In conclusion, one third of a large sample of MTBI patients experiences severe fatigue six months after injury, and this experience is associated with limitations in daily functioning. Our finding that acute symptoms and mechanism of injury rather than injury severity indices appear to be related to higher levels of fatigue warrants further investigation.

Many patients with mild traumatic brain injury (MTBI) concurrently sustain extracranial injuries; however, little is known about the impact of these additional injuries on outcome. We assessed the impact of additional injuries on the severity of postconcussional symptoms (PCS) and functional outcome 6 months post-injury. A questionnaire (including the Rivermead Post-Concussion Questionnaire and SF-36) was sent to consecutive MTBI patients (hospital admission Glasgow Coma Score 13-15; age range 18-60 years) admitted to the emergency department of a level-I trauma center, and, to serve as a baseline for PCS, a control group of minor-injury patients (ankle or wrist distortion). Of the 299 MTBI respondents (response rate 52%), 89 had suffered additional injuries (mean Injury Severity Score [ISS] of 14.5 +/- 7.4). After 6 months, 44% of the patients with additional injuries were still in some form of treatment, compared to 14% of patients with isolated MTBI and 5% of the controls. Compared to patients with isolated injury, MTBI patients with additional injuries had resumed work less frequently and reported more limitations in physical functioning. Overall, they did not report higher levels of PCS, despite somewhat more severe head injury. Regardless of the presence of additional injuries, patients that were still in treatment reported significantly more severe PCS, with highest rates in patients with isolated MTBI. In conclusion, many patients with additional extracranial injuries are still in the process of recovery at 6 months after injury. However, despite more severe impact to the head and inferior functional outcomes, these patients do not report more severe PCS.

Even in a sample of non-referred MTBI patients, poor effort was common and was strongly associated with inferior test performance. These findings imply that effort testing should be part of all cognitive assessments, also outside mediolegal settings. Behavioural factors like distress and personality should be considered as potential threats to the validity of neuropsychological testing after MTBI.

Although CCT was not predictive of SP scores, it was related to working experience. There are good reasons to assume that although SP-scores were more authentic, they were less valid than CCT scores, mainly because they focussed more on thoroughness than on efficiency in data gathering. The results underpin the assumption that for valid performance assessment the most important issue is what information about the candidate is collected and now how authentic the method is.

Objective To assess rheumatologists' performance for 8 rheumatologic conditions and to explore possible explanatory factors. Methods After written informed consent was obtained, 27 rheumatologists (21% of all Dutch rheumatologists) practicing in 16 outpatient departments were each visited by 8 incognito “standardized patients” (SPs). The diagnoses of these 8 cases account for about 23% of all new referred patients in the Netherlands. Results for ordered lab tests as well as real radiographs with corresponding results from a radiologist were simulated. Information from the visits was obtained from the SPs, who completed predefined case‐specific checklists, and by collecting data on resource utilization. Feedback was provided. Results Altogether 254 encounters took place, of which 201 were first visits and 53 were followup visits. SPs were unmasked twice during a visit. There was considerable variation in resource utilization (lab tests and imaging) between cases and between rheumatologists. Mean costs per rheumatologist ranged from US $ 4.67 to $ 65.36 per visit for lab tests and from US $ 33.15 to $ 226.84 per visit for imaging tests. No significant correlations were seen between resource utilization costs and number of years of clinical experience or performance on checklist scores. Rheumatologists with longer experience had lower total item checklist scores (r = −0.47; P < 0.05). Conclusion A considerable variation in resource utilization was found among 27 Dutch rheumatologists. The information obtained is an excellent source for discussion on the appropriateness of care. Arthritis Care Res 45:16–27, 2001. © 2001 by the American College of Rheumatology.