An Objective Structured Clinical Examination Case for Opioid Management: Standardized Patient Ratings of Communication Skills as a Predictor of Systems-Based Practice Scores.

The Wayne State University Office of Graduate Medical Education (WSUGME) uses an objective structured clinical examination (OSCE) to assess its programs' contribution to enhancing residents' communication skills. In response to revisions in Michigan's opioid-prescribing mandates in 2017, WSUGME developed a pain management case in collaboration with faculty and the Wayne State University School of Medicine to educate residents about these mandates while gauging their skills in Systems-Based Practice (SBP), an Accreditation Council for Graduate Medical Education Core Competency. This study examined whether resident OSCE performance predicted year-end milestones scores in SBP1 (coordinates patient care within various health care delivery settings), SBP2 (works in interdisciplinary teams to enhance patient safety and improve patient care quality), and SBP3 (practices and advocates for cost-effective, responsible care). Participants included two cohorts of first- (PRG-1) and second-year (PRG-2) residents in 6 programs: one cohort from academic year 2018-2019 (n=33), the other from 2019-2020 (n=37). Before the OSCE, WSUGME emailed residents the new state prescription requirements. During the simulated encounter, standardized patients rated residents on a validated communication instrument, and WSUGME conducted a linear regression of patient ratings on resident SBP milestone scores. The ratings of communication skills of PRG-1 residents did not predict any of the year-end SBP milestones. However, ratings of communication skills of PRG-2 residents predicted SBP1 and SBP2, though not SBP3, milestones. The OSCE opioid case proved to be a valid measure of PRG-2 residents' competence gained across the first year but was less meaningful when applied to PRG-1 residents.

Building a Culture of Well-Being in Primary Care Resident Training Programs.

Background: Monitoring and improving resident physicians' well-being are crucial because clinical care burdens can cause burnout, depression, and suicide. Burnout negatively affects patient care. Promoting well-being requires cultural change best achieved through a merging of institutional top-down efforts with resident and faculty bottom-up efforts. Methods: The Wayne State University Office of Graduate Medical Education targeted three residency programs (52 residents) at one hospital site for wellness interventions as part of the Alliance of Independent Academic Medical Centers (AIAMC) National Initiative VI. Institution-led efforts included promotion of employee wellness resources, prioritization of wellness at administrative meetings, and program evaluation and assessment. Resident- and faculty-led efforts included the formation of wellness committees that organized events and activities and communicated with program evaluation committees to address wellness concerns. Impact was assessed using mixed methods: the quantitative Resident Wellness Scale, a modified form of the Medical School Learning Environment Survey, and a qualitative Resident Wellness Semi-Structured Interview. Results: Institutional efforts were successfully applied through multiple administrative channels. Resident-led efforts were less successful initially, but wellness committees led by faculty champions were formed within programs and strengthened the resident-led efforts. Quantitative measures indicated that well-being increased and then declined, perhaps attributable to cohort effects. Qualitative analysis revealed multiple dimensions of well-being. We discuss limitations of the work and future directions. Conclusion: Resident well-being requires cooperation and a combination of top-down institutional and bottom-up trainee efforts. Because resident well-being is a complex phenomenon, efforts to improve and sustain it must also be multidimensional and broadly applied.

Using a Direct Observation Tool (TOC-CEX) to Standardize Transitions of Care by Residents at a Community Hospital.

Background: High-quality transitions of care are crucial for patient safety in hospitals, yet few undergraduate curricula include transition-of-care training. In 2012, the Wayne State University Office of Graduate Medical Education (WSUGME) required its residency programs to use the SAIF-IR mnemonic (summary, active issues, if-then contingency planning, follow-up activities, interactive questioning, readback) to ensure accurate and uniform handoffs. Subsequent program evaluations indicated that resident awareness and adoption of the mnemonic at our primary clinical site, Ascension Providence Rochester Hospital (APRH), could be improved. According to our institution's 2016 Clinical Learning Environment Review (CLER), 88% of residents reported following a standardized transition of care handoff, and 53% reported that faculty rarely supervised their handoffs. A 2016 WSUGME internal survey also revealed low rates of awareness (7% to 10%) of the mandated mnemonic. WSUGME then created a direct observation tool, the Transitions of Care-Clinical Evaluation Exercise (TOC-CEX), for faculty to monitor resident skill in using the mnemonic and thus standardize transitions of care as a practice habit at APRH. Methods: Since 2014, WSUGME had relied on 2 methods for training residents in the required handoff mnemonic: (1) introduction to the SAIF-IR mnemonic during the WSUGME orientation for all interns and (2) simulations during an objective simulated handoff evaluation activity for all postgraduate year (PGY) 1s and PGY 2s. In 2017, WSUGME innovated a direct observation tool, the TOC-CEX, for adoption by faculty at APRH to assess resident knowledge of and monitor their skill in using the SAIF-IR mnemonic in 3 primary care programs. The total number of possible participants was 138, and the actual number of individuals in the sample was 95. A majority (86%) of the observations during the study period were of PGY 1 residents, and thus the analysis reflects the ratings of 99% of all interns but only 69% of all possible residents. Results: WSUGME found that faculty use of a direct observation instrument in the clinical learning environment during 2017-2019 increased awareness and adoption of the SAIF-IR mnemonic among residents. Using a z-test of equal proportions on resident responses on an internal WSUGME survey, we found a significant rise in the percentage reporting yes to the question "Does your program have a mechanism for monitoring handoffs?" (χ2 [3]=23.6, P<0.0001) and in the percentage identifying SAIF-IR in response to the question "Does your program endorse a specific mnemonic for organizing the contents of a verbal handoff?" (χ2 [3]=45.0, P<0.0001). The increase from 2016 to 2017 is the result of the implementation of the TOC-CEX in the interim (question 1: χ2 [1]=12.4, P<0.0005; question 2: χ2 [1]=10.1, P<0.0025). Conclusion: Our research found that use of the TOC-CEX to monitor resident handoffs resulted in improved awareness and adoption of the SAIF-IR mnemonic in the clinical learning environment. Program leadership reported that the practice was both feasible and well accepted by residents, faculty, and the APRH chief medical officer as the TOC-CEX became a customary component of APRH organizational culture and was perceived as central to quality patient care.

Integration of Continuous Quality Improvement Methods Into Annual Program and Institutional Evaluation.

BACKGROUND: The Accreditation Council for Graduate Medical Education's Next Accreditation System requires continuous program improvement as part of program evaluation for residency training institutions and programs. OBJECTIVE: To improve the institutional- and program-level evaluation processes, to operationalize a culture of continuous quality improvement (CQI), and to increase the quality and achievement of action items, the Wayne State University Office of Graduate Medical Education (WSU GME) incorporated CQI elements into its program evaluation process. METHODS: Across 4 academic years, WSU GME phased the following 4 CQI elements into the evaluation process at the program and institutional levels, including the annual program evaluation (APE) and the annual institutional review: (1) An APE template; (2) SMART (specific, measurable, accountable, realistic, timely) format for program and institutional goals; (3) Dashboard program and institutional metrics; and (4) Plan-do-study-act cycles for each action item. RESULTS: Action item goals improved in adherence to the SMART format. In 2014, 38% (18 of 48) omitted at least 1 field, compared with 0% omitting any fields in 2018. More complete action items took less time to resolve: 1.7 years compared with 2.4 years (t (43.3) = 2.87, P = .003). The implementation of CQI in the APE was well received by program leadership. CONCLUSIONS: After leveraging CQI methods, both descriptions of institutional- and program-level goals and the time required for their achievement improved, with overall program director and program coordinator satisfaction.

Development of the Resident Wellness Scale for Measuring Resident Wellness.

PURPOSE: Graduate medical education programs have a responsibility to monitor resident wellness. Residents are at risk of burnout, depression, and suicide. Burnout and depression are associated with poor patient care. Many existing tools measure burnout, depression, and general human well-being, but resident wellness is a distinct construct. We aimed to develop an instrument to measure resident wellness directly. METHODS: An expert panel from two purposefully different graduate medical education institutions generated a behavior- and experience-based model of resident wellness. The panel and resident leaders from both institutions generated 92 items, which were tested alongside anchor scales measuring burnout, depression, personality, optimism, life satisfaction, and social desirability in a convenience sample of 62 residents. Ten items were selected using a combination of factor analysis, a genetic algorithm, and purposeful selection. The 10-item scale was distributed to 5 institutions at which 376 residents completed it anonymously. Exploratory factor analysis was used to examine the factor structure of the scale. RESULTS: The model of resident wellness aligned with an accepted framework of well-being in the literature. The 10-item Resident Wellness Scale broadly covered the model and correlated meaningfully with anchor scales. The factor structure of the scale suggested sensitivity to meaningful work, life security, institutional support, and social support. CONCLUSIONS: This novel Resident Wellness Scale is designed to track residents' wellness longitudinally. It is sensitive to aspects of resident wellness that have been shown to reduce burnout and depression and appears to be a psychometrically strong measure of resident wellness.

Health Disparities Educational Initiative for Residents.

BACKGROUND: The Wayne State University Graduate Medical Education (GME) Office and Ascension Crittenton Hospital developed an educational initiative to increase resident awareness of health disparities and local community health priorities. The Plan-Do-Study-Act (PDSA) rapid-cycle performance improvement framework was used for implementation and evaluation. METHODS: During the first PDSA cycle, residents attended 5 didactic sessions. During the second PDSA cycle, residents participated in a problem-based learning (PBL) case. The following data were collected: evaluations of the didactic sessions and case, the number of appointments for diabetes self-management and education (DSME) referred by faculty and residents, and responses to questions on the annual GME surveys related to resident understanding of health disparities and the hospital's community health needs assessment (CHNA). RESULTS: Eighty-eight percent of residents defined health disparities at least partially correctly in both project years. The percentage of residents who knew how to access their hospital's CHNA increased from 25% to 29% year over year. Residents rated PBL more effective in achieving learning objectives than didactics, but the difference was not statistically significant. Six appointments for DSME were referred by program faculty and residents in the 2-month period immediately before the didactic sessions, and 6 referrals were made in a 2-month period between the didactic sessions and the PBL case. In the 2-month period immediately following the PBL case, 9 appointments for DSME were referred by residents and program faculty. CONCLUSION: Residents have a good understanding of health disparities, although many may not recognize disparities that exist in their local community. PBL was more effective than didactics for resident education about local health disparities, CHNA, and DSME. Aligning GME and hospital leadership in a common vision for disparities education, as well as community engagement, is critical to successful outcomes.

Preparing Academic Medical Centers for the Clinical Learning Environment Review: Alliance of Independent Academic Medical Centers National Initiative IV Outcomes and Evaluation.

BACKGROUND: Driven by changes to improve quality in patient care and population health while reducing costs, evolvement of the health system calls for restructuring health professionals' education and aligning it with the healthcare delivery system. In response to these changes, the Accreditation Council for Graduate Medical Education's Clinical Learning Environment Review (CLER) encourages the integration of health system leadership, faculty, and residents in restructuring graduate medical education (GME). Innovative approaches to achieving this restructuring and the CLER objectives are essential. METHODS: The Alliance of Independent Academic Medical Centers National Initiative (NI) IV provided a multiinstitutional learning collaborative focused on supporting GME redesign. From October 2013 through March 2015, participants conducted relevant projects, attended onsite meetings, and participated in teleconferences and webinars addressing the CLER areas. Participants shared best practices, resources, and experiences. We designed a pre/post descriptive study to examine outcomes. RESULTS: Thirty-three institutions completed NI IV, and at its conclusion, the majority reported greater CLER readiness compared with baseline. Twenty-two (88.0%) institutions reported that NI IV had a great impact on advancing their efforts in the CLER area of their project focus, and 15 (62.5%) reported a great impact in other CLER focus areas. Opportunities to share progress with other teams and the national group meetings were reported to contribute to teams' success. CONCLUSION: The NI IV learning collaborative prepared institutions for CLER, suggesting successful integration of the clinical and educational enterprises. We propose that national learning collaboratives of GME-sponsoring health systems enable advancement of their education mission, leading ultimately to better healthcare outcomes. This learning model may be generalizable to newfound programs for academic medical centers.

Resident Ratings of Communication Skills Using the Kalamazoo Adapted Checklist.

BACKGROUND: The Kalamazoo Essential Elements Communication Checklist-Adapted (KEECC-A) is a well-regarded instrument for evaluating communication and interpersonal skills. To date, little research has been conducted that assesses the accuracy of resident self-ratings of their communication skills. OBJECTIVE: To assess whether residents can accurately self-rate communication skills, using the KEECC-A, during an objective structured clinical examination (OSCE). METHODS: A group of 104 residents from 8 specialties completed a multistation OSCE as part of an institutional communication skills curriculum conducted at a single institution. Standardized patients (SPs) and observers were trained in rating communication skills using the KEECC-A. Standardized patient ratings and resident self-ratings were completed immediately following each OSCE encounter, and trained observers rated archived videotapes of the encounters. RESULTS: Resident self-ratings and SP ratings using the KEECC-A were significantly correlated (r104 = 0.238, P = .02), as were resident self-ratings and observer ratings (r104 = 0.284, P = .004). The correlation between the SP ratings and observer (r104 = 0.378, P = .001) ratings were larger in magnitude, but not significantly different (P > .05) from resident/SP or resident/observer correlations. CONCLUSIONS: The results suggest that residents, with a modicum of training using the KEECC-A, can accurately rate their own communication and interpersonal skills during an OSCE. Using trained observers to rate resident communication skills provides a unique opportunity for evaluating SP and resident self-ratings. Our findings also lend further support for the reliability and validity of the KEECC-A.

Personality Assessment Screener, Childhood Abuse, and Adult Partner Violence in African American Women Using Primary Care.

This study assessed the relationship between psychopathology with the Personality Assessment Screener (PAS) and childhood physical and sexual abuse and adult physical and sexual partner violence in a primary care sample of 98 urban-dwelling African American women. Patients completed the PAS, the Childhood Trauma Questionnaire, and the Conflict Tactics Scale. The PAS total score significantly correlated with all measures of childhood and adult abuse. Stepwise regression analyses revealed that PAS element scores of Suicidal Thinking and Hostile Control significantly predicted a history of childhood physical abuse; Suicidal Thinking, Hostile Control, and Acting Out significantly predicted a history of childhood sexual abuse; Suicidal Thinking, Negative Affect, and Alienation significantly predicted current adult partner physical violence; and Psychotic Features, Alcohol Problems, and Anger Control significantly predicted current adult sexual partner violence. The PAS appears to be a useful measure for fast-paced primary care settings for identifying patients who need a more thorough assessment for abuse.

Training family medicine residents to practice collaboratively with psychology trainees.

OBJECTIVE: This article will describe a training curriculum for family medicine residents to practice collaboratively with psychology (doctoral) trainees at the Wayne State University/Crittenton Family Medicine Residency program. METHODS: The collaborative care curriculum involves a series of patient care and educational activities that require collaboration between family medicine residents and psychology trainees. Activities include: (1) clinic huddle, (2) shadowing, (3) pull-ins and warm handoffs, (4) co-counseling, (5) shared precepting, (6) feedback from psychology trainees to family medicine residents regarding consults, brief interventions, and psychological testing, (7) lectures, (8) video-observation and feedback, (9) home visits, and (10) research. The activities were designed to teach the participants to work together as a team and to provide a reciprocal learning experience. RESULTS: In a brief three-item survey of residents at the end of their academic year, 83% indicated that they had learned new information or techniques from working with the psychology trainees for assessment and intervention purposes; 89% indicated that collaborating with psychology trainees enhanced their patient care; and 89% indicated that collaborating with psychology trainees enhanced their ability to work as part of a team. Informal interviews with the psychology trainees indicated that reciprocal learning had taken place. CONCLUSIONS: Family medicine residents can learn to work collaboratively with psychology trainees through a series of shared patient care and educational activities within a primary care clinic where an integrated approach to care is valued.

Improving Immunization Rates Using Lean Six Sigma Processes: Alliance of Independent Academic Medical Centers National Initiative III Project.

BACKGROUND: Quality improvement education and work in interdisciplinary teams is a healthcare priority. Healthcare systems are trying to meet core measures and provide excellent patient care, thus improving their Hospital Consumer Assessment of Healthcare Providers & Systems scores. Crittenton Hospital Medical Center in Rochester Hills, MI, aligned educational and clinical objectives, focusing on improving immunization rates against pneumonia and influenza prior to the rates being implemented as core measures. Improving immunization rates prevents infections, minimizes hospitalizations, and results in overall improved patient care. Teaching hospitals offer an effective way to work on clinical projects by bringing together the skill sets of residents, faculty, and hospital staff to achieve superior results. METHODS: WE DESIGNED AND IMPLEMENTED A STRUCTURED CURRICULUM IN WHICH INTERDISCIPLINARY TEAMS ACQUIRED KNOWLEDGE ON QUALITY IMPROVEMENT AND TEAMWORK, WHILE FOCUSING ON A SPECIFIC CLINICAL PROJECT: improving global immunization rates. We used the Lean Six Sigma process tools to quantify the initial process capability to immunize against pneumococcus and influenza. RESULTS: The hospital's process to vaccinate against pneumonia overall was operating at a Z score of 3.13, and the influenza vaccination Z score was 2.53. However, the process to vaccinate high-risk patients against pneumonia operated at a Z score of 1.96. Improvement in immunization rates of high-risk patients became the focus of the project. After the implementation of solutions, the process to vaccinate high-risk patients against pneumonia operated at a Z score of 3.9 with a defects/million opportunities rate of 9,346 and a yield of 93.5%. Revisions to the adult assessment form fixed 80% of the problems identified. CONCLUSIONS: This process improvement project was not only beneficial in terms of improved quality of patient care but was also a positive learning experience for the interdisciplinary team, particularly for the residents. The hospital has completed quality improvement projects in the past; however, this project was the first in which residents were actively involved. The didactic components and experiential learning were powerfully synergistic. This and similar projects can have far-reaching implications in terms of promoting patient health and improving the quality of care delivered by the healthcare systems and teaching hospitals.

The effects of PTSD symptoms on health care resource utilization in a low-income, urban primary care setting.

Individuals with posttraumatic stress disorder (PTSD) symptoms engage in greater rates of health care utilization. Existing literature is limited, however, because the number of visits to health care providers is exclusively used as an outcome. Low-income women (N = 96) screening positive for PTSD symptoms (n = 23; 23.9%) were compared to those who did not (n = 73) on a range of health care utilization outcomes obtained through a chart review. Significant PTSD symptoms were associated with more complaints per visit, ordered labs, and prescribed medications--beyond the effects of age, depression symptoms, and chronic illness. Individuals with PTSD symptoms are a challenge to primary care as currently practiced. Collaboration with mental health professionals and specific primary care procedures to diagnose and treat PTSD are needed.

Pediatric symptom checklist ratings by mothers with a recent history of intimate partner violence: a primary care study.

Screening for psychosocial problems is an effective way to identify children who need further evaluation, and many brief, psychometrically strong measures exist for this purpose. More research is needed, however, about the performance of these measures in special populations who are familiar to primary care settings. The purpose of this study was to examine and compare maternal ratings on the Pediatric Symptom Checklist (PSC) between low-income, urban mothers who had suffered intimate partner violence (IPV) in the past year (n = 23) and a demographically-matched comparison group of mothers (n = 23). Victims of violence rated their children as having significantly more problems in a number of categories (Total PSC Score, Externalizing, and Internalizing) than did mothers in the comparison group. The PSC shows promise as an adequate screening tool for psychosocial problems in the children of women who have suffered IPV, but more research is needed.

A social psychological approach to improving the outcomes of racially discordant medical interactions.

BACKGROUND: Medical interactions between Black patients and non-Black physicians are less positive and productive than racially concordant ones and contribute to racial disparities in the quality of health care. OBJECTIVE: To determine whether an intervention based on the common ingroup identity model, previously used in nonmedical settings to reduce intergroup bias, would change physician and patient responses in racially discordant medical interactions and improve patient adherence. IINTERVENTION: Physicians and patients were randomly assigned to either a common identity treatment (to enhance their sense of commonality) or a control (standard health information) condition, and then engaged in a scheduled appointment. DESIGN: Intervention occurred just before the interaction. Patient demographic characteristics and relevant attitudes and/or behaviors were measured before and immediately after interactions, and 4 and 16 weeks later. Physicians provided information before and immediately after interactions. PARTICIPANTS: Fourteen non-Black physicians and 72 low income Black patients at a Family Medicine residency training clinic. MAIN MEASURES: Sense of being on the same team, patient-centeredness, and patient trust of physician, assessed immediately after the medical interactions, and patient trust and adherence, assessed 4 and 16 weeks later. KEY RESULTS: Four and 16 weeks after interactions, patient trust of their physician and physicians in general was significantly greater in the treatment condition than control condition. Sixteen weeks after interactions, adherence was also significantly greater. CONCLUSIONS: An intervention used to reduce intergroup bias successfully produced greater Black patient trust of non-Black physicians and adherence. These findings offer promising evidence for a relatively low-cost and simple intervention that may offer a means to improve medical outcomes of racially discordant medical interactions. However, the sample size of physicians and patients was small, and thus the effectiveness of the intervention should be further tested in different settings, with different populations of physicians and other health outcomes.

Implementing teams in a patient-centered medical home residency practice: lessons learned.

INTRODUCTION: The "new model of care" calls for a new approach for primary care delivery that focuses on patient centeredness, quality, safety, effective and efficient care, and interdisciplinary teamwork. Medical education needs to parallel this health care reorganization. Implementing a team approach in a residency practice, especially in ambulatory settings, poses unique challenges. METHODS: We introduced interdisciplinary teams in a family medicine residency site, integrating clinical and educational objectives. RESULTS: We report our challenges and successes in the transformational journey to a patient-centered medical home, for which a team approach is critical to achieving high quality care. CONCLUSION: Establishing high-functioning interdisciplinary teams takes leadership commitment; the engagement of everyone in the practice; investment in staff, resident, and faculty development; and clear communication of vision and goals. Integration of clinical and educational objectives can be powerfully synergistic. Clinical, organizational, and educational outcomes are needed to evaluate impact.

Personality assessment screener in a primary care sample of low-income urban women.

The diagnostic efficiency of the Personality Assessment Screener (PAS; Morey, 1997) total score was evaluated using selected scales from the Patient Health Questionnaire (Spitzer, Kroenke, & Williams, 1999), the fourth edition of the Personality Diagnostic Questionnaire (Hyler, 1994), and the Alcohol Use Disorders Identification Test (Saunders, Aasland, Babor, DeLaFuente, & Grant, 1993) as reference standards. Complete data were collected from 110 women seeking treatment at an urban family medicine training clinic. Total PAS scores were effective in identifying patients with mood disorders, cluster B personality disorders, and alcohol use disorders, but the optimum cut scores were higher than the cut score of 19 recommended by Morey (1997). The 10 PAS element scores showed good convergent and discriminant correlations with the reference measures. These findings support the utility of the PAS to screen for major forms of psychopathology in an urban primary care setting.

Incoming resident experience and comfort with procedures designated as "basic".

BACKGROUND: Recent consensus guidelines have recommended uniformity in procedural training in family medicine residency programs. The consensus documentation suggestions are based on expectations of procedural training prior to residency. Few studies have evaluated the perceived baseline level of procedural competency prior to residency training. METHODS: Twenty incoming PGY-1 residents completed a "procedural experience survey," asking respondents to identify their prior experience and current comfort levels with 19 "basic" procedures. RESULTS: For seven procedures, no prior experience was the most common response. For 15 of the 19 procedures, at least one respondent reported no prior experience. The residents' self-reported comfort levels varied widely for each procedure. CONCLUSIONS: The survey results showed that experience and comfort with procedures often performed in family medicine varies widely among incoming residents. This raises the question of whether documentation of resident competence in these procedures should be recommended as a baseline and monitored throughout residency training.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Defensive Functioning Scale: a validity study.

OBJECTIVE: We assess the convergent and predictive validity of the Defensive Functioning Scale (DFS) with measures of life events, including childhood abuse and adult partner victimization; dimensions of psychopathology, including axis I (depressive) and axis II (borderline personality disorder) symptoms; and quality of object relations. METHOD: One hundred and ten women from a university-based urban primary care clinic completed a research interview from which defense mechanisms were assessed. The quality of object relations was also assessed from interview data. The women completed self-report measures assessing depression, borderline personality disorder symptoms, childhood physical and sexual abuse, and adult partner physical and sexual victimization. RESULTS: Inter-rater reliability of the scoring of the DFS levels was good. High adaptive defenses were positively correlated with the quality of object relations and pathological defenses were positively correlated with childhood and adult victimization and symptom measures. Although major image distorting defenses were infrequently used, they were robustly correlated with all study variables. In a stepwise multiple regression analysis, major image distorting defenses, depressive symptoms, and minor image distorting defenses significantly predict childhood victimization, accounting for 37% of the variance. In a second stepwise multiple regression analysis, borderline personality disorder symptoms and disavowal defenses combined to significantly predict adult victimization, accounting for 16% of the variance. CONCLUSIONS: The DFS demonstrates good convergent validity with axis I and axis II symptoms, as well as with measures of childhood and adult victimization and object relations. The DFS levels add nonredundant information to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition beyond axis I and axis II.