Dr. Rebecca Cogwell Anderson

This article is the third in a series featuring Rebecca Cogwell Anderson, PhD, who is a professor and the director of Transplant Psychological Services at the Medical College of Wisconsin.

Rebecca Cogwell Anderson, PhD, spends about 30% of her time teaching, with the remainder of her time divided between patient care and administrative responsibilities.

"When I start talking about teaching, I start smiling," says Anderson.
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Finally, Anderson computer-scores the BSI, which provides test results quickly, and discusses the report with the students. "The BSI serves almost like a test key," she says.
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To complement their textbook education on the tool, Anderson asks them to take the assessment privately as a way to familiarize themselves with it. She also asks students to read the narrative section of a MBMD interpretive report, write a summary, and then compare it to the MBMD's summary.

Anderson administers the MBMD as part of her standard diagnostic protocol with surgical patients-and uses it as a teaching tool when she and the students are seeing patients. "When I give the test, I'm looking for specific factors that could affect how the patient responds to medical treatment, such as whether the patient struggles with overeating or substance abuse, has adequate social support, has a spiritual component in their life, or is in distress. The student should be asking about these same factors in the clinical interview. As with the BSI, we can use the MBMD results as a check against what the student has observed."

In addition, Anderson may have her students write up a report based on the MBMD treatment recommendations, the clinical interview, and other test results.
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Editor's note: This is the third of a series of three articles featuring Dr. Rebecca Cogwell Anderson. Previous articles, " Medically oriented psychological tests help improve care for breast surgery candidates" and " Measuring both sides of the transplant equation: Psychological tests help evaluate organ recipients and donors" discuss her use of the BSI and MBMD tests with mastectomy and organ transplant patients.

Rebecca Cogwell Anderson, PhD, serves as director of Transplant Psychological Services at the Medical College of Wisconsin.As the only psychologist in the department of surgery, she spends about 60 percent of her time providing patient care.The remainder of her time is devoted to teaching and administrative responsibilities.

Anderson conducts psychological evaluations of candidates for various surgeries, including breast-related procedures such as prophylactic mastectomies, breast reductions, reconstructive surgery, and breast augmentations.Her protocol incorporates use of the BSI® (Brief Symptom Inventory) and MBMDÔ (Millonnostic) tests.

"I'm a big fan of the BSI and the MBMD instruments," Anderson says."Since I evaluate so many patients, I appreciate that these tools provide me with the information I need in a much more efficient way than if I had to use multiple tests to gain the same insights."

Assessing surgical readiness

For some of the breast surgery candidates Anderson sees, a pre-op evaluation is required by insurance.In other cases, patients are referred to Anderson by a surgeon who has identified a possible concern.

The first step in her protocol is to conduct a clinical interview that focuses on the patient's specific needs and any concerns the referring surgeon has indicated.Typical concerns include whether the patient has realistic expectations and whether she is self-motivated to have the surgery or is being urged by someone else to consider it.In the case of breast reduction or augmentation, it is also important to ascertain whether the patient is old enough to make the right choice for herself.

At this initial session, the patient takes the MBMD and BSI tests as well as the Breast Evaluation Questionnaire, an instrument published by Anderson and plastic surgeon Bruce Cunningham, MD, that helps assess a patient's satisfaction with her breasts.
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Anderson then holds a second meeting with the patient to discuss the interview findings and test results.Following this, she develops a written treatment plan based on her interview and the test results and meets with the care team to discuss her recommendations.

Evaluating coping skills

In administering the MBMD test as part of her pre-op evaluation, Anderson is primarily seeking to learn whether the patient will be able to handle the stress of surgery."The MBMD gives me insights into the patient's social support and identifies the woman's strengths and weaknesses in coping with medical concerns," she says."It helps raise possible red flags.For example, if the MBMD shows that the patient might have difficulty coping with complications, that's valuable information for me to share with the surgeon."

"The MBMD hits the nail on the head in terms of what I need to communicate with the medical team," says Anderson."It helps guide our treatment planning and enables us to give more comprehensive patient care."She also likes that the test is brief enough to be well-tolerated by patients#8212,and that it provides an easy-to-read Interpretive Report for practitioners.

Guiding patient decisions

To illustrate the benefits of the MBMD test, Anderson cites the case of a patient who was debating about whether to have breast reconstruction following a mastectomy.The surgical option under consideration involved using the patient's own tissue to reconstruct the breast, a procedure with which there is more potential for complications and more down-time in terms of recovery.

"I picked up in the interview that this woman was likely to have an extremely difficult time with surgical complications if they arose," says Anderson."When I administered the MBMD, the test results confirmed this concern."

With the care team's guidance, the patient opted not to have the reconstructive surgery."My interview didn't dictate the decision and the MBMD didn't dictate the decision- but both of these sources provided useful information to help us counsel the patient so that she could arrive at a decision," says Anderson.
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In addition, Anderson often re-administers the BSI test after surgery to evaluate the patient's response following treatment."As a brief instrument that is easy for me and the patient, the BSI is well-suited for both pre- and post-surgical assessment," she says.

Improving patient care

Having administered the MBMD and BSI tests for some time, Anderson has been impressed with the value they add to her evaluations."These tools help me address possible setbacks the patient might encounter, work more effectively with the care team, and develop better patient education plans," she says.
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Editor's note: Dr. Anderson uses assessment tools to facilitate psychological evaluations of candidates for various surgeries.More articles featuring Dr. Anderson's use of assessment tools will be coming in future issues of Bridging the Gap.

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This article is the second in a series featuring Rebecca Cogwell Anderson, PhD, who serves as director of Transplant Psychological Services at the Medical College of Wisconsin.

As part of her many responsibilities, Rebecca Cogwell Anderson, PhD, conducts psychological evaluations of organ transplant candidates and potential donors."We need to ensure that both the transplant recipient and the donor are stable psychiatrically, medically and socially before the surgery—and that they have adequate resources to support them post-operatively," she says.

The majority of these procedures are liver and kidney transplants.With kidney transplant candidates, Anderson sees patients based on referrals from a medical team member who has a concern about the patient's possible non-compliance, substance abuse, eating disorder, or psychological problems such as depression or anxiety.With liver transplant patients, Anderson evaluates all candidates since these individuals are often very sick and the illness may have a significant impact on their quality of life.

Identifying crucial issues with transplant candidates

As part of evaluating transplant patients, Anderson administers the MBMD (Millon Behavioral Medicine Diagnostic) and the BSI® (Brief Symptom Inventory) tests at the first session.

The MBMD test helps assess for several issues that are critical with transplant candidates."A primary concern is to ensure that transplant patients have adequate social support," says Anderson."Many people think a transplant is an instant cure, but it's a process.Patients need time to get their strength back and they may have emotional ups and downs post-operatively.If a patient doesn't appear to have sufficient support, I will try to involve family members in our discussions to make sure there is a plan in place."

In addition, the MBMD assessment helps Anderson identify whether the patient may have issues with compliance.Anderson describes the case of a male patient in his mid-50's who was waiting for a liver transplant."His MBMD results indicated that compliance was likely to be a problem because of his passive indifference to his medical condition," she says.
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The MBMD test also provides Anderson with health history information, including whether the patient may have problems with drugs or alcohol—a vital issue with transplant patients.And, the test helps identify whether there is the potential for decompensation post-operatively."If the MBMD results point to a concern in this area, I'm going to alert the medical team—particularly because steroids, which are often used with transplant patients, can increase a patient's risk for decompensation," she says.

Improving quality of life

Anderson also administers the BSI test to transplant patients, which gives her perspective on psychological symptoms during a specific timeframe."If there are significant scale elevations on the BSI scales, I might refer the patient to a psychiatrist for medication therapy, incorporate the information when developing a psychological treatment plan, or in some cases administer the MCMI-III (Millon Clinical Multiaxial Inventory-III), which provides an in-depth assessment of psychopathology."

The BSI test often illuminates issues that a patient might not readily share.As an example, Anderson relates the case of a male patient who was referred to her for evaluation prior to a second kidney transplant after the first kidney transplant had failed.

During Anderson's initial meeting with the patient, he presented as somewhat typical.But on his BSI results, the paranoid ideation and psychoticism scales were both very elevated."While elevation on one of these scales doesn't necessarily mean that the patient is hallucinating or psychotic, we're concerned when both scales are markedly elevated," she says.

"When I went over the test results with him—as I do with all patients who are tested—I asked him about whether he'd had irrational thoughts or hallucinations," she says."He admitted that he was having auditory hallucinations, which had begun after his first transplant.He said he'd never told anyone that he heard voices because he was afraid they'd think he was crazy."

Anderson talked with the transplant doctors, who reduced the patient's steroid levels, and referred him to a psychiatrist, who prescribed an antipsychotic medication.In addition, Anderson conducted therapy with the patient.As a consequence of these steps, the patient's symptoms resolved.

"Because the patient was functioning, he probably would have been approved for the transplant list and experienced the same positive surgical outcome, even if we had not detected that he was having hallucinations," says Anderson."But he would have continued hearing voices-and thinking he was crazy because of it.Information obtained from the BSI enabled us to significantly improve his quality of life."

Measuring progress

Anderson has found the BSI test useful for other applications beyond initial assessment.On occasion, she readministers the test to transplant patients if they have been on the waiting list for a long time and she is concerned that their coping skills might be deteriorating."Since the BSI is a point-in-time assessment, I can compare current and past results to see whether the patient is improving or having more difficulty."

In addition, Anderson readministers the test to patients who report that their coping difficulties have increased following surgery."If the BSI test indicates that the patient is doing better, I can go over the results with the person; seeing progress in black and white often helps improve the patient's state of mind.On the other hand, if the BSI confirms that the patient's distress has increased, I can share the test and retest results with the team to help them determine next steps."

Assessing psychosocial readiness in donors

The BSI and MBMD tests also help Anderson evaluate a number of psychosocial factors that are as important to consider in the donor as in the transplant recipient—factors that donors might not think to discuss with the team."Potential donors may be selfless people who are highly focused on the needs of the transplant recipient, not on their own needs," says Anderson."And, they may be reticent to reveal any concerns about themselves for fear that it will disqualify them as donors."

To help surface these issues, Anderson administers the MBMD and BSI tests to all potential donors."If the tests identify any concerns, Anderson and the transplant coordinator make the decision about whether to ask the person to come in for a clinical interview.For any donor with whom they conduct a clinical interview, they share the test and interview findings with the medical team so that they can develop a treatment plan if needed.

"About 85% of the time we are able to eliminate any concerns that have been raised," says Anderson."For example, if the BSI indicates that the donor is experiencing depression, we might refer the person to his or her family doctor to address this issue before undergoing surgery."

The MBMD test helps Anderson assess such factors as whether the donor will be able to deal with the stress of surgery, can manage possible complications, and has sufficient social support."If the MBMD brings issues to light, we can talk with the donors to make sure that they have clear expectations about the surgery—and we can take practical steps to address concerns," she says.

Attending to donors' needs

Anderson cites the case of a female donor whose MBMD results indicated she would have a difficult time coping if medical complications occurred that might extend her stay at the hospital.Following up on this concern in the clinical interview, Anderson discovered that the woman was very fearful of hospitals because she'd had some negative experiences while previously hospitalized for an unrelated issue."We developed a treatment plan to help reduce her anxiety about the hospital stay.As part of this plan, we sat with her in an empty hospital room so that she could become more comfortable in a simulated patient situation."

The MBMD test also helps Anderson identify the presence of serious psychiatric or psychosocial distress."In these cases, we might determine that the individual needs more time to deal with a psychiatric issue or to move beyond stressful circumstances such as a difficult job or family situation," she says."This doesn't necessarily mean the person will never qualify to be a donor—simply that now isn't a good time."

Supporting better treatment planning

Anderson has discovered multiple benefits in using the MBMD and BSI tests—both with transplant recipients and donors.And, she notes that her colleagues have come to appreciate the tests as well.

As part of her many responsibilities, Rebecca Cogwell Anderson, PhD, conducts psychological evaluations of organ transplant candidates and potential donors. "We need to ensure that both the transplant recipient and the donor are stable psychiatrically, medically and socially before the surgery-and that they have adequate resources to support them post-operatively," she says.

As part of her many responsibilities, Rebecca Cogwell Anderson, PhD, conducts psychological evaluations of organ transplant candidates and potential donors."We need to ensure that both the transplant recipient and the donor are stable psychiatrically, medically and socially before the surgery—and that they have adequate resources to support them post-operatively," she says.

Dr. Rebecca Anderson of the Medical College of Wisconsin will then describe the effectiveness and benefits of Mentor's saline filled breast implants.
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Dr. Rebecca Anderson will be presenting these results.
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It's now a pleasure to turn the podium over to Dr. Rebecca Anderson.She's a full-time Ph.D. clinical psychologist in the Department of Plastic Surgery at the Medical College of Wisconsin in Milwaukee.She actively counsels patients undergoing plastic surgery, and many of those are patients having implants.

She also occupies a unique role within plastic surgery as being one of the key players in the outcomes movement within plastic surgery, which is funded by the Educational Foundation.

Dr. Anderson.

DR. ANDERSON: Thank you, Dr. Cunningham.
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MR. PURKAIT: Thank you, Dr. Anderson.
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DR. CUNNINGHAM: I don't believe that we broke down or at least I have not seen a breakdown of the data that Dr. Anderson presented, namely the chest circumference measurements by shape, and if we do have it, perhaps we can get it put up.
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MR. PURKAIT: -- show the complication rate and then Dr. Anderson will show the effectiveness.
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And I would like to ask Dr. Anderson to spend a second or two talking about that.

DR. ANDERSON: We had used the breast evaluation questionnaire to assess patient satisfaction in the saline perspective study.
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DR. BANDEEN-ROCHE: I believe my question series is for Dr. Anderson: concerns about the quality of life data, and certainly include the lack of a control group.
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DR. ANDERSON: I suppose you could characterize it as body image.
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DR. ANDERSON: I'm not a statistician, but, yes, I understand the concept you're talking about, and that's probably true.

Are you referring to the Tennessee self-concept scale?
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DR. ANDERSON: Okay.
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DR. ANDERSON: It's very possibly true that they would have over a period of three years adjusted to their cancer and shown an improvement.
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DR. ANDERSON: Well, you know, it was relatively nice to see that they weren't a real depressed group of patients to start with, which is consistent with one of my studies, which looked at psychological adjustment in breast reconstruction patients, and I suppose that it is theoretically possible that levels of depression would have decreased over time in these patients.
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DR. CUNNINGHAM: I can speak to, you know, what I see clinically, and perhaps Dr. Anderson can speak to that as well.
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That's the basis of the data that Dr. Anderson presented.It's the basis of the data that I presented.

Rebecca Cogwell Anderson, PhDMedical College of WisconsinDepartment of Plastic SurgeryMilwaukee WI