Adam M. Brenner

Uses and Limitations of Simulated Patients in Psychiatric Education

ObjectivesThe use of standardized patients (SPs) is becoming prominent as a learning and evaluation tool in both undergraduate and graduate medical education. As increasing attempts are made to extend this tool to psychiatric training and education, it has been suggested that SPs can be useful not only to expose students to the variety of psychopathologic states, but also to teach and assess complex interpersonal processes such as empathic engagement and psychodynamic psychotherapy. The author argues that current enthusiasm for this modality should be tempered with caution about its limitations.MethodsCurrent uses of SPs in psychiatry as described in the psychiatric education and general medical education literature are critically reviewed.ResultsInherent problems in the use of SPs in psychiatry are described as they relate to the nature of empathy and the uniquely interpersonal nature of psychiatry.ConclusionSPs are useful additions to our educational toolbox but have intrinsic limitations for our field due to psychiatry’s roots in the nature of empathy and the patient-psychiatrist relationship. Standardized patients are most appropriate for exposing trainees to a variety of psychopathologies and testing very discrete skills; the use of SPs is most problematic for teaching psychotherapy and assessing complex interpersonal skills, such as empathic responsiveness.

Can We Predict "Problem Residents"?

Purpose This study investigates whether data available at the time of residency application can be used to predict more accurately future problems of performance, both during and after residency. Method The authors identified all residents with reported problematic behavior across 20 years (1987–2007) at a single residency program and created a set of matched controls. Problems were further divided into “major” (leading to significant disruptions of performance and disciplinary action) and “minor” (remediable and resolved). Application materials were then reviewed for United States Medical Licensing Examination (USMLE) scores, evidence of academic failures, interviewer ratings, negative interviewer comments, negative comments in the deans letter, and negative comments in letters of recommendation. Results The presence of any negative comments in the deans letter yielded significant correlations with future problems. Further, those applicants with future major problems had significantly more negative comments in the deans letter than did those with future minor problems. Other factors such as USMLE scores, failed courses, letters of recommendation, and interviewer ratings and comments did not predict future problems. Conclusions Most of the factors the authors assessed in prospective applicants did not predict future problems, with the exception of negative (even mildly so) comments in the deans letter. The authors suggest that more attention should be paid to the use of the deans letter to assess risk among applicants, and prospective study of this assessment should be performed.

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

ObjectiveThe author describes the results of a reflection exercise for psychiatry clerkship students.MethodsThe author performed a qualitative analysis on 100 “reflection” papers written by medical students in their psychiatry clerkship and identified the most prominent thematic content.ResultsThe most common thematic content involved social issues in psychiatry, the reality of mental illness, the role of trauma, difficulties forming alliances with patients, the efficacy of interventions, the power of empathic connection, and students’ personal identifications.ConclusionReflection exercises can foster students’ awareness of their preexisting attitudes toward mental illness and the evolution of their views during training. Educators can use reflection exercises to better appreciate their students’ concerns and target curriculum content toward specific issues.

The role of personal psychodynamic psychotherapy in becoming a competent psychiatrist

The Accreditation Council for Graduate Medical Education (ACGME) has launched a competency movement that is causing a paradigm shift in psychiatric training. Psychiatry, like all medical specialties, is expected to attest to the specific competencies of its graduates.1 In particular, the Residency Review Committee for Psychiatry (RRC) has defined the need for competency in several of the psychotherapies,2 thereby generating, in turn, much discussion about how to develop this set of skills. The American Association of Directors of Psychiatric Residency Training (AADPRT) has provided specific guidelines for competency in each type of psychotherapy, including, most controversially, psychodynamic psychotherapy.3 These guidelines state that the competent resident will “demonstrate understanding of the concept of the unconscious” and also of “the multiple and complex meanings” underlying behavior. Toward this end, the resident should be able to establish an alliance with the patient that allows for “an inquiry into the patient’s inner life.” Finally, the AADPRT guidelines specify that the resident should be able to recognize, utilize, and manage aspects of transference and countertransference, and to “utilize selfreflection to learn about his/her own responses to patients.” One of the difficulties of attaining such competence in psychodynamic psychotherapy is that physicians-in-

Teaching supportive psychotherapy in the twenty-first century.

&NA; Although supportive psychotherapy has had a long history in our field, relatively little attention has been paid to defining a body of material that residents should be taught in order to fulfill our current educational mandate. Teaching the evidence base for the efficacy of supportive psychotherapy is reviewed. The article then discusses three different conceptualizations of supportive psychotherapy—as comprising the fundamental elements of all psychotherapies, as one end of a spectrum of dynamic therapies, and as a distinct set of directly helpful therapeutic interventions. The importance of each of these perspectives to an integrated model of supportive therapy is discussed in the context of the teaching and training needs of psychiatric residents.

Can We Address the Shortage of Psychiatrists in the Correctional Setting with Exposure During Residency Training

Psychiatry residents at the University of Texas Southwestern Medical Center were surveyed to investigate their attitudes towards inmates, towards various aspects of correctional psychiatry and whether rotating at the local jail is associated with these attitudes. The overall opinion towards correctional psychiatry was fairly neutral though significantly more negative than towards inpatient psychiatry. While citing a high need for psychiatrists at correctional facilities, residents reported they are not likely to work there when they complete residency. No statistical differences were found between those residents who had rotated at the local jail and those who had not. Given the severe shortage of mental health providers in correctional facilities it is important to expose residents to this and understand ways to promote correctional psychiatry as a career.

Climate Change: A Call to Action for the Psychiatric Profession

Climate change has the potential to catastrophically impact planetary and public health. The Lancet and the University College of London Institute for the Global Health Commission asserted that climate change is the biggest global health threat of this century [2]. The seriousness of this threat warrants the medical profession’s collective attention and concerted effort to mitigate it. The American Psychiatric Association (APA) released a position statement in 2017 that climate change “poses a threat to public health including mental health. Those with mental health disorders are disproportionally impacted by the consequences of climate change. APA recognizes and commits to support and collaborate with patients, communities, and other health care organizations engaged in efforts to mitigate the adverse health and mental health effects of climate change” [3]. The American Association of Community Psychiatrists has similarly recognized the disproportionate burden of climate change on vulnerable populations including those with mental illness [4]. The American Psychiatric Association has not to date, however, proposed specific formal actions in order to respond to climate change. Altha Stewart, who becomes President of the Association in May of 2018, was reported as saying that she will put the mental health issues related to climate change on the front burner [5]. Because of our special interest in educational issues, we searched for articles on climate change in education journals including Academic Medicine,Medical Education, Journal of Graduate Medical Education,Medical Teacher, and Teaching and Learning in Medicine using the search term “climate change.” We found two articles and one letter to the editor [6–8]. The first argued that the global environmental changes ahead require doctors to be professional, environmentally responsive, and socially accountable and require that doctors align their educational and research activities with the related challenges [6]. The second argued that an overwhelmed medical school curriculum should make way for a thoughtful exploration of environmental stressors (including climate change) and their impacts on human health [7]. The third argued that the profession should negotiate means of reducing its own carbon footprint both individually and collectively while assessing and preparing for the healthcare needs associated with climate change [8]. Other articles in other journals have presented a case for teaching about climate change in medical education [9, 10]. Academic Psychiatry, whose mission is to further knowledge and stimulate evidence-based advances in academic medicine in six key domains including education, leadership, finance and administration, career and professional development, ethics and professionalism, health, and well-being, has not previously addressed climate change. Our goals for this editorial, therefore, are to briefly review the scientific consensus on climate change, the associated potential consequences of climate change on human health and mental well-being, and the policies of professional societies. We comment on what we can do as a psychiatric profession to respond, with a particular focus on opportunities for leadership and education.We wish to encourage a rich and academic discourse in the pages of this journal on possible responses to * John Coverdale jhc@bcm.edu

Providing Psychiatric Care for an Expanding Population of Cancer Survivors: Imperatives for Psychiatric Education and Leadership

The number of cancer survivors, defined as people from the point of cancer diagnosis through end of life regardless of treatment outcome, is currently greater than 15 million and predicted to exceed 20 million by 2026 [1]. For patients in the midst of treatment for cancer, the prevalence of psychiatric diagnoses is approximately 50%, with the majority being diagnosed with adjustment disorder [2]. For people on surveillance for the recurrence of cancer, myriad potential issues may cause psychological distress, including (but certainly not limited to) cognitive changes secondary to systemic chemotherapy, disfigurement, chronic pain, sexual dysfunction and infertility, and depression and anxiety related to fear of recurrence and ultimately death. Recognition is growing that effectively addressing the behavioral and psychosocial components of cancer care is key to improving overall outcomes. Caring for cancer survivors is an increasingly important responsibility for the profession of psychiatry, and preparing psychiatric residents and fellows to care for people living with and surviving cancer is an increasingly important responsibility in academic psychiatry. Who is caring for, or will care for, this large number of patients? Although fellows trained in hematology, medical oncology, hospice, and palliative medicine are expected per Accreditation Council for Graduate Medical Education (ACGME) requirements to manage some behavioral components of care, interacting with psychologists and psychiatrists as they learn to do so is not obligatory [3, 4]. Psychiatry is one of the specialties allowed to train in palliative medicine, but according to the American Board of Psychiatry and Neurology, only 110 psychiatrists have been certified between the years 2000 and 2015 [5]. The subspecialty of psycho-oncology, which began formally during the 1970s, has the stated goal of “incorporating the psychological, social, spiritual and existential dimensions and seeking to help the patient find a tolerable meaning to the presence of the unwelcome intruder of serious illness and threat to the future and to life itself,” but it does not have associated formal fellowship training [6]. Psychosomatic medicine fellowships may lean heavily toward training in cancer care, for example, the combined program at theMemorial SloanKettering andNew York Presbyterian Hospital, but ACGME program requirements in psychosomatic medicine do not require any specific exposure to oncologic populations [7, 8]. In addition, the number of psychosomatic medicine fellows produced yearly (e.g., 87 in 2015– 2016) is certainly not enough to manage the large number of cancer survivors [7]. Are general psychiatric residents currently well prepared to treat cancer survivors? The ACGME requires 2 months of consultation-liaison psychiatry, but, as in psychosomatic medicine, treatment of cancer patients is not guaranteed to be a core part of this experience [9]. In addition, if encounters with patients who have cancer do occur in these settings, psychiatric residents are more likely to focus on the acute psychiatric needs of this population than on longitudinal concerns. Most cancers occur in individuals over the age of 70 years, but only 1month of focused experience is required in geriatric psychiatry [9, 10]. It is entirely possible that a resident graduating from a program without a large associated cancer center or without considerable exposure * Mary K. Morreale mmorreale@wayne.edu

Stigma and Mental Health: A Proposal for Next Steps

It might be difficult for yet another commentary exploring the effects of stigma onmental illness to sound fresh and exciting. For this reason, we want to begin by accentuating and actively guarding against the phenomena of intellectual and emotional fatigue that accompanies stringent calls to action that seem nevertheless continually ignored. In this way, we can both recognize the laudable advances that we have made in the fight against stigma, such as in the case where insurance policies in the USA have been challenged and amended in favor of mental health parity [1] and also keep in mind that much remains to be done. In this editorial, we intend to identify some areas for further attention and to argue that the practice of psychiatry will be advanced and enriched by an intermingling of coherent and consistent policy initiatives with grass-root actionable endeavors.

Availability and attitudes toward correctional psychiatry training: results of a national survey of training directors.

An online survey was developed and administered to estimate how often psychiatry residents train at correctional facilities and to explore the residency directors’ attitudes towards this training. The survey contained two factual and eight opinion questions assessing their experiences with and attitudes toward resident training in correctional facilities, and allowed for free responses. Ninety-five people participated out of 492 for a response rate of 20%. Thirty percent of responders make a correctional rotation mandatory and another 25% offer it as an elective. Approximately one-third (36%) of responders have worked at a correctional facility themselves. Opinions towards correctional psychiatry were mostly positive with the exception of various logistical difficulties being mentioned in free responses. These provisional findings should generate interest in this area as providing more resident rotations at correctional facilities may increase access to care of this patient population and provide residents valuable training opportunities.