Improving oversight of the graduate medical education enterprise: one institution's strategies and tools.

Accreditation organizations, financial stakeholders, legal systems, and regulatory agencies have increased the need for accountability in educational processes and curricular outcomes of graduate medical education. This demand for greater programmatic monitoring has placed pressure on institutions with graduate medical education (GME) programs to develop greater oversight of these programs. Meeting these challenges requires development of new GME management strategies and tools for institutional GME administrators to scrutinize programs, while still allowing these programs the autonomy to develop and implement educational methods to meet their unique training needs. At the Medical University of South Carolina (MUSC), senior administrators in the college of medicine felt electronic information management was a critical strategy for success and thus proceeded to carefully select an electronic residency management system (ERMS) to provide functionality for both individual programs and the GME enterprise as a whole. Initial plans in 2002 for a phased deployment had to be changed to a much more rapid deployment due to regulatory issues. Extensive communication and cooperation among MUSC's GME leaders resulted in a successful deployment in 2003. Evaluation completion rates have substantially improved, duty hours are carefully monitored, patient safety has improved through more careful oversight of residents' procedural privileges, regulators have been pleased, and central GME administrative visibility of program performance has dramatically improved. The system is now being expanded to MUSC's medical school and other health professions colleges. The authors discuss lessons learned and opportunities and challenges ahead, which include improving tracking of development of procedural competency, establishing and monitoring program performance standards, and integrating the ERMS with GME reimbursement systems.

Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder.

BACKGROUND: There are concerns regarding the validity of combat exposure reports of veterans seeking treatment for combat-related post-traumatic stress disorder (PTSD) within US Veterans Affairs Medical Centers. AIMS: To verify combat exposure history for a relevant sample through objective historical data. METHOD: Archival records were reviewed from the US National Military Personnel Records Center for 100 consecutive veterans reporting Vietnam combat in a Veterans Affairs PTSD clinic. Cross-sectional clinical assessment and 12-month service use data were also examined. RESULTS: Although 93% had documentation of Vietnam war-zone service, only 41% of the total sample had objective evidence of combat exposure documented in their military record. There was virtually no difference between the Vietnam 'combat' and 'no combat' groups on relevant clinical variables. CONCLUSIONS: A significant number of treatment-seeking Veterans Affairs patients may misrepresent their combat involvement in Vietnam. There are implications for the integrity of the PTSD database and the Veterans Affairs healthcare system.

Remote psychotherapy for terminally ill cancer patients.

We conducted a feasibility study of remote psychotherapy in 10 terminally ill cancer patients with diagnoses of adjustment disorder or major depression. Subjects received six sessions of individual cognitive therapy with the same therapist. Sessions alternated between face-to-face sessions and remote sessions delivered by analogue videophone. After each therapy session, a brief questionnaire was used to evaluate the subjects' level of satisfaction with the session, sense of connectedness to the therapist and overall progress being made in the therapy. Nine patients completed the study. Of 53 completed therapy sessions, 21 were by videophone and 32 were conducted face to face. Participants reported strong positive perceptions and acceptance after almost all therapy sessions, regardless of service delivery mode. The study suggests that there may be a role for the delivery of psychotherapy using low-bandwidth videophones.

Prevalence of posttraumatic stress disorder in Veterans Affairs primary care clinics.

Although posttraumatic stress disorder (PTSD) is relatively common in community epidemiologic surveys (5-6% for men, 10-12% for women), and psychiatric patients with PTSD are known to have poor functioning and high levels of psychiatric comorbidity, there are no studies that address PTSD prevalence, functioning, and burden in primary care settings. This article reports on (1) the prevalence of PTSD using Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition diagnostic criteria in Veterans Affairs (VA) primary care settings, (2) associated sociodemographic characteristics and comorbidities, (3) functional status related to PTSD, (4) the extent to which PTSD was recognized by providers and (5) health services use patterns (including specialty mental health) of PTSD patients. Patients were randomly selected from those who had an outpatient visit in FY 1999 at one of four VA hospitals; 888 patients consented (74.1% of 1198 contacted); 746 patients (84.0% of consenting patients; 62.3% of contacted patients) were reached for telephone diagnostic interviews. Diagnostic interviews with the Clinician Administered PTSD Scale yielded estimates of current PTSD prevalence of 11.5%. At statistically significant levels, PTSD was positively associated with a variety of comorbid psychiatric disorders, war zone service, age <65 years, not working, less formal education and decreased functioning. Of patients diagnosed with PTSD by study procedures, 12-month medical record review indicated that providers identified only 46.5% and only 47.7% had used mental health specialty services. PTSD-positive [PTSD(+)] patients who used mental health care in the past 12 months were more apt to be identified as having PTSD than nonmental health service users (78.0% vs. 17.8%). Although PTSD(+) patients had more medical record diagnoses than PTSD-negative [PTSD(-)] patients (6.28 vs. 4.95), their use of primary care, urgent care and inpatient care was not different from PTSD(-) patients.

Neural correlates of speech anticipatory anxiety in generalized social phobia.

Patients with generalized social phobia fear embarrassment in most social situations. Little is known about its functional neuroanatomy. We studied BOLD-fMRI brain activity while generalized social phobics and healthy controls anticipated making public speeches. With anticipation minus rest, 8 phobics compared to 6 controls showed greater subcortical, limbic, and lateral paralimbic activity (pons, striatum, amygdala/uncus/anterior parahippocampus, insula, temporal pole)--regions important in automatic emotional processing--and less cortical activity (dorsal anterior cingulate/prefrontal cortex)--regions important in cognitive processing. Phobics may become so anxious, they cannot think clearly or vice versa.

Service use and satisfaction among elderly former prisoners of war in South Carolina.

OBJECTIVE: This project was developed to evaluate the use of and satisfaction with Veteran's Affairs (VA) medical services and disability benefits among surviving elderly prisoners of war (POWs) in South Carolina. METHOD: A single-assessment quantitative survey strategy was implemented to learn more about the service use patterns and satisfaction with care of two groups of male former POWs (N = 87): those who were members of a national POW service organization and those who were not. RESULTS: Data show that the majority of these POWs had used the VA for medical care in the previous year, received disability compensation through the VA, and were satisfied with VA primary care medical services. Furthermore, differences between these two POW groups were minimal. CONCLUSIONS: Results provide preliminary evidence that many former POWs rely heavily upon the VA for provision of primary medical and specialty care and disability compensation and that POWs are generally satisfied with the VA services and benefits they receive.

Disability compensation seeking among veterans evaluated for posttraumatic stress disorder.

OBJECTIVE: This study sought to further examine the relationship between compensation-seeking status and reporting of symptoms among combat veterans who were evaluated for posttraumatic stress disorder (PTSD). METHODS: Archival data were drawn for 320 adult male combat veterans who were consecutively evaluated at a Department of Veterans Affairs (VA) PTSD outpatient clinic from 1995 to 1999. The veterans were compared on variables from their clinical evaluation, including diagnostic status and self-report measures such as the Minnesota Multiphasic Personality Inventory-2, which includes scales designed to detect feigned or exaggerated psychopathology. RESULTS: Compensation-seeking veterans reported significantly more distress across domains of psychopathology, even after the effects of income had been controlled for and despite an absence of differences in PTSD diagnoses between groups. However, compensation-seeking veterans also were much more likely to overreport or exaggerate their symptoms than were non-compensation-seeking veterans. CONCLUSIONS: This study provided further evidence that VA disability compensation incentives influence the way some veterans report their symptoms when they are being evaluated for PTSD. These data suggest that current VA disability policies have problematic implications for the delivery of clinical care, evaluation of treatment outcome, and rehabilitation efforts within the VA.

Racial differences in psychotic symptoms among combat veterans with PTSD.

We tested the hypothesis that race may influence clinical presentation and symptomatology in combat veterans with posttraumatic stress disorder (PTSD). African-American and Caucasian veterans were administered the Psychotic Screen Module of the Structured Clinical Interview for DSM, Minnesota Multiphasic Personality Inventory-2 (MMPI-2), and other psychometric measures at a Veterans Affairs outpatient PTSD clinic. Subjects were consecutive referrals who were not matched for level of combat trauma or preexisting trauma; however, there were no group differences in other relevant demographic or diagnostic variables. Significant racial differences, with modest effect sizes, were found on clinician ratings of psychotic symptoms, MMPI-2 scale 6 ("paranoia"), and a measure of dissociation. No significant differences were found for the MMPI-2 scale 8 ("schizophrenia"), or on measures that might suggest comorbid depression or anxiety. African-Americans with PTSD endorsed more items suggesting positive symptoms of psychosis, without higher rates of primary psychosis, depression, or anxiety than Caucasians.

Patient satisfaction among combat veterans receiving specialty PTSD treatment.

BACKGROUND: Despite the difficulties with successfully developing effective treatments for posttraumatic stress disorder (PTSD), very little research has been conducted on veterans' perceptions of satisfaction with the treatments they receive through the VA. OBJECTIVE: Our objective was to evaluate combat veterans' satisfaction with Veterans Affairs (VA) services and to evaluate the reliability and preliminary validity of a measure of patient satisfaction, the Charleston Psychiatric Outpatient Satisfaction Scale-VA PTSD Version, which was originally designed for general psychiatric outpatients. METHOD: Fifty-one combat veterans currently receiving specialty mental health care at a VA outpatient PTSD clinic were asked to complete two instruments designed to assess their satisfaction with services provided within the VA mental health and primary care clinics. RESULTS: Data show that the reliability (alpha = 0.96 and 0.95) and validity of these two measures of patient satisfaction were good and indicate that veterans receiving specialty mental health care for PTSD rate their mental health and primary care quite positively. CONCLUSIONS: These results provide preliminary support for the internal reliability and convergent validity of a novel measure of patient satisfaction for use with combat veterans suffering from PTSD and treated within a VA hospital specialty mental health clinic; the results also support the satisfaction of these patients with mental health and primary care services received through the VA.