Glendon R. Tait

Understanding Palliative Care on the Heart Failure Care Team: An Innovative Research Methodology

CONTEXT There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team. OBJECTIVES To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team. METHODS This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams. RESULTS We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps. CONCLUSION We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

End-of-Life Care Education for Psychiatric Residents: Attitudes, Preparedness, and Conceptualizations of Dignity.

ObjectiveThe authors examined psychiatric residents’ attitudes, perceived preparedness, experiences, and needs in end-of-life care education. They also examined how residents conceptualized good end-of-life care and dignity.MethodsThe authors conducted an electronic survey of 116 psychiatric residents at the University of Toronto. The survey had a mix of qualitative and quantitative questions.ResultsEighty-two of116 invited psychiatric residents participated for a response rate of 71%. With favorable attitudes, residents felt least prepared in existential, spiritual, cultural, and some psychological aspects of caring for dying patients. Trainees conceptualized dignity at the end of life in a way very similar to that of patients, including concerns of the mind, body, soul, relationships, and autonomy. Residents desired more longitudinal, contextualized training, particularly in the psychosocial, existential, and spiritual aspects of care.ConclusionThis is the first study to examine the end-of-life educational experience of psychiatric residents. Despite conceptualizing quality care and the construct of dignity similarly to dying patients, psychiatric residents feel poorly prepared to deliver such care, particularly the nonphysical aspects of caring for the dying. These results will inform curriculum development in end-of-life care for psychiatric residents, a complex area now considered a core competency.

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

Adaptive practices in heart failure care teams: implications for patient-centered care in the context of complexity.

Background Heart failure (HF), one of the three leading causes of death, is a chronic, progressive, incurable disease. There is growing support for integration of palliative care’s holistic approach to suffering, but insufficient understanding of how this would happen in the complex team context of HF care. This study examined how HF care teams, as defined by patients, work together to provide care to patients with advanced disease. Methods Team members were identified by each participating patient, generating team sampling units (TSUs) for each patient. Drawn from five study sites in three Canadian provinces, our dataset consists of 209 interviews from 50 TSUs. Drawing on a theoretical framing of HF teams as complex adaptive systems (CAS), interviews were analyzed using the constant comparative method associated with constructivist grounded theory. Results This paper centers on the dominant theme of system practices, how HF care delivery is reported to work organizationally, socially, and practically, and describes two subthemes: “the way things work around here”, which were commonplace, routine ways of doing things, and “the way we make things work around here”, which were more conscious, effortful adaptations to usual practice in response to emergent needs. An adaptive practice, often a small alteration to routine, could have amplified effects beyond those intended by the innovating team member and could extend to other settings. Conclusion Adaptive practices emerged unpredictably and were variably experienced by team members. Our study offers an empirically grounded explanation of how HF care teams self-organize and how adaptive practices emerge from nonlinear interdependencies among diverse agents. We use these insights to reframe the question of palliative care integration, to ask how best to foster palliative care-aligned adaptive practices in HF care. This work has implications for health care’s growing challenge of providing care to those with chronic medical illness in complex, team-based settings.

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

‘Who is on your health-care team?’ Asking individuals with heart failure about care team membership and roles

Complex, chronically ill patients require interprofessional teams to address their multiple health needs; heart failure (HF) is an iconic example of this growing problem. While patients are the common denominator in interprofessional care teams, patients have not explicitly informed our understanding of team composition and function. Their perspectives are crucial for improving quality, patient‐centred care.

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

Creating Discursive Order at the End Of Life: The Role of Genres in Palliative Care Settings

This article investigates an emerging practice in palliative care: dignity therapy. Dignity therapy is a psychotherapeutic intervention that its proponents assert has clinically significant positive impacts on dying patients. Dignity therapy consists of a physician asking a patient a set of questions about his or her life and returning to the patient with a transcript of the interview. After describing the origins of dignity therapy, the authors use a rhetorical genre studies framework to explore what the dignity interview is doing, how it shapes patients’ responses, and how patients improvise within the dignity interview’s genre ecology. Based on a discourse analysis of the interview protocol and 12 dignity interview transcripts (legacy documents) gathered in two palliative care settings in Canadian hospitals, the findings suggest that these patients appear to be using the material and genre resources (especially eulogistic strategies) associated with dignity therapy to create discursive order out of their life events. This process of genre negotiation may help to explain the positive psychotherapeutic results of dignity therapy.

Pulling together and pulling apart: influences of convergence and divergence on distributed healthcare teams

Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the the relationship between competent individuals and competent teams . Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members’ perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team’s collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams’ delivery of care for the complex, chronically ill.

The Research Innovation and Scholarship in Education Program: An Innovative Way to Nurture Education

ObjectiveEducation is becoming a recognized career path in psychiatry. Yet, there are few published accounts of how to create sustainable structures within departments to support this academic focus. The authors document the creation and 5-year progress of the Research Innovation and Scholarship in Education (RISE) program at the largest psychiatry department in Canada.MethodsThe authors analyzed the RISE archive of early proposals for enhancing scholarship in the department, the 5-year plan, annual reports, and curricular vitae of members and also gathered testimonials from inaugural residents and fellows of the program. Materials were analyzed using Boyer’s framework of scholarship.ResultsOrganizationally, RISE has embodied all four tenets of Boyer’s model of scholarship. The program has allowed education research, teaching, and creative professional development to flourish in the department, and there are considerably fewer barriers to pursuing an education career path. However, as the program expands, more work needs to be done to increase funding and protected time so that even more residents, fellows, and faculty can engage in educational scholarship.ConclusionEnhancing medical education scholarship through a model that actively integrates research with teaching, creative professional development, and mentorship can help the trajectories of faculty and students wishing to make education a priority in their careers.