In This Issue: Capacity for Caring and Generating New Knowledge

To the Editor:

While informative, your editorial and issue, collectively based on the “Capacity for Caring and Generating New Knowledge” (1), failed to address the needs and advancements in automation technologies to complement the delivery of family medicine and academic health center care. Such gaps exist in psychiatry, among other medical specializations, which, ultimately, impact health policy.

Where demand exceeds psychiatrist supply, it equates to a lack of adequate psychiatric care access, time, resources, and treatment for the patients who require it the most. Furthermore, administrative issues, resources deficits, and long working hours commonly increase the incidence of stress and burnout among psychiatrists (2, 3). Time constraints are a major limitation. Psychiatrists in military and combat settings increasingly experience these same barriers, where language and cultural differences prevent adequate psychiatric assessments and treatments of soldiers, enemy prisoners of war, and other foreign nationals (4). A proliferation of Improvised Explosive Devices generates a significant need to detect, treat, monitor, and rehabilitate soldiers and civilians with Traumatic Brain Injury (TBI) (5). Such blast-related injuries further complicate the administration of manual cognition tests.

We believe emerging challenges for family medicine physicians and psychiatrists include the rapid detection of cognitive impairment, significant improvement of psychiatric emergency service decisions, the effective delivery of psychiatric consultation and treatment to the masses, and the dire need to communicate and evaluate patients in disaster response and combat settings. The California Verbal Learning Test (CVLT), Clock Drawing Test (CDT), Trail- Making Test, and Wechsler Memory Scale subtest are utilized as lone or combined cognitive screens to facilitate cognitive impairment detection or psychiatric emergency service decisions. However, numerous methods of administering, scoring, interpreting, recording, and reporting techniques of the CDT and other paper-based cognition assessment tests lead to subjectivity. These also limit the use of manual tests to small clinical settings, trained examiners, and physically able patients who can draw or hold a writing instrument. Many patients may have physical inabilities, low vision, hearing loss, or linguistic differences that pose obstacles to the administration and completion of paper-based tests. Manual tests therefore burden psychiatric emergency services because they require time and labor, overwhelmingly in short supply when immediate decisions are required.

It is a public health priority to ensure that psychiatrists and other clinicians are aware when cutting edge tools are available to improve the delivery of cognition screenings in psychiatric practices, emergency services, and combat settings. Such tools and technical devices can be augmented through automation, engineering solutions, and the Internet. Studies show that the Automatic Clock Drawing Test ™ (ACDT), Times2Tell ™, a multimedia and interactive product available through SpecialtyAutomated Systems Corp., <http://www.specialtyautomated.com> in several different languages, objectively and rapidly screens for cognitive impairment and predicts at- fault collision involvement (5). These computerized tests may also be used to improve competence assessments of dementia drivers and others with cognitive impairment (6). Because the clock is a universal symbol of time, the ACDT standardizes clock-drawing administration, scoring, interpreting, and reporting with automatic feedback. Supplementary computerized verbal learning and memory tests describe brain functioning and rehabilitation potential. Such tools can be used to monitor long-term changes in patients after head injury and to improve the recovery process.

To summarize, practices and studies involving the use of computerized tools are now needed to increase the quantity and quality of family medicine and mental health treatments. Such techniques can be utilized to rapidly improve telemedicine capabilities, psychiatric evaluations, cognitive domain assessments, rehabilitation, pharmaceutical treatments, and screening of the masses for referral to intensive psychiatric services in clinical, combat, and disaster response settings. Diagnostic tools, such as the ACDT, will ensure equal access and optimization of family medicine and medical specialty services to all patients, regardless of culture, disability, education, ethnicity, language, race, or socioeconomic status.

References:

1. Stange, K. In This Issue: Capacity for Caring and Generating New Knowledge. Ann Fam Med 2006 4: 386-388.

2. Fothergill A, Edwards D, Burnard P. Stress, burnout, coping and stress management in psychiatrists: findings from a systematic review. Int J Soc Psychiatry. 2004;50:54-65.

3. Harrison T, Cook C, Robertson M, Willey J. Work-related stress and the psychiatrist: a case study. Psychiatr. Bull., October 1, 2006; 30(10): 385 - 387.

4. Griffeth, BT and Bally, RE Language and Cultural Barriers in the Assessment of Enemy Prisoners of War and Other Foreign Nationals . Psychiatr Serv 57:258-259, February 2006

5. Straus, SH, 2006, in press.

6. Naidu A, McKeith IG. Driving, dementia and the Driver and Vehicle Licensing Agency: a survey of old age psychiatrists. Psychiatr. Bull., July 1, 2006; 30(7): 265-268.

Competing interests:   The authoress, through ESRA Consulting Corporation, shares patents pending on ACDT products. She is owner of ESRA Consulting Corporation and a co-owner of SpecialtyAutomated Systems Corporation, the company that manufactures the ACDT Times2Tell, one of the test instruments mentioned in this letter.