Showing papers in "Academic Psychiatry in 2020"

Unconscious Bias and the Diagnosis of Disruptive Behavior Disorders and ADHD in African American and Hispanic Youth.

Abstract: Diagnostic evaluation of psychiatric disorders in children and adolescents relies in part on subjective interpretations of information from a clinician. Clinicians must interpret and contextualize information obtained from family, caregivers, and educators in order to assign an appropriate diagnosis. However, environmental and sociocultural influences can make the diagnosis of psychiatric disorders challenging, and appreciating these influences should be a priority in academic psychiatry. This can be particularly true for the provision of a diagnosis of oppositional defiant disorder (ODD), conduct disorder (CD), and attentiondeficit/hyperactivity disorder (ADHD), as diagnosing these complex conditions can be nuanced. There is a growing body of evidence indicating that when compared to non-Hispanic white youth, some ethnic and racial minority youth are more likely to receive a diagnosis of a disruptive behavior disorder and are less likely to receive a diagnosis of ADHD [1–8]. When controlling for confounding variables such as adverse childhood experiences, prior juvenile offenses, genetics, and sociodemographics, these diagnostic and treatment disparities remain [6–8]. Although the cause of these diagnostic disparities is multifactorial, there is concern that unconscious biases may play a role in diagnostic decision-making. As a result of these biases, psychiatrists and trainees may judge and interpret behaviors seen in ODD, CD, and ADHD differently based on race or ethnicity, putting vulnerable populations at risk [5, 9]. Additionally, the current standard of practice is to routinely consider a broad differential of comorbid disorders when youth exhibit disruptive symptoms; however, biases may lead clinicians less likely to explore these potential explanations for behavior [10–12]. When a diagnosis of a disruptive behavior disorder is provided in place of ADHD (or ADHD is not included as a concurrent diagnosis), there are significant clinical implications, as this can limit access to medications, therapy, and other supportive services. This lack of services can put ethnic and racial minority children at risk for perpetuating the disparities which currently exist in the medical, educational, and juvenile justice systems. Recognizing the magnitude of this concern, this commentary reviews how unconscious bias can lead to diagnostic disparities in the assessment of disruptive behavior disorders and ADHD, the implications that these biases can have on ethnic and racial minority youth, and how this challenging clinical topic should be addressed in academic psychiatry.

How to Cope with the Challenges of Medical Education? Stress, Depression, and Coping in Undergraduate Medical Students

Abstract: Up to 90% of medical students experience stress. Studies have observed a relationship between stress and depression. Coping strategies to deal with stress and depression are of great interest. This study aimed to evaluate the prevalence of stress and depression and the efficacy of coping strategies in undergraduate medical students. This survey was conducted with 589 second-year and sixth-year students in 2017 at the Medical University of Vienna. The questionnaire included a stress and coping questionnaire, depression screening, substance use questionnaire, and questionnaire concerning leisure time activities. The coping strategies were included in a regression model to assess their predictive value for stress and depression screening scores. The most common stressor was performance pressure overload (92.1%). Overall, 52.4% of the participating students reached critical scores in the depression screening. Positive thinking and active coping were associated with lower stress scores. Positive thinking also was a protective factor against depressive symptoms. Less than 2% of all students reached high-risk values for substance use. Accessible counseling for students in need of psychological care should be provided. Different interventions of positive psychology showed a positive impact on depression screening scores.

US Psychiatry Faculty: Academic Rank, Gender and Racial Profile

Abstract: The gender and racial underrepresentation persist in academic psychiatry faculty appointments. Our study investigated the gender and racial distribution and its temporal trends in academic psychiatry faculty positions across the USA over a 12-year period. Using the annual reports of the Association of American Medical Colleges (AAMC), a retrospective cross-sectional study was conducted. Simple descriptive statistics analyzed the time trends and the distribution of gender and race across academic ranks, tenure, and degree types. Over the 12-year study period, the White race was the most represented at each rank. In the lower academic ranks, there was an increased representation of Asians, while the minority race/ethnicities experienced minimal increment. Similarly, males were overrepresented at higher academic ranks, with females increasing in proportion at lower academic ranks. Females and minorities remain underrepresented in academic psychiatry faculty positions, especially among senior academic and leadership positions. Differences in tenure tracks and degree types may contribute to the overrepresentation of White and male academic physicians.

Diversity by Race, Ethnicity, and Sex within the US Psychiatry Physician Workforce.

Abstract: This study assessed the distribution of race, ethnicity, and sex within the US psychiatry physician workforce and trends from 1987 to 2016. The authors used physician workforce data to assess differences in race, ethnicity, and sex among psychiatric practicing physicians, faculty, fellows, residents, residency applicants, and medical graduate cohorts. Binomial tests were used for comparison between individual cohorts and to US population statistics. A simple linear regression model was used to assess trends among psychiatric residents and faculty over years 1987–2016. Within psychiatry, historically underrepresented minorities in medicine (URMs) had less representation as residents (16.2%), faculty (8.7%), and practicing physicians (10.4%) compared with the US population (32.6%), Ps < 0.0001. Females were underrepresented as psychiatric practicing physicians (38.5%, P < .0001). There was greater URM representation among residents (16.2%) compared with that of Psychiatry faculty and practicing physicians (Ps < .0001). Racial/ethnic representation did not differ significantly compared with subspecialty fellows; however, the addiction subspecialty contained the least URM and female diversity. Historical trends indicated the proportion of female faculty (0.9%/yr) increased nearly 1.5 times faster than that of female trainees (0.6%/year). Conversely, the proportion of URM residents (0.26%/year) increased over 4 times faster than that of URM faculty (0.06%/year), with black faculty actually decreasing in proportion. Female and URM representation within the psychiatry physician workforce is significantly lower than US population demographics; however, trends indicate diminishing underrepresentation. While psychiatry residency remains more diverse than other specialties, specific trends identify poor minority representation among psychiatry faculty and fellows as areas needing attention.

Co-producing Psychiatric Education with Service User Educators: a Collective Autobiographical Case Study of the Meaning, Ethics, and Importance of Payment.

Abstract: Co-production involves service providers and service users collaborating to design and deliver services together and is gaining attention as a means to improve provision of care. Aiming to extend this model to an educational context, the authors assembled a diverse group to develop co-produced education for psychiatry residents and medical students at the University of Toronto over several years. The authors describe the dynamics involved in co-producing psychiatric education as experienced in their work. A collaborative autobiographical case study approach provides a snapshot of the collective experiences of working to write a manuscript about paying service users for their contributions to co-produced education. Data were collected from two in-person meetings, personal communications, emails, and online comments to capture the fullest possible range of perspectives from the group about payment. The juxtaposition of the vision for an inclusive process against the budgetary constraints that the authors faced led them to reflect deeply on the many meanings of paying service user educators for their contributions to academic initiatives. These reflections revealed that payment had implications at personal, organizational, and social levels. Paying mental health service user educators for their contributions is an ethical imperative for the authors. However, unless payment is accompanied by other forms of demonstrating respect, it aligns with organizational structures and practices, and it is connected to a larger goal of achieving social justice, the role of service users as legitimate knowers and educators and ultimately their impact on learners will be limited.

Understanding the Experiences of First-Generation Medical Students: Implications for a Diverse Physician Workforce.

Abstract: Calls for a diverse physician workforce continue to grow, and a key approach to answering these calls lies in ensuring that first-generation (First Gen) undergraduate students are able to become medical students and, eventually, physicians. The Association of American Medical Colleges (AAMC) defines First Gen individuals applying for medical school as candidates “whose parents have not earned an associate’s degree or higher” [1]. Although a large proportion of First Gen students in health professions are also underrepresented minority (URM) students, it is important to note that First Gen students come from different racial and ethnic backgrounds, and differ in regard to socioeconomic and immigration statuses [2]. Moreover, the obstacles faced by students differ depending on students’ backgrounds. For instance, URM First Gen students face different issues (e.g., ethnic and racial biases) than non-URM First Gen students. Published reports have indicated that 51% of First Gen undergraduate students are from minority backgrounds, while only 30% of non-First Gen undergrads are from minority backgrounds [3]. In addition, 27% of First Gen undergraduate students reported parental incomes of less than $20,000, while only 6% of non-First Gen undergrads reported the same [3]. Additionally, 46% of First Gen undergraduates are not US citizens [4]. In addition to diverse backgrounds, advantages that First Gen students bring to the institutions they attend include personal qualities, such as grit, innovative thinking, and insight into health disparities [5]. While this information on undergraduate First Gen students is valuable, it does not reveal the trajectories of First Gen undergraduates who become medical students. Difficulties in studying the First Gen population are due, in part, to historical reports’ infrequent use of the term “first-generation” and conflation of demographic identifiers. Past research has used terms like “underrepresented minority,” “low socioeconomic status,” “disadvantaged,” “at-risk,” and “vulnerable” to describe First Gen students and since these terms were often used as proxies for First Gen status, many historical details on this group went uncaptured. However, more recently, accrediting organizations have begun advising medical schools on how to collect information on First Gen applicants [6]. For instance, beginning in 2017, the AAMC introduced a “First Generation College Student Indicator” on the American Medical College Application Service [1, 5]. The AAMC has also encouraged medical schools to undertake “holistic reviews” that allow admissions committees to give equal consideration to the experiences, attributes (including First Gen status), and metrics of medical school applicants [6]. Since medical schools are increasingly collecting information on their First Gen populations and considering this metric for admission into medical school, residencies, and fellowships, the need for data on First Gen individuals in medical training is a priority for medicine and academia. The specific aims of this commentary are the following: (a) to identify educational challenges unique to the First Gen population and (b) to highlight how First Gen status among physicians can diversify the physician workforce and positively impact healthcare. While URM and First Gen students often share similar life experiences that can help diversify the physician workforce, the First Gen narrative is the primary focus of this commentary. This piece highlights initiatives aimed at diversifying the medical school pipeline and increasing matriculation for First Gen students. This commentary also advocates for research on the First Gen medical student population and illustrates the unique role that academic psychiatrists have in supporting the First Gen physician workforce. * Karen Miotto kmiotto@mednet.ucla.edu

The Medical Student Response to the Mental Health Consequences of COVID-19

Abstract: To the Editor: As the worldwide number of coronavirus disease 2019 (COVID-19) cases continues to rise, the medical community has identified another imminent crisis—the mental health consequences of the pandemic. An estimated 45% of American adults feel that COVID-19 has had a negative impact on their mental health [1]. As physical distancing measures remain in place, medical providers continue to anticipate surges in isolation-related mental health conditions, including depression, anxiety, and suicide. Shelter-in-place orders may lead to increasing rates of substance use relapse, overdose, domestic violence, and child abuse [2]. Furthermore, the trauma of caring for individuals with COVID-19, felt by both frontline health care providers and the general public, will likely have lasting consequences. The threat of an enduring mental health crisis has led physicians to call for early preventive efforts [2]. However, the increased burden of mental illness resulting from this pandemic will likely place additional strain on an already overextended mental health care system. The medical community must leverage all of its available assets to combat this threat. We believe that medical students represent a significant untapped resource that should be mobilized to address this impending mental health crisis. At the time of the writing of this manuscript, the Association of American Medical Colleges stated, “Unless there is a critical health care workforce need locally, we strongly suggest that medical students not be involved in any direct patient care activities” [3]. At the height of the pandemic, medical schools across the country subsequently shifted to virtual learning and barred students from in-person clinical work. In response, students developed new roles to serve their communities. They made headlines collecting personal protective equipment for hospitals, providing child care for essential workers, and ensuring food security for high-risk community members [4]. Medical students also advocated for their incorporation into telemedicine efforts in order to relieve overburdened medical providers [5]. Missing from this discourse was a discussion of the ways medical students could be voluntarily mobilized to address the mental health challenges resulting from this pandemic. The resistance to medical student involvement in the COVID-19 response is based on reasonable safety concerns, but a carefully designed medical student mental health response could avert these risks. Recently proposed interventions to address the mental health consequences of COVID19 were designed for remote delivery [2]. The use of digital teleconferencing programs to deliver these interventions would enable medical students to avoid exacerbating infection risks and shortages of personal protective equipment. Whereas medical students may present a liability in the direct care of patients with COVID-19, they are well suited to provide remote mental health support. We propose the following three interventions as examples of a medical student response to the mental health consequences of COVID-19. First, medical students could serve in a preventive mental health system operating by a stepped care model. Under the supervision of primary care physicians, students could use telehealth systems to perform thorough mental wellness checks across large patient panels. This cannot currently be offered by physicians due to patient care burdens related to COVID-19. Students could fill these gaps by performing standardizedmental health screens, offering psychoeducation, and alerting providers about patients who require a higher level of psychiatric care. Such a system could be crucial for identifying isolation-related experiences including domestic violence, child abuse, and substance use relapse, which may go unnoticed as resources are diverted to the COVID-19 response. This triage strategy would alleviate the burden on health care * Anthony N. Almazan anthony_almazan@hms.harvard.edu

Entrustable Professional Activities in Psychiatry: A Systematic Review

Abstract: Entrustable professional activities (EPAs) represent discrete clinical tasks that can be entrusted to trainees in psychiatry. They are increasingly being used as educational framework in several countries. However, the empirical evidence available has not been synthesized in the field of psychiatry. Therefore, the authors conducted a systematic review in order to summarize and evaluate the available evidence in the field of EPAs in undergraduate and graduate medical education in psychiatry. The authors searched PubMed, Cochrane Library, ERIC, Embase, PsycINFO, all Ovid journals, Scopus, Web of Science, MedEdPORTAL, and the archives of Academic Psychiatry for articles reporting quantitative and qualitative research as well as educational case reports on EPAs in undergraduate and graduate psychiatry education published since 2005. All included articles were assessed for content (development, implementation, and assessment of EPAs) and quality using the Quality Assessment Tool for Studies with Diverse Designs. The authors screened 2807 records and included a total of 20 articles in the final data extraction. Most studies were expert consensus reports (n = 6, 30%) and predominantly conducted in English-speaking countries (n = 17, 85%). Papers reported mainly EPA development and/or EPA implementation studies (n = 14, 70%), whereas EPA assessment studies were less frequent (n = 6, 30%). Publications per year showed an increasing trend both in quantity (from 1 in 2011 to 7 in 2018) and quality (from a QATSDD score of 27 in 2011 to an average score of 39 in 2018). The main focus of the articles was the development of individual EPAs for different levels of training for psychiatry or on curricular frameworks based on EPAs in psychiatry (n = 10, 50%). The lack of empirical controlled studies does currently not allow for meta-analyses of educational outcomes. The concept of EPA-based curricula seems to become increasingly present, a focus in the specialty of psychiatry both in UME and GME. The lack of empirical research in this context is an important limitation for educational practice recommendations. Currently there is only preliminary but promising data available for using EPAs with regard to educational outcomes. EPAs seem to be effectively used from a curriculum design perspective for UME and GME in psychiatry.

Electroconvulsive Therapy: a Video-Based Educational Resource Using Standardized Patients.

Abstract: Video-based depictions of electroconvulsive therapy (ECT) can be useful for educational purposes, but many of the readily available resources may worsen already stigmatized views of the procedure. Educators’ common reliance on such material highlights the paucity of equipoised depictions of modern ECT well suited for the training of health professionals. The authors developed and tested a new educational module enhanced by videotaped depictions of a simulated patient undergoing the consent, treatment, recovery, and follow-up phases of ECT. The didactic intervention interspersed 7 short video clips (totaling 14 min) into a 55-min lecture on treatment-resistant depression. The session, part of an intensive course of preclinical psychiatry, was delivered online through synchronous videoconferencing with Zoom. The primary outcome measure was change in the Questionnaire on Attitudes and Knowledge of ECT (QuAKE). Fifty-three out of 63 (87%) eligible second-year medical students completed assessments at baseline and after exposure to the didactic intervention. QuAKE scores improved between baseline and endpoint: the Attitudes composite increased from 49.4 ± 6.1 to 59.1 ± 5.7 (paired t 10.65, p < 0.001, Cohen’s d 0.69), and the Knowledge composite from 13.3 ± 1.2 to 13.9 ± 0.8 (paired t 3.97, p < 0.001, Cohen’s d 0.23). These video-based educational materials proved easy to implement in the virtual classroom, were amenable to adaptation by end-use instructors, were well received by learners, and led to measurable changes in students’ knowledge of and attitudes toward ECT.

Implicit Stigma Recognition and Management for Health Professionals.

Abstract: Stigma against individuals with mental illness has disastrous consequences for patient outcomes. Better approaches to reducing stigma in health care professionals are required. Implicit stigma education is an emerging area of research that may inform the design and implementation of stigma reduction programs. In this “in brief report,” the authors describe the evaluation of a novel implicit stigma reduction workshop for health professionals. The authors conducted a realist evaluation using a longitudinal multiple case study approach. Once a conceptual model was established, three case studies were conducted on physicians and nurses (n = 69) at an academic health sciences center. Within each case, pre- and post-attitudinal scales and qualitative data from semi-structured interviews were used. Consistent with realist evaluation principles, context-mechanism-outcome configuration patterns were analyzed. An implicit stigma recognition and management workshop produced statistically significant changes in participant attitudes in two out of three contexts. The qualitative evaluation described the perceptions of sustainable changes in perspective and practice. The degree to which individual participants learned with and worked among inter-professional teams influenced outcomes. Implicit stigma recognition and management is a useful educational strategy for reducing stigma among health professionals. Once stigma is recognized, curricular interventions may promote behavioral change by encouraging explicit alternative behaviors that are sustained through social reinforcement within inter-professional teams.

Comfort Level and Barriers to the Appropriate Use of Clozapine: a Preliminary Survey of US Psychiatric Residents.

Abstract: Clozapine is the gold standard treatment for treatment-resistant schizophrenia. Prior surveys of mental health providers have identified multiple causes for underutilization of clozapine; however, no previous survey has been conducted to assess US psychiatry residents’ level of comfort in prescribing clozapine. A survey was sent via email to program directors of Accreditation Council for Graduate Medical Education–affiliated psychiatry residency programs requesting the survey to be distributed to current residents. The survey included questions regarding demographics, clozapine-prescribing practices, comfort levels with prescription, and perceived barriers to prescription. A total of 164 psychiatric residents completed the survey, 37% PGY-1 and 2 residents and 63% PGY-3 or higher. One-third of the respondents had a clozapine clinic in their program. Only 18% of the residents felt “very” comfortable in initiating clozapine and 41% felt “somewhat” comfortable. Two main reasons for not starting clozapine were (1) side effect profile (41%) and (2) limited experience and inadequate training in clozapine use (38%). More than 4/5ths of the residents (83%) responded that they would feel more comfortable in prescribing clozapine if they were trained in a clozapine clinic. Major limitation of this study has been the small sample size, lack of representativeness, and generalization. Forty-one percent of the respondents did not feel comfortable with clozapine prescription. Major concerns cited included the side effect profile as well as lack of experience and training. The majority of the respondents felt that they would be more comfortable prescribing clozapine if they had the opportunity to train in a clozapine clinic.

“I Feel Like I Know Them”: the Positive Effect of Celebrity Self-disclosure of Mental Illness

Abstract: The media is often perceived as portraying psychiatric illness in a negative, stigmatizing, and even dangerous fashion [1]. In the case of suicide, it has long been documented that media reporting of celebrity suicides can lead to an augmentation in copycat suicides, a phenomenon historically known as the Werther effect [2]. After the highly publicized suicide of the actor Robin Williams, the average suicide rate increased from 113–117 to 142 suicide deaths per day. In addition, among the individuals who died by suicide immediately after the actor’s death, around two-thirds of them used a method identical to that of Williams [3]. In contrast, calls for help also increase after celebrity deaths by suicide. The day after the death of Williams, calls placed to the National Suicide Prevention Lifeline (NSPL) increased by 300% [3], suggesting that media reporting of celebrity suicides may also promote help-seeking. Collaborating with the media is particularly important given the changing landscape of information consumption. Currently, the general public is getting the bulk of their mental health education from movies, television, and entertainment news [4]. As such, representation of mental illness matters. Yet, mental illness is often left out of storytelling. For example, one study by the Annenberg Center found that out of 4598 film characters analyzed, only 1.7% experienced a mental health condition and out of 1220 TV characters, only 7% had psychiatric disorders. This is compared with the 18.9% of the population in the U.S. with mental illness [5]. Even if characters with psychiatric disorders are portrayed, the portrayals are often stigmatizing or incorrect; the mentally ill characters are often associated with words including “crazy,” “weird,” “psycho,” and “freak” [5]. Besides possibly ostracizing those with mental illness in society, portraying psychiatric illnesses incorrectly or not at all could have other consequences. Without knowing the facts about mental disorders, including the warning signs to recognize in themselves or others, help-seeking might be limited. As it stands, 35% of American adults suffering from major depressive disorder did not receive treatment in 2017 [6]. Additionally, particular groups who are often underrepresented in both the media and mental health treatment [7] are at heightened risk for not identifying with mental illness portrayals. The Annenberg study found that of the characters with mental health conditions in the films sampled in the study, zero were LGB (lesbian, gay, bisexual) characters, none was transgender, only 7% were teens, and no characters in film were Hispanic/Latino or Native American [5]. Additionally, only 11 characters were Black or African American [5] even though it has been documented that they are more likely to experience severe psychiatric illnesses and are less likely to seekmental healthcare than their Caucasian counterparts [7]. This paper will attempt to counter the idea that media and celebrity culture are only a negative influence on mental health and, instead, will argue the potential benefits. It will discuss the positive portrayal of mental health in the media, specifically by celebrities, with the hypothesis that selfdisclosure and advocacy can lead to normalization and awareness of mental health in the general population and, hopefully, even encourage help-seeking.

Transforming Psychiatry from the Classroom to the Clinic: Lessons from the National Neuroscience Curriculum Initiative.

Abstract: Individual residency programs often struggle to keep pace with scientific advances and new training requirements. Integrating a modern neuroscience perspective into the clinical practice of psychiatry is particularly emblematic of these challenges. The National Neuroscience Curriculum Initiative (NNCI) was established in 2013 to develop a comprehensive set of shared, open-access resources for teaching neuroscience in psychiatry. The NNCI developed a collaborative, team-based approach with a peer-review process for generating and reviewing content. Teaching resources have included interactive sessions for the classroom paired with a comprehensive facilitator’s guide. Brief accessible reviews and short videos have been developed for self-study and teaching in clinical settings. Dissemination efforts have included hands-on training for educators through national workshops. All resources are freely available on the NNCI website. Outcome measures have included the number of educational resources developed, feedback from workshop attendees, the number of US psychiatry residency programs who have adopted NNCI resources, as well as analytics from the NNCI website. To date, the NNCI has developed over 150 teaching sessions, reflecting the work of 129 authors from 49 institutions. The NNCI has run over 50 faculty development workshops in collaboration with numerous national and international organizations. Between March 2015 and June 2019, the website (www.NNCIonline.org) has hosted 48,640 unique users from 161 countries with 500,953 page views. More than 200 psychiatry training programs have reported implementing NNCI teaching materials. This multisite collaborative provides a model for integrating cutting-edge science into medical education and the practice of medicine more broadly.

Therapy and E-therapy—Preparing Future Psychiatrists in the Era of Apps and Chatbots

Abstract: In both Canada and the USA, residency includes learning about psychotherapy. The Royal College of Physicians and Surgeons of Canada mentions several psychotherapies in its training objectives and states that residents must “demonstrate proficiency in assessing suitability for and prescribing and delivering” such treatments, including cognitive behavioral therapy [1]. The Accreditation Council for Graduate Medical Education (ACGME) in the USA sets out competency frameworks and assessments for psychotherapy in psychiatry postgraduate education [2]. Yet on neither side of the 49th parallel is there mention of e-therapies in training requirements. E-therapies are psychotherapies delivered by websites or apps, either through the Internet or via cellular data. They can take different forms: as applications (computer programs, commonly called apps) for smartphones, as a novel part of more traditional outpatient clinical care embedded in a clinic’s offerings (with the oversight of human therapists), or as chatbots, programs enhanced with artificial intelligence (AI) [3]. Apps serve different functions, including e-therapy, and are increasingly popular. Torous et al. found that many patients of a Boston-area private outpatient mental health clinic use apps; for those under 25 years of age, 80% had downloaded a mental health app [4]. E-therapy apps may offer users everything from thought logs that can be populated to comprehensive and interactive cognitive behavioral therapy (CBT). In several countries, outpatient mental health services actively experiment with e-therapies, offering them as part of a menu of interventions [5]. So a person with panic disorder may see a psychiatrist for medications, but receive his CBT through a web-based program. Expansion of e-therapies has been included in government policy (for example, in Australia) [5]. Chatbots—which we could classify as apps 2.0—are programs “that use machine learning and artificial intelligence methods to mimic human-like behaviors and provide a task-oriented framework with evolving dialogue able to participate in conversation” [6]; some include psychotherapeutic interventions (like cognitive behavioral therapy techniques) offered in real-time and may have a role to play in patient care—in a sense, therapy without the (human) therapist. Chatbots may offer certain advantages: unlike a human therapist, a chatbot is always available when the patient chooses to make contact, never distracted by thinking about what to barbeque for supper (or anything else), and “remembers” everything a patient told it through its data repository, using that information to develop a more data-informed understanding of the patient. Our relentless tendency to anthropomorphize everything from pets to technology leads, in our experience, to a tendency to give chatbots a gender and a character—a twenty-first century form of transference that has long been recognized in the domain of traditional psychotherapy. Work in the area is supportive of this view, though we acknowledge that research in this area has just begun, and that for some patients, the concept of therapist-free therapy will likely be unworkable [7]. Though historically psychotherapy involved a therapist and her patient, the nature of psychotherapy itself is changing with technology—for better and worse. In this brief paper, we discuss the impact of new technologies, and its implications for the education of trainee psychiatrists.

The Impact of Mental Illness Disclosure in Applying for Residency.

Abstract: Medical students have higher rates of depression than age-matched peers. Given the societal stigma against mental illness, students with depression often seek guidance on disclosing this in residency applications. This study aimed to answer whether disclosing a mental illness during the residency application process affects an applicant’s success in the National Resident Matching Program. The authors hypothesized candidates disclosing mental illness would receive fewer interviews and would be ranked lower than those disclosing physical illness. The authors randomized program directors from residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) to receive one of two surveys. Both surveys included similar demographic information and three applicant vignettes, varying only in presence and type of illness disclosed (major depression or diabetes mellitus). The authors analyzed data using the Generalized Estimating Equation method for ordinal logistic regression. Out of 3838 ACGME residency programs, 596 responded (16.9%). A total of 380 (10.7%) program directors (survey 1, n = 204, 5.3%; survey 2, n = 176, 4.6%) completed the survey. Applicants who disclosed a history of depression had higher odds of being in a lower category of receiving an invitation (OR = 3.60, p < .001 for a “perfect” applicant, OR = 2.39, p < .001 for a “good” applicant with leave of absence) and a lower category for match ranking (OR = 1.94, p = .01 for a perfect applicant, OR = 2.30, p < .001 for a good applicant with leave of absence) compared with the candidate who disclosed a history of diabetes. However, strong applicants who disclosed depression still fared better in the application process than an average applicant without disclosed illness (OR = 0.13, p < .001 for invite and OR = 0.04, p < .001 for rank). Disclosing depression during the residency application process puts an applicant at a notable, however not insurmountable, disadvantage compared with applicants who do not disclose mental illness.

The Future is Knocking: How Artificial Intelligence Will Fundamentally Change Psychiatry

Abstract: Artificial intelligence (AI) is inducing a profound transformation of both the practice and structure of medicine. This implies changes in tasks, where certain processes may be taken over byAI applications, as well as novel ways of collaborating and integrating information. Consider a recent example where AI is used to avoid suicide attempts by using smartphones’ native sensors and signal processing techniques [1]. This new suicide prevention technique requires the psychiatrist to acquire new skills (handling and interpreting continuous patient data sent by a dedicated application) and interact with new actors (programmers, data managers, etc.). Further, the abundance of individual patient data may contribute to a shift in conceptualizing care—from the traditional identification of general risk factors towards more tailored prevention strategies in the sense of personalized medicine [1]. Thus, unlike past technologies, AI has the potential to not only enhance medical capacity but also change the way health professionals are organized and embedded into the broader medical context. In particular, the implementation of AI applications is leading to a redistribution and renegotiation of responsibilities—and thus power—both within medicine and in relation with other stakeholders. This article discusses the future impact of AI on psychiatry, highlights the challenges for research, and outlines perspectives for the next generation of psychiatrists. Artificial Intelligence: General Background

Effect of a Single-Session Communication Skills Training on Empathy in Medical Students.

Abstract: Empathy scores have been found to decline over the years spent in medical school. The authors aimed to evaluate the change in empathy levels in medical students following a single-session communication skills training. Eighty-two second-year medical students were randomized into intervention and control groups. The intervention comprised of a single-session empathetic communication skills training using PowerPoint, video clips, and roleplay. Empathy was assessed using the Jefferson Scale of Empathy-Student version (JSE) at baseline, post-intervention (for the intervention group), and at follow up after 3 weeks. The mean JSE score of the intervention group was 109.7 ± 11.8 at baseline, with significant improvement post-intervention (114.2 ± 10.6, p = 0.014). However, the score declined at the 3-week follow-up (106.8 ± 11.8). The mean baseline JSE score of the control group was 107.5 ± 12.4, with a decline at follow-up (101.8 ± 16.0). Though both groups showed a decline in the JSE score at follow-up, the decline was significant only for the control group (p = 0.020), which did not receive the training. The study showed significant improvement immediately, and lower decline at follow-up, in empathy levels following a communication skills training. The findings suggest a need to incorporate a regular training program into the existing medical curriculum, to enhance empathy and prevent its decline over the years.

Understanding Assessment Systems for Clinical Competency Committee Decisions: Evidence from a Multisite Study of Psychiatry Residency Training Programs.

Abstract: This multisite study examines how clinical competency committees in Psychiatry synthesize resident assessments to inform milestones decisions to provide guidelines that support their use. The study convened training directors and associate training directors from three psychiatry residency programs to examine decision-making processes of clinical competency committees. Annual resident assessments for one second year and one third year resident were used in a mock clinical competency committee format to assign milestones for two consecutive reporting periods. The committees reflected on the process and rated how the assessment tools impacted the assessment of milestones and evaluated the overall process. The authors compared reliability of assessment between the mock committees and examined both reliability of end of rotation assessments and their composite scores when combined with clinical skills evaluations. End of rotation evaluations were the most informative tool for assigning milestones and clarifying discrepancies in performance. In particular, the patient care and medical knowledge competencies were the easiest to rate, while the systems-based practice and practice-based learning and improvement were the most difficult. Reliability between committees was low although higher number of available evaluations improved reliability in decision-making. The results indicate that the medical knowledge and patient care competencies are the easiest to rate and informed most by end of rotation evaluations and clinical skills examinations. Other evaluation tools may better capture performance on specific sub-competencies beyond workplace-based assessment, or it may be helpful to reconsider the utility of how individual sub-competencies are evaluated.

The Psychiatry Milestones 2.0: How Did We Get from 1.0 to 2.0 and What Can Users Expect?

Abstract: Graduate medical education (GME) in psychiatry, like other medical specialties, has been transitioning to competencybased training and assessment. Competency-based medical education was born from a desire to certify physicians based on training outcomes, rather than training inputs such as the amount of time one spends in training [1]. The transition to a focus on training outcomes has been at least 25 years in the making. In 1994, The Accreditation Council for Graduate Medical Education (ACGME) began efforts to determine the expected competencies of physicians-in-training and to introduce methods of assessing training outcomes [2]. From an initial list of thirteen competency domains, the ACGME outcome project advisory committee identified six general core competencies thought to be common to physicians training across all specialties [3]. The core competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice were approved by the ACGME board in 1999 [4]. The next phase of competency-based GME was to involve “translation of the core competencies into specialty-based competencies” [5]. Following this, residency programs were expected “to develop instructional and assessment methods for integrating the competencies (into) their curricula” [5]. In order to assist programs with this integration, the ACGME developed an assessment “toolbox” of online evaluation methodologies [6]. A portfolio comprised of documents that chronicled resident transition from novice to competent physician was seen as particularly promising. However, as reported by Lurie et al., these portfolios were not straightforward to interpret and peer-reviewed literature found no evidence that assessment tools could directly assess the six core competencies [7]. It was against this backdrop that the ACGME began to focus on the developmental aspects of the acquisition of knowledge and skills by physicians-in-training, a project named the Milestones. The ACGME defines Milestones as “specific behaviors, attributes, or outcomes in the six general competency domains to be demonstrated by residents during residency” [5]. The Milestones are an integral part of ACGME’s Next Accreditation System (NAS) and one way in which the ACGME is trying to redevelop the standards for GME [8]. Under this system, the residency program’s Clinical Competency Committee (CCC) is charged with

The Mental Status Exam Through Video Clips of Simulated Psychiatric Patients: an Online Educational Resource.

Abstract: The Mental status exam (MSE) is a core component of psychiatric education. Innovative ways of teaching the MSE by making it “come alive” may prove useful in a wide range of curricular initiatives. The authors developed a publicly available online repository of sixteen video-based depictions by simulated psychiatric patients (SPPs) of ten common forms of psychopathology. They tested the practical feasibility and didactic efficacy of including the video clips through an education trial embedded into two pre-clinical psychiatry courses. One hundred fifty-three students participated in the study (75 medical, 78 nursing). Students in the intervention group (n = 73) performed better on an objective MSE standardized instrument’s overall score than did those in the control group (n = 80; F2,150 = 4.817, p = 0.009), with a main effect for intervention over control (beta = 2.69; 95% CI = 0.56, 4.82; p = 0.014), but no effect for discipline. Among medical students, those in the intervention group improved on MSE knowledge and competence subjective self-ratings, compared with those in the control group (p ≤ 0.001). Video clips of SPPs depicting psychopathology are an effective complement to teach the MSE and enhance students’ sign and symptom recognition on objective and subjective measures. This publicly available online video repository can help psychiatric educators enhance their teaching efforts to different types of learners.

First Year Burnout and Coping in One US Medical School.

Abstract: Physician burnout is increasingly recognized as important for patient safety and physician wellness. Though several studies have examined burnout among medical students, few studies have examined the relationships between coping strategies and burnout. We hoped to preliminarily examine these relationships among first year medical students. This cross-sectional study administered to first year medical students uses validated psychologic assessment tools including the COPE inventory and the MIB-HS inventory to assess correlations between the results. Standard correlational statistic methods were used to analyze the data in reaching our conclusions. A total of 167 students participated, including 53% females. The adaptive coping strategy of planning was significantly associated with decreased levels of emotional exhaustion and a preserved sense of personal accomplishment on the burnout assessment survey. Additionally, the adaptive coping strategy of positive reinterpretation/growth was also significantly associated with preservation of the sense of personal accomplishment. These results highlight the benefit of using adaptive coping strategies to prevent burnout. These data emphasize the importance of providing students programming during early medical training that encourages students to develop and enhance these strategies to promote wellness while in training and beyond.

Neuroimaging Education in Psychiatry Residency Training: Needs Assessment

Abstract: The authors investigated the attitudes, self-perceived knowledge, and the need for a dedicated neuroimaging curriculum among psychiatrists-in-training. An anonymous voluntary 20-item Web-based survey was distributed to psychiatry residents at seven university-based USA programs between December 2017 and February 2019. Of 302 psychiatry residents, 183 (response rate, 60.5%) completed the survey. Although a large majority of residents (83%) believed that neuroradiology education is important to psychiatric training, only 7% reported that they are receiving adequate training in this discipline. The majority (80%) believed that there should be a formal neuroimaging curriculum during their training. Self-perceived competence and comfort level was found to be low with several psychiatrically relevant neuroimaging modalities. In particular, regarding CT head/brain MRI, there was a marked difference in self-perceived competence at interpreting the actual brain images (8%) versus the radiological reports/impression summaries (48%). Comfort level with functional neuroimaging was especially low (7%). Clinically, only 26% reported confidence at being able to explain neuroimaging topics to patients. Compared to junior residents, senior residents rated higher confidence at interpreting the radiological reports/impression summaries of CT head/brain MRI (p = 0.008) and PET/SPECT (p = 0.014), but no difference was found with the actual brain images. Further, senior residents were less likely to identify with “neurophobia” (p = 0.028) and more likely to believe that a neuroimaging curriculum should be included in psychiatric residency training (p = 0.027) when compared to junior residents. Psychiatrists-in-training have a very strong interest in neuroimaging education. Future educational interventions should address this need.

Psychotherapy and the Professional Identity of Psychiatry in the Age of Neuroscience.

Abstract: Interviewing for residency positions in psychiatry, I was asked repeatedly why I wrote in my application that I felt drawn to the field because I wanted to perform psychotherapy. Responses to this interest varied considerably. On one extreme, there are a handful of departments that regard psychotherapy as the core skill in clinical psychiatry, and at these places—I can think of a few—I had little explaining to do. On the other hand, there are a number of programs that vow to make psychotherapy as effectively optional as they can get away with. One chief resident told me in no uncertain terms that therapy didactics and supervision were “available” to residents only because the accreditation council requires them. Then there is the most common response, which I would describe as basically encouraging but imbuedwith skepticism. It reminds me of the way medical schools react when an entering student declares an interest in primary care for the poor. Every medical school wants these kinds of students in their class, but you can tell that the deans, having heard this before, are aware of the odds. They know that most of them, in keeping with the majority of like-minded medical students, will eventually get pulled in another direction [1, 2]. Rational students succumb to market forces; likewise, a psychiatry resident’s desire to perform psychotherapy might be replaced by other, more practical, considerations as they develop a career. (A notable exception exists in the handful of very large cities fostering a market for private practice therapy, but this is not the norm nationwide.) Before moving further, I should clarify that by psychotherapy I mean all of the deliberate interactions that might be thought of as “talking cures,” which take as axiom that we can bring about change in a patient’s experience by sharing in it. Psychotherapy is also a scientific discipline, based on measured observation, which has demonstrated beyond ambiguity that a therapist’s choice to sit with a patient, to utter (or not), and to listen with purpose [3] has therapeutic action [4]. In the modern landscape, psychotherapy runs the gamut from brief to prolonged, tightly framed to spontaneous, individual to collective, suggestive to analytic, and so on, but for my argument here (and perhaps for the benefit of patients [5]), these differences are not as important as their commonalities. By this definition, I do not think anyone disputes that many patients need psychotherapy. A common line from program directors is “we teach therapy because therapy works,” enumerating (and justifying) it as one of many tools in the therapeutic shed. They point out that beyond the role of psychotherapy in the conditions we see most commonly, several epidemiologically significant psychiatric disorders have no FDA-approved medication or somatic treatment but a wealth of evidence for psychotherapeutic intervention. Borderline personality disorder [6], specific phobia [7], somatoform disorders [8], and anorexia nervosa [9] come to mind. Of course, physicians are far from the only providers in the healthcare system. Our colleagues in internal medicine know that physical activity, nutrition counseling, and tobacco intervention programs are almost certainly more effective than some of the pharmacotherapies employed for similar ends. They are nonetheless delegated to professionals less scarce in the ecosystem because they come at an opportunity cost for prescribing physicians. Likewise, in American psychiatry, all residents learn the basics of the major branches of psychotherapy [10], but most practicing psychiatrists today do not perform therapy with their patients, even informally, and the number of psychiatrists who perform psychotherapy has declined substantially since the 1990s [11]. Some of this is because psychotherapy has the lowest professional barrier of the modes of intervention used in psychiatry. A medical doctor can offer as much talk therapy as their heart desires, but so can a clinical psychologist, a nurse practitioner, a psychiatric nurse, a social worker, a mental health counselor—and arguably also a minister, a vocational * Ren Belcher lrbelcher@partners.org

Strategies for Enhancing Resilience in Medical Students: a Group Concept Mapping Analysis

Abstract: Research has consistently shown that medical students have greater rates of stress and mental-ill health in comparison with non-medical students. The objective of this study was to investigate the resilience strategies employed by medical students in an Irish medical school to inoculate themselves against the deleterious effects of stress on health and wellbeing. Group concept mapping was utilized incorporating qualitative and quantitative methodologies. The stages undertaken by year 3 students at an Irish medical school involved brainstorming/idea generation, categorization, and rating of resilience strategies students employed to manage stress during medical school. The data was analyzed utilizing The Concept System® software through multidimensional scaling and hierarchical clustering. Categories of resilience strategies employed included “friends and family,” “de-stress through exercise/sport,” “extra-curricular non-medical activities,” “self-enabled distraction,” “organization,” and “enhancing emotional and mental wellbeing.” Students rated spending time with “friends and family” to be most effective when seeking to relieve stress, whereas students rated “de-stressing through exercise/sport” as being of greatest importance in relation to inclusion in a resilience-based intervention. Students recognized the value of incorporating strategies to enhance emotional and mental wellbeing into a resilience-promoting program. “Self-enabled distraction” rated poorly on both scales. Strategies rated by students to be important to incorporate in a stress reduction management program are accessible, are feasible, and can be implemented into the medical curriculum.

A Virtual Standardized Patient-Based Assessment Tool to Evaluate Psychiatric Residents' Psychopharmacology Proficiency.

Abstract: A virtual standardized patient-based assessment simulator was developed to address biases and practical limitations in existing methods for evaluating residents’ proficiency in psychopharmacological knowledge and practice. The simulator was designed to replicate an outpatient psychiatric clinic experience. The virtual patient reported symptoms of a treatment-resistant form of major depressive disorder (MDD), requiring the learner to use various antidepressants in order for the patient to fully remit. Test scores were based on the proportion of correct responses to questions asked by the virtual patient about possible side effects, dosing, and titration decisions, which depended upon the patient’s tolerability and response to the learner’s selected medications. The validation paradigm included a novice-expert performance comparison across 4th year medical students, psychiatric residents from all four post-graduate year classes, and psychiatry department faculty, and a correlational analysis of simulator performance with the PRITE Somatic Treatments subscale score. Post-test surveys evaluated the test takers’ subjective impressions of the simulator. Forty-three subjects completed the online exam and survey. Total mean scores on the exam differed significantly across all the learner groups in a step-wise manner from students to faculty (F = 6.10, p = 0.0001). Total mean scores by residency class correlated with PRITE Somatic Therapies subscale scores (p < 0.01). The post-test survey mean Likert results ranged from 3.33 ± 1.20 to 4.4 ± 0.79, indicating neutral to favorable responses for use of the simulator. This simulator demonstrated strong construct validity and high participant acceptability for assessing proficiency in the psychopharmacologic treatment of MDD.

Prevalence and Socio-Demographic Correlates of Mental Health Problems Among Iranian Health Sciences Students.

Abstract: The primary objective of the present study was to compare the mental health status of Iranian medical vs other health sciences students and to examine how demographic factors relate to their mental health problems. A total of 560 medical and other health sciences students (250 (44.6%) males and 310 (55.4%) females) were recruited from Iran University of Medical Sciences. Data were obtained by self-administered questionnaire, including questions on socio-demographic characteristics. The Beck Depression Inventory, Beck Anxiety Inventory, General Health Questionnaire, and WHO well-being index were used to assess mental health status of students. Ten percent of students had BDI scores consistent with clinically significant depression (6.6% mild, 1.8% moderate, 1.6% severe), and 28.7% had BAI scores consistent with clinically significant anxiety (20.7% mild, 7.1% moderate, 0.9% severe). Kurdish students had an odds ratio (OR) of 2.71 (95% CL, 1.22–6.02) for mild to severe depression symptoms when compared to Persian students. The prevalence of distressed health sciences students and poor psychological well-being was 13.4% and 14.1%, respectively. Maternal education gave an OR of 0.57 (0.35–0.93) for anxiety symptoms, after adjustment for all other factors. The possibility of general psychiatric morbidity was significantly lower in students who studied medicine (OR, 0.40 (0.21–0.71)). Being born in the capital city was associated with better psychological well-being (OR, 0.48 (0.26–0.86)). Ethnicity, birthplace, discipline, and maternal educational level were major determinants of mental health status among health sciences students. Further research should be undertaken to determine the prevalence of psychological disorders using more reliable diagnostic interview.

Implementation of a Longitudinal Mentorship Program for Quality of Life, Mental Health, and Motivation of Brazilian Medical Students.

Abstract: Mentoring has been used as a strategy for mental health prevention and the promotion of quality of life in medical students, with mixed results. The aim of this study was to compare the levels of mental health, quality of life, and academic motivation of medical students after implementation of a longitudinal curricular mentoring program relative to those students without mentoring in their curricula. The results of the mentoring program were assessed by comparing two classes of 2nd-year students of a school of medicine (one that had received mentoring since admission and another which had no exposure to the method during the course). Self-report questionnaires were used to collect data on sociodemographics, quality of life (WHOQOL-BREF), mental health (DASS-21), and academic motivation (Academic Motivation Scale-AMS). A total of 95 medical students were included: 55 received the mentoring program and 40 did not receive the program. The Multivariate GLM regression model revealed no significant main effect of mentoring on domains of the WHOQOL-BREF (Wilks’s Lambda = 0.938, F = 1.427, p < 0.232); the DASS-21 (Wilks’s Lambda = 0.051, p < 0.985); or the AMS (Wilks’s Lambda = 0.957, F = 0.628, p < 0.708). Likewise, the Univariate GLM regression showed no significant main effect of mentoring on medical students’ perceived health (F = 0.585; d.f. = 1; p = 0.446). Mentoring promoted no significant changes in the students of this Brazilian institution. These results highlight the challenges faced in structuring, maintaining, and assessing an effective mentoring program for students on medicine courses.

Medical Students Who Do Not Match to Psychiatry: What Should They Do, and What Should We Do?

Abstract: Although the evidence is anecdotal, it appears that psychiatry is facing a relatively new phenomenon: U.S. medical school graduates who are unable to match to psychiatry. Psychiatry has seen U.S. and International Medical Graduate (IMG) physicians not matching to psychiatry in the past, but not in the numbers seen lately. As noted by Bailey et al. [1], the difficulty in matching has been increasing, and for the most part, it has not been widely publicized and addressed.

A Free Online Video Series Teaching Verbal De-escalation for Agitated Patients.

Abstract: All healthcare professionals encounter and must be prepared to manage agitated patients. Agitation poses a safety risk for patients and professionals; healthcare workers experience 50% of all occupational assaults in the USA, with younger clinicians and those in emergency, psychiatric, and geriatric care settings placed at higher risk [1–3]. Repeated exposure to violence is a risk factor for burnout [3]. Moreover, agitation is a clinical presentation with a broad differential diagnosis including myriad life-threatening medical conditions [4]. Agitation is a nonspecific and extreme form of arousal accompanied by increased verbal and motor activity [5]. The presence of agitation may also complicate the diagnosis and treatment of concurrent conditions. Thus, trainees must learn to manage agitated patients in order to feel safe at work, maintain the safety of their patients and colleagues, and appropriately treat severe medical and psychiatric illnesses. Training contributes to a greater sense of safety and resilience in the workplace [6, 7]. The first-line treatment for all forms of agitation is verbal deescalation [4, 8]. Verbal de-escalation is a process by which the clinician collaborates with an agitated patient to decrease the intensity and discomfort of agitation. However, verbal deescalation is challenging to teach. Episodes for trainees to practice occur unpredictably, and it is difficult to maintain an agitated patient’s safety while also allowing the trainee space to make mistakes and receive feedback. Episodes of agitation are quite heterogeneous, so it is difficult to learn core skills and immediately re-apply them. Anecdotally, many faculties have not received training in contemporary de-escalation techniques. Effective curricula for teaching de-escalation skills are not widely available. Trainings commonly used by healthcare facilities are proprietary and emphasize physical safety skills for frontline staff rather than the assessment and team leadership skills expected of physicians [9, 10]. Simulation curricula appear effective in enhancing postgraduate residents’ sense of safety and performance in verbal de-escalation but are resource-intensive and may be difficult to conduct in institutions without experienced faculty [11–13]. A video-based curriculum is a promising tool for teaching skills to safely manage agitation. In this paper, we describe our production and evaluation of a video curriculum designed to teach medical students core principles in the management of agitation through verbal de-escalation.

"From All Walks of Life": Attending an Alcoholics Anonymous Meeting to Reduce Addiction Stigma Among Medical Students.

Abstract: Substance use disorders (SUDs) are stigmatized conditions in medicine, with negative attitudes toward patients with SUDs beginning to form in medical school. Only a few studies with small samples show that attending an Alcoholics Anonymous (AA) meeting may help decrease addiction stigma. This study examined whether attending an AA meeting impacts medical student attitudes toward patients with SUDs and any gender and age group differences within these attitudes. As part of their psychiatry clerkship, 138 third-year medical students attended an AA meeting and wrote reflection essays discussing expectations before the meeting, feelings while there, and thoughts on how these feelings might affect patient care. The authors performed a thematic analysis to identify themes and t tests to compare theme frequency by gender and age group. A primary theme in student responses was a reduction in stigmatizing attitudes, which was broken down into three subthemes: complexity of addiction (46%), diversity of people with addiction (37%), and practical applications (66%). Practical applications comprised compassionate care (53%) and intention to address SUDs clinically (35%). While no gender differences were found in theme frequency, younger students showed significantly higher frequency of all themes. Attending an AA meeting can challenge medical students’ stigmatizing attitudes about addiction and increase flexibility of thinking. Younger students’ biases may not be as solidified, stressing the importance of early exposure to patients in recovery during medical school. Attending an AA meeting and reflecting on the experience may be one way to decrease addiction stigma among medical students.