Command economies, graduated responsibility, and Competence-Based Medical Education.

Competence-Based Medical Education (CBME) rightly emphasizes that residents should actively take charge of their own education by ensuring they are progressing towards competence in an array of Entrustable Professional Activities (EPAs). Paradoxically, many CBME curricula then dictate exactly how this is to happen by listing a multitude of variables that must be checked off regarding the specifics of cases encountered. This is burdensome and unrealistic as well as contrary to the spirit of CBME. We want residents to know how to learn so they can problem solve in new situations. This is not achieved by dictating that they see nearly everything during their residency. Command economies with complete and rigid planning from above do not work. This also applies to residency training.

La formation médicale basée sur les compétences (FMBC) souligne à juste titre que les résidents devraient prendre activement en main leur éducation en veillant à développer leurs compétences dans une variété d'activités professionnelles confiables (APC). Paradoxalement, un grand nombre de programmes de FMBC dictent précisément comment cela devrait se passer en dressant la liste d'une multitude de variables qui doivent être cochées selon les particularités des situations cliniques rencontrées. Ceci est fastidieux et peu réaliste de même que contraire à l'esprit de la FMBC. Nous voulons que les résidents sachent comment apprendre de façon à ce qu'ils puissent résoudre les problèmes lorsqu'une nouvelle situation se présente. Il n'est pas possible d'arriver à ce but en exigeant qu'ils soient exposés à presque tout durant leur résidence. Les économies dirigées dont la planification complète et rigide imposée par la direction ne fonctionnent pas. Ceci s'applique aussi aux programmes de résidence.

Abuse as a risk factor for prenatal depressive symptoms: a meta-analysis.

Depression is the most common mental disorder in pregnancy. An important risk factor in the development of prenatal depression is lifetime history of abuse. The current review quantitatively synthesized research on the association between history of abuse and prenatal depressive symptoms using a meta-analytic technique. A total of 3322 articles were identified through electronic searches of the following databases: PsycINFO, PubMed, CINAHL, and EMBASE Cochrane Collaboration databases between the years of 1980 and 2016. All were independently screened against the following inclusion criteria: articles reporting on original data that included measures of prenatal depression and abuse. Data were extracted by the first and second authors. Descriptive analyses were conducted using Excel version 15.32, and all analyses involving effect sizes were conducted using comprehensive meta-analysis (CMA) version 3.0. Seventy articles met the inclusion criteria and were included in the meta-analyses. Meta-bias detected no publication bias. Abuse had a significant positive relation with prenatal depressive symptoms, with effect sizes in the moderate range for any abuse ([Formula: see text] = 0.287), physical abuse ([Formula: see text] = 0.271), sexual abuse ([Formula: see text] = 0.259), and emotional abuse ([Formula: see text] = 0.340; Cohen 1969. Statistical power analysis for the behavioral sciences. Academic Press, New York). The meta-analyses found a robust relation between abuse and prenatal depressive symptoms holding across a variety of demographic and study design characteristics. These results reinforce the established association between trauma victimization and subsequent psychopathology, extending current knowledge to specifically address the under-studied area of prenatal depression. These findings highlight the need for women who have survived child or adulthood abuse to receive appropriate referral and psychological treatment to mitigate their risk for prenatal depression.

Towards a shared mental model of progressive competence in postgraduate medical education.

Many professions have hierarchies and a promotion structure. Postgraduate medicine has a tradition of promoting residents based on time spent in a certain specialty. The military, too, may promote its personnel based on factors other than just merit. Both professions have been criticized for divorcing competence from promotion. While Competency-Based Medical Education (CBME) partly solves this problem in medicine, many models of CBME, including the Canadian one, retain distinct stages of training. We urgently need a shared mental model of what a learner in each stage looks like. Some models have been proposed but fall short.

Improving suicide risk assessment in the emergency department through physician education and a suicide risk assessment prompt.

OBJECTIVE: To determine the efficacy of two interventions on suicide risk assessment within emergency departments (EDs) on improving the documentation of suicide risk factors by emergency medicine and psychiatric physicians during suicide risk assessment. METHOD: An educational intervention on suicide was provided to all emergency medicine and psychiatry physicians and was followed by the placement of a suicide risk assessment prompt within local EDs. The medical charts of all ED patients presenting with suicidal ideation or behaviours were reviewed immediately and six months after the interventions and compared to pre-intervention. Differences in the documentation of 40 biopsychosocial suicide risk factors between specialties and after the interventions were determined. RESULTS: The documentation of 34/40 (p ≤ 0.008) and 33/40 (p ≤ 0.009) suicide risk factors was significantly improved by emergency medicine and psychiatry physicians, respectively, after the interventions and maintained six months later. Immediately and six months after the interventions, the documentation of 8/40 (p ≤ 0.041) and 14/40 (p ≤ 0.048) suicide risk factors, respectively, significantly differed between specialties. CONCLUSION: This suggests that providing a brief educational intervention on suicide to emergency medicine and psychiatry physicians followed by placing a prompt for important, yet commonly undocumented risk factors within the ED is a low-cost and effective intervention for improving documentation of suicide risk assessments within the ED.

Relationship between Bullying and Suicidal Behaviour in Youth presenting to the Emergency Department.

OBJECTIVE: Increasing numbers of adolescents are visiting emergency departments with suicidal ideation. This study examines the relationship between bullying and suicidal ideation in emergency department settings. METHOD: A chart review was conducted for all patients under 18 years of age presenting with a mental health complaint to the emergency departments at Kingston General or Hotel Dieu Hospitals in Kingston, Canada, between January 2011 and January 2015. Factors such as age, gender, history of abuse, history of bullying, type and time of bullying, and diagnoses were documented. RESULTS: 77% of the adolescents had experienced bullying, while 68.9% had suicide ideation at presentation. While controlling for age, gender, grade, psychiatric diagnosis, and abuse, a history of bullying was the most significant predictor of suicidal ideation. Individuals in this study who reported cyber bullying were 11.5 times more likely to have suicidal ideation documented on presentation, while individuals reporting verbal bullying were 8.4 times more likely. CONCLUSIONS: The prevalence of bullying in adolescent patients presenting to emergency departments is high. The relationship found between suicidal ideation and bullying demonstrates that clinicians should ask questions about bullying as a risk factor for suicide ideation during the assessment of children and adolescents.

OBJECTIF: Un nombre croissant d'adolescents se rend aux services d'urgence avec une idéation suicidaire. Cette étude examine la relation entre l'intimidation et l'idéation suicidaire dans le contexte des services d'urgence. MÉTHODE: Un examen des dossiers a été mené pour tous les patients de moins de 18 ans qui se sont présentés avec une plainte de santé mentale aux services d'urgence du Kingston General ou de l'Hôtel Dieu de Kingston, Canada, entre janvier 2011 et janvier 2015. Les facteurs comme l'âge, le sexe, les antécédents d'abus, les antécédents d'intimidation, le type et le moment de l'intimidation, et les diagnostics ont été documentés. RÉSULTATS: Soixante-dix-sept pour cent des adolescents avaient connu l'intimidation, tandis que 68,9 % avaient une idéation de suicide en se présentant. En contrôlant pour l'âge, le sexe, l'année de scolarité, le diagnostic psychiatrique et l'abus, des antécédents d'intimidation étaient le prédicteur le plus significatif de l'idéation suicidaire. Les sujets de cette étude qui ont déclaré une cyberintimidation étaient 11,5 fois plus susceptibles d'avoir une idéation suicidaire documentée lorsqu'ils se présentent, alors que les sujets déclarant une intimidation verbale en étaient 8,4 fois plus susceptibles. CONCLUSIONS: La prévalence de l'intimidation chez les patients adolescents qui se présentent aux services d'urgence est élevée. La relation observée entre l'idéation suicidaire et l'intimidation démontre que les cliniciens devraient poser des questions sur l'intimidation comme facteur de risque de l'idéation suicidaire durant l'évaluation des enfants et des adolescents.

Assessing Suicide Risk: What is Commonly Missed in the Emergency Room?

OBJECTIVE: Although risk assessment for suicide has been extensively studied, it is still an inexact process. The current study determined how busy emergency clinicians actually assessed and documented suicide risk, while also examining the differences between psychiatric and emergency medicine opinions on the importance of various suicide predictors. METHOD: Phase 1 of the study involved the administration of a survey on the relative importance of various suicide predictors for the specialties of psychiatry and emergency medicine. In phase 2 of the study, a chart review of psychiatric emergency room patients was conducted to determine the actual documentation rates of the suicide predictors. RESULTS: Several predictors that were deemed to be important, including suicidal plan, intent for suicide, having means available for suicide, and practicing suicide (taking different steps leading up to suicide but not actually attempting suicide), had low documentation rates. CONCLUSIONS: Medical specialties have different opinions on the importance of various suicide predictors. Also, some predictors deemed important had low documentation rates. Educational interventions and simple assessment tools may help to increase documentation rates of several suicide predictors in busy clinical settings.