Impairment of physical and psychosocial function in recurrent syncope.

Physical and psychosocial function have rarely been assessed in syncope. We used two valid and reliable measures of health status, the Sickness Impact Profile (SIP) and the Symptom Checklist 90 (SCL-90-R), to assess functional impairment in 62 patients with recurrent syncope seen in a syncope specialty clinic. Mean total SIP scores were markedly elevated at 17 (SD = 14), indicating a level of impairment similar to severe rheumatoid arthritis and chronic low back pain. SIP psychosocial scores were significantly greater than SIP physical scores (20 vs 11, p less than 0.0001). SCL-90-R scores were also high, comparable to those of psychiatric inpatients. Somatization, anxiety and depression dimensions of the SCL-90-R were particularly elevated. SCL-90-R subscale scores were highly correlated with SIP psychosocial scores (all r greater than 0.4, and p less than 0.001). Neither age nor number of comorbid diseases correlated with measures of psychosocial function, suggesting that syncope itself causes psychosocial impairment. Although this was a referral population, these data suggest that function can be seriously impaired by syncope, that the degree of impairment is similar to that reported in other chronic diseases, and that syncope leads to significantly greater psychosocial than physical impairment.

Institutional change: embracing the initiative to train more generalists.

Dartmouth Medical School was one of 16 U.S. medical schools that received a Generalist Physician Initiative (GPI) grant from The Robert Wood Johnson Foundation in 1994. This article describes institutional change at the school, noting that while the context in which the GPI was launched was receptive, the grant enabled Dartmouth to accelerate institutional changes already under way. Perhaps even more important is that Dartmouth used an approach to change that worked, and although the specific actions may not generalize to other schools, the authors hope the principles will. Key among these principles were capitalizing on a sense of urgency for change, creating and empowering a guiding coalition, developing and communicating the vision, generating short-term wins, consolidating gains, and anchoring new approaches to the existing institutional culture. Changes at Dartmouth are described in the areas of admission and recruitment, undergraduate and graduate medical education, and supporting community practice. The authors also describe shortcomings in developing the program, such as maintaining the guiding coalition in the face of the changing health care system and clinical pressures, developing a vision and strategy in areas managed by the state, and engagement of a broad-based group.

Impact of a preceptor education board and computer network to engage community faculty at Dartmouth Medical School.

In 1994, as part of the Generalist Physician Initiative of The Robert Wood Johnson Foundation, Dartmouth Medical School established two programs to support and engage community-based teaching. The Preceptor Education Board and Community Computer Network were established to support a network of community-based preceptors and to facilitate communication between course directors at the school and community-based teachers. The board's mission is to organize, develop, and support a network of community-based primary care faculty, and to create and review community-based curricula. Through the board, community faculty members have made substantial contributions to curriculum, evaluation, faculty development, governance, and financing in community-based teaching. The Community Computer Network provides hardware, software, network systems, and support. Course directors and students have reported improved community-based educational experiences as a direct result of the Network. These two initiatives are dynamic and effective ways to improve the quality of community-based education and preceptors' morale. These efforts have strengthened the community faculty and their connection to the academic medical center.

Using early clinical experiences to integrate quality-improvement learning into medical education.

Health care providers are delivering care in an increasingly complex environment; this requires that providers develop new competencies to better understand their work and to design changes that can help them succeed. Recognizing these new educational requirements, Dartmouth Medical School created a model two-pronged program for teaching quality improvement to its medical students. The goal of the program is to provide students with an active learning experience as well as an education in the theory and application of continuous quality improvement. The program includes two educational experiences: one curriculum is for all medical students and the other is for selected, highly motivated students. The first curriculum is incorporated in Dartmouth's required "On Doctoring" course, in which students spend time with community-based physician preceptors. The quality-improvement curriculum is designed around an improvement project developed at the students' preceptor sites. The second curriculum for students with a special interest in quality improvement is offered as an elective summer program between the first and second years of medical school. Working in groups of two, students identify an area for improvement within a preceptor's practice, assist the practice in articulating an improvement plan, help implement that plan, and write up their experiences. The authors describe the two curricula, factors associated with their successful implementation, and lessons learned.

Geriatric education: a system approach.

This article describes an institutionwide geriatric educational initiative (called Geriatrics Awareness Month) that provided didactic and formal experiential learning designed for health professionals. From an educational perspective, to learn geriatrics requires systems thinking, and, to learn systems thinking, geriatrics provides an excellent clinical context. The authors evaluated the didactic and experiential aspects of Geriatric Awareness Month. For attendees of didactic sessions, the availability of pocket-sized educational materials was deemed most valuable. Despite busy schedules, house staff were able to make a change in their practice and study the effect of this change.

Patient desire for information and decision making in health care decisions: the Autonomy Preference Index and the Health Opinion Survey.

OBJECTIVES: To compare results on the Autonomy Preference Index (API) and the Health Opinion Survey (HOS), two instruments that measure patient desire for information and involvement in decision making. DESIGN: Cross-sectional survey. SETTING: University-based primary care outpatient longitudinal and acute care clinic. PATIENTS: 167 patients with benign prostatic hyperplasia, back pain, or mild hypertension seen from October 1991 to December 1992. MEASUREMENTS AND MAIN RESULTS: On the API and the HOS (both scaled from 0 to 1), the patients had intermediate desire for involvement in decision making (median API: 0.42; HOS: 0.36) and higher desire for information (median API: 0.97; HOS: 0.57). With either instrument, the desire for information exceeded that for involvement in decision making (p < 0.0001). The API information scores were higher than the HOS information scores (p < 0.0001), probably because the HOS focuses on patient behavior rather than desire. Variation in desire for information and involvement in decision making was substantial and largely unexplained. CONCLUSIONS: Most patients have a high desire for information, the desire for information and involvement in decision making varies substantially among patients, and the API is preferable to the HOS for researchers interested in focusing solely on patient desire for information.

The utility of the Psychosomatic Symptom Checklist among hospitalized patients.

We examined the utility of the Psychosomatic Symptom Checklist in an inpatient medical setting with particular emphasis on the putative ability of the PSC to discriminate psychosomatic from nonpsychosomatic patients. First, 80 hospitalized psychosomatic patients were compared to 80 hospitalized medical patients on the PSC. Second, a sample of 187 psychosomatic patients was studied to examine the relationship among psychosomatic distress, depression, and functional impairment. The results indicate that while psychosomatic patients scored significantly higher than comparable medical patients on the PSC, discriminant analyses indicate that the PSC is not able to identify psychosomatic patients in an inpatient medical setting. Factor analyses and correlations show that the PSC is positively related to increased depression and decreased functional status. Results are interpreted in light of current psychosomatic theory.

A survey of primary care physicians' perceptions and needs regarding the precepting of medical students in their offices.

OBJECTIVE: To assess the interest, perceptions, and needs of primary care physicians with regard to office-based precepting of medical students. DESIGN: Random survey. SETTING: The New England region of the United States (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut). PARTICIPANTS: Family physicians, general internists and paediatricians. MAIN OUTCOME MEASURES: These included: (1) practice and preceptor demographics; (2) Likert scale agreement or disagreement with various positive and negative perceptions about precepting students; rating (from unimportant to necessary) of potential benefits from medical schools associated with the support of precepting in the office setting, and (3) comparisons among physician groups to determine differences in perceptions and needs. RESULTS: There is a high level of interest in precepting regardless of primary care specialty, practice structure, payment mechanism, or precepting experience. Negative impacts included decreased productivity and increased length of the day by a median of 60 minutes. Positive impacts included keeping one's own knowledge up-to-date and enhanced enjoyment of practice. Benefits such as academic appointments, continuing medical education credits, faculty development, computer linkages for clinical information and medical library access are rated highly. Monetary payment, whether as a modest honorarium or as compensation for lost time/income, was felt to be important by half of our sample. CONCLUSION: A significant interest in precepting medical students on a regular basis is expressed by primary care physicians in the ambulatory medicine setting. The results of this survey can be used by medical schools to address negative perceptions and to develop appropriate benefits packages to recruit and retain these primary care preceptors.

Minnesota Multiphasic Personality Inventory (MMPI) cluster groups among chronically ill patients: relationship to illness adjustment and treatment outcome.

Cluster analysis of the MMPI has been utilized widely in the chronic low back pain literature to try to identify reliable patient subtypes predictive of treatment outcome. We extended this methodology to patients with heterogeneous chronic medical conditions by replicating prototypic MMPI cluster group profiles and by relating cluster groups to clinical baseline and outcome data. Subjects were two independent samples (n = 254 and n = 263) of chronically ill patients admitted to an inpatient medicine/psychiatry unit. Using a four-cluster solution, similar cluster profile groups were replicated in both samples. Consistent differences emerged between cluster groups on functional impairment, psychiatric diagnoses, depression, and psychosomatic symptoms. Cluster group membership also predicted changes in functional impairment and depression six months after treatment. Results are discussed in terms of similarities between chronic low back pain and chronic illness and tailoring treatment to different patient types.

Recurrent syncope as a chronic disease: preliminary validation of a disease-specific measure of functional impairment.

BACKGROUND: A disease-specific measure of functional health in syncope would provide an important outcome measure for use either in clinical trials or in the clinical management of patients with recurrent syncope. METHODS AND MEASUREMENTS: In a previous study the authors used formal functional status measures to determine physical and psychosocial impairment in recurrent syncope. This study provides a preliminary assessment of a disease-specific measure of function. The measure was pilot tested on 84 subjects, and validated in a separate cohort of 49 patients. The measure consists of 1) an 11-question matrix of yes/no questions, assessing the ways that syncope interferes with a patient's life (the result is expressed as a proportion of the total number of ways that syncope might interfere and is called the Impairment Score), and 2) three Likert-scale questions that assess the patient's fear and worry about syncope. Correlations were obtained between scores on the disease-specific measure and other measures of functional health. RESULTS: Among the 49 patients in the test cohort, final scores on the disease-specific measure correlated with both physical and psychosocial dimension scores on a measure of functional status, the Sickness Impact Profile (r = 0.35-0.36, p = 0.01), and with five of ten subscale scores on a measure of psychological distress, the Symptom Checklist 90-R (r = 0.30-0.43, p = 0.004-0.02). CONCLUSIONS: This new disease-specific quality-of-life measure in syncope measures both physical and psychosocial components of impairment and could be a valuable adjunct in measuring outcomes in syncope patients.

The impact of psychologic factors on measurement of functional status. Assessment of the sickness impact profile.

In this study the relationship between four psychologic health constructs (depression, anxiety, patient response bias, and hostility) and the Sickness Impact Profile (SIP) measurement of functional status was evaluated. The SIP, Carroll Depression Rating Scale (CDRS); and the Minnesota Multiphasic Personality Inventory (MMPI) were administered to 332 patients hospitalized for treatment of combined medical and psychiatric problems. Pearson's product-moment correlation was high between CDRS and SIP Total score (r = 0.67) and between CDRS and SIP Psychosocial subscale (r = 0.72); correlation was lower between CDRS and SIP Physical subscale (r = 0.44). Six MMPI scales (depression, anxiety, psychasthenia, lie, K, hostility) correlated with SIP Total score (r = 0.18 to 0.50), with SIP Psychosocial score (r = 0.28 to 0.65) and less well with SIP Physical subscale (r = 0.07 to 0.25). Factor analysis of the SIP categories showed two factors with eigenvalues greater than 1. Promax factor rotation showed all SIP Psychosocial categories and all measured psychologic variables loaded most heavily on factor 1. SIP Physical categories loaded most heavily on factor 2. Stepwise multiple regression analysis showed that psychologic variables account for 49% of the SIP total variance, 62% of SIP Psychosocial subscale variance, but only 19% of SIP Physical subscale variance. The CDRS accounts for the major portion of the explained variance with only minor additional contributions from the MMPI scales. We conclude that 1) the SIP discriminates psychosocial and physical dysfunction even in medical patients with extensive psychiatric comorbidity; 2) the SIP measures at least two dimensions of health, one of which is strongly related to depression; and 3) constructs measured by MMPI scales do not have substantial independent contribution to SIP variance.