Stuart J. Goldman

Screening for Sudden Cardiac Death in the Young: Report From a National Heart, Lung, and Blood Institute Working Group

Sudden cardiac death (SCD) in the young (SCDY) has a devastating impact on families, care providers, and the community and attracts significant public and media attention. Sudden cardiac death is defined as an abrupt and unexpected death due to a cardiovascular cause, typically occurring 1 hour from the onset of symptoms. Depending on the source, “young” is variably defined as those less than 25, 30, 35, or 40 years of age. Estimates of the incidence of SCDY (not including infants) vary broadly from 0.6 to 6.2 per 100 000 persons. 1–3 Sudden infant death syndrome (SIDS) may be related to SCD in some infants. Sudden infant death syndrome is defined as the sudden death of an infant 1 year of age that cannot be explained after a thorough investigation is conducted, including an autopsy, death scene evaluation, and review of the clinical history. The incidence of SIDS ranges from 50 to 100 in 100 000,4 and emerging data suggest that as many as 10% to 15% of SIDS deaths are associated with functional cardiac ion channelopathy gene variants.5 The most common diagnoses that increase risk for SCDY include hypertrophic cardiomyopathy (HCM), coronary artery anomalies of wrong sinus origin, myocarditis, arrhythmogenic right ventricular cardiomyopathy, and ion channelopathies.6 The latter category includes hereditary diseases such as the congenital long-QT syndromes (LQTS), catecholaminergic polymorphic ventricular tachycardia, and Brugada syndrome, among other less common channelopathies. These diseases are typically undetected before the SCD event. Estimated prevalence rates of these conditions range from 1 per 500 persons for HCM to 1 per 2500 for the LQTS. SCD related to these diagnoses has been documented in infancy and during competitive athletics. In addition, prescription stimulant use for treatment of attention deficit hyperactivity disorder (ADHD) has been postulated to be a trigger for SCD.7,8 Sudden cardiac death in the young is a critical public health issue. A young life cut short represents a devastating event for families, and is associated with many lost productive years. There is significant dissonance among experts in the field about the best approach to prevent SCDY in the United States. Some experts support the implementation of largescale cardiovascular screening programs in infants, in athletes, or in all children to identify at-risk individuals in an effort to prevent SCDY. Cardiovascular screening for SCDY typically involves the addition of an ECG to the current standard of care of history and physical examination. Echocardiography and genetic testing represent alternative or additional screening modalities. Observational data from the Veneto region of Italy suggest that ECG screening can successfully identify at-risk cardiovascular diseases and dramatically reduce the incidence of SCD in competitive athletes.9,10 Proponents of ECG screening in the United States suggest that it can be effective, feasible, and cost-effective. 11 Critics of ECG screening cite a lack of evidence to support its effectiveness or feasibility in the United States; lack of clinical accuracy; cost implications; and the potential clinical, financial, and emotional consequences of falsepositive screening test results. 12 Cost estimates for a national ECG screening program in the United States for

The Educational Kanban: promoting effective self-directed adult learning in medical education.

The author reviews the many forces that have driven contemporary medical education approaches to evaluation and places them in an adult learning theory context. After noting their strengths and limitations, the author looks to lessons learned from manufacturing on both efficacy and efficiency and explores how these can be applied to the process of trainee assessment in medical education. Building on this, the author describes the rationale for and development of the Educational Kanban (EK) at Children’s Hospital Boston—specifically, how it was designed to integrate adult learning theory, Japanese manufacturing models, and educator observations into a unique form of teacher–student collaboration that allows for continuous improvement. It is a formative tool, built on the Accreditation Council for Graduate Medical Education’s six core competencies, that guides educational efforts to optimize teaching and learning, promotes adult learner responsibility and efficacy, and takes advantage of the labor-intensive clinical educational setting. The author discusses how this model, which will be implemented in July 2009, will lead to training that is highly individualized, optimizes faculty and student educational efforts, and ultimately conserves faculty resources. A model EK is provided for general reference. The EK represents a novel approach to adult learning that will enhance educational effectiveness and efficiency and complement existing evaluative models. Described here in a specific graduate medical setting, it can readily be adapted and integrated into a wide range of undergraduate and graduate clinical educational environments.

Pediatrician-Psychiatrist Collaboration to Care for Children With Attention Deficit Hyperactivity Disorder, Depression, and Anxiety

Objective: To describe pediatrician experiences collaborating with psychiatrists when caring for children with attention deficit hyperactivity disorder (ADHD), depression, and anxiety. Method: A random sample of Massachusetts primary care pediatricians completed a mailed self-report survey. Results: Response rate was 50% (100/198). Most pediatricians preferred psychiatrists to initiate medications for anxiety (87%) or depression (85%), but not ADHD (22%). Only 14% of respondents usually received information about a psychiatry consultation. For most (88%), the family was the primary conduit of information from psychiatrists, although few (14%) believed the family to be a dependable informant. Despite this lack of direct communication, most pediatricians reported refilling psychiatry-initiated prescriptions for ADHD (88%), depression (76%), and anxiety (72%). Conclusions: Pediatricians preferred closer collaboration with psychiatrists for managing children with anxiety and depression, but not ADHD. The communication gap between psychiatrists and pediatricians raises concerns about quality of care for children with psychiatric conditions.

Developmental Epidemiology of Depressive Disorders

Definitions, understanding, and treatment of childhood depressive disorders are changing. The last 40 years have seen a move from questioning whether depression even existed in younger children to evidence-based descriptive models. The field is now moving toward developmentally informed multifactorial models that more accurately reflect the complexity, heterogeneity, and dimensionality of depressive disorders. Knowledge about genetic, temperamental, and developmental risks has increased. Inability to self-regulate seems to be common in depressive and related disorders. Positive modulation can be promoted through experiences, psychotherapies, and, possibly, medications. The authors provide an overview of childhood depressive disorders with emphasis on the developmental/etiologic underpinnings.

Psychiatry Morbidity and Mortality Rounds: Implementation and Impact.

ObjectiveThis study assessed the implementation of psychiatry morbidity and mortality rounds (M&Ms) on the clinical and educational practice in a children’s hospital.MethodsAttendees to monthly M&Ms between July 2005 and May 2007 included staff and trainees from psychiatry, psychology, nursing, and social work. Cases were selected based on a priori risk criteria and each rated on the hospital’s four-level risk management scale. M&Ms were reviewed for recurrent patterns that contributed to adverse patient care. Attendees completed a survey at the end of each year, evaluating the educational value of the rounds.ResultsPossible opportunities for patient care improvement were found in 80% of the cases and fell into four overlapping areas: diagnostic/formulation errors, communication problems, system-based problems, and class/culture misunderstandings. Identifying these problems led to corrective actions and positive changes in patient care.ConclusionM&Ms appear to be a potentially productive venue for self-appraisal and case review to aid psychiatry programs in patient safety efforts and clinician education.

Current Perspectives on the Pharmacotherapy of Depressive Disorders in Children and Adolescents

&NA; Major depressive disorder occurs in approximately 2% of prepubertal children and 5% of adolescents. Studies investigating the pharmacotherapy of early‐onset major depressive disorder in these young patients have been inconclusive. Early open trials and anecdotal experience suggested a beneficial role for antidepressant therapy. Double‐blind placebo‐controlled trials have failed to demonstrate the robust response seen in adults, but the studies have been small and concerns have been raised regarding methodology. Nevertheless, the significant morbidity associated with depressive disorders and the positive open trial experiences with antidepressants have led to the recommendation that antidepressants be used early in life when a patient presents with symptoms of a depressive disorder and has significant functional incapacity because of these symptoms. This article will review the studies of antidepressant efficacy in juvenile‐onset major depressive disorder and then propose a pharmacotherapy model.

Case Study: An Integrated Medical and Psychiatric Approach to Conversion Symptoms in a Four-Year-Old

Conversion disorder is a challenging diagnosis in children and adolescents. Medical and psychiatric diagnoses need to be evaluated both separately and in relation to each other. This case highlights both the diagnostic criteria for a conversion disorder in a young child and the need for an integrated medical and psychiatric approach by physicians.

Recruitment and Training of Child and Adolescent Psychiatry Residents from Pediatrics

This article describes a 21-year experience of recruiting and training child and adolescent psychiatry residents with pediatric backgrounds. Three grounds of physicians are compared: those with previous training in general psychiatry alone, those with previous training in both general psychiatry and pediatrics, and those with previous training in pediatrics alone. Residents with pediatric backgrounds compared favorably with those with general psychiatry training. Those with only pediatric training were not only able to successfully complete the residency, but also the majority entered the field of child psychiatry. The findings support accepting residents directly from pediatrics as a viable pathway into child psychiatry.

Promoting Interdisciplinary Collaboration: Trainees Addressing Siloed Medical Education

ObjectiveProfessional siloing within medical institutions has been identified as a problem in medical education, including resident training. The authors discuss how trainees from different disciplines can collaborate to address this problem.MethodA group of trainees from psychiatry, developmental medicine, neurology, and education came together to develop a community of practice (CoP) to promote interdisciplinary collaboration.ResultsA key outcome was the development of a seminar including speakers and attendees (N=20 to 35) from psychiatry, developmental medicine, neurology, and education. The CoP, developed in 2008, continues to grow and develop through their seminar, which fosters institution-wide interdisciplinary collaboration.ConclusionIn an attempt to break down interdisciplinary silos, a CoP and interdisciplinary seminar were created. Trainee organizers benefited from an educational context that embodied adult-learning theory and promoted lifelong learning. The unique seminar that was created continues to promote a community sense of learning and practice. Outcome measures are currently being used to objectively measure these efforts.

Enhancing Adult Learning in Clinical Supervision.

Objective/BackgroundFor decades, across almost every training site, clinical supervision has been considered “central to the development of skills” in psychiatry. The crucial supervisor/supervisee relationship has been described extensively in the literature, most often framed as a clinical apprenticeship of the novice to the master craftsman. This approach fails to directly incorporate adult-learning theory (ALT), despite a clear literature supporting its superiority.MethodIn this article, the author describes the basic principles of ALT, reviewing the limitations of current supervisory practice from the ALT perspective. He then describes system insights gleaned from elements of the manufacturing process and integrates them into a model that enhances ALT-informed approaches to clinical supervision that can be utilized in all settings.ResultsAlthough there are clear benefits of ALT and the proposed “pull” manufacturing management-informed approaches to supervision, there are several anticipated areas of likely resistance: the issues of time for the collaborative goal-setting, monitoring progress, and revising the educational plan. Much of this is already a factor in the current, labor-intensive patterns of individual supervision, and, in practice, even the formal monthly review has, in almost all cases, taken appreciably less than half of a supervisory hour. Any possible increases in time or effort would be more than compensated for by the inherent efficiency of resident-specific teaching and learning.ConclusionCurrent supervisory practices can be revised to include principles of ALT and “pull” manufacturing systems that can enhance resident education.