Psychiatry Clinical Skills Evaluation: a Multisite Study of Validity.

OBJECTIVE: Since 2007, the American Board of Psychiatry and Neurology (ABPN) has required that residency programs conduct a specific clinical skills evaluation (CSE) of physician-patient interaction, psychiatric interview and mental status examination, and case presentation on a directly observed patient interview as a prerequisite for certification. The authors examined a multisite database of CSE assessments to investigate the validity of the evaluation. METHODS: The authors collected 1156 CSE assessments from 4 residency programs conducted over a 6-year period, compared scoring patterns among the programs, score improvement over 4 years of residency, time and number of CSEs required to meet ABPN requirements, and patterns of scoring for individual faculty evaluators. RESULTS: The distribution of scores within each of the 4 programs showed similar, but nonidentical patterns. The number of CSEs required to meet the ABPN standards (3.5) and the point in training at which this was completed (late PGY-2) were the same in all programs. CSE scores were highly correlated with year of training but were not correlated with performance on an unrelated cognitive examination. Individual faculty members tended to stay within a moderate range of scores over multiple residents, partially attributable to year of training. CONCLUSIONS: Taken together, these findings support the validity of the CSE as a measure of residents' clinical skills in the specified areas and demonstrate a moderate-high degree of consistency in the scoring of the CSE across these 4 programs.

Psychiatry Clinical Skills Evaluation: Interrater Reliability of the American Board of Psychiatry and Neurology Required Assessment.

OBJECTIVE: The American Board of Psychiatry and Neurology (ABPN) requires applicants to successfully complete at least 3 Clinical Skills Evaluations (CSE) as part of the credentialing requirements to sit for the psychiatry certification examination. The authors examined a database of CSE assessments conducted at a single site to determine the interrater and test-retest reliability of the evaluation. METHODS: The authors examined 159 CSE assessments of 51 practicing psychiatrists who completed residency prior to the implementation of CSEs, but did not previously sit for the ABPN examination and later required CSEs to do so. Of these, 36 were simultaneously observed by 2 evaluators, at least 1 of whom had extensive experience with the CSE and 8 of whom were novice evaluators. At least 3 CSEs were done on the same day by each candidate. RESULTS: The intraclass correlations for CSEs observed by 2 evaluators for the 3 clinical skills assessed (patient-physician relationship, conduct of the interview, and case presentation), were in the low-moderate "good" range for interrater reliability. Test-retest reliability for all candidates was in the moderate-high "good" range. Significant learning took place between the 1st and 3rd CSEs, with a mean improvement of 0.42-0.49 points on an 8-point scale (p < 0.01). CONCLUSIONS: These data demonstrate good interrater reliability for the CSE even when conducted by novice faculty evaluators and good test-retest reliability despite significant learning that occurred over the series of assessments. The study supports both the educational and assessment value of the CSE.

The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia.

(Reprinted with permission from American Journal of Psychiatry 2016; 173:543-546).

DSM-5 Teaching Materials: A Critical Review.

OBJECTIVE: The publication of DSM-5 by the American Psychiatric Association (APA) in 2013 was accompanied by the release of a series of APA-approved "essential guides" to aid clinicians and trainees in its use and the transition from DSM-IV. Several of these were explicitly designated as study guides, but all serve educational as well as clinical functions. To assist trainees and educators in their selection of appropriate materials for study and teaching, several of these books were reviewed from the perspective of psychiatry education. METHODS: DSM-5 and seven of the 11 essential guides featured on the American Psychiatric Publishing website were selected for review as to their value as education tools and the audience most likely to find them useful. RESULTS: Four of the books reviewed were intended as teaching tools; two were designated as aids to clinicians, but with novice practitioners specifically included as target users; and two were not designed as teaching tools at all, but only as clinical manuals. All eight of these books had significant value as texts or teaching tools, although they differed significantly in the quality and uniqueness of their content, their specific focus, and the readers for whom they would be most helpful. CONCLUSION: DSM-5 and the essential guides that accompany it have significant value as texts and study guides for teachers and trainees and make a valuable contribution to psychiatry education.

Perceptions of Supervision in an Outpatient Psychiatry Clinic.

OBJECTIVES: There is little guidance regarding best practices in supervision of psychiatric residents. As a result, expectations for both supervisors and trainees are often unclear. This study explored the experiences of trainees and supervisors in outpatient supervision, in order to identify areas for potential improvement. METHODS: The authors conducted focus groups of residents and faculty members. The sessions were transcribed and analyzed via established methods of qualitative data analysis. RESULTS: A number of themes emerged. In general, residents desire an explicit structure to supervisory sessions, with more specific and concrete instruction. Attendings prefer to let residents lead discussion in supervision and focus on interpersonal aspects, such as the mentor-mentee relationship. Findings were situated within an established model of skill acquisition, the five-stage progression described by Dreyfus and Dreyfus. CONCLUSIONS: The differing experiences of trainees and supervisors reflect their respective stages of skill development as ambulatory psychiatrists. Potential interventions to improve the educational value of supervision include explicit agenda-setting at the beginning of supervision, regular bidirectional feedback, and more frequent opportunities for residents to observe attending interviews with patients.

The Impact of Financial Disclosure on Attendee Assessment of Objectivity in Continuing Medical Education Programs in Psychiatry: A Randomized, Controlled Trial.

OBJECTIVE: The purpose of financial conflict of interest disclosures by speakers at continuing medical education (CME) programs is to assist attendees in their assessment of the objectivity of the information presented. This empirical study was undertaken to determine what level of disclosure is optimal to achieve this goal. METHODS: Attendees at five CME programs were randomly assigned to receive either a standard financial disclosure, an intermediate level that included whether speakers received more or less than 5% of their income from each company they disclosed, or a high level of disclosure that included the percent of their income derived from each company. A total of 169 attendees (85.4% response rate) completed a questionnaire regarding the objectivity of the CME presentation they attended. RESULTS: Attendees receiving the highest level of disclosure came significantly closer to the ratings of speaker bias made by peer reviewers than did attendees receiving medium or low levels of disclosure (p = 0.03; effect size 0.31). Among the minority of attendees who received the highest level of disclosure but whose assessment of bias differed from that of peer reviewers, however, there was a tendency to underestimate bias (5.9 vs 31.4%; p < 0.0001). CONCLUSIONS: The major limitation of this study was an overall low level of bias in the presentations, making it difficult to generalize these findings to less objective programs. The study did not address whether the process of disclosure had an impact on speakers' behavior. This study provides mixed support for higher levels of financial disclosure than are currently required for CME programs.

Medical education teaching resources.

OBJECTIVE: Numerous monographs on psychiatry education have appeared without a review specifically intended to assist psychiatry faculty and trainees in the selection of appropriate volumes for study and reference. The authors prepared this annotated bibliography to fill that gap. METHODS: The authors identified titles from web-based searches of the topics "academic psychiatry," "psychiatry education," and "medical education," followed by additional searches of the same topics on the websites of major publishers. Forty-nine titles referring to psychiatry education specifically and medical education generally were identified. The authors selected works that were published within the last 10 years and remain in print and that met at least one of the following criteria: (1) written specifically about psychiatry or for psychiatric educators; (2) of especially high quality in scholarship, writing, topic selection and coverage, and pertinence to academic psychiatry; (3) covering a learning modality deemed by the authors to be of particular interest for psychiatry education. RESULTS: The authors reviewed 19 books pertinent to the processes of medical student and residency education, faculty career development, and education administration. These included 11 books on medical education in general, 4 books that focus more narrowly on the field of psychiatry, and 4 books addressing specific learning modalities of potential utility in the mental health professions. CONCLUSION: Most of the selected works proved to be outstanding contributions to the medical education literature.

Clinical skills verification in general psychiatry: recommendations of the ABPN Task Force on Rater Training.

OBJECTIVE: The American Board of Psychiatry and Neurology (ABPN) announced in 2007 that general psychiatry training programs must conduct clinical skills verification (CSV), consisting of observed clinical interviews and case presentations during residency, as one requirement to establish graduates' eligibility to sit for the written certification examination. To facilitate implementation of these requirements, the ABPN convened a task force to prepare training materials for faculty and programs to guide them in the CSV process. This article reviews the specific requirements for the CSV experience within general residency programs, and briefly describes the recommendations of the task force for faculty training and program implementation. METHODS: Materials prepared by the ABPN Task Force include background information on the intent of the observed interview, a literature review on assessment methods, aids to train faculty in direct observation of clinical work, directions for effective feedback, notes regarding special issues for cross-cultural trainees, clarification of performance standards, and recommendations for structuring and conducting the assessments. RESULTS: Recommendations of the task force include the use of a variety of clinical settings for CSV assessments, flexibility in the duration of CSV interviews, use of formative and summative feedback after each CSV assessment, and frequent use of the CSV across all years of training. Formal faculty training is recommended to help establish performance parameters, increase interrater reliability, and improve the quality of feedback. CONCLUSIONS: The implementation of the CSV process provides psychiatry training programs with an excellent opportunity to assess how interviewing skills are taught and evaluated. In the process, psychiatry educators have an opportunity to establish performance parameters that will guide the training of residents in patient interaction and evaluation.

Psychiatric residents' attitudes toward and experiences with the clinical-skills verification process: a pilot study on U.S. and international medical graduates.

OBJECTIVE: The authors report on a pilot study of the experiences and perceptions of foreign international medical graduate (F-IMG), United States international medical graduate (US-IMG), and United States medical graduate (USMG) psychiatric residents with the newly mandated Clinical Skills Verification (CSV) process. The goal was to identify and suggest remedies to any problems with the implementation of CSV in order to facilitate its success as an evaluation tool with all the three groups of residents. METHOD: The authors designed a 51-item survey questionnaire to gather demographic data and information about three principal content areas: 1) views on the effectiveness of the program; 2) the assessment experience; and 3) evaluation and feedback. A link to the survey was e-mailed to the directors of nine general-psychiatry residency programs in the United States with a request to forward it to the residents. The data were collected from February 2010 through March 2010. RESULTS: Sixty-three general-psychiatry residents (51.2% of 123 eligible residents) from nine selected programs completed the entire survey. Both IMG and USMG residents felt that the CSV was helpful in improving their clinical skills. Both groups of IMG residents, in contrast to their USMG counterparts, wanted more supervised interviews and were more likely to experience feedback as excessively negative and critical. In comparison to USMGs and US-IMGs, F-IMGs were less comfortable conducting an observed interview. They also had had less exposure to and experience with the CSV processes before their residency. CONCLUSIONS: Most residents reported positive experiences with the CSV. The survey also revealed notable commonalities and differences between IMG and USMG residents in their experiences and perceptions of the CSV process, mostly related to their cultural and medical school backgrounds. Authors recommend that residency programs take definitive steps toward addressing the unique needs of these groups of residents.

Clinical skills verification, formative feedback, and psychiatry residency trainees.

OBJECTIVE: The authors describe the implementation of Clinical Skills Verification (CSV) in their program as an in-training assessment intended primarily to provide formative feedback to trainees, strengthen the supervisory experience, identify the need for remediation of interviewing skills, and secondarily to demonstrating resident competence for American Board of Psychiatry and Neurology (ABPN) certification in Psychiatry. METHODS: The authors review the background and context of the implementation of CSV, and describe how the experience is structured within their residency program. RESULTS: The authors have embedded CSV experiences into clinical rotations across all years of residency training, aiming to complete 6-12 evaluations for each resident in each year. The authors provide training to faculty regarding supervision and formative feedback, including interrater reliability sessions for the CSV assessment. CONCLUSION: Effective incorporation of the CSV assessment into regular clinical settings can improve clinical supervision, residents' training experience, and the field's ability to consistently produce qualified, competent psychiatrists.

Clinician-educator tracks for residents: three pilot programs.

OBJECTIVE: Over the past 30 years, clinician-educators have become a prominent component of medical school faculties, yet few of these individuals received formal training for this role and their professional development lags behind other faculty. This article reviews three residency tracks designed to build skills in teaching, curriculum development and assessment, education research, and career development to meet this need. METHODS: The residency clinician educator tracks at University of Michigan, Baylor College of Medicine, and University of California Davis are described in detail, with particular attention to their common elements, unique features, resource needs, and graduate outcomes. RESULTS: Common elements in the tracks are faculty mentorship, formal didactics, teaching opportunities, and an expectation of scholarly productivity. Essential resources include motivated faculty, departmental support, and a modest budget. Favorable outcomes include a high percentage of graduates in clinical faculty positions, teaching programs created by the residents, positive effects on recruitment, and enhancement of faculty identity as clinician educators. CONCLUSION: Clinician-educator tracks in residency present a viable means to address the training needs of clinical track faculty. The programs described in this article provide a model to assist other departments in developing similar programs.

Psychopharmacology curriculum field test.

OBJECTIVE: As part of an effort to improve psychopharmacology training in psychiatric residency programs, a committee of residency training directors and associate directors adapted an introductory schizophrenia presentation from the American Society of Clinical Psychopharmacology's Model Psychopharmacology Curriculum to develop a multimodal, interactive training module. This article describes the module, its development, and the results of a field trial to test its feasibility and usefulness. METHODS: Nineteen residency programs volunteered to use the module during the first half of the 2007-2008 academic year. Evaluation consisted of a structured phone interview with the training director or teaching faculty of participating programs during February and early March 2008, asking whether and how they used the curriculum, which components they found most useful, and how it was received by faculty and residents. RESULTS: Of the 19 programs, 14 used the module and 13 participated in the evaluation. The most commonly used components were the pre- and postmodule questions, video-enhanced presentation, standard presentation, problem- or team-based teaching module, and other problem-based teaching modules. No two programs used the module in the same fashion, but it was well received by instructors and residents regardless of use. CONCLUSION: The results of this field trial suggest that a dynamic, adult-centered curriculum that is exciting, innovative, and informative enough for a wide variety of programs can be developed; however, the development and programmatic barriers require considerable time and effort to overcome.

A case control study: White-collar defendants compared with defendants charged with other nonviolent theft.

We examined the clinical, criminal, and sociodemographic characteristics of all white-collar crime defendants referred to the evaluation unit of a state center for forensic psychiatry. With 29,310 evaluations in a 12-year period, we found 70 defendants charged with embezzlement, 3 with health care fraud, and no other white-collar defendants (based on the eight crimes widely accepted as white-collar offenses). In a case-control study design, the 70 embezzlement cases were compared with 73 defendants charged with other forms of nonviolent theft. White-collar defendants were found to have a higher likelihood of white race (adjusted odds ratio (adj. OR) = 4.51), more years of education (adj. OR = 3471), and a lower likelihood of substance abuse (adj. OR = .28) than control defendants. Logistic regression modeling showed that the variance in the relationship between unipolar depression and white-collar crime was more economically accounted for by education, race, and substance abuse.

A survey of the interactions between psychiatry residency programs and the pharmaceutical industry.

OBJECTIVE: The authors report a survey of the American Association of Directors of Psychiatry Residency Training (AADPRT) on interactions between the pharmaceutical industry and psychiatry residency programs. METHODS: American Association of Directors of Psychiatry Residency Training membership was anonymously surveyed by e-mail and by paper distribution at the 2002 annual meeting. RESULTS: Twenty-seven percent of AADPRT members participated. Lunches for residents were the most common interaction, reported by 93% of programs, nearly all of which permitted literature and gifts to be distributed. Only 4% required faculty to be present. Retreats (27%) and travel funds (34%) were sponsored less frequently. One third of programs had written policies governing these interactions, but half of respondents did not know if their parent institutions had such policies. A minority of programs (40%) had formal didactic instruction for residents on this topic. Support for more information, direction, and teaching was widespread. CONCLUSIONS: The authors recommend more structured teaching and the establishment of formal program and institutional policies to govern these interactions.

Comparing efficacy of first-line atypical antipsychotics: no evidence of differential efficacy between risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole.

Objective To evaluate the comparative efficacy of the first-line atypical antipsychotics risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole. Methods We reviewed published short-term, randomised, controlled clinical trials of first-line atypical antipsychotics in the treatment of schizophrenia or schizoaffective disorder that used the Positive and Negative Syndrome Scale to assess efficacy. We used a combined overview analysis to compare the extent of improvement in global symptoms and positive and negative symptoms. We did not analyse adverse event data. Results Although we found considerable variation in the degree of improvement with a particular atypical antipsychotic across different studies, the range and average improvement were similar among all first-line atypicals for all efficacy parameters considered. Dosage was a critical determinant of efficacy, although the most effective dose of each agent varied across studies. There were insufficient data for ziprasidone and aripiprazole to allow their inclusion in the formal overview comparison. Conclusion Despite confounding and methodological limitations, the data we reviewed do not support assertions of differential efficacy between the first-line atypical antipsychotics. Additional controlled comparative studies of the atypical antipsychotics should be of particular interest.

Extrapyramidal side effects of antipsychotic treatment: scope of problem and impact on outcome.

Previously, clinicians worked with antipsychotic drugs (conventional or typical) that almost invariably caused extrapyramidal symptoms (EPS) at clinically effective doses. This led to the false impression that all antipsychotics were the same, and that EPS were an unavoidable consequence of effective antipsychotic therapy. EPS adversely impact several aspects of antipsychotic efficacy and tolerability, thereby worsening outcome of afflicted individuals. EPS reduce beneficial effects of antipsychotic treatment on the negative, cognitive, and mood symptom domains, while increasing the risk of tardive dyskinesia and reducing compliance. By definition, the newer generation of "atypical" antipsychotic agents are significantly better than conventional agents with regard to EPS (i.e., they are clinically effective at doses at which they do not cause EPS). Pharmacologically, this difference is expressed in the greater degree of separation between respective dose response curves for antipsychotic and EPS effects observed for "atypical" in contrast to conventional agents. Clinically, this EPS advantage of atypical antipsychotics translates into several important benefits, including better negative symptom efficacy, less dysphoria, less impaired cognition, a lower risk of TD, and better overall outcome.