Brief negotiation program for promoting behavior change: the Kaiser Permanente approach to continuing professional development.

BACKGROUND: Behavior change counseling is one of the most difficult and constant challenges faced by health providers. It has a significant impact on clinical outcomes as well as patient and provider satisfaction. By encouraging patients to participate in a partnership with health care professionals, Brief Negotiation offers techniques to motivate behavior change successfully. We review the key components of Brief Negotiation and describe how one large group model health maintenance organization was able to identify key staff members, develop educational opportunities and implement Brief Negotiation system-wide into standard care practices. OBJECTIVES: To expose a maximum number of health care professionals to a recommended model of behavior change counseling; to increase the satisfaction and confidence of health care professionals in counseling for behavior change; and to increase the likelihood of improved patient health outcomes. METHOD: Two departments created one-day, two-day, six-hour and one-to-two-hour skill-based programs targeted to physicians, nurse practitioners, care managers, clinical health educators, behavioral medicine specialists, physical therapists, pharmacists and medical assistants. Practice protocols, strategic departmental alliances and intranet sites complemented the educational interventions. RESULTS: Over 1000 health care professionals have been exposed to the Brief Negotiation model in over two years. A mailed survey to graduates of the one- and two-day programs indicated that 67% of physicians and 79% of other health professionals felt more confident about working with patients on behavior change after having attended the Brief Negotiation program. CONCLUSIONS: System-wide professional development requires multiple exposures to the Brief Negotiation model, considerable resources for curriculum development, training time and follow-up, and credible clinical trainers. Questions remain about the amount of training needed for long-term clinician behavior change and for improved health outcomes in patients.

Effects of different forms of central nervous system prophylaxis on neuropsychologic function in childhood leukemia.

A comparison of the late effects on intellectual and neuropsychologic function of three different CNS "prophylaxis" regimens was conducted in 104 patients treated for childhood acute lymphocytic leukemia. Of the children studied, 33 were randomized to treatment with intrathecal (IT) methotrexate alone, 36 to IT methotrexate plus 2,400 rad cranial irradiation, and 35 to IT methotrexate plus intravenous intermediate dose methotrexate. All patients were in their first (complete) continuous remission, were a minimum of one year post-CNS prophylaxis and had no evidence of CNS disease at the time of evaluation. In contrast to the other two treatment groups, children whose CNS prophylaxis included cranial irradiation attained significantly lower mean Full Scale IQs (P less than .001), performed more poorly on the Wide Range Achievement Test, a measure of school abilities, and exhibited a greater number of difficulties on a variety of other neuropsychologic measures. The poorer performance of the irradiated group was independent of sex of the patient, time since treatment and age at diagnosis. These data suggest that the addition of 2,400 rad cranial irradiation to CNS prophylaxis in ALL puts these children at greater risk for mild global loss in intellectual and neuropsychologic ability.

Teaching brief psychotherapy for spouses of cancer patients: us of a codable supervision format.

While there has been increasing recognition of the psychosocial needs of cancer patients, the plight of the patient's spouse has been less well addressed. As part of an ongoing study in this area, we have developed a counseling manual which defines the parameters of a therapy intervention for cancer patients' spouses with problematic adjustment. In order to monitor the consistency of the therapy, we have also developed a codable supervision rating sheet, which is the topic of this report. All therapist communications are rated on a three-dimensional format which specifies general content area, level of intervention, and the presence of a focus specific to the therapy. This codable rating sheet is used in a group supervision process. It provides an innovative method to teach and supervise therapy, helps delineate specific elements of therapy judged to be important, and also has implications for psychotherapy research which extend beyond this specific project.

Defining discipline roles in consultation psychiatry: the multidisciplinary team approach to psychosocial oncology.

Multiple mental health professions are often involved in the management of cancer patients. Psychiatry, psychology, social work, and nursing have all developed entrees to the medical setting that lead to clinical involvement of one or more of these professions at any given time. Much confusion remains about the specific contribution of these different mental health professions, and lack of role definition makes it difficult for programs to logically plan for mental health services or for services already in place to organize themselves in a collaborative manner. While these disciplines have interacted formally and informally in a number of settings for many years, there have been few published attempts to delineate the unique contributions of each and to suggest a model for their collaborative interaction. This paper attempts to define the unique contributions of each of these disciplines in relation to an oncology consultation program in a general hospital setting. The definitions are proposed as a model that can be generalized to other consultation programs.

Self-scanned photodiode array: high performance operation in high dispersion astronomical spectrophotometry.

We have developed a multichannel spectrophotometric detector system using a 1024 element self-scanned silicon photodiode array, which is now in routine operation with the high-dispersion coudé spectrograph of the University of Texas McDonald Observatory 2.7-m telescope. We discuss operational considerations in the use of such arrays for high precision and low light level spectrophotometry. A detailed description of the system is presented. Performance of the detector as measured in the laboratory and on astronomical program objects is described, and it is shown that these arrays are highly effective detectors for high dispersion astronomical spectroscopy.

Self-scanned digicon: a digital image tube for astronomical spectroscopy.

We have successfully fabricated, tested, and operated a digital image tube consisting of a magnetically focused image intensifier tube in which a self-scanned linear array of 1024 silicon photodiodes operating in the EBS mode serves as the photoelectron image detector, amplifier, and intermediate image storage device. Integral on-chip MOS shift registers driven by an external clock sequentially interrogate the photodiodes through MOS FET multiplex switch arrays. Each output frame is a sequence of 256 analog pulses on each of four video lines. Laboratory and observing tests show that the output signal is photoelectron shot noise limited over at least a range of 1-10(5) detected photoelectrons per picture element, indicating that single photon detection is achieved. High-resolution astronomical spectroscopy has been carried out in the coudé spectrograph of the 2.7-m telescope at McDonald Observatory. Examples are shown.

Mars: Detection of Atmospheric Water Vapor during the Southern Hemisphere Spring and Summer Season.

Water vapor was found to reappear in the atmosphere of Mars during its southern hemisphere spring and summer season, with a maximum vertical column abundance of 45 to 50 microns of precipitable water averaged over the entire planet. Although the spring-summer seasons for each hemisphere are generally symmetrical with respect to the appearance of water vapor, the data suggest that water vapor may appear later in the season and in slightly larger amounts during the southern hemisphere spring-summer.

Wavelength errors in spectrographs. I: the effect of surface irregularities in camera mirrors.

High-dispersion astronomical coudé spectrographs frequently give lower-precision radial velocities than expected. This is explained i part in terms of the variable spectral shifts along the plate produced by a camera mirror with zonal imperfections. For a mirror with a sinusoidal zonal irregularity, the standard deviation in the radial velocity depends inversely on the angular dispersion and size of the grating or prism and directly on the amplitude of the surface fluctuation. For a 300-mm grating with 1200 lines/mm used in first order at lambda = 0.5 microm, a standard deviation of 0.06 km/sec is obtained for a single measurement if the surface has a peak-to-valley fluctuation of 1/20 wavelength of green light.

A comparison of photon counting and current measuring techniques in spectrophotometry of faint sources.

The component of dark noise produced by Cerenkov pulses in photomultipliers due to cosmic ray mu mesons is discussed. It is shown by integration of pulse height spectra that this source of noise can be the limiting factor in de measuring spectrophotometry of faint astronomical sources. Direct current methods of photometry are compared with photon counting, and the advantage of photon counting is demonstrated under various operating conditions.

A single-photon counting astronomical spectrophotometer.

A spectrophotometer originally used with current measuring photometry has been modified to take advantage of the increased information rate obtainable through single-photon counting. Through careful guiding, relative wavelength displacements between successive scans can be kept to 0 +/- 0.1 A. In one test, shot noise appears to dominate for count rates less than l0(4)/see on photometric nights. Used with the 208-cm Struve reflector at McDonald Observatory, objects as faint as m(p) = 15.3 have been successfully observed with a slit width of 150 A, corresponding to a resolution of 40. Objects as bright as V = 0.0 are observed with integration times of 1 sec and a slit width of 0.1 A, corresponding to a resolution of 50,000.