Sexual functioning in patients undergoing bone marrow transplantation: a longitudinal study.

Patients undergoing bone marrow transplantation (BMT) reported numerous sexual difficulties pretransplantation and at 1- and 3-years post transplantation. The most commonly reported problems pretransplant were a lack of sexual interest for men and self-perceived unattractiveness for women. At year 1, men reported more concern about physical attractiveness and increased problems with erection, ejaculation and orgasm. Women reported more sexual problems across all categories. At year 3, difficulties for men remained relatively consistent or decreased compared to year 1 with the exception of an increased concern about physical appearance. At year 3, women reported increased sexual interest; concerns about body appearance, vaginal dryness, painful intercourse and orgasm remained higher than at baseline, although all had decreased from year 1. Half of patients at all time points reported no discussion of sexuality with their health care provider. Baseline level of depression was significantly and positively related to sexual functioning at year 3 post transplant. These results suggest that sexual problems are significant for BMT survivors and that treatment of depression and health-care-provider education are possible interventional targets for improving sexual function and quality of life following BMT.

Accuracy of health-related quality of life assessment: what is the benefit of incorporating patients' preferences for domain functioning?

This study investigated the accuracy benefit of incorporating patients' preferences for domains of functioning into health-related quality of life (HRQOL) measurement. Using policy-capturing techniques, 102 medical outpatients judged the HRQOL of 16 scenarios describing varying levels of functioning in 3 domains. For each participant, regression analysis determined relative domain preferences and 2 decision models were built: one incorporating (preference-weighted) and one ignoring (equally weighted) domain preferences. To assess accuracy, the average proportion of judgment variance accounted for by each model was determined and both accounted for approximately 50%. However, for patients showing the greatest differences in importance across domains, the preference-weighted model was more accurate. Findings are discussed in the context of enhancing HRQOL assessment.

A structured interview for medical school admission, Phase 1: initial procedures and results.

PURPOSE: Despite their widespread use, medical school admission interviews often are unstructured and lack reliability. This report describes the development of a structured admission interview designed to eliminate bias and provide valid information for selecting medical students, with preliminary information about the interview's reliability and validity. METHOD: After screening applications, 490 applicants to a public medical school residency program were interviewed by two faculty members using a structured interview format. Interview scores were compiled and correlated with undergraduate grade-point averages (GPAs); Medical College Admission Test (MCAT) scores; Iowa Evaluation Form (IEF) scores, an in-house evaluation of applicants' noncognitive abilities; and eventual admissions status. RESULTS: Interrater agreement was good; the percentages of rater pairs whose scores differed by one point or less ranged from 87% to 98%. Scores on the structured interview revealed low to moderate correlations with other admission criteria: 10 (p < 0.05) for cumulative GPA, 0.18 (p < 0.01) for MCAT Biological Science, 0.08 (p > 0.05) MCAT Physical Science, and 0.10 (p < 0.05) MCAT Verbal Reasoning. None of the correlations between the overall interview scores and the IEF scores reached statistical significance (p = 0.05). Higher overall scores on the structured interview did predict a greater likelihood of being accepted into the medical school and the interview score accounted for 20% of the incremental variance in admission status beyond GPA, MCAT, and IEF scores. CONCLUSIONS: The moderate-to-low correlations with other admission criteria suggest that the interview provided information about candidate credentials not obtained from other sources and accounted for a substantial proportion of the variance in admission status. This finding supports the considerable time and resources required to develop a structured interview for medical student admissions. Final judgment on the validity and utility of this interview should be made after follow-up performance data have been obtained and analyzed.

The relationship of demographic factors, locus of control and self-efficacy to successful nursing home adjustment.

This study investigated demographic and psychological predictors of 58 older adults' successful adjustment to a nursing home. Predictors included demographic variables, locus of control, and self-efficacy beliefs. Successful adjustment was defined by activity level and by positive and negative affect. Findings suggest that demographic variables were not effective predictors of successful adjustment. Perceived self-efficacy accounted for more of the unique variance in adjustment than locus of control. Results are discussed in the context of improving resident adjustment to nursing home environments.

Dissociation, somatization, substance abuse, and coping in women with chronic pelvic pain.

OBJECTIVE: To examine the relationships between histories of sexual or physical abuse and current reports of dissociation, somatization, substance abuse, adaptive coping, and maladaptive coping strategies among chronic pelvic pain patients. METHODS: Using a structured interview, we assessed sexual and physical abuse and somatization. The Dissociative Experiences Scale was used to assess dissociation, and an abbreviated version of the COPE scale was employed to assess adaptive and maladaptive coping strategies as well as substance abuse. Participants included 46 women with chronic pelvic pain. RESULTS: Women with self-reported sexual or physical abuse histories were found to have significantly higher dissociation, somatization, and substance abuse scores than women without such a history. Significant positive correlations were found between reports of both dissociation and somatization with maladaptive coping strategies and among dissociation, somatization, and substance abuse. CONCLUSION: These results support the association between a positive abuse history and the high levels of dissociation, somatization, and substance abuse often noted in the chronic pelvic pain population. Findings suggest that such psychological variables are more likely to be associated with abuse than with the general medical condition. These psychological variables are conceptualized as maladaptive coping, which may be addressed as part of a biopsychosocial model of treatment for chronic pelvic pain patients.

Energy level and sleep quality following bone marrow transplantation.

While problems with sleep and energy level (ie fatigue) are commonly reported during recovery from bone marrow transplantation (BMT), little in-depth information regarding these two problem areas in BMT patients is available. Using both questionnaire and telephone interview methods, information regarding current sleep and energy level problems was obtained from 172 adult BMT survivors drawn from five different BMT treatment centers. Respondents were a mean of 43.5 months post-BMT at the time of the initial assessment. Similar questionnaire data was obtained from 137 respondents (80%) at a follow-up assessment 18 months after the initial assessment. Results suggested that half to two-thirds of disease-free BMT recipients experience problems with regard to current energy level or sleep quality. While for the majority of patients these problems were rated as mild, 15-20% of BMT recipients showed moderate to severe problems in these areas with corresponding decrements in quality of life. Furthermore, both cross-sectional and longitudinal analyses suggested that problems in these areas did not simply abate with time. Only low to moderate correlations were obtained between indices of sleep and energy problems and measures of anxious and depressed mood. Finally, the presence of current sleep problems was associated with older age at BMT, receipt of TBI during pre-BMT conditioning, and female gender. Further research needs to address the specific etiology of chronic problems with sleep and energy level in BMT recipients as well as evaluate biobehavioral strategies for managing these problems.

A prospective study to select and evaluate anesthesiology residents: phase I, the critical incident technique.

STUDY OBJECTIVE: To develop categories of behavior that define an applicant's aptitude for anesthesia, and to attempt to determine the relative importance of these behaviors to successful residency performance. DESIGN: Prospective open study. SETTING: Anesthesia residencies at three midwest university teaching hospitals. INTERVENTIONS: Using a structured interview format known as the critical incident technique, faculty anesthesiologists were asked to describe examples of effective and ineffective behaviors observed among anesthesia residents during the twelve months prior to the interview. MEASUREMENTS AND MAIN RESULTS: Interviews initially held with 34 anesthesiologists generated 172 incidents. These incidents formed the basis for a categorization analysis performed by two anesthesiologists. Six categories were developed: preparedness, interpersonal skills, response to teaching, data monitoring, technical skills, and emergency situations. Validation of these categories was confirmed with three subsequent interviews, in which 92 anesthesiologists generated 475 incidents. Most incidents were found to conform to the previously defined categories using a reallocation index with a range of 0.70 to 0.80. The category "technical skills" fell below the defined range. Over 60 percent of the incidents involved noncognitive personal attributes: preparedness, interpersonal skills, and response to teaching. CONCLUSION: Effective behavior in six categories identifies an applicant's aptitude for anesthesia. Selection of residents may be enhanced by routinely assessing noncognitive characteristics.

Evaluating the effectiveness of communication skills training: a review of research.

This review considers the effectiveness of communication skills training programs within medical school settings. Several components of training are evaluated: microcounseling, standardized patients, role play, and videotape review. Overall, these interventions have been shown to be effective in improving targeted communication skills (ie, use of open-ended questions). However, outcome data that support the transfer of training to actual patient encounters and subsequent patient outcomes (ie, satisfaction, adherence) are lacking.

Quality of life following bone marrow transplantation: findings from a multicentre study.

Questionnaires assessing a range of quality of life (QOL) outcomes were completed by 200 adult bone marrow transplant (BMT) recipients from five BMT treatment centres. Respondents had undergone allogeneic (46%) or autologous BMT (54%) for a haematological malignancy and were disease free and at least 12 months post BMT (mean 43 months). Variability in post-BMT QOL was reported with deficits in physical, sexual and occupational functioning particularly likely. Allogeneic recipients reported poorer QOL than autologous recipients. Greater age at BMT, lower level of education and more advanced disease at BMT were consistent risk factors for poorer QOL. Contrary to previous research, evidence for improved functional status with the passage of time post BMT was obtained. Factors generally not associated with post-BMT QOL included disease diagnosis, dose of total body irradiation, presence of chronic graft-versus-host disease (GVHD), type of GVHD prophylaxis and extent of marrow graft match. In conclusion, while many BMT recipients reported normal QOL, the majority indicated that their QOL was compromised relative to premorbid status. Prospective, longitudinal research will be necessary to further identify risk factors for poor post-BMT QOL and identify the temporal trajectory of post-BMT QOL.

'Returning to normal' following bone marrow transplantation: outcomes, expectations and informed consent.

The psychosocial impact of bone marrow transplantation (BMT) was investigated in 172 disease-free adult BMT survivors drawn from five different BMT treatment centers. Respondents were a mean of 43.5 months after BMT. Both questionnaire and interview assessments were utilized. Survivors' perceptions of whether they had 'returned to normal' following BMT, recollections of pre-BMT expectations for returning to normal and current psychological distress were assessed. The results indicated that only a minority of respondents considered themselves to have 'returned to normal' following BMT. Reports of less than normal physical, cognitive, occupational, sexual and/or interpersonal functioning were common. In contrast, few patients reported pre-BMT expectations for such. Discordance between pre-BMT expectations for returning to normal and current functional status was associated with greater current psychological distress. Finally, despite the presence of any functional deficits and despite any discordance between pre-BMT expectations and current functional status, survivors' evaluations of their decision to pursue BMT were generally quite positive. Results are discussed in terms of their implications for: (1) the process of obtaining informed consent for BMT, and (2) clinical strategies for enhancing post-BMT psychological adjustment.

The efficacy of preparation for surgery and invasive medical procedures.

In this article, we review published research evaluating the effectiveness of preparation interventions for adult patients undergoing surgery or invasive medical procedures. This review is meant to assist practitioners in selecting or designing an intervention. In general, preparation interventions have been shown to be effective across a range of health outcomes. However, the relative efficacy of different strategies has been difficult to assess, as has the contribution of several patient variables to outcome. Considering interventions used prior to surgery, there is not a clear demonstration of effectiveness, in part because large numbers of outcome variables have been used. In contrast, the preparation intervention literature using adult patients facing invasive medical procedures has shown the relative superiority of modeling procedures and coping strategies. In this review, we consider methodological weaknesses in previous research, and make suggestions for improving future research.

Joseph E. Whitley Award. The effect of preradiology clinical training on the performance of radiology residents.

RATIONALE AND OBJECTIVES: A multi-institutional study was developed to evaluate whether having preradiology clinical training has an effect on the quality of performance of radiology residents assessed both after 1 year of training and at the end of the 4-year residency. MATERIAL AND METHODS: Five faculty members from each of nine collaborating institutions that accept residents both directly from medical school and with postgraduate clinical training completed 1,015 evaluation forms on their 203 residents who had just completed their first year of radiology training or had finished training in the past 2 years. Each resident was evaluated by two senior faculty, two junior faculty, and the residency program director using a cross-institutionally validated, behavior-oriented, standardized instrument that assessed five behavioral characteristics: conscientiousness, curiosity, interpersonal skills, confidence, and recognition of limits. The differences between residents who did and did not have preradiology clinical training were evaluated by analysis of variance and by simple effects testing. RESULTS: At the conclusion of training, no significant differences in resident performance were found between residents who did and did not have postgraduate clinical training before radiology residency. Among residents who had just finished their first year of training, those who had had clinical training scored significantly higher on four of the five behavioral scales. CONCLUSIONS: Clinical training before radiology residency does not correlate with any measurable benefit in performance at the end of radiology residency. Training programs should consider elimination of this requirement.

Evaluation of resident applicants by letters of recommendation: a comparison of traditional and behavior-based formats.

RATIONALE AND OBJECTIVES: Traditional, narrative letters of recommendation solicited by medical students applying for radiology residency are widely used as a selection tool. Letters of recommendation are considered a source of reliable information about the attitudes and behaviors (non-cognitive variables) of the resident applicant. However, in many instances, this information is not present or is highly encoded and cannot be extracted. This study attempted to document the deficiencies of traditional letters of recommendation and determine the effectiveness of a structured letter of recommendation in obtaining information regarding noncognitive variables. METHODS: One hundred thirteen randomly selected letters of recommendation were analyzed by two radiologists with experience in residency selection. Deficiencies in inclusion of information or the ability to extract information about noncognitive variables were documented. A standard behavioral assessment was sent to the writers of these letters of recommendation and these results tabulated. RESULTS: The traditional letters of recommendation were frequently deficient in data regarding the noncognitive variables. In letters that contained such data, two experienced reviewers could not reliably extract the information. The structured form produced clearly identifiable information about the letter writer's assessment of noncognitive variables. CONCLUSIONS: Traditional letters of information are frequently deficient in data regarding noncognitive variables. A standardized statement is effective in eliciting information on noncognitive variables related to applicant performance.

Critical performance behaviors of radiology residents: evaluation of two category systems.

OBJECTIVE: Previous research has suggested that certain behavioral aspects of job performance are critical for successful performance in a diagnostic radiology residency. We report two studies conducted to determine the long-term stability of critical performance behaviors for radiology residents and refine their definitions. SUBJECTS AND METHODS: A trained psychology graduate student conducted critical incident interviews with 20 senior faculty in diagnostic radiology. From these interviews, the faculty generated 120 descriptions of exemplary or poor resident performance. These descriptors were then independently sorted by two radiologists into the previously defined categories of behaviors to evaluate consistency of the behaviors. As a second study, the 120 descriptors were sorted into an expanded behavioral definition system and the reproducibility, using the expanded system, was compared with the original results. RESULTS: The interrater reliability for placing the current incidents in the originally described behavioral categories was good (Cohen's kappa 0.70). The overall distribution of incidents showed strong similarity to the original data. Sorting into the expanded categories improved the Cohen's kappa from 0.70 to 0.92, indicating that the expanded behavioral definitions improved reliability for categorizing a behavioral incident. CONCLUSION: The critical behaviors necessary for successful performance in diagnostic radiology residency are stable over time. The expanded and refined system of definitions of these behaviors is more efficacious than the original system was.

The predictive utility of behavior-based interviewing compared with traditional interviewing in the selection of radiology residents.

RATIONALE AND OBJECTIVES: This study compares the predictive use of measures based on traditional faculty and resident interviews of residency applicants with measures obtained through behavior-based interviewing. A special emphasis was placed on predicting residents' noncognitive abilities. METHODS: One hundred fifty-one resident applicants, over a 3-year period, were interviewed using standard interviews by faculty and residents. These residents also were interviewed with an experimental behavior-based accomplishment interview. Four years later, during their diagnostic radiology residency, evaluations of performance were gathered on these applicants from their residency director. RESULTS: Results indicated that scores based on responses given during the accomplishment interviews added considerable predictive utility to the low prediction demonstrated by traditional interviews. CONCLUSIONS: These findings imply that improving unstructured faculty and resident interviews to obtain, in a more rigorous manner, desired information about noncognitive abilities may be a key to successful resident selection.

Religious orientation and coping with cancer.

In this study we investigated the role of religious orientation in coping with stresses associated with cancer. A measure of daily coping and the Religious Orientation scale were administered to forty hematology-oncology patients in order to examine frequency of eight coping responses across religious orientations. It was found that proreligious and intrinsic participants used religion significantly more often than nonreligious and extrinsic types to cope with stresses associated with their cancer. We concluded that religious orientation and commitment influence the coping process, and suggest that religious commitment be included in studies of coping with cancer.

Two-year adjustment of bone marrow transplant survivors.

Very little systematic analysis exists on the psychological and emotional factors involved in bone marrow transplantation, either during or after treatment. However, recent published findings, contrary to earlier anecdotal and case study evidence, indicate that bone marrow transplant survivors appear to be functioning adequately on a variety of 'quality of life' variables. The purpose of the present study was to compare bone marrow transplant survivors to a matched sample of patients undergoing maintenance chemotherapy in four areas of function; physical health, including symptoms and physician visits; personal functioning, emphasizing ability to care for self; psychological functioning; and role functioning, including employment and sexual difficulties. Our data reveal that the bone marrow transplant patients were experiencing greater difficulties than the maintenance chemotherapy patients in several areas. For example, the bone marrow transplant patients had experienced greater disruption of vocational functioning and reported more sexual difficulties. However, in spite of more objective difficulties, bone marrow transplant patients, compared to maintenance chemotherapy patients, viewed themselves as equally healthy and reported similarly low levels of psychological distress. The findings are discussed in the context of necessary future research on bone marrow transplant survivors.

Cognitive dysfunction in adult survivors of allogeneic marrow transplantation: relationship to dose of total body irradiation.

Bone marrow transplant (BMT) patients are exposed to several potential sources of neurologic damage including the neurotoxicity of pre-BMT preparative regimens. The latter generally include a combination of total body irradiation (TBI) and high-dose chemotherapy. Cognitive functioning in 30 adult allogeneic BMT patients (mean of 47 months post-BMT) treated for either acute or chronic leukemia was assessed by two standardized self-report questionnaires. Consistent with hypothesis, results of both univariate and multivariate analyses indicated that increased dose of TBI was associated with increased cognitive dysfunction. Furthermore, this relationship remained even after the impact of psychological distress upon cognitive functioning was accounted for. TBI-related cognitive impairment primarily involved slowed reaction time, reduced attention and concentration, and difficulties in reasoning and problem-solving. These results complement previous findings of an inverse association between dose of TBI and self-perceptions of health and physical functioning in BMT survivors and indicate the importance of including quality of life measures in clinical trials of therapeutic innovations in the field of BMT.

The quality of life in adult survivors of allogeneic bone marrow transplantation. Correlates and comparison with matched renal transplant recipients.

Research on the quality of life (QOL) following bone marrow transplantation has been hampered by assessment of a limited range of QOL domains as well as by a failure to assess relevant comparison groups. The QOL of adult survivors (n=29) of allogeneic BMT (mean of 51 months post-BMT) drawn from two BMT centers was assessed. QOL was also assessed in a sample of renal transplantation (RT) patients (n=29) matched with BMT patients with regard to age, sex, and time since transplant. Results indicated few differences between the BMT and RT groups across a broad range of QOL domains. Overall, neither group reported what might be considered a "normal" QOL. Multivariate analysis of the correlates of post-BMT QOL revealed that (1) less education, increased dosage of total-body irradiation during pre-BMT conditioning, and an older age at BMT were all associated with poorer status on several measures of post-BMT QOL; (2) time post-BMT was unrelated to post-BMT QOL; and (3) post-BMT affective status was more difficult to predict than post-BMT health or functional status. It was concluded that, while results indicate an acceptable post-BMT QOL, further research is necessary to identify means by which post-BMT QOL can be improved.

A prospective study of cognitive and noncognitive selection criteria as predictors of resident performance.

The primary purpose of this study was to compare objective measures of diagnostic radiology resident applicant performance, such as National Board (NBME) scores, with nonobjective measures, such as conscientiousness and interpersonal skills, in their prediction of resident performance. A second purpose of the study was to examine the predictive usefulness of the Accomplishment Interview (AI), a behavioral selection interview. Thirty resident applicants were interviewed using standard interviews, the AI, and objective data on the applicants were gathered. Four years later, during their diagnostic radiology residency, evaluations were gathered on these applicants, allowing for comparison of current resident performance with past predictive data. Results indicated that noncognitive factors were as important as cognitive factors in the prediction of resident behavior. Further, objective measures, such as NBME scores, failed to adequately predict residents' performance. The implications of these findings for resident selection are discussed.