Experience and impact of inappropriate patient sexual behaviors within a large VA healthcare system.

Inappropriate patient sexual behaviors (IPSBs) can negatively impact work performance, job satisfaction, and the psychological well-being of clinicians and staff. Although the Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, the rate of IPSBs in VHA hospitals is unknown. The unique demographic and cultural characteristics of military populations may be associated with IPSBs. To evaluate the extent and impact of IPSBs within a large VA healthcare system (VAHS), a survey was disseminated to all staff. Among the 32% of staff who responded (N = 1359), over half (n = 789; 58.1%) of participants reported at least one instance of IPSB during the past year; this included 67.9% (n = 644) of staff who identified as women and 33.4% (n = 126) of staff who identified as men. There was a significantly greater impact of IPSBs for women, as compared to men, on psychological well-being (X2 1 = 60.4, p < .001, odds ratio [OR] = 4.55, 95% confidence interval [CI]: [3.08, 6.79]), work satisfaction (X2 1 = 43.0, p < .001, OR = 3.51, 95% CI: [2.40, 5.18]), and workplace practices (X2 1 = 48.9, p < .001, OR = 4.02, 95% CI: [2.69, 6.11]). The results of this project highlight the need for overcoming barriers to reducing the pervasiveness and impact of these experiences.

Lessons Learned From Implementing a Caring Contacts Clinical Practice Guideline Recommendation.

The U.S. Department of Veterans Affairs (VA) and Department of Defense clinical practice guideline on the treatment of veterans at risk for suicide recommends considering caring contacts interventions after a psychiatric hospitalization for suicidal ideation or suicide attempt. This quality improvement project examined the implementation of the recommendation at a large VA health care system. The project enrolled 29% of hospitalized veterans (N=135 of 462). Enrollment barriers included lack of staff availability and veteran ineligibility due to homelessness or housing instability. Opportunities to improve the reach of the intervention in future quality improvement processes are discussed, especially because acceptability of the intervention was high among veterans.

Implementation strategy to increase clinicians' use of the caring letters suicide prevention intervention.

Caring Letters is recommended in multiple best practice guidelines; however, the Caring Letters intervention has not been widely implemented. The process of tracking, scheduling, and mailing letters for multiple patients over many months may represent a significant barrier for busy clinicians. This evaluation examined whether the use of centralized administrative support (Centralized Caring Letters; CCL) was associated with increased utilization of the intervention. These procedures were tested in the Department of Veterans Affairs (VA) Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program. In REACH VET, VA clinicians are routinely asked to consider Caring Letters as one option for veterans identified as at-risk. In this evaluation, clinicians at two VA facilities were offered assistance in the tracking, preparation, mailing, and documentation of Caring Letters for veterans they chose to enroll in CCL. The utilization of Caring Letters increased more than 14-fold after CCL was implemented. In the year that preceded CCL, 3% of REACH VET veterans were sent Caring Letters at the two sites; this increased to 43% of cases after the implementation of CCL (45% at Site 1 and 41% at Site 2). In qualitative interviews with providers, clinicians described Caring Letters as beneficial and stated that the centralized features of the program were helpful. Caring Letters were discontinued for 30% of enrolled veterans, often because of a bad address (9% of enrolled) or relocation (8% of enrolled). Although there are barriers for the use of Caring Letters, CCL was associated with a very large increase in the use of Caring Letters. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Medical student mistreatment: understanding 'public humiliation'.

INTRODUCTION: Mistreatment in medical school is an enduring problem in medical education. Little is known about the concept of 'public humiliation,' one of the most common forms of mistreatment as identified on the AAMC Graduation Questionnaire. The objective of this study was to further investigate 'public humiliation' and to understand the underpinnings and realities of 'public humiliation' in medical education. METHOD: Focus groups of medical students on clinical rotation at the University of Washington School of Medicine were conducted over one and a half years. Qualitative analysis of responses identified emergent themes. RESULTS: Study results included responses from 28 third year and one fourth-year medical student obtained over five different focus groups. Participants defined the term 'public humiliation' as negatively, purposefully induced embarrassment. Risk factors for the experience of public humiliation in educational settings were found to include the perceived intent and tone of the teacher, as well as situations being 'public' to patients and taking place during a medical or surgical procedure. Socratic teaching or 'pimping' was not found to be a risk factor as long as learners were properly oriented to the teaching practice. DISCUSSION: This study investigated and defined 'public humiliation' in the setting of medical student mistreatment. More subtle forms of mistreatment, like public humiliation, may be amenable to interventions focused on teaching educators about the importance of orientation and clear communication of intent during the teaching process.

Psychotropic Medication Monitoring: A Review.

OBJECTIVE: To address a gap in the literature for concise recommendations on psychotropic medication monitoring geared to prescribers in primary care psychiatry. DATA SOURCES: Large institutional guidelines from the United States, United Kingdom, Canada, and Australia/New Zealand combined with manual searches for psychiatric medication monitoring consensus and other recommendations up to January 31, 2018. STUDY SELECTION: Any available guidelines and consensus statements making psychotropic medication monitoring recommendations for treatment of adults and published in English. DATA EXTRACTION: Manual identification of all specific recommendations on psychotropic medication monitoring from the sources. RESULTS: Psychotropic medication monitoring recommendations vary by source, but there is considerable agreement among English-language sources, which can be readily summarized for teaching and everyday use. CONCLUSIONS: For prescribers working in many disciplines, medication monitoring may be improved by having more ready access to recommendations.

Practical Interventions to Enhance Resident Ownership of Patient Care.

OBJECTIVE: In the modern training environment, some question whether trainees have the opportunity to develop ownership of patient care, which includes concepts such as advocacy, autonomy, commitment, communication, follow-through, knowledge about the patient, responsibility, and teamwork. Despite descriptions of what ownership is, there is little discussion of how to foster ownership during residency. The objective of this study was to solicit psychiatry resident and faculty perspectives on ways to enhance resident ownership in training. METHODS: Twenty-nine of 74 (39.2%) residents and 31 of 68 (45.6%) faculty members surveyed provided narrative responses to a voluntary, anonymous, electronic survey asking two structured, open-ended questions about what factors make it more or less likely that a resident will take "ownership" of patient care. RESULTS: The coding process produced four overarching categories of themes (attending, resident, educational program, and environment) that reflect domains for possible interventions to increase ownership, with conceptual guidance from the Theory of Planned Behavior. From these factors, the authors propose a number of practical yet theory-based interventions which include setting expectations, modeling, promoting autonomy, countertransference supervision, changing residency culture, and longer rotations. CONCLUSIONS: These interventions address subjective norms, attitudes, perceived ability and control, environment, and actual resident abilities, all of which, according to the Theory of Planned Behavior, would be likely to influence patient care ownership. Future studies could develop curricula and examine the effectiveness of the interventions proposed here in reinforcing or developing ownership in physicians.

Understanding ownership of patient care: A dual-site qualitative study of faculty and residents from medicine and psychiatry.

INTRODUCTION: With changes in duty hours and supervision requirements, educators have raised concerns about erosion of patient care ownership by resident physicians. However, the definition of ownership is unclear. This qualitative study investigated definitions of ownership in medicine and psychiatry faculty and residents. METHODS: The authors distributed an anonymous online survey regarding definitions of ownership to faculty and residents at the psychiatry and internal medicine residency programs at the University of Washington and the Harvard Longwood psychiatry residency and conducted a qualitative analysis of free-text responses to identify emergent themes. RESULTS: 225 faculty (48.6%) and 131 residents (43.8%) across the three programs responded. Responses yielded themes in five domains: Physician Actions, Physician Attitudes, Physician Identity, Physician Qualities, and Quality of Patient Care. All groups identified themes of advocacy, communication and care coordination, decision-making, follow through, knowledge, leadership, attitudes of going 'above and beyond' and 'the buck stops here', responsibility, serving as primary provider, demonstrating initiative, and providing the best care as central to ownership. Residents and faculty had differing perspectives on 'shift work' and transitions of care and on resident decision-making as elements of ownership. DISCUSSION: This study expanded and enriched the definition of patient care ownership. There were more similarities than differences across groups, a reassuring finding for those concerned about a decreasing understanding of ownership in trainees. Findings regarding shared values, shift work, and the decision-making role can inform educators in setting clear expectations and fostering ownership despite changing educational and care models.

Anxiety disorders in primary care.

Anxiety disorders are the most common psychiatric condition presenting to primary care practitioners. Yet they can be easily overlooked or misdiagnosed. Patients that struggle with anxiety disorders are more likely to seek treatment from primary care providers than mental health specialists. Given the costs in terms of debilitation and associated financial burden, and increased risk of suicide, the identification and successful treatment of anxiety is imperative. By means of clinical acumen and the use of screening tools, the provider can develop expertise in recognition and effective treatment of anxiety disorders.

Ownership of patient care: a behavioural definition and stepwise approach to diagnosing problems in trainees.

In medical education, behavioural definitions allow for more effective evaluation and supervision. Ownership of patient care is a complex area of trainee development that crosses multiple areas of evaluation and may lack clear behavioural definitions. In an effort to define ownership for educational purposes, the authors surveyed psychiatry teaching faculty and trainees about behaviours that would indicate that a physician is demonstrating ownership of patient care. Emerging themes were identified through analysis of narrative responses in this qualitative descriptive study. Forty-one faculty (54 %) and 29 trainees (52 %) responded. Both faculty and trainees identified seven core elements of ownership: advocacy, autonomy, commitment, communication, follow-through, knowledge and teamwork. These seven elements provide a consensus-derived behavioural definition that can be used to determine competency or identify deficits. The proposed two-step process enables supervisors to identify problematic ownership behaviours and determine whether there is a deficit of knowledge, skill or attitude. Further, the theory of planned behaviour is applied to better understand the relationship between attitudes, intentions and subsequent behaviour. By structuring the diagnosis of problems with ownership of patient care, supervisors are able to provide actionable feedback and intervention in a naturalistic setting. Three examples are presented to illustrate this stepwise process.

Laparoscopic gastric fundoplication for treatment of gastroesophageal reflux disease (GERD). Results from 150 consecutive cases.

Gastroesophageal reflux disease (GERD) is common and often not adequately managed with lifestyle changes and medication. Laparoscopic gastric fundoplication has widely been accepted as the mainstay in surgical treatment for patients who fail medical management. We present a review of 150 consecutive patients with symptoms of failed medical management of GERD who were operated on at a community hospital. Patients received either a 360 degrees wrap (Nissen Fundoplication) or a 270 degrees wrap (Toupet) and, if warranted, a repair of a hiatal hernia. Thirty-nine percent of the patients were discharged on the first postop day, and another 47% were discharged on the second postop day. Heartburn and coughing were completely eliminated in 90% of patients and reduced to a level that was well tolerated in all but three patients. Some dysphagia, early satiety, and bloating were typical in the immediate postop period but were generally minor and improved substantially in the first 4 to 8 weeks. Six percent of patients had some complication, some severe and requiring reoperation, but all resolved. Eighty-five percent of the patients stated that the outcomes was either "perfect" or "much better." Laparoscopic gastric fundoplication for treatment of chronic GERD is an excellent option for patients who have medically uncontrolled reflux symptoms.