Virtual Interviewing and Diversity Among Psychiatry Residents.

OBJECTIVE: Psychiatry residency program directors were surveyed regarding their impression of the impact virtual interviewing had on the perceived and actual diversity of individuals selected for interviews and residency training. METHODS: A link to an anonymous survey was sent to 299 psychiatry residencies. Psychiatry program directors provided information about their programs and rated their perception of the impact of virtual interviewing on candidates they interviewed and matched. They also reported the demographic information of incoming residency classes for 2020-2023. This data was assessed for differences in the average number of residents by each diversity category and interview format (i.e., in person or virtual) and between diversity categories and cohorts. A linear trend analysis assessed whether the number of residents in each demographic category had a significant change over time. RESULTS: Sixty-five program directors (21.7%) provided at least partial data. Half of the responding program directors believed that virtual interviewing had increased the diversity of interviewed applicants, but there were no statistically significant differences in the average number of incoming residents who were identified as women or were in an Underrepresented in Medicine category when comparing the in-person interview year (2020) and the virtual interview years (2021-2023). CONCLUSIONS: The analyzed data demonstrated that the type of interview (in-person vs virtual) did not appear to affect the diversity of incoming psychiatry residents. Ongoing efforts to increase diversity, equity, inclusion, and belonging should be paired with measurements of their impact.

Assessing Medical Students' Comfort with Telemedicine.

OBJECTIVE: The Association of American Medical Colleges (AAMC) has recommended that the provision of telemedicine services become an entrustable professional activity (EPA). Given its increased scope, medical student comfort with telemedicine was explored. METHODS: An institutional review board-approved 17-question, anonymous voluntary survey was created based on the AAMC's EPAs and administered to students at Northeast Ohio Medical University across 4 weeks. The primary outcome of this study was to assess medical students' self-reported telemedicine comfort levels. RESULTS: The response rate was 141 students (22%). At least 80% of students believed that they were able to gather essential and accurate patient information, counsel patients and families, and communicate effectively across a broad range of social, economic, and cultural backgrounds using telemedicine. In total, 57% and 53% of students, respectively, believed that they were able to gather information and diagnose patients using telemedicine as well as they did in person, 38% of respondents believed that their patient's health outcome was the same via telemedicine or in-person visits, and 74% of respondents wished that telemedicine was formally taught in school. Most of the students believed they could effectively gather essential information and counsel patients via telemedicine, but there was a notable decrease in confidence for medical students when comparing telemedicine and in-person care directly. CONCLUSIONS: Despite the EPAs created by the AAMC, students did not self-report the same comfort level with telemedicine as they had with in-person patient visits. There are opportunities for improvement in the telemedicine medical school curriculum.

The Burden of Leadership: a Survey of Burnout Experiences Among Psychiatry Program Directors.

OBJECTIVE: The objectives of this study were to examine the prevalence of burnout, specify contributors to and protective factors against burnout, and gather suggestions to improve well-being in psychiatry Program Directors. METHODS: A survey regarding burnout and wellness was distributed to psychiatric Program Directors through the email listserv of the American Association of Directors of Psychiatric Residency Training (AADPRT). RESULTS: The survey response rate was 273 responses out of 880 members surveyed (31%). The majority of respondents were current residency or fellowship Program Directors or Associate Program Directors or had another current educational role (93%, 227/245). Almost half of current Program Directors or Associate Program Directors reported feeling burned out almost daily or once a week (44%, 93/210). These Program Directors reported a desire to resign (77%), experienced discrimination within the past 5 years (66%), and struggled with finding meaning in their job (44%). The most frequently endorsed contributors to burnout were increasing administrative burden and insufficient support. CONCLUSIONS: The survey findings confirm that burnout characteristics are common among respondents, associated with a desire to resign and a struggle to find meaning in the highly demanding position of Program Director or Associate Program Director. Advocacy for resources, decreased administrative overload, and increased protected time would enhance well-being in Program Directors. Most striking was the frequency of discrimination reported and its relationship to burnout. Departments may benefit from a careful review of policies, procedures, and training to decrease hostile workplaces for women, international medical graduate, and under-represented in medicine Program Directors.

Contemporary Supportive Therapy: A Review of History, Theory, and Evidence.

Supportive psychotherapy interventions were developed as a part of psychodynamic psychotherapy work, and supportive psychotherapy was historically considered to be the default form of therapy only for lower-functioning patients. These roots unfortunately have resulted in supportive psychotherapy being viewed as an inferior form of treatment. In reality, supportive psychotherapy is a practical and flexible form of psychotherapy that helps patients with a wide range of psychiatric illnesses, including mood disorders, anxiety disorders, posttraumatic stress disorder, schizophrenia, personality disorders, eating disorders, body dysmorphic disorder, and substance use disorders. In addition, supportive psychotherapy can be well-suited to higher-functioning patients, as well as to patients who are chronically lower-functioning. There is also evidence to support the use of supportive psychotherapy in patients with certain medical illnesses, including coronary artery disease, some gastrointestinal illnesses, HIV infection, and certain types of cancer. The goals of supportive psychotherapy include helping patients to understand emotional experiences, improving affective regulation and reality-testing, making use of their most effective coping strategies, and engaging in collaborative problem solving to reduce stressors and increase effective engagement with support systems.

Supportive Therapy in the Medically Ill: Using Psychiatric Skills to Enhance Primary Care.

Supportive therapy is a practical, flexible, and patient-centered psychosocial intervention that can help improve outcomes for patients struggling with a wide variety of medical illnesses. Due to its highly adaptable nature, brief supportive therapy can be practiced in busy clinical settings by consultation and liaison psychiatrists and primary care providers. In supportive therapy, the patient and provider work collaboratively to reduce distress and enhance functioning. The available evidence supports the use of supportive therapy techniques in managing the mental health consequences of medical conditions. This narrative review helps primary care providers learn and implement the basic goals and interventions of supportive therapy.

The Best Practice Conference: An Interactive Practice-Based Learning Activity for Resident and Faculty Development.

This article was migrated. The article was marked as recommended. Objective: The Best Practice Conference (BPC) was designed to use active techniques to enhance measurable learning from a continuing medical education program. Design: The BPC incorporated flipped-classroom techniques, guided discussion, and peer based components to enhance learning. The impact of the BPC was measured by comparing pre-conference, post-conference, and 3-month follow-up data. Setting: The BPC started with emails to likely attendees. The conference occurred during a regularly scheduled Grand Rounds time slot. There were subsequent follow up e-mails to those who had attended. Methods: The Best Practice Conference involved e-mail contact with residents and faculty members who were likely to attend the conference. These e-mails included clinical scenarios, questions about treatment options, and journal articles. The BPC lasted for 1.5 hours and included a variety of active learning techniques. These conferences were attended by psychiatry residents and faculty members. The attendees were contacted several months later and asked questions about the BPC. Results: Between 39 - 48% of attendees changed their recommended treatment over the course of the conference, and three months later approximately 10% of attendees reported that their practice patterns had changed because of the Best Practice Conference. The Best Practice Conference catalyzes developmental learning where clinicians critically evaluate their practice habits in the context of the medical literature and the practices of their peers. Conclusions: The Best Practice Conference promotes impactful Practice Based Learning and Improvement among residents and faculty members.

DSM-5 Criteria and Its Implications for Diagnosing PTSD in Military Service Members and Veterans.

This review addresses how changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 posttraumatic stress disorder (PTSD) criteria has the potential to affect the care and careers of those who have served in the military, where the diagnosis often determines fitness for duty and veterans' benefits. PTSD criteria changes were intended to integrate new knowledge acquired since previous DSM editions. Many believe the changes will improve diagnosis and treatment, but some worry these could have negative clinical, occupational, and legal consequences. We analyze the changes in classification, trauma definition, symptoms, symptom clusters, and subtypes and possible impacts on the military (e.g., over- and under-diagnosis, "drone" video exposure, subthreshold PTSD, and secondary PTSD). We also discuss critiques and proposals for future changes. Our objectives are to improve the screening, diagnosis, and treatment of those service members who have survived trauma and to improve policies related to the military mental healthcare and disability systems.

Benzodiazepines for PTSD: A Systematic Review and Meta-Analysis.

OBJECTIVE: Although benzodiazepines (BZDs) are commonly used in the treatment of posttraumatic stress disorder (PTSD), no systematic review or meta-analysis has specifically examined this treatment. The goal of this study was to analyze and summarize evidence concerning the efficacy of BZDs in treating PTSD. METHODS: The review protocol was undertaken according to the principles recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and is registered with the PROSPERO international prospective register of systematic reviews (http://www.crd.york.ac.uk/PROSPERO, registration number CRD42014009318). Two authors independently conducted a search of all relevant articles using multiple electronic databases and independently abstracted information from studies measuring PTSD outcomes in patients using BZDs. Eighteen clinical trials and observational studies were identified, with a total of 5236 participants. Outcomes were assessed using qualitative and quantitative syntheses, including meta-analysis. RESULTS: BZDs are ineffective for PTSD treatment and prevention, and risks associated with their use tend to outweigh potential short-term benefits. In addition to adverse effects in general populations, BZDs are associated with specific problems in patients with PTSD: worse overall severity, significantly increased risk of developing PTSD with use after recent trauma, worse psychotherapy outcomes, aggression, depression, and substance use. Potential biopsychosocial explanations for these results are proposed based on studies that have investigated BZDs, PTSD, and relevant animal models. CONCLUSIONS: The results of this systematic review suggest that BZDs should be considered relatively contraindicated for patients with PTSD or recent trauma. Evidence-based treatments for PTSD should be favored over BZDs.

The Best of Both Worlds: Psychiatry Training at Combined Civilian-Military Programs.

Air Force psychiatry faces the task of training competent military psychiatrists in an era of continuing reductions. Beginning in the 1980s, the Air Force started collaborating with University partners to create hybrid training programs, civilian-military psychiatry residencies. These mergers provide stability for Air Force psychiatry training in the face of increased operational missions and uncertain military recruiting. As a result of these combined programs, Air Force psychiatry residents gain access to a broader range of civilian clinical experience and expertise while maintaining a focus on distinctive military requirements. The combining of programs opens up options for academic activities which may not have otherwise existed. Both military and civilian residents benefit from the occupational psychiatry experiences available within military clinical sites. These programs give civilian residents a chance to assist active duty members and their families and provide insight into the military "lifecycle." These collaborations benefit the universities by providing access to a larger pool of residents and faculty. The synthesis of the military and civilian programs raises some ongoing obstacles such as civilian residents' ability to gain access to military resources. The programs must also accommodate separate mechanisms for selecting residents (the National Residency Matching Program versus the Joint Selection Board for Graduate Medical Education). Military residents must also comply with military standards and requirements while maintaining the universities' standards of conduct and professionalism. Merging military training programs into university programs creates a vibrant opportunity to create exceptional military and civilian psychiatrists.

Serotonin syndrome in the deployed setting.

Serotonin syndrome is a potential side effect of some psychotropic medications in common use today. With over 8000 adverse events related to this condition in 2004 alone, this risk warrants further attention. The deployed environment presents a unique set of stressors and risks involved in treatment with any psychotherapeutic agent. The following case illustrates one incidence of rapid titration of a selective serotonin reuptake inhibitor (SSRI) (fluoxetine) contributing to the emergence of serotonin syndrome.

Violence and mental illness.

Violence attracts attention in the news media, in the entertainment business, in world politics, and in countless other settings. Violence in the context of mental illness can be especially sensationalized, which only deepens the stigma that already permeates our patients' lives. Are violence and mental illness synonymous, connected, or just coincidental phenomena? This article reviews the literature available to address this fundamental question and to investigate other vital topics, including etiology, comorbidity, risk factor management, and treatment. A psychiatrist who is well versed in the recognition and management of violence can contribute to the appropriate management of dangerous behaviors and minimize risk to patients, their families, mental health workers, and the community as a whole.

Recognizing and managing erotic and eroticized transferences.

Transference has been proposed as a critical concept in psychotherapy. The transference may be positive, negative, or sexualized. When the transference becomes sexualized, there are potentially damaging outcomes depending on the management of the transference. This paper addresses the significance of early experiences in residency training with sexualized transference and focuses on the therapeutic relationship in which the transference has become eroticized. The author will explore the potential benefits and challenges of properly managing such transference.

The management of suicidality: assessment and intervention.

A potentially suicidal patient is among the most difficult challenges faced by healthcare providers. This article reviews rates of suicide in America among the population as a whole and subpopulations based on age and race. In 2003, nearly 11 Americans out of every 100,000 killed themselves. The rates of suicide were highest among whites, Native Americans, and elderly males. Suicide rates are elevated among many common mental illnesses, including major depression, bipolar disorder, schizophrenia, and alcoholism. Although statistical risk factors are significant, they are of limited help in determining what should be done with specific patients. Documenting demographic information, checking off diagnostic criteria, and asking patients if they have thoughts of killing themselves are only the start of the evaluation of suicidality. The complete assessment of suicidality requires inquiring into static and dynamic risks factors, warning signs and psychosocial stresses. Patients who report suicide plans should be asked about the plan in detail, including the chance of rescue, preparations for, and rehearsal of the suicide attempt. Interventions to reduce the risk of suicide should then be targeted towards eliminating or minimizing these various factors. Despite our best efforts patients will occasionally kill themselves. Studies have found that a majority of experienced psychiatrists have had a patient commit suicide. Following the suicide of a patient, clinicians will often experience a professional as well as personal response. Most providers who have experienced a patient suicide find talking to co-workers, peers, and friends to be useful.

Suicide and the air force mental health provider: frequency and impact.

Although suicide is relatively common among mental health patients, few studies have been published detailing the effects of a patient's suicide on his or her mental health provider. We reviewed data from 97 active duty, Air Force, mental health providers who responded to an anonymous survey. Forty-eight percent of the providers had experienced a patient's suicide. One-third of them reported a sense of responsibility for that patient's death. More than 20% reported significant emotional or behavioral changes following the death. Many providers experienced alterations in their self-esteem and their use of peer consultation following the suicide. Speaking to clergy members, friends, and other providers was generally beneficial following the suicide of a patient. Recommendations are given to minimize the impact of this tragedy on providers.