Notes from the archives: Margaret Floy Washburn and her cats.

Margaret Floy Washburn was one of the leading psychologists of her generation, whose most important work was The Animal Mind (Goodman, 1980). As E. G. Boring noted, that text "reflected her own love of animals and her intense interest in their behavior" (1971, p. 547). What about the role of animals in Washburn's personal life? (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Pilot study to evaluate hypercoagulation and inflammation using rotational thromboelastometry and calprotectin in COVID-19 patients.

INTRODUCTION: Abnormal coagulation and inflammation are hallmarks of SARs-COV-19. Stratifying affected patients on admission to hospital may help identify those who at are risk of developing severe disease early on. Rotational Thromboelastometry (ROTEM) is a point of care test that can be used to measure abnormal coagulation and calprotectin is a measure of inflammation. AIM: Assess if ROTEM can measure hypercoagulability on admission and identify those who will develop severe disease early on. Assess if calprotectin can measure inflammation and if there is a correlation with ROTEM and calprotectin. METHODS: COVID-19 patients were recruited on admission and ROTEM testing was undertaken daily for a period of 7 days. Additionally inflammatory marker calprotectin was also tested for the same period. RESULTS: 33 patients were recruited to the study out of which 13 were admitted to ITU and 20 were treated on the ward. ROTEM detected a hypercoagulable state on admission but did not stratify between those admitted to a ward or escalated to ITU. Calprotectin levels were raised but there was no statistical difference (p = 0.73) between patients admitted to a ward or escalated to ITU. Significant correlations were observed between FIBA5 (r = 0.62; p<0.00), FIBCFT (r = -0.57; p<0.00), FIBMCF (r = 0.64; p<0.00) and INMCF (r = 0.57; p<0.00) and calprotectin. CONCLUSION: COVID-19 patients were hypercoagulable on admission. The correlations between ROTEM and calprotectin underline the interactions between inflammation and coagulation.

Sponge functional roles in a changing world.

Sponges are ecologically important benthic organisms with many important functional roles. However, despite increasing global interest in the functions that sponges perform, there has been limited focus on how such functions will be impacted by different anthropogenic stressors. In this review, we describe the progress that has been made in our understanding of the functional roles of sponges over the last 15 years and consider the impacts of anthropogenic stressors on these roles. We split sponge functional roles into interactions with the water column and associations with other organisms. We found evidence for an increasing focus on functional roles among sponge-focused research articles, with our understanding of sponge-mediated nutrient cycling increasing substantially in recent years. From the information available, many anthropogenic stressors have the potential to negatively impact sponge pumping, and therefore have the potential to cause ecosystem level impacts. While our understanding of the importance of sponges has increased in the last 15 years, much more experimental work is required to fully understand how sponges will contribute to reef ecosystem function in future changing oceans.

Crowding does not adversely affect time to percutaneous coronary intervention for acute myocardial infarction in a community emergency department.

STUDY OBJECTIVE: Multiple studies have linked emergency department (ED) crowding to delays in patient care, such as treatment with antibiotics and analgesics. Multiple studies have also demonstrated the benefit of timely percutaneous coronary intervention for patients with acute ST-segment elevation myocardial infarction (STEMI). We therefore study whether increased occupancy rates in our community ED might correlate with delays in door-to-balloon time for patients with acute STEMI who are referred for emergency percutaneous coronary intervention. METHODS: This study was a single-institution prospective observational study. For every patient arriving in our ED from June 2007 through October 2009 with acute STEMI treated with percutaneous coronary intervention, we measured the ED occupancy rate on arrival and the door-to-balloon time and determined the correlation between these variables in univariate and multivariate analyses controlling for patient characteristics, occupancy rate, times to ECG and catheter laboratory activation, and the availability of the catheterization laboratory team (in-house versus on-call). RESULTS: During the study period, 210 patients were treated with emergency percutaneous coronary intervention in accordance with the hospital protocol. For these patients, the mean ED occupancy rate at arrival was 127% (range 28% to 214%). The mean time to balloon inflation was 65 minutes (range 25 to 142 minutes). The time to balloon inflation did not significantly change with increasing occupancy rate in univariate analysis (Spearman's correlation -0.02; 95% confidence interval -0.13 to 0.11) or in multivariate analysis, with the only significant variable being the availability of the catheterization laboratory team in house, which was associated with reduced time to balloon inflation. CONCLUSION: Times to achieve emergency percutaneous coronary intervention for acute STEMI do not correlate positively with crowding as measured by the occupancy rate in our ED.

Archival Oddities: Leo Kamin Pounding out Copy for the Daily Worker.

This short research report focuses on psychologist Leon Kamin, who is best known for his research on what became known as the Kamin (blocking) effect. In the 1970s and 1980s he became prominent both inside and outside of psychology, not for laboratory research but for his writings on the heritability of intelligence. Kamin was no stranger to political activism. He joined the Communist Party U.S.A. at age 17, when he was a sophomore at Harvard. By 1949, he was writing for the Daily Worker (pen name: Leo Soft) and was employed as its New England editor in 1949-1950. In January 1954, Kamin was called to testify by Joseph McCarthy's anti-Communist Senate subcommittee, which was visiting Boston and justified its interest in Harvard by citing its winning research grants from the U.S. Department of Defense. Kamin refused to "name names" and he was indicted for contempt of the Senate. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Archival oddities: The manifesto of the upper left hand corner club.

Forty-two years ago, a small group within the Cheiron Society formed a dissident caucus, the Upper Left Hand Corner Club (ULHCC). The founding document, preserved in an old file folder, featured a diagram of the place of the history of psychology in relation to other fields, such as social history and the history of ideas. The goal of the caucus was to move the history of psychology to the upper left-hand corner of the diagram. That meant shifting the history of psychology from a somewhat immature version of the history of ideas, in which the precursors of late 20th century psychological theories could be discovered in the work of earlier figures ranging from Wilhelm Wundt and William James to William Wordsworth and Isaac Newton (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Commissioning of output factors for uniform scanning proton beams.

PURPOSE: Current commercial treatment planning systems are not able to accurately predict output factors and calculate monitor units for proton fields. Patient-specific field output factors are thus determined by either measurements or empirical modeling based on commissioning data. The objective of this study is to commission output factors for uniform scanning beams utilized at the ProCure proton therapy centers. METHODS: Using water phantoms and a plane parallel ionization chamber, the authors first measured output factors with a fixed 10 cm diameter aperture as a function of proton range and modulation width for clinically available proton beams with ranges between 4 and 31.5 cm and modulation widths between 2 and 15 cm. The authors then measured the output factor as a function of collimated field size at various calibration depths for proton beams of various ranges and modulation widths. The authors further examined the dependence of the output factor on the scanning area (i.e., uncollimated proton field), snout position, and phantom material. An empirical model was developed to calculate the output factor for patient-specific fields and the model-predicted output factors were compared to measurements. RESULTS: The output factor increased with proton range and field size, and decreased with modulation width. The scanning area and snout position have a small but non-negligible effect on the output factors. The predicted output factors based on the empirical modeling agreed within 2% of measurements for all prostate treatment fields and within 3% for 98.5% of all treatment fields. CONCLUSIONS: Comprehensive measurements at a large subset of available beam conditions are needed to commission output factors for proton therapy beams. The empirical modeling agrees well with the measured output factor data. This investigation indicates that it is possible to accurately predict output factors and thus eliminate or reduce time-consuming patient-specific output measurements for proton treatments.

Arnold Gesell's progressive vision: child hygiene, socialism and eugenics.

In October 1913, The American Magazine published an article by Arnold Gesell that portrayed Alma, Wisconsin (his hometown) as overflowing with the mentally and morally unfit. In "The Village of a Thousand Souls", Gesell called for the observation and segregation of the unfit as a eugenic measure. This article explores the reasons behind this infamous article by someone who became a famous developmental psychologist and pediatrician. Gesell's papers at the Library of Congress reveal his socialist views of poverty, injustice, and human development. The archives of his father's photography studio at the Wisconsin Historical Society reveal his manipulation of the photographic record to fit his negative view of Alma. Typical of the era, Gesell's Progressive vision combined social control and negative eugenics with egalitarianism and the benevolent engineering of the environment.