Religion in the clinic: the role of physician beliefs.

BACKGROUND: Although studies have identified physician beliefs that may cause them to avoid spiritual topics in the clinic (eg, lack of time), it is unknown to what extent these beliefs predict behavior. The purpose of the present study was to identify physician beliefs about religion and medicine that predict attention to religious issues in the clinic. METHODS: The study was cross-sectional and correlational. Seventy-eight physicians completed a self-report survey of religious behavior in the clinic and beliefs about religion and medicine. RESULTS: Most physicians do not initiate religious discussions with patients, though a majority accept a link between religion and health. Physician personal discomfort with addressing religious topics was the sole multivariate predictor of clinical religious behavior. Time, role definition, health relevance of religion, and physician religiousness were not significant predictors. CONCLUSIONS: Avoidance of religion in the clinic may be primarily belief-based. Future research is needed to examine the role of medical education in creating and/or maintaining these beliefs.

Pain assessment in cognitively impaired and unimpaired older adults: a comparison of four scales.

The purpose of the study was to compare the psychometric properties of four established pain scales in a population of hospitalized older adults (mean age, 76 years) with varying levels of cognitive impairment. Patients made ratings of current pain three times/day for 7 days. They also made retrospective daily, weekly, and bi-weekly ratings of usual, worst, and least pain levels over a 14-day period. Ratings were made on four different scales, varying in numeric and verbal demands: a five-point verbal rating scale, a seven-point faces pain scale, a horizontal 21-point (0-100) box scale, and two vertical 21-point (0-20) box scales (measuring pain intensity and pain unpleasantness). The accuracy, reliability, construct validity, postdictive validity, and bias susceptibility of each scale were evaluated. The horizontal 21-point box scale emerged as the best scale with respect to both psychometrics and validity, regardless of mental status. Pain intensity did not vary as a function of mental status. Retrospective estimates of pain varied by mental status: a combination of usual/worst pain was best for cognitively impaired patients, while a combination of usual/least pain was best for unimpaired patients. These findings support the use of the 21-point box scale for pain assessment in older patients, including those with mild-to-moderate cognitive impairment. They also support the ability of older, cognitively impaired patients to rate pain reliably and validly.

Work injury management of refractory low back pain: relations with ethnicity, legal representation and diagnosis.

While psychosocial factors are known to influence treatment outcomes in low back pain patients, relatively little is known about how they may influence work injury management of low back pain. This study examined medical and psychosocial factors associated with work injury management decisions relative to patients with occupational low back pain. A retrospective review of 132 patients who had settled their injury claims showed that two psychosocial factors, ethnicity and litigation status, were associated with work injury management. Temporary total disability costs and impairment ratings were lower for African Americans than for Caucasians, but only in the absence of legal representation. Similarly, patients with specific pathology underwent more treatment, especially diagnostic testing, than patients with non-specific back pain, but only in the presence of legal representation. Having evidence of a specific lesion and legal representation were also associated with claimants' final disability ratings. Results are discussed in terms of a model of social judgment in which properties of the judge, target, and context influence judgments. Implications for work injury management and disability determination, as well as future research are discussed.

Disability management of low back injuries by employer-retained physicians: ratings and costs.

BACKGROUND: Medico-legal models of disability determination for low back pain lack empirical support. Besides diagnostic and functional parameters, social and situational factors may influence impairment/disability ratings and costs. METHODS: Archival data from employer-retained occupational medicine physician files and public court records were examined for 184 Workers' Compensation claimants with low back injuries. Regression was used to predict ratings, costs, and settlement duration from medical, functional, social, and situational variables. RESULTS: Diagnosis, surgery, pain, rating year, and clinic predicted impairment ratings from employer-retained physicians. The clinic effect partially reflected claimant ethnicity. Diagnosis, surgery, tests ordered, legal representation, and impairment rating predicted disability ratings at the administrative law judge level. Diagnosis, tests, and impairment rating predicted costs. For musculoskeletal diagnoses, settlement duration was related negatively to treatment duration and positively to costs. CONCLUSIONS: Social and situational parameters influence disability management among employer-retained physicians, while functional variables have little impact. For musculoskeletal low back pain, increased disability and cost may result from variation in treatment duration.

Does exposure to issues of spirituality predict medical students' attitudes toward spirituality in medicine?

In 1999, the authors surveyed 137 third-year medical students regarding exposures to and attitudes toward spiritual and religious issues in medicine. Path analysis showed that greater exposures predicted more positive attitudes toward these issues.

Student religiosity and attitudes toward religion in medicine at a private Catholic medical school.

BACKGROUND AND OBJECTIVES: This study examined attitudes of medical students at a private Catholic medical school toward religion in medical education and practice and the relationship of these attitudes to medical student religiosity. METHODS: Surveys were mailed to first- and second-year medical students at Saint Louis University. The survey concerned attitudes about the integration of religious issues into the medical school curriculum and clinical practice and the personal importance of religion in the student's life (i.e., religiosity). RESULTS: The response rate was 61% (188/308). Nearly half of the students supported the introduction of religious studies into the medical curriculum, primarily through electives and modelling during clinical clerkships. Students with a higher level of personal religiosity were more likely to advocate training and participation in religious inquiry and behavior in the medical clinic. CONCLUSIONS: A significant minority of medical students at this Catholic university supported attention to religious issues in the medical school curriculum. The percentage might be lower at medical schools with no religious affiliation. The data indicate that students' religiosity is associated with their support for religious inquiry with patients and for the inclusion of religious issues in the medical school curriculum.

Internist judgments of chronic low back pain.

OBJECTIVE: To examine the consistency of internist judgments about low back pain; to examine the influence of different clinical factors on those judgments. DESIGN: 2 x 4 mixed between- and within-subjects analog experiment. SETTING: Academic health sciences center, school of medicine; department of internal medicine. PARTICIPANTS: Forty-eight internal medicine physicians. INTERVENTIONS: Vignettes describing hypothetical chronic low back pain patient varied by patient pain level (low versus high) and clinical information type (history versus physical examination versus functional disability versus medical diagnostics). OUTCOME MEASURES: Clinical judgments regarding patient medical, psychological, and disability status; referral, treatment, and test ordering options. RESULTS: Within-physician consistency was very high, while between-physician consistency was very low. Medical diagnostics had the only consistent influence on judgments. Patient pain level had no effect. Physical examination and functional information had little or no effect. CONCLUSIONS: While there is little agreement among internists regarding judgments of low back pain, individual physicians hold consistently to their opinions. These findings suggest that management of low back pain may be idiosyncratic, potentially compromising patient care.

Postsecondary education and dementia risk in older Jesuit priests.

Lack of early childhood education has been implicated as a risk factor for dementia in late life. It is unclear whether dementia risk is also associated with less education in the adult years. The purpose of the present study was to determine whether amount of postsecondary education (i.e., education beyond the high school or 12th-grade level) is associated with dementia after age 60. Cognitive function (assessed by a neuropsychological test battery) and the prevalence of dementia (assessed by clinical criteria) were determined in 86 Jesuit priests (age 60 to 98) who had from 0 to 23 years of postsecondary education. Logistic regression was used to estimate the odds of dementia as a function of postsecondary education. The risk of dementia was increased in those with less postsecondary education (odds ratio = 3.4; 95% confidence interval, 1.2 to 10.0) after adjustment for age, IQ, and depression. These findings support an association between amount of postsecondary education and risk of dementia in late life.

Construct validity of the computerized version of the Category Test.

The purpose of the current study was to investigate the construct validity of the computer version of the Category Test (CT) in relation to the standard version. As part of a comprehensive neuropsychological assessment, outpatient rehabilitation clients completed either the standard CT (n = 49) or the computerized version (n = 56). Two principal component factor analyses were performed and the factor structures compared to a solution reported previously in the literature. Inspection of the factor loadings revealed a similarity between the computerized CT and standard CT groups as well as with the previously reported analysis. The results of this study suggest that regardless of the mode of administration the CT loads on a "spatial abilities", factor and provides support for the construct validity of the computerized CT as part of a comprehensive neuropsychological testing battery.

Physician judgments of chronic pain patients.

Recent evidence has indicated that physician judgments of patients can be influenced by contextual factors. This study examined three contextual factors relevant to hypothetical patients with low back pain, using vignettes that were varied in a 2 x 2 x 2 factorial design: level of reported pain (high vs low), level of supporting medical evidence (high vs low), and the valence of the physician-patient interaction (positive vs negative). Perceived levels of pain, disability, emotional distress, and somatic preoccupation were rated by internists after reading a vignette. Ratings of pain and disability were lower for patients without supporting medical evidence; ratings of distress, somatic preoccupation, and disability were greater for patients who exhibited negative rather than positive affect; internist ratings of pain were lower than patient ratings among patients reporting high levels of pain, while ratings were inflated for patients with low levels of pain. The results suggest that characteristics of both the patient and the situation may influence medical judgments.

The effects of medical evidence and pain intensity on medical student judgments of chronic pain patients.

This study examined symptom judgments made by medical students of hypothetical chronic low back pain patients. Eight vignettes were varied as to the pain intensity reported by the hypothetical patient (low vs. moderate vs. high vs. very high) and the availability of medical evidence supportive of the pain report (present vs. absent). Ninety-five subjects read vignettes and made judgments of patient emotional distress, pain intensity, and pain-related disability. Subjects significantly discounted pain level when intensity was high but slightly augmented pain level when intensity was low. Judgments of pain and disability were higher for patients for whom medical evidence was present compared to those for whom it was absent. The results support and extend previous research on the effects of situational and patient variables on observer pain judgments. Future research should examine the influence of these biasing variables on the assessment and treatment of chronic pain patients.

Development of a brief version of the Survey of Pain Attitudes.

Because patient attitudes and beliefs about pain have been shown to affect treatment outcomes and adjustment to illness, a number of self-report instruments have been developed assess those constructs. The Survey of Pain Attitudes (SOPA) is a well-researched instrument that assesses patient feelings about pain control, solicitude (solicitous responses from others in response to one's pain), medication (as appropriate treatment for pain), pain-related disability, pain and emotions (the interaction between emotions and pain), medical cures for pain, and pain-related harm (pain as an indicator of physical damage or harm). The factor structure of the SOPA, however, has not been verified and its length makes its administration cumbersome. The present study examined the factor structure of the SOPA and developed a brief 30-item version of the original. Factor analysis showed that the SOPA did not contain seven unique dimensions. The brief version (the SOPA-B), however, clearly reflected the seven dimensions described for the SOPA. The psychometric properties of the SOPA-B were comparable to those of the SOPA. The SOPA-B appears to be a practical, easily-administered alternative to the longer version.

Relationship between social desirability and self-report in chronic pain patients.

OBJECTIVE: To examine the relationship between social desirability and self-report in data collected from chronic pain patients. SETTING: A multidisciplinary pain management center located in a major university medical center. PATIENTS: Two hundred persons presenting with chronic pain, including low back, head/neck, and extremity pain. MEASURES: Marlowe-Crowne Social Desirability Scale, Beck Depression Inventory--Short Form, Spielberger Trait Anxiety Inventory, Psychosomatic Symptom Checklist, McGill Pain Questionnaire, Pain Disability Index, Quality of Life Scale, Pain Drawing. RESULTS AND CONCLUSIONS: Correlations showed that patients with greater social desirability response bias reported less depression and anxiety but higher levels of pain severity. When depression effects were controlled in a regression analysis, social desirability correlated positively with self-reported disability. These results show systematic response patterns associated with social desirability, suggesting that social desirability response biases should be considered in both research and clinical assessments of chronic pain patients.

Anger, depression, and disability: a path analysis of relationships in a sample of chronic posttraumatic headache patients.

Anger and depression are common affective concomitants of chronic headache. Previous research suggests that the affective component of headache may contribute to the patient's perceptions of the degree to which the headache is disabling. The present study examined the relationship between anger expression, anger suppression, depression, and headache-related disability (interference with function) in a sample of chronic posttraumatic headache patients. A path analytic model indicated a direct relationship between depression and perceived disability. Anger suppression and anger expression each had a direct influence on depression, but their effects on disability were mediated through depression. The results partially replicate a previous path analytic study of the relationships among these variables in a chronic headache sample.

The influence of body size on linear measurements used to reflect cervical range of motion.

BACKGROUND AND PURPOSE: The purposes of the study were to demonstrate that linear measurements of cervical range of motion are confounded by differences in body size when comparisons are made between groups and to introduce an alternative measure of range of motion that adjusts for variation in body size. SUBJECTS: The sample consisted of 42 subjects (25 female, 17 male) with chronic posttraumatic headaches. METHODS: Using a tape measure, a physical therapist measured the distance between two anatomical landmarks with the subject's neck in the anatomical neutral position and with the subject's neck fully laterally flexed, rotated, and forward flexed. Range of motion was effected with two measurements: the distance between the landmarks at full flexion/rotation and the proportion of distance traversed between the landmarks. RESULTS: The end-of-range values were significantly correlated with body size. No significant correlations emerged between the proportion-of-distance values and body size. CONCLUSION AND DISCUSSION: Linear measurements of cervical motion are potentially confounded by body size when subjects of nonequivalent size are compared. Proportion-of-distance measurement is presented as a more valid alternative to end-of-range measurement.

The short form of the Beck Depression Inventory: validity issues with chronic pain patients.

OBJECTIVE: To investigate the validity of the Beck Depression Inventory short form when used to screen for depression in chronic pain patients. SETTING: A multidisciplinary pain management center located in a major university medical center. PATIENTS: Seven hundred sixty-five persons presenting for evaluation of chronic pain, including low back pain, head/neck pain, and extremity pain. MEASURES: Beck Depression Inventory short form, McGill Pain Questionnaire, Pain Disability Index, pain drawing, and Quality of Life Scale. RESULTS AND CONCLUSIONS: Items on the Beck Depression Inventory short form reflecting pain-related interference with function (i.e., disability) were endorsed to a greater degree than affective and cognitive items. A factor analysis of the inventory yielded two affective/cognitive factors and one "disability" factor (work inhibition and fatigue). The correlations between the factor scores and the Pain Disability Index suggested that endorsement of the work inhibition and fatigue items by chronic pain patients may not be indicative of affective disturbance. The results suggest that these items should be evaluated critically for their contribution to the total score of the Beck Depression Inventory short form when assessing depression in chronic pain patients.