Mary Morreale

Survey of Sexual Education among Residents from Different Specialties.

ObjectiveThis study aims to determine how residents are being educated regarding sexual health, and it assesses attitudes toward sexual education and barriers to evaluating patients’ sexuality.MethodsAn anonymous Internet survey was sent to 195 residents in family practice, internal medicine, obstetrics and gynecology, and psychiatry at a single site.ResultsOne hundred seventeen surveys were completed, for a response rate of 60%. Participants reported a lack of formal education on sexual health. Although participants perceived their patients’ sexuality as important and appeared to have the appropriate knowledge to evaluate sexual issues, they failed to inquire about sexual health regularly, especially for patients from non-Western cultures. Lack of comfort or confidence did not appear to impose major barriers to the evaluation of sexual health; instead, most respondents reported lack of time.ConclusionImplementation of a formal curriculum will signal to residents that patients’ sexuality is an important topic to address.

The impact of stress and psychosocial interventions on assisted reproductive technology outcome

In natural cycles of attempted conception, stress has been shown to predict lower conception rates. The objective of this article is to determine whether stress affects the outcome of assisted reproductive technology (ART) as well. In addition, this article analyzes the effect that psychosocial interventions targeting the reduction of stress have on ART outcomes. This review examined available PubMed articles published in the past 15 years, and 28 articles were included. Looking specifically at numbers of women studied, stress appears to negatively affect ART outcome; interventions targeting stress reduction appear beneficial. Because stress appears to negatively affect ART outcome, and psychosocial interventions do not have detrimental effects, screening for stress should occur and some type of intervention considered during the ART process.

Incorporating Active Learning Into a Psychiatry Clerkship: Does It Make a Difference?

ObjectiveMedical students’ satisfaction with the psychiatry clerkship, sense of preparedness for an institutional Objective Structured Clinical Exam (OSCE), expressed likelihood of choosing psychiatry as a specialty, and National Board of Medical Examiners (NBME) psychiatry shelf-examination scores were compared after a curriculum based on Active Learning (AL) techniques was introduced.MethodsIn consecutive academic years, two groups of students were compared after completing a 1-month psychiatry clerkship. The first group (N=108) received traditional lectures, and the second (N=102) was taught via AL. Participants were surveyed regarding satisfaction, sense of preparedness for an institutional OSCE, and expressed likelihood of choosing psychiatry as a specialty. NBME psychiatry shelf-examination scores were analyzed; independent-samples t-tests were used to evaluate the data.ResultsSatisfaction and sense of preparedness for the institutional OSCE increased with AL techniques. NBME scores were not significantly different between groups. Professed likelihood of choosing psychiatry as a specialty did not increase with the interventional curriculum.ConclusionWe confirmed findings from previous studies that student satisfaction improves with active learning (AL). Sense of preparedness for the OSCE examination improved with AL, as well. NBME psychiatry exam scores and professed interest in psychiatry as a specialty were not different from those taught in a traditional format.

Survey of the Importance of Professional Behaviors Among Medical Students, Residents, and Attending Physicians

ObjectiveThe authors compared the importance of items related to professional behavior among medical students rotating through their psychiatry clerkship, psychiatry residents, and attending psychiatrists.MethodsThe authors sent an electronic survey with 43 items (rated on the scale 1: Not at All Important; to 5: Very Important) to medical students, psychiatry residents, and attending psychiatrists at one academic center.ResultsMedical students rated several items in the categories Personal Characteristics and Interactions With Patients significantly less important than did residents and attending psychiatrists. Both medical students and attending psychiatrists rated the category Social Responsibility significantly less important than did residents.ConclusionAll three groups surveyed rated the majority of items as Important or Very Important, indicating that they value professional behavior. Resident physicians had the highest mean score in every category measured. Overall, medical students rated most items related to professionalism as less important than the two other groups surveyed.

Sexual Health Education: A Psychiatric Resident’s Perspective

ObjectiveThis report discusses psychiatric residents’ perceptions of sexual health education and their opinions regarding curricular improvements.MethodsAn anonymous, web-based survey was sent to residents in one general psychiatry program (N=33). The response rate was 69.7%.ResultstResidents reported inadequate experience in multiple areas of sexual health. In every topic surveyed, 61.5% or more of the early residency group and 20% or more of the late residency group reported “none” or “too little” to both clinical and didactic experiences. Approximately one-half of residents responded that more time should be spent on every topic surveyed. The teaching modalities of didactics and outpatient clinical work were thought to provide the greatest educational benefit.ConclusionPsychiatric residents value education regarding sexual health and would like more opportunities to learn about this topic.

Providing Psychiatric Care for an Expanding Population of Cancer Survivors: Imperatives for Psychiatric Education and Leadership

The number of cancer survivors, defined as people from the point of cancer diagnosis through end of life regardless of treatment outcome, is currently greater than 15 million and predicted to exceed 20 million by 2026 [1]. For patients in the midst of treatment for cancer, the prevalence of psychiatric diagnoses is approximately 50%, with the majority being diagnosed with adjustment disorder [2]. For people on surveillance for the recurrence of cancer, myriad potential issues may cause psychological distress, including (but certainly not limited to) cognitive changes secondary to systemic chemotherapy, disfigurement, chronic pain, sexual dysfunction and infertility, and depression and anxiety related to fear of recurrence and ultimately death. Recognition is growing that effectively addressing the behavioral and psychosocial components of cancer care is key to improving overall outcomes. Caring for cancer survivors is an increasingly important responsibility for the profession of psychiatry, and preparing psychiatric residents and fellows to care for people living with and surviving cancer is an increasingly important responsibility in academic psychiatry. Who is caring for, or will care for, this large number of patients? Although fellows trained in hematology, medical oncology, hospice, and palliative medicine are expected per Accreditation Council for Graduate Medical Education (ACGME) requirements to manage some behavioral components of care, interacting with psychologists and psychiatrists as they learn to do so is not obligatory [3, 4]. Psychiatry is one of the specialties allowed to train in palliative medicine, but according to the American Board of Psychiatry and Neurology, only 110 psychiatrists have been certified between the years 2000 and 2015 [5]. The subspecialty of psycho-oncology, which began formally during the 1970s, has the stated goal of “incorporating the psychological, social, spiritual and existential dimensions and seeking to help the patient find a tolerable meaning to the presence of the unwelcome intruder of serious illness and threat to the future and to life itself,” but it does not have associated formal fellowship training [6]. Psychosomatic medicine fellowships may lean heavily toward training in cancer care, for example, the combined program at theMemorial SloanKettering andNew York Presbyterian Hospital, but ACGME program requirements in psychosomatic medicine do not require any specific exposure to oncologic populations [7, 8]. In addition, the number of psychosomatic medicine fellows produced yearly (e.g., 87 in 2015– 2016) is certainly not enough to manage the large number of cancer survivors [7]. Are general psychiatric residents currently well prepared to treat cancer survivors? The ACGME requires 2 months of consultation-liaison psychiatry, but, as in psychosomatic medicine, treatment of cancer patients is not guaranteed to be a core part of this experience [9]. In addition, if encounters with patients who have cancer do occur in these settings, psychiatric residents are more likely to focus on the acute psychiatric needs of this population than on longitudinal concerns. Most cancers occur in individuals over the age of 70 years, but only 1month of focused experience is required in geriatric psychiatry [9, 10]. It is entirely possible that a resident graduating from a program without a large associated cancer center or without considerable exposure * Mary K. Morreale mmorreale@wayne.edu

The Focus Group: A Method for Curricular Review

The first 2 years of medical school provide a foundation from which all subsequent learning is built. According to the Liaison Committee on Medical Education (LCME) guidelines, “there must be integrated institutional responsibility in a medical education program for the overall design, management, and evaluation of a coherent and coordinated curriculum” (1).Wayne State University School ofMedicine (WSU-SOM) has implemented student-run focus groups as a way in which students can constructively contribute to the process of curricular review. The purpose of this column is to detail the use of such focus groups and describe their utility. WSU-SOM utilizes several methods of curricular evaluation. For many years, 1stand 2nd-year students have been required to complete an online evaluation for each professor after successful completion of their respective course. Onethird of the student population is required to submit evaluations after any given examination. For example, in a course that has two exams, one-third of the student population evaluates the first half, and a different third evaluates the second. Students anonymously submit their responses, using an internal web page, and the results are sent to the appropriate instructors, course directors, and academic deans. Although this evaluation is helpful in critiquing a course, it does have limited usefulness. For example, the majority of questions are closed-ended, and students are asked to select an answer ranging from “not helpful” to “very helpful.” It is difficult for feedback to be fully expressed with this method. For course directors, anonymous feedback may not always be constructive in nature, including irrelevant and unduly critical comments. Also, students’ comments often do not include suggestions on how to change aspects of the course that have been graded as poor. The aforementioned evaluation system also fails to offer a way for course directors to request specific feedback about unique aspects of their own course. In order to solicit more detailed feedback from students, WSU-SOM implemented focus groups. A focus group is a “technique involving the use of in-depth group interviews in which participants are selected because they are a purposive, although not necessarily representative, sampling of a specific population, this group being ‘focused’ on a given topic” (2). Although the focus groupmay be utilized at other medical schools, our search of PubMed found no evidence of other authors’ describing this method as a means of curriculum review. The focus group design incorporates many features to minimize potential bias and error and ensure a productive critique of the course. The students charged with leading the focus groups are members of the Medical Education and Evaluation Committee, a voluntary extracurricular program that encourages exploration of medical education. At the beginning of each academic year, the students in this program convene with the overseeing dean to organize the focus groups. This particular dean is a trained, Ph.D. educator who teaches quantitative and qualitative research methods, including focus-group methodology. The student leaders are provided written guidelines that demonstrate proper interviewing techniques necessary for an objective focus group. For the courses that are to be evaluated, students select group leaders, including a moderator and comoderator. During the final week of a particular course, a random list of 50 students is generated from the class of approximately 300 students to participate in the focus group. The group leaders contact the selected students to explain the purpose of the focus group, remind students of the anonymity of their responses, and solicit participation on a chosen date at the conclusion of the course. It is important to note that, unlike the online evaluations that are mandatory, no student is required to attend the focus-group meeting. Discounting the complimentary lunch, it can be reasonably assumed that Received January 5, 2012; revised May 17, 2012; accepted July 16, 2012. From the Dept. of Psychiatry, Wayne State University School of Medicine, Detroit, MI. Send correspondence to Dr. Morreale; e-mail: mmorreale@ med.wayne.edu Copyright

What has happened to teaching human sexuality in psychiatric training programs

A 1999 poll of 500 American adults ages 25 years or older (1) revealed that 71% of respondents were concerned that their doctor would dismiss discussions related to issues of sexual problems and would say that the problems were “just in their head.” In addition, 68% were concerned that their doctor would be uncomfortable talking about the problem because it was sexual in nature, and 76% felt that there were no medical treatments available to help them. Yet this survey also indicated that people felt that sexual health was important—91% of married men and 84% of married women ranked a satisfying sexual life as important, and 94% of those polled stated that sexual enjoyment added to the quality of life at any age. Interestingly, more than 90% of respondents also believed that sexual difficulties cause problems such as depression and emotional distress. In a recent study of 501 undergraduate and graduate students in Vermont (2), 45% of participants preferred most to receive sexual health information from a provider who initiates the conversation, 32% preferred most to receive sexual health information from a provider after they themselves initiate the conversation, and 19% preferred most to receive the information from their provider after first filling out a questionnaire addressing sexual concerns. The same participants least preferred to receive the information from the internet (25%), textbooks or pamphlets (22%), or friends or family members (13%). The majority of this sample also felt much less comfortable when their provider was uncomfortable or ignored their sexual concerns, while almost three-quarters felt much more comfortable when their provider was knowledgeable about sexual concerns. Over two-thirds of the respondents also felt much more comfortable when their provider seemed comfortable addressing sexual concerns. Interestingly, while 75% of 125 medical students in another part of this study perceived that taking a sexual history would be an important part of their future career, only 58% felt adequately trained to do so. In addition, only 38% of medical students in this arm of the study felt adequately trained in addressing and treating sexual concerns of their future patients. In spite of the obvious limitations of the poll (1) (e.g., date, small sample size) and the very selected population of participants in the study (2), the message seems to be fairly clear: our patients feel that sexuality is important to them and that sexual difficulties may be connected to other mental health issues; they would like to get sexual health information from educated providers. However, we physicians may be inadequately prepared to address the sexual concerns of their patients. These are interesting and sobering notions. We dare to say that these notions are especially interesting to the field of psychiatry. Many psychological theories are rooted in early sexual experiences and sexual development. Sexual therapy used to be part of residency training at least in some programs. The assessment of both interpersonal and sexual relationships used to be an integral part of a complete biopsychosocial evaluation of our patients. Although the aforementioned survey and study (1, 2) did not focus specifically on psychiatry, their results suggest this may not still be so. Psychiatrists conduct very little research in human sexuality. Major psychiatric journals rarely publish articles focused on human sexuality beyond sexual trauma or a rare discussion related to revising the DSM diagnostic criteria. Even the composition of the DSM-V committee addressing diagnostic issues in human sexuality illustrates the lack of interest in this field—only one committee member is a psychiatrist. The situation in teaching human sexuality may be similar. The Residency Review Committee for Psychiatry has no Received January 8, 2010; accepted January 22, 2010. The authors are affiliated with the Department of Psychiatry and Behavioral Neurosciences at Wayne State University School of Medicine in Detroit. Address correspondence to Richard Balon, M.D., UPC Jefferson, 2751 E. Jefferson, Ste. 200, Detroit, MI 48207; rbalon@wayne.edu (e-mail). Copyright

Prescribing of Phosphodiesterase-5 Inhibitors Among Psychiatrists

Phosphodiesterase-5 (PDE-5) inhibitors—avanafil, sildenafil, tadalafil, and vardenafil—are approved and widely used for treatment of erectile dysfunction of various etiologies. They are also used outside of the indications approved by the U.S. Food and Drug Administration and with weak evidence from clinical trials for other sexual dysfunctions, including premature ejaculation (e.g., Asimakopoulos, Miano, Finazzi Agro, Vespasiani, & Spera, 2012; Jannini, McMahon, Chen, Aversa, & Perelman, 2011), female sexual dysfunction (e.g., Schoen & Bachmann, 2009) and sexual dysfunction associated with serotonin reuptake inhibitors and other antidepressants (e.g. Fava et al., 2006; Nurnberg, Fava, Gelenberg, Hensley, & Paine, 2007; Nurnberg et al., 2008; Segraves et al., 2007). These medications are widely prescribed by urologists and likely by primary care physicians as well as physicians of various other specialists. Because sexual dysfunctions associated with antidepressants and other psychotropic medications is a fairly frequent problem (e.g., Balon, 2006; Segraves & Balon, 2003) and treatment of sexual dysfunctions is in the scope of the practice of psychiatry, one might assume that psychiatrists prescribe PDE-5 frequently. However, psychiatrists seem to be hesitant and reserved to prescribe medications they view as having potentially serious side effects or which they view out of the scope of their practice. For example,

Introducing Motivational Interviewing into Medical Schools

It was with some hesitancy that I began to readMotivational Interviewing: A Guide for Medical Trainees. Although I have attended several medical student lectures related to the topic, I never imagined myself utilizing motivational interviewing (MI) in my practice. Shortly after beginning this manual, however, I was surprised to find myself doing just that. During a busy day in an outpatient consultation clinic, I easily fell into several of the strategies described by Drs. Douaihy, Kelly, and Gold, the editors of this book, and members of the Motivational Interviewing Network of Trainers (MINT). MI is defined as a “therapeutic conversation that employs a guiding style of communication geared towards enhancing behavior change and improving health status outcomes” (p. 2). The core tenet of MI is that health care providers should guide patients toward articulating their own desire to promote health, rather than counseling in a directive manner, which can lead to resistance. Per the editors, evidence to support the efficacy of MI is strong; when compared to giving advice, MI led to better outcomes in 75 % of randomized controlled trials (p. 5). The first part of Motivational Interviewing: A Guide for Medical Trainees describes the fundamentals of MI and contains multiple definitions, communication techniques, suggestions for effectively structuring conversations, and strategies for potential roadblocks. Following this, the editors focus on the application of MI in “challenging encounters,” such as the angry, overwhelmed, withdrawn, manipulative, and nonadherent patient. The latter half of this book explores the use of MI in various settings, including primary care and pediatrics, and delves into utilizing MI for familycentered models of care. Especially helpful for psychiatrists is chapter 13, titled “Special Populations and Settings,” which discusses howMI can be incorporated into screening for risky behaviors, substance use and eating disorders, and chronic pain. Only one chapter seemed superfluous to me, “Integrating Motivational Interviewing Into Using an Electronic Medical Record and Electronic Communication,” which describes how MI can be integrated into patient encounters where electronic medical records are utilized. The manual ends with a summary, in both a narrative and bulletpointed format. Online access to eight “video” encounters are included if the book is purchased, although a more appropriate term would be audio encounters, because they simply contain voice and rudimentary drawings. Nonetheless, listening to the practice of MI was quite helpful. Motivational Interviewing: A Guide for Medical Trainees would be an excellent choice for faculty interested in learning and teachingMI and could easily be utilized as a teaching text for resident physicians. This book is a practical guide that is truly written for trainees, often addressing this population directly. Many mnemonics and summary charts are included, which are helpful for any level of learner. Each chapter concludes with a self-assessment quiz that could serve as a simple method for review or be used as a starting point for discussion if the book is assigned as teaching material. In my opinion, the most helpful aspect of the book is the repetitive use of example conversations between patient and physician, which, although contrived at times, make the concepts feel accessible and easy to incorporate into any clinical encounter. * Mary Morreale mmorreale@med.wayne.edu