Psychometric Properties of a Healthcare Provider Burden Scale: Preliminary Results.

Measures are lacking that assess the clinical burden that healthcare providers perceive in treating chronic conditions. This study presents a preliminary psychometric evaluation of a novel self-report measure of provider burden in the treatment of chronic pain. Data for eight burden items were available from vignette studies examining the effects of patient pain severity and medical evidence on clinical burden and judgments for chronic pain. Participants (N = 922) were 109 physicians and 813 non-physicians, all acting in the role of physician (232 community members without chronic pain, 105 community members with chronic pain, and 476 American Chronic Pain Association members with chronic pain). Factor analyses of burden items yielded one-factor solutions in all samples, with high factor loadings and adequate explained variance. Internal consistency reliability was uniformly high (≥ 0.87). Burden scores were significantly higher among physicians compared to nonphysicians; nonphysician groups did not differ on any burden score. Significant correlations of burden score with indicators of psychosocial complications in patient care supported scale validity. Burden score was not associated with gender, age, or education. Results provide initial support for the psychometric properties of a Healthcare Provider Burden Scale (HPBS). Research utilizing larger and representative healthcare provider groups is needed.

Community Perspectives on Patient Credibility and Provider Burden in the Treatment of Chronic Pain.

OBJECTIVE: This study examined factors influencing lay perceptions of a provider's clinical burden in providing care to a person with chronic pain. DESIGN: In a between-subjects design that varied three levels of pain severity (4, 6, or 8 out of 10) with two levels of medical evidence (low/high), participants rated the credibility of pain reported by a hypothetical patient and the psychosocial factors expected to mediate the effects of evidence and severity on a provider's burden of care. SETTING: A randomized vignette study in which community participants were recruited via Amazon Mechanical Turk. SUBJECTS: 337 community participants. METHODS: Using a Qualtrics platform, participants read one of six vignettes describing a hypothetical patient with varying levels of medical evidence and pain severity and then rated perceived pain severity, pain credibility, psychosocial variables, and burden. RESULTS: Serial mediation models accounted for all effects of medical evidence and pain severity on burden. Low medical evidence was associated with increased burden, as mediated through lower pain credibility and greater concerns about patient depression, opioid abuse, and learning pain management. Higher levels of reported pain severity were associated with increased burden, as mediated through greater pain discounting and concerns about opioid abuse. CONCLUSIONS: The lay public is skeptical of chronic pain that is not supported by medical evidence or is reported at high levels of severity, raising concerns about psychosocial complications and drug seeking and expectations of higher burden of care. Such negative stereotypes can pose obstacles to people seeking necessary care if they or others develop a chronic pain condition.

Serious Ethical Violations in Medicine: A Statistical and Ethical Analysis of 280 Cases in the United States From 2008-2016.

Serious ethical violations in medicine, such as sexual abuse, criminal prescribing of opioids, and unnecessary surgeries, directly harm patients and undermine trust in the profession of medicine. We review the literature on violations in medicine and present an analysis of 280 cases. Nearly all cases involved repeated instances (97%) of intentional wrongdoing (99%), by males (95%) in nonacademic medical settings (95%), with oversight problems (89%) and a selfish motive such as financial gain or sex (90%). More than half of cases involved a wrongdoer with a suspected personality disorder or substance use disorder (51%). Despite clear patterns, no factors provide readily observable red flags, making prevention difficult. Early identification and intervention in cases requires significant policy shifts that prioritize the safety of patients over physician interests in privacy, fair processes, and proportionate disciplinary actions. We explore a series of 10 questions regarding policy, oversight, discipline, and education options. Satisfactory answers to these questions will require input from diverse stakeholders to help society negotiate effective and ethically balanced solutions.

Sexual Violation of Patients by Physicians: A Mixed-Methods, Exploratory Analysis of 101 Cases.

A mixed-method, exploratory design was used to examine 101 cases of sexual violations in medicine. The study involved content analysis of cases to characterize the physicians, patient-victims, the practice setting, kinds of sexual violations, and consequences to the perpetrator. In each case, a criminal law framework was used to examine how motives, means, and opportunity combined to generate sexual misconduct. Finally, cross-case analysis was performed to identify clusters of causal factors that explain specific kinds of sexual misconduct. Most cases involved a combination of five factors: male physicians (100%), older than the age of 39 (92%), who were not board certified (70%), practicing in nonacademic settings (94%) where they always examined patients alone (85%). Only three factors (suspected antisocial personality, physician board certification, and vulnerable patients) differed significantly across the different kinds of sexual abuse: personality disorders were suspected most frequently in cases of rape, physicians were more frequently board certified in cases of consensual sex with patients, and patients were more commonly vulnerable in cases of child molestation. Drawing on study findings and past research, we offer a series of recommendations to medical schools, medical boards, chaperones, patients, and the national practitioners database.

Maladaptive Perfectionism, Impostorism, and Cognitive Distortions: Threats to the Mental Health of Pre-clinical Medical Students.

OBJECTIVE: While medical student wellness has been a subject of recent study and discussion, current efforts may fail to address possible underlying, harmful cognitive distortions regarding academic performance. The authors sought to examine dysfunctional thoughts (maladaptive perfectionism, impostor phenomenon) and negative feelings (shame, embarrassment, inadequacy) that may contribute to poor mental health in pre-clinical medical students. METHODS: A survey was administered to first-year medical students at Saint Louis University that included assessments for maladaptive perfectionism, impostor phenomenon, depression, and anxiety, as well as questions about feelings of shame, embarrassment, inadequacy, comparison, and self-worth. RESULTS: A total of 169 students (93%) participated. Students who met criteria for maladaptive perfectionism were significantly more likely to report greater feelings of shame/embarrassment and inadequacy (P < 0.001) than their peers who did not; similar associations were observed in students who reported high/intense levels of impostor phenomenon (P < 0.001). Furthermore, students who reported feelings of shame/embarrassment or inadequacy were significantly more likely to report moderate/severe levels of depression symptoms (P < 0.001) and moderate/high levels of anxiety symptoms (P = 0.001) relative to students who did not report these negative feelings. CONCLUSIONS: These preliminary data support a model for how negative thoughts may lead to negative emotions, and depression and anxiety in medical students. The authors propose strategies for preventive interventions in medical school beginning in orientation. Further research is needed to develop targeted interventions to promote student mental health through reduction of cognitive distortions and negative feelings of shame, embarrassment, and inadequacy.

Physician Judgments and the Burden of Chronic Pain.

Objective: In a moderated mediation model, this study examined the interaction effect of pain severity and medical evidence on physician judgments of chronic pain. The effects of higher pain severity on physician judgments were expected to be mediated through anticipated clinical burden, but only when medical evidence was low. Design: Participants were randomly assigned to one of six case descriptions of a chronic pain patient in a 3 × 2 design that varied by reported pain severity (4, 6, 8/10) and medical evidence (low vs high). Setting: An academic training program for medical residents/fellows. Subjects: Residents/fellows in clinical departments at postgraduate year 2 or higher (N = 109). Methods: Participants read case descriptions and then made judgments about the patient and rated the level of burden they expected to assume in treating the patient. Results: Higher pain severity occasioned greater pain discounting and higher likelihood of prescribing opioid medication. When medical evidence was low, participants had less trust in the patient's pain report, attributed pain more to psychosocial than medical factors, and were less likely to refer for possible surgery. Analyses yielded no support for moderated mediation as expected burden was high across all conditions. Significant associations were found between expected burden and multiple clinical judgments. Conclusions: Results did not support the proposed moderated mediation model as all patients were expected to be burdensome across clinical presentations, reflecting negative expectations of patients with chronic pain. Such expectations can have adverse implications for patient-provider communication, shared decision-making, and the delivery of personalized care.

Cognitive Behavioral Therapy for Maladaptive Perfectionism in Medical Students: A Preliminary Investigation.

OBJECTIVES: Maladaptive perfectionism is associated with psychological distress and psychopathology. Medical students have been found to be particularly prone to maladaptive perfectionism. Recent research has indicated that Cognitive Behavioral Therapy (CBT) that targets unhealthy perfectionism leads to reductions in perfectionism and related distress. This preliminary investigation aimed to evaluate the efficacy of a CBT program directed at medical students who had significant levels of maladaptive perfectionism. The impact on associated psychological distress was also assessed. METHODS: The study used a case series methodology with an A-B design plus follow-up. First-year medical students who screened positive for maladaptive perfectionism and consented for the study (N = 4) were assessed at baseline to evaluate the levels of maladaptive perfectionism, anxiety, and depression. They participated in an eight-session CBT program for reducing maladaptive perfectionism after a waiting period. Assessments were repeated post CBT and at 3- and 6-month follow up periods. RESULTS: Results indicated positive and durable effects on maladaptive perfectionism among program participants. CONCLUSION: The current research provides promising results for the use of CBT in at risk medical students with maladaptive perfectionism.

Mistreatment of medical students in the third year may not be the problem.

Mistreatment and abuse of medical students has been recognized as a significant problem in medical schools. We believe, however, that the problem of mistreatment has been viewed incorrectly. This misperception of mistreatment exists in two primary ways. First, mistreatment has tended to be viewed as a "diagnosis" of unprofessionalism of the perpetrator when it may be more appropriately viewed as a symptom with a range of possible underlying causes. The second misconception that appears to be prevalent is the belief that the link between mistreatment and student well-being, distress, and falling empathy is clear. It is not. We present (1) evidence that other factors in the clinical learning environment may be having a greater negative impact on student mental health and well-being and (2) recommendations for changes that may produce enhancement to medical student mental health in the clerkship year.

Placebo-controlled augmentation trials of the antioxidant NAC in schizophrenia: A review.

BACKGROUND: Several studies have reported that schizophrenia is associated with mitochondrial abnormalities, glutathione deficit, and increased brain oxidative stress (free radicals). N-acetylcysteine (NAC) is a strong antioxidant with potential therapeutic benefit in schizophrenia, according to some reports. We conducted a review of the published controlled studies, with the goal of determining the efficacy profile of NAC as an adjunctive treatment for schizophrenia. METHODS: An online search was conducted for all placebo-controlled, double-blind, randomized clinical trials of NAC in schizophrenia, and a review was conducted. RESULTS: Two studies met the criteria for inclusion. Berk et al (2008) used NAC as an adjunctive treatment to atypical antipsychotics in subjects with chronic schizophrenia who were stable on antipsychotic medications. Treatment at 8 weeks was less efficacious than placebo, but at 24 weeks produced significant reductions vs placebo in Positive and Negative Syndrome Scale (PANSS) negative (d = 0.52), general (d = 0.46), and total (d = 0.57) scores. Farokhnia et al (2013) used NAC as an adjunctive treatment to risperidone in subjects with chronic schizophrenia who were experiencing an acute exacerbation episode. Eight weeks of treatment led to clinically significant reductions vs placebo in PANSS negative (d = 0.96), general (d = 0.59), and total (d = 0.88) scores. CONCLUSIONS: The data suggest that adjunctive NAC may be efficacious in reducing negative and general symptoms in schizophrenia.

Ideomotor limb apraxia as a staging tool in individuals with Alzheimer's disease (ILIAD).

BACKGROUND: Ideomotor apraxia (IMA) is known to affect individuals with Alzheimer's disease (AD). Combined with impaired cognitive function, IMA can support evidence of probable AD. However, apraxia is a condition that is difficult to diagnose. The Postural Knowledge Test (PKT), developed by Mozaz et al, was designed to easily identify limb apraxia in multiple sclerosis yet demonstrated potential utility for AD. ILIAD is a pilot study to investigate correlation between the PKT and Mini-Mental State Examination (MMSE). METHODS: Participants with mild, moderate, and severe AD were administered the MMSE by 1 examiner, followed by the PKT by a second blinded examiner. RESULTS: Seventy-seven participants with mild (25), moderate (26), and severe AD (26) met study criteria. Correlation was demonstrated between the MMSE and PKT at 0.835 among all AD groups. Correlation between MMSE and PKT-1 (transitive) and PKT-2 (intransitive) separately was 0.819 and 0.793. CONCLUSIONS: There is significant correlation between the MMSE (memory loss) and PKT (IMA). This suggests the PKT may be used in conjunction with the MMSE to aid in staging AD and to monitor disease severity. Correlation between the MMSE and separate PKT tests suggests that administration of only 1 test may be necessary clinically, saving valuable time.

Medical Judgments Across the Range of Reported Pain Severity: Clinician and Lay Perspectives.

BACKGROUND: While increasing evidence suggests that observers discount high-severity chronic pain, factors that occasion such discounting are poorly understood, particularly regarding health provider vs lay perspectives. OBJECTIVE: This study examined the effects of supporting medical evidence and comorbid psychological distress (pain behavior) on medical student and lay clinical judgments of increasingly severe patient pain reports. DESIGN: In a 2 × 2 × 2 × (7) mixed between- and within-subject design, participants (medical students vs lay) made clinical judgments after reading vignettes describing a hypothetical patient that varied in levels of medical evidence and pain behavior (low vs high) and pain severity (4/10-10/10). SUBJECTS: Fourth-year medical students (N = 115) and lay persons in the community (N = 300) participated in this research. RESULTS: While both medical student and lay judgments plateaued at high levels of pain severity, judgments regarding cause (medical vs psychological), treatment (opioid prescription), and disability showed growing divergence as levels of reported pain severity increased. Divergence relative to medical and psychological causes of pain was found irrespective of the level of supporting medical evidence; divergence relative to opioid treatment and support for a disability claim was found when supporting medical evidence was low. CONCLUSIONS: The results indicate differing expectations of chronic pain treatment for health care providers relative to the lay public that could impact clinical care, especially at high pain severity levels, where lay expectations diverge significantly from those of health professionals.

Association of Posttraumatic Growth and Illness-Related Burden With Psychosocial Factors of Patient, Family, and Provider in Pediatric Cancer Survivors.

Research has indicated that childhood cancer may lead to posttraumatic growth (PTG), given cancer's association with posttraumatic stress. PTG may be associated with family/home and health care dynamics, as well as parental resilience, distress, and coping. This cross-sectional study investigated the associations of psychosocial factors of the patient, family, and health care team with PTG and illness-related burden (IRB) in childhood cancer survivors. The sample comprised 61 children and adolescents (7-18 years of age), their parents, and their nurses. Respondents completed their assessment an average of 1.73 years after the end of treatment for the child's disease, which was either leukemia, a solid tumor, or lymphoma. Regression analyses showed that PTG was positively associated with the patients' posttraumatic stress symptoms. It was also positively associated with the parents' religious coping, and with measures of stronger family and oncologist relationships (R2 = .32). IRB was positively associated with patient-reported posttraumatic stress symptoms, negatively associated with the nurse's trust in the family, and positively associated with parent-reported mental distress, lower family socioeconomic status, and female gender (R2 = .53). There was no significant association with parenting style or parent-reported posttraumatic stress symptoms in the child. The findings suggested that the young cancer patient's psychosocial and resource milieu (e.g., financial) may be instrumental in PTG and IRB. Psychosocial interventions with high-risk families and their health care teams could increase growth and reduce burden.

The Plastic Surgery Match: A Quantitative Analysis of Applicant Impressions From the Interview Visit.

BACKGROUND: The integrated plastic surgery match is a competitive process not only for applicants but also for programs vying for highly qualified candidates. Interactions between applicants and program constituents are limited to a single interview visit. The authors aimed to identify components of the interview visit that influence applicant decision making when determining a final program rank list. METHODS: Thirty-six applicants who were interviewed (100% response) completed the survey. Applicants rated the importance of 20 elements of the interview visit regarding future ranking of the program on a 1 to 5 Likert scale. Data were analyzed using descriptive statistics, hierarchical cluster analysis, analysis of variance, and Pearson correlations. A literature review was performed regarding the plastic surgery integrated residency interview process. RESULTS: Survey questions were categorized into four groups based on mean survey responses:1. Interactions with faculty and residents (mean response > 4),2. Information about the program (3.5-4),3. Ancillaries (food, amenities, stipends) (3-3.5),4. Hospital tour, hotel (<3).Hierarchical item cluster analysis and analysis of variance testing validated these groupings. Average summary scores were calculated for the items representing Interactions, Information, and Ancillaries. Correlation analysis between clusters yielded no significant correlations. A review of the literature yielded a paucity of data on analysis of the interview visit. CONCLUSIONS: The interview visit consists of a discrete hierarchy of perceived importance by applicants. The strongest independent factor in determining future program ranking is the quality of interactions between applicants and program constituents on the interview visit. This calls for further investigation and optimization of the interview visit experience.

Compliance Disengagement in Research: Development and Validation of a New Measure.

In the world of research, compliance with research regulations is not the same as ethics, but it is closely related. One could say that compliance is how most societies with advanced research programs operationalize many ethical obligations. This paper reports on the development of the How I Think about Research (HIT-Res) questionnaire, which is an adaptation of the How I Think (HIT) questionnaire that examines the use of cognitive distortions to justify antisocial behaviors. Such an adaptation was justified based on a review of the literature on mechanisms of moral disengagement and self-serving biases, which are used by individuals with normal personalities in a variety of contexts, including research. The HIT-Res adapts all items to refer to matters of research compliance and integrity rather than antisocial behaviors. The HIT-Res was administered as part of a battery of tests to 300 researchers and trainees funded by the US National Institutes of Health. The HIT-Res demonstrated excellent reliability (Cronbach's alpha = .92). Construct validity was established by the correlation of the HIT-Res with measures of moral disengagement (r = .75), cynicism (r = .51), and professional decision-making in research (r = -.36). The HIT-Res will enrich the set of assessment tools available to instructors in the responsible conduct of research and to researchers who seek to understand the factors that influence research integrity.

Professional Decision-Making in Research (PDR): The Validity of a New Measure.

In this paper, we report on the development and validity of the Professional Decision-Making in Research (PDR) measure, a vignette-based test that examines decision-making strategies used by investigators when confronted with challenging situations in the context of empirical research. The PDR was administered online with a battery of validity measures to a group of NIH-funded researchers and research trainees who were diverse in terms of age, years of experience, types of research, and race. The PDR demonstrated adequate reliability (alpha = .84) and parallel form correlation (r = .70). As hypothesized, the PDR was significantly negatively correlated with narcissism, cynicism, moral disengagement, and compliance disengagement; it was not correlated with socially desirable responding. In regression analysis, the strongest predictors of higher PDR scores were low compliance disengagement, speaking English as a native language, conducting clinical research with human subjects, and low levels of narcissism. Given that the PDR was written at an eighth grade reading level to be suitable for use with English as a second language participants and that only one-fourth of items focused on clinical research, further research into the possible roles of culture and research ethics training across specialties is warranted. This initial validity study demonstrates the potential usefulness of the PDR as an educational outcome assessment measure and a research instrument for studies on professionalism and integrity in research.

A Mixed-Method Analysis of Reports on 100 Cases of Improper Prescribing of Controlled Substances.

Improper prescribing of controlled substances contributes to opioid addictions and deaths by overdose. Studies conducted to-date have largely lacked a theoretical framework and ignored the interaction of individual with environmental factors. We conducted a mixed-method analysis of published reports on 100 cases that occurred in the United States. An average of 17 reports (e.g., from medical boards) per case were coded for 38 dichotomous variables describing the physician, setting, patients, and investigation. A theory on how the case occurred was developed for each case. Explanatory typologies were developed and then validated through hierarchical cluster analysis. Most cases involved physicians who were male (88%), >40 years old (90%), non-board certified (63%), and in small private practices (97%); 54% of cases reported facts about the physician indicative of self-centered personality traits. Three explanatory typologies were validated. Increasing oversight provided by peers and trainees may help prevent improper prescribing of controlled substances.

Heart failure is a major contributor to hospital readmission penalties.

BACKGROUND: The Hospital Readmissions Reduction Program provides incentives to hospitals to reduce early readmissions for heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PNE). METHODS AND RESULTS: To examine the contribution of each diagnosis to readmissions penalty size, data were obtained from the Center for Medicare and Medicaid Services, American Hospital Association, and United States Census Bureau including number of cases; readmissions payment adjustment factor (values <1 indicate a penalty for excess readmissions), excess readmission ratio (ERR, or ratio of adjusted predicted readmission based on comorbidities, frailty, and individual patient demographics to expected probability of readmission at an average hospital) for each diagnosis, hospital teaching status, bed number, and zip code socioeconomic status. Of 2,228 hospitals with ≥25 cases per diagnosis, 1,636 received a penalty. Univariate correlation coefficients between penalty and ERR were -0.66, -0.61, and -0.43 for HF, PNE, and AMI, respectively (all P < .001). Correlation between ERRs was greatest for PNE and HF (0.30; P < .001) and weakest for PNE and AMI (0.12; P < .001). In regression analyses, the HF ERR explained the most variance in the penalty (R(2) range 0.21-0.44). CONCLUSION: HF ERR, not the number of cases, was related to penalty magnitude. These findings have implications for the design of hospital-based quality initiatives regarding readmissions.

Development of a brief validated geriatric depression screening tool: the SLU "AM SAD".

OBJECTIVES: Combining five commonly observed symptoms of late-life depression to develop a short depression screening tool with similar sensitivity and specificity as the conventional, more time-consuming tools. METHODS: We developed the St. Louis University AM SAD (Appetite, Mood, Sleep, Activity, and thoughts of Death) questionnaire. The frequency of each symptom in the prior 2 weeks is quantified as 0, 1, or 2. Patients 65 years or older from our clinics were administered the AM SAD, the Geriatric Depression Scale (GDS-15), the Montgomery-Asberg Depression Rating Scale (MADRS), and the St. Louis University Mental Status Exam (SLUMS). RESULTS: 100 patients were selected. AM SAD correlation with GDS was 0.72 and MADRS 0.80. AM SAD yielded a sensitivity and specificity of 79% and 62% against diagnosis of depression; of 88% and 62% with GDS-15; and 92% and 71% with MADRS. CONCLUSIONS: The AM SAD can be reliably used as a short depression screening tool in patients with a SLUMS score of 20 or higher.