Art Walaszek

Clinical Ethics Issues in Geriatric Psychiatry

Psychiatrists face a number of ethical challenges when caring for older adults and their families. Of paramount importance is ensuring that older adults have the capacity to make decisions about their medical care and their overall welfare. Psychiatrists must remain alert for the possibility of incapacity, which, if suspected, should prompt a thorough evaluation of decisional capacities. There is a robust literature guiding clinicians conducting such evaluations. Geriatric care focuses on maintaining or improving quality of life, which is especially relevant in end-of-life situations. With the aging of the United States population, discussion must take place at a societal level regarding a fair and just distribution of medical resources. Psychiatrists must be vigilant that the mental health needs of older adults, including access to effective therapies, are addressed adequately in such discussions.

A Didactic and Experiential Quality Improvement Curriculum for Psychiatry Residents

BACKGROUND Quality improvement (QI) education in residency training is important and necessary for accreditation. Although the literature on this topic has been growing, some specialties, in particular psychiatry, have been underrepresented. METHODS We developed a didactic and experiential QI curriculum within a US psychiatry residency program that included a seminar series and development of QI projects. Evaluation included resident knowledge using the Quality Improvement Knowledge Application Tool, implementation of resident QI projects, and qualitative and quantitative satisfaction with the curriculum. RESULTS Our curriculum significantly improved QI knowledge in 2 cohorts of residents (N  =  16) as measured by the Quality Improvement Knowledge Application Tool. All resident QI projects (100%) in the first cohort were implemented. Residents and faculty reported satisfaction with the curriculum. CONCLUSIONS Our curriculum incorporated QI education through didactic and experiential learning in a moderately sized US psychiatry residency program. Important factors included a longitudinal experience with protected time for residents to develop QI projects and a process for developing faculty competence in QI. Further studies should use a control group of residents and examine interprofessional QI curricula.

Neurology Didactic Curricula for Psychiatry Residents: A Review of the Literature and a Survey of Program Directors

ObjectiveMinimal literature exists on neurology didactic instruction offered to psychiatry residents, and there is no model neurology didactic curriculum offered for psychiatry residency programs. The authors sought to describe the current state of neurology didactic training in psychiatry residencies.MethodsThe authors electronically surveyed 172 directors of U.S. psychiatric residency training programs to examine the types and extent of neurology didactic instruction offered to their residents.ResultsFifty-seven program directors (33%) responded. The majority of these psychiatry residency programs offer neurology didactic instruction to their residents, as provided by both neurology and psychiatry faculty, in a number of different settings and covering many topics. However, room for improvement likely remains.ConclusionsThe authors hope this report will guide psychiatry residencies in optimizing their neurology didactic curricula. Further research should explore tools for assessing resident knowledge in neurology and measure the effectiveness of neurology curricula in increasing knowledge and improving clinical outcomes.

Geriatric patients improve as much as younger patients from hospitalization on general psychiatric units.

Objectives: To determine whether geriatric patients aged 65 and older on general adult psychiatric units improve as much as younger patients, over what duration their improvement occurs, and their risk of readmission.

Becoming a Psychiatrist-Researcher: What It Means and How to Do It

The title is not a non sequitur. It is possible to be both a psychiatrist and researcher. However, it is not easy. This article provides some information and advice for medical students, residents, research fellows, and junior faculty who have such an ambition, or need to respond to an expectation to do research by, for example, a departmental chair or promotions committee. We describe the financial and other rewards for those doing research, the skills that are required to conduct research, the opportunities for obtaining research funding or training that are available at various stages of a psychiatrist’s career, the obstacles to success in this endeavor, and some strategies for overcoming those obstacles.

Keep Calm and Recruit On: Residency Recruitment in an Era of Increased Anxiety about the Future of Psychiatry

The goal of residency recruitment is to select those applicants who are most likely to become compassionate, knowledgeable and effective psychiatrists. A corollary goal is to identify applicants who may have trouble with residency training and then to either not recruit those applicants or anticipate that they will need support and training beyond the usual curriculum in order to ensure that they succeed. Recent trends in psychiatry residency recruitment include: a greater number of available firstyear positions in psychiatry residencies, a greater number of US medical students applying to psychiatry residencies, and residency training directors receiving many more applications than in the past. This abundance of riches would seem to be a boon to our field, but it has in somewaysmade the task of holistically evaluating and ranking candidates more challenging than ever. Residencies may also have to train residents to attain somewhat different skillsets than in the past, including a greater ability to work with healthcare professionals from other specialties and disciplines, facility with technologies to improve access to mental health care (e.g., telepsychiatry), competence to provide care to an increasingly diverse population, comfort with medical complexity (as our population ages), and knowledge of how health care systems work and how to change them. This in turn suggests that residency training directors may need to alter recruitment strategies to reflect the changing needs of our field. After reviewing trends in psychiatry residency recruitment and strategies to promote successful recruitment, I propose approaches to help align residency recruitment with the needs of our field. Trends in Psychiatry Residency Recruitment

Incorporating Technology into the Psychiatric Residency Curriculum

How has academic medicine, specifically psychiatry residency training, adapted to the technological era? As part of the 2017 Accreditation Council for Graduate Medical Education (ACGME) ProgramRequirements in Psychiatry, ACGME expects residents to develop skills in the use of information technology to optimize learning. Consistent with this requirement, a survey of medical students and residents found that 96% of respondents agreed or strongly agreed that “technology skills are important in medical training” [1]. Some training programs have developed initiatives to incorporate technology-based interventions within trainee education including the National Neuroscience Curriculum Initiative (NNCI). In 2013, psychiatry program directors at Columbia, Yale, Pittsburgh, and Brown collaborated to create the NNCI. They incorporate modern technology to develop neurobiology education material for residents. Their website, www.nncionline.org, provides web-based courses designated for use in the classroom, clinical setting, or for self-study. Incorporating technology into an academic setting offers numerous benefits to both users and developers. To help accommodate the busy clinical schedules of residents, most technologybased education resources are available 24/7, allowing for ondemand education [2–6]. A strength of digital databases is that they allow for storage and quick distribution of countless articles and educational resources [3, 7–10]. Also, by being able to electronically submit responses anonymously, technology provides residents the opportunity to give and receive feedback easily without the anxiety of direct confrontation [8, 11]. For residency programs, a key advantage of a technologically based educational curricula is that it is a non-consumable resource. Its constant availability decreases the time commitment associated with in person lectures by eliminating to need of scheduling yearly lecturers who may reschedule, cancel, or arrive later than planned [3]. The ease of communication allows for potential collaboration between programs to help create a more standardized educational experience for users [11–13]. Technology-based education can take various forms based on the needs of the institution or target audience. It may function as a stand-alone intervention or could be incorporated with traditional educational modalities in a hybrid model. The goal of this review article is to investigate the progress that technology-based education has made within psychiatric training as well as barriers to the implementation process, and strategies for overcoming these barriers.

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

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

American Association of Directors of Psychiatric Residency Training (AADPRT) Position Statement on the Executive Order on Immigration

The American Association of Directors of Psychiatric Residency Training strives to ensure that we are training psychiatry residents and fellows to deliver the very best mental health care to the people of the USA. Our organization represents several hundred residency training directors, program administrators, and other faculty and staff, who in turn educate nearly 7000 residents and fellows. One of our goals as educators is to foster an environment wherein residents can learn how to become the very best psychiatrists. Thus, we are deeply concerned about the impact of the immigration executive order on current and future psychiatry residents, in particular, International Medical Graduates (IMGs). IMGs constitute approximately one-third of psychiatry residents, over one-half of psychiatry fellows, and one-quarter of psychiatrists in practice. IMGs are more likely to practice in rural areas and they disproportionately care for patients with Medicare and Medicaid. In other words, they are vitally important for the mental health of our nation. We fear that the executive order is resulting in uncertainty and apprehension that will affect our residents’ training—and perhaps even jeopardize residents’ ability to enter or complete their training. Our concern extends to our residents’ families, who are vital supports for our residents. We are concerned about our faculty who are IMGs and who are essential in training residents, medical students, and other health care providers. The executive order creates an environment whereby every non-US citizen IMG could experience significant anxiety. We urge our nation to consider the effects of the executive order on the current and future supply of psychiatrists—and in turn the unintended consequences on the mental health of our nation. We are trying to get a clearer sense of the scope of the impact of the executive order on psychiatry residents and faculty, and on our patients. In the meantime, we encourage our members to express their concerns and views through the democratic process, including reaching out to their elected officials and partnering with organizations that communicate directly with elected officials. Our nation is fortunate to have so many psychiatric educators who are passionate about ensuring that all of our residents, colleagues, and patients, irrespective of national origin, are treated with respect and dignity.

Residency Patient Safety Curricula and American Board of Psychiatry and Neurology Patient Safety Courses.

To the Editor: There have been many important changes in recent years in the requirements for maintaining certification through the American Board of Psychiatry and Neurology (ABPN). One such change, originating from the American Board ofMedical Specialties, involves the requirement for completion of a Patient Safety Course, with the meaningful goal of improved patient safety. Beginning with those who pass a certification or maintenance of certification (MOC) exam in 2016, diplomates will be required to complete a Patient Safety Course within the 3 years prior to board certification/recertification or within their first MOC block [1]. Thus, for example, diplomates who are taking their initial certification exam in 2016 can complete the Patient Safety Course during the time of their residency training. According to the ABPN, one of two options can be used to complete the Patient Safety Course: “a Patient Safety Course required by an accredited institution (e.g., hospitals, clinics, training programs), or a Patient Safety Course listed on the ABPN Approved Products List” [1]. The candidate must be able to provide documentation of successful completion of the Patient Safety Course if audited. Anecdotally, many psychiatry residency programs are unaware that they could be informing their residents that their already existing (or to be developed) Patient Safety Courses could count for future ABPN credit. Our residency program’s quality improvement (QI) and patient safety curriculum has been previously described in the literature [2] and has received Institutional Review Board exemption for study of it. Since its inception in 2009, it has consisted of didactic and experiential components. All post-graduate year (PGY) three residents work in pairs to implement QI projects during one half-day per week of protected time for 9 months. A 15.5-h interactive didactic course addressing patient safety and QI topics accompanies the hands-on experience. A number of additions to our QI curriculum have been made within the past 2 years in response to the ACGME Milestones [3] and with a goal of improving our residents’ understanding and application of patient safety principles. For example, the Milestones state that, by the time of graduation, residents should “participate in formal analysis (e.g., root cause analysis...) of medical errors and sentinel events” and “develop content for and facilitate a patient safety presentation or conference focusing on systems-based errors in patient care (i.e., a morbidity and mortality [M&M] conference”. Consequently, this program’s curriculum now requires each resident to participate in the presentation of an M&M conference case and to participate in a Department of Psychiatry Peer Review meeting where adverse outcomes and root cause analyses are discussed. In other words, residents learn how to implement methods of improving patient safety. These new curricular elements appeared to align with ABPN recommended topics for Patient Safety Courses [1]. Several pre-existing elements did as well, e.g., our teaching about patient safety culture by highlighting the importance of our institution’s online system in which errors or near misses can be anonymously reported, and viewing of an online video that demonstrates resistance that can be met by providers who speak up about patient safety concerns [4]. In consultation with the ABPN, it was determined that our QI and patient safety curriculum for residents would meet the ABPN requirements for a Patient Safety Course. Thus, graduates of our * Claudia L. Reardon clreardon@wisc.edu