Showing papers in "Academic Psychiatry in 2014"

The Relation Between Burnout and Sleep Disorders in Medical Students

Abstract: The aim of this study is to assess the mutual relationships between burnout and sleep disorders in students in the preclinical phase of medical school. This study collected data on 127 medical students who filled in the Maslach Burnout Inventory-Student Survey, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Beck Depression Inventory, and Beck Anxiety Inventory. Hierarchical logistic regressions tested the reciprocal influence between sleep disorders and burnout, controlling for depression and anxiety. Regular occurrence of emotional exhaustion, poor sleep quality, and excessive daytime sleepiness affected 60, 65, and 63 % of medical students, respectively. Emotional exhaustion and daytime sleepiness influenced each other. Daytime sleep dysfunctions affected unidirectionally the occurrence of cynicism and academic efficacy. The odds of emotional exhaustion (odds ratio (OR) = 1.21, 95 % confidence interval (CI) = 1.08 to 1.35) and cynicism (OR = 2.47, 95 % CI = 1.25 to 4.90) increased when daytime sleepiness increased. Reciprocally, the odds of excessive daytime sleepiness (OR = 2.13, 95 % CI = 1.22 to 3.73) increased when emotional exhaustion worsened. Finally, the odds of academic efficacy decreased (OR = 0.86, 95 % CI = 0.75 to 0.98) when daytime sleepiness increased. Burnout and sleep disorders have relevant bidirectional effects in medical students in the early phase of medical school. Emotional exhaustion and daytime sleepiness showed an important mutual influence. Daytime sleepiness linked unidirectionally with cynicism and academic efficacy.

A Review of Multidisciplinary Clinical Practice Guidelines in Suicide Prevention: Toward an Emerging Standard in Suicide Risk Assessment and Management, Training and Practice

Abstract: The current paper aims to: (1) examine clinical practice guidelines in suicide prevention across fields, organizations, and clinical specialties and (2) inform emerging standards in clinical practice, research, and training. The authors conducted a systematic literature review to identify clinical practice guidelines and resource documents in suicide prevention and risk management. The authors used PubMed, Google Scholar, and Google Search, and keywords included: clinical practice guideline, practice guideline, practice parameters, suicide, suicidality, suicidal behaviors, assessment, and management. To assess for commonalities, the authors reviewed guidelines and resource documents across 13 key content categories and assessed whether each document suggested validated assessment measures. The search generated 101 source documents, which included N = 10 clinical practice guidelines and N = 12 additional resource documents (e.g., non-formalized guidelines, tool-kits). All guidelines (100 %) provided detailed recommendations for the use of evidence-based risk factors and protective factors, 80 % provided brief (but not detailed) recommendations for the assessment of suicidal intent, and 70 % recommended risk management strategies. By comparison, only 30 % discussed standardization of risk-level categorizations and other content areas considered central to best practices in suicide prevention (e.g., restricting access to means, ethical considerations, confidentiality/legal issues, training, and postvention practices). Resource documents were largely consistent with these findings. Current guidelines address similar aspects of suicide risk assessment and management, but significant discrepancies exist. A lack of consensus was evident in recommendations across core competencies, which may be improved by increased standardization in practice and training. Additional resources appear useful for supplemental use.

Mental health and suicidal behavior among graduate students.

Abstract: The objective of this paper is to describe the mental health and service utilization of graduate students at a large southeastern university and identify psychological factors associated with their student suicidal behavior. E-mail invitations to complete the Interactive Screening Program, an online anonymous mental health questionnaire, were sent to graduate students. The questionnaire included the Patient Health Questionnaire (PHQ-9) as well as items assessing suicide behavior, anxiety, negative emotion, substance use, eating behavior, and service utilization. A total of 301 graduate students responded to the questionnaires between 14 July 2010 and 24 January 2012. With regards to suicide, 7.3 % of the sample reported thoughts of suicide, 2.3 % reported having plans for suicide, and 1.7 % had hurt themselves in the past 2 weeks; while 9.9 % had ever made a suicide attempt in their lifetime. Graduate students had PHQ-9 scores indicating mild depression, and more than half endorsed feeling nervous, irritable, stressed, anxious, lonely, or having fights/arguments. In terms of service utilization, 22.2 % of the sample was currently taking some type of medication, and 18.5 % currently in counseling/therapy are females and those with higher PHQ-9 scores more likely to be using services. Those endorsing suicidal behavior in the past 2 weeks had significantly higher depression scores than those without such behavior and were characterized by more anxiety, negative emotions (such as loneliness, anger, hopelessness, desperation, and being out of control), substance use, and eating problems. Graduate students experience significant amounts of stress and anxiety, and their suicidal behavior is strongly characterized by depression, hopelessness, desperation, lack of control, and eating problems. Future work with this population should focus on the development and evaluation of mental health and wellness interventions and on ways to promote help-seeking, especially among male students.

Where Are the Women

Abstract: To the Editor: I read with great interest Dr. Roberts’ recent Academic Psychiatry editorial “Where Are the Women Editors?” [1]. Indeed, I thought to myself, where are the women? Ten years ago, when I interviewed for my first faculty position, I had asked the same question. After training in a medical school with 90 % women (in Europe), a residency with a female program director, in a class of 90 % women, and a geriatric fellowship at a premier research-based institution (with less women, yet highly visible), it seemed surprising to me that the only woman on my interview panel that day was the department administrator. I took the job, and quickly realized that the interview was a cross-section of life in the department. In my 10 years, I have witnessed quite a bit of junior faculty turnover, especially among women [2]. This reality is hard to notice at the Association for Academic Psychiatry, where five of the past ten presidents are highly accomplished women. Yet, I was saddened to hear at this year’s meeting (in Portland, Oregon, September 17–20, 2014) that several women we know and respect have left academia. What an incredible loss. I know how hard they fought to stay: they taught and mentored, developed innovative curricula, completed and contributed to faculty development courses, published in Academic Medicine, won teaching awards. They worked hard and gave of themselves wholeheartedly. Somehow, that was not enough. At the national level, half of newly minted full-time assistant professors leave their institution after 8 years on average, and that is equally true for men and women, according to a recent AAMC Analysis in Brief [3]. Newly appointed associate professors seem to fare better, with a 10-year average time to 50 % attrition. M.D.s and faculty in clinical departments leave sooner than Ph.D.s and those in basic science departments. A previous Analysis in Brief [4] tracked faculty over 17 years (1981 to 1997) and showed that almost half of firsttime assistant professors left academia, not just their institutions, with a slight gender difference: 43 % for men, 45 % for women. Many of us struggle to stay in academia. We put up a courageous fight and make it one more year, to the next annual meeting, where we receive a much-needed infusion of mentorship. We go home energized and revitalized and inspire others to pursue academic careers. We love what we do, and do what we love. Let us just hope that will be enough.

Uncertainty and Ambiguity and Their Association with Psychological Distress in Medical Students

Abstract: The practice of medicine is inherently uncertain. We sought to measure the level of psychological distress among medical students and to ascertain if an intolerance of uncertainty and ambiguity were associated with distress. The authors conducted a cross-sectional study with a population consisting of 4th year undergraduate medical students at an Irish university. Psychological distress was measured with the GHQ-12 scale. The “tolerance of ambiguity” scale and the “Intolerance of Uncertainty Scale (IUS)-12” were used to measure the respective variables. One hundred students (class size of 123) participated in this study giving a response rate of 81 %. A total of 27 % of the students met the criteria for psychological distress. Student psychological distress, as measured by GHQ-12 caseness, was associated with a higher intolerance of uncertainty (mean 31.70 (6.18)) compared with those who were not distressed (mean IUS score 26.66 (6.58)) (t (98) = −5.52, p < 0.001). A relative lack of tolerance for uncertainty may prove to be an important predictor of psychological distress in undergraduates. There is an argument for designing appropriate interventions so that learners can come to recognize and embrace uncertainty rather than its remaining unacknowledged and potentially contributing to psychological morbidity.

Listening to Depression and Suicide Risk in Medical Students: the Healer Education Assessment and Referral (HEAR) Program

Abstract: A growing body of literature documents high rates of burnout, depression, and suicidal ideation among physicians and medical students. Barriers to seeking mental health treatment in this group include concerns about time, stigma, confidentiality, and potential career impact. The authors describe a 4-year trial of the Healer Education Assessment and Referral (HEAR) program, designed to increase mental health services utilization (MHSU) and decrease suicide risk (SR) as assessed by an Interactive Screening Program (ISP)at one US medical school. Over a 4-year period, medical students were engaged in face-to-face, campus-wide, educational group programs and were invited to complete an individual, online, and anonymous survey. This survey contained the 9-item Patient Health Questionnaire (PHQ-9) scale to assess depression and items to identify suicidal thoughts and behaviors, substance use, distressing emotional states, and the use of mental health treatment. Students who engaged in this ISP by corresponding electronically with a counselor after completing the survey were assessed and when indicated, referred to further treatment. The HEAR program was delivered to 1,008 medical students. Thirty-four percent (343/1,008) completed the online screening portion. Almost 8 % of respondents met the criteria for high/significant SR upon analysis of the completed screens. Ten out of 13 of the students with SR who dialogued with a counselor were not already receiving mental health treatment, indicating that this anonymous ISP identified a high proportion of an untreated, at risk, and potentially suicidal population. MHSU among medical students who completed the survey was 11.5 % in year 1 and 15.0 % by year 4. SR among medical students was 8.8 % in year 1 and 6.2 % in year 4 as assessed by the ISP. This novel interventional program identified at risk, potentially suicidal medical students at one institution. Based on this single-site experience, we suggest that future multisite studies incorporate a comparison group, acquire baseline (prematriculation) data regarding MHSU and SR, and use an individualized yet anonymous identification system to measure changes in individual participants’ mental health status over time.

Impact of the Psychiatry Clerkship on Medical Student Attitudes Towards Psychiatry and to Psychiatry as a Career

Abstract: The psychiatry clerkship forms part of the core curriculum of medical schools worldwide and provides psychiatric educators with an ideal opportunity to positively influence students. The aim of this paper is to systematically review literature on the impact of the psychiatry clerkship to determine the effect on attitudes towards psychiatry and to psychiatry as a career. A systematic review was undertaken. The following key search words were used to search a number of electronic databases: medical student/s, attitude/s, psychiatry and clerkship. Studies published in the English language from 1990 to the present were included. Studies were included if they were based on a pre-/post-design, i.e. the same students must have participated in the study both before and after the clerkship. Twenty-six studies from 19 countries were identified for the review. Sixteen studies reported an overall improvement in attitudes towards psychiatry post-clerkship, and ten found no change in attitudes. In terms of career choice, nine studies reported an increase in the number of students interested in psychiatry as a career post-clerkship, nine found no impact on career choice and, in eight studies, it was not assessed. A number of positive and negative factors regarding the clerkship were identified. Overall, the psychiatry clerkship has a positive impact on students' attitudes towards psychiatry, but does not improve interest in psychiatry as a career option. For those students particularly interested in psychiatry, the challenge is to maintain their enthusiasm post-clerkship. Charismatic teachers, mentorship and stigma reduction may be effective strategies. Future research needs to more clearly identify specific components of the clerkship that are viewed favorably by students.

Reducing Stigma Towards Substance Users Through an Educational Intervention: Harder Than It Looks

Abstract: Stigma towards people with substance use disorders is pervasive and imbedded in our US culture. Prejudicial attitudes that are part of a health care practitioner’s value system are a barrier to people accessing health care and substance use treatment. This study aimed to reduce stigmatizing attitudes of graduate health care professional students by implementing an innovative curriculum combining multiple teaching methods. Physician assistant students received a 3-h educational intervention that consisted of lecture and discussion sessions, direct interaction with a recovering substance user, viewing a film portrayal of addiction and addiction treatment, and written self-reflection. Changes in student attitudes were measured using a subscale of the Attitudes to Mental Illness Questionnaire (AMIQ) instrument and analysis of coded written reflections. A follow-up focus group resulted in additional qualitative insight into attitudes. Post-intervention scores for the “heroin” AMIQ vignette significantly improved compared to pre-test scores (p < 0.007), but the effect was small and the mean post-test scores still reflected very negative attitudes. Students’ neutral attitude towards alcohol use did not change as a result of the intervention. Written reflections demonstrated that this sample of students continued to harbor stigma towards people with substance use following the intervention. Focus group data suggested students believed that stigma beliefs about substance use were common among health care professionals, though they believed that their own level and quality of care would not be influenced by these beliefs. The persistence of negative attitudes following this and others’ educational interventions suggests the need for a new approach to changing health care professionals’ stigma towards substance users.

Attitudes Toward Mental Illness and Changes Associated with a Brief Educational Intervention for Medical and Nursing Students in Nigeria

Abstract: This study assessed beliefs about mental disorders and changes in those beliefs following an educational intervention for a convenience sample of Nigerian medical and nursing students. A 43-item questionnaire was used to assess perceptions regarding mental disorders and attitudes toward people with mental illness before and after a 4-day educational intervention. Factor analysis identified four domains: (1) socializing with people with mental illness, (2) belief in witchcraft or curses as causes of mental illness, (3) favorable attitudes toward normalization of the lives of people with mental illness, and (4) biopsychosocial approaches to mental illness. The greatest changes were in attitudes favoring normalization of the lives of people with mental illness (p = 0.0002), socializing with the mentally ill (p = 0.01), and biopsychosocial perspectives on mental illness (p = 0.01). Brief educational interventions may alter some stigmatizing negative attitudes toward mental illness in healthcare trainees in low- and middle-income countries.

Beyond the DSM: Development of a Transdiagnostic Psychiatric Neuroscience Course

Abstract: Objective Clinical and neurobiological data suggest that psychiatric disorders, as traditionally defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), are (1) more comorbid than expected by chance, (2) often share neurobiological signatures, and (3) reflect alterations across multiple brain systems that mediate particular mental processes. As such, emerging conceptualizations such at the National Institute of Mental Health’s Research Domain Criteria Project (RDoC) have suggested that a different way to understand psychopathology may be with respect to the degree of dysfunction in each of these brain systems, seen dimensionally, which both cross traditional diagnostic boundaries and extend to a healthy range of functioning. At present, however, this scientific perspective has not been incorporated into neuroscience education in psychiatry, nor has its relationship to clinical care been made clear.

Assessing medical students' communication skills by the use of standardized patients: emphasizing standardized patients' quality assurance.

Abstract: The objective structured examination is one of the most valid, reliable, and effective tools for assessing clinical and communication skills, often by use of standard patients (SPs). SPs can also be assessors of those skills. One of the crucial areas when utilizing SP-based assessment is the quality and consistency assurance of their portrayal of the case and their ability to fill in checklists in an adequate way. The aim of this study was to assess the validity and reliability of SPs’ ability to assess students’ communication skill via a Calgary-Cambridge checklist. This cross-sectional and correlational study was conducted at the Tehran University of Medical Science. We first analyzed validity; the criterion validity of the SPs’ filling in the checklists was assessed through determining the correlation between the SPs’ completed checklists and the checklists filled in by three physician raters individually and then reproducibility: it was assessed by a test-retest approach inter-rater reliability. The mean correlation for assessing the validity of SPs’ completed checklists by individual SPs was 0.81. The inter-rater reliability was calculated by kappa coefficient, and the total correlation among the three raters was 0.85. The reliability of the test-retest approach showed no significant differences between the test and re-test results. The increased number of medical students and different faculties’ responsibilities such as doing educational, research, and health services duties assessing medical student communication skills is a complex issue. The results of our study showed that trained SPs can be used as a valid tool to assess medical students’ communication skills, which is also more cost effective and reduces work load of medical faculties.

Description of Internet Addiction among Chilean Medical Students: A Cross-Sectional Study

Abstract: Internet addiction (IA) has been described as an emerging behavior related to the development of new technologies, with scarce studies on the subject and none involving medical students. The Internet Addiction Test (IAT) is a screening instrument used to detect IA worldwide, which was published in 1998 and inspired by the DSM-IV criteria for pathologic gambling. The objective of this study aims to measure the prevalence of IA in Chilean medical students and its possible association with demographic variables and depressive symptoms. First- to fifth-year undergraduate medical students at a medical school in Santiago de Chile answered a self-administered survey that included demographic data, the IAT scale, and the Goldberg's General Health Questionnaire (GHQ-12) to screen for IA and depressive symptoms, respectively. Three hundred eighty-four students participated, achieving a response rate of 69.8 %, of which 11.5 % were classified as problematic users according to the IAT. The authors found a statistical association between positive results on the IAT and positive scores on the GHQ-12, as well as with the male gender. In this first study of IA in medical students, the authors found a rate of incidence similar to what has been published in the literature focusing on college students. Additionally, there was a positive association between emotional symptoms and other abuse behaviors.

Neuropsychiatry and neuroscience education of psychiatry trainees: attitudes and barriers.

Abstract: The American Association of Directors of Psychiatric Residency Training (AADPRT) Task Force on Neuropsychiatry and Neuroscience Education of Psychiatry Residents was established in 2011 with the charge to seek information about what the field of psychiatry considers the core topics in neuropsychiatry and neuroscience to which psychiatry residents should be exposed; whether there are any “competencies” in this area on which the field agrees; whether psychiatry departments have the internal capacity to teach these topics if they are desirable; and what the reception would be for “portable curricula” in neuroscience. The task force reviewed the literature and developed a survey instrument to be administered nationwide to all psychiatry residency program directors. The AADPRT Executive Committee assisted with the survey review, and their feedback was incorporated into the final instrument. In 2011–2012, 226 adult and child and adolescent psychiatry residency program directors responded to the survey, representing over half of all US adult and child psychiatry training directors. About three quarters indicated that faculty resources were available in their departments but 39 % felt the lack of neuropsychiatry faculty and 36 % felt the absence of neuroscience faculty to be significant barriers. Respectively, 64 and 60 % felt that neuropsychiatry and psychiatric neuroscience knowledge were very important or critically important to the provision of excellent care. Ninety-two percent were interested in access to portable neuroscience curricula. There is widespread agreement among training directors on the importance of neuropsychiatry and neuroscience knowledge to general psychiatrists but barriers to training exist, including some programs that lack faculty resources and a dearth of portable curricula in these areas.

The Psychiatry OSCE: a 20-year retrospective.

Abstract: Twenty years ago researchers at the University of Toronto launched the Psychiatry Skills Assessment Project (PSAP), a research program exploring Objective Structured Clinical Examinations (OSCEs) in psychiatry. Between 1994 and 2005 PSAP produced publications on the feasibility, reliability, validity, ethics, and practical concerns of OSCEs in psychiatry. The current review has two parts: a review of the state of the art of OSCEs in psychiatry 20 years after they were introduced and documentation of the impact of the PSAP research program. A literature search identified all publications on OSCEs and psychiatry. Articles were coded thematically, and locations of agreement and controversies were identified. Bibliometric analysis identified citations of PSAP research papers, which were analyzed thematically. As of May 2013, there were 250 publications related to OSCEs in psychiatry (not including 10 PSAP papers), published in 29 different countries and ten languages. Prominent topics were the validity and acceptability of OSCEs and SPs, systems issues in adopting OSCEs in psychiatry, and the effects on learning. Eighty-eight percent of all publications cited PSAP work (300 citations). Citations were employed for four purposes: as evidence/justification (54 %); to frame replication research (14 %); to support adaptation of OSCEs in other countries and professions (15 %); and for debate (18 %). Over the past 20 years, use of OSCEs has grown steadily in psychiatry, and several national certification organizations have adopted OSCEs. PSAP work, introduced two decades ago, continues to provide a scholarly foundation for psychometric, practical, and ethical issues of interest to this field.

Teaching psychiatry residents to work at the interface of mental health and primary care.

Abstract: The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings

Training for Suicide Risk Assessment and Suicide Risk Formulation

Abstract: Suicide and suicidal behaviors are highly associated with psychiatric disorders. Psychiatrists have significant opportunities to identify at-risk individuals and offer treatment to reduce that risk. Although a suicide risk assessment (SRA) is a core competency requirement, many lack the requisite training and skills to appropriately assess for suicide risk. Moreover, the standard of care requires psychiatrists to foresee the possibility that a patient might engage in suicidal behavior, hence to conduct a suicide risk formulation (SRF) sufficient to guide triage and treatment planning. An SRA gathers data about observable and reported symptoms, behaviors, and historical factors that are associated with suicide risk and protection, ascertained by way of psychiatric interview; collateral information from family, friends, and medical records; and psychometric scales and/or screening tools. Based on data collected via an SRA, an SRF is a process whereby the psychiatrist forms a judgment about a patient's foreseeable risk of suicidal behavior in order to inform triage decisions, safety and treatment plans, and interventions to reduce risk. This paper addresses the need for a revised training model in SRA and SRF, and proposes a model of training that incorporates the acquisition of skills, relying heavily on case application exercises.

Helping Psychiatry Residents Cope with Patient Suicide

Abstract: Every clinical specialty has its own high risk patient challenges that threaten to undermine their trainees’ professional identity, evolving sense of competence. In psychiatric training, it is patient suicide, an all-too frequently encountered consequence of severe mental illness that may leave the treating resident perplexed, guilt-ridden, and uncertain of their suitability for the profession. This study evaluates a patient suicide training program aimed at educating residents about patient suicide, common reactions, and steps to attenuate emotional distress while facilitating learning. The intervention was selected aspects of a patient suicide educational program, “Collateral Damages,”—video vignettes, focused discussions, and a patient-based learning exercise. Pre- and post-survey results were compared to assess both knowledge and attitudes resulting from this educational program. Eight psychiatry residency training programs participated in the study, and 167 of a possible 240 trainees (response rate = 69.58 %) completed pre- and post-surveys. Knowledge of issues related to patient suicide increased after the program. Participants reported increased awareness of the common feelings physicians and trainees often experience after a patient suicide, of recommended “next” steps, available support systems, required documentation, and the role played by risk management. This patient suicide educational program increased awareness of issues related to patient suicide and shows promise as a useful and long overdue educational program in residency training. It will be useful to learn whether this program enhances patient care or coping with actual patient suicide. Similar programs might be useful for other specialties.

The Milestones for General Psychiatry Residency Training

Abstract: The Accreditation Council of Graduate Medical Education’s (ACGME)Milestones project represents the most recent development in the evolution of medical training in the USA. Beginning with the establishment of the American Medical Association (AMA) in 1845, medical training in the USA has been increasingly focused on the development of high caliber physicians whose practice is scientifically based. The Association of American Medical Colleges (AAMC) was established in 1876 to reform medical education which had previously been entirely unregulated but with minimal practical effect. The AMA, however, through the formation of its Council on Medical Education [5, 6] was able to influence training in medical schools, hospital internship programs, and specialty training. Abraham Flexner’s report for the Carnegie Foundation published in 1910 essentially established our current system of training and resulted in the closure of inadequate schools and curricular reform that banished naturopathy and other alternative practices from medical education. Flexner strongly endorsed the residency program established by John Hopkins in 1889 that would subsequently become the framework for all residency training in the USA [4]. Subsequently, the AMA began a program, in 1914, of evaluation and approval of hospital internships and published the “Essentials of Approved Residencies and Fellowships” in 1928. The American Board of Psychiatry and Neurology (ABPN), established in 1934, was charged by the AMA, American Psychiatric Association (APA), and American Neurological Association with the task of establishing training standards in psychiatry and neurology as well as the certification of specialists in these areas [5]. In 1940, the AMACouncil onMedical Education in conjunctions with the American Board of Internal Medicine and the American College of Physicians established the Conference Committee on Graduate Training in Internal Medicine, a forerunner of the ACGME Residency Review Committees (RRC). The American College of Surgeons and American Board of Surgery followed suit in 1949. With the establishment of Medicare and federal funding for residency training, academic educators realized that the multiple councils then in existence with widely varying standards for approval of training programs required reform. The need for oversight and uniformity of standards was thought compelling and was supported by the AMA, other medical groups, and the government. In 1972, the AMA brought together the AMA, the American Board of Medical Specialties (ABMS), the American Hospital Association, the AAMC, and the Council ofMedical Specialty Societies to form a Liaison Committee for Graduate Medical Education (LCGME) to coordinate and oversee the activities of the several independent RRC’s then in existence [7]. A more independent and streamlined organization was required to accomplish these tasks, and the ACGME replaced the LCGME in 1981. In the following years, our current system of RRC’s, program requirements, and periodic accreditation site visits was developed. The milestones for residency training represent the next step in the outcomes-based accreditation project of the ACGME [10, 14]. Milestones are based on the six core competencies for graduate medical education established in 1999 by the ACGME and the ABMS and describe specific behaviors, attributes, or outcomes to be demonstrated by residents as they progress through training. The core competencies focus on educational outcomes, as opposed to educational process, as a measure of success in achieving training goals and objects. The US Department of Education mandated the use of outcome measures for all educational programs receiving federal funding in the 1980’s, including those for accreditation [1]. The ACGME C. R. Thomas (*) University of Texas Medical Branch at Galveston, Galveston, TX, USA e-mail: crthomas@utmb.edu

Training in integrated mental health-primary care models: a national survey of child psychiatry program directors.

Abstract: The objective of this study was to assess current trainee exposure to integrated mental health/primary care models in US child and adolescent psychiatry fellowship programs In June 2013, an electronic survey was sent to all US child and adolescent psychiatry fellowship program directors (N = 123) Fifty-two responses were obtained from the 120 eligible participants (43 %) The majority of the program directors who responded (63 %) indicated that fellows in their programs regularly participate in clinical care and/or consultation within an outpatient pediatric primary care setting Program directors identified barriers to increasing training exposure to integrated care delivery as competing clinical demands and challenging financial models for indirect consultation in primary care settings Many child psychiatry fellowship program directors view training in integrated care models as an important part of their teaching and service mission, and are creating novel avenues for exposure Current funding models, however, may limit the widespread implementation of these opportunities

Usefulness of the Patient Health Questionnaire-9 for Korean Medical Students

Abstract: Depression may be highly prevalent among medical students, lowering their functioning and quality of life. Using appropriate extant depression scales to screen for depression and determining factors associated with depression can be helpful in managing it. This study examines the validity and reliability of the Patient Health Questionnaire-9 (PHQ-9) for medical students and the relationship between their scores and sociodemographic variables. This study surveyed 174 medical students using demographic questionnaires, the PHQ-9, the Beck Depression Inventory (BDI), the Patient Heath Questionnaire-15 (PHQ-15), the Beck Anxiety Inventory (BAI), and the Perceived Stress Scale (PSS). It calculated the Cronbach’s α for internal consistency and Pearson’s correlation coefficients for test-retest reliability and convergent validity of the PHQ-9. In order to examine the relationship between depression and demographic variables, this study performed independent t tests, one-way analysis of variance, chi-square, and binary logistic regressions. The PHQ-9 was reliable (Cronbach’s α = 0.837, test-retest reliability, r = 0.650) and valid (r = 0.509–0.807) when employed with medical students. Total scores on the PHQ-9 were significantly higher among low-perceived academic achievers than among high-perceived academic achievers (p < 0.01). Depression was more prevalent in poor-perceived academic achievers than in high-perceived academic achievers. Similarly, poor-perceived academic achievers were at greater risk of depression than were high-perceived academic achievers (odds ratio [95 % confidence interval] 3.686 [1.092–12.439], p < 0.05). The PHQ-9 has satisfactory reliability and validity in medical students in South Korea. Depression is related to poor-perceived academic achievement when measured with the PHQ-9. Early screening for depression with the PHQ-9 in medical students and providing prompt management to high scorers may not only be beneficial to students’ mental health but also improve their academic performance.

Engaging medical students in research: reaching out to the next generation of physician-scientists.

Abstract: Objective The authors describe a multifaceted educational training approach aimed at increasing medical student involvement in psychiatric research.

Clinical Examiners, Simulated Patients, and Student Self-assessed Empathy in Medical Students During a Psychiatry Objective Structured Clinical Examination

Abstract: This tudy aims to assess and compare objective and subjective scores of empathy in final-year medical students by using firstly a validated student self-assessment just prior to the psychiatry objective structured clinical examination (OSCE), and then comparing this to clinical examiner's and simulated patient's (SP’s) assessments of empathy of students using a Global Rating of Empathy scale (GRE) during a psychiatry OSCE. In 2011, all final-year medical students in the University College Dublin were invited to complete a subjective, self-assessed empathy questionnaire (The Jefferson scale of physician empathy—student version (JSPE-S)). They were also assessed for empathy in four OSCEs by the clinical examiner and the SP acting in that OSCE scenario. Included in the analysis were 163 of 184 final-year students JSPE-S (88.6 %) questionnaires. The female students scores on the JSPE-S were significantly higher than those of their male peers (t = 3.34, p = 0.001). Concurrent validity was greater between the SPs’ assessments of empathy in the OSCE and the JSPE-S score than between the clinical examiners assessments of empathy and the JSPE-S score (r = 0.23, p < 0.005; r = 0.14, p < 0.08). Inter-rater reliability of SP's and clinical examiner's using the GRE was found to be high (F = 0.868 (df = 171, 171), p value <0.001). SPs may be valid assessors of empathy in medical students during an OSCE.

Interventional psychiatry: how should psychiatric educators incorporate neuromodulation into training?

Abstract: Objective Interventional psychiatry is an emerging subspecialty that uses a variety of procedural neuromodulation techniques in the context of an electrocircuit-based view of mental dysfunction as proximal causes for psychiatric diseases.

Neuropsychiatry and neuroscience milestones for general psychiatry trainees.

Abstract: For nearly 50 years, psychiatric thought leaders have suggested that advances in our understanding of the brain should lead psychiatry training to include more clinical neuroscience [1–13]. The importance to psychiatric training of a foundation in neurology has been acknowledged since at least 1939, when the predecessor of the Accreditation Council on Graduate Medical Education (ACGME), the American Medical Association (AMA) Council on Medical Education and Hospitals, established the requirement that “a program of graduate studies should run concurrently with clinical instruction, covering the fundamentals of neuroanatomy, neuropathology, neurophysiology, psychobiology, and psychopathology [14].” In 1987, the ACGME and American Board of Psychiatry and Neurology (ABPN) initiated the current two-month neurology experience requirement. The 2007 ACGME ProgramRequirements in Psychiatry included little guidance as to the content or goals of this experience beyond “supervised clinical experience in the diagnosis and treatment of patients with neurological disorders/conditions” and the competencies and didactic components listed in Table 1. A number of trends in recent years argue strongly for increased attention to clinical neuroscience in psychiatric training:

Physician, Heal Thyself: a Qualitative Study of Physician Health Behaviors

Abstract: The authors explore how physicians perceive their own health and barriers to healthcare, as well as what might motivate their behavior. This qualitative study uses semi-structured interviews of a purposive sampling of physicians, both staff and housestaff, from Walter Reed Army Medical Center and the Medical College of Wisconsin. Transcripts of interviews that probed attitudes and behaviors towards self-care were coded independently by two reviewers using grounded theory qualitative methods. The authors conducted 28 interviews until no new themes emerged. Common barriers to healthcare included inadequate time, fear of consequences, and concern about confidentiality, particularly for stigmatizing diseases identified as mental health problems, chronic pain, substance abuse, and sexual dysfunction. Common behaviors included neglecting one's health, minimizing symptoms, self-diagnosing, and a strong desire not to burden colleagues. Participants were split into those who felt it was fine to self-medicate and others who avoided it. Participants proposed solutions for identified problems, including building time into schedules for self-care, monitoring electronic medical record access to make providers accountable, obtaining care at other institutions, and working to change the culture around healthcare for physicians. All participants in this study perceived significant unresolved issues pertaining to self-care. Physicians commonly neglect their own care and experience barriers to care, some self-generated and some systems based. The results and suggested interventions provide fodder for future research.

Teaching clinical neuroscience to psychiatry residents: model curricula.

Abstract: It has been proposed that the future of psychiatry is best grounded in the clinical neurosciences because advances in the assessment, treatment, and prevention of brain disorders are likely to originate from studies based on the clinical and translational neurosciences [1]. This exciting potential is reflected by the National Institute of Mental Health’s strategic plan for research, which emphasizes the links between the neurosciences, genomics, and individual and public health outcomes [2]. Psychiatry trainees must therefore become skilled in being able to find, understand, critically appraise, and incorporate those advances that can meaningfully contribute to mental health and to the care of people living with mental illness. Developing the requisite neuroscientific knowledge and skills for residents, however, is an especially challenging proposition for educators for several important reasons. First, there is a phenomenal rate of discovery and complexity of advances in the neurosciences and neuropsychiatry. Second, some programs are limited in the availability of faculty as well as trained educators in the neurosciences and neuropsychiatry. One early survey of program directors, for example, found that a lack of neuropsychiatric faculty was the most common reason for not providing neuropsychiatry training [3]. Last, but not least, our field has not yet really defined clinical neuroscience—a broad interdisciplinary domain that encompasses numerous areas and clearly much more than just neuropsychiatry. Much work remains to be done in characterizing clinical neuroscience, drawing connections between this basic, translational, and applied scientific field to the human aspects of human development, attachment, health, and healing that occur in the work of psychiatrists, and discerning what part of clinical or other neurosciences should be taught to residents, medical students, and our colleagues in the field (e.g., as a part of continuing medical education). Clarification of these issues should be the next step in making clinical neuroscience an integral part of what we teach. One important response to the challenges presented by the acceleration of the field coupled with insufficiently prepared faculty is to develop well-designed neuroscience curricula that are portable across residency training programs. Our patients, as well as the field of psychiatry, will be best served when training programs work together to standardize learning objectives and curricula and to share the best educational practices [4]. To this end, this edition of Academic Psychiatry presents an exceptional compendium of articles concerning the education of psychiatry residents in the neurosciences [5–15]. One of these articles reported on a survey of residency training directors confirming the earlier finding [3] that a lack of qualified faculty constituted a barrier to training in the neurosciences and neuropsychiatry [12]. The vast majority of respondents in this survey identified a need for portable curricula [12]. In another survey, chief residents indicated that they did not feel adequately prepared to translate findings from neuroscience research into clinical practice [13]. Four of the articles [7, 9–11] described a neuroscience curriculum targeted to psychiatry residents. One commentary proposed a novel idea for a pilot training program based on the “triple board approach” [15]. J. Coverdale (*) Baylor College of Medicine, Houston, TX, USA e-mail: jhc@bcm.edu

Implementation of online suicide-specific training for VA providers

Abstract: Due to the gap in suicide-specific intervention training for mental health students and professionals, e-learning is one solution to improving provider skills in the Veterans Affairs (VA) health system. This study focused on the development and evaluation of an equivalent e-learning alternative to the Collaborative Assessment and Management of Suicidality (CAMS) in-person training approach at a Veteran Health Affairs medical center. The study used a multicenter, randomized, cluster, and three group design. the development of e-CAMS was an iterative process and included pilot testing. Eligible and consenting mental health providers, who completed a CAMS pre-survey, were randomized. Provider satisfaction was assessed using the standard VA evaluation of training consisting of 20 items. Two post training focus groups, divided by learning conditions, were conducted to assess practice adoption using a protocol focused on experiences with training and delivery of CAMS. A total of 215 providers in five sites were randomized to three conditions: 69 to e-learning, 70 to in-person, 76 to the control. The providers were primarily female, Caucasian, midlife providers. Based on frequency scores of satisfaction items, both learning groups rated the trainings positively. In focus groups representing divided by learning conditions, participants described positive reactions to CAMS training and similar individual and institutional barriers to full implementation of CAMS. This is the first evaluation study of a suicide-specific e-learning training within the VA. The e-CAMS appears equivalent to the in-person CAMS in terms of provider satisfaction with training and practice adoption, consistent with other comparisons of training deliveries across specialty areas. Additional evaluation of provider confidence and adoption and patient outcomes is in progress. The e-CAMS has the potential to provide ongoing training for VA and military mental health providers and serve as a tutorial for psychiatrists in preparation for specialty boards.

Teaching residents about emotional intelligence and its impact on leadership.

Abstract: Although leadership is a core component of the work life of physicians, most physicians are ill-prepared to assume leadership roles upon completion of residency training. The authors sought to determine if medical residents could learn the components of emotional intelligence and thereby facilitate improved leadership styles. The authors created an educational workshop that included readings (provided to attendees in preparation for the workshop), a formalized presentation on emotional intelligence, and role-playing of scenarios (with debriefing and discussion) involving leadership opportunities. The majority of participants reported that they left the workshop more informed about leadership and with more skills that could enhance their roles as leaders. While enhancing knowledge and skills, which were demonstrated after attendance at a seminar, additional measures of effective leadership are still needed.

The critical need to diversify the clinical and academic workforce.

Abstract: Only a small proportion of faculty in the medical schools of the USA reflects racial and ethnic minority groups, according to the Association of AmericanMedical Colleges [1]. In 2010, 8 % of faculty were underrepresented minority individuals, defined as self-reported Black/African American, Hispanic/ Latino, Native American, Alaskan Native, Native Hawaiian, or Pacific Islanders [1, 2]. According to the US Census, in the same year, 17 % of the population self-identified as Hispanic/ Latino [3] and 13% as Black/African American [4], with both groups growing more rapidly (43 % and 15 %, respectively) than the average growth rate of 9.7 % from 2000 to 2010 [3, 4]. People of racial and ethnic minority backgrounds are expected to make up more than half of the population by 2060 per population projections from the 2010 census [5]. These data regarding underrepresentation of racial and ethnic minority groups in medicine have important public health implications. There is evidence that ethnic minority physicians are more likely to provide care for ethnic minority and socioeconomically disadvantaged patients [6]. There is also a link between race and ethnic concordance of physicians and patients and the quality of patient-physician communication, other health care processes, and some patient outcomes [6]. In one study, patients with providers from the same racial backgrounds were more satisfied and rated their physicians as more engaged and participatory than those with providers from different racial groups [7]. It has also been suggested that physicians’ unconscious biases may contribute to racial and ethnic disparities in the use of medical procedures such as thrombolysis for myocardial infarction [8]. Women are on the way to greater representation in medicine. At this time, approximately 70% of the overall physician workforce is male [9]. Women are most highly represented in pediatrics (58 %), internal medicine/pediatrics (50 %), child and adolescent psychiatry (48 %), obstetrics and gynecology (47 %), and geriatric medicine (47 %). Looking ahead, nearly half (46 %) of residents and fellows in programs accredited by the Accreditation Council for GraduateMedical Education are female [2]. Two-thirds or more of residents are women in several fields, including obstetrics and gynecology (81 %); pediatrics (73 %); endocrine, diabetes, and metabolism (67 %); and rheumatology (66 %). Nearly 62 % of the 838 total residents and fellows in child and adolescent psychiatry are women, and 55 % of the 4,947 total psychiatry residents are women. Women will have greater presence in absolute numbers and in proportion in the physician workforce of the future; primary care and “cognitive” specialties, rather than procedural specialties except obstetrics, will have greater representation of women relative to other fields.

Assessing resident performance on the psychiatry milestones.

Abstract: The assessment of learners to determine their achievement of educational goals is an integral and time-honored feature of education across the continuum. The expectation for evaluation of resident performance first appeared in the general graduate medical education accreditation requirements in 1966 [1] and was added to and made more explicit in the psychiatry requirements in 1975 [2]. Since then, accreditation requirements for resident assessment have evolved, for example, to broaden the scope of what to assess from clinical skills and knowledge to competencies in six domains and to require use of multiple evaluators (e.g., faculty, patients, peers, self, and other professional staff) [3]. Starting in July 2014, graduate medical education (GME) programs in all specialties will be required to assess and report on residents’ achievement of milestones in each of the six domains of general competencies [4]. Milestones describe the six domains more specifically in terms of knowledge, skills, attitudes, behaviors, and other attributes residents are expected to learn and demonstrate. Furthermore, milestones are organized into levels that form a developmental progression, from less to more advanced [5, 6]. The ACGME’s new accreditation model calls for use of two separate but related processes to assess residents’ demonstration of milestones: (1) the ongoing, formative assessment of residents’ milestone-related learning and performance by faculty and other appropriate assessors; (2) semi-annual reporting of resident performance on milestones by the program’s Clinical Competency Committee (CCC) using the specialty’s standard milestones report form [4]. Current ACGME requirements for formative assessment state that programs must provide objective assessments based on specialty-specific milestones [4], but do not include other detailed specifications unique to milestone assessment. How then should programs perform formative assessments of milestones? Or, more generally, how do approaches to assessments of residents need to change (if at all) in the age of milestones? In this article, we focus on development and implementation of formative assessments helpful for addressing the new accreditation requirements on milestone assessment. We identify desirable features of milestones assessment and then describe the milestone assessment tool development work the Psychiatry Milestone Working Group (PMWG) is performing. We then discuss the advantages and disadvantages of this and other approaches.