Showing papers in "Academic Psychiatry in 2011"

Professional Boundaries in the Era of the Internet

Abstract: Objective The era of the Internet presents new dilemmas in educating psychiatrists about professional boundaries. The objective of this overview is to clarify those dilemmas and offer recommendations for dealing with them.

Training Physician-Scientists: A Model for Integrating Research Into Psychiatric Residency

Abstract: The number of physicians engaged in research careers has declined significantly over the past two decades. Physicians with in-depth experience and formal training in research design, development, implementation, statistical analysis, and interpretation of scientific information are rare. In response to this shortage, the Medical University of South Carolina (MUSC) launched an NIH-funded research track in 2006 to address the institutional, financial, and regulatory barriers to research training during residency. The primary aim was to incorporate a research track within a 4-year psychiatric residency program for physicians. A secondary goal was to extend recruitment into earlier phases of medical training by offering summer research fellowships to medical and undergraduate students. This article describes the program including core mechanisms of training, recruitment, and outcomes to date. The program provides a model to effectively integrate research training during residency without increasing the number of years of residency training. The training components described herein should be exportable to other psychiatric residency training programs and potentially other specialties of medicine.

Acculturative Stressors and Acculturative Strategies as Predictors of Negative Affect Among Chinese International Students in Australia and Hong Kong: A Cross-Cultural Comparative Study

Abstract: Objective There are few studies comparing cross-cultural adaptation of migrant groups in two different cultural settings. This study compares the level of negative affect and acculturative stressors between Chinese international students in Australia and Mainland Chinese students in Hong Kong. The predictive effects of acculturative stressors and acculturative strategies on negative affect were also compared between the two groups.

Web-based simulation in psychiatry residency training: a pilot study.

Abstract: Medical specialties, including surgery, obstetrics, anesthesia, critical care, and trauma, have adopted simulation technology for measuring clinical competency as a routine part of their residency training programs; yet, simulation technologies have rarely been adapted or used for psychiatry training. The authors describe the development of a web-based computer simulation tool intended to assess physician competence in obtaining informed consent before prescribing antipsychotic medication to a simulated patient with symptoms of psychosis. Eighteen residents participated in a pilot study of the Computer Simulation Assessment Tool (CSAT). Outcome measures included physician performance on required elements, pre- and post-test measures of physician confidence in obtaining informed consent, and levels of system usability. Data suggested that the CSAT increased physician confidence in obtaining informed consent and that it was easy to use. The CSAT was an effective educational tool in simulating patient—physician interactions, and it may serve as a model for use of other web-based simulations to augment traditional teaching methods in residency education.

Integration of international medical graduates in u.s. Psychiatry: the role of acculturation and social support.

Abstract: The authors investigated whether social support and acculturation could predict the mental health of international medical graduates pursuing psychiatric residencies in the United States. A 55-item online survey was assembled by combining three validated instruments for mental health, social support, and acculturation. A link to the survey was e-mailed to training directors of all psychiatric residency and fellowship programs. Directors were requested to forward the survey to their international medical graduate residents for completion between December 2008 and February 2009. One hundred eight international medical graduates from 70 different psychiatric residencies and fellowships completed the entire survey. Respondents’ mental health scores were normally distributed. The vast majority scored very high on survey items related to mental health. Acculturation, social support, and postgraduate training year were significant predictors of mental health. Residency training programs should attempt to incorporate measures that would help boost the social support and acculturation of international medical graduates (especially junior-level trainees). Acculturation could be improved by language training and courses in American history, culture, and customs, and social support could be expanded by mentoring relationships.

Recent Trends in American Board of Psychiatry and Neurology Psychiatric Subspecialties.

Abstract: Objective This article reviews the current status and recent trends in the American Board of Psychiatry and Neurology (ABPN) psychiatric subspecialties and discusses the implications of those trends as well as several key questions whose answers may well determine subspecialty viability.

Cultural Competence Clinic: An Online, Interactive, Simulation for Working Effectively With Arab American Muslim Patients

Abstract: This pilot study investigates the impact of an online, interactive simulation involving an Arab American Muslim patient on the knowledge, skills, and attitudes of 2nd-year medical students regarding culturally competent healthcare, both in general and specific to Arab American Muslim patients. Participants (N=199), were 2nd-year Michigan State University College of Osteopathic Medicine students enrolled in a behavioral medicine course that included instruction on culturally competent healthcare. Students were randomly assigned to a control (N=102) or an experimental group (N=97). The experimental group was directed to an online, interactive patient simulation that featured an Arab American Muslim patient, and both groups completed a modified Clinical Cultural Competence Questionnaire to assess their knowledge, skills, and attitudes about culturally competent healthcare in general and specific to Arab American Muslim patients. There were knowledge and skills differences on two outcome measures for Arab American Muslim cultural competence measures in the experimental group. Across all of the measures, bilingual participants scored higher than English-speaking—only participants. Preliminary data support the hypothesis that an online, interactive patient simulation involving the care of an Arab American Muslim patient has the potential to improve the knowledge and skills of 2nd-year medical students regarding the care of Arab American Muslim patients beyond the basic cultural-competence curriculum.

Training and validation of standardized patients for unannounced assessment of physicians' management of depression.

Abstract: Standardized patients (SPs) have been developed to measure practitioner performance in actual practice settings, but results have not been fully validated for psychiatric disorders. This study describes the process of creating reliable and valid SPs for unannounced assessment of general-practitioners’ management of depression disorders in Iran. Ten psychology and nursing students (potential SPs) took part in a five-session course involving training in dialogue and body language. Five scenarios, along with corresponding checklists representing common presentations of mood disorders in primary-care settings, were developed by an expert group. The SPs’ role-play performance of their respective scenario was videotaped and scored independently by three psychiatrists according to an observational rating scale to assess validity. The role-play was repeated after 1 week with the same scenario and the same doctor, to assess test-retest reliability. The reliability of each checklist to be used by the SPs was assessed by testing interrater reliability between groups of SPs. The cutoff score for the SPs’ portrayal validity was 90% or above for all SPs. Mean interrater reliability for the checklists was acceptable for the SPs watching the same videos and filling in the checklists, while the mean kappa for assessing concurrent validity in filling in the checklists was lower. The test-retest performance for assessing reliability resulted in a mean kappa of 0.72. All SPs except one, who was not recruited, performed acceptably well. The authors have demonstrated a thorough validation of the technique of using standardized patients in the portrayal of depressive disorders in primary-care settings in Iran, which creates confidence in employing this technique to evaluate doctors’ performance, for example, after an educational intervention. Similar methods of validation can be used for SPs’ portrayal of other psychiatric disorders.

What Medical Students Say About Psychiatry: Results of a Reflection Exercise

Abstract: Objective The author describes the results of a reflection exercise for psychiatry clerkship students.

The practice of psychiatry in the 21st century: challenges for psychiatric education.

Abstract: To consider how shifting scientific, technological, social, and financial pressures are likely to significantly alter psychiatric practice, careers, and education in the 21st century, this article reviews trends and innovations likely to have an effect on tomorrow’s psychiatrists and their educators. The psychiatric profession and its educators can anticipate great change, creating opportunities as well as challenges. Although considerable adaptability will be required to keep up with current trends, personal and professional rewards for psychiatric educators and practitioners are likely to remain substantial.

Psychiatric residents' needs for education about informed consent, principles of ethics and professionalism, and caring for vulnerable populations: results of a multisite survey.

Abstract: The authors examined psychiatric residents’ perceived needs for education in informed consent, principles of ethics and professionalism, and treating vulnerable populations. A written survey was distributed to psychiatric residents (N=249) at seven U.S. residency programs in 2005. The survey contained 149 questions in 10 content domains, 6 questions regarding personal ethics experiences during training, and 5 demographic questions. Here, the authors report responses to items regarding informed consent, professional principles, and care of vulnerable populations. A total of 151 psychiatric residents responded to the survey (61% overall response rate). On a scale of 1: Much Less, to 5: Same, to 9: Much More Education Desired, psychiatric residents indicated that 9 topics relating to informed consent, 10 issues surrounding professional principles, and 25 topics relating to care of vulnerable populations should receive more educational attention than currently provided. No topics were rated as needing less education. Higher ratings of the need for additional educational attention were associated with more reported ethical conflicts encountered during training. Psychiatric residents at seven diverse U.S. training programs expressed the need for greater educational attention to issues around informed consent, ethical and professional principles, and treating vulnerable populations. These findings reflect the ongoing need for educators to devote curricular attention to these areas so that trainees can incorporate such knowledge effectively into their daily clinical practice in an always-complex, highly fragmented medical care environment.

Leadership Experiences and Characteristics of Chairs of Academic Departments of Psychiatry

Abstract: Objective Effective leadership in academic medicine requires a broad constellation of skills, experiences, and core values. The authors sought to describe and define these.

Development and Initial Testing of a Structured Clinical Observation Tool to Assess Pharmacotherapy Competence

Abstract: The authors developed and tested the feasibility and utility of a new direct-observation instrument to assess trainee performance of a medication management session. The Psychopharmacotherapy-Structured Clinical Observation (P-SCO) instrument was developed based on multiple sources of expertise and then implemented in 4 university-based outpatient medication management clinics with 7 faculty supervising 17 third-year residents. After each observation by a faculty member of a medication management session, residents received feedback in writing (the completed P-SCO) and verbally in person. Targets were 8 P-SCO observations per academic year per resident (or 0.67 per month) and 16 observations per year completed by each faculty (or 1.3 per month). Qualitative thematic analysis was employed to compare the frequency, specificity, type (reinforcing vs. corrective), and content of comments documented on the P-SCO forms to midpoint and end of rotation global assessments by the same faculty for the same residents in the same rotation. Faculty completed 2.4 (SD=1,2) P-SCOs per month during the study period. Each resident received 1.1 (SD=0.53) P-SCO observations per month. Faculty and residents completed significantly more observations than targeted (p=0.03 and p=0.003, respectively). Two percent of the P-SCOs had no written comments. Less than 3% of the P-SCO comments were nonspecific compared with 43% for the global assessments. Residents received, on average, 3.3 times more total, 2.6 times more reinforcing, and 5.3 times more corrective patient care specific comments on the P-SCO than on the global assessment (p<0.001). For the numerical ratings, residents received an average of 4.2 “exceeds expectations” and 1.7 “below expectations” ratings on P-SCOs compared with 2.6 and 0, respectively, on global assessments (p<0.02). Faculty can feasibly use the P-SCO instrument in a training clinic. Compared with traditional global assessment, the P-SCO provided much more specific feedback information, a better balance of corrective to re-enforcing comments, and a greater spread of ratings related to competency in pharmacodverbally

A Resident, Rural Telepsychiatry Service: Training and Improving Care for Rural Populations

Abstract: A major gap exists between the mental health care received by residents of rural communities, versus their urban counterparts, encompassing disparities in access to and quality of care (1). Recruiting and retaining mental health professionals who have experience and expertise in clinical work with rural patients is extremely challenging and are major contributing factors in these disparities (2, 3). This is particularly germane for rural veterans, whose barriers to care include not only geographic distance but also a scarcity of available psychiatrists in rural locations with expertise in veterans’ mental health issues (4). Rural veterans’ mental health issues are escalating at this time, with returning OEF (Operation Enduring Freedom)/OIF (Operation Iraqi Freedom) veterans having high rates of mental health conditions and disproportionately rural backgrounds (5). Telepsychiatry, in the form of live-interactive videoconferencing, is being widely adapted as one tool to address gaps in rural mental health delivery (6). This treatment has been shown to be effective with a wide range of populations and settings during the past two decades (7, 8). The Department of Veterans Affairs (VA) is the world’s largest telemedicine provider, with a robust and growing telepsychiatric program (9). In order to continue to expand and capitalize on this work in rural areas, the VA needs psychiatrists to gain training, comfort, and experience— not only in the provision of telepsychiatric care, but in work with rural populations. Most telepsychiatrists have lived and trained in urban areas; they provide care from urban sites to rural sites, and have limited experience working in rural and frontier communities. There is a paucity of literature on telepsychiatry training for psychiatric residents; a recent literature search found only one article describing tele-health training for residents, and one describing a model of such a program (10); thus, more information is needed to demonstrate the usefulness of training residents in telepsychiatry, the sustainability of these services, the model of teaching applied, and the impact of telepsychiatry on recruitment and retention into systems of care with telepsychiatric and rural missions. The purpose of this article is to present a model of a resident telepsychiatry training service, which began in 2003 at the Denver VA Medical Center in the Eastern Colorado Health Care System (DVAMC). This service was created to improve the access for rural Colorado veterans to mental health care, train psychiatric residents in the use of telepsychiatry, introduce residents to issues surrounding veteran populations from rural areas, and increase recruitment of psychiatrists with interest and expertise in using telepsychiatry into the VA system to provide care to this population. We provide a descriptive account of the telehealth training program at the Denver VA, including the clinic model and structure, process, and a discussion about VA and rural mental health workforce issues.

Survey of the importance of professional behaviors among medical students, residents, and attending physicians.

Abstract: Objective The authors compared the importance of items related to professional behavior among medical students rotating through their psychiatry clerkship, psychiatry residents, and attending psychiatrists.

The consultation conference: a new model of collaboration for child psychiatry and primary care.

Abstract: Because of the relative shortage of available child psychiatrists, primary-care providers are increasingly expanding their role in the provision of mental health care. Accordingly, there is an increased need to develop a standardized approach to teaching specialized skills to these providers. One method of doing so is to expand the child psychiatrist’s consultative role to include the structured discussion of patient cases. By emphasizing the reasoning behind treatment recommendations, the psychiatrist can assist the primary-care provider in applying this knowledge to other patients in his or her practice. A group setting, or “consultation conference,” can be used to involve more providers—who, in turn, become resources for each other. This model of a group conference adapts principles of adult learning (1–5) to facilitate the dual consultative and educational goals. Providers who care for patients in the same (or similar) setting come together as a group to share their experience and knowledge. The psychiatrist assists in that group setting, functioning both as expert resource and facilitator. Participants discuss problem cases, thus learning in their own context while receiving assistance in the understanding and management of actual patients (indirect consultation).

Using multiple assessments to evaluate medical students' clinical ability in psychiatric clerkships.

Abstract: No single assessment method can successfully evaluate the clinical ability of medical students in psychiatric clerkships; however, few studies have examined the efficacy of multiple assessments, especially in psychiatry. The aim of this study was to examine the relationship among different types of assessments of medical students’ clinical ability in psychiatric clerkships and whether it is reasonable to use multiple assessments. A group of 196 students were enrolled during their psychiatric clerkship between September 2008 and May 2009 in Kaohsiung, Taiwan. The mini-clinical evaluation exercise (mini-CEX) and standardized patient (SP)-based test were used to evaluate “does” and “show how” in psychiatric clinical ability. A multiple-choice examination was used to evaluate knowledge of psychiatry. There were statistically significant but weak correlations among the scores on the multiple-choice examination, SP-based test, and overall clinical competence domain on the mini-CEX. A blended assessment composed of a multiple-choice examination, mini-CEX, and SP-based test can evaluate different dimensions of clinical ability. It is reasonable to use multiple methods to assess medical students’ competency in psychiatric clerkships.

Psychiatry Trainees’ Training and Experience in Fetal Alcohol Spectrum Disorders

Abstract: Background/Objective Alcohol is a teratogen. Fetal alcohol spectrum disorders (FASDs) affect about 1% of live births, causing severe impairment. Individuals affected by FASDs are over-represented in psychiatric settings.This study reports on the education and experience of psychiatry trainees in approaching FASDs.

Why I teach.

Abstract: Teaching is at the core of my being and always has been. Sometimes I think I’m out of step with the times. We live in an era of shrinking budgets for academic centers. The emphasis is now on soliciting donations from philanthropists, obtaining research grants, and increasing clinical revenues to survive another day. No one seems to be able to pay for education these days. One of my colleagues on the West Coast asked her chairman about reimbursement for the time she spent preparing her seminar for the residents. She was told that there was no money available. Her chairperson clarified that “teaching is something we do out of the goodness of our hearts. It’s part of the Hippocratic Oath.” Those who commit themselves to teaching may seem a bit like Don Quixote, striving to see the world as it should be, rather than as it is. So why do I teach? In this communication I will offer a personal answer to that question. I will tell the reader why I teach, without any implication that this is why the reader should teach. Each teacher of psychiatry will develop his or her own justification, but my reflections may stimulate others to consider their own motivations. When one embarks on a career path to become a psychiatric educator, there is much to discourage one from the journey. John Maynard Keynes (British economist; 1883– 1946) is said to have defined education as “the inculcation of the incomprehensible into the indifferent by the incompetent.” At least once or twice a month, I arrive in the classroom to find that only 5 out of 14 residents have shown up. We sit for a few minutes, and then I ask them whether they did the reading. Silence ensues. They break eye contact with me. I try to avoid shaming them, so I go ahead and cover the reading in my lecture. During the lecture, they whisper to each other and sometimes doze off. I return to my office, questioning my commitment to teaching and wondering whether I’d be better off in private practice. So I return to the question of what motivates me to teach. It IS, in fact, written in the Hippocratic Oath, but that’s hardly a major reason. Preparing this article engaged me in an effort to articulate what it is that keeps me in the classroom. I obviously derive some pleasure out of it. My motives can’t be so noble and pure that it’s simply a matter of masochistically enduring the teaching experience for the benefit of others. Shortly after I received notice that I had won the Vestermark Award, I was beginning my work on this lecture while flying home to Houston, Texas, after I did some teaching in Santiago, Chile. I was reading Irv Yalom’s book, Staring at the Sun (1), and I came across a heartbreaking passage about an extraordinary woman who cared for African children with AIDS. She ran a shelter with very little help from others. Children were dying every day, and someone asked her how she eased the dying children’s terror. She responded that there were two things she did: “I never let them die alone in the dark, and I say to them, ‘you will always be with me here in my heart (p 132). ’” When I read that passage, I found myself suddenly overwhelmed with the sensation that I was going to start sobbing. My eyes welled up with tears, and I was struggling to keep my composure. A flood of memories then went through my head: I flashed on an episode from my third year in medical school when I said goodbye to a 71-year-old woman patient I had taken care of in the hospital during a complicated endocrine work-up. She was to be discharged that day, and as I walked out of her room, she called to me and said, “Dr. Gabbard, I’ll never forget you and your kindness to me.” I got choked up, nodded to her, and stumbled out of her room. I started to walk down the hospital corridor, but I stopped myself. I returned to her room. I stood in her doorway and said to her, “I just wanted to say that I won’t forget you either.” I then recalled another memory. The first time I had my own personal psychotherapy was when I was an undergraduate, struggling with an Eriksonian identity crisis, trying to figure out who I was and what I wanted to do. I Received October 5, 2010; revised February 8, 2011; accepted March 8, 2011. From the Dept. of Psychiatry, Baylor College of Medicine, Houston, TX and SUNY Upstate Medical University, Syracuse, NY; ggabbard12@aol.com (e-mail). Copyright © 2011 Academic Psychiatry

A Framework for Understanding Media Depictions of Mental Illness

Abstract: Mass media depictions of persons with mental illness are generally negative and stigmatizing. From the earliest published studies (1, 2) to more recent work (3–5) media portrayals of mental illness have been characterized by crime and violence (6, 7), unpredictability (8–10), and social incompetence (11, 12). These portrayals are of great concern to mental health professionals because they subvert the recovery of people experiencing a mental illness (13, 14), threaten funding for mental health services (15), and encourage fear of those living with a mental illness (16, 17). Factual or fictional media depictions are the primary source of information on mental illness for the general public (18). George Gerbner (19), directing his comments to mental health professionals, said that the persistent nature of these negative depictions reflect “deeply rooted and highly functional cultural mechanisms that maintain a social structure with all its inequities” (p 22). In our view, four particularly important cultural mechanisms contribute to the persistence of these negative depictions: language in use, culture, social practices, and institutions. Understanding how these cultural mechanisms sustain the stigmatizing depictions is an important step in effectively reducing stigma. The primary goal of this column is to provide psychiatrists and other mental health professionals with a framework that enables understanding of the role of each of these cultural mechanisms in media depictions of mental illnesses. To this end, we provide brief descriptions of each mechanism and outline how the mechanisms combine in media depictions. To assist understanding and to illustrate the relevance of the theoretical discussion, we provide illustrative examples of how each cultural mechanism operates.

Teaching motivational interviewing skills to third-year psychiatry clerkship students.

Abstract: Background Despite a large percentage of health care costs being related to smoking, obesity, and substance abuse, most physicians are not confident in motivating patients to change health behaviors. Motivational interviewing (MI) is a directive, patient-centered approach for eliciting behavior change. The purpose of this study was to teach students MI skills and assess their confidence and knowledge during the psychiatry clerkship using smoking cessation as the target behavior.

Enhancing Adult Learning in Clinical Supervision

Abstract: Objective/Background For decades, across almost every training site, clinical supervision has been considered “central to the development of skills” in psychiatry. The crucial supervisor/supervisee relationship has been described extensively in the literature, most often framed as a clinical apprenticeship of the novice to the master craftsman. This approach fails to directly incorporate adult-learning theory (ALT), despite a clear literature supporting its superiority.

Teaching Psychosomatic Medicine Using Problem-Based Learning and Role-Playing

Abstract: Problem-based learning (PBL) has been implemented in medical education world-wide. Despite its popularity, it has not been generally considered useful for residency programs. The author presents a model for the implementation of PBL in residency programs. The author presents a description of a PBL curriculum for teaching psychosomatic medicine to PGY 2 members in a psychiatry training program. The goals of PBL are to encourage self-directed learning; enhance curiosity, using case-based, con-textualized learning; promote collaborative practice; and support patient-centered care. The addition of role-playingexercises helps PGY 2 residents to develop their skills from simply developing a differential diagnosis to being able to construct biopsychosocial formulations, and it provides these residents an opportunity to practice presenting case formulations to the patient and family. Residents and faculty enjoyed the PBL role-playing sessions. Residents wanted the learning objectives given to them rather than generating their own learning objectives, to move through the cases faster, and to receive more information and more cases. Teaching psychosomatic medicine, using PBL and role-playing, allows many of the proposed Academy of Psychosomatic Medicine residency core competencies to be met. However, further refinement of the PBL method needs to take place in order to adapt its use to residency programs.

Promoting interdisciplinary collaboration: trainees addressing siloed medical education.

Abstract: Objective Professional siloing within medical institutions has been identified as a problem in medical education, including resident training. The authors discuss how trainees from different disciplines can collaborate to address this problem.

Teaching “Global Mental Health:” Psychiatry Residency Directors’ Attitudes and Practices Regarding International Opportunities for Psychiatry Residents

Abstract: Objective The authors surveyed Psychiatry Residency Training Directors’ (RTDs’) attitudes about the role and feasibility of international rotations during residency training.

Are We Heading Into a Workforce Crisis

Abstract: Thirty-three years ago, George Engel (1) contended that all of medicine was in crisis. The crisis, he suggested, had its origin in medicine’s adherence to a model of disease defined solely in terms of “somatic parameters”—a model that was no longer adequate for the “scientific tasks and social responsibilities” of the profession. Speaking of psychiatry, he stated that our specialty had been falsely polarized into those who held that psychiatry should concern itself with “problems of living” and, in contrast, those who held that the scope of psychiatry should be the identification, treatment, and cure of “biological brain dysfunctions, either biochemical or neurophysiological in nature.” Engel summarized that modern medicine was “faced with the necessity and the challenge to broaden the approach to disease to include the psychosocial without sacrificing the enormous advantages of the biomedical model,” which had become a “cultural imperative” in today’s society (1). Whether taken individually or together, the articles that make up this issue of Academic Psychiatry suggest that the biopsychosocial model has indeed emerged as a predominant paradigm in our field. It is clear that psychiatry concerns itself with problems of living as well as biologically driven conditions. It is clear that psychiatric educators concern themselves with preparing professional learners to provide pharmacotherapies as well as psychotherapies and to become astute scientists, teachers, clinicians, learners, advocates, and good citizens of the profession. Psychiatric educators work to help early career colleagues to serve in community-based programs and highly specialized academic centers and to be generalistspecialists as well as subspecialty experts. It is clear that psychiatrists-in-training have the courage to face tragedy, whether in caring for individual patients or seeking to help in truly catastrophic situations in our world, and they embrace their colleagues from many nations in their work.