Robert J. Birnbaum

Motor cortical excitability in schizophrenia

BACKGROUND Transcranial magnetic stimulation (TMS) provides a method to examine cortico-cortical motor excitability and hemispheric asymmetry in unmedicated and medicated schizophrenia patients. METHODS Fourteen right-handed schizophrenia patients (seven on conventional neuroleptics and seven medication-free) were compared with seven right-handed, age- and gender-matched normal control subjects. Motor threshold for induction of motor-evoked potentials (MEPs) and bihemispheric intracortical inhibition and facilitation were measured with single-pulse and paired-pulse TMS. RESULTS Medicated patients showed an approximately 5% higher motor thresholds in both hemispheres than unmedicated patients and control subjects. Normal control subjects had a nearly 10% higher threshold for the left than the right hemisphere, whereas the opposite was true for the patient groups (5-10% higher threshold on the right than the left). Medicated patients showed significantly decreased intracortical inhibition relative to unmedicated patients and control subjects. This difference was more pronounced for the right than for the left hemisphere. CONCLUSIONS Treatment with conventional neuroleptics is associated with increased motor threshold and decreased intracortical inhibition, whereas unmedicated patients did not differ from normal control subjects on these measures; however, schizophrenia may be characterized by a reversed pattern of interhemispheric corticospinal excitability.

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.

Borderline, Bipolar, or Both?

Of all of the diagnostic dilemmas that confront psychiatry today, the resolution of the controversy surrounding the interrelationship of borderline personality disorder (BPD) and bipolar disorder is an especially vehement one. The controversy goes, indeed, to the heart of modern psychiatry, reflecting its quest to find diagnostic schema that have clinical utility and that also map correctly, and with some real precision, to brain function. With recent advances in the cognitive neurosciences, functional neuroimaging, and molecular neurogenetics, we are finally poised to identify and elaborate such diagnostic schema. 1‐4 And as noted in the articles on both sides of this Clinical Controversy—one by Joel Paris and the other by Daniel Smith and his colleagues—doing so is vitally important with regard to BPD and bipolar disorder because of their prevalence and high morbidity. In order to savor fully the challenge that these authors face, it is necessary to understand the historical context in which the relevant issues arise. Traditionally in personality research, there have been deep, systematic divisions between the psychodynamically and somatically oriented theoretical camps. Some psychodynamically oriented practitioners view the encroaching observations of the neurosciences as a kind of Trojan horse. The pleasing offering, the promise of an etiological explanation and efficacious somatic intervention, belies the true agenda of the neurosciences: to purge the field of personal narrative. Some somatically oriented practitioners belittle efforts to identify systematically the environmental antecedents and catalysts that shape behavior, characterizing those efforts as a hollow pursuit that places an arbitrary, post hoc meaning upon deterministic,

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.

Problem-based learning and psychiatry residency education.

problem.3 The faculty tutor’s role in PBL is to facilitate this small-group learning process; tutors rarely gratify curiosity by supplying answers; rather, they work to excite curiosity by encouraging the use of various learning tools.4 The tutorial process is reported to enhance the psychosocial skills of its participants by making them more versed in group dynamics, more comfortable with silence, and more able to hear a diverse set of opinions respectfully.5 The data so far6,7 suggest that, compared with their counterparts in traditional curricula, medical school graduates of PBL curricula appear to perform as well if not slightly better on clinical examinations and faculty evaluations and slightly worse on basic science examinations.

Gaps in preparedness of clergy and healthcare providers to address mental health needs of returning service members.

To elucidate gaps in the preparedness of clergy and healthcare providers to care for service members (SM) with deployment-related mental health needs. Participants identified clinically relevant symptoms in a standardized video role play of a veteran with deployment-related mental health needs and discussed their preparedness to deal with SM. Clergy members identified suicide and depression most often, while providers identified difficulty sleeping, low energy, nightmares and irritability. Neither clergy nor providers felt prepared to minister to or treat SM with traumatic brain injury. Through a mixed methods approach, we identified gaps in preparedness of clergy and healthcare providers in dealing with the mental health needs of SM.

Simulation-based ongoing professional practice evaluation in psychiatry: a novel tool for performance assessment.

BACKGROUND Ongoing professional practice evaluation (OPPE) activities consist of a quantitative, competency-based evaluation of clinical performance. Hospitals must design assessments that measure clinical competencies, are scalable, and minimize impact on the clinicians daily routines. A psychiatry department at a large academic medical center designed and implemented an interactive Web-based psychiatric simulation focusing on violence risk assessment as a tool for a departmentwide OPPE. METHODS Of 412 invited clinicians in a large psychiatry department, 410 completed an online simulation in April-May 2012. Participants received scheduled e-mail reminders with instructions describing how to access the simulation. Using the Computer Simulation Assessment Tool, participants viewed an introductory video and were then asked to conduct a risk assessment, acting as a clinician in the encounter by selecting actions from a series of drop-down menus. Each action was paired with a corresponding video segment of a clinical encounter with a standardized patient. Participants were scored on the basis of their actions within the simulation (Measure 1) and by their responses to the open-ended questions in which they were asked to integrate the information from the simulation in a summative manner (Measure 2). RESULTS Of the 410 clinicians, 381 (92.9%) passed Measure 1,359 (87.6%) passed Measure 2, and 5 (1.2%) failed both measures. Seventy-five (18.3%) participants were referred for focused professional practice evaluation (FPPE) after failing either Measure 1, Measure 2, or both. CONCLUSIONS Overall, Web-based simulation and e-mail engagement tools were a scalable and efficient way to assess a large number of clinicians in OPPE and to identify those who required FPPE.

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.

Autonomic Arousal and Learning in Web-Based Simulation: A Feasibility Study

Introduction: Autonomic arousal is an important component of understanding learning as it is related to cognitive effort, attention, and emotional arousal. Currently, however, little is known about its relationship to online education. We conducted a study to determine the feasibility of measuring autonomic arousal and engagement in online continuing medical education (CME). Method: Using the Computer Simulation Assessment Tool (CSAT) platform, health care providers were randomly assigned to either high‐ or low‐valence versions of a Web‐based simulation on risk assessment for a returning veteran. Data were collected on participants’ actions within the simulation, self‐reported cognitive engagement, knowledge retention, and autonomic arousal measured using galvanic skin response (GSR). Results: Participants in the high‐valence condition (n = 7) chose a lower percentage of critical actions (M = 79.2, SD = 4.2) than participants in the low valence (n = 8) condition (M = 83.9, SD = 3.6, t(1,14) = 2.44, p = .03). While not statistically significant, high‐valence participants reported higher cognitive engagement. Participants in the high‐valence condition showed a larger increase in physiologic arousal when comparing mean tonic GSR during the orientation simulation to the study simulation (high‐valence mean difference = 4.21 &mgr;S, SD = 1.23 vs low‐valence mean difference = 1.64 &mgr;S, SD = 2.32, t(1,13) = ‐2.62, p = .01). Discussion: In addition to being consistent with previous engagement research, this experiment functioned as a feasibility study for measuring autonomic arousal in online CME. The current study provides a framework for future studies, which may use neurophysiology to identify the critical autonomic and engagement components associated with effective online learning.