Faculty Bibliography

BACKGROUND: Physician job satisfaction has been linked to various patient care and health system outcomes. A survey instrument that concisely measures physicians' satisfaction with various job facets can help diverse stake-holders to better understand and manage these outcomes. OBJECTIVE: To document the development and validation of a multidimensional physician job satisfaction measure and separate global satisfaction measures. DESIGN: Self-administered questionnaire: Physician Worklife Survey (PWS). SUBJECTS: A pilot study employed a national American Medical Association Masterfile sample of US primary care physicians and random samples from four states. Responses (n = 835; 55% return rate) were randomly assigned to developmental (n = 560) or cross-validation (n = 275) samples. A national sample (n = 2,325; 52% response rate) of physicians was used in a subsequent validation study. RESULTS: A 38-item, 10-facet satisfaction measure resulting from factor and reliability analyses of 70 pilot items was further reduced to 36 items. Reliabilities of the 10 facets ranged from .65 to .77. Three scales measuring global job, career, and specialty satisfaction were also constructed with reliabilities from .84 to .88. Results supported face, content, convergent, and discriminant validity of the measures. CONCLUSIONS: Physician job satisfaction is a complex phenomenon that can be measured using the PWS

In the freshwater coelenterate, hydra, asexual reproduction via budding occurs at the base of the gastric region about two-thirds of the distance from the head to the foot. Developmental gradients of head and foot activation and inhibition originating from these organizing centers have long been assumed to control budding in hydra. Much has been learned over the years about these developmental gradients and axial pattern formation, and in particular, the inhibitory influence of the head on budding is well documented. However, understanding of the role of the foot and potential interactions between the foot, bud, and head patterning systems is lacking. The purpose of this study was to investigate the role of the foot in the initiation of new axis formation during budding by manipulating the foot and monitoring effects on the onset of first bud evagination and the time necessary to reach the 50% budding point. Several experimental situations were examined: the lower peduncle and foot (PF) were injured or removed, a second PF was laterally grafted onto animals either basally (below the budding zone) or apically (above the budding zone), or both the head and PF were removed simultaneously. When the PF was injured or removed, the onset of first bud evagination was delayed and/or the time until the 50% budding point was reached was longer. The effects were more pronounced when the manipulation was performed closer to the anticipated onset of budding. When PF tissue was doubled, precocious bud evagination was induced, regardless of graft location. Removal of the PF at the same time as decapitation reduced the inductive effect of decapitation on bud evagination. These results are discussed in light of potential signals from the foot or interactions between the foot and head patterning systems that might influence bud axis initiation

OBJECTIVE:To determine if there is a core subset of depressive symptoms that could be used to efficiently diagnose depression after administering the 2-item PRIME-MD a screening questionnaire for depression. METHODS:One thousand patients selected randomly and by convenience from 4 primary care clinics were assessed by PRIME-MD and completed a questionnaire measuring the following validation variables: functional status and well-being, disability days, somatic symptoms, depression severity, suicidal thoughts, health care utilization, and the physician-patient relationship. RESULTS:Four symptoms (sleep disturbance, anhedonia, low self-esteem, and decreased appetite) accounted for virtually all the depression symptom-related variance in functional status and well-being, with 8.3% of patients having 2 of these symptoms and 8.2% having 3 or 4 of these symptoms. There was excellent agreement between diagnosis based on core symptoms and major depression (K= 0.77; overall accuracy rate, 94%). There were significant differences (P<.001) among patients with negative depression screen, 0 to 1, 2, and 3 to 4 core symptoms with scores on each of the validation variables getting progressively worse in these 4 groups. A cutoff point of 2 core symptoms identified all but 3 patients with major depression and an additional 5% of the entire sample without major depression who were significantly (P<.05) worse than patients without depression on each of the validation variables. CONCLUSION/CONCLUSIONS:A strategy that includes the use of a 2-item depression screener followed by the evaluation of 4 core depressive symptoms is an efficient and effective way of identifying and classifying primary care patients with depression in need of clinical attention.

STUDY DESIGN/METHODS:Cross-sectional data were analyzed from the Veterans Health Study, an observational study of patients receiving ambulatory care. OBJECTIVE:To develop a method of stratifying patients with low back pain by combining patient reports of radiating leg pain with the results of straight leg raising tests. SUMMARY AND BACKGROUND DATA/BACKGROUND:Four hundred thirty-four participants with low back pain were identified through patient reports of ever having had low back pain, of low back pain that began more than 3 months ago, and of a health-care visit for low back pain in the past year. Four hundred twenty-eight patients with low back pain were included in the current analysis. METHODS:Participants were mailed a health-related quality of life questionnaire and had an interview that included a low back pain questionnaire and a straight leg raising test. Patients' reports of radiating leg pain and results of the straight leg raising tests were combined into four hierarchical groups. This stratification was evaluated in relation to responses to the health-related quality of life questionnaire, localized low back pain, disability, and use of medical services. RESULTS:The intensity of localized low back pain and disability increased from Group 1 (low back pain alone) to Group 4 (pain below knee with positive straight leg raising test result), whereas health-related quality of life decreased. Group 4 patients were 5.1 times more likely than were Group 1 patients to use medications for low back pain (95% confidence interval 1.2, 22.9), 6.8 times more likely to have a spinal magnetic resonance study (95% confidence interval, 2.7, 17.2), and 3.9 times more likely to have surgery (95% confidence interval, 1.3, 11.4). CONCLUSIONS:The method of measuring correlation performs well in identifying patients with different levels of localized low back pain intensity, health-related quality of life, and use of services. It may be useful in studies of health outcomes, in clinical trials, and in predicting demands on health care resources.

BACKGROUND:The Department of Veterans Affairs Health Care System (VA) is the largest integrated single payer system in the United States. To date, there has been no systematic measurement of health status in the VA. The Veterans Health Study has developed methods to assess patient-based health status in ambulatory populations. OBJECTIVES/OBJECTIVE:To describe the health status of veterans and examine the relationships between their health-related quality of life, age, comorbidity, and socioeconomic and service-connected disability status. METHODS:Participants in the Veterans Health Study, a 2-year longitudinal study, were recruited from a representative sample of patients receiving ambulatory care at 4 VA facilities in the New England region. The Veterans Health Study patients received questionnaires of health status, including the Medical Outcomes Study Short Form 36-Item Health Survey; and a health examination, clinical assessments, and medical history taking. Sixteen hundred sixty-seven patients for whom we conducted baseline assessments are described. RESULTS:The VA outpatients had poor health status scores across all measures of the Medical Outcomes Study Short Form 36-Item Health Survey compared with scores in non-VA populations (at least 50% of 1 SD worse). Striking differences also were found with the sample stratified by age group (20-49 years, 50-64 years, and 65-90 years). For 7 of the 8 scales (role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health), scores were considerably lower among the younger patients; for the eighth scale (physical function), scores of the young veterans (aged 20-49 years) were almost comparable with the levels in the old veterans (>65 years). The mental health scores of young veterans were substantially worse than all other age groups (P<.001) and scores of screening measures for depression were significantly higher in the youngest age group (51%) compared with the oldest age groups (33% and 16%) (P<.001). CONCLUSIONS:The VA outpatients have substantially worse health status than non-VA populations. Mental health differences between the young and old veterans who use the VA health care system are sharply contrasting; the young veterans are sicker, suggesting substantially higher resource needs. Mental health differences may explain much of the worse health-related quality of life in young veterans. As health care systems continue to undergo a radical transformation, the Department of Veterans Affairs should focus on the provision of mental health services for its younger veteran.

The chronic constriction injury model of mononeuropathy is a direct, partial nerve injury yielding thermal hyperalgesia. The inflammation that results from this injury is believed to contribute importantly to both the neuropathological and behavioral sequelae. This study involved administering a single dose (250 ng) of interleukin-10 (IL-10), an endogenous anti-inflammatory peptide, at the site and time of a chronic constriction injury (CCI) lesion to determine if IL-10 administration could attenuate the inflammatory response of the nerve to CCI and resulting thermal hyperalgesia. In IL-10-treated animals, thermal hyperalgesia was significantly reduced following CCI (days 3, 5 and 9). Histological sections from the peripheral nerve injury site of those animals had decreased cell profiles immunoreactive for ED-1, a marker of recruited macrophages, at both times studied (2 and 5 days post-CCI). IL-10 treatment also decreased cell profiles immunoreactive for the pro-inflammatory cytokine tumor necrosis factor alpha (TNF-alpha) at day 2, but not day 5. Qualitative light microscopic assessment of neuropathology at the lesion site did not suggest substantial differences between IL-10 and vehicle-treated sections. The authors propose that initial production of TNF-alpha and perhaps other proinflammatory cytokines at the peripheral nerve lesion site importantly influences the long-term behavioral outcome of nerve injury, and that IL-10 therapy may accomplish this by downregulating the inflammatory response of the nerve to injury.