Carol I. Ping Tsao

When Residents Need Health Care: Stigma of the Patient Role

ObjectiveWhether and under what circumstances medical residents seek personal health care is a growing concern that has important implications for medical education and patient welfare, but has not been thoroughly investigated. Barriers to obtaining care have been previously documented, but very little empirical work has focused on trainees who seek health care at their home institution.MethodsA self-report survey on special issues in personal health care of residents was created and distributed at the University of New Mexico School of Medicine in 2001. The authors report findings regarding stigma, fear of jeopardy to training status, and attitudes toward seeking self-care for residents in dual roles as patients and trainees.ResultsResidents (N = 155) rated their concerns regarding stigma and jeopardy to training status and the likelihood of seeking care at their training institution for six vignettes. The vignettes were paired to make comparisons between attending or supervisor as treating physician and between clinical scenarios. Alcohol abuse, nausea and diarrhea, panic attacks, and pregnancy were the most highly stigmatizing to residents; diabetes and hypertension were the least. Differences were also found for gender and specialty.ConclusionResidents’ perceived stigma for clinical situations was an influential factor, strongly affecting concern about jeopardizing training status and likelihood of avoiding care at their home institution.

Stigma in mental health care.

Received November 28, 2007; accepted December 12, 2007. Drs. Tsao, Tummala, and Roberts are affiliated with the Departments of Psychiatry and Behavioral Health at the Medical College of Wisconsin in Milwaukee, Wis. Address correspondence to Carol I. Ping Tsao, M.D., Psychiatry and Behavioral Health, Medical College of Wisconsin, 5000 W. National Ave, Milwaukee, WI 53295; ctsao@mcw.edu (e-mail). Copyright 2008 Academic Psychiatry Stigma marks someone as different from others, leading to devaluation of that person. A social construction, stigma occurs within relationships. In his classic 1963 description, Goffman (1) defines stigma as “an attribute that is deeply discrediting,” where a person is diminished “from a whole and usual person to a tainted, discounted one.” Shifting from a focus on individual traits, subsequent formulations have identified certain psychosocial processes that lead to stigmatization. These include labeling, stereotyping, separating, status loss, and discrimination in a context of power imbalance (2). Stigma affects people adversely. Academic achievement is lower for members of stigmatized groups as compared with nonstigmatized groups, and members of stigmatized groups are at greater risk for both mental and physical diseases (3). Patients with mental illnesses are stigmatized and suffer adverse consequences such as increased social isolation, limited life chances, and decreased access to treatment (4– 6). In addition to poorer social functioning as assessed by housing and employment status (7), those with the stigma of mental illness also encounter a significant barrier to obtaining general medical care (8) and to recovery from mental illness (9). As stated by Chin and Balon (10), “The added burden that stigma imposes on the struggle to recovery can alter behavior, generate anxiety, and ultimately cause isolation from the mainstream culture.” In this issue, several manuscripts make a case for increasing familial involvement in the care of patients with mental illnesses with the aims of improving social and health outcomes for patients and providing support to family members. Suggestions range from managing confidentiality while increasing family engagement in the treatment of distressed adolescents (11) to optimizing the benefits of family money management (12) to inclusion of family across the spectrum of psychiatric clinical care (13) to more formalized reintegration of family therapy training in psychiatry residency programs (14) to making afterdeath calls to family members (15). Stigma also affects family members of persons with mental illness. Referred to as “courtesy” (1) or “associative” (16) stigma, its psychological impact can be quite deleterious. In a Swedish study, 18% of relatives of patients with severe mental illness reported that the patient would be better off dead (17). This figure increased to 40% in relatives who felt that the patient’s mental illness caused mental health problems in themselves (17). In this issue, two articles report literature reviews on stigma of families with mental illness (18) and stigma associated with suicide (19). In the first article (18), parental stigmatization of children with mental illnesses and the stigmatization of children with parents who have mental illnesses are explored. Parents are often blamed for causing mental illness in their children through poor parenting. Children are often perceived as being somehow tainted by their parents’ mental illness. In the second article (19), three survivors of suicide report their experiences and make suggestions to further diminish stigma associated with suicide. Survivors of suicide, as compared with other bereaved persons, experience more guilt and less social support. Candid disclosure about the decedent’s struggle with mental illness and suicide being the cause of death, having someone to talk with openly about the loss, and/or participation in a suicide support group can provide significant comfort to familial survivors of suicide and may go some distance in decreasing stigma. As a group, mental health professionals are no less susceptible to stigmatizing beliefs than the general population (20–22). And medical education has only a very limited benefit with regard to reducing stigmatizing beliefs (23). In a study of resident physicians from an array of medical

Maintenance ECT for recurrent medication-refractory mania

Maintenance electroconvulsive therapy (ECT) can sometimes be the only treatment that yields extended periods of euthymia to patients with severe, treatment-resistant mania. We describe a case of a patient with recurrent and severe mania who responded acutely to ECT after failing various medication trials and could only maintain euthymia with maintenance ECT.

One-Minute Preceptor Model: Brief Description and Application in Psychiatric Education

To the Editor: In 1992, Neher et al. (1) introduced an instructional algorithm to enhance clinical teaching. Used and studied primarily by faculty physicians and resident physicians in family medicine and internal medicine, there are as yet no papers reporting on its use among faculty or resident physicians in psychiatry. This letter reviews the five steps of the One-Minute Preceptor model for an audience of psychiatric educators, including psychiatric residents, using a hypothetical case.

Authorship in Scholarly Manuscripts: Practical Considerations for Resident and Early Career Physicians

The effective presentation of new knowledge through published scholarship is essential to advancing the field of medicine, and the generation of outstanding scholarship is essential to advancing the careers of academic physicians. Indeed, academic reputation and standing remains largely based on the quantity and quality of publications across diverse career tracks in academic medical centers and universities (2). Academic writing is therefore important, but learning to write papers for publication is not easy. Moreover, learning to respond to the many complexities that arise when collaborating with colleagues in developing written scholarship can be very difficult—scientifically, interpersonally, professionally, and ethically. This is especially true in modern academic settings where expectations and standards for scholarly productivity are demanding, where rigorous intellectual work often derives from a shared process, and where interdisciplinary collaboration is highly valued. Perhaps one of the most vexing issues encountered by resident physicians and early career faculty is how best to approach the assignment of authorship. There are both

A review of ethics in psychiatric research.

Purpose of review To summarize important recent contributions to the literature on the subject of ethics in psychiatric research. Recent findings Current literature reflects an expansion in the range of psychiatric research on ethics topics. Articles continue to appear on core ethics subjects such as informed consent, but many recent contributions focus on diverse issues such as third-party privacy, the ethics of Internet-based research, revisiting the wisdom of imposing medical ethics requirements on observational research, and psychiatric research ethics as applied to special populations such as children or older persons. Summary Psychiatric research is critical for the elucidation, prevention, and treatment of mental diseases. Increased attention and novel approaches taken to obtain informed consent, correcting therapeutic misconception, and guarding privacy will advance the research enterprise and continue to ensure that the subjective experiences of participants in psychiatric research remain positive.

Ethics and professionalism preparation for psychiatrists-in-training: A curricular proposal

Potential ethical issues and challenges to professionalism arise commonly in the care of patients with psychiatric illnesses. As such, education and training in medical ethics especially as applied to psychiatry and professionalism should be offered to trainees during the formative years of residency and fellowship. This article proposes a curriculum for senior residents and fellows that uses a case-centred seminar to discuss ethical dilemmas, approaches to analysing ethical issues, and to develop a course of action for resolution. Representative ethical issues and the clinical arenas in which these are most likely to arise are suggested.

Medical Student Communication Skills and Specialty Choice

ObjectiveThe aim of this study was to determine if communication skills differ for medical students entering person or technique-oriented specialties.MethodsCommunication ratings by clerkship preceptors on an institutionally required end of clerkship medical student performance evaluation (SPE) form were compiled for 2011/2012 academic year (Class of 2013). M3 clerkships and the Class of 2013 match appointments were categorized as person or technique-oriented clerkships/specialties. Mean differences in SPE communication scores were determined by analyses of variance (ANOVA) and independent t tests. Score associations were determined by Pearson correlations. Inter-item reliability was reported with Cronbach alpha.ResultsThe Class of 2013 match appointments were as follows: person-oriented (N = 91) and technique-oriented (N = 91) residency specialties. There was no significant difference in mean communication scores for medical students who entered person-oriented (mean 7.8, SD 0.4) versus technique-oriented (mean 7.9, SD 0.4) specialties (p = 0.258) or for person-oriented clerkship (mean 7.8, SD 0.4) versus technique-oriented clerkship (mean 7.9, SD 0.6) ratings for medical students who matched into person-oriented specialties (p = 0.124). Medical students who matched into technique-oriented specialties (mean 8.1, SD 0.5) received significantly higher (p = 0.001) communication ratings as compared with those matching into person-oriented specialties (mean 7.8, SD 0.5) from technique-oriented clerkships.ConclusionsCommunication with patients and families is a complex constellation of specific abilities that appear to be influenced by the rater’s specialty. Further study is needed to determine if technique-oriented specialties communication skill rating criteria differ from those used by raters from person-oriented specialties.

Three-Session Psychiatric Malpractice Curriculum for Senior Psychiatry Residents

Received September 5, 2007; revised November 13 and December 22, 2007, and February 25, 2008; accepted March 26, 2008. The authors are affiliated with the Department of Psychiatry and Behavioral Health at the Medical College of Wisconsin in Milwaukee. Address correspondence to Carol I. Ping Tsao, M.D., Medical College of Wisconsin, Psychiatry and Behavioral Health, 5000 W. National Ave, Milwaukee, WI 53295; ctsao@mcw.edu (e-mail). Copyright 2009 Academic Psychiatry Psychiatrists are among the least frequently sued of all physicians, but in recent years malpractice claims have become more common against psychiatrists, and corresponding judgments have increased (1). Few events in a physician’s professional life cause as much anxiety as being sued in a medical malpractice action. However, U.S. general psychiatry residencies do not routinely instruct trainees about medical malpractice. Though there are many papers on psychiatric malpractice, including “Malpractice and the Psychiatrist: A Primer for Residents” (2), we are not aware of any papers on malpractice curricula in medical education. Furthermore, the Accreditation Council on Graduate Medical Education does not require any specific training on medical malpractice (3). Given the importance of psychiatric malpractice in psychiatrists’ professional lives, psychiatric residency training programs could benefit from a brief course of study on the basics of medical malpractice as applied to psychiatry. At a minimum, increasing awareness of higher risk clinical situations and demystifying the legal process are anticipated to enhance residents’ sense of control and reduce their anxieties. Though the practice of medicine can never be entirely risk-free for patient or physician, instruction about malpractice may also serve a preventive goal when residents adopt some practices that make their future work more lawsuit-proof. Here we propose a curriculum for PGY-3 or PGY-4 residents that consists of two 90-minute didactic seminars, facilitated by a faculty psychiatrist, followed by a 3-hour mock trial on psychiatric malpractice. Session 1 presents a basic overview of tort law as applied to psychiatric medical negligence. Session 2 delves more specifically into the reasons psychiatrists are sued and what legal responses are available to psychiatrists. Finally, session 3 consolidates and places the learned material in the courtroom context. Resident physicians will need to research the literature to fully engage in some of the discussion questions. They might begin their investigation with one of two forensic psychiatry textbooks, such as Rosner’s Principles and Practice of Forensic Psychiatry (4) or Appelbaum and Gutheil’s Clinical Handbook of Psychiatry and the Law (5). The time spent in seminar sessions is built on the expectation of some outside preparation and designed to be interactive. Candid discourse about past clinical experiences and current or possible future conundrums is invited to contain residents’ undue anxiety about being sued and to assure residents that they are in the supportive company of others who very likely share similar concerns. This curriculum anticipates that lecture-style instruction will be minimal and the majority of each seminar will be devoted to discussion. Relatively long sessions, 90 minutes instead of 60 or 45, are suggested in the hope that there will be time for adequate discussion. Some questions designed to initiate discussion are suggested for sessions 1 and 2.

Using Learning Through Discussion in Medical Education Settings

Learning Through Discussion [1] is a straightforward methodology that can be easily learned and easily remembered by medical trainees to organize and optimize small group discussions. Though this methodologymay be familiar in other academic settings, such as colleges and universities [1], it appears relatively unknown, and thus unutilized, in medical education. A PubMed search using the term “LearningThrough-Discussion” resulted in “no items found.” In 2012, the AAMC and MedBiquitous Curriculum InventoryWorking Group [2] released a comprehensive list of instructional methods. Though Learning Through Discussion was not included among the 30 methodologies, it can be combined with “Journal Club” which also emphasizes critical reading skills [2].