John Manring

Psychotherapy Training for Residents: Reconciling Requirements with Evidence-Based, Competency-Focused Practice.

ObjectiveThe Accreditation Council for Graduate Medical Education (ACGME) and the Royal College of Physicians and Surgeons of Canada (RCPSC) changed the training requirements in psychotherapy, moving toward evidence-based therapies and emphasizing competence and proficiency as outcomes of training. This article examines whether the therapies selected for training are evidence based and the authors review research concerning methods for training and assessment that effectively lead to competence in these psychotherapies.MethodsThe authors searched PsycINFO and PubMed for studies from 2000 to 2009 using the terms meta-analysis, metaanalyses, and psychotherapy combined with specific psychotherapies listed in the ACGME and RCPSC requirements to determine if high-level evidence supported the use of these therapies in patients with psychiatric disorders. A similar systematic search was carried out using the same search engines for all years with the terms psychotherapy, competence, training, evaluation, and therapist rating scales for the specific therapies selected by the ACGME and the RCPSC to determine if empirically validated therapist competency scales and specific teaching methods that enhance competence could be identified.ResultsMeta-analyses support the use of several psychotherapies in the treatment of patients with psychiatric disorders and specifically those selected for training. Empirically validated rating scales assess therapist competence in several therapies, and specific teaching methods enhance therapist skill.ConclusionThe Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada have incorporated evidence-based psychotherapies in their new guidelines. Evidence-based methods for assessing competence and for teaching psychotherapy are available and could be encouraged or required in the future.

Dexamethasone Suppression Test in Hospitalized Depressed Patients with Borderline Personality Disorder

There is considerable disagreement about the relationship between borderline personality disorder and the affective disorders. The authors report the results of a study of the relationship between dexamethasone suppression and depressive subtype in hospitalized depressed borderline patients. Twenty-three patients met research criteria for unipolar major depressive episode without psychosis of at least moderate severity. Thirteen patients also met criteria for borderline personality disorder. Dexamethasone suppression test (DST) results showed no significant correlation with either melancholia or borderline personality disorder alone. However, of the 13 borderlines, eight failed to suppress and six of those eight were not melancholic. The authors conclude that abnormal response to dexamethasone in nonmelancholic borderlines casts some doubt on the specificity of the DST for melancholia.

Learning psychotherapy in the digital age.

There is substantial literature documenting the process factors that lead to effective psychotherapy. Similarly, there is now a wealth of data attesting to the effectiveness of several psychotherapy brands. Little is known about the elements that facilitate learning how to be an effective clinician. One important step, after reading about a treatment model and seeing techniques demonstrated, is having the chance to practice the approach and receiving feedback and coaching from an experienced, knowledgeable supervisor. To accomplish this efficiently, most programs rely not only on trainee accounts of what went on in their therapy sessions, but also on recordings and videos of therapeutic encounters. This article describes our experience over a 5-year period in developing the use of Webcams for training psychology interns and psychiatric residents in the delivery of psychotherapy services. Pragmatic and technical details are given about how we went about establishing a recording system that is easy to use and provides secure, confidential storage of information at a reasonable cost. Discussion addresses both the weighing of choices that need to be made and overcoming the hesitation of trainees to reveal their work during treatment sessions.

Personality traits related to chronic pain location.

BACKGROUND Previous research has yielded inconsistent findings on the relationship between personality characteristics and chronic pain. The present study examines measures of alexithymia, somatosensory amplification, attachment, counterdependency, and emotional distress in 140 consecutive general medical outpatients seen in psychiatric consultation. METHODS Forty-five subjects having no chronic pain (NP) were compared to 49 subjects with chronic pain restricted to their back and/or extremities (BE) and with 46 subjects having pain involving other regions of the body (OP). RESULTS Findings demonstrated marked counterdependency traits in the BE group relative to the other two groups. By contrast, traits of alexithymia and somatosensory amplification, insecure attachment, and a high level of emotional distress characterized the OP group. A multiple logistic regression model combining counterdependency and secure attachment was 86% accurate in predicting BE (c = 0.86). CONCLUSIONS The studys findings suggest that personality traits vary according to chronic pain location, although the nature of the relationship still needs to be determined.

Using Meaningful Outcomes to Differentiate Change from Innovation in Medical Education

Major changes are being advocated and implemented in order to transform medical education. For instance, the influential Carnegie report [1] to mark the 100th anniversary of the 1910 Flexner Report calls for sweeping changes to both undergraduate and graduate education with an emphasis on increasing professionalism and replacing “seat time”with competence-based standards; the MCAT has been revised to include behavioral and social sciences and public health strategies in order to make “better doctors” [2]; reductions in the length ofmedical education have been instituted at some schools by either structuring it within 3 years or by competence-based evaluations that will allow students to graduate at their own pace [1, 3]. The AMA’s Innovation grants aim to accelerate this transformation [4]. The goal is to make better doctors. How will we know if we are succeeding? As with clinical practice with its firm embrace of evidence-based medicine, it is critical to define meaningful outcomes. Some outcomes like patient mortality are more meaningful than others such as patient satisfaction [5]. This is regularly captured in Patient-Oriented Evidence that Matters (POEMs) [6], which ask “With this intervention, did more patients improve? Have fewer complications? Live longer? Have a better quality of life?” In contrast, the medical education literature fails to distinguish among outcomes. Norcini et al. write: “Much of the research on the competence of ...graduates has focused largely on educational measures of quality” [7] such as multiple-choice examinations. “A more fundamental question is: Are there differences in clinical outcomes for patients cared for by these physicians?” [7, p. 1462]. Ideally, we need to show that teachers teach well, learners learn and apply this effectively, and patients get better. In reality, there is little evidence to show whether repeated changes in educational requirements and curricula have been effective or destructive [1–3]. To address this, we utilize a long-established hierarchy for evaluating systems of training which gauges the level and sophistication of attempts at medical education reform. This model highlights gaps and illuminates steps that must be taken to move forward in a meaningful way. More importantly, it allows us to present the first models of how to structure the Psychiatry clerkship and residency (using the learning of psychotherapy and psychopharmacology as examples) to obtain evaluations with the most meaningful outcomes.

Comments: The Milestones Hypothesis

In a recent issue, Norman et al1 and Carter2 use evocative metaphors to describe the status of the Milestone project. Norman et al1 summarize the promise of competency-based education/Milestones and categorically state, “Regrettably, these declarations appear to be more a matter of faith than of evidence.”1 Although, at this point, there is insufficient evidence that this major overhaul will be meaningful, its transformational potential remains promising. In support of the Milestones, Carter2 states that “the Next Accreditation System (NAS) and Milestones are akin to designing a plane in flight. . . . Starting in July 2014, we will all be aboard this plane that is now in midflight.” Carters statement emphasizes an important point: Milestones may be a very good idea, but their greatest challenge lies in it being an incomplete and unproven hypothesis. The next step is to replace faith with evidence. The traditional scientific approach to developing an untested hypothesis (the Milestones) into a proven theory would require studies to answer the essential question as to whether their adoption will produce better doctors in unsupervised practice and to have as many of these (positive) answers before the Milestones are broadly prescribed. For instance, it can be hypothesized that the elaborate Milestones are better than the current system of 6 general competencies, which it seeks to replace. However, the previous hypothesis—that adoption of the 6 general competencies would lead to better physicians—was never tested, and it will be a while before there are data to support the hypothesis that Milestones will be an improvement over the general competencies. This is an opportunity to sift through a bank of competencies, generate data, and then pick only those competencies that are proven to produce good physicians. For instance, do we need more (eg, interprofessional collaboration, personal and professional development),3 fewer, or different competencies and Milestones? There are suggestions that Milestones will be more expensive, at least to the consumers, so we need evidence that this extra expense is worthwhile. It is important to define outcomes a priori: better at what? Milestones carry the promise to be useful in giving more detailed and accurate feedback to trainees but do not address the critical question: Will their use make better physicians? Will there be better clinical outcomes4 or fewer adverse events5 or more cost-effective care? A positive answer to these questions is needed to make these changes meaningful and longitudinally successful. It is heartening that there are ongoing studies of the Milestones in several disciplines. These are difficult to conduct and even more difficult to fund. Therefore, we applaud the Accreditation Council for Graduate Medical Education, which “although not a funding agency, has agreed to use interest from reserves (but no current accreditation fee revenue) to provide seed funding”6 for independent educational research on other important questions. This may infuse foundations and government agencies with more confidence to support studies of critical projects, such as the Milestones. We are clearly on the right track. Addressing this promising hypothesis with scientific rigor and prudence would lead us to delay full implementation of the unproven Milestones; to conduct studies to refine their specifics, prove clinical relevance, and minimize the burden; and then to confidently prescribe a proven remedy that reliably leads to graduating the finest physicians.