What Might Aducanumab Teach Us About Clinicians' Judgment About Whether to Recommend Emerging Alzheimer's Interventions?

Alzheimer's disease (AD) is an incurable, progressive deterioration that ends, eventually, in death. For many years, AD's hallmark etiological feature was beta-amyloid plaque accumulation in the brain, but, to date, costly drugs designed to reduce beta-amyloid levels offer only marginal clinical benefit and pose significant risk of harm. Thus, there is strong interest in finding alternative AD-modifying interventions, and, despite controversy, aducanumab-an antibody-recently received approval by the US Food and Drug Administration. This article considers how ethical issues in the care of patients with AD could influence, for better or worse, clinicians' judgment about whether and when to recommend aducanumab.

Delirium on clozapine: A tale of friend turned foe-A case report.

Treatment resistant schizophrenia (TRS) is often encountered in clinical practice. Clozapine remains the drug of choice in the management of TRS. Several studies have shown that clozapine is the most effective antipsychotic medication to date for TRS. But it is also well known that it has multiple side effects. Some side effects are transient and relatively benign, while other adverse effects are menacing, serious and life-threatening. Delirium may occur with clozapine and is a therapeutic challenge as there is always a risk of precipitating delirium on clozapine rechallenge. Limited management strategies are available as alternatives for the management of psychiatric illness stabilized on clozapine. In this case report, we describe an older adult patient who developed delirium on clozapine. The aims of this case report are to discuss the mechanism by which clozapine leads to delirium, revisit various factors which could possibly lead to delirium, and discuss the different management strategies available for management of psychiatric illness for a patient previously stabilized on clozapine.

What Do Medical Students Perceive as Meaningful in the Psychiatry Clerkship Learning Environment? A Content Analysis of Critical Incident Narratives.

OBJECTIVES: In order to better understand the professional development of medical students during their psychiatry clerkship, this study identifies common themes and characteristics of students' critical incident narratives which are designed to capture a recount of clerkship experiences they perceived as meaningful. METHODS: A total of 205 narratives submitted by psychiatry clerkship students in 2010-2011 were subjected to a thematic analysis using a methodological approach and adaptation of categories derived from prior similar research. Descriptive content analysis was also carried out to assess the valence of the narrative content, characters involved, and whether there was evidence that the experience changed students' perspectives in some way. RESULTS: Narratives contained a variety of positive (19%) and negative content (24%) and many contained a hybrid of both (57%). The most common theme (29%) concerned issues of respect and disrespect in patient, clinical, and coworker interactions. In general, the majority (68%) of students' meaningful experience narratives reflected a change in their perspective (e.g., I learned that...). Narratives containing positive and hybrid content were associated with a change in students' perspective (χ(2) = 10.61, df = 2, p < 0.005). CONCLUSIONS: Medical students are keenly aware of the learning environment. Positive and hybrid critical incident narratives were associated with a stated change in their beliefs, attitudes, or behaviors due to the experience. Understanding the events that are meaningful to students can also provide rich feedback to medical educators regarding the ways in which students perceive clinical learning environments and how to best foster their professional development.

Adverse childhood experiences and geriatric depression: results from the 2010 BRFSS.

OBJECTIVE: Adverse childhood experiences (ACEs), including physical, sexual, and emotional abuse, have been shown to result in a variety of poor outcomes including depression. The majority of research has examined the impact of such events on adolescents and young adults leaving a dearth of information regarding how these events may affect depressive symptom point prevalence later in life. METHODS: Data from the U.S. CDC's 2010 Behavioral Risk Factor Surveillance Survey (BRFSS) were used to estimate the point prevalence of depression in individuals 60 years of age and greater based on presence or absence of certain ACEs. Depressive symptoms were assessed using eight items from the Patient Health Questionnaire (PHQ). Subjects with a PHQ score of 10 or greater were categorized as depressed. Six different types of ACE were included in the study: parents being physically abusive to each other, being physically harmed by a parent, being sworn at by the parent, being touched sexually by an adult, being forced to sexually touch an adult, and being forced into a sexual encounter. ACEs were categorized as never, single if subject reported it occurring once, or repeated if subject reported multiple episodes. RESULTS: The study sample consisted of 8,051 adults aged 60 years and greater who responded to questions about adverse childhood experiences. The study sample comprised 53% women, 83% Caucasian patients, and had a mean age of 70.4 years. After controlling for age, sex, and race, depression was significantly correlated with repeated ACEs of all types (adjusted odds ratio [AOR] ranging from 2.41 to 9.78, all statistically significant). The only ACE where a single occurrence was significantly associated with late-life depression was forced sexual intercourse (AOR: 2.92, 95% CI: 1.06-8.02). After controlling for all types of abuse in a single model, repeated physical abuse and repeated forced sexual intercourse remained significant (AOR: 2.94, 95% CI: 1.68-5.13; AOR: 3.66, 95% CI: 1.01-13.2, respectively). DISCUSSION: These results indicate a significant association between repeated ACEs and depression in older adults. When controlling for all forms of abuse, repeated physical abuse and forced sexual intercourse are significantly correlated with late-life depression. They emphasize the need to continue developing techniques to help individuals with a history of ACEs in order to decrease their negative effects, not only immediately, but also later in life.

Do they stay or do they go? Residents who become faculty at their training institutions.

OBJECTIVE: Few data exist on the topic of internal hiring of trainees in academic medicine. This study examines nationally representative data to determine the frequency of faculty psychiatrists who are employed in the same department in which they completed their residency training. METHOD: Estimates of internal faculty hiring were obtained by reviewing a random sample of publically available psychiatry department websites in the United States. RESULTS: Among the 26 departments reviewed, there was wide variation in the rates of psychiatrists who received training in the same department in which they were currently employed as faculty members, with a median of 45.5%, ranging from 0% to 71%. CONCLUSION: Results suggest that departmental hiring of one's own graduates is common practice in academic psychiatry, and there is wide variation in this practice across psychiatry departments in the United States.

The impact of stress factors in simulation-based laparoscopic training.

BACKGROUND: This study aimed to quantify learner reactions manifesting from a realistic contextual stressor while training with a laparoscopic simulator, and to identify learner-derived stress-modifying behaviors. Stress factors are known to affect cognitive and psychomotor performance. Simulation-based medical training typically occurs in environments that are relatively stress free compared with the applied context. Training is most effective when it occurs in a highly faithful context, so the inclusion of typical clinical stressors in simulated laparoscopic learning environments may be beneficial. METHODS: Preclinical medical students (N = 27) completed tasks using a laparoscopic simulator under the following 2 conditions: faculty direct observation (stressor) and unobserved (no stressor). The data included simulator performance, blood pressure, real-time heart rates, videotaped behavior, and pre/post surveys of latent anxiety and stress factors associated with participating in the research (eg, STAI 9). RESULTS: Physiologic and behavioral manifestations of stress were observed for all participants during the stressor condition and during poor performance on simulator tasks. Stress was highest during periods of poor performance under the stressor condition. Focusing on the task itself mitigated stress reactions and improved performance on the simulator. CONCLUSION: Stress reactions can be induced in a laboratory setting where simulation-based training occurs. Stressors imposed on the learner during simulation-based training may help support the acquisition of stress management skills that are necessary in the applied clinical setting. A ramped-up sequence of acquiring technical skills and clinical decision making, followed by stress management techniques, may lead to a more efficient transfer of learning from the simulated context to the clinical area.

Residents' perspectives on professionalism.

BACKGROUND: Research defining professionalism exists, yet little is known about how residents view this important attribute for medical practice. Knowing more about residents' interpretations of professionalism and about how they value professionalism would enhance definitions and facilitate support for the development of professionalism skills and behaviors at the graduate level. PURPOSE: The purpose of this phenomenological study was to investigate how residents think about professionalism, how they value it, and how it plays out in their educational lives. METHODS: This study uses qualitative methods, employing 5 focus groups representative of a range of disciplines. Methods include providing unstructured prompts, member checking and informant feedback to support credibility, and content analysis to discern significant patterns. RESULTS: Content analysis supported that residents highly value professionalism and see it as a complex construct, dependent on the situation, discipline, and on personal experience. Challenges to professionalism are common in graduate medical education and a great concern for residents. CONCLUSIONS: Physician educators often discuss professionalism as an overarching concept in medicine, especially in classes during the preclinical years. Although some general principles are applicable, residents relate more deeply to aspects of professionalism that concern their own clinical practice, situation, and specialty. Implications for measurement of professional skills and for further research are included in this report.

Geriatrics attitudes and knowledge among surgical and medical subspecialty house officers.

OBJECTIVES: To examine geriatrics knowledge and attitudes of non-primary care house officers (HOs) before and after a multidisciplinary faculty development program. DESIGN: Serial cross-sectional surveys. PARTICIPANTS: HOs. SETTING: A large midwestern academic medical center. INTERVENTION: Faculty from seven surgical and six medical subspecialties participated in weekly seminars for 9 months and implemented geriatrics curricula in their HO programs. MEASUREMENTS: HO geriatrics attitudes and knowledge were measured using the University of California at Los Angeles Geriatrics Attitudes Scale (GAS; 14 items), two scales of the Maxwell Sullivan test (Therapeutic Potential and Time/Energy; six items each; lower scores denote more-favorable attitudes), and the Geriatrics Clinical Knowledge Assessment (20 multiple choice items; range 0-100%). Repeat surveys were administered in seven disciplines after geriatrics curriculum implementation. RESULTS: Baseline (n=175) geriatrics attitudes were favorable (e.g., 3.7 for GAS; 2.1 for Time/Energy), with more-favorable attitudes among medical subspecialty than surgical HOs (e.g., mean GAS 3.8 and 3.6, respectively; P=.001), and with advanced training. Mean baseline knowledge scores were 65.1% among all HOs. No differences in attitudes or knowledge were observed between the first (n=100) and second (n=90) cohorts in the seven disciplines that administered subsequent tests. CONCLUSION: Geriatrics attitudes of non-primary care HOs are positive, and knowledge is moderate, suggesting need for and potential effect of geriatrics curricula. Demonstrating effects on learner outcomes of faculty development programs may require more than one faculty member per discipline and measures that are curriculum-specific and detailed rather than general and brief.

"It's high-tech, but is it better?": applications of technology in psychiatry education.

OBJECTIVE: This article reviews the existing literature on the use of computer assisted instruction (CAI) in the field of psychiatry to answer the questions, 1) Is CAI an effective tool for teaching psychiatry? and 2) What are the best methods for studying CAI in a real-world training environment? METHOD: A Medline search was conducted for relevant articles, which were divided into three categories: media comparative (head-to-head trials), demonstration (reports of single CAI interventions), or analytical (commentary/reviews). RESULTS: Twenty articles were identified. Although they tend to show that CAI is as good as or sometimes better than traditional teaching methods, the data are extremely variable and there are significant methodological difficulties that complicate interpretation of the data. These problems are consistent with difficulties experienced in other medical specialties when studying CAI. CONCLUSIONS: It is difficult to draw conclusions about the efficacy of CAI in psychiatry from this disparate sample of articles. Efforts to compare CAI interventions with traditional teaching methods have significant inherent limitations and biases and are very difficult to conduct in a naturalistic educational setting. The author offers alternative approaches to studying CAI in psychiatry.