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March 25, 2009
Randall F. Stewart, M.D.
Health Sciences Library & Informatics Center
1 University of New Mexico
Albuquerque, New Mexico 87131-0001
Phone: (505) 272-3965
Fax: (505) 272-8254
rstewart@salud.unm.edu
Dear BMC Psychiatry:
Thank you for the opportunity to revise and resubmit our manuscript. We believe the changes
will addresses the concerns raised by the reviewers. This cover letter briefly describes the
approach we took to make the corrections.
Survey instrument. Both reviewers required additional information on the survey instrument.
The first paragraph of the "Instrument & Data Collection" section (p.9) has been re-written as
two paragraphs. The first describes the original PSQ-18 and why we chose it. We clarify that
reversing the score for positively worded questions is a characteristic of the original PSQ-18 as a
way of reducing acquiescence bias.
In the second paragraph, we more explicitly explain why we eliminated certain questions and
added new questions of our own. We clarify that the questions that were added and their
associated sub-scales were from an unpublished and un-validated instrument of our own
creation.
Also, in the "Limitations" section we critique the instrument in a separate paragraph. In place of
the former statement that the changes "may have changed" it's validity, we state more explicitly
that this survey has not been validated. We add that the ad hoc analysis was performed in an
attempt to address this weakness, and that the concept of subscales has been retained for its face
validity. Reported sub-scales use names that have been based on, but are different from the
PSQ-18 names. Table 2 has been edited to show the mapping between original PSQ-18
subscales and our reported subscales. Figure 1 has been edited to use the non-PSQ-18 subscale
naming.
Reporting of mean scores. In the "Electronic Health Record Associations" section, we've
appended a sentence that raw, mean scores are available from the primary author. Earlier
versions of the paper did include a table with this data, but we removed it for several reasons.
Since the focus of this project was on changes to the patient-psychiatrist relationship, and not on
clinic performance per se, we felt the emphasis on performance actually distracted from the main
results. In addition, the table itself was seen as rather homogenous and unrevealing, and did not
contribute to the paper's intended message. Third, because of balanced keying, the results can be
difficult to read and open to misinterpretation regarding the positive or negative aspects of high
or low scores. Finally, the UNM-PC clinics routinely perform patient satisfactions surveys for
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quality control, but do not make this information publicly available, except through hospital
approved venues. We wished to honor the Center's decision to not publish raw performance
data, especially since this was not the purpose of the study, and in light of the possibility of
misinterpretation. We hope that making the data available in this proposed way will satisfy the
intent of the review's comment. We have attached a table of raw scores to the end of this letter
so the reviewers can evaluate the usefulness of the data.
Scheduling. We added two sentences explaining that the 24-month period between the end of
pre-implementation recruitment and the beginning of post-implementation recruitment was due
to EHR implementation scheduling delays. We also clarified that post-implementation
recruitment started four months after implementation so that physicians could become proficient
with the EHR prior to collecting data.
Clarity. The discussion on page 6, describing how changes to communication patterns could
lead to changes in psychiatric diagnosis and treatment evaluation has been edited to make
associations between cause and effect more explicit and to give reasons why changes to
communication style, eye contact, and body language could lead to altered diagnosis. A few
sentences were added to elaborate on the findings of "idealism" by Cruickshank in 1985.
Editing. Minor edits were made through out to simplify language, remove extraneous detail,
and to use shorter sentences.
Since completing this fellowship research project, I've taken a with Standards & Terminology
Services at the Salt Lake City VA. Contact information has been updated, but the Authors'
Information has remained the same to show my academic associations at the time the research
was performed.
Sincerely,
Randall F. Stewart
Table: Raw scores
Question (1=strongly agree; 5 = strongly disagree)
1. Psychiatrists sometimes ignore what I tell them.
2. My psychiatrists understands what I tell him or her.
3. Those who provide my psychiatric care sometimes
hurry too much when they treat me.
4. Psychiatrists act too businesslike and impersonal
toward me.
5. The psychiatrist answers all of my questions.
6. My psychiatric record is kept safe.
7. My psychiatrist is too quiet.
8. I worry about who sees my psychiatric record.
9. I have some doubts about the ability of the
psychiatrists who treat me.
10. Sometimes psychiatrists make me wonder if their
diagnosis is correct.
11. I worry about the future.
12. I worry about my psychiatric care.
13. The computer gets in the way of the psychiatrist.
14. I am comfortable with the computer in my
psychiatrist’s office.
15. The psychiatric care I have been receiving is just
about perfect.
16. My psychiatrist could be a lot better.
17. I wish that I had a different psychiatrist.
18. Psychiatrists are good about explaining the reasons
for tests.
19. I think my psychiatrists office has everything needed
to provide complete psychiatric care.
20. When I go for psychiatric care, they are careful to
check everything when treating and examining me.
21. My psychiatrist treats me in a very friendly and
courteous manner.
22. Psychiatrists usually spend plenty of time with me.
23. I am dissatisfied with some things about the
psychiatric care I receive.
Pre
3.71
1.79
3.56
Post
3.86
2.01
3.61
F
0.96
2.35
0.11
p
0.328
0.127
0.740
3.90
3.89
0.01
0.939
1.97
2.12
4.13
3.42
4.01
2.05
2.04
4.23
3.20
3.92
0.43
0.33
0.81
1.17
0.53
0.515
0.566
0.368
0.281
0.468
3.58
3.35
2.34
0.127
2.44
3.26
4.04
2.19
2.55
3.24
4.08
1.93
0.67
0.01
0.22
3.42
0.407
0.936
0.640
0.066
3.45
2.34
0.01
0.940
3.95
4.28
2.12
3.79
4.25
2.09
1.02
0.06
0.01
0.312
0.813
0.923
2.16
2.27
0.18
0.674
2.11
2.15
0.11
0.740
1.54
1.55
0.00
0.985
2.34
3.76
2.23
3.61
0.44
0.96
0.506
0.329