Alan K. Louie

Machine Learning and the Profession of Medicine

This Viewpoint discusses the opportunities and ethical implications of using machine learning technologies, which can rapidly collect and learn from large amounts of personal data, to provide individalized patient care.

Evaluation of an Evidence-Based Tobacco Treatment Curriculum for Psychiatry Residency Training Programs.

ObjectiveSmokers with mental illness and addictive disorders account for nearly one in two cigarettes sold in the United States and are at high risk for smoking-related deaths and disability. Psychiatry residency programs provide a unique arena for disseminating tobacco treatment guidelines, influencing professional norms and increasing access to tobacco cessation services among smokers with mental illness. The current study evaluated the Rx for Change in Psychiatry curriculum, developed for psychiatry residency programs and focused on identifying and treating tobacco dependence among individuals with mental illness.MethodsThe 4-hour curriculum emphasized evidence-based, patient-oriented cessation treatments relevant for all tobacco users, including those not yet ready to quit. The curriculum was informed by comprehensive literature review consultation with an expert advisory group, faculty interviews, and a focus group with psychiatry residents. This study reports on evaluation of the curriculum in 2005–2006, using a quasi-experimental design, with 55 residents in three psychiatry residency training programs in Northern California.ResultsThe curriculum was associated with improvements in psychiatry residents’ knowledge, attitudes, confidence, and counseling behaviors for treating tobacco use among their patients with initial changes from pre- to posttraining sustained at 3-months’ follow-up. Residents’ self-reported changes in treating patients’ tobacco use were substantiated through systematic chart review.ConclusionThe evidence-based Rx for Change in Psychiatry curriculum is offered as a model tobacco treatment curriculum that can be implemented in psychiatry residency training programs and disseminated widely, thereby effectively reaching a vulnerable and costly population of smokers.

Systemic hypertension associated with tricyclic antidepressant treatment in patients with panic disorder

In a sample of 114 patients, 6 patients developed hypertension while taking tricyclic antidepressants. All these patients were diagnosed as having panic disorder, with or without major depression. Half of the 6 patients had a previous diagnosis of hypertension, which had been well controlled by antihypertensive drugs for years. A comparison group of patients with major depression, who had never had panic attacks, had no cases of hypertension induced by these antidepressants. These findings raise the possibility that patients who have panic disorder may experience cardiovascular disregulation that increases their risk for antidepressant-induced hypertension.

Residents as Teachers

Residents are entrusted with extensive teaching duties in medical schools across the country, and the educational experience of medical students during clinical training is greatly shaped by resident-teachers. We know this to be true in relation to our own learning as students and our observations in our current academic roles.We also know this to be true on the basis of the findings of the AAMC Graduate Questionnaire documenting that residents are important teachers, yet may also belittle, diminish, or unfairly treat their medical students (1). In addition to this critical role, residents are often responsible for teaching junior residents and interns. Chief residents in many programs are handed this responsibility along with their administrative duties. Residents are also in positions of teaching a wide range of others, including members of the multidisciplinary team, residents in other specialties during Consultation Rotations, family members of patients in the context of care, and, finally, teaching in community settings, includingmental health awareness programs and schoolor forensic-based educational programs. Capable, and, especially, gifted teachers possess specific skills and also have a capacity for understanding their formative influence upon others. Few residents will come to postgraduate training with well-developed teaching skills or the sense of their salience in student education. Few residents (as well as few faculty) are informed about principles of adult education and its theory or practice. Moreover, residents are busy—very busy! —mastering the many clinicallybased competencies that constitute their field of medicine. For these reasons, intentional efforts to enhance the strengths of residents as teachers are, in our view, not only valuable, but necessary. Assessing the extent to which psychiatry programs across the nation teach their residents to teach is the aim of the article by Crisp-Han et al. published in this issue of Academic Psychiatry (2). In recent years our journal has featured many articles offering guidance and perspectives on the role of resident-teachers (3–17), although this survey is the first to assess what psychiatric residency training programs are actually doing in this regard. Remarkably, formal curricular attention to help residents acquire and strengthen teaching skills was reported by73%of the programdirectorswhoparticipated in the study, and 79% viewed this effort as “very important.” Although these high percentages suggested relative consensus about having a curriculum on pedagogy, the topics chosen for each program’s curriculum were less consistent. For instance, the topic of “evaluation and feedback” was included in only 60%of the programs. Sixty percent seems low, given the fact that one would assume that all residents are involved in evaluation and feedback for medical students on psychiatry clerkships. In contrast, teaching about “lecturing skills” and “small-group skills” occurred in 45% and 42% of programs, respectively, which are skills that residents generally perform infrequently during their residencies. The manner in which topics were taught similarly varied, with “group discussion” (65%) and “lecturing” (62%) as the most common. With regard to evaluation of residents’ teaching performances, most programs used ratings by medical students (91%) and/or faculty members (76%). Attempts to standardize evaluation of residents’ teaching abilities were generally lacking, and only seven programs employed validated instruments to this end. Last, of note, left unclear by the survey is whether most of the instruction and evaluation focused on the teaching ofmedical students. If this is the case, the teaching of patients, families, nonpsychiatry members of the profession, and members of the general public merits more attention, because many physicians will only teach medical students during their residencies, but will teach others for the rest of their careers. Accepted November 13, 2012. From the Dept. of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA (AKL, LWR); the Dept. of Psychiatry, Harvard University, Massachusetts General Hospital, Boston,MA (EVB);Dept. of Psychiatry, Baylor College ofMedicine, Houston, TX (JC); Dept. of Psychiatry, University of Toronto, Wilson Centre, Toronto General Hospital, Toronto, Ontario, Canada (GRT); the University Psychiatric Center, Detroit, MI (RB); Dept. of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA (LWR). Send correspondence to Dr. Louie; e-mail: louiemd@stanford.edu Copyright

Cell-Free Desensitization of Opioid Inhibition of Adenylate Cyclase in Neuroblastoma × Glioma NG108–15 Hybrid Cell Membranes

Abstract: When membranes from neuroblastoma |MX glioma NG108–15 hybrid cells were incubated in a cell‐free system with opioid agonists, a time‐, temperature‐, and dose‐dependent desensitization to opioid inhibition of adenylate cyclase activity was observed. The composition of the system during the incubation was manipulated to elucidate the biochemical mechanisms of desensitization. Receptor coupling appeared to be a prerequisite for desensitization, because both magnesium and sodium, which are necessary for coupling, were required for desensitization. Removal of ATP and addition of cyclic AMP or cyclic GMP had no effect on desensitization.

Teaching Clinical Neuroscience to Psychiatry Residents: Model Curricula

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

Physician Wellbeing: A Critical Deficiency in Resilience Education and Training.

As physicians, we hold a unique place in society. We are entrusted with the responsibility of healing people and advancing the health of populations. This role is an honor and a privilege, and yet it is one that comes with the cost of jeopardizing our wellbeing. Physicians may be considered an “at risk” population, with higher rates of depression, anxiety, suicide, divorce, stress, and emotional exhaustion than other segments of the overall population. The role played by physicians requires many sacrifices—long hours, isolation from friends and family, psychological stress and responsibility in caring for very sick patients, tolerance of uncertainty, sleep deprivation, and huge economic burdens following many years of costly education, among others. Threats to the wellbeing of physicians begin early in training. The stresses of medical school, residency, and postgraduate work all involve managing tremendous pressures to acquire information, garner skills, develop and integrate a professional identity with the early-career physician’s sense of self, and balance work and life. Roughly half of medical students experience burnout over the first 4 years of medical training. Burnout is defined as emotional exhaustion, depersonalization (i.e., treating patients as objects), and feelings of worthlessness. Burnout results in poor self-care and patient care, diminished empathy, medical error, and poor physical health [2]. Among medical students, more than 20 % will suffer from depression within the first 2 years and up to 9 % will have suicidal ideation before graduation [3]. The number of those who are depressed may increase during the first year of residency [4]. Among practicing physicians, the suicide rate is approximately double the rate in the general population [5]. In the USA, approximately one physician dies by suicide every day—thus each year we lose to suicide about the number of graduates from two medical schools. Many factors contribute to the distress experienced by physicians. Shortages of health care professionals, demanding caseloads, verbal abuse and other belittling or bullying behaviors, tremendous debt following lengthy medical education, increased regulatory pressures, decreased insurance reimbursements for services, and staying current with overwhelming amounts of new knowledge are but a few examples. These challenges are compounded by our profession’s hidden curriculum—the reluctance to admit weakness, expose our shame of suffering from the stigma of a psychiatric disorder, or even discuss the pressures we share. It turns out that we are all deeply imperfect and that we will need to overcome much on our paths as physicians. With greater recognition of the risks associated with becoming and being a physician has also come greater understanding that our profession has, to a great extent, failed to * Eugene V. Beresin eberesin@partners.org

Strengthening Psychiatry’s Numbers

Atotal of 681 students graduating from allopathic medical schools in the United States matched into psychiatry residencies in 2013 (1). This number, small as it is, represents an increase in the percentage of U.S. medical student seniors entering psychiatry. Last year, only 3.9% of U.S. seniors—616 men and women—matched in psychiatry programs as PGY-1 residents, whereas, this year, the figure rose a tad to 4.2% (1). When compared with the ever-increasing numbers of people living in the U.S., that is, the base population of individuals who may be affected by neuropsychiatric diseases and behavioral conditions, this slight increase does not nearly keep pace (Table 1). Also, the number of U.S. medical students matching into psychiatry presents only a part of the whole picture: 681 U.S. medical students filled just about half of the positions offered in the 2013 match (1,360 positions offered; 1,330 filled); the remaining positions were filled with international medical graduates (U.S. and non-U.S. citizens), Canadian medical students, graduates fromosteopathic schools, and students who graduated the previous year. Moreover, of the nearly three-quarters-of-a-million active physicians in the United States, psychiatry is third only to preventivemedicine and clinical pathology as the specialty with the most physicians who are age 55 years or older (2). In sum, psychiatry is among the lowest specialties in terms of overall growth. Juxtapose these psychiatry workforce data against the pattern of need for mental health care in the country. Annually, nearly 60 million people in the United States experience a mental health disorder, and more than half of the adults with serious mental illness in need of services do not receive mental health care (3). Although the lifetime prevalence of psychiatric disorders is estimated to be 24%, psychiatric disorders are stigmatized and undertreated in this country, despite being a major cause of disability and premature mortality (4, 5). As the percentage of elderly people in our country increases, the absolute numbers of individuals in need of neuropsychiatric and behavioral care will also escalate disproportionally (6). At the other end of the life spectrum, almost 50% of psychiatric disorders begin in childhood and adolescence (7). More than one-third of young people with depression overall do not receive mental health care, and estimates for young people who are African American and Hispanic run as high as 78% and 86%, respectively (8). The Affordable Care Act (2010) and the Mental Health Parity Act (2008), taken together, will bring more patients into mental health treatment in the coming years. Indeed, the American Psychiatric Association (APA) recently predicted a shortage of 22,000 child and adolescent psychiatrists and 2,900 geriatric psychiatrists in the United States by 2015 (9). In the United States, approximately 8,000 child and adolescent psychiatrists care for about 20–30 million youth with serious mental illness (10), hardly sufficient for the task at hand. Furthermore, because we graduate only about 325 child psychiatrists per year, we are losing ground, with the numbers who retire. There are only about 6,000 child psychologists are in the United States, another major shortage area for treating our nation’s youth. These shortages exist, paradoxically, in one of the most economically successful regions of theworld.When looking from a global perspective, the gap is even greater between the numbers of psychiatrists, including subspecialists, needed and the burden of neuropsychiatric disease. Psychiatrists who serve in schools of medicine have increased in absolute numbers over the past decade, as they From the Dept. of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA (LWR, MG, AKL), The Dept. of Psychiatry, Sleep Epidemiology Research Center, Stanford University (MO), The Dept. of Psychiatry, Harvard Univ., and Massachusetts General Hospital, Boston, MA (EVB), Dept. of Psychiatry, Baylor College of Medicine, Houston, TX (JC), Dept. of Psychiatry and Behavioral Neurosciences,Wayne State University, Detroit, MI (RB), and the Dept. of Psychiatry, University of Toronto, Toronto, Ontario, Canada (GRT). Send correspondence to Dr. Roberts; e-mail: RobertsL@stanford.edu Copyright

Clinical features of cocaine-induced panic

A growing literature supports an association between use of cocaine and panic disorder (Jeff et al 1978; Washton and Gold 1984; Aronson and Craig 1986; Anthony et al 1989), including reports of autonomous panic disorder that did not remit after the cessation of cocaine use (Pohl et al 1987; Post et al 1987; Price and Giannini 1987; Louie et al 1989; Bystritsky et al 1991; Geracioti and Post 1991). In this report we further explore the relationship between cocaine use and the development of panic by describing the results of a telephone survey of 95 cocaine users with apparent panic. Our goal is to provide additional evidence for a relationship between cocaine and panic in a relatively large sample.

Human Trafficking and Psychiatric Education: A Call to Action

Human trafficking, including labor and sex trafficking, is an enormous global health problem involving severe forms of abuse and human rights violations. Human trafficking is defined as “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power.... for the purpose of exploitation” ([1], p. 42). Exploitation includes “the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery” ([1], p. 42). The illegal worldwide profits of forced labor amount to an estimated