title: The relationship between level of training and accuracy of violence risk assessment.
abstract: OBJECTIVE
  Although clinical training programs aspire to develop competency in violence risk assessment, little research has examined whether level of training is associated with the accuracy of clinicians' evaluations of violence potential. This is the first study to compare the accuracy of risk assessments by experienced psychiatrists with those performed by psychiatric residents. It also examined the potential of a structured decision support tool to improve residents' risk assessments.
  
  
  METHODS
  The study used a retrospective case-control design. Medical records were reviewed for 151 patients who assaulted staff at a county hospital and 150 comparison patients. At admission, violence risk assessments had been completed by psychiatric residents (N=38) for 52 patients and by attending psychiatrists (N=41) for 249 patients. Trained research clinicians, who were blind to whether patients later became violent, coded information available at hospital admission by using a structured risk assessment tool-the Historical, Clinical, Risk Management-20 clinical subscale (HCR-20-C).
  
  
  RESULTS
  Receiver operating characteristic analyses showed that clinical estimates of violence risk by attending psychiatrists had significantly higher predictive validity than those of psychiatric residents. Risk assessments by attending psychiatrists were moderately accurate (area under the curve [AUC]=.70), whereas assessments by residents were no better than chance (AUC=.52). Incremental validity analyses showed that addition of information from the HCR-20-C had the potential to improve the accuracy of risk assessments by residents to a level (AUC=.67) close to that of attending psychiatrists.
  
  
  CONCLUSIONS
  Having less training and experience was associated with inaccurate violence risk assessment. Structured methods hold promise for improving training in risk assessment for violence.
authors.affiliation: Department of Psychiatry, University of California, San Francisco (UCSF), CA, USA.
authors.forename: Alan R
authors.initials: AR
authors.lastname: Teo
authors.forename: Sarah R
authors.initials: SR
authors.lastname: Holley
authors.forename: Mark
authors.initials: M
authors.lastname: Leary
authors.forename: Dale E
authors.initials: DE
authors.lastname: McNiel
mesh_terms: D000328:Adult; D000374:Aggression / Q000523:psychology; D016022:Case-Control Studies; D002983:Clinical Competence; D003661:Decision Support Techniques; D005260:Female; D006757:Hospital Units; D006766:Hospitals, County; D006801:Humans; D007396:Internship and Residency; D008297:Male; D001523:Mental Disorders / Q000523:psychology; D011570:Psychiatry / Q000193:education / Q000706:statistics & numerical data*; D012372:ROC Curve; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods / Q000706:statistics & numerical data*; D014754:Violence / Q000517:prevention & control* / Q000523:psychology