Kathy M. Sanders

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.

Discontinuation Reactions Following Sertraline

Despite the widespread use of the seleclive serotonin uptake inhibitors (SSRIs), data regarding discontinuation and switching from one medication to another are lacking. Moreover. it is unclear how rapidly these medications should be tapered to avoid adverse events associated with withdrawal. Many clinicians assume that SSRIs can be stopped suddenly, but discontinuation syndromes have been reported following cessation of fluoxetine (Stoukides and Stoukides 1991 ), sertraline (Louie et al 1994!. paroxetine (Barr 1994), and fluvoxamine (Mallya et al 1993). We present two cases in which discontinuation symptoms occurred when sertraline was stopped and review the literature on discon tinuation syndromes following SSRIs.

A 4-Year Curriculum on Substance Use Disorders for Psychiatry Residents.

ObjectiveThe authors describe an addiction psychiatry curriculum integrated in a general psychiatry training program to demonstrate comprehensive and practical approaches to educating general psychiatric residents on the recognition and treatment of substance use disorders.MethodsThe Massachusetts General Hospital/McLean Hospital adult psychiatric residency training program provides training in addiction psychiatry in multiple treatment settings during the 4 years of residency. Addiction specialists, nonspecialty psychiatrists, and residents and fellows provide training.ResultsAdult psychiatric residencies can provide comprehensive addiction psychiatry training that spans multiple treatment settings and postgraduate years by training general staff psychiatrists, senior residents, and fellows to assist core addiction faculty in providing addiction psychiatry education.ConclusionSubstance use disorders are common among patients presenting to general psychiatry treatment settings, and thus it is important that all psychiatric residents be well trained in the screening, diagnosis, and treatment of outpatients with these problems.

Failure to Record Delirium as a Complication of Intra-aortic Balloon Pump Treatment: A Retrospective Study

This study was conducted to determine whether or not diagnosis and treatment of delirium among patients treated with the intra-aortic balloon pump (IABP) correlates with the recording of this complication on discharge records. Since prior episodes of delirium are one of the few clear risk factors for future episodes of delirium, accurate recording of delirium on the discharge summary and list of discharge diagnoses is useful to clinicians. A retrospective review of the charts of all patients (N = 198) who underwent placement of an IABP during 1988; assessment of the type and frequency of medical and neuropsychiatric complications during IABP treatment; and comparison of chart review findings with the Massachusetts General Hospitals computer-generated lists of discharge diagnoses for the same IABP-treated patients was completed. Only 12% of patients diagnosed and treated for delirium had delirium recorded as a discharge diagnosis. In contrast, 44% and 52% of patients who had been diagnosed and treated for cerebrovascular accident and pneumonia, respectively, had these diagnoses recorded among the discharge diagnoses. Receiving a discharge diagnosis of organic brain syndrome increased the likelihood that delirium was recorded as a discharge diagnosis. Delirium is underdiagnosed as a complication associated with IABP-treatment and is under-reported on the list of discharge diagnoses, even when it is diagnosed. Further study is warranted to determine if making the diagnosis of delirium during a patients hospital course and recording its a complication at the time of discharge is translated into a higher level of preparedness by physicians during subsequent hospitalizations.

Training in a Clozapine Clinic for Psychiatry Residents: A Plea and Suggestions for Implementation

ObjectiveThe authors sought to develop a model educational clinic and curriculum for psychiatric residents, to increase knowledge and comfort about clozapine prescribing. This matters because clozapine is an important evidence-based treatment for refractory schizophrenia that remains underutilized in clinical practice.MethodsThis is a description of how the Clozapine Clinic of the Massachusetts General Hospital (MGH) Schizophrenia Program was integrated into the curriculum of the MGH-McLean Adult Psychiatric Residency.ResultsPGY-II residents participated in a weekly clozapine clinic with direct patient contact and accompanying curriculum-based instruction for a 6-week period. The method of teaching by participating in a dedicated Clozapine Clinic received favorable feedback. Residents’ knowledge about clozapine increased.ConclusionResidency programs should determine whether their trainees receive sufficient training in the use of clozapine and consider setting up clozapine clinics where feasible.

Low Incidence of Extrapyramidal Symptoms in Treatment of Delirium with Intravenous Haloperidol and Lorazepam in the Intensive Care Unit

We retrospectively reviewed 11 patients in an intensive care unit who were treated for delirium with intrave nously administered haloperidol and lorazepam. The cu mulative doses for each episode of delirium ranged from 25.5 to 1,929 mg of haloperidol and 19.5 to 2,274 mg of lorazepam. Neuroleptic-induced rigidity developed in 1 patient. After administration of the neuroleptic was dis continued, there were no residual extrapyramidal symp toms.

Geriatric Epilepsy: A Review

After the turn of the century, the proportion of population over 60 years of age is expected to be over 20%. Recent epi demiologic studies show a higher incidence of new-onset epilepsy in the population over 60 years of age compared with preceding decades of life. The predominant seizure type in up to 80% of these new cases of epilepsy is simple and com plex partial manifestation. This paper reviews the literature documenting the increased incidence of partial seizures in the aging population, explores the known etiologies of new-onset epilepsy, and uses five case vignettes presenting with com plex partial symptomatology. (J Geriatr Psychiatry Neurol 1991;4:98-105).

The Four General Competencies

A comprehensive assessment and outcome-based system of medical education is underway. All specialty residency programs within the Accreditation Council for Graduate Medical Education (ACGME) have specific medical knowledge and patient care requirements for professional practice. This process of defining the unique knowledge-base and patient care activities for psychiatry is discussed in another paper in this series. However, when it was time for the psychiatry milestone work group to decide how to approach the four general competencies (systems-based practice (SBP), practice-based learning and improvement (PBLI), professionalism (PROF), and interpersonal and communication skills (ICS)) shared by all physicians in training and throughout a life time of practice, we considered whether to adopt the general subcompetencies and milestones as defined by the ACGMEExpert Panel onmilestones or create specific subcompetencies and milestones applied to psychiatry. We chose to develop psychiatry-specific general competencies (table). This article will describe some of that process as well as highlight the unique aspects they bring to psychiatry. With these four general competencies, we define psychiatry’s contribution to the larger healthcare delivery system though our adherence to professional knowledge and behavior, as well as how we lead the clinical team within a system of care surrounding any given individual served. This is evident in our commitment to lifelong learning, maintaining, and enhancing our interpersonal and communication skills, and howwe know and utilize the larger system of care for the benefit of patients and their families. All this is possible when the individual psychiatrist is compelled by high ethical and professional standards. These four competencies bring the practitioner out of the individual doctor patient relationship (as rich, meaningful, and healing as it is) to membership within a healthcare delivery system with numerous multidisciplinary providers, as well as family and society. It is this context that we can best understand psychiatry training and the four general competencies. General competencies from a psychiatry perspective: The strength that psychiatry brings to the general competencies lies in our long standing participation and leadership in a multidisciplinary treatment team model of care. The inherent knowledge, skills, and attitudes in communicating with other healthcare providers, families, and patients are explicitly outlined in the general competencies (SBP, PBLI, PROF, and ICS). One could understand practice-based learning and improvement as an inherent component of professionalism. However, since lifelong learning for individual healthcare providers is so important to a vital and safe healthcare delivery system, it is a separate and distinct competency serving as a significant guide and standard for physician practice and ethos. Psychiatry is in a position to guide as well as to teach our medical and surgical colleagues what we know about the four general competencies in the evolving era of healthcare transformation through behavioral health integration.

Medical and neuropsychiatric complications associated with use of the intraaortic balloon pump

We conducted a retrospective chart review of 195 consecutive patients who had an intraaortic balloon pump (IABP) placed at the Massachusetts General Hospital during the calendar year 1988 to determine the incidence of complications associated with IABP treatment. Demographics, medical and psychiatric history, hospital course, medical and neuropsychiatric complications observed while on the IABP, pharmacological management, and outcome were recorded. Patients ranged in age from 26 to 81 years, with a mean of 62 years. Women comprised only 25% of the sample but had a mortality (40%) twice that of men (20%; p = 0.008). An IABP was inserted for cardiogenic shock in 52% of patients, for refractory angina in 36%, and intraoperatively in 12%. Patients were treated with an IABP for a mean of 4.4 days (range, several hours to 36 days). Complications included delirium (34%), mortality (25%), peripheral vascular insufficiency (17%), bleeding (14%), acute renal failure (14%), infection (8%), and stroke (4.6%). Delirium was associated only with a history of seizures and with development of a residual organic brain syndrome. Mortality was associated with female sex, cardiogenic shock, and number of complications present per patient. Vascular insufficiency was associated with female sex, history of peripheral vascular disease, valve replacement surgery, and mortality. Residual organic brain syndromes were more common in patients in whom delirium developed. A review of the literature on complications associated with IABP therapy is provided. This study highlights the common but previously unrecognized complication of delirium in IABP patients.