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Longitudinal models of clinical care and education can positively impact the patient and provider experience in terms of health outcomes, satisfaction, and motivation. While residency programs have seen an increase in primary care longitudinal clinical experiences (LCEs), defined as outpatient clinics in which patients are seen by residents over the course of their entire training, less is known about such opportunities in psychiatry residency programs. This qualitative study explores the impact of a longitudinal training model on psychiatric resident skill development, relationships in the clinical learning environment, and professional identity formation.The authors conducted 24 semi-structured interviews of residents, graduates, and faculty in three well-established LCE clinics in a single, multi-site, academic psychiatry residency program. Transcripts were analyzed using inductive thematic analysis techniques.Themes were categorized into benefits and challenges. For benefits, themes included longitudinal relationships, improved feedback, near-peer teaching, early outpatient exposure, graduated independence, skill development, patient population expertise, and solidification of professional identity. For challenges, themes included system logistics, offsite panel management, and intermittent presence of junior trainees.Results suggest that overall, residents and faculty find the LCE a positive learning opportunity that has contributed to their professional development. LCEs do appear to have distinct challenges, largely logistical in nature, which can interfere with the favorability of residents' experiences. Developing strategies up front to minimize these logistical challenges will support the success of a longitudinal program.

Alison R Hwong,1 Stefana Morgan,1 Chelsea Anne Young,2 Aaron D Besterman,3 Michael Jacob,1 Jody Williams,1 Victor I Reus,1 Carol A Mathews,4 Erick Hung,1 Susan Voglmaier1 1Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA; 2Department of Psychiatry, Stanford University, Palo Alto, CA, USA; 3Department of Psychiatry, University of California, San Diego, CA, USA; 4Department of Psychiatry, College of Medicine at the University of Florida, Gainesville, FL, USACorrespondence: Alison R HwongUniversity of California, San Francisco, Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, 401 Parnassus Avenue, Box 0984, San Francisco, CA, 94143-0983, USATel +1 406 414 7185Email alison.hwong@ucsf.eduAbstract: Psychiatry residency programs with robust research training can prepare physician-scientists to make contributions that advance the mental health field. Our psychiatry residency developed a chief resident for research position to help provide mentorship, community building, and advising around scholarly activities for residents. We present the process of implementing this new position in our residency to offer a model for engaging psychiatry residents in research.Keywords: academic psychiatry, residency training, research career

Author(s): Buzza, Colin; Fiskin, Anna; Campbell, Jorien; Guo, Jennifer; Izenberg, Jacob; Kamholz, Barbara; Hung, Erick; Acharya, Bibhav | Abstract: BackgroundDespite an increase in psychiatry trainees' interest in global mental health (GMH), there is a lack of relevant training competencies developed using educational frameworks that incorporate viewpoints from high- and low-income countries. Objective: The aim of this study was to determine competencies for a two-year post-graduate GMH fellowship for psychiatrists utilizing Kern's six-step process as a theoretical framework for curriculum development. Methods: We conducted a targeted needs assessment via key informant interviews with a purposive sample of stakeholders (n = 19), including psychiatry trainees, generalist clinicians, medical directors, psychiatrists, researchers, and GMH educators from high- and low-resource settings in the United States and abroad. We analyzed data using a template method of thematic analysis. Findings: We tabulated learning objectives across 20 domains. Broadly, clinical objectives focused on providing supervision for short-term, evidence-based psychotherapies and on identifying red flags and avoiding harmful medication use among vulnerable populations such as children and the elderly. Non-clinical objectives focused on social determinants of health, education, and clinical supervision as part of capacity-building for non-specialists, engagement in a systems-wide project to improve care, and ethical and equitable partnerships that involve reciprocal and bidirectional education. Several competencies were also relevant for global health work in general. Conclusions: A theory-informed framework for curriculum development and a diverse set of key informants can provide educational objectives that meet the priorities of the trainees and the clinical sites in both low- and high-income settings. Limitations of this study include a small sample size and a focus on clinical needs of specific sites, both of which may affect generalizability. Given the focus on training specialists (psychiatrists), the low-resource sites highlighted the importance of educating and supervising their permanent, generalist clinicians, rather than providing direct, independent patient care.

Objective Integrated care models are an evidence-based approach for integrating physical and behavioral health services. The American Association of Directors of Psychiatric Residency Training Integrated Care Task Force sought to describe current practices for providing training in integrated care to general and child and adolescent psychiatry residents.

International audience; BackgroundMental illnesses are the largest contributors to the global burden of non-communicable diseases. However, there is extremely limited access to high quality, culturally-sensitive, and contextually-appropriate mental healthcare services. This situation persists despite the availability of interventions with proven efficacy to improve patient outcomes. A partnerships network is necessary for successful program adaptation and implementation.Partnerships networkWe describe our partnerships network as a case example that addresses challenges in delivering mental healthcare and which can serve as a model for similar settings. Our perspectives are informed from integrating mental healthcare services within a rural public hospital in Nepal. Our approach includes training and supervising generalist health workers by off-site psychiatrists. This is made possible by complementing the strengths and weaknesses of the various groups involved: the public sector, a non-profit organization that provides general healthcare services and one that specializes in mental health, a community advisory board, academic centers in high- and low-income countries, and bicultural professionals from the diaspora community.ConclusionsWe propose a partnerships model to assist implementation of promising programs to expand access to mental healthcare in low- resource settings. We describe the success and limitations of our current partners in a mental health program in rural Nepal.

Purpose To develop entrustable professional activities (EPAs) for psychiatry and to demonstrate an innovative, validity-enhancing methodology that may be relevant to other specialties. Method A national task force employed a three-stage process from May 2014 to February 2017 to develop EPAs for psychiatry. In stage 1, the task force used an iterative consensus-driven process to construct proposed EPAs. Each included a title, full description, and relevant competencies. In stage 2, the task force interviewed four nonpsychiatric experts in EPAs and further revised the EPAs. In stage 3, the task force performed a Delphi study of national experts in psychiatric education and assessment. All survey participants completed a brief training program on EPAs. Quantitative and qualitative analysis led to further modifications. Essentialness was measured on a five-point scale. EPAs were included if the content validity index was at least 0.8 and the lower end of the asymmetric confidence interval was not lower than 4.0. Results Stages 1 and 2 yielded 24 and 14 EPAs, respectively. In stage 3, 31 of the 39 invited experts participated in both rounds of the Delphi study. Round 1 reduced the proposed EPAs to 13. Ten EPAs met the inclusion criteria in Round 2. Conclusions The final EPAs provide a strong foundation for competency-based assessment in psychiatry. Methodological features such as critique by nonpsychiatry experts, a national Delphi study with frame-of-reference training, and stringent inclusion criteria strengthen the content validity of the findings and may serve as a model for future efforts in other specialties.

Background.In low- and middle-income countries, mental health training often includes sending few generalist clinicians to specialist-led programs for several weeks. Our objective is to develop and test a video-assisted training model addressing the shortcomings of traditional programs that affect scalability: failing to train all clinicians, disrupting clinical services, and depending on specialists.Methods.We implemented the program -video lectures and on-site skills training- for all clinicians at a rural Nepali hospital. We used Wilcoxon signed-rank tests to evaluate pre- and post-test change in knowledge (diagnostic criteria, differential diagnosis, and appropriate treatment). We used a series of ‘Yes’ or ‘No’ questions to assess attitudes about mental illness, and utilized exact McNemar's test to analyze the proportions of participants who held a specific belief before and after the training. We assessed acceptability and feasibility through key informant interviews and structured feedback.Results.For each topic except depression, there was a statistically significant increase (Δ) in median scores on knowledge questionnaires: Acute Stress Reaction (Δ = 20, p = 0.03), Depression (Δ = 11, p = 0.12), Grief (Δ = 40, p < 0.01), Psychosis (Δ = 22, p = 0.01), and post-traumatic stress disorder (Δ = 20, p = 0.01). The training received high ratings; key informants shared examples and views about the training's positive impact and complementary nature of the program's components.Conclusion.Video lectures and on-site skills training can address the limitations of a conventional training model while being acceptable, feasible, and impactful toward improving knowledge and attitudes of the participants.

“Ms. V,” a 60-year-old college-educated woman, was brought by her daughter to the emergency department at a teaching hospital for the evaluation of heart palpitations. Ms. V had personality changes and mood swings with aggressive verbal and physical behaviors that had progressively worsened over the past year. A psychiatric consultation was requested to evaluate these emotional outbursts. On the day of admission, Ms. V had had a court hearing for assaulting her brother, who is disabled due to mental retardation. One month before presentation, she had held a pillow over his face in front of the brother’s social worker, who then called the police. After this event, her brother, who has been dependent on others for self-care since childhood, disappeared for several days. She was unconcerned about her legal situation and appeared cold and indifferent. She did not report that she did anything more than throw a pillow at her brother’s face, and she laughed when she heard that he was missing. Ms. V’s daughter reported that her mother had become increasingly irritable, with episodes of unprovoked shouting of profanities at strangers and family members. These behaviors were uncharacteristic of the patient’s personality at baseline. She had had an increase in goal-directed activities, cleaning the house constantly, checking the locks, and checking the stove. Two years before, Ms. V was fired from her job as a school administrative assistant because of difficulties managing her relationships with the students’ parents. Since then, she had not made any attempts to seek other employment. There was no history of head trauma, loss of consciousness, seizures, or previous contact with mental health providers. Ms. V reported no new stressors but did report some “moodiness” over the last 6 months. She reported no angry outbursts or violence but endorsed a decreased need for sleep (now 6 hours, down from 8, per night). Although she did not report feeling euphoric, she reported increased irritability, daytime energy, task-oriented behavior, impulsivity, distractibility, racing thoughts, and pressured speech. Ms. V did not report feeling depressed or experiencing anhedonia. She reported no anxiety or psychotic symptoms, substance use, or recent changes in medications. Ms. V did not report any specific memory complaints, word-finding difficulties, misplacing or losing objects, or problems using transportation, following directions, or navigating. Her family history was notable for a brother with mental retardation and a sister with unipolar depression. Ms. V’s vital signs were within normal limits, and complete physical and neurologic examinations were unremarkable. A CBC, a Chem 10 (basic chemistries), liver function tests, tests of thyroid-stimulating hormone, free thyroxine, rapid plasma reagin, B12, and folate, an ECG, a chest X-ray, and a head computerized tomography with and without contrast showed no abnormalities.

The rapidly evolving field of neuroethics is concerned with the ethical questions that new technologies will pose about autonomy, privacy, the definition of normal, and individuality.

Although health professionals increasingly are expected to be able to assess and manage patients' risk for suicide, few methods are available to evaluate this competency. This report describes development of a competency-assessment instrument for suicide risk-assessment (CAI-S), and evaluates its use in an objective structured clinical examination (OSCE).The authors developed the CAI-S on the basis of the literature on suicide risk-assessment and management, and consultation with faculty focus groups from three sites in a large academic psychiatry department. The CAI-S structures faculty ratings regarding interviewing and data collection, case formulation and presentation, treatment-planning, and documentation. To evaluate the CAI-S, 31 faculty members used it to rate the performance of 31 learners (26 psychiatric residents and 5 clinical psychology interns) who participated in an OSCE. After interviewing a standardized patient, learners presented their risk-assessment findings and treatment plans. Faculty used the CAI-S to structure feedback to the learners. In a subsidiary study of interrater reliability, six faculty members rated video-recorded suicide risk-assessments.The CAI-S showed good internal consistency, reliability, and interrater reliability. Concurrent validity was supported by the finding that CAI-S ratings were higher for senior learners than junior learners, and were higher for learners with more clinical experience with suicidal patients than learners with less clinical experience. Faculty and learners rated the method as helpful for structuring feedback and supervision.The findings support the usefulness of the CAI-S for evaluating competency in suicide risk-assessment and management.

Objectives.—To describe physiological attributes (height, weight, sex, resting heart rate, etc) of climbers attempting to summit Mt Everest and to investigate differences between successful and unsuccessful summiteers. Methods.—One-hundred thirteen Everest climbers were surveyed by questionnaire before and after the spring 2003 climbing season. Climbers’ previous high-altitude climbing experience and physical characteristics were recorded, as well as health before and during expedition, medication used, body weight before expedition and after summit attempt, and ultimate summit success or failure. Results.—The most common afflictions among climbers were cough, diarrhea, nausea, and vomiting, and the most common medications used were acetazolamide, aspirin, and antibiotics. Average postacclimatization, presummit ‘‘rest’’ altitude was 4571 m, and average weight carried 10.7 kg. Average body mass loss during expedition, regardless of success, was 7%. Conclusions.—Oxygen use and existence of gastrointestinal disorders are strongly correlated with success in summiting Mt Everest. On the other hand, a history of acute mountain sickness before the attempt is correlated with failure in summiting Mt Everest. Several other factors were found to be marginally correlated with chance of success, but the power of the study was limited by a low postsummit attempt questionnaire return rate (34%).