Assessment of QTc and Risk of Torsades de Pointes in Ventricular Conduction Delay and Pacing: A Review of the Literature and Call to Action.

BACKGROUND: Assessment of the heart rate-corrected QT-interval on the 12-lead electrocardiogram when prescribing medications known to increase the risk of Torsades de Pointes has become a common part of consultation-liaison psychiatry practice. OBJECTIVES: Highlighted by a patient who experienced psychiatric decompensation due to inaccurate interpretation of QTc prolongation in the setting of a wide QRS complex, we aimed to describe the approach to QTc interpretation in patients with ventricular conduction delay. METHODS: We reviewed the current literature on the approach to assessment of prolonged repolarization in patients with ventricular conduction delay due to bundle branch block (BBB) and ventricular pacing. RESULTS: Physicians of any specialty may perform initial electrocardiogram interpretation and should be proficient in the definition, recognition, and understanding of the basic pathophysiology of electrocardiographic abnormalities. We discuss current approaches to assessment of the QT-interval in patients with a wide QRS complex due to bundle branch block and ventricular pacing, including bivariate QTc modification, univariate QT-interval modifications, and use of the JT-interval. CONCLUSIONS: The QT-interval is prolonged ipso facto in patients with a wide QRS complex from ventricular conduction delay/ventricular pacing and must be adjusted for QRS duration. Multiple formulae have been proposed to account for wide QRS complex in this setting with no single universally accepted methodology. We suggest the use of either the Bogossian formula or JT-interval followed by Hodges or Framingham heart-rate correction to adjust for a wide QRS complex. It is critical that the C-L psychiatrist be able to identify a wide QRS complex on the electrocardiogram, understand implications for accurate assessment of prolonged depolarization, and apply an appropriate correction methodology.

The AAGP Scholars Program: Predictors of Pursuing Geriatric Psychiatry Fellowship Training.

OBJECTIVE: The American Association for Geriatric Psychiatry (AAGP) Scholars Program was developed to recruit trainees into geriatric psychiatry fellowships and is considered a pipeline for fellowship recruitment. Nonetheless, the number of trainees entering geriatric psychiatry fellowship is declining, making it important to identify modifiable factors that may influence trainees' decisions to pursue fellowship. We analyzed survey data from Scholars Program participants to identify demographic characteristics, attitudes toward program components, and behaviors after the program that were independently associated with the decision to pursue fellowship. METHODS: Web-based surveys were distributed to all 289 former Scholars participants (2010-2018), whether or not they had completed geriatric psychiatry fellowships. We conducted a hierarchical binary logistic regression analysis to examine demographics, program components, and behaviors after the program associated with deciding to pursue geriatric psychiatry fellowship. RESULTS: Sixty-one percent of Scholars decided to pursue geriatric psychiatry fellowship. Attending more than one AAGP annual meeting (relative variance explained [RVE] = 34.2%), maintaining membership in the AAGP (RVE = 28.2%), and rating the Scholars Program as important for meeting potential collaborators (RVE = 26.6%) explained the vast majority of variance in the decision to pursue geriatric psychiatry fellowship. CONCLUSION: Nearly two-thirds of Scholars Program participants decided to pursue geriatric psychiatry fellowship, suggesting the existing program is an effective fellowship recruitment pipeline. Moreover, greater involvement in the AAGP longitudinally may positively influence Scholars to pursue fellowship. Creative approaches that encourage Scholars to develop collaborations, maintain AAGP membership, and regularly attend AAGP annual meetings may help attract more trainees into geriatric psychiatry.

Plagiarised letters of recommendation submitted for the National Resident Matching Program.

OBJECTIVES: Residency is a critical step in the professional development of physicians. Given the high stakes of the process, it is not surprising, although nonetheless troubling, that professional misconduct may occur: multiple studies have, rightfully, condemned applicants for plagiarising personal statements or misrepresenting publications. To date, however, no studies have examined whether faculty members may engage in similar behaviours. METHODS: Software was used to evaluate 3864 unique applications containing 13 617 letters of recommendation submitted through the Electronic Residency Application Service (ERAS) to the Yale University Department of Psychiatry Residency Program in recruitment cycles from 2013-2014 to 2016-2017. The software identified pairs of letters written by different authors with at least 75 words of shared language, counting only words present in contiguous phrases of at least eight words (Shared Wording Across People, SWAP). Independent reviewers determined whether the shared language reflected acceptable forms of common usage (e.g. describing a setting of care) or was intended to convey unique attributes of an applicant, thereby representing plagiarism. RESULTS: We found that 5.1% of letters contained SWAP and 4.1% of letters contained plagiarism. In total, 11.8% of all applications included at least one plagiarised letter. By comparison, 2.6% of applicants' personal statements contained plagiarism. CONCLUSIONS: The present data demonstrate a surprising prevalence of plagiarism in letters of recommendation written for residency applicants. These data call into question both the relative weight that should be accorded to letters of recommendation and, more broadly, beg further discussion of how we conceptualise professionalism in medicine.