Training Military Psychiatrists to Adapt and Overcome: How COVID-19 Highlighted the Unique Flexibility of Military Psychiatry in Training and in the Fleet.

PURPOSE OF REVIEW: Born out of necessity, military medicine continues to find itself at the forefront of medical innovation. This generation of military physicians has never previously been challenged with continuing to provide top notch medical support to servicemembers in a variety of operational settings in the midst of a global pandemic. While military medicine has always been able to uniquely meet the educational goals of residency training, COVID-19 brought new challenges to the forefront. RECENT FINDINGS: While the threat presented by COVID-19 was different from the historical battlefield threats and challenges that have given birth to military medicine, it was nevertheless ready to pivot and adjust course, focusing on how to best meet the medical needs of the military patient population in an ever-changing geopolitical environment while continuing to meet and exceed the educational standards that training programs are held to. Historically and currently, mental health remains one of the most common reasons that servicemembers are evacuated from combat zones. The COVID-19 pandemic provided an opportunity for modern military psychiatry to showcase its ability to adjust the educational focus in certain areas of residency training to prepare the next generation of military psychiatrists to be able to face the newest threat to force wellness.

The training value of working with armed forces inpatients in psychiatry.

Over the last 10 years, the UK armed forces (UKAF) have been involved in operations worldwide. Mental health in the armed forces (AF) has been the subject of considerable interest in part because of a perceived added risk of psychological distress in this population. Inpatient psychiatric services are provided through partnerships with NHS hospitals. The Cavell Centre, Peterborough's acute inpatient psychiatric unit has up to four beds for service personnel, under the care of a civilian consultant psychiatrist and his AF Foundation Year 2 doctor (F2). This was the only Ministry of Defence (MoD) inpatient unit which had a training post for an AF doctor, but the post ended in August 2014 with the closure of MoD Hospital Unit Peterborough (MDHU(P)). This article outlines the differences in civilian and AF inpatient care and discusses the training value of AF doctors managing service personnel who are psychiatric inpatients.

Suicide Response Guidelines for Residency Trainees: A Novel Postvention Response for the Care and Teaching of Psychiatry Residents who Encounter Suicide in Their Patients.

Suicide is an event that is almost universally encountered by psychiatrists and psychiatry residents. Because psychiatric patients are at a higher risk for completing suicide than patients of other specialties, psychiatry residents are at risk for experiencing the suicide of a patient during their training. A review of the literature shows that there is continually growing research into the negative emotional effects of patient suicides on psychiatry residents and the need for clear response protocols when a suicide occurs, also known as postvention protocols. However, there are no Graduate Medical Education requirements to specifically train psychiatry residents about this, even with a well-voiced desire by residents to receive this training. In the National Capitol Consortium Psychiatry Residency, encounters with patient suicides by residents in a time of war led us to a place in which interventions were designed and instituted to care for the caregiver, in this case focusing on psychiatry trainees. Our process and product, described here, offers an example of a systematic postvention response. It addresses aspects of what is known in the research base, combined with acknowledgement of the human response and the institutional need for a consistent and objective response.

US Military Child and Adolescent Psychiatry Training Programs and Careers of Military Child Psychiatrists.

Military child and adolescent psychiatry (CAP) fellowship programs offer educational experiences universal to all civilian training programs in the USA. They also offer unique training opportunities not found in civilian CAP fellowships in order to prepare graduates to serve the needs of military families. Military-specific curricula and exposures prepare trainees to address various issues faced by military families, in contending with frequent military moves, parental deployments, and disrupted social ties. Curricula are also designed to provide the psychiatrist with a greater understanding of the rigors of military service. CAP training and subsequent assignments prepare military psychiatrists for diverse career paths in the military environment. CAP military careers often include duties in addition to treating patients. Administrative roles, academic teaching positions, as well as school consultation positions are all career options available to military CAP.

Impact of an Enduring War on Two Military Psychiatry Residency Programs.

Four active duty military psychiatrists at different points in their careers were asked to reflect on the impact that the wars in Iraq and Afghanistan had on their respective training in military psychiatry residency programs. The result is an inside look from four unique perspectives on how military psychiatry residency training adapted over time to prepare their graduates to practice psychiatry in a wartime setting as many graduates went to the front lines of war shortly after graduation. This article will provide an understanding of the challenges faced by these residency programs striving to meet the behavioral health needs created by war while balancing this with ongoing ACGME requirements, how those challenges were met, and the impact it had on residents.

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.

Large-Scale Simulation for Teaching Combat and Operational Stress Control: Operation Bushmaster.

Large-scale high-fidelity casualty simulation and exposure to realistic environmental stressors in Operation Bushmaster represents a unique teaching environment that challenges military medical students to apply skills in assessment and acute management of stress responses. While this training event is specific to military medical students, the skills demonstrated could be readily applied in natural disaster or other mass civilian casualties. Schools seeking to teach mass casualty response could implement many of the elements of the curriculum outlined in this article on a smaller scale. Doing so exposes students to decision making in a disaster where the number of patients exceeds available resources and damage to infrastructure may limit their capabilities. Our experience with large-scale simulation suggests that this is an effective teaching tool.

Educating medical professionals about suicide prevention among military veterans.

The aim of this paper was to discuss the results of a review of literature related to suicide in military veteran populations. Suicide in veteran populations has been increasing in recent years, and continues to be a medical and social problem across the globe. For medical health professionals, knowledge of the risk factors for suicide, careful assessment, and appropriate interventions are key to suicide prevention. The main aim of this review is to better understand the risk factors present in veteran suicide and find ways by which to educate medical professionals in suicide prevention. Key suicide risk factors found in veteran populations include posttraumatic stress disorder, major depressive disorder, physical injuries, substance use disorders, traumatic brain injury, combat-related guilt, access to firearms, and insufficient social support. Some psychosocial difficulties are unique to veteran populations, and medical professionals should be culturally sensitive to these factors. Psychosocial changes upon discharge from active duty, as well as stigma against mental health disorders and treatment, should also be considered and assessed. Given that general practitioners may be the first line of defense for these veterans, they should be educated in risk factors for veteran suicide and proper assessment techniques. Any suicide risk in a veteran population should be taken very seriously, and responded to appropriately.

Casualties.

Privation and disease have mainly killed soldiers until very recently. Now that enemy action predominates, faster and better control of bleeding and infection before and during evacuation spares ever more lives today. This essay focuses on psychological war wounds, placing them in the context of military casualties. The surgeon's concepts of 'primary' wounds in war, and of would 'complications' and 'contamination', serve as models for psychological and moral injury in war. 'Psychological injury' is explained and preferred to 'Post-Traumatic Stress Disorder', being less stigmatizing and more faithful to the phenomenon. Primary psychological injury equates to the direct damage done by a bullet; the complications - for example, alcohol abuse - equate to hemorrhage and infection. Two current senses of 'moral injury' equate to wound contamination. As with physical wounds, it is the complications and contamination of mental wounds that most often kill service members or veterans, or blight their lives.

"The dangers of this atmosphere": a Quaker connection in the Tavistock Clinic's development.

During the Second World War, through innovations in officer selection and group therapy, the army psychiatrists John Rickman and Wilfred Bion changed our understanding of leadership. They showed how soldiers under stress could develop real authority through their attentiveness to each other. From contrasting experiences 25 years earlier each had seen how people in groups are moved by elemental forces that undermine judgement and thought. This article arose from my experiences as a trainee at the Tavistock Clinic, where the method of reflective work discussion, giving individuals seated in a circle the choice to speak or to remain silent, seemed similar to a Quaker meeting. Many decades later, I found that this association had a basis in fact. Among other influences on Bion -- a childhood in India, distinguished service in the First World War, and a surgical apprenticeship with Wilfred Trotter -- there is a little-acknowledged Quaker source, in John Rickman, for Bion's radical work in the army that led to new methods of training and organizational consultancy in the postwar Tavistock.

War's long shadow: masculinity, medicine, and the gendered politics of trauma, 1914-1939.

War is an inherently traumatizing experience, and during the First World War more than 15,000 Canadian soldiers were diagnosed with some form of war-related psychological wounds. Many more went unrecognized. Yet the very act of seeking an escape from the battlefield or applying for a postwar pension for psychological traumas transgressed masculine norms that required men to be aggressive, self-reliant, and un-emotional. Using newly available archival records, contemporary medical periodicals, doctors' notes, and patient interview transcripts, this paper examines two crises that arose from this conflict between idealized masculinity and the emotional reality of war trauma. The first came on the battlefield in 1916 when, in some cases, almost half the soldiers evacuated from the front were said to be suffering from emotional breakdowns. The second came later, during the Great Depression, when a significant number of veterans began to seek compensation for their psychological injuries. In both crises, doctors working in the service of the state constructed trauma as evidence of deviance, in order to parry a larger challenge to masculine ideals. In creating this link between war trauma and deviance, they reinforced a residual conception of welfare that used tests of morals and means to determine who was deserving or undeserving of state assistance. At a time when the Canadian welfare state was being transformed in response to the needs of veterans and their families, doctors' denial that "real men" could legitimately exhibit psychosomatic symptoms in combat meant that thousands of legitimately traumatized veterans were left uncompensated by the state and were constructed as inferior, feminized men.

Ethical considerations in military psychiatry.

Military psychiatrists are faced with multiple, difficult questions that shape the context for ethical patient care. These questions are difficult to answer and future efforts, including policy and evidence-based treatment practices, should aim at reducing the ambiguity faced by military psychiatrists. New research should focus on issues as diverse as optimal approaches to informed consent, evidence-derived approaches to protecting confidentiality, outcomes of care for individuals in widely varying military roles, and medication use in the field. Training for mental health care providers who deal with military patients should be provided not only in military graduate medical education but also in job-specific courses and in ethics. This should include specific training for personnel who will be dealing with specific populations, such as the US Army's current "Dealing with Detainee course" and the Army Medical Department's "Combat Operational Stress Course" for deploying military psychiatrists and psychologists.

Collaborative academic training of psychiatrists and psychologists in VA and medical school settings.

OBJECTIVE: The authors review the background and contemporary strengths of Dean's Committee Veterans Affairs Medical Centers in the collaborative academic training of psychiatrists and psychologists. METHODS: The authors discuss the problems and prospects of the current health care environment as it impacts the behavioral health treatment of returning veterans from the wars in Iraq and Afghanistan and the educational agenda for psychiatry and psychology. The medical education program in psychiatry and the internship program in psychology at the Syracuse Veterans Affairs Medical Center and the SUNY Upstate Medical University provide an exemplar of academic collaboration in clinical training. RESULTS: Within this combined educational environment, opportunities and challenges abound for interns and residents to receive advanced training in the state-of-the-art assessment and treatment of disorders related to psychological trauma, posttraumatic stress disorder, sexual trauma, traumatic brain injury, polytrauma, behavioral health in primary care, and telepsychiatry. CONCLUSION: There is tremendous mutual benefit from academic collaboration for both institutions as they grapple with their respective treatment and educational missions.

The impact of VA and Navy Hospital Collaboration on medical school education.

OBJECTIVE: The U.S. Department of Veterans Affairs (VA) is the largest single provider of medical education in the United States and is often the preferred training site for medical students and residents. However, changing priorities of patients and the marketplace are forcing medical schools and the VA to consider new ways of practicing medicine and relating to each other. This article reviews the value of that relationship. METHODS: The authors describe a VA and Department of Defense sharing agreement and the development of a federal medical center as well as the involvement of a local medical college and the impact on education. RESULTS: The federal medical center will provide more clinical services to veterans, active duty service members, and their beneficiaries. Trainees see a variety of young adults of both genders and are exposed to behaviors and pathology not commonly seen in typical general adult inpatient VA psychiatric units. CONCLUSION: The federal facility will provide accessible, high quality health care for active duty and veteran patients. It benefits trainees by enriching their training experience and allowing students and residents to receive a comprehensive clinical experience by caring for diversified patients with a wide range of pathology.

Medical student psychiatry examination performance at VA and non-VA Clerkship Sites.

OBJECTIVE: The authors examined the effects of medical student assignment to U.S. Department of Veterans Affairs (VA) Medical Center inpatient and outpatient psychiatry clerkship sites versus other university and community sites on the performance outcome measure of National Board of Medical Examiners (NBME) subject examination scores. METHODS: NBME psychiatry scores were compared for stratified random samples of 70 students each for inpatient and outpatient VA and non-VA sites, controlling for baseline clinical knowledge as reflected by second year Human Behavior course scores. RESULTS: No significant differences were demonstrated in NBME scores between VA and non-VA sites for either inpatient or outpatient programs. CONCLUSION: Assessed students rotating through several VA clinical sites were as well prepared for NBME subject examinations as those assigned to other sites. Additional measures of educational outcome for VA sites are recommended to assess and enhance clinical education provided by the VA and to strengthen collaboration with university-based medical student teaching programs.