Acute and Longer-Term Outcomes Using Ketamine as a Clinical Treatment at the Yale Psychiatric Hospital.

OBJECTIVE: Ketamine has emerged as a rapid-acting antidepressant, though controversy remains whether sufficient data exist to justify its use outside of research protocols. In October 2014, the authors' institution began providing ketamine as an off-label therapy on a case-by-case basis for patients unable to participate in research protocols. Here, the participant experience during 29 months of providing ketamine as a clinical treatment for severe and treatment-resistant mood disorders through February 2017 is described. METHODS: Patients were initially treated with a single- or double-infusion protocol (0.5 mg/kg for 40 minutes intravenously) and were later transitioned to a 4-infusion protocol over 2 weeks. RESULTS: Fifty-four patients received ketamine, with 518 total infusions performed. A subset of 44 patients with mood disorders initiated the 4-infusion protocol, of whom 45.5% responded and 27.3% remitted by the fourth infusion. A subsample (n = 14) received ketamine on a long-term basis, ranging from 12 to 45 total treatments, over a course of 14 to 126 weeks. No evidence was found of cognitive decline, increased proclivity to delusions, or emergence of symptoms consistent with cystitis in this subsample. CONCLUSIONS: In general, ketamine infusions were tolerated well. The response and remission rates in this clinical sample were lower than those observed in some research protocols. The small number of patients who were treated on a maintenance schedule limits the conclusions that can be drawn regarding the long-term safety of ketamine; however, no long-term adverse effects were observed in this sample.

Effective Research Mentorship for Residents: Meeting the Needs of Early Career Physicians.

OBJECTIVE: Challenges in pursuing research during residency may contribute to the shortage of clinician-scientists. Although the importance of mentorship in facilitating academic research careers has been described, little is understood about early career research mentorship for residents. The aim of this study was to better understand the mentorship process in the context of psychiatry residency. METHOD: Semi-structured interviews were conducted with experienced faculty mentors in a psychiatry department at a large academic medical center. Interviews were analyzed using inductive thematic analysis. Results from faculty interviews identified several key themes that were explored with an additional sample of resident mentees. RESULTS: Five themes emerged in our study: (1) being compatible: shared interests, methods, and working styles; (2) understanding level of development and research career goals in the context of residency training; (3) establishing a shared sense of expectations about time commitment, research skills, and autonomy; (4) residents' identity as a researcher; and (5) the diverse needs of a resident mentee. There was considerable congruence between mentor and mentee responses. CONCLUSIONS: There is an opportunity to improve research mentoring practice by providing guidance to both mentors and mentees that facilitates a more structured approach to the mentorship relationship.

A Case Suspended in Time: The Educational Value of Case Reports.

Although medical case reports have fallen out of favor in the era of the impact factor, there is a long tradition of using case reports for teaching and discovery. Some evidence indicates that writing case reports might improve medical students' critical thinking and writing skills and help prepare them for future scholarly work. From 2009 through 2015, students participating in the case reporting program at a VA hospital produced 250+ case reports, 35 abstracts, and 15 journal publications. Here, three medical students who published their case reports comment on what they learned from the experience. On the basis of their comments, the authors propose five educational benefits of case reporting: observation and pattern recognition skills; hypothesis-generating skills; understanding of patient-centered care; rhetorical versatility; and use of the case report as a rapidly publishable "mini-thesis," which could fulfill MD thesis or scholarly concentration requirements. The authors discuss the concept of the case report as a "hybrid narrative" with simultaneous medical and humanistic significance, and its potential use to teach students about their dual roles as engaged listeners and scientists. Finally, the authors consider the limitations and pitfalls of case reports, including patient confidentiality issues, overinterpretation, emphasis on the rare, and low initial publication rates. Case reports allow students to contribute to medical literature, learn useful scholarly skills, and participate in a tradition that links them with past generations of physicians. The authors conclude that the case report can be an effective teaching tool with a broad range of potential educational benefits.