Psychiatry Residency Directors' Attitudes Toward and Uses of the Medical Student Performance Evaluation and Other Potential Tools for Residency Selection.

OBJECTIVE: A survey was conducted to determine US psychiatry residency directors' attitudes regarding current measures of medical student performance and their preferences for the future. METHODS: A team of psychiatry medical student educators and residency program directors developed a 23-question survey. In July 2021, links to the survey were sent out to all program directors registered with the American Association of Directors of Psychiatric Residency Training. RESULTS: Seventy program directors out of 223 initiated the survey, resulting in a response rate of 31.4%. Forty percent of respondents reported that the most important use of the Medical Student Performance Evaluation (MSPE) is in screening out applicants for interviews, and only 26.1% reported that the MSPE in its current form could be trusted to provide a valid and reliable assessment of a student's medical school performance. Most respondents agreed that in the absence of United States Medical Licensing Examination (USMLE) step 1 numerical scores, the existing MSPE format/content requirements should be modified, use a set of ranking categories that are uniform across all medical schools, and be supplemented with additional measures of the student's character and ability specific to psychiatry. CONCLUSIONS: US psychiatry program directors are eager for change when it comes to the MSPE and how it reports rankings, grades, and professionalism. The transition of the USMLE step 1 score reporting to pass/fail presents an opportunity to pursue this change and for stakeholders from all medical specialties to work together toward a shared goal of an improved residency selection process.

Expansion of telehealth curriculum: National survey of clinical education leaders.

INTRODUCTION: In response to the COVID pandemic and the rapid changes in delivery of and education on telehealth services, the Research Committee of the Alliance of Clinical Education (ACE) surveyed its multidisciplinary group of medical educators to determine how telehealth was being taught pre-COVID versus during-COVID. METHODS: An online survey was developed by the ACE Research Committee and sent via email to the ACE delegation. The objective of the survey was to determine changes in telehealth curriculum for medical students due to the rapid transition to telehealth, and the barriers for developing and delivering a telehealth curriculum. RESULTS: Forty-nine percent of recipients (31/63) responded representing eight different disciplines in addition to institutional curriculum developers. Most programs had no formal didactics and no clinical experiences in telehealth prior to the pandemic. Most respondents added didactics and clinical telehealth encounters during COVID, although few schools required this of all students. DISCUSSION: Given the barriers of faculty training to pivot to telehealth, and the potential benefits to healthcare cost and patient satisfaction, there is a need for more formal study on best practices for teaching telehealth to prepare our future physicians.

Introducing Telepsychiatry to Medical Students with Simulated Patients: An Innovation by Necessity.

This article was migrated. The article was marked as recommended. Introduction: The abrupt discontinuation of medical student-patient contact due to the covid-19 pandemic resulted in a rapid change to virtual teaching. Student education was restructured to include online cases, small group discussions, synchronous and asynchronous lectures, and modified problem-based learning and team-based learning sessions. However, the key focus of the clerkship experience, contact with patients, was missing. Process: The Psychiatry Clerkship directors have previously provided complex simulated encounters to students using video-taped encounters of physician-simulated patient interactions to teach and assess student note writing skills. This concept was adapted to a live encounter for individual students on the psychiatry clerkship. Students reviewed the patient chart, performed the encounter, provided an oral patient presentation to faculty, and wrote a patient note. Individualized feedback was provided for each step of the process. Outcomes: The process was well received by students and faculty and provided an opportunity to directly observe student skills despite distancing from direct patient care. The simulated patients had a very positive experience and appreciated the opportunity to advance their own skills while contributing to student's education. Discussion: Removing students from clinical sites stimulated the rapid development of a process to observe learners involved in patient encounters. These educational sessions allowed direct observation of skills required in the initial evaluation of a patient presenting to psychiatry for care.

The Facilitator Instrument for Team-Based Learning (FIT).

Construct: We sought to evaluate the quality of Team-Based Learning facilitation in both large and small group settings. Background: Team Based Learning (TBL) is an increasingly popular small group instructional strategy in health science education. TBL facilitation skills are unique and differ from those needed to lecture or facilitate other types of small groups. Measuring facilitation skills and providing feedback to TBL instructors is important, yet to date no valid instrument has been developed and published for this purpose. Approach: We created an 11-item instrument (ratings of each item on a 7-point scale) designed to assess TBL facilitation skills, considering major sources of validity. Twelve experts in TBL facilitation and training developed the content of the FIT. To ensure response processes were valid, we used an immediate retrospective probing technique with 4th year medical students who were not part of the study. The Facilitator Instrument for Team-Based Learning (FIT) was piloted with 2,840 medical students in 7 schools in large (year 1 and 2) and small (year 3) courses. The internal structure of the FIT was analyzed. Results: In total, 1,559 and 1,281 medical students in large and small TBL classes, respectively (response rate 88%) rated 33 TBL facilitators. The composite mean score for the FIT was 6.19 (SD = 1.10). Exploratory factor analysis and Cronbach's alpha indicated that all items loaded on 1 factor, accounting for 77% of the item variance. Cronbach's alpha for the 11 items was 0.97. Analysis of facilitator variables and course context indicated that FIT scores were statistically significantly correlated with type of class (pre-clinical or clinical) and size of class as well as the facilitator enjoyment in using TBL as a method. Gender and the amount that facilitators used TBL each year was weakly correlated, with other factors not correlated (years facilitating TBL, confidence in facilitating TBL, and age). Conclusions: Analysis of FIT scores from 2,840 medical students across multiple institutions and teaching settings suggests the utility of the FIT in determining the quality of TBL facilitation across a range of medical education settings. Future research is needed to further analyze course contexts and facilitator variables that may influence FIT scores with additional facilitators. Additionally, FIT scores should be correlated with additional measures of TBL facilitator quality, such as direct observations, especially if these data are used for summative decision-making purposes.

A Difficult Patient Encounter: Using a Standardized Patient Scenario to Teach Medical Students to Treat Medication-Seeking Patients.

INTRODUCTION: Substance dependence and the misuse of prescription narcotic medications have recently been a topic of increased national attention. Since this is both a difficult and increasingly important area for medical student training, we created an addition to our psychiatry clerkship curriculum to address this need using a standardized patient scenario. METHODS: Standardized patient scenarios are a useful instructional and assessment tool for providing medical students with exposure to specific clinical scenarios that could not be consistently and reliably encountered in clinical rotations. We present a standardized patient scenario designed to challenge psychiatry clerkship students with recognizing and managing substance use disorders in patients with a difficult interaction style and medication-seeking behavior. Our scenario is unique in its expectations of students to appropriately manage a difficult clinical interaction in which collaborative treatment planning and advanced communication skills are critical to treatment success. RESULTS: In a narrative analysis of student postencounter reflections on this experience, most students who provided feedback indicated that the encounter was valuable to their psychiatry clerkship education. DISCUSSION: The inclusion of this learning opportunity in our clerkship has added value by assessing students' interpersonal communication skills and clinical ability to evaluate and manage substance use disorders, as well as by instructing students to manage a common and difficult clinical scenario regardless of their future specialty choice.

The ADMSEP Milestones Project.

OBJECTIVE: Credentialing bodies mandate that a medical school's curriculum be based upon recognized guidelines. Within the field of psychiatry, the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) has previously published recommended guidelines for the pre-clinical and clerkship curriculum. Ongoing changes within the Liaison Committee on Medical Education's requirements for medical school curricula, and the publication of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, necessitated review of these guidelines. METHODS: ADMSEP convened a task force of psychiatric educators to develop a consensus report outlining new guidelines. The ADMSEP membership reviewed and approved this final document. RESULTS: The guidelines outline six core learning objectives with corresponding competencies. Each of these competencies specifies accompanying milestones to be achieved through the course of medical school. CONCLUSIONS: ADMSEP believes these guidelines will aid educators in crafting a school's psychiatric curriculum. Clearly articulated milestones may foster the further development of validated educational and assessment tools by ADMSEP and other organizations.

"I started to feel like a 'real doctor'": medical students' reflections on their psychiatry clerkship.

OBJECTIVE: Medical students' reflective journals can be a rich source for understanding what students learn and think about during clinical rotations and can offer educators and mentors insight into students' professional identity formation. The aim of this paper is to ascertain, from reflective accounts, students' development and reactions to psychiatry following their psychiatry clerkship. METHOD: The patterns, recurrent categories, and themes in 100 psychiatry clerks' reflective journals were analyzed using grounded theory. Constant comparative method was employed to identify and quantify emergent themes and uncover relationships between these themes. RESULTS: The most common "unprompted" themes that students reported were the recognition of the complexity of the illness condition and the fact that the psychiatric patient does not exist in a vacuum (52 %); an acknowledgement of one's respect for the struggle of patients with mental illness (49 %); an expressed or demonstrated empathy for patients (48 %); and a reduced skepticism of the biological basis of mental illness and efficacy of treatments (46 %). CONCLUSION: Reflective exercises-along with quality mentorship-can be used to understand students' experience with clinical encounters, facilitate change, refine assumptions among students, and promote critical self-assessment and personal growth.

Are reports of life event stress among suicidal youth subject to cognitive bias?

Severity of depressive symptoms, hopelessness, and suicidal ideation were examined to determine whether they were significantly associated with the accuracy of suicidal adolescents' ratings of stressful life events. The sample included 130 inpatient adolescents who endorsed suicide-related behaviors. Stress interviews were administered, and the severity of stressful events was rated separately by adolescents and an independent team. A residualized cognitive bias score was created by regressing adolescents' severity ratings to the independent team's severity ratings of the same events. Depressive symptoms, but not hopelessness or suicidal ideation, were significantly associated with cognitive bias scores. A negative cognitive bias in adolescents' reports of life stress may be present at higher levels of depression relative to minimal levels of depression. Further research on the relations between stress and suicide-related behaviors is encouraged to include independent ratings of stress severity.

Precipitating events in adolescent suicidal crises: exploring stress-reactive and nonreactive risk profiles.

Factors distinguishing adolescents who experienced a precipitating event in the week preceding a suicidal crisis from those who did not were examined. Among 130 suicidal inpatients (mean age = 15.01 years), those who experienced a precipitating event reported significantly lower depressive symptom scores, better perceived problem solving, less suicidal intent, and a lower rate of prior suicide attempts than those without a precipitating event. Levels of trait impulsivity, suicidal ideation, and current attempt status did not differentiate groups. Findings provide preliminary evidence consistent with at least two possible pathways to a suicidal crisis. Clinical implications and future directions are discussed.

Erythema multiforme vs. DRESS syndrome associated with the combined use of lamotrigine and cyclobenzaprine: a case report.

Lamotrigine is FDA-approved as a maintenance treatment of bipolar disorder, but its common off-label uses include bipolar depression and antidepressant augmentation in patients with major depressive disorder. Among other adverse effects, cutaneous reactions, particularly erythema multiforme, are cited as concerns during treatment with this medication. In order to minimize the risk of cutaneous side effect, efforts have been made to identify factors associated with a higher rate of lamotrigine-induced rash. We report here a case of Drug Reaction with Eosinophilia and Systemic Symptoms apparently precipitated by the associated use of lamotrigine and cyclobenzaprine.

Potential for oxytocin use in children and adolescents with mental illness.

BACKGROUND: Oxytocin, long known for its role in childbirth and breastfeeding, has recently come under investigation for its psychoactive properties. We investigated its potential for use in adolescent psychiatric populations for anxiety, depression, attachment disorders, and conduct disorder. METHODS: We conducted a thorough search of the literature using the Pubmed and Psychinfo databases and reviewed both the Journal of the American Academy of Child and Adolescent Psychiatry from January 2000 until June 2010 and the new research abstracts from the 2009 and 2008 American Academy of Child and Adolescent Psychiatry conferences. We also surveyed the studies, both ongoing and recruiting, currently receiving National Institutes of Health funding to study oxytocin. RESULTS: We found numerous articles outlining benefits of intranasal oxytocin administration on individual traits, both in healthy and psychiatric populations. We also found ongoing phase II clinical trials for oxytocin uses as an antipsychotic or anxiolytic. CONCLUSIONS: Given the research already conducted, we recommend investigation into the therapeutic use of oxytocin in adolescent populations for anxiety, psychosis, attachment disorders, and conduct disorder.

Managing negative reactions in forensic trainees.

The treatment of adolescent offenders often provokes strong feelings in providers on the treatment team. These feelings, or countertransference reactions, can hinder effective patient care. However, with supervision and acknowledgment, these reactions can also be used effectively in becoming aware of the patient's internal state. In this article, a resident and her supervisor discuss reactions to a particular patient on a subacute unit for adolescent offenders. We also discuss methods of teaching trainees to recognize these countertransference reactions and to work through them to provide more effective patient care.

Domains of chronic stress and suicidal behaviors among inpatient adolescents.

Little is known about the role of chronic stress in youth suicidal behaviors. This study examined the relations between specific domains of chronic stress and suicidal behaviors among 131 inpatient youth (M age = 15.02 years) who completed measures of stress, suicidal ideation, suicide attempt, and suicide intent. After controlling for demographics, diagnostic status, past history of attempt, and life event stress, the predictors of suicidal ideation were chronic stress in family relationships, close friendship, and physical health. Chronic close friendship stress also predicted suicide intent among attempters after controlling for covariates. No domain robustly predicted the presence of an attempt or moderated the relation between life event stress and suicidal behaviors. These findings highlight the role of certain domains of chronic stress in suicidal ideation and suicide intent.

Factor structure and psychometric properties of the Modified Scale for Suicidal Ideation among suicidal youth.

BACKGROUND: Although suicidal behaviors occur at a high rate in adolescence, relatively few interview-based measures are available to assess suicidal ideation among youth. Existing interview measures are limited by a paucity of empirical study, a failure to conform to standard suicide nomenclature, or a lengthy administration time. This study presents data on the psychometric properties and factor structure of the brief, layperson-administered Modified Scale for Suicidal Ideation (MSSI) among suicidal youth. METHODS: The MSSI was administered to an inpatient sample of 102 suicidal youth aged 13-17 years. Additional interview and self-report measures were administered to examine the convergent validity of the MSSI. RESULTS: Consistent with previous findings among suicidal adults, the MSSI displayed good internal consistency and expected patterns of convergent validity. Principal component analysis revealed a bidimensional structure, with factors corresponding to (1) Desire and Ideation and (2) Plans and Preparations. Each factor displayed acceptable internal consistency and expected patterns of convergent validity via associations with hopelessness, depressive symptoms, impulsivity, and a self-report measure of suicidal behaviors. The Plans and Preparations factor significantly associated with the presence of a current suicide attempt and with greater suicide intent among attempters, whereas the Desire and Ideation factor did not. CONCLUSIONS: The MSSI appears to be a reliable and valid instrument to assess suicidal ideation among distressed youth. Clinicians are encouraged to pay particular attention to responses on the Plans and Preparations factor given its stronger association with suicide attempt and more serious suicide intent.

Thought suppression and suicidal ideation: preliminary evidence in support of a robust association.

BACKGROUND: The suppression of unwanted thoughts appears to contribute to the development and maintenance of emotional disorders. This report tested the thought suppression paradigm in relation to suicidal ideation. Based on the ironic process theory, we hypothesized that the suppression of unwanted thoughts, especially suicidal thoughts, would associate with a higher frequency and a greater intensity of suicidal ideation. METHODS: Study 1 examined cross-sectional associations between self-reported thought suppression and the frequency of suicidal ideation in a nonclinical sample of 166 undergraduate students. Study 2 extended cross-sectional findings in an inpatient sample of 71 suicidal adolescents. Study 3 examined prospective associations between suicidal thought suppression and increases in self-reported suicidal ideation over a 4-week period in a separate nonclinical sample of 118 undergraduate students. RESULTS: Findings across studies support a robust association between thought suppression and suicidal ideation, even controlling for general depressive symptoms. Participants in Studies 1 and 2 who endorsed greater tendencies toward suppression of thoughts, especially suicidal thoughts (Study 2), displayed higher concurrent levels of suicidal ideation. Participants in Study 3 who endorsed greater baseline tendencies toward suppression of suicidal thoughts displayed an increase in the severity of suicidal ideation over time. CONCLUSIONS: Suppression of suicidal thoughts may represent 1 mechanism contributing to the persistence of suicidal ideation. Clinicians may wish to explore patients' reactions to suicidal ideation and consider acceptance-oriented strategies among patients who attempt to control unwanted suicidal thoughts.