Psychiatric Management, Administration, and Leadership: a Continuum or Distinct Concepts?

To clarify the relationship between the concepts of management, administration, and leadership in psychiatry. The authors provide a review of the conceptual evolution of administrative psychiatry and develop operational definitions of these three domains. Based upon their experiences, they discuss relevant core competencies and personal attributes. The authors found that the terms psychiatric management, psychiatric administration, and psychiatric leadership are often used interchangeably, yet they each have a different and distinct focus. Additionally, some in the field consider the concepts overlapping, existing on a continuum, while others draw distinct conceptual boundaries between these terms. Psychiatrists in leadership positions function in all three domains. While these are distinct concepts, the authors recommend that administrative psychiatrists integrate all three in their everyday work. The authors suggest the distinctions among these concepts should inform training and identify core competencies related to these distinctions. Mentoring should focus on the practical integration of the concepts of management, administration, and leadership in administrative psychiatry. The authors present a cohesive framework for future development of a curriculum for education and research.

Role of Leadership in Narrowing the Gap between Science and Practice: Improving Treatment Outcomes at the Systems Level.

It's been well documented that health care does not reliably transfer what we know from science into clinical practice. As a result, Americans do not always receive the care suggested by the scientific evidence. Despite the best intentions of a dedicated and skilled healthcare workforce, this can often lead to poor clinical outcomes. As research and technology rapidly advance, this gap between science and practice appears to be widening. There is an increasing public concern about a lack of access to appropriate treatment, pervasiveness of unsafe practices, and wasteful uses of precious health care resources leading to suboptimum treatment outcomes. Leadership has a critical role in creating and sustaining the environment that supports health services for individuals and populations that increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Leadership has some responsibility to improve outcomes by insuring effective use of evidence-based treatment guidelines; measurement-based care; knowledge and skills management; care coordination; and information technologies. This paper addresses leadership issues in these components of a system's ability to improve treatment outcomes.

Ethical Challenges in Psychiatric Administration and Leadership.

As with all professional ethical principles, those in psychiatry have to evolve over time and societal changes. The current ethical challenges for psychiatric administration and leadership, especially regarding for-profit managed care, need updated solutions. One solution resides in the development by the American Association of Psychiatric Administrators (AAPA) of the first set of ethical principles designed specifically for psychiatric administrators. These principles build on prior Psychological Theories of leadership, such as those of Freud, Kernberg, and Kohut. Supplementing these theories are the actual real life models of psychiatrist leadership as depicted in the memoirs of various psychiatrists. Appreciating these principles, theories, and models may help emerging leaders to better recognize the importance of ethical challenges. A conclusion is that psychiatrists should have the potential to assume more successful leadership positions once again. In such positions, making the skills and well-being of all in the organization seems now to be the foremost ethical priority.

3D ultrasound can contribute to planning CT to define the target for partial breast radiotherapy.

PURPOSE: The role of three-dimensional breast ultrasound (3D US) in planning partial breast radiotherapy (PBRT) is unknown. This study evaluated the accuracy of coregistration of 3D US to planning computerized tomography (CT) images, the seroma contouring consistency of radiation oncologists using the two imaging modalities and the clinical situations in which US was associated with improved contouring consistency compared to CT. MATERIALS AND METHODS: Twenty consecutive women with early-stage breast cancer were enrolled prospectively after breast-conserving surgery. Subjects underwent 3D US at CT simulation for adjuvant RT. Three radiation oncologists independently contoured the seroma on separate CT and 3D US image sets. Seroma clarity, seroma volumes, and interobserver contouring consistency were compared between the imaging modalities. Associations between clinical characteristics and seroma clarity were examined using Pearson correlation statistics. RESULTS: 3D US and CT coregistration was accurate to within 2 mm or less in 19/20 (95%) cases. CT seroma clarity was reduced with dense breast parenchyma (p = 0.035), small seroma volume (p < 0.001), and small volume of excised breast tissue (p = 0.01). US seroma clarity was not affected by these factors (p = NS). US was associated with improved interobserver consistency compared with CT in 8/20 (40%) cases. Of these 8 cases, 7 had low CT seroma clarity scores and 4 had heterogeneously to extremely dense breast parenchyma. CONCLUSION: 3D US can be a useful adjunct to CT in planning PBRT. Radiation oncologists were able to use US images to contour the seroma target, with improved interobserver consistency compared with CT in cases with dense breast parenchyma and poor CT seroma clarity.

Treatment of invasive breast carcinoma with ultrasound-guided radiofrequency ablation.

BACKGROUND: Radiofrequency ablation (RFA) is a minimally invasive thermal ablation technique. This study reports the safety and efficacy of RFA as a minimally invasive strategy for breast cancers <3 cm diameter in postmenopausal women. METHODS: Twenty-two postmenopausal women (aged 60 years or older) with clinical T-1N0 core biopsy proven breast cancers were studied. Thermocoagulation was undertaken using a sonographically guided RF probe under local anesthesia and sedation. The ablated tumor was resected between 1 and 2 weeks later. Endpoints were technical success, completeness of tumor kill, marginal clearance, skin damage, and patient reports of pain and procedural acceptability. RESULTS: The procedure was well tolerated and cosmesis was excellent. Pathology revealed a central ablation zone surrounded by hyperemia. Coagulative necrosis was complete in 19 of 22 patients. Disease at the ablation zone margin was found in 3 patients and 5 patients had disease distant to the ablation zone consisting of multifocal tumors (2), in-transit metastasis (1), and extensive ductal carcinoma in situ with microinvasive carcinoma (2). Ninety-five percent of patients would be willing to have RFA again. CONCLUSIONS: Radiofrequency ablation can be safely applied in an outpatient setting with acceptable patient tolerance. By itself, RFA cannot be considered effective local therapy. Trials to evaluate RFA complemented with breast irradiation are justified.