John A. Fromson

Error-related negativity abnormalities in generalized anxiety disorder and obsessive-compulsive disorder.

Enhanced error-related negativity (ERN) has been associated with anxiety among both non-clinical and clinical populations. However, whether it is abnormal among adult patients with generalized anxiety disorder (GAD) is still unknown. The present study investigated it across GAD and obsessive-compulsive disorder (OCD). Event related brain potentials (ERPs) were recorded from a group of 27 GAD patients, 25 OCD patients and 27 healthy control participants during a modified Erikson Flankers task. ERP difference waveforms were obtained by subtracting ERP to correct response (CRN) from ERP to error response (ERN). The Ne component of ERPs at medial frontal electrodes were analyzed and reported. The Ne component of ERP difference waveform was enhanced only in OCD patients, but not in GAD patients, as compared to the healthy controls. An exploratory analysis also revealed higher Ne amplitude of error trial waveforms in both GAD and OCD patients than in healthy controls, and an insignificant group difference in Ne component of correct trial waveforms. The Ne amplitude of error trial waveforms also correlated with Hamilton Anxiety Rating Scale (HAMA) scores and with Hamilton Depression Rating Scale (HAMD) scores across the three subject groups. The main findings of the present study suggest that error processing is altered in OCD but not in GAD, and that ERN abnormalities in GAD are possibly associated with an overactive response checking process or excessive response monitoring.

Uses of Coercion in Addiction Treatment: Clinical Aspects

Coerced or involuntary treatment comprises an integral, often positive component of treatment for addictive disorders. By the same token, coercion in health care raises numerous ethical, clinical, legal, political, cultural, and philosophical issues. In order to apply coerced care effectively, health care professionals should appreciate the indications, methods, advantages, and liabilities associated with this important clinical modality. An expert panel, consisting of the Addiction Committee of the Group for the Advancement of Psychiatry, listed the issues to be considered by clinicians in considering coerced treatment. In undertaking this task, they searched the literature using Pubmed from 1985 to 2005 using the following search terms: addiction, alcohol, coercion, compulsory, involuntary, substance, and treatment. In addition, they utilized relevant literature from published reports. In the treatment of addictions, coercive techniques can be effective and may be warranted in some circumstances. Various dimensions of coercive treatment are reviewed, including interventions to initiate treatment; contingency contracting and urine testing in the context of psychotherapy; and pharmacological methods of coercion such as disulfiram, naltrexone, and the use of a cocaine vaccine. The philosophical, historical, and societal aspects of coerced treatment are considered.

Socially Sanctioned Coercion Mechanisms for Addiction Treatment

Coercion as a strategy for treatment of addiction is an effective but often negatively perceived approach. The authors review current policies for involuntary commitments and explore coercive dimensions of treating alcohol and drug dependence in the workplace, sports, and through professional licensure. Gender-specific issues in coercion are considered, including evidence for improved treatment retention among pregnant and parenting women coerced via the criminal justice system. Social security disability benefits represent an area where an opportunity for constructive coercion was missed in the treatment of primary or comorbid substance use disorders. The availability of third-party funding for the voluntary treatment of individuals with substance use disorders has decreased. This unmet need, coupled with the evidence for positive clinical outcomes, highlights the call for implementing socially sanctioned mechanisms of coercion.

Web-Based Simulation in Psychiatry Residency Training: A Pilot Study.

BackgroundMedical specialties, including surgery, obstetrics, anesthesia, critical care, and trauma, have adopted simulation technology for measuring clinical competency as a routine part of their residency training programs; yet, simulation technologies have rarely been adapted or used for psychiatry training.ObjectiveThe authors describe the development of a web-based computer simulation tool intended to assess physician competence in obtaining informed consent before prescribing antipsychotic medication to a simulated patient with symptoms of psychosis.MethodEighteen residents participated in a pilot study of the Computer Simulation Assessment Tool (CSAT). Outcome measures included physician performance on required elements, pre- and post-test measures of physician confidence in obtaining informed consent, and levels of system usability.ResultsData suggested that the CSAT increased physician confidence in obtaining informed consent and that it was easy to use.ConclusionsThe CSAT was an effective educational tool in simulating patient—physician interactions, and it may serve as a model for use of other web-based simulations to augment traditional teaching methods in residency education.

Surgeons in Difficulty: An Exploration of Differences in Assistance-Seeking Behaviors between Male and Female Surgeons

BACKGROUND Physician burnout is associated with diminished ability to practice with requisite skill and safety. Physicians are often reluctant to seek help for an impaired colleague or for impairment that affects their own ability to practice. To better support surgeons in difficulty, we explored sex differences in assistance-seeking behaviors under stress. STUDY DESIGN Surgeons in 3 national societies completed an IRB-approved anonymous multiple-choice and free-text response survey. Responses were explored with the general linear model using item-specific continuous and categorical methods. STUDY DESIGN Two hundred and twelve surgeons (n = 79 [37.3%] male, n = 133 [63%] female) responded. Although men and women worked similar hours (p > 0.05), women worked more clinical (p < 0.01) and fewer administrative hours (p < 0.01) in later age (F = 7.88; degrees of freedom [df] 4/145; p < 0.01). Women were less satisfied with work-life balance, as identified by aggregate variables related to emotional/decisional partnership, non-work-related chore support, and personal fulfillment (F = 15.29; df 3/16; p < 0.01), but change jobs less frequently (F = 4.23; df 1/201; p < 0.05). Males are more likely to seek help from colleagues (chi-square 107.5; p < 0.01) or friends (chi-square 123.8; p < 0.01) and women are more likely to seek support from professional counselors (chi-square 146.8; p < 0.01). Almost one-third of surgeons would ignore behaviors that adversely impact well being and could result in potential personal or patient safety. CONCLUSIONS The differences between the assistance-seeking and reporting behaviors of male and female surgeons in distress could have implications for identification and treatment of this population. These findings can be used to develop educational activities to teach surgeons how to effectively handle these challenging situations.

Enhancing informed consent best practices: gaining patient, family and provider perspectives using reverse simulation

Background Obtaining informed consent in the clinical setting is an important yet challenging aspect of providing safe and collaborative care to patients. While the medical profession has defined best practices for obtaining informed consent, it is unclear whether these standards meet the expressed needs of patients, their families as well as healthcare providers. The authors sought to address this gap by comparing the responses of these three groups with a standardised informed consent paradigm. Methods Piloting a web-based ‘reverse’ simulation paradigm, participants viewed a video showing a standardised doctor engaging in an informed consent discussion. The scenario depicted a simulated patient with psychotic symptoms who is prescribed an atypical antipsychotic medication. 107 participants accessed the simulation online and completed a web-based debriefing survey. Results Survey responses from patients, family members and healthcare providers indicated disparities in information retention, perception of the doctors performance and priorities for required elements of the consent process. Conclusions To enhance existing informed consent best practices, steps should be taken to improve patient retention of critical information. Adverse events should be described in the short-term and long-term along with preventative measures, and alternative psychosocial and pharmacological treatment options should be reviewed. Information about treatment should include when the medication takes therapeutic effect and how to safely maintain the treatment. The reverse simulation design is a model that can discern gaps in clinical practice, which can be used to improve patient care.

Assessing clinicians' management of first episode schizophrenia using clinical case vignettes

Background: Patients with first episode schizophrenia may present in a variety of clinical settings to providers who have a range of knowledge and skills. A thoughtful workup of patients with new‐onset psychosis is critical, and the treatment of first episode schizophrenia differs from that of chronic psychotic disorders. Clinical case vignettes with free‐form responses can be used to carefully assess whether front line practitioners provide guideline‐adherent management of first episode psychosis.

Outcomes Assessment in Psychiatric Postgraduate Medical Education: An Exploratory Study Using Clinical Case Vignettes

The efficient and accurate assessment of clinical performance is a substantial challenge in continuing medical education (CME) and other educational settings. Currently, educational outcomes measurement in many CME programs is imperfect (1), as outcomes are often assessed through brief postparticipation questions that measure either mere participation or knowledge of isolated facts. A recent review of CME assessment activities at a large academic medical center found that over 80% of educational assessment tools measured only Kirkpatrick level 1 outcomes (2) (satisfaction/reaction), and that no educational assessment items measured outcomes related to clinical practice or patient care outcomes (3). The dilemma when attempting to assess higher-level educational outcomes is that, on one hand, closed-ended multiple-choice questions and other commonly used assessment tools are unlikely to reflect clinical practice, while on the other hand, more comprehensive tools such as simulated patients or chart reviews are time-consuming, expensive, and simply not practical in most settings. However, clinical case vignettes that allow open-ended freetext responses are a promising assessment tool that may assess clinical performance in a more efficient manner. These vignettes present a clinical case in several parts, and responses are scored with a standardized system generated a priori using extant literature and other sources of expert guidance. Such clinical vignettes, first utilized by Peabody et al. (4–6) to assess the performance of primary care physicians and internal medicine residents, appear to be essentially equivalent to standardized patients and chart audits in assessing actual clinical behavior in the management of common outpatient conditions and the provision of appropriate preventative care (4). However, case vignettes with open-ended questions and algorithmic scoring of freeform responses have only rarely been used in CME activities, (7) and to our knowledge have not yet been used to assess clinicians’ ability to evaluate and treat patients with psychiatric illness (i.e., to perform clinically relevant needs assessments). In this article, we will describe the development and implementation of clinical case vignettes to assess guideline-adherent assessment and treatment of patients with bipolar disorder and firstepisode schizophrenia among clinicians attending psychiatric CME activities.

Comment on “Examining Burnout, Depression, and Attitudes Regarding Drug Use Among Lebanese Medical Students During the 4 Years of Medical School”

To the Editor: We read with great interest the article by Talih et al. in a recent issue of the journal [1]. The authors performed a crosssectional study to evaluate the prevalence of burnout, depressive symptoms, anxiety symptoms, and attitudes toward substance use in medical students. They detected high rates of depression, burnout, and suicidal ideation among medical students in the Middle East. The authors should be congratulated for performing a well-designed study in an important topic in graduate medical education and overall physician practice [2, 3]. Additionally, the need to identify specific areas for potential interventions to prevent burnout in medical students is an innovative concept that needs to be further explored [4, 5]. Although the study by Talih et al. was well designed and well conducted, there are some questions regarding it that need to be clarified in order to determine the validity of the results. First, the analysis of burnout across medical school years would need to be adjusted for confounding factors. This would validate the authors’ important findings. Second, the authors reported a 42% response rate for the survey. The potential for generalization of the results relies on excluding response bias by contrasting the characteristics of nonrespondents with respondents of the survey. Lastly, the authors did not present common factors associated with burnout (e.g., working hours and control over personal life), and these factors can significantly change the study results. We would welcome comments to address these issues as they were not discussed by the authors. This would help to further validate the findings of this important study.

Correction to: Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol

The name of Heather Burrell Ward was incorrectly captured.