Being a 'good' doctor: Understanding and managing professional boundaries is challenging and can lead to stress and burnout.

OBJECTIVE: The aim is to increase the understanding of non-sexual boundary challenges and potential personal and professional impacts on doctors and medical students. METHOD: We examined peer-reviewed and grey literature and published commentary and cases from Australian health practitioner boards and medico-legal insurance companies. Key ideas relating to the objective of our study were subsequently framed into a narrative. RESULTS: Compared to 'sexual' boundary crossings, the literature examining 'non-sexual' boundaries is scanty, fragmented, and difficult to find. There are gaps in knowledge around the prevalence and consequences of non-sexual boundary challenges and crossings, although the safety and wellbeing of health professionals and patients are of concern. Non-sexual boundary crossings may represent a 'slippery slope' to boundary violations. Opportunities for doctors and medical students to access relevant training appear limited. CONCLUSIONS: We identified several categories of boundary challenges based on context, the nature of the existing relationship, and the type of behaviour. Non-sexual boundary challenges may be related to stress, burnout, and risk for future boundary violations. Future research to investigate the impacts on doctors and medical students in maintaining professional boundaries in their relationships with patients and colleagues, their specific training needs, and the effectiveness of training in reducing work-related stress and burnout is needed.

The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review.

Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.

A meta-analysis of cranial electrotherapy stimulation in the treatment of depression.

BACKGROUND: Depression rates have reached historic highs, with 49% of Americans reporting unabating symptoms and signs of depression, representing a 12% increase compared to the same time in 2019. With depression as a moderating factor for suicide, the need for efficacious treatments for depression has never been more pronounced. Although the armamentarium of the psychiatrist seems impressive having multiple medications and psychotherapy options, with guidelines for combination and augmentation treatments; many patients do not improve or are not suitable candidates for the usual, customary and reasonable (UCR) depression treatments. The use of various forms of brain stimulation technology as a complementary or alternative treatment for depression is growing and is expected to be part of the armamentarium of most psychiatrists by 2030. One form of brain stimulation, available in a phone sized prescription device, is cranial electrical stimulation (CES) which has been used as a treatment for depression since the 1970s. We have conducted two meta-analyses of CES research for depression separating randomized controlled trials (N = 5) from non-randomized studies on interventions (N = 12). For the double-blind RCTs 100 µA was used for 1 hour per day as 100 µA is a subsensory level of current so identical sham treatment devices could be used. METHODS: Our literature review followed Cooper's Taxonomy of Literature Reviews that is appropriate for the behavioral and physical sciences and the PRISMA reporting guidelines. The evaluation of strengths and limitations of the research studies included in this report adheres to recommended published guidelines in the Cochrane Handbook for Systematic Reviews of Interventions, and in the Handbook of Research Synthesis and Meta-Analysis. We used the Cohen's d effect size summary metric in all analyses. Homogeneity of effect sizes within the fixed and random effects models are reported. Meta-analyses were performed using the Compressive Meta-Analysis, version 3 program. RESULTS: The 5 RCTs represent a combined N of 242 and the 12 NRSIs represent 16 data sets with a combined N of 1173 for total of 1415 subjects across 17 studies. There were male and female subjects, from adolescents to 60 years old. The average effect for the 5 RCTs was calculated as d = -0.69 (i.e., the mean depression level at posttest for the active group was -0.69 standard deviations lower than the mean depression level for the sham group), a medium effect. The additional 12 NRSI studies analyzed show a small effect of d = -0.43 in favor of the active treatment group. CONCLUSION: We conclude that CES has a small to medium significant effect in symptoms of depression across moderate to severe patients in civilian, military, veterans, advanced cancer and pediatric populations.

Diagnostic processes in mental health: GPs and psychiatrists reading from the same book but on a different page.

OBJECTIVE: To explore the clinical reasoning processes underpinning diagnostic and management decision-making in treating patients presenting with psychological distress in general practice. METHOD: Practising GPs were invited to attend small-group workshops in which two case histories were presented. Discussion was GP-facilitated and recorded for thematic analysis. GPs provided demographic data, completed personality and attitudinal questionnaires, and answered a series of multiple-choice questions embedded in the cases. RESULTS: GPs recognize the possibility of psychiatric disorders early in the clinical reasoning process, but are cautious about applying definitive diagnoses. GPs perceive that patients may be resistant to a psychiatric diagnosis and instead emphasize the need to build rapport and explore and exclude physical comorbidities. GPs see patients with a broad spectrum of distress, illness and impairment, in whom the initial presentation of psychological symptoms is often poorly differentiated and somatically focused, requiring elucidation over time. GPs therefore adopt a longitudinal strategy for diagnosis rather than investing heavily in cross-sectional assessment. CONCLUSION: GPs appear cognizant of possible psychiatric disorders and management strategies, but employ diagnostic strategies and decision-making processes that, in addition to experience and expertise, likely reflect key differences between the primary care and specialist practice settings.