The feasibility of standardized patient assessments as a best practice in an academic training program.

The use of standardized patient assessments (SPAs) in psychiatry is an emerging best practice. This column describes a survey of resident and faculty supervisors at a large academic department examining current practices, attitudes, and perceived barriers to incorporating SPAs into clinical practice. Although the study found that SPAs were not routinely used in clinical practice or supervision, residents and faculty were fairly optimistic about their potential value. The results suggest that educational initiatives should be integrated into clinical practice, start early within training, include both trainees and faculty supervisors, and set use of SPAs as an expected standard of care.

Reducing medical students' stigmatization of people with chronic mental illness: a field intervention at the "living museum" state hospital art studio.

OBJECTIVE: The authors designed an intervention to reduce beginning medical students' stigmatization of people with chronic mental illness (CMI). METHODS: Pre-clinical medical students visited a state psychiatric facility's "Living Museum," a combination patient art studio/display space, as the intervention. During the visit, students interacted with artist-guides who showed their work and discussed their experiences creating art. Students completed a self-assessment survey developed to measure attitudes and feelings toward people with CMI after half of the class visited the Living Museum, constituting a Visit/No-Visit cross-sectional comparison. RESULTS: Students who visited the Living Museum (N=64), as compared with those who did not visit (N=110), endorsed more positive attitudes toward people with CMI. Among the students who visited, however, those who reported having spoken individually with a patient-artist (N=44), paradoxically, indicated less-positive feelings toward people with CMI. CONCLUSIONS: An intervention in which pre-clinical medical students visited patient-artist guides in an art-studio setting generally improved students' attitudes toward people with CMI. Thus, nontraditional psychiatric settings offer a valuable adjunct to more traditional clinical settings to reduce stigma when introducing medical students to the field of psychiatry.

Personality disorders in hypochondriasis: prevalence and comparison with two anxiety disorders.

OBJECTIVE: Symptoms of hypochondriasis are sometimes attributed to personality psychopathology by health care providers. The goals of this study were to assess the prevalence of personality disorder (PD) comorbidity in hypochondriasis (HYP) and to compare the PD comorbidity profile of patients with HYP with that found among patients with other disorders characterized by intrusive thoughts and fears. METHODS: Structured Clinical Interview for DSM-IV Axis I and Axis II Disorders (SCID-I and SCID-II) were administered to 179 individuals: 62 with HYP, 46 with obsessive-compulsive disorder (OCD), and 71 with social anxiety disorder (SAD). For group contrasts, the samples were "purified" of the comparison comorbid disorders. General linear models were used to test the combined effect of group (HYP, OCD, SAD), age, and gender on the PD outcome variables. RESULTS: 59.7% of HYP subjects had no Axis II comorbidity. The most common PDs in HYP were paranoid (19.4%), avoidant (17.7%), and obsessive-compulsive (14.5%). HYP significantly differed from SAD in the likelihood of a cluster C disorder, whereas no significant difference was noted for HYP vs. OCD. The proportion of subjects having at least two PDs was not significantly different for HYP vs. OCD or for HYP vs. SAD. CONCLUSION: Although 40% of patients with hypochondriasis have PD comorbidity as assessed by the SCID-II, the amount of PD comorbidity is not significantly different than found among individuals with two comparison anxiety disorders. Therefore, health providers should be aware that PD may complicate the clinical profile of HYP, but they should avoid assuming that PD psychopathology is the primary source of hypochondriacal distress.

Measurement-based care in psychiatric practice: a policy framework for implementation.

This article describes the need for measurement-based care (MBC) in psychiatric practice and defines a policy framework for implementation. Although measurement in psychiatric treatment is not new, it is not standard clinical practice. Thus a gap exists between research and practice outcomes. The current standards of psychiatric clinical care are reviewed and illustrated by a case example, along with MBC improvements. Measurement-based care is defined for clinical practice along with limitations and recommendations. This article provides a policy top 10 list for implementing MBC into standard practice, including establishing clear expectations and guidelines, fostering practice-based implementation capacities, altering financial incentives, helping practicing doctors adapt to MBC, developing and expanding the MBC science base, and engaging consumers and their families. Measurement-based care as the standard of care could transform psychiatric practice, move psychiatry into the mainstream of medicine, and improve the quality of care for patients with psychiatric illness.

Discrediting the notion "working with 'crazies' will make you 'crazy'": addressing stigma and enhancing empathy in medical student education.

People with mental illness around the world continue to suffer from stigmatization and limited care. Previous studies utilizing self-report questionnaires indicate that many medical students regard clinical work with psychiatric patients as unappealing, while the professionalism literature has documented a general decline in students' capacity for empathy over the course of medical school. Through in-depth interviews, this study attempts to better understand the formation of medical students' perceptions of psychiatry and the implications of that process for a more general understanding of the impact of emotionally-laden experiences on medical students' capacity for empathy. Forty-seven fourth-year medical students who had expressed interest or performed well in psychiatry were asked a series of questions to elicit their perceptions of the field of psychiatry. Interview transcripts were systematically coded using content analysis and principles of grounded theory. Stigma, stereotypes, and stressfully intense emotional reactions seemed to adversely affect the students' expected satisfaction from and willingness to care for the mentally ill, despite enjoying psychiatry's intellectual content and the opportunity to develop in-depth relationships with patients. Teaching faculty need to directly address the stigma and stereotypes that surround mental illness and actively help medical students cope with the stress that they report experiencing during their psychiatry clerkship in order to improve the recognition and treatment of psychiatric illness by newly graduating physicians. More generally, the relationships that we identify among stress, stigmatization, and stereotyping along an empathic spectrum suggest that increased attention should be paid to the stress that empathy can entail. This perspective may allow for the creation of similarly targeted interventions throughout the medical school curriculum to counteract the decline in empathy, the so-called "hardening of the heart," associated with physician-training worldwide.

Systems-based practice defined: taxonomy development and role identification for competency assessment of residents.

PURPOSE: To demonstrate a methodology for coding and taxonomy development and to operationally define residents' competence in systems-based practice (SBP) in terms of observable roles, actions, and behaviors. METHODS: The Accreditation Council for Graduate Medical Education's (ACGME's) full-text definition of SBP and the 6 discrete expectations it contains were content analyzed. Structured interviews of 88 health care professionals using a variant of focus group interviews called nominal group processes were conducted and qualitatively analyzed to identify the key attributes of SBP. Themes obtained from these 2 procedures were conceptually matched and organized to create a taxonomy of observable SPB behaviors and the SBP domain. RESULTS: Six general resident roles emerged, under which 35 specific behavioral attributes were subsumed. From the SBP domain specified. Sample SBP items categorized by roles were derived that reflected "in-context" representations of ACGME SBP expectations. CONCLUSION: Our comprehensive analysis created an operational representation of the SBP competency. The taxonomy development model provides a framework for constructing assessment instrument(s) that could be applied to the other ACGME competencies or complex concepts in medical education.

Advances in understanding illness anxiety.

Illness anxiety, also known in its more severe form as hypochondriasis, is a debilitating and chronic condition in which normal bodily symptoms are misinterpreted as signs of serious medical illness. Patients suffer with the fear that they are ill despite reassurance to the contrary and often overuse medical services in the process. This article critically evaluates the recent literature on illness anxiety and related, medically unexplained symptoms, highlighting new and interesting findings in the areas of prevalence, classification/diagnosis, management, and evidence-based treatment and new frontiers in understanding illness anxiety, such as brain imaging, neuroimmunology, and cyberchondria.

Medical students' perceptions of psychiatry as a career choice.

OBJECTIVE: This study describes medical students' perceptions of the field of psychiatry and identifies the impact of those perceptions on their career choices in order to explore the questions: Are we as a field doing all that we can to enhance the educational experience of all medical students, regardless of their career preferences? What are the most appropriate ways to encourage interested medical students that would allow for more targeted recruitment efforts toward the most receptive students? METHODS: Third-year (n=131) and fourth-year medical students (n=117) at a northeastern, urban, private university medical school completed anonymous self-report questionnaires. Students rated the impact of intellectual interest, status, earning potential, healthcare reform, quality of life, satisfaction, and stress of working with psychiatric patients on their consideration of a psychiatric career. Respondents were then systematically divided into two groups: 1) those who considered psychiatry as a possible career choice and 2) those who did not. RESULTS: When compared to students who had been coded as "not seriously considering" a career in psychiatry, students coded as "seriously considering" gave significantly higher positive ratings to the field's intellectual content and quality of life. There were also significant differences between the groups regarding the satisfaction involved in working with psychiatric patients. Students from both groups were equally concerned about stress levels in the field. CONCLUSIONS: Acknowledging, discussing, and providing a context for stressful experiences during the psychiatry clerkship are likely to bring about productive approaches to improve recruitment into the field as well as to improve all students' psychiatric education.