Matthew Goldenberg

Suicide among soldiers: a review of psychosocial risk and protective factors.

Suicide is difficult to predict and prevent and remains a leading cause of death worldwide. Although soldiers historically have had a suicide rate well below that of the general population, the suicide rate among members of the U.S. Army has increased markedly over the past several years and now exceeds that of the general population. This paper reviews psychosocial factors known to be associated with the increased risk of suicidal behavior in general and describes how some of these factors may be especially important in understanding suicide among soldiers. Moving forward, the prevention of suicide requires additional research aimed at: (a) better describing when, where, and among whom suicidal behavior occurs, (b) using exploratory studies to discover new risk and protective factors, (c) developing new methods of predicting suicidal behavior that synthesize information about modifiable risk and protective factors from multiple domains, and (d) understanding the mechanisms and pathways through which suicidal behavior develops. Although the scope and severity of this problem is daunting, the increasing attention and dedication to this issue by the Armed Forces, scientists, and society provide hope for our ability to better predict and prevent these tragic outcomes in the future.

Posttraumatic stress disorder and traumatic stress: from bench to bedside, from war to disaster

War is a tragic event and its mental health consequences can be profound. Recent studies indicate substantial rates of posttraumatic stress disorder and other behavioral alterations because of war exposure. Understanding the psychological, behavioral, and neurobiological mechanism of mental health and behavioral changes related to war exposure is critical to helping those in need of care. Substantial work to encourage bench to bedside to community knowledge and communication is a core component of addressing this world health need.

Correlation of National Board of Medical Examiners scores with United States Medical Licensing Examination Step 1 And Step 2 scores.

Purpose Determine whether the National Board of Medical Examiners (NBME) Subject Examination performance from six clerkships correlated with United States Medical Licensing Examination (USMLE) Steps 1 and 2 Clinical Knowledge (CK) Examination scores. Also, examine correlations between medical students’ preclinical and clinical year mean cumulative grade point average (GPA), subject exam, and USMLE performance. Method The sample consisted of 507 students from the 2008–2010 graduating classes from the authors’ medical school. Pearson correlations followed by stepwise linear regressions were used to investigate variance in USMLE Steps 1 and 2 CK scores explained by subject exam scores and GPA. Results Data from 484 (95.5%) students were included. USMLE Steps 1 and 2 CK scores had moderate-to-large positive correlations with all subject exam scores and with both GPA variables. Correlations between composite subject exam scores and USMLE Steps 1 and 2 CK exams were 0.69 and 0.77, respectively. Regression analysis demonstrated that subject exams and GPA accounted for substantial variance in Steps 1 and 2 CK exam scores (62% and 61%); when entered into the regression model first, primary care clerkship subject examination scores accounted for most of this variance. Conclusions The moderate-to-large correlations between subject exam performance and USMLE scores provide reassurance that subject exam scores are associated with USMLE performance. Furthermore, the considerable variance in USMLE scores accounted for by primary care NBME scores may be due to primary care topics being reinforced through all clerkships and comprising a significant portion of the USMLE examinations, particularly Step 2 CK.

Mental health training for health workers in Africa: a systematic review

Commitment to building mental health treatment capacity in Africa is increasing but little agreement exists on strategies to train health workers on mental health or evaluation of training efforts. We systematically reviewed published literature on interventions to train health-care workers in Africa on mental health. 37 studies met our inclusion criteria. Training outcomes focused on changes in knowledge and attitude, with few studies evaluating skill and practice and only two studies measuring clinical outcomes. Quality of study methodology was generally not high, with scarce follow-up data and use of control cohorts. Existing studies provide examples of many training and evaluation strategies, but evidence to draw conclusions about the efficacy of different training techniques is inadequate. Key knowledge gaps include development and testing of innovative educational strategies; development of standardised, competency-based learning objectives and outcome measures; and training that facilitates implementation of integrated mental health systems. African institutions need to be empowered to do research in these areas to encourage the development of best practices for the continent.

Is poor performance on NBME clinical subject examinations associated with a failing score on the USMLE step 3 examination

Purpose To investigate the association between poor performance on National Board of Medical Examiners clinical subject examinations across six core clerkships and performance on the United States Medical Licensing Examination Step 3 examination. Method In 2012, the authors studied matriculants from the Uniformed Services University of the Health Sciences with available Step 3 scores and subject exam scores on all six clerkships (Classes of 2007–2011, N = 654). Poor performance on subject exams was defined as scoring one standard deviation (SD) or more below the mean using the national norms of the corresponding test year. The association between poor performance on the subject exams and the probability of passing or failing Step 3 was tested using contingency table analyses and logistic regression modeling. Results Students performing poorly on one subject exam were significantly more likely to fail Step 3 (OR 14.23 [95% CI 1.7–119.3]) compared with students with no subject exam scores that were 1 SD below the mean. Poor performance on more than one subject exam further increased the chances of failing (OR 33.41 [95% CI 4.4–254.2]). This latter group represented 27% of the entire cohort, yet contained 70% of the students who failed Step 3. Conclusions These findings suggest that individual schools could benefit from a review of subject exam performance to develop and validate their own criteria for identifying students at risk for failing Step 3.

Undergraduate Neuroscience Majors: A Missed Opportunity for Psychiatry Workforce Development

ObjectiveThis study sought to determine whether and to what extent medical students with an undergraduate college major in neuroscience, relative to other college majors, pursue psychiatry relative to other brain-based specialties (neurology and neurosurgery) and internal medicine.MethodsThe authors analyzed data from AAMC matriculation and graduation surveys for all students who graduated from US medical schools in 2013 and 2014 (n = 29,714). Students who majored in neuroscience, psychology, and biology were compared to all other students in terms of their specialty choice at both time points. For each major, the authors determined rates of specialty choice of psychiatry, neurology, neurosurgery, and, for comparison, internal medicine. This study employed Chi-square statistic to compare odds of various specialty choices among different majors.ResultsAmong medical students with an undergraduate neuroscience major (3.5% of all medical students), only 2.3% preferred psychiatry at matriculation, compared to 21.5% who chose neurology, 13.1% neurosurgery, and 11% internal medicine. By graduation, psychiatry specialty choice increased to 5.1% among neuroscience majors while choice of neurology and neurosurgery declined. Psychology majors (OR = 3.16, 95% CI 2.60–4.47) but not neuroscience majors (OR 1.28, 0.92–1.77) were more likely than their peers to choose psychiatry.ConclusionsPsychiatry struggles to attract neuroscience majors to the specialty. This missed opportunity is an obstacle to developing the neuroscience literacy of the workforce and jeopardizes the neuroscientific future of our field. Several potential strategies to address the recruitment challenges exist.

Missing the point: self-inflicted traumatic brain injury in psychosis

A 36-year-old man was brought to the emergency department by emergency medical services after being found acting unusually at a gas station with blood on his head and clothing. He presented acutely psychotic and reported that he had a pen in his head. Medical evaluation was notable for a superficial puncture wound to the right temple, and he was medically cleared for psychiatric evaluation. After he developed nausea and headache later that evening, the CT scan revealed a temporal bone fracture, pneumocephalus, intraparenchymal haemorrhage and the presence of a metal pen tip lodged in the brain parenchyma. The full nature of the injury went undiscovered in the emergency department for 16 hours due to the superficial appearance of the injury and his acute psychosis with prominent delusional thought content and disorganisation. He underwent craniotomy with removal of the pen and subsequent hospitalisation for intravenous antibiotics, followed by a prolonged psychiatric hospitalisation for psychosis.

House Calls: Physicians in the US Congress, 2005-2015.

Objectives Physicians occupy a prominent position in the US healthcare system, and physicians who serve in Congress may bring a particular perspective, expertise, and influence to health-related legislation. The purpose of this study was to describe physician membership in the US Congress between 2005 and 2015. Methods Congressional biographical records were searched to identify physicians who served in the US Congress from 2005 to 2015. Political and demographic characteristics of physician-members were compared with those of nonphysician-members of Congress and of all US physicians. The numbers of physicians in recent Congresses also were compared with those in each Congress since 1945. Results A total of 27 physicians representing 17 states have served in Congress since 2005. There has been a significant increase in physician representation since 1987, reaching a high of 20 members (3.7%) in the Congresses immediately following passage of the Patient Protection and Affordable Care Act. Physician-members were mostly men (93%) and more likely than their Congressional colleagues to be Republican (78% vs 53% of all members, P = 0.007) and from the South (63% vs 35% of all members, P = 0.003). Compared with physicians in general, physicians in Congress were more likely to be men (93% vs 70%, P = 0.009) and surgeons (26% vs 11%, P = 0.01). Conclusions Physician representation in Congress has increased substantially since 2000, potentially reflecting the greater political prominence of healthcare issues, as well as increased interest by and recruitment of physician-candidates. Physicians in Congress differ from their colleagues and from physicians in general in various demographic and political characteristics.

Integration of Primary Care and Psychiatry: A New Paradigm for Medical Student Clerkships

BackgroundPublic health crises in primary care and psychiatry have prompted development of innovative, integrated care models, yet undergraduate medical education is not currently designed to prepare future physicians to work within such systems.AimTo implement an integrated primary care–psychiatry clerkship for third-year medical students.SettingUndergraduate medical education, amid institutional curriculum reform.ParticipantsTwo hundred thirty-seven medical students participated in the clerkship in academic years 2015–2017.Program DescriptionEducators in psychiatry, internal medicine, and pediatrics developed a 12-week integrated Biopsychosocial Approach to Health (BAH)/Primary Care–Psychiatry Clerkship. The clerkship provides students clinical experience in primary care, psychiatry, and integrated care settings, and a longitudinal, integrated didactic series covering key areas of interface between the two disciplines.Program EvaluationStudents reported satisfaction with the clerkship overall, rating it 3.9–4.3 on a 1–5 Likert scale, but many found its clinical curriculum and administrative organization disorienting. Students appreciated the conceptual rationale integrating primary care and psychiatry more in the classroom setting than in the clinical setting.ConclusionsWhile preliminary clerkship outcomes are promising, further optimization and evaluation of clinical and classroom curricula are ongoing. This novel educational paradigm is one model for preparing students for the integrated healthcare system of the twenty-first century.

Faster, Higher, Stronger: How Sports Science Is Creating a New Generation of Superathletes—And What We Can Learn From Them By Mark McClusky: New York, NY: Penguin Group, 2014. 274 pp. ISBN-13: 978-1-59463-153-5.

Every four years as a kid, as I watched the world’s best athletes compete for gold medals, I too wanted to be an Olympian. My preferred events varied, sometimes by the hour. I was a runner, so becoming an Olympic marathoner had its appeal. I also fantasized, however transiently, on other sports: soccer, diving, wrestling, high jump, curling, biathlon. One summer, I even learned how to racewalk, a sport whose rules require one straight knee and one heel on the ground at all times, resulting in a notably hipswinging gait. Regardless of the sport, I loved the idea of marching into the stadium beneath my country’s flag, of watching the lighting of the flame, of striving toward the Olympic motto: Citius, Altius, Fortius. Journalist Mark McClusky co-opts that famous motto as the title of his book, Faster, Higher, Stronger: How Sports Science Is Creating a New Generation of Superathletes—And WhatWe Can Learn From Them. The subtitle gives a good sense of the book’s content—a wide-ranging and fascinating look at various ways in which science is driving athletic progress. McClusky, who has written for Sports Illustrated andWiredmagazine and is himself an athlete and fitness enthusiast, explains why neither he nor I, despite our Olympic-sized dreams, made it: “These elite athletes,” he quotes a physiology expert, “they aren’t like us” (p. ix). McClusky goes on to explain that elite athletes differ from us mere mortals in all sorts of ways: from their genetics, equipment, diet, and training to their minds. Increasingly, he writes, such athletes are turning to science for an ever greater competitive edge: “Although races can still be won through hard work and effort, they are increasingly won by competitors who not only work hard, but are smarter than the competition as well.” (p. xi) For a sports fan and scientist, Faster, Higher, Stronger is a panoply of interesting facts and anecdotes. I knew that Bradley Wiggins became the first British cyclist to win the Tour de France in 2012. I had not known, however, that his success—and that of other U.K. cyclists recently—has been partly due to the hiring of a sports scientist to focus on “marginal gains.”Among the small changes that have summed to Britain’s most successful cycling run in years: riders bring their own pillows to competitions; they are fastidious about hand hygiene (no colds on race day!); and they spray alcohol on their tires to briefly increase friction and stability at the standing start. I was heartened to learn that I swing my legs at about the same rate as Olympic sprinting champion Usain Bolt of Jamaica. So why does it take me nearly twice as long to run 100 meters? When Bolt hits the