Psycho-social counselling in predictive genetic testing for cancer: the association between number of supportive sessions and client characteristics as assessed by psycho-social workers.

Given the increased demand on genetic services, it is important to identify clients who may require relatively more extensive psychosocial support. This paper describes which client characteristics, as assessed in the first psycho-social counselling session, were associated with requiring relatively more psycho-social support (> or = 3 sessions) in the process of predictive testing for cancer. The study population consisted of 244 counselees for hereditary cancer. Data were derived from an electronic data-base, used by psycho-social workers for the systematic registration of relevant details of each counselling session. Data were analysed for two respective groups: (A) patients who had a known mutation in the family and (B) patients with an as yet unknown mutation in the family. Results show that two or more psychosocial sessions were given if the information derived from the first session indicated the client to have childhood experiences with cancer (in group A), to experience the family role and/or the psychological impact as burdensome (in both groups) or to experience the social impact as burdensome (in group B). We conclude that the first assessment by a psychosocial worker already provides valuable information on the psychological support needs of patients. These findings provide insight into possible problem areas for clients dealing with predictive genetic testing.

Using standardized video cases for assessment of medical communication skills: reliability of an objective structured video examination by computer.

OBJECTIVE: Using standardized video cases in a computerized objective structured video examination (OSVE) aims to measure cognitive scripts underlying overt communication behavior by questions on knowledge, understanding and performance. In this study the reliability of the OSVE assessment is analyzed using the generalizability theory. METHODS: Third year undergraduate medical students from the Academic Medical Center of the University of Amsterdam answered short-essay questions on three video cases, respectively about history taking, breaking bad news, and decision making. Of 200 participants, 116 completed all three video cases. Students were assessed in three shifts, each using a set of parallel case editions. About half of all available exams were scored independently by two raters using a detailed rating manual derived from the other half. Analyzed were the reliability of the assessment, the inter-rater reliability, and interrelatedness of the three types of video cases and their parallel editions, by computing a generalizability coefficient G. RESULTS: The test score showed a normal distribution. The students performed relatively well on the history taking type of video cases, and relatively poor on decision making and did relatively poor on the understanding ('knows why/when') type of questions. The reliability of the assessment was acceptable (G = 0.66). It can be improved by including up to seven cases in the OSVE. The inter-rater reliability was very good (G = 0.93). The parallel editions of the video cases appeared to be more alike (G = 0.60) than the three case types (G = 0.47). DISCUSSION: The additional value of an OSVE is the differential picture that is obtained about covert cognitive scripts underlying overt communication behavior in different types of consultations, indicated by the differing levels of knowledge, understanding and performance. The validation of the OSVE score requires more research. CONCLUSION AND PRACTICE IMPLICATIONS: A computerized OSVE has been successfully applied with third year undergraduate medical students. The test score meets psychometric criteria, enabling a proper discrimination between adequately and poorly performing students. The high inter-rater reliability indicates that a single rater is permitted.

Diabetes Fear of Injecting and Self-Testing Questionnaire: a psychometric evaluation.

OBJECTIVE: To study the psychometric properties of the Diabetes Fear of Injecting and Self-Testing Questionnaire (D-FISQ). RESEARCH DESIGN AND METHODS: Two groups of patients were studied. Sample A consisted of 252 insulin-treated diabetes patients. Sample B incorporated 24 insulin-treated patients with high scores (> or = 95th percentile) on the D-FISQ. Test-retest correlations were assessed in both samples. Discriminant and convergent validity of the D-FISQ were assessed with questionnaires concerning fear of hypoglycemia, trait anxiety, and fear of bodily injury, illness, or death. To evaluate criterion-related validity, sample B participated in a behavioral avoidance test (BAT), in which the current level of avoidance of either self-injecting or self-testing was determined. Exploratory factor analysis (EFA) was performed to study whether 2 factors (fear of self-injecting [FSI] and fear of self-testing [FST]) could be detected. RESULTS: Test-retest correlations ranged from 0.50 to 0.68 (P < 0.001). Correlations between D-FISQ and fear of hypoglycemia, trait anxiety, and fear of bodily injury, illness, or death ranged from 0.28 to 0.45 (P < 0.001). Patients who refused to do a BAT for self-injecting or self-testing had higher scores on FSI (P = 0.095) and FST (P = 0.01). EFA yielded 2 separate factors, FSI and FST. CONCLUSIONS: Results from this study support reliability and validity of the D-FISQ, a self-report instrument that can be used for both clinical and research purposes.

Insulin-treated diabetes patients with fear of self-injecting or fear of self-testing: psychological comorbidity and general well-being.

OBJECTIVE: To examine psychological functioning and self-management behaviours of Dutch adult patients with insulin-requiring diabetes mellitus suffering from extreme fear of self-injecting (FSI) and/or fear of self-testing (FST). METHODS: A cross-sectional survey was performed in a sample of insulin-treated diabetes patients (n=1275; 51.1% male; age 49.7+/-15.8 years; 58.0% Type 1 diabetes), assessing FSI and FST. Patients completed the questionnaires concerning trait/state anxiety, depression, fear of hypoglycemia, diabetes-related distress, diabetes self-care activities, and general well-being. Comparisons were made on these measures between patients with extremely high scores on FSI and/or FST (> or = 95th percentile) and the other patients. Patients with extreme scores on FSI and/or FST were invited to take part in a second survey to assess the prevalence of major depression, common fears/phobias, and psychoneuroticism. RESULTS: People with extreme FSI/ FST scores, as compared to the other patients, reported higher levels of trait/state anxiety and depression. This group also reported more fear of hypoglycaemia and diabetes-related distress, had lower levels of general well-being, and reported less frequent self-monitoring of blood glucose. The second survey showed 11.1% of patients with extreme FSI/FST reporting scores indicating major depression. Prevalence of scores greater than or equal to the high scores on phobias (38.0-63.3%) and psychoneuroticism (27.8%) were consistently higher than norm group prevalences. DISCUSSION: Extreme levels of FSI and/or FST are associated with high diabetes-related distress, poor general well-being, and psychological comorbidity, as well as poorer adherence to the diabetes treatment regimen. It is concluded that patients with extreme FSI/FST are often burdened with more than this specific phobia.

Phobia of self-injecting and self-testing in insulin-treated diabetes patients: opportunities for screening.

AIMS: To define clinically relevant cut-off points for severe fear of self-injecting (FSI) and self-testing (FST) (phobia) in insulin-treated patients with diabetes, and to estimate the magnitude of these phobias in our research population. METHODS: FSI and FST were assessed in a cross-sectional survey using the Diabetes Fear of Injecting and Self-testing Questionnaire (D-FISQ). A sample of 24 insulin-treated adult diabetic patients was selected from the high-scorers on FSI and/or FST (> or = 95th percentile). FSI and FST were re-assessed, after which patients participated in a behavioural avoidance test (BAT), thereby determining the current level of avoidance of either self-injecting or self-testing. FSI and FST scores were linked to the outcome of the BATs. Cut-off scores for severe FSI/FST were determined and extrapolated to the total study population (n = 1275). RESULTS: Seven patients participated in the self-injecting BAT: two patients refused to perform an extra injection. In the self-testing BAT (n = 17) four patients declined to perform the extra blood glucose self-test. Extrapolation of FSI and FST cut-off scores to the total research population showed that 0.2-1.3% of the population scored in the severe FSI range. In FST, 0.6-0.8% of the total study population obtained scores in the cut-off range. CONCLUSIONS: Severe FSI and FST, characterized by emotional distress and avoidance behaviour, seems to occur in a small group of insulin-treated patients with diabetes. The D-FISQ can be of use to health care professionals (physicians, nurse specialists) in quickly providing valuable information on levels of FSI and FST in diabetes patients.

Development and validation of the diabetes fear of injecting and self-testing questionnaire (D-FISQ): first findings.

To quantify the degree of fear of self-injecting insulin and self-testing of blood glucose in adult insulin-treated diabetic patients, the Diabetes Fear of Injecting and Self-testing Questionnaire (D-FISQ) was developed. The D-FISQ is a 30-item self-report questionnaire consisting of two subscales that measure Fear of Self-Injecting (FSI) and Fear of Self-Testing (FST). To test validity and internal consistency, the D-FISQ was administered to a sample of 266 insulin-treated patients (Type 1 and Type 2); four diagnosed injection phobic insulin-requiring diabetic patients also completed the D-FISQ. The minimal score was obtained on the subscales by 62% (FSI) and 57% (FST) of the population. The D-FISQ demonstrated high internal consistency, with Cronbach's as of 0.94 (D-FISQ), 0.94 (FSI), and 0.90 (FST). Spearman rho between fear of self-injecting and fear of self-testing was 0.59 (p < 0.001), justifying two separate subscales. Construct validity was confirmed by a correlation of 0.44 with Spielbergers Trait Anxiety Inventory (Spearman rho, p < 0.001). FSI-scores from the injection phobic patients were all > or =95th percentile, while three scored > or =95% on FST, indicating discriminative validity. Results confirm homogeneity and validity of the D-FISQ and suggest usefulness of this instrument in both clinical practice and research.

Assessment of medical communication skills by computer: assessment method and student experiences.

BACKGROUND: A computer-assisted assessment (CAA) program for communication skills designated ACT was developed using the objective structured video examination (OSVE) format. This method features assessment of cognitive scripts underlying communication behaviour, a broad range of communication problems covered in 1 assessment, highly standardised assessment and rating procedures, and large group assessments without complex organisation. SETTING: The Academic Medical Centre (AMC) at the University of Amsterdam, the Netherlands. Aims To describe the development of the AMC Communication Test (ACT); to describe our experiences with the examination and rating procedures; to present test score descriptives, and to present the students' opinions of ACT. DESIGN: The ACT presents films on history taking, breaking bad news and shared decision making. Each film is accompanied by 3 types of short essay questions derived from our assessment model: "knows", "knows why/when" and "knows how". Evaluation questions about ACT were integrated into the assessment. Participants A total of 210 third year medical undergraduates were assessed. This study reports on the 110 (53%) students who completed all evaluation questions. RESULTS: Marking 210 examinations took about 17 days. The test score matched a normal distribution and showed a good level of discrimination of the students. About 75% passed the examination. Some support for the validity of our assessment model was found in the students' differential performance on the 3 types of questions. The ACT was well received. Student evaluations confirmed our efforts to develop realistic films that related well to the communication training programme. CONCLUSIONS: The ACT is a useful assessment method which complements interpersonal assessment methods for the evaluation of the medical communication skills of undergraduates.

Genetic counseling for familial conditions during pregnancy: an analysis of patient characteristics.

Reproductive genetic counseling for a familial genetic risk factor preferably takes place before conception. However, of the women with a family history of genetic conditions who attend our department of clinical genetics, about 10-20% attend for the first time during a pregnancy. The current study aims to explore patient-related factors that may affect this late timing of reproductive genetic counseling. Consecutive pregnant (n = 100) and non-pregnant (n = 84) women visiting the department of clinical genetics for a genetic risk factor which was not age related completed a questionnaire immediately prior to the consultation. The questionnaire asked for (a) background characteristics, i.e. socio-demographic, obstetric, and disease characteristics (b) cognitive factors, i.e. initiative of referral, knowledge of the risk factor involved, risk perception, worry, child wish, attitudes toward abortion, and preferred participation in decision making, and (c) reasons for the timing of the consultation and for seeking genetic counseling. Pregnant women appeared to be higher educated, considered their children more often as healthy and were less often affected themselves, as compared to non-pregnant women. They also estimated their chance of having an affected child as lower, and they worried less. Furthermore, the initiative for referral was taken less often by the pregnant woman herself and more often by a medical worker. There were no major differences between the two study groups in knowledge, perceived severity of the risk factor, child wish, attitudes toward abortion, desired participation in decision making, and reasons to seek genetic counseling. Women indicated no specific reasons for their timing of referral for reproductive genetic counseling, e.g. during vs before pregnancy. Our data suggest that this timing of referral is not influenced predominantly by the women's level of knowledge. Rather, women's estimation of genetic risks and their degree of worry, which may be in accordance with the actual risk figures, seem to play a role in seeking genetic counseling. Although further studies are required, a more active role of health care providers seems warranted if we want to prevent genetic counseling for familial genetic conditions during pregnancy as much as possible.