David A. Ross

The Future of Psychiatry as Clinical Neuroscience: Why Not Now?

In 2012, Thomas Insel,1 director of the National Institute of Mental Health, wrote an essay entitled The Future of Psychiatry ( = Clinical Neuroscience), echoing a familiar trope in our field.2 The themes he described then are even more relevant today. Technologic advances have enhanced our ability to study the brain, and new findings have reshaped the fundamental way in which we understand psychiatric illness. For example, although depression was once characterized as simply a monoaminergic deficit, new research is expanding our understanding of depression across multiple levels of analysis—from circuits, to neurotransmitters, to synaptic plasticity, to second messenger systems, to epigenetic and genetic differences.3 To date, however, these advances seem largely limited to the pages of our leading research journals. We have not yet experienced a paradigm shift in the way most physicians approach patient care or in the way we communicate about our field with each other and with the lay public. Given how much progress has already been made, why does this transition remain a thing of the future? What barriers prevent our field from embracing a new identity today?

Cortical plasticity in an early blind musician: an fMRl study

Many studies have examined tactile perception and simple auditory perception in the blind, but none have previously investigated the neural basis of musical ability in this group. This topic is of particular interest because it has been suggested that early blind individuals may possess advanced musical skills (such as absolute pitch). Presumably, these skills could be the result of neural plasticity. It has been hard to empirically assess this claim because of the difficulty in recruiting an adequate number of subjects for use in a conventional paradigm. In the present paper, we report data from a congenitally blind musician, subject ML. Behavioral tests show that she possessed absolute pitch abilities that were similar to those of a reference group of AP musicians with normal vision. To examine the neural basis of her abilities we then tested subject ML and five control subjects using an fMRI paradigm. A regions-of-interest analysis found that similar areas (the right secondary auditory cortex, left IFG, left SMG) were activated in ML and the control subjects, to a similar degree, in response to music processing. However, ML showed additional activations in left parietal association cortices and extrastriate regions of the occipital lobe. Subject MLs data are consistent with a vast body of literature on blindness-induced plasticity. They extend these findings by demonstrating that cortical plasticity may underlie special musical skills as well. These data illustrate the potential value of case studies to investigate particularly rare phenotypes.

Do scores on three commonly used measures of critical thinking correlate with academic success of health professions trainees? A systematic review and meta-analysis.

Purpose To determine whether the three commonly used measures of critical thinking correlate with academic success of medical professionals in training. Method The search for English-language articles (from 1980 to 2011) used Medline, Embase, Scopus, Cochrane Library on Ovid, Proquest Dissertations, Health and Psychosocial Instruments, PsychINFO, and references of included articles. Studies comparing critical thinking with academic success among medical professionals were included. Two authors performed study selection independently, with disagreement resolved by consensus. Two authors independently abstracted data on study characteristics, quality, and outcomes, with disagreement resolved by a third author. Critical thinking tests studied were the California Critical Thinking Skills Test (CCTST), California Critical Thinking Disposition Inventory (CCTDI), and Watson-Glaser Critical Thinking Appraisal. Correlation coefficients were pooled in meta-analysis. Results The search identified 557 studies: 52 met inclusion for systematic review, 41 of which were meta-analyzed. Critical thinking was positively correlated with academic success, r = 0.31 (95% confidence intervals [CI] 0.26, 0.35), with a moderate statistical heterogeneity (I2 = 67%). In subgroup analysis, only student type had statistical significance for correlation, although bias was likely due to low numbers for some student types. In direct comparison, using studies that employed two critical thinking tests, the CCTDI (r = 0.23, 95% CI 0.15, 0.30) was significantly inferior (P < .001) to the CCTST (r = 0.39, 95% CI 0.33, 0.45). Conclusions Critical thinking was moderately correlated with academic success of medical professionals in training. The CCTDI was inferior to the CCTST in correlating with academic success.

An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review

Importance Posttraumatic stress disorder (PTSD) is a common psychiatric illness, increasingly in the public spotlight in the United States due its prevalence in the soldiers returning from combat in Iraq and Afghanistan. This educational review presents a contemporary approach for how to incorporate a modern neuroscience perspective into an integrative case formulation. The article is organized around key neuroscience “themes” most relevant for PTSD. Within each theme, the article highlights how seemingly diverse biological, psychological, and social perspectives all intersect with our current understanding of neuroscience. Observations Any contemporary neuroscience formulation of PTSD should include an understanding of fear conditioning, dysregulated circuits, memory reconsolidation, epigenetics, and genetic factors. Fear conditioning and other elements of basic learning theory offer a framework for understanding how traumatic events can lead to a range of behaviors associated with PTSD. A circuit dysregulation framework focuses more broadly on aberrant network connectivity, including between the prefrontal cortex and limbic structures. In the process of memory reconsolidation, it is now clear that every time a memory is reactivated it becomes momentarily labile—with implications for the genesis, maintenance, and treatment of PTSD. Epigenetic changes secondary to various experiences, especially early in life, can have long-term effects, including on the regulation of the hypothalamic-pituitary-adrenal axis, thereby affecting an individual’s ability to regulate the stress response. Genetic factors are surprisingly relevant: PTSD has been shown to be highly heritable despite being definitionally linked to specific experiences. The relevance of each of these themes to current clinical practice and its potential to transform future care are discussed. Conclusions and Relevance Together, these perspectives contribute to an integrative, neuroscience-informed approach to case formulation and treatment planning. This may help to bridge the gap between the traditionally distinct viewpoints of clinicians and researchers.

Racial Disparities in Medical Student Membership in the Alpha Omega Alpha Honor Society

Importance Previous studies have found racial and ethnic inequities in the receipt of academic awards, such as promotions and National Institutes of Health research funding, among academic medical center faculty. Few data exist about similar racial/ethnic disparities at the level of undergraduate medical education. Objective To examine the association between medical student race/ethnicity and induction into the Alpha Omega Alpha (A&OHgr;A) honor society. Design, Setting, and Participants This study analyzed data from the Electronic Residency Application Service, the official service used by US medical students to apply to residency programs. A total of 4655 US medical students from 123 allopathic US medical schools who applied to 12 distinct residency programs associated with one academic health center in the 2014 to 2015 academic year were studied. Main Outcomes and Measures Membership in the A&OHgr;A society among black, white, Hispanic, and Asian medical students. Results A total of 4655 unique applications were analyzed in the study (median age, 26 years; 2133 women [45.8%]). Overall, self-reported race/ethnicity in our sample was 2605 (56.0%) white (691 [71.5%] of A&OHgr;A applicants were white), 276 (5.9%) black (7 [0.7%] A&OHgr;A), 186 (4.0%) Hispanic (27 [2.8%] A&OHgr;A), and 1170 (25.1%) Asian (168 [17.4%] A&OHgr;A). After controlling for US Medical Licensing Examination Step 1 scores, research productivity, community service, leadership activity, and Gold Humanism membership, the study found that black (adjusted odds ratio [aOR], 0.16; 95% CI, 0.07-0.37) and Asian (aOR, 0.52; 95% CI, 0.42-0.65) medical students remained less likely to be A&OHgr;A members than white medical students. No statistically significant difference was found in A&OHgr;A membership between white and Hispanic medical students (aOR, 0.79; 99% CI, 0.45-1.37) in the adjusted model. Conclusions and Relevance Black and Asian medical students were less likely than their white counterparts to be members of A&OHgr;A, which may reflect bias in selection. In turn, A&OHgr;A membership selection may affect future opportunities for minority medical students.

Integrating Neuroscience in the Training of Psychiatrists: A Patient-Centered Didactic Curriculum Based on Adult Learning Principles

ObjectiveThe authors describe the development and implementation of a new adult psychiatry residency didactic curriculum based on adult learning principles and an integrative, patient-centered approach that includes a progressive 4-year neuroscience curriculum.MethodThe authors describe the process of conducting a needs assessment, engaging stakeholders and developing guiding principles for the new curriculum. The curriculum was evaluated using qualitative measures, a resident survey, course evaluations, and a pilot version of a specialized assessment tool.ResultsFeedback from the resident survey and from course evaluations was positive, and residents indicated interest in receiving additional training in neuroscience. Residents self-reported not incorporating neuroscience into formulation and treatment planning as often as other perspectives. They also reported that neuroscience was reinforced less by clinical faculty than other perspectives. Performance on the curriculum assessment corroborated that clinical application of neuroscience may benefit from additional reinforcement.ConclusionsResidents responded well to the design and content of the new didactic curriculum. The neuroscience component appears to have achieved its primary objective of enhancing attitudes to the field. Continued work including enhancing the culture of neuroscience at the clinical sites may be required to achieve broader behavioral goals.

A quantitative experimental paradigm to optimize construction of rank order lists in the National Resident Matching Program: the ROSS-MOORE approach.

Purpose As part of the National Resident Matching Program, programs must submit a rank order list of desired applicants. Despite the importance of this process and the numerous manifest limitations with traditional approaches, minimal research has been conducted to examine the accuracy of different ranking strategies. Method The authors developed the Moore Optimized Ordinal Rank Estimator (MOORE), a novel algorithm for ranking applicants that is based on college sports ranking systems. Because it is not possible to study the Match in vivo, the authors then designed the Recruitment Outcomes Simulation System (ROSS). This program was used to simulate a series of interview seasons and to compare MOORE and traditional approaches under different conditions. Results The accuracy of traditional ranking and the MOORE approach are equally and adversely affected with higher levels of intrarater variability. However, compared with traditional ranking methods, MOORE produces a more accurate rank order list as interrater variability increases. Conclusions The present data demonstrate three key findings. First, they provide proof of concept that it is possible to scientifically test the accuracy of different rank methods used in the Match. Second, they show that small amounts of variability can have a significant adverse impact on the accuracy of rank order lists. Finally, they demonstrate that an ordinal approach may lead to a more accurate rank order list in the presence of interviewer bias. The ROSS-MOORE approach offers programs a novel way to optimize the recruitment process and, potentially, to construct a more accurate rank order list.

Integrating a Neuroscience Perspective Into Clinical Psychiatry Today

As psychiatrists, we are asked to treat patients with extremely complex illnesses. There are many possible ways to think about and formulate cases, including a range of psychological and social perspectives, each with their own strengths and limitations. To varying degrees, these perspectives have rightfully guided the development of our field and continue to shape the standards of our practice. During the past 20 years, revolutionary new tools and approaches in neuroscience have led to unprecedented progress in our ability to understand the biological underpinnings of psychiatric illnesses.1 This work very much complements rather than competes with our other rich traditions. In fact, distinctions between “psychological” and “biological” are rapidly fading as evidence demonstrates that all effective treatments (whether psychotherapy or pharmacologic agents) alter core brain networks and thus are all biological in nature.2 Cognitive neuroscience is providing contemporary neural system models for understanding psychodynamic concepts such as our sense of self, defenses and drives, and unconscious thoughts and motivations.1 In addition, an understanding of epigenetics offers novel insights into how social context and environmental factors translate into biological changes at the level of gene expression.3 Collectively, these advances offer a new framework for drawing together the seemingly diverse perspectives of a traditional biopsychosocial formulation.4 They present an opportunity to create a new dialogue with our patients, their families, and other health care professionals about the cause and meaning of psychiatric symptoms. They ground psychiatric disorders and associated maladaptive behaviors in the context of a brain disease and away from issues of character and moral fiber that often drive the shame, blame, and stigma many patients face. While many of these findings have not yet translated into novel therapeutic approaches, they can still guide and inform our treatment choices. For example, understanding the role that fear conditioning and learning plays in posttraumatic stress disorder helps to clarify why trauma-focused psychotherapies are currently our most effective treatments.5,6 Despite the relevance of neuroscience to the practice of psychiatry, figuring out how to best integrate this perspective into our field remains a challenge.7 Psychiatry has been a well-established clinical discipline since long before we had the power to study the brain in a nuanced manner, let alone to develop sophisticated biological explanations of psychiatric illness. Accordingly, it is no surprise that such a large practice gap should exist: although mental illness is increasingly understood in terms of genetics, developmental neurobiology, and underlying neural circuitry, these essential perspectives are frequently absent from clinical work. This practice gap is also evident within residency training: program directors in psychiatry overwhelmingly believe that it is important to incorporate neuroscience teaching into their curricula; yet, for a host of reasons, few programs have been able to do so in a comprehensive manner.7 In response to these challenges, the National Neuroscience Curriculum Initiative (NNCI) was developed to help improve the teaching of neuroscience in psychiatry, with an initial focus on residency programs. Through a collaboration between educators and neuroscientists, the overarching aim of the NNCI has been to create, pilot, and disseminate a comprehensive set of shared resources, rooted in principles of adult learning, that will help train psychiatrists to integrate a modern neuroscience perspective into every facet of their clinical work. Interest in this effort has exceeded expectations. Between March 2015 and November 2016, the NNCI website (http://www .NNCIonline.org) has hosted more than 15 000 unique users from 130 countries with more than 127 000 page views. Most importantly, more than 75 psychiatry training programs have reported implementing NNCI teaching materials. While these efforts are transforming neuroscience teaching in the classroom, such gains will have limited effect if they are not reinforced in clinical settings. If residents spend most of their time training on clinical services where a neuroscience perspective is essentially absent, the implication is that it is not important. To this end, we must address the challenge of “translational teaching”: how do we bridge the gap in neuroscience education from the classroom to the clinic? This is a particularly daunting task. As modern medicine becomes increasingly complex, we have each become specialists in our own narrow niches. Most teaching faculty—and psychiatrists in general—are understandably immersed in the practical demands of clinical work. At the same time, neuroscientists are immersed in cutting-edge research, which is often focused on molecular studies or animal models that may seem remote from the clinical reality of patient care. As seen in various sociopolitical contexts, each group may exist in its own echo chamber and communicate primarily (if not exclusively) with those who share similar perspectives. Opportunities for dialogue between researchers and clinicians are limited, all the more so because each group speaks a fundamentally different language. Thus, a major part of the challenge at hand is to facilitate communication across this deep cultural divide. With all of these issues in mind, we are pleased to be able to publish the inaugural Educational Review in the JAMA Psychiatry. In many ways, this article6 is the embodiment of all the ideas and principles that we have VIEWPOINT

Absolute Pitch in Children prior to the Beginning of Musical Training

Absolute pitch (AP) is a rare skill, historically defined as the ability to name notes. Until now, methodologic limitations made it impossible to directly test the extent to which the development of AP depends on musical training. Using a new paradigm, we tested children with minimal musical experience. Although most children performed poorly, two performed comparably to adult possessors of AP. Follow‐up testing showed that the performance of both children progressed to that of “classic” AP. These data support the theory that AP can result from differences in the encoding of stimulus frequency that are independent of musical experience.

The Use of a Small Private Online Course to Allow Educators to Share Teaching Resources Across Diverse Sites: The Future of Psychiatric Case Conferences?

ObjectiveThe authors sought to demonstrate the feasibility of integrating small private online course (SPOC) technology with flipped classroom techniques in order to improve neuroscience education across diverse training sites.MethodsPost-graduate medical educators used SPOC web conferencing software and video technology to implement an integrated case conference and in-depth neuroscience discussion.ResultsTen psychiatry training programs from across the USA and from two international sites took part in the conference. Feedback from participants was largely positive.ConclusionThis pilot demonstrated the feasibility of such a program and provided a diverse audience with the opportunity to engage in an interactive learning experience with expert faculty discussants. This may be a useful model for programs with limited local expertise to expand their teaching efforts in a wide range of topics.