Joan M. Anzia

Professionalism and the Internet in Psychiatry: What to Teach and How to Teach It

The digital revolution has had a profound impact on medicine and patient care. Patients have a growing expectation that they can find medical information on the web and discuss it with their physician by e-mail (1). Physicians, including psychiatrists, are increasingly using blogs and Twitter to promote their practices (2, 3). The internet itself is used as a vehicle for therapeutic modalities, even psychotherapy (4). Social networking among patients, physicians, and other “friends” are blurring boundaries as never before (5, 6). The potential clinical, legal, ethical, and professionalism issues in using the internet and digital media in psychiatry have been outlined elsewhere, including explicit recommendations for resident education in this area (7). This article focuses on how to teach residents about appropriate use of the internet. The evidence of unprofessional online behavior among physicians and the complexity of the potential issues raised with internet use in psychiatry suggest that psychiatric residents, educators, and administrators need explicit teaching about potential clinical, ethical, and legal pitfalls of internet use. In 2010, the President of the American Association of Directors of Psychiatric Residency Training (AADPRT) established a Taskforce on Professionalism and the Internet, charged with reviewing the literature and creating a curriculum to teach psychiatric trainees about online professionalism. Participants in a Taskforce-run workshop on this subject were asked for examples from their own experience of online professionalism concerns (8), and an outpouring of vignettes ensued. TheTaskforce undertook to create a curriculum based on vignettes designed to promote similar discussion. The principles elicited in these vignettes might be seen as extensions of well-established principles of professionalism (9, 10). Trainees accustomed to continual use of interactive technologies, however, may overlook boundary and other professionalism issues if they are not made explicit in training. The curriculum strives to address principles, rather than specific technologies, since the latter are expected to continue to evolve rapidly. The vignettes in this curriculum (available online at aadprt.org (11)) are designed for either group discussion or individual study; they are accompanied by relevant references and a teacher’s guide. The vignettes are organized around nine issues that may be relevant to various teaching venues: liability, confidentiality, and privacy; psychotherapy and boundaries; safety issues; mandated reporting; libel; conflicts of interest; academic honesty; “netiquette;” and professionalism remediation. We discuss the first eight of these topics, using vignettes from the curriculum for illustration. Where vignettes are based on actual cases, all identifying details are disguised.

The effect of an end-of-clerkship review session on NBME psychiatry subject exam scores

ObjectiveThe NBME Psychiatry Subject Examination (PSE) is used throughout North America to test MS—III end-of-clerkship knowledge; yet, literature on PSE preparatory methods remains sparse. This study assesses the effect of a curriculum intervention on NBME PSE scores.MethodsAn optional 1.5-hour review session and accompanying fill-in-the- blank handout was offered to 62 MS—III students 3 days before their exam. Students who did not attend the session were e-mailed the handout with completed answers. The primary outcome measure was a change in scores, with students in the previous year serving as the control group.ResultsThe average raw PSE score of students offered the review session was 84.53, versus 77.15 for matched controls (p <0.0001). The effect size for the intervention was 0.89.ConclusionThis study may suggest that offering a comprehensive review session to third-year medical students 3 days before their NBME PSE significantly improves their scores.

“Collateral Damages”: Preparing Residents for Coping With Patient Suicide

Losingapatienttosuicideisone ofthemost taxing emotional issues psychiatrists, psychiatry trainees, and other mental health workers ever face. Balon (1) noted that “we find it emotionally more tolerable to see our patients dying of cancer than of suicide.” Some psychiatrists reported stress levels in the weeks after a patient’s suicide comparable to levels reported in people seeking treatment after the death of a parent (2). Younger, less-experienced clinicians are more affected by patient suicide than older clinicians (2), and the psychological impact of patient suicide may be especiallypronounced in trainees (3). The most junior psychiatry trainees often care for the most challenging patients in minimally-structured settings (3). Poor outcomes may have profound effects on the trainee’s developing sense of self and may trigger feelings of personal failure. Reactions such as shock and disbelief, self-appraisal, and working through to a resolution have been described (4), as have feelings of shame, guilt, isolation, anger, abandonment, and fear of litigation (5). Despite patients’ suicide being an “occupational risk” for anyone caring for severely ill psychiatric patients, most training programs provide relatively little educational attention on helping trainees learn about and cope with the completed suicide of one of their patients (4, 6–8). Furthermore, a national survey of chief residents of psychiatry residency programsidentified lack of audio or video teachingmaterials as common barriers to education on suicide care (9). In an effort to fill this important training gap, we have developed an interactive curriculum to help psychiatrists, psychiatry trainees, and training programs cope with patient suicide. We developed a DVD, “Collateral Damages,” that provides multimodalteachingmaterialstoeducate,inform,and,most important, stimulate discussion in the aftermath of patient suicide. The Collateral Damages DVD consists of 1) a video program that includes introductory comments; five brief vignettes (two from senior faculty, two from junior faculty, and one from a trainee) on patients who killed themselves and the clinicians’ immediate emotions, thoughts, and behaviors; a panel discussion of the five psychiatrists who have provided their narratives plus two training directors, that focuses on universal themes, processes, and procedures to follow after a patient suicide, principles of dealing with families, critical-incident review, risk-management, and the roles of counseling/support trainees and colleagues, and closingcomments;2)aPowerPointpresentationemphasizing suicide-related basic epidemiological facts, emotional reactions to patient suicide,and a brief overviewofresources available to grieving individuals; 3) a patient-based case learning exercise covering Accreditation Council for GraduateMedicalEducation(ACGME)competenciesasameans

Clinical Skills Verification in General Psychiatry: Recommendations of the ABPN Task Force on Rater Training

ObjectiveThe American Board of Psychiatry and Neurology (ABPN) announced in 2007 that general psychiatry training programs must conduct Clinical Skills Verification (CSV), consisting of observed clinical interviews and case presentations during residency, as one requirement to establish graduates’ eligibility to sit for the written certification examination. To facilitate implementation of these requirements, the ABPN convened a task force to prepare training materials for faculty and programs to guide them in the CSV process. This article reviews the specific requirements for the CSV experience within general residency programs, and briefly describes the recommendations of the task force for faculty training and program implementation.MethodsMaterials prepared by the ABPN Task Force include background information on the intent of the observed interview, a literature review on assessment methods, aids to train faculty in direct observation of clinical work, directions for effective feedback, notes regarding special issues for cross-cultural trainees, clarification of performance standards, and recommendations for structuring and conducting the assessments.ResultsRecommendations of the task force include the use of a variety of clinical settings for CSV assessments, flexibility in the duration of CSV interviews, use of formative and summative feedback after each CSV assessment, and frequent use of the CSV across all years of training. Formal faculty training is recommended to help establish performance parameters, increase inter-rater reliability, and improve the quality of feedback.ConclusionsThe implementation of the CSV process provides psychiatry training programs with an excellent opportunity to assess how interviewing skills are taught and evaluated. In the process, psychiatry educators have an opportunity to establish performance parameters that will guide the training of residents in patient interaction and evaluation.

Mental Health During Residency Training: Assessing the Barriers to Seeking Care

ObjectivesResident and fellow physicians are at elevated risk for developing depression compared to the general population; however, they are also less likely to utilize mental health services. We sought to identify the barriers to seeking mental health treatment among residents across all specialties at a large academic medical center in Chicago, IL.MethodsResidents and fellows from all programs were asked to complete an anonymous self-report questionnaire.ResultsOf the 18% of residents and fellows that completed the survey, 61% felt they would have benefited from psychiatric services. Only 24% of those who felt they needed care actually sought treatment. The most commonly reported barriers to seeking care were lack of time (77%), concerns about confidentiality (67%), concerns about what others would think (58%), cost (56%), and concern for effect on one’s ability to obtain licensure (50%).ConclusionsDespite feeling that they require mental health services, few trainees actually sought care. This study identifies an overall need for improved access to mental health providers and psychoeducation for medical housestaff.

Identity Issues Specific to Women and US Citizens Graduating from International Medical Schools: A Perspective

International medical graduate (IMG) physicians are a diverse group, hailing from many different cultures and countries. There are two subgroups of IMG physicians that warrant special attention, both because of the unique challenges they face and because they are fast-growing groups: women and US citizens who graduate from international medical schools (USIMG physicians). In this chapter we explore the challenges women IMG physicians and USIMG physicians face and discuss practical tips and pathways for their success.