Showing papers in "Academic Psychiatry in 2019"

Maladaptive Perfectionism, Impostorism, and Cognitive Distortions: Threats to the Mental Health of Pre-clinical Medical Students.

Abstract: While medical student wellness has been a subject of recent study and discussion, current efforts may fail to address possible underlying, harmful cognitive distortions regarding academic performance. The authors sought to examine dysfunctional thoughts (maladaptive perfectionism, impostor phenomenon) and negative feelings (shame, embarrassment, inadequacy) that may contribute to poor mental health in pre-clinical medical students. A survey was administered to first-year medical students at Saint Louis University that included assessments for maladaptive perfectionism, impostor phenomenon, depression, and anxiety, as well as questions about feelings of shame, embarrassment, inadequacy, comparison, and self-worth. A total of 169 students (93%) participated. Students who met criteria for maladaptive perfectionism were significantly more likely to report greater feelings of shame/embarrassment and inadequacy (P < 0.001) than their peers who did not; similar associations were observed in students who reported high/intense levels of impostor phenomenon (P < 0.001). Furthermore, students who reported feelings of shame/embarrassment or inadequacy were significantly more likely to report moderate/severe levels of depression symptoms (P < 0.001) and moderate/high levels of anxiety symptoms (P = 0.001) relative to students who did not report these negative feelings. These preliminary data support a model for how negative thoughts may lead to negative emotions, and depression and anxiety in medical students. The authors propose strategies for preventive interventions in medical school beginning in orientation. Further research is needed to develop targeted interventions to promote student mental health through reduction of cognitive distortions and negative feelings of shame, embarrassment, and inadequacy.

The Use of Technology by Youth: Implications for Psychiatric Educators

Abstract: Today’s youth are using technology in a variety of ways, from texting and tweeting to chatting, online gaming, and posting through a variety of Internet portals. Of US adults and those aged 18–29, respectively, 88% and 99% use the Internet [1]. As of 2017, approximately 95% of American adults have a cell phone and 77% a smartphone [1]. Social media—usually defined as web-based and mobile services that allow people to share a connection, monitor progress, and create/manipulate text, audio, photos, and/or video [2, 3]—is also exponentially growing [4]. Social media and networking options like Twitter and Facebook are common among the Digital Native (Z; 1998–present), Millennial (Y; 1981–1997), and X (1965– 1980) Generations (Table 1) [5, 6]. On a typical day, American teenagers (13to 17-year-olds) spend an average of six and a half hours and tweens spend an average of four and a half hours on screen media use. [1, 5, 6]. These behaviors, experiences, and events may be positive or negative, healthy or unhealthy, and normal or problematic. Positive aspects of technology for the youth include being able to speak more freely (finding one’s voice/community) online, learning/knowledge gains, communication/engagement with others, and creative exploration. Youth are also open to the use of technology for the assessment and interventions in healthcare, such as web-based technologies which support youth with depressive symptoms [7] and text messaging services as an intervention for adolescent obesity or suicidal thinking [8]. Despite these potential benefits, concerns about media use—especially excess use—of television and computer games have arisen due to potential changes in mood, promotion of sedentary lifestyles, withdrawal from other activities, and severely impaired sleep patterns [9]. Problematic social media behaviors may range from disinhibition and the posting of ill-advised photos, to more extreme examples like online bullying, sexting, frank exploitation, and other destructive or addictive behaviors [10–15]. Disinhibition of behaviors may be encouraged by the ability to post anonymously [16]. In addition, according to the New York Times, “The nearuniversal access to digital technology, starting at ever younger ages, is transforming modern society in ways that can have negative effects on physical and mental health, neurological development and personal relationships, not to mention safety on our roads and sidewalks” [17]. Concerns about adverse effects of the Internet have led to proactive efforts toward cyberhealth [18], discussion of risks associated with excess online and screen activity [19], and a call for research on how technology “changes” us [20]. Finally, the “opportunity costs” need to be accounted for, that is, time spent on one activity costs an opportunity to spend it on another (perhaps better, healthier) activity. This paper will examine these issues, with more breadth than depth, in order to:

Interventions to Prevent and Reduce Burnout Among Undergraduate and Graduate Medical Education Trainees: a Systematic Review.

Abstract: The authors conducted a systematic review of the published literature to identify interventions to prevent and/or reduce burnout among medical students and residents. The authors searched 10 databases (from the start of each through September 21, 2016) using keywords related to burnout, medical education, and prevention. Teams of two authors independently reviewed the search results to select peer-reviewed, English language articles describing educational interventions to prevent and/or reduce burnout among medical students and/or residents that were evaluated using validated burnout measures. They assessed study quality using the Medical Education Research Study Quality Instrument and the Cochrane Risk of Bias Tool. Fourteen studies met inclusion criteria and all used the Maslach Burnout Inventory as at least one measure of burnout. Four were single group pre-post studies, 6 non-randomized two-group studies, and 4 randomized controlled trials. None of the studies were designed specifically to target burnout prevention. In 12 studies, residents were the targeted learners. Six of the 14 studies reported statistically significant changes in burnout scores: 5 reported improvement and 1 reported worsening of burnout. Of the 5 studies that reported statistically significant benefit, 1 studied a complementary and alternative medicine elective, 1 studied the Respiratory One Meditation method, and 3 studied duty hour changes. This review highlights the need for rigorously designed studies in burnout prevention and reduction among residents and especially medical students.

Developing "a Way of Being": Deliberate Approaches to Professional Identity Formation in Medical Education.

Abstract: Professional socialization and the development of reflective capacity are critical elements that shape a medical trainee’s professional identity. A 2010 Carnegie Foundation Report argues that professional identity formation should be an important focus of medical educators and that identity transformation remains the highest purpose of medical education [1]. Education achieves this highest purpose when a person develops new ways of thinking and relating with peers [2]. Ultimately, the professional ideal is to develop physicians who can bring their “whole person to provide whole person care” [3]. An ideal professional identity embraces empathy, mindful attention to patient care, integrity, self-awareness, teamwork, beneficence, respect, and equal regard for all, as well as an eagerness to learn, resilience, and attention to self-care. Professional identity formation has antecedents in the student’s life prior to matriculation into medical school, but it is a lifelong endeavor, achieved through critical reflection and exposures to role models who “pass the torch” from generation to generation. Professional identity formation is measured externally by reputation for excellence among peers and patients. In this paper, we discuss how at Renaissance School of Medicine at Stony Brook University we have integrated evidence-based approaches to enhance professional identity formation among our trainees and faculty. In a time of increasing burnout among physicians and trainees, we believe purposeful integration of such approaches into an institution’s learning processes may enhance resilience and a sense of belonging and wellbeing within a community of practice [4–7]. Definitions of Professional Identity Formation

ERASE: a New Framework for Faculty to Manage Patient Mistreatment of Trainees.

Abstract: In medical education, mistreatment is defined as behavior, intentional or unintentional, which “shows disrespect for the dignity of others and unreasonably interferes with the learning process.” [1] Medical educators and the Association of American Medical Colleges have long collected and monitored reports of mistreatment of medical students [2]. The literature is rife with studies on the prevalence and impact of bullying and harassment by supervisors in medicine [3]. Of growing concern, however, is mistreatment by those whom physicians are trained to serve: their patients [4]. Stories of discriminatory comments by patients toward physicians and other medical personnel abound and may be becoming more widespread in the current sociopolitical climate [5]. A large, recent survey found that nearly 60% of responding physicians had experienced biased comments from patients [6]. Physicians reported being subject to discriminatory language regarding race, gender, religion, accent, age, andweight, among others. Women and ethnic minorities were the most likely to report experiencing verbal mistreatment. Nearly 50% of physicians had patients request a different clinician based on a personal characteristic; gender, ethnicity, and race were the most common characteristics prompting such demands. Among physicians, over half reported a moderate to strong emotional impact of bias and discrimination [6]. Less is known about the prevalence of harassment, mistreatment, and discriminatory comments by patients toward trainees. A 2011 study of family medicine residents at one program reported that 45% of residents experienced intimidation, harassment, and/or discrimination; among those, 35% reported patients as a source [7]. A survey of psychiatry residents’ experiences with patient mistreatment at 13 US programs revealed that 86% had been threatened, 57% had received unwanted advances, and 11% had been sexually harassed [8]. A 12-year longitudinal study found that among medical students, 60% reported experiences of harassment and mistreatment, with patients perpetrating 15% of incidents of sexual harassment and 11% of ethnicity-basedmistreatment [9]. The impact of mistreatment by patients on trainees varies widely, ranging from no effect to avoidance of certain patient types, increased anxiety, or even change in career interest [8]. Trainees who experience mistreatment by patients at our institution—Yale University School of Medicine—have described that, in the immediate wake of such an event, their learning often stops. Equally concerning, faculty response in these situations is frequently felt to be insufficient or absent [4]. Educators are often at a loss regarding how to best help trainees who experience harassment and mistreatment by patients [4]. The academic medicine literature offers limited guidance other than emphasizing the need for greater faculty development in this area [10]. In this report, we describe the content, implementation, and evaluation of a novel approach to empowering faculty to address mistreatment of trainees by patients.

The Effects of Interprofessional Education in Mental Health Practice: Findings from a Systematic Review.

Abstract: The aim of this study was to conduct a systematic review of studies describing the effects of interprofessional education (IPE) on undergraduate healthcare students’ educational outcomes, compared with conventional clinical training in mental health. MEDLINE, CINAHL, PsychINFO, and EMBASE were searched for studies published in January 2001–August 2017. All retrieved papers were assessed for methodological quality; Kirkpatrick’s model was employed to analyze and synthesize the included studies. The following search terms were used: undergraduate, interprofessional education, and educational outcomes. The eight studies that met the inclusion criteria were highly diverse regarding the studied IPE interventions, methods, and outcomes. Participants included students receiving clinical training in mental health from the following professions: medicine, nursing, occupational therapy, physiotherapy, psychology, and social work. The results of the studies suggest that students respond well to IPE in terms of more positive attitudes toward other professions and improvement in knowledge and collaborative skills. Limited evidence of changes in behavior, organizational practice, and benefits to patients was found. Based on the eight included studies, IPE interventions appear to have an impact regarding positive attitudes toward other professions and increased knowledge of and skills in collaboration compared to conventional clinical training. However, further study of both the processes and the long-term impacts of undergraduate IPE in mental health is needed. The authors recommend that service users are involved in the implementation and evaluation of IPE interventions in mental health to undergraduate healthcare students.

Rural Mental Health Training: an Emerging Imperative to Address Health Disparities

Abstract: The lack of access tomental health services in the USA is a clear cause for concern for psychiatric educators. As reviewed by Fortney et al. [1], the problem is so severe that most individuals with a current mental health disorder residing in the USA do not receive necessary specialty services. Inadequately treatedmental health disorders, moreover, account for approximately onequarter of all disabling health conditions in the country. The shortage of mental health resources in the USA, as in other countries, is far worse in rural communities, where there may be a complete lack of specialty providers and significant delays between onset of psychiatric illness and formal diagnosis. Thomas et al. [2] found that nearly every county (96%) in the USA had a shortage of psychiatrists—three-quarters had a “severe” shortage—and a significant minority had a shortage of non-psychiatrist mental health professionals. Rural counties overall had more significant shortages. Frontier communities, which have been defined as less than or equal to 6 persons/mi; 2.3 persons/km [3], are the most remote and among the most underserved of communities in the USA. A recent review [4] indicated that more than 60% of all US counties and 80% of all rural US counties do not have a single psychiatrist (let alone psychiatric subspecialists for specialized populations such as children/adolescents). In rural US counties overall, 590 psychiatrists serve more than 27 million Americans (2.2 per 100,000), in comparison to 612 psychiatrists per 100,000 people in New York. At the lowest end of the range, there is only 1 psychiatrist per 100,000 people in rural Idaho.While almost 8.7% of the US population lives in rural counties, just 1.6% of US psychiatrists practice in those same areas. In evaluating counties on the basis of level of rurality (metropolitan, micropolitan, small adjacent, and remote rural), Bennett et al. [5] found that between 2000 and 2010 the already high proportions of counties without community mental health facilities (ranging from 73% in urban settings to 92% in all rural areas) increased even further to 78% in urban areas and 94% in all rural areas. It is noteworthy that, in rural settings, families often must travel hundreds of miles to visit relatives hospitalized in chronic mental illness facilities. Between 2000 and 2010, there were even increases in percentages of rural counties without primary care physicians (11.5% to 12.5%). The impact of such shortages is felt among duallydiagnosed and vulnerable populations in rural areas. An analysis of health and other demographic trends across the urbanrural spectrum [6] indicates that in more rural areas, the population tends to be older, and in general there are higher rates of smoking, obesity, physical inactivity, child/adolescent/ young adult death, unintentional injury, suicide, and serious mental illness. Of note, substance abuse and drug overdoses are a significant problem in rural areas, particularly with lack of access, stigma, isolation, and unemployment [7]. Of interest, climate change and drought will further exacerbate mental health issues in rural communities [8]. Further, 50% of psychiatric disorders begin before age 14 and 75% by age 26. Unfortunately, the approximately 8000 child and adolescent psychiatrists in the USA are not equitably distributed, and rural populations areas are among the most underserved. Since early intervention is the most important means for prevention of chronic mental illness, the consequences of workforce shortages in these areas will have the greatest impact on the trajectory of morbidity and mortality * Anthony P. S. Guerrero GuerreroA@dop.hawaii.edu

A One-Year Institutional View of Resident Physician Burnout.

Abstract: This prospective study explores the prevalence, associated characteristics, and trajectory of burnout over one academic year in a multidisciplinary sample of resident physicians using a relatively new burnout survey instrument. All residents from a U.S. academic health center (n = 633) were invited to complete the Copenhagen Burnout Inventory (CBI) three times, with 4-month time lags between invitations. A total of 281 (44%) provided complete CBI survey responses at least once, and 43 (7%) did at all three times. Descriptive statistics, cross-sectional analyses, correlations, and multivariable linear regression analyses were computed, as well as repeated measures ANOVAs and paired t tests, as appropriate, for each CBI domain (personal, work, patient-related burnout). About half had CBI scores indicating moderate-to-high levels of personal burnout (49–52%) and work-related burnout (45–49%), whereas patient-related burnout was less common (14–24%). However, patient-related burnout increased significantly from the beginning to the end of the year. Regression analyses indicated patient-related burnout was significantly higher for postgraduate year 1–2 residents compared to PGY 4+ residents, but was not significantly different by gender. Personal and work burnout scores were significantly higher for females. Persistently high burnout was observed in only 6% of respondents. In this study of resident physicians using the CBI, burnout was prevalent and higher levels of burnout were observed for females on the personal and work burnout domains, while junior residents had higher patient-related burnout. Persistently, high burnout was rare. The CBI demonstrated high reliability, was practical to administer, and produced similar results with existing burnout research.

Approaches for Departments, Schools, and Health Systems to Better Implement Technologies Used for Clinical Care and Education.

Abstract: Rapidly shifting how health care and business are managed, technology can enormously impact the quality of service care delivery, education/training, faculty development, and administration in academic health centers [1, 2]. While the shift to include technology is consistent with the Institute of Medicine’s health professional education movement, the question is how to efficiently do that in a metric-, data-, and reimbursement-driven care era [3–5]. Leaders of departments, schools, and health systems are obliged to understand the external forces at play related to health care, which push for “faster, cheaper, better” services [6, 7]. Technology creates challenges to overcome such as clinical competence, as well as uncertain cost and operational requirements [4]. To date, the most widely researched and implemented technology in psychiatric settings has been telepsychiatry (TP; video) or telebehavioral health (TBH). Randomized controlled trials show that TBH is effective and comparable to in-person care via a variety of models [8–11]. Guidelines by the American Telemedicine Association in 2013 and 2017 [12, 13] provide clinical, administrative, and technical contexts. Psychiatric leaders must now also consider social media, mobile health, apps, and other technologies—each associated with assorted benefits, risks, and costs. This paper is designed to help leaders “step back” and broadly envision how academia and technology may reasonably interface. If psychiatric faculty and administrators fail to technologically progress, young professionals may opt toward other technology-hip areas of medicine, and clinical boundary and privacy violationsmay becomemore common. This paper complements the curricular and competency papers [14–18], which provide more operational, concrete examples for faculty, residents, and administrators. This paper aims to help readers in three ways:

LGBT-Specific Education in General Psychiatry Residency Programs: a Survey of Program Directors.

Abstract: Lesbian, gay, bisexual, transgender (LGBT) and other sexual minority individuals are at higher risk than non-LGBT individuals for multiple psychiatric conditions and suicide. However, little is known regarding LGBT-specific training among psychiatric residents. The authors sought to characterize LGBT-specific training among adult psychiatry residency programs. An anonymous, cross-sectional survey was electronically distributed to U.S.-based adult psychiatry program directors between February and April 2018. Survey topics included program demographics, characteristics of LGBT-specific training, perceived barriers to implementation, and anticipated needs. Seventy-two program directors (30.8%) provided complete survey responses. Over half (55.6%) of these programs had ≤ 5 h of LGBT-specific training (“lower-hour programs”). Lower- and higher-hour (> 5 h of LGBT-specific education) programs were similar on measured demographic variables, but lower-hour programs covered fewer LGBT-specific topics and program directors were more likely to report lack of interested or topic-expert faculty as a barrier to enhancing LGBT-specific training. Results of this survey suggest a need for the development and implementation of LGBT-specific educational curricula for use in U.S.-based adult psychiatry programs. In addition, future research may explore effective ways for programs to recruit, retain, and support teaching faculty with LGBT-specific expertise.

Adverse Childhood Experiences in Medical Students: Implications for Wellness.

Abstract: The primary purpose of the study was to assess the prevalence of adverse childhood experiences (ACEs) in a cohort of third-year medical students and characterize their childhood protective factors. The authors developed a web-based anonymous survey distributed to all third-year medical students in one school (N = 98). The survey included the 10-item ACE Study questionnaire, a list of childhood protective factors (CPF) and questions to assess students’ perception of the impact of ACEs on their physical and mental health. The medical school’s IRB approved the student survey as an exempt study. The authors computed descriptive and comparative statistical analyses. Eighty-six of 98 students responded (88% response rate). Forty-four students (51%) reported at least one ACE exposure and 10 (12%) reported ≥ 4 exposures. The latter were all female. The average difference in the ACE score between male and female medical students was − 1.1 (independent t test with unequal variances t(57.7) = − 2.82, P = .007). Students with an ACE score of ≥ 4 were significantly more likely to report a moderate or significant effect on their mental health, compared with students with scores ≤ 3 (chi-square test, P = < .0001). Most students reported high levels of CPF (median score = 13 of a maximum score = 14). ACEs and CPF were inversely associated (Pearson correlation = − 0.32, P = .003). A sizeable minority of medical students reported exposure to multiple ACEs. If replicated, findings suggest a significant vulnerability of these medical students to health risk behaviors and physical and mental health problems during training and future medical practice.

Residents' Experiences with Mentorship in Academic Medicine.

Abstract: Although mentorship is essential for the professional development of physicians, the literature on trainees’ mentorship experiences and perceptions of effective mentoring is more limited. This descriptive study examines residents’ experiences of mentoring and their perceptions about the impact of mentorship on professional development, comparing experiences in mentoring that is assigned versus self-initiated. A web-based self-administered cross-sectional survey of all senior residents (≥PGY-3) at a major urban academic medical center was conducted from March 27 to May 31, 2015. Of the 327 eligible senior residents, 204 (62%) responded and completed the survey. Most residents (82%) reported multiple mentors and 65% reported that their primary mentorship relationship was self-initiated. Residents who self-initiated their primary mentorship were significantly more likely to strongly/somewhat agree that their mentor had a positive impact on publications and scholarly projects (88 vs 44%, p = 0.0063) as well as research (88 vs 55%, p = 0.0001) compared to residents with assigned mentorship, with no significant differences measured by gender, race, or ethnicity. Forty-four percent of residents indicated they had unmet needs for mentoring in at least one of several professional areas. Most residents perceive mentoring relationships as important to many aspects of their career development. Still 44% of residents reported unmet needs for mentoring in one or more areas, a result that needs further exploration. Since the majority of residents’ primary mentoring relationships were self-initiated rather than assigned, and these were seen as more important for research and publications, programs should consider how to support the connection between residents and potential mentors.

Understanding Health Disparities Through the Eyes of Community Members: a Structural Competency Education Intervention.

Abstract: While there is wide recognition that social inequalities result in health disparities for segments of the US population [1], inclusion of information about health disparities and methods to address disparities are irregularly addressed in medical education [2]. Hansen and Metzl argue that political and economic structures directly impact health disparities through their effect on patient presentations and ability to work within the healthcare delivery system. They have strongly recommended that medical professionals develop “structural competency” in order to provide effective care [3]. Several residency programs have reported structural competency education interventions, teaching about the concept more broadly [4] or with a more specific intervention [5, 6]. Previously reported broad-based structural compentency interventions involved medical residents and faculty discussing these issues together [4]. Our challenge was to educate trainees about the effects of community structures on patients without having teachers who had a firsthand understanding of the myriad forces acting upon people living in economically disadvantaged neighborhoods [7].

Current Trends in Psychiatric Education Among Obstetrics and Gynecology Residency Programs.

Abstract: This study sought to evaluate the status of psychiatric education in Ob/Gyn residencies. A 17-item anonymous questionnaire was sent to program directors of 239 Ob/Gyn US residencies. Data analysis was performed using STATA 14.2. Ninety-five programs participated (40%), including partial responses. The majority of Ob/Gyn programs offered didactics in psychiatric topics (84%), with most of the sessions provided by Ob/Gyn faculty. Programs that reported didactics led by psychiatric faculty (57.9%) were more likely to have a higher number of mental health didactics in total. Fewer than half of programs covered intimate partner violence (47%), non-obstetric depression (44%), anxiety (43%), medication management (30%), eating disorders (26%), human trafficking (20%), or PTSD (11%). Elective rotations involving mental health were offered by 20% of programs. Barriers to psychiatric training were lack of integration between Ob/Gyn and psychiatry (46%), ACGME surgical requirements (42%), and lack of knowledgeable instructors (38%). Most program directors (81%) disagreed that residents are fully equipped to identify psychiatric needs in patients. Lack of integration between Ob/Gyn and psychiatry was the most cited barrier to effective psychiatric education of Ob/Gyn residents, highlighting the importance of increased partnership between the two fields. Didactic instruction decreased compared to 2001, and considerable gaps still remain. Most program directors perceive that residents are not equipped to identify patients’ psychiatric needs.

Challenges and Perspectives to the Fall in Psychiatry Fellowship Applications.

Abstract: According to the U.S. Department of Labor [1], there has never been a better time to be a physician. Employment for physicians is expected to grow 13% between 2016 and 2026, faster than for any other occupation. In psychiatry, demand for expert clinicians continues to grow [2]. Despite this, applications to psychiatry fellowship programs continue to stagnate or decline even as applications to general psychiatry residency programs rise [3–6]. The Institute of Medicine published a report in 2012 projecting that by 2030, there will be 72 million adults above the age of 65 in the USA. About 14–20% of these individuals (10 to 14 million people) will have a mental health or substance use disorder. The Institute estimates that in 2030, the ratio of geriatric psychiatrists to individuals over the age of 65 will drop from 1:23,000 to 1:27,000. At the same time, shortages in psychiatrists trained in addiction, consult-liaison, and child and adolescent psychiatry continue to grow [2]. This paper will review the trends in psychiatry fellowship applications, analyze why residents are choosing not to pursue fellowship, and discuss potential solutions to the growing demand for specialty-trained practitioners.

Subspecialisation in Postgraduate Psychiatry and Implications for a Resource-Limited Specialised Child and Adolescent Mental Health Service.

Abstract: The importance of mental health in the overall well-being of individuals is being increasingly recognised around the world. Among all the age categories, adolescents and youth appear to have the highest prevalence of mental health disorders [1]. However, adolescents and youth are the age group with least access to mental health services, probably due to a lack of specialised services catering to the developmental and cultural needs of this group [1]. Women, young and old, also require more specialised mental health services. While affluent countries of the world are well on their way to developing age and need specific services [2], it appears that the developing world is struggling to strike the appropriate balance between general mental health services and subspecialties in psychiatry [3].

Measuring Self-Compassion in Medical Students: Factorial Validation of the Self-Compassion Scale-Short Form (SCS-SF).

Abstract: The primary purpose of this study was to evaluate the factorial structure of the short-form version of the self-compassion scale (SCS-SF) and validate its use with medical students. Two hundred medical students completed an electronic questionnaire containing the 12-item SCS-SF and the 16-item Oldenburg burnout inventory. The authors performed reliability and confirmatory factor analyses (CFA) to evaluate the internal consistency and factorial structure of the SCS-SF scores, and correlational analyses to examine relationships of self-compassion with student engagement and exhaustion. The internal consistency of the SCS-SF was 0.86. Self-compassion scores were positively correlated with engagement scores (r = 0.24; p < 0.01) and negatively correlated with exhaustion scores (r = − 0.44; p < 0.001). The CFA results for the two-factor model (formed by three positive and three negative components) indicated an improved fit over the single-factor model. The positive factor (self-compassion) was positively correlated with engagement scores (r = 0.17; p < 0.05) and negatively correlated with exhaustion scores (r = − 0.32; p < 0.001). The negative factor (self-criticism) was negatively correlated with engagement scores (r = − 0.25; p < 0.001) and positively correlated with exhaustion scores (r = 0.44; p < 0.001). The SCS-SF scores had good internal consistency and expected relations with student engagement and exhaustion. Although the single, general self-compassion factorial structure had an acceptable fit with the data, the hierarchical two-factor structure of the SCS-SF provides support for the idea that distinguishing between self-compassion and self-criticism in medical students may be important.

An Intervention in Social Connection: Medical Student Reflection Groups.

Abstract: Rates of medical student depression and suicide are higher than aged-matched peers. Although medical schools have implemented wellness interventions, no program has reported on interventions targeting social support. As one potential intervention, reflection groups for medical students led by psychiatry residents were designed and implemented. It was hypothesized that groups would encourage connectedness among peers, teach coping and emotional self-awareness skills, increase empathy, and decrease loneliness. Voluntary, biweekly support groups were implemented between 2017 and 2018 at Stanford University School of Medicine for first- and second-year medical students. Participants were surveyed at baseline and 6 months. Surveys included qualitative assessments of groups and validated surveys to assess empathy, wellness, and loneliness. Separate surveys assessed attrition. Analyses included statistical analyses (descriptive statistics) and thematic analysis. In both cohorts, a total number of 30 students participated in groups, and 18 completed post-surveys. Students reported groups improved well-being (55.6% strongly agreed, 27.8% agreed), enhanced self-awareness (44.4% strongly agreed, 38.9% agreed) and ability to empathize (50.0% strongly agreed, 27.8% agreed), and promoted connection (61.1% strongly agreed, 33.3% agreed). Initial attrition was high, with 84% of students not continuing due to feeling too overwhelmed by classes. Thematic analysis demonstrated groups may benefit students in improving impostor syndrome and connection with others (decreased loneliness), allowing exposure and tolerance to diverse perspectives, increasing insight into the importance of self-care and emotional self-awareness, allowing practice for collaborative skills, and increasing thoughtful approaches to patient care. There is preliminary evidence reflection groups may be a feasible, effective intervention to improve loneliness and social belonging in medical school.

Difficult Conversations: Training Medical Students to Assess, Educate, and Treat the Patient with Chronic Pain.

Abstract: Chronic pain, along with opioid abuse and misuse, continues to be a prevalent problem across the USA. Medical students have minimal training in biopsychosocial treatment of chronic pain and often lack the knowledge and skill necessary to address chronic pain with their patients. While there are a variety of treatment options available, research repeatedly has demonstrated that biopsychosocial treatment is the most effective option for chronic pain. Engaging patients in this type of treatment requires training and education. The authors implemented a simulation workshop with standardized patients to educate medical students on the physical, psychological, and social aspects of chronic pain and also train students on the most effective ways to discuss chronic pain and educate their patients. Outcomes were measured by a pre- and post-test survey of knowledge, attitudes, and confidence in treating chronic pain, as well as satisfaction with the learning experience. Test and survey results indicated improvements in knowledge, attitudes, and confidence in treating chronic pain. Additionally, students were satisfied with the experience as evidenced by high post-workshop ratings. Chronic pain training during medical school is associated with students feeling more prepared to provide non-opioid biopsychosocial pain treatment. Additionally, training with standardized patients allows students to learn how to effectively educate their patients, reduce negative confrontations, and maintain a positive physician-patient relationship.

Narrative Podcasts as a Teaching Tool in Psychiatry.

Abstract: Medical education is increasingly informed by modern theories of adult learning, which argue that adults benefit from educational experiences that are self-directed, born from the learner’s own goals, draw upon adults’ unique lived experiences, and apply immediately relevant information [1]. As such, educators are developing curricula that expand past the traditional lecture format and utilize alternate formats such as flipped classrooms or team-based learning sessions [2]. Additionally, educators are incorporating new technology and social media into teaching with the goal of appealing to increasingly tech-savvy “digital native” students and creating more collaborative, effective, and efficient learning sessions [3]. However, medical educators who have historically utilized traditional lecture-based teaching may experience barriers to integrating multimedia into teaching sessions, such as unfamiliarity with which multimedia resources to use or how to best integrate them into their teaching. In this article, we will demonstrate how narrative podcasts (brief, freely available, and easily accessible audio files with a storyline) can be used as powerful educational tools. We will discuss specific examples of how to incorporate podcasts into a lesson plan and provide a curated list of podcast episodes that can serve as useful teaching tools in order to help educators develop modernized curricula to teach psychiatric concepts to twenty-first century medical students and residents. Why Podcasts?

A Call to Action: the Need for Integration of Transgender Topics in Psychiatry Education.

Abstract: Transgender is a term that “encompasses individuals whose gender identity differs from the sex originally assigned to them at birth [and/] or whose gender expression varies significantly fromwhat is traditionally associated with or typical for that sex... as well as other individuals who vary from or reject traditional cultural conceptualizations of gender in terms of the male–female dichotomy [1].” For example, individuals may identify strongly with another gender or with a variance that falls outside of traditional gender constructs, such as identifying with both genders or identifying with neither gender. As background terminology, cisgender refers to a person whose gender identity corresponds with their birth sex. An individual’s gender identity (internal sense of self) and gender expression (outward expression of gender) may be fluid and evolving over time [2]. Healthcare providers, including psychiatrists and psychiatry residents, are increasingly providing assessment and treatment of transgender individuals given the changing demographics in the USA. Of note, the 2016 percentage of adults who identified as transgender in the USA was double the estimate from 2011 [3]. Explanations for this increase include an increase in visibility, more sophisticated data collection over time, and social acceptance of transgender people that may relate to comfort in identifying as transgender on a survey [3]. Reports from 2016 cited that an estimated 1.4 million adults in the USA identified as transgender, based on data from the CDC’s Behavioral Risk Factor Surveillance System [3]. States varied in their demographics, with high percentages of adult residents identifying as transgender in the District of Columbia (2.8% of its population, or 14,550 individuals) and Hawaii (0.8% of its population, or 8450 individuals). Massachusetts was noted at that time to have 29,900 individuals, 0.57% of its population, who identified as transgender. Overall, the age group of 18to 24-year-olds was noted to have a higher percentage (0.66%) of its population identifying as transgender (205,850 individuals) than older age groups. However, given the larger population size of age 25–64, the 0.58% percentage of individuals identifying as transgender in that population represented 967,100 individuals in the USA. Both the variation in transgender presentation and the growing size of this population highlight the need for healthcare professionals to approach gender identity with fewer assumptions and an open perspective regarding patient needs [4]. However, in both the general population and in medical healthcare, stigma continues to exist against transgender individuals. In the general USA population, a 2013 sample of over 2000 heterosexual adults noted significantly less favorable self-reported attitudes towards transgender people than attitudes towards gay men, lesbians, and bisexuals [4]. Although public awareness of transgender individuals may be increasing due to popular culture transgender individuals and political discussions, the ability of transgender individuals to integrate in society at large, such as navigating bathroom laws or serving in the US military, remains a topic fraught with contemporary controversy [2].

Faculty Development for Teaching Faculty in Psychiatry: Where We Are and What We Need.

Abstract: A Faculty Development Task Force surveyed the American Association of Directors of Psychiatric Residency Training membership to assess faculty development for graduate medical education faculty in psychiatry departments and barriers to seeking graduate medical education careers. An anonymous Survey Monkey survey was emailed to 722 American Association of Directors of Psychiatric Residency Training members. The survey included questions about demographics, the current state of faculty development offerings within the respondent’s psychiatry department and institution, and potential American Association of Directors of Psychiatric Residency Training faculty development programming. Two open-response questions targeted unmet faculty development needs and barriers to seeking a career in graduate medical education. Results were analyzed as frequencies and open-ended questions were coded by two independent coders. We limited our analysis to general psychiatry program director responses for questions regarding faculty development activities in an attempt to avoid multiple responses from a single department. Response rates were 21.0% overall and 30.4% for general program directors. General program directors reported that the most common existing departmental faculty development activities were educational grand rounds (58.7%), teaching workshops (55.6%), and funding for external conference attendance (52.4%). Of all survey respondents, 48.1% expressed the need for more protected time, 37.5% teaching skills workshops, and 16.3% mentorship. Lack of funding (56.9%) and time (53.9%) as well as excessive clinical demands (28.4%) were identified as the main barriers to seeking a career in graduate medical education. Despite increasing faculty development efforts in psychiatry departments and institutions, real and significant unmet faculty development needs remain. Protected time remains a significant unmet need of teaching faculty which requires careful attention by departmental leadership.

Neurology Training for Psychiatry Residents: Practices, Challenges, and Opportunities.

Abstract: Historically, neurology, psychiatry, and neuroscience overlapped; it is only recently that disciplinary silos have divided these fields. In the eighteenth and nineteenth century, many significant figures in neurology and psychiatry, including Freud, Charcot, Alzheimer, and Kraepelin, emerged from a shared epistemological background [1]. In the early twentieth century, a period of rapid medical specialization, most physicians in these fields enjoyed board certification in both specialties [2]. However, in the second half of the twentieth century, training pathways for neurology and psychiatry diverged [1]. By the 1980s, there was little emphasis on cross-training between neurology and psychiatry [2]. Over the past three decades, there has been an increase in residency training emphasis on neuroscience, “a broad discipline encompassing the study of the nervous system and behavior using cellular and molecular biology, animal models, neuroanatomy, neuroimaging, genetics, neuropsychology, and basic pharmacology (as opposed to clinical pharmacology)” [3]. Since 2006, there has been a boom in neuroscience education with the rapidly developing National Neuroscience Curriculum Initiative [4], but the challenge of clinical application remains [5]. Neuroscience, neuropsychiatry, and neurology are distinct entities [3, 5, 6]. Neuroscience in psychiatry involves understanding psychiatric illness through the lens of neuroscientific knowledge ranging from functional anatomy to genomics; examples include microstructural neurodevelopmental aspects of schizophrenia and the neurobiology of suicide. Neurology and neuropsychiatry are fundamentally clinical. Neurology refers to the care of patients with disease of the brain, spinal cord, and peripheral nerves. Neuropsychiatry refers to the care of patients with affective, behavioral, and cognitive symptoms in the setting of neurologic disorders such as stroke or epilepsy, as well as to the care of patients with psychiatric illness that have comorbid or iatrogenic neurologic symptoms [5]. Neurology and neuropsychiatry training for psychiatry residents is not yet standardized. In this article, we critically review the current state of neurology and neuropsychiatry training for psychiatric residents: we explicitly consider the goals of such training, identify the gaps in training and the barriers to achieving these goals, and present suggestions for improving the neurology and neuropsychiatry training of psychiatrists.

Positioning Psychiatry as a Leader in Trauma-Informed Care (TIC): the Need for Psychiatry Resident Education.

Abstract: Trauma is highly prevalent in patient populations, particularly those encountered by psychiatrists and psychiatry residents. Exposure to traumatic events increases an individual’s toxic stress burden and increases the risk of mental health problems and chronic physical disease [1]. Adverse childhood experiences (ACEs), including abuse and neglect, have been linked to an array of medical sequelae, including heart, lung, and liver diseases, obesity, diabetes, depression, substance use, and sexually transmitted infections [1–3]. Adverse experiences also lead to epigenetic cellular and molecular mechanisms that produce changes in gene expression, producing lasting effects in the body as well as alterations in neuronal structure and function [4]. The impact of adverse experiences across the lifespan impact interpersonal dynamics as well as individual health, and there is an emerging appreciation of the convergence of discussions about the impact of trauma on workplace morale and safety, with related concerns about resilience and burnout [5]. Trauma is ubiquitous worldwide, whether from adverse childhood experiences (ACEs), abuse, life events, or disasters. The scope of potentially traumatic events has, moreover, expanded in recent years to include experiences of social determinants of health, from food security to race, gender, and religious bias. Trauma-informed care (TIC) provides a framework for considering trauma at all levels, including patients, providers, and the overall organizational culture. Psychiatry as a field is uniquely positioned to advance trauma-informed care (TIC) and its implications for patient and clinician engagement. The field combines an understanding of neurobiological underpinnings of the effect of trauma, its consequences, and its sequela, with the psychodynamic and psychotherapeutic engagement with patients in their trauma narrative. Psychiatry resident education in TIC is essential to train the next generation of psychiatrists who are already interacting with patients and who will continue to shape this role in the future.

A Qualitative Study Exploring the Determinants, Coping, and Effects of Stress in United Kingdom Trainee Doctors.

Abstract: Evidence suggests United Kingdom trainee doctors are experiencing high levels of stress; however, little is known about what determinants contribute to stress, coping mechanisms to mitigate stress, and the effects of stress are in current trainee doctors. Hence, this study aims to explore the determinants, coping mechanisms as well as the effects of stress in this group. Focus groups were undertaken with trainee doctors in North West England to better understand the determinants, coping mechanisms, and effects of stress. Informed written consent was obtained and focus groups were recorded and transcribed. Transcriptions were analyzed using QSR NVivo v11. A total of 44 trainee doctors participated in 11 focus groups. Respondents comprised UK graduates and international medical graduates, across all stages of training in a range of different specialties. Four main themes were identified as determinants: (1) Expectations and guilt, (2) Feeling undervalued, (3) Managing uncertainty and risk, (4) Work environment. Four main themes were identified as coping mechanisms: (1) Reflection and insight, (2) Work-life balance, (3) Work and training environment, (4) Development as a doctor. Two main themes were identified as effects of stress: (1) Negative outcome on wellbeing, (2) Outcome on career. A range of determinants contributes to stress in trainee doctors and they utilize a range of mechanisms to cope. Stress in their working lives can also affect their wellbeing and careers. These findings could be used to improve the understanding of stress in trainee doctors and assist in the development of supportive interventions.

Psychiatry Residents Integrating Social Media (PRISM): Using Twitter in Graduate Medical Education

Abstract: Social media can promote knowledge-acquisition, skill building, and—via exposure to role models—clinically excellent patient care [1]. Today’s medical learners describe online media as their preferred platform for delivery of educational material [2]. In response, many medical specialties are exploring ways to incorporate social media tools into the education of their learners [3–6]. The emergency medicine website Academic Life in Emergency Medicine (ALiEM) uses a variety of social media—blogs, Twitter, podcasts, and videos—to deliver educational content in an interactive format—including book and journal clubs—to providers and trainees [7]. Other medical specialties are also innovating in this space, including nephrology and family medicine. The Twitter-based Nephrology Journal Club @NephJC led by Joel Topf, MD and the Family Medicine Vital Signs blog from the University of Utah Family Medicine Residency Training Program (RTP) are two prominent examples of how social media can be harnessed to enhance graduate training and foster life-long learning in medicine [8]. Medical educators have especially embraced Twitter, a social media platform that enables teachers to connect— across boundaries of time, space, and hierarchy—with a worldwide community of educators, learners, and other healthcare stakeholders. Twitter also provides an efficient mechanism for medical educators to 1) stay current with the latest peer-reviewed articles in their field, curated by their colleagues; 2) access evidence-based medicine practitioners and scholars; and 3) advocate on behalf of the public [9]. Not surprisingly, Twitter has also become a resource for RTPs across medical specialties. In a recent survey, 58% of emergency medicine RTPs reported having a Twitter account [10]. One internal medicine RTP that launched a Twitter account for their trainees demonstrated increased use of Twitter for medical education purposes over a 6-month period, with the residents reporting that Twitter was useful for these purposes [4]. Another internal medicine RTP created a chief resident-led Twitter account, which the residents perceived as informative and beneficial to their training [11]. In its use of social media in graduate medical education (GME), psychiatry is lagging behind emergency medicine, internal medicine, and other specialties [12]. The relatively late adoption of social media professionally by psychiatrists may be due to heightened concerns around doctor-patient boundaries in psychiatry [13], which can be addressed through education and training of psychiatrists and psychiatry trainees in the professional use of social media [14]. Psychiatrists are now using social media tools in a variety of settings. A review of psychiatrists’ use of Twitter describes its utility in patient care and advocacy, education, and scientific investigation [15]. A collaboration of two US and UK psychiatry graduate training programs’ book groups via blogs and Twitter is just one example of how social media is being used successfully in psychiatry GME [16]. Twitter may also be helpful in the dissemination and recognition of a psychiatrist’s scholarship, as evidenced by an analysis of Twitter mentions and citations of American Journal of Psychiatry articles that revealed an association between Twitter mentions and later citations [17]. Although published reports of social media use in psychiatry RTPs are lacking, social media remains a ubiquitous presence in the lives of our trainees. In an attempt to bridge this gap between teachers and learners, we launched the Psychiatry Residents Integrating Social Media (PRISM) study, a project designed to promote the use of social media within RTPs. As part of this project, we created a Twitter account for Johns Hopkins psychia t ry res idents (@PhippsPsych) to disseminate educational resources considered helpful in training. * Anne L. Walsh annewalsh@jhmi.edu

Introducing a Structural Competency Framework for Psychiatry Residents: Drawing Your Neighborhood.

Abstract: Training medical students and residents to address the social determinants shaping the health of their patients is a key component in reducing health disparities [1, 2]. The World Health Organization recognizes differences in community resources as major contributors to health inequality [3] and impacts emotional well-being and mental health [4]. Yet, while physicians understand these factors significantly impact their patient’s health, many feel ill-equipped to intervene, contributing to frustration and burnout [5]. To empower physicians to address social determinants of health, medical educators have begun incorporating structural competency (SC) into training. Developed by two psychiatrists, Metzl and Hansen, SC starts with understanding how structures—the large-scale organization of social, economic, and political power—impact health downstream [6]. It bridges research on social determinants of health to practical clinical interventions, building tools to recognize and act on systemic causes of health inequalities [6]. Our aim was to design an educational activity to introduce the basic concepts of SC to psychiatry residents. We began by anticipating sources of resistance to engaging with the material such as finding the concepts too abstract, unrelated to clinical medicine, or uncomfortably far from conventional medical topics. SC is grounded in the literature of critical race studies, sociology, economics, urban planning, anthropology, and public health [7]—subjects not traditionally included in medical education. Also, there are significant differences in trainees’ subjective experiences with institutional structures and historical associations of exclusion or privilege. Exploring these, especially in a group setting, might be disquieting. Yet, we also recognized that complex emotional experiences, including discomfort, can have educational utility [8, 9]—a “pedagogy of discomfort” which invites “critical inquiry regarding values and cherished beliefs, and to examine constructed self-images in relation to how one has learned to perceive others” [10]. Guided by insights from adult learning theory, we recognized that older learners are self-directed, with a wealth of personal experience, and more internally motivated by experiential learning about problem-centered issues [11]. Therefore, we were careful in designing an introduction to SC that was tailored to adult learners and anticipated resistance while permitting discomfort. Drawing, as a method for exploring the social, political, and economic organization of place, has strong precedent in the fields of education and community activism. As an intuitive pedagogical device, it is used by educators in primary schools to explore spatial thinking and the meaning of civic sites [12]. Collaborative map drawing is used by organizers to collect data about their neighborhoods while strengthening the sense of community cohesion for further advocacy [13]. Mapping activities for community participatory action research harness participants’ lived experiences, asking them to reconcile divergent subjective accounts of the same neighborhood leading to “larger group discussions about issues not directly represented on [their] maps” [14].

Family Skills for the Resident Toolbox: the 10-min Genogram, Ecomap, and Prescribing Homework.

Abstract: In psychiatry residency, training generally focuses on the individual, and families are approached using a medical model. However, the therapeutic relationship between provider and patient is often rooted in patients’ prior relationships and thus can be viewed through a systemic lens. The systems model focuses on attending to individuals within the context of their relationships and dynamic interactions. Systemic work in psychiatry began in the 1950s and has continued among the family systems therapists for the past 60 years. Neuroscience embraces complex dynamic systems models, discussing brain function in terms of functional connectomes, nested hierarchies, and communities. A recent neuroimaging study, “Families that fire together smile together,” highlights the importance of a healthy family emotional climate in promoting emotional maturity in adolescents [1]. Consideration of the family context in which a patient lives is essential to quality psychiatric care and thus should be included in residency training. Training in family interventions and family therapy has been recently articulated for both adult and child psychiatry training programs [2, 3]. A model curriculum was created for residency programs [4] and a new approach to families is described in a curriculum for psychiatry residents focusing on understanding and navigating complex systems [5]. However, residency programs may face challenges in operationalizing these models including a lack of familyoriented psychiatrists to act as role models [2]. Heru et al. [6] make a call for addressing barriers that exist from a resident’s perspective. Our aim in this article is to help residents tackle these barriers with practical tools. Residents rarely have access to direct assistance when interacting with families and often problematize family interactions, rather than seeing families as treatment allies [6]. Learning to work with families is considered difficult, time intensive, and the purview of other disciplines such as social workers or marriage and family therapists. However, family interventions can be parsed into three levels of expertise. The first level, the inclusion of family in a patient’s initial evaluation and/or subsequent care, requires no formal training. It is generally expected that all psychiatric residents become comfortable and competent with this level of family involvement over the course of their training. The second level, learning discrete family-oriented skills, requires at least 6 h of introduction to basic techniques of psychoeducational interventions. The third level, family systemic therapy, requires intensive supervision and understanding of systemic components [7]. This article provides tools for residents and supervisors at the second level. Though some psychiatric residents may go on to the third level of training to become couples or family therapists, our intention is to provide practical tools for the general psychiatric resident that can be used in many different contexts. Using case examples from various settings in which psychiatric residents work, we describe three tools: the 10-min genogram, creation of an ecomap, and prescription of familyoriented homework. We illustrate how these tools can be incorporated into an individual patient or family encounter in useful and time-efficient ways.

How to Prepare Prospective Psychiatrists in the Era of Artificial Intelligence.

Abstract: A few years ago, AlphaGo—an artificial intelligence developed by Google’s DeepMind to play the ancient Chinese board-game Go—beat a human Korean Go Champion who was considered one of the best players of the time. This became an instant sensation around the globe as Go, played with black and white stones on a grid and heavily reliant on human instinct, was assumed to be too complex for an artificial intelligence to learn and to eventually outperform human minds [1]. The emergence of such an advanced technology as AlphaGo and its potential threat to humandriven endeavors seem to have sprung fully formed from the worst fears of the general public, and even of more rarified individuals, like Stephen Hawking and Elon Musk [2, 3]. Clinicians are no exception to such fears of potential invasion and/or takeover of their specialized practice by artificial intelligence or other rapidly emerging technological advances [4]. There has been ongoing talk between this anxiety and the hope for the benefits of these new technologies to advance clinical care, particularly as technology-savvy millennials are growing in number [5]. However, most medical school curricula have lagged behind popular culture and basic science in reflecting these shifting attitudes [6]. Psychiatry has long been thought to be immune from technological invasion given emphasis on establishing face-to-face therapeutic alliances as a primary treatment modality. In this brief article, we discuss some of the ways that emerging technological advances, including artificial intelligence, have impacted the field of psychiatry and how educators can prepare trainee psychiatrists in best practices. Artificial Intelligence in Psychiatry Practice

The Benefits of Required Forensic Clinical Experiences in Residency.

Abstract: The growth of forensic psychiatry has spurred efforts to improve forensic psychiatry training in general psychiatry residency. The Accreditation Council for Graduate Medical Education requires that residencies provide an experience that “exposes” residents to forensic issues, but leaves the specifics to individual programs. However, there is growing need for psychiatrists to understand the unique circumstances of individuals with mental illness involved in the criminal justice system. The authors developed a new mandatory forensic rotation for general psychiatry residents and conducted a pilot study to assess its impact on residents’ interest and comfort working with criminal justice-involved patients, interest in forensic fellowship, and knowledge of available resources for consultation and supervision. Rotation completion was associated with a significantly increased interest in working with forensic populations and pursuing forensic fellowship, but no changes in residents’ level of comfort or knowledge of supervisory and consultative resources. This study adds to the growing body of literature describing the benefits of expanding forensic education for residents.