Joanna MacDonald

Privacy, professionalism and Facebook: a dilemma for young doctors

Medical Education 2010: 44: 805–813

The oral examination: a study of academic and non-academic factors

Summary. The oral examination in psychiatry for final‐year medical students at Wellington and Dunedin School of Medicine, University of Otago, was studied. Between December 1989 and April 1990, 40 medical students were videorecorded during such an examination. The transcripts of the recording of each oral, and at a later date the videorecordings, were individually scored by a panel of six research psychiatrists who were experienced examiners. In addition verbal and non‐verbal behaviour was rated using visual analogue scales and the students completed personality and anxiety questionnaires. There was a low level of agreement between research psychiatrists in the allocation of oral marks. The oral score was positively associated with the level of confidence of the student and negatively with anxiety in men.

Supervision in psychiatry: terra incognita?

Purpose of review Supervision is accepted as a part of postgraduate psychiatric training programmes (at least in the western world). However, despite its ubiquity, it is little researched. The purpose of this review was to synthesize research on supervision in psychiatry in the last 3 years (2009–2011). Given the dearth of such research, the boundary was extended to include general medicine and other mental health professions. Recent findings The lack of research into supervision in psychiatry was confirmed by a comprehensive search of literature. The few articles published specific to psychiatry did, however, reflect the position of psychiatry, bridging medicine and the psychotherapies. Thus, they span from the impact of workplace-based assessments and reframing the theories of learning applicable to psychiatric training, through to the learning of psychotherapy by psychiatric trainees. The literature on supervision in general medicine is dominated by the impact of competency-based training, with its associated methods of assessment, and issues around the decision to entrust trainees with various professional activities. The psychotherapy supervision literature has been notable for two disparate themes: the centenary of psychotherapeutic supervision in 2009 prompted a number of scholars to write reflective pieces capturing advances and areas for further research; whereas the development of evidence-based clinical supervision has given rise to a considerable body of work. Summary Research into supervision in psychiatry remains largely a terra incognita. If supervision is to continue to occupy a role as a key component of psychiatric training, research to justify that is needed urgently.

Patients' appraisal of psychiatric trainee interview skills.

ObjectiveThe aim of this pilot project was to explore the extent to which judgments made by psychiatrist examiners accord with those of patients in postgraduate clinical examinations, so as to inform further consideration of the role of patients in such assessments.MethodSenior psychiatrist examiners (N=8) and patients (N=30) rated 16 aspects of trainee psychiatrist interviewing style and performance during 30 observed clinical interviews (OCIs) conducted in the format of official examinations.ResultsSignificant differences were apparent in the judgments of examiners and patients regarding 7 of 16 rated aspects of trainee performance. Differences were evident largely in domains in which patients could be expected to be “expert,” reflecting their subjective experience of the interviewer. By contrast, there was little difference in the judgments of patients and examiners on the more technical criteria.ConclusionThese preliminary findings provide some challenge to the assumption that psychiatrists are the best judges of the “technical” skills and knowledge required by the profession. They support previous findings, with simulated patients, of the discrepancy between patient and examiner judgments of the more subjective elements of the examination. Psychiatric patients could contribute to clinical examinations as co-examiners, rather than merely constituting the substrate for the examination.

'Is it the crime of the century?': factors for psychiatrists and service users that influence the long-term prescription of hypnosedatives.

Given the longstanding controversy about hypnosedative use, we aimed to investigate the attitudes of prescribing psychiatrists and service users towards long-term use of hypnosedative medication, and their perceptions of barriers to evidence-based nonmedication alternatives. Qualitative data from focus groups in Aotearoa/NZ were analysed thematically. A novel research design involved a service user researcher contributing throughout the research design and process. Service users and psychiatrists met to discuss each other’s views, initially separately, and subsequently together. Analysis of the data identified four key themes: the challenge, for both parties, of sleep disturbance among service users with mental health problems; the conceptual and ethical conflicts for service users and psychiatrists in managing this challenge; the significant barriers to service users accessing evidence-based nonmedication alternatives; and the initial sense of disempowerment, shared by both service users and psychiatrists, which was transformed during the research process. Our results raise questions about the relevance of the existing guidelines for this group of service users, highlight the resource and time pressures that discourage participants from embarking on withdrawal regimes and education programmes on alternatives, highlight the lack of knowledge about alternatives and reflect the complex interaction between sleep and mental health problems, which poses a significant dilemma for service users and psychiatrists.

The Low Pass Rate in the RANZCP Clinical Examinations: Is the Exam the Problem?:

Objectives: The aim of this study was to examine the role of supervision during psychiatric training in ensuring that registrars are adequately trained to meet the standards of the RANZCP examinations and to consider the implications for improving examination pass rates. Method: Audiotaped recordings of 50 h of supervision involving six supervisors and thirteen trainees, obtained 2000–2003, were transcribed and analysed thematically in a qualitative study, informed by a postmodern, Foucaultian perspective. Results: Until an examination loomed, supervisors rarely required evidence of theoretical study or structured case presentations from their trainees. The examination and the examiners served to justify the supervisors requiring such discipline. This enabled the supervisors to remain in a supportive role, while requiring higher standards from trainees. Paradoxically, while requiring higher standards ‘for the exam’, trainees were told that the examiners expected nothing more than ‘good psychiatric practice’. In presenting cases, the attributes of prioritization, thoughtfulness, conciseness and good timing were valued, as reported in both undergraduate and other postgraduate medical training. Conclusions: Much of supervision bore little relationship to preparation for college examinations until these were imminent. While the daily practice of trainees and supervisors continues to be at variance with the practices required to pass the examination (reflected by reference to ‘exam-style’ and ‘non-exam style’ presentations) the pass rates will remain low. If we believe that the standard set in the examination is that required of a practising psychiatrist, change is required to supervision and daily practice standards to reflect these standards.

Maximizing the Chances of Passing the College Examinations

What follows constitutes personal opinions and observations based on almost 10 years as a pre-examination supervisor in Wellington and 6 years on the Examinations Committee of the RANZCP. Having been asked to present this information at the recent ANZAPIT Conference in Wellington, and also quite frequendy less formally, it seemed potentially useful to disseminate the information more widely. I will examine each of the separate components of the examination in order, using the format that has existed for candidates sitting under the 1987 By-laws. Candidates under the 1992 By-laws will need to reorder some of the information.

‘Out of the frying pan’: the challenges of prescribing for insomnia in psychiatric patients

Objectives: Managing insomnia is a common challenge for psychiatrists and their patients. We have observed an increasing use of quetiapine as a hypnosedative. Methods: We conducted an audit with the aim of establishing the prescribing patterns of local general psychiatrists in New Zealand, comparing them with established guidelines and determining the extent of the prescribing of quetiapine as a hypnosedative. Participant psychiatrists were recruited from peer review groups. Each participant provided anonymised prescribing information from 10 patients and noted their intention when prescribing. Results: Twenty-five clinicians (58% response rate) responded with prescriptions for 100 in-patients and 177 community mental health patients. 60% of in-patients and 62% of community patients were prescribed medications to aid with sleep. The most commonly prescribed medications were zopiclone, quetiapine and benzodiazepines. Prescribing adhered with the recommended guidelines for 20% of benzodiazepine and 35% of zopiclone prescriptions. Two thirds (60%) of the community prescriptions for quetiapine were primarily for hypnosedation. Conclusions: There is little concordance between guidelines for hypnosedative prescribing and the practices of general psychiatrists. Less zopiclone and fewer benzodiazepines were prescribed than in other studies, while more quetiapine was prescribed. The ‘off-label’ use of quetiapine and the duration of zopiclone and benzodiazepine use are discussed.

Reflections on training in psychiatry

Objective: There is limited information as to whether graduates from postgraduate specialist medical training programmes in Australia and New Zealand feel prepared for practice, and none regarding the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) training programme. The aims of this study were: to assess the effectiveness of the RANZCP training programme in producing psychiatrists who feel prepared for their roles; and to obtain Fellowship applicants’ perceptions of the training programme. Methods: Applicants for Fellowship (i.e. trainees who had successfully completed RANZCP training) were invited to complete an anonymous online survey that assessed their preparedness for practice and their impressions of the training programme, supervision, training specialties and course content. Results: The response rate was 66% from 101 applicants. Fellowship applicants largely felt prepared for practice and had positive perceptions of the training programme. The majority stated that most of their learning goals were met, but continued training and ongoing learning was required. Areas for improvement included assessments, administration, the balance between service delivery and training, and ongoing training. Conclusions: Fellowship applicants largely felt confident in their ability to deliver psychiatric services and that the training programme was meeting their needs.

Exploring educational interventions to facilitate health professional students’ professionally safe online presence

Abstract Objective: To establish the most effective approach and type of educational intervention for health professional students, to enable them to maintain a professionally safe online presence. Method: This was a qualitative, multinational, multi-institutional, multiprofessional study. Practical considerations (availability of participants) led us to use a combination of focus groups and individual interviews, strengthening our findings by triangulating our method of data collection. The study gathered data from 57 nursing, medical and paramedical students across four sites in three countries (Aotearoa/New Zealand, Australia and Wales). A content analysis was conducted to clarify how and why students used Facebook and what strategies they thought might be useful to ensure professional usage. A series of emergent codes were examined and a thematic analysis undertaken from which key themes were crystallized. Results: The results illuminated the ways in which students use social networking sites (SNS). The three key themes to emerge from the data analysis were negotiating identities, distancing and risks. Students expressed the wish to have material about professional safety on SNS taught to them by authoritative figures to explain “the rules” as well as by peers to assist with practicalities. Our interactive research method demonstrated the transformative capacity of the students working in groups. Conclusions: Our study supports the need for an educational intervention to assist health professional students to navigate SNS safely and in a manner appropriate to their future roles as health professionals. Because health professional students develop their professional identity throughout their training, we suggest that the most appropriate intervention incorporate small group interactive sessions from those in authority, and from peers, combined with group work that facilitates and enhances the students’ development of a professional identity.