Validating the knowledge represented by a self-organizing map with an expert-derived knowledge structure.

BACKGROUND: Professionals are reluctant to make use of machine learning results for tasks like curriculum development if they do not understand how the results were generated and what they mean. Visualizations of peer reviewed medical literature can summarize enormous amounts of information but are difficult to interpret. This article reports the validation of the meaning of a self-organizing map derived from the Medline/PubMed index of peer reviewed medical literature by its capacity to coherently summarize the references of a core psychiatric textbook. METHODS: Reference lists from ten editions of Kaplan and Sadock's Comprehensive Textbook of Psychiatry were projected onto a self-organizing map trained on Medical Subject Headings annotating the complete set of peer reviewed medical research articles indexed in the Medline/PubMed database (MedSOM). K-means clustering was applied to references from every edition to examine the ability of the self-organizing map to coherently summarize the knowledge contained within the textbook. RESULTS: MedSOM coherently clustered references into six psychiatric knowledge domains across ten editions (1967-2017). Clustering occurred at the abstract level of broad psychiatric practice including General/adult psychiatry, Child psychiatry, and Administrative psychiatry. CONCLUSIONS: The uptake of visualizations of published medical literature by medical experts for purposes like curriculum development depends upon validation of the meaning of the visualizations. The current research demonstrates that a self-organizing map (MedSOM) can validate the stability and coherence of the references used to support the knowledge claims of a standard psychiatric textbook, linking the products of machine learning to a widely accepted standard of knowledge.

Rapidly expanding gender-affirming care based on consensus instead of evidence justifies rigorous governance and transparency.

OBJECTIVE: Public services offering gender-affirming care to minors have rapidly expanded across Australia. Despite limited evidence of safety and efficacy, no public information about these services is routinely available. Data from freedom of information requests sent to Australian public gender services for minors is summarised. Gender service numbers increased rapidly in Queensland (2017:190 - 2022:922) and in Victoria (2019:472 - 2023:1290). Limited transparency prevented strong confidence in the number of patients receiving hormone therapy. Staff FTE employed by gender services jumped after 2020 in NSW (to 16.7 across two sites in 2023), Queensland (to 11.4 in 2023), Victoria (to 9.4 in 2022), and WA (to 10.2 in 2023). CONCLUSIONS: Despite low confidence in their safety and efficacy, the number of patients seen by public gender services has expanded rapidly since 2018. Limited transparency makes it difficult to judge the number of patients seen, treatments provided, and outcomes achieved. Safe, effective care of this vulnerable group requires clear treatment goals, and annual reporting.

The gender-affirming model of care is incompatible with competent, ethical medical practice.

OBJECTIVE: To examine the compatibility of gender-affirming care with the principles and practices of psychiatry. CONCLUSIONS: The assumption that there is no pathology involved in the development of gender diversity is a necessary precondition for the unquestioning affirmation of self-reported gender identity. Cases where psychosis is the undeniable cause of gender diversity demonstrate this assumption is categorically false. To protect this false assumption, gender-affirming guidelines forbid the application of the core psychiatric competencies of phenomenology and psychopathology to the assessment of gender diversity. They substitute the political goal of expanding personal liberty for the evidence-based medicine processes of clinical reasoning, rendering them incompatible with competent, ethical medical practice.

Health, mental health, and hearing indigenous voices.

OBJECTIVE: To identify the issues raised by the unsuccessful Voice referendum and propose removal of barriers to reporting and prevention of family violence in remote communities as the most ambitious measure of success in hearing First Nations voices. CONCLUSIONS: The Voice referendum was partly justified to improve the mental health of First Nations Australians, despite concern the process and its outcome might worsen both. Aboriginal and Torres Strait Islander leaders revealed the tensions that arise between individual and communal interests when marginalised groups fight for self-determination. While a unified First Nation Voice is likely to amplify prominent messengers, we should also be interested in hearing diverse, dissenting voices. As the most marginalised group within a marginalised community, the ability to hear the voices of women and children subject to family violence in rural/remote Australian communities may be the best measure of success in overcoming the barriers that was the motivation for the referendum.

An overview of the peer review process in biomedical sciences.

OBJECTIVE: This paper aims to provide an introductory resource for beginner peer reviewers in psychiatry and the broader biomedical science field. It will provide a concise overview of the peer review process, alongside some reviewing tips and tricks. CONCLUSION: The peer review process is a fundamental aspect of biomedical science publishing. The model of peer review offered varies between journals and usually relies on a pool of volunteers with differing levels of expertise and scope. The aim of peer review is to collaboratively leverage reviewers' collective knowledge with the objective of increasing the quality and merit of published works. The limitations, methodology and need for transparency in the peer review process are often poorly understood. Although imperfect, the peer review process provides some degree of scientific rigour by emphasising the need for an ethical, comprehensive and systematic approach to reviewing articles. Contributions from junior reviewers can add significant value to manuscripts.

Defining the passage of wisdom: A taxonomy of supervision for RANZCP trainees and Fellows.

OBJECTIVE: Trainees and Fellows of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) work in complex interpersonal and organisational environments. Engagement in supervision can be a helpful way for trainees and Fellows to achieve interpersonal, professional, and organisational success. Supervision comes in many forms depending on the stage and state of one's career. An awareness of different supervision models is relevant to trainees' understanding of what is expected of them and their supervisors in their work and educational contexts. This paper explores the taxonomy of supervision models available to RANZCP trainees and Fellows in Australia and New Zealand. CONCLUSION: Supervision is a heterogeneous concept with multiple aims, outcomes, and processes that change with ones' stage of career.

Defining the Boundaries of Psychiatric and Medical Knowledge: Applying Cartographic Principles to Self-Organising Maps.

Biases in selection, training, and continuing professional development of medical specialists arise in part from reliance upon expert judgement for the design, implementation, and management of medical education. Reducing bias in curriculum development has primarily relied upon consensus processes modelled on the Delphi technique. The application of machine learning algorithms to databases indexing peer-reviewed medical literature can extract objective evidence about the novelty, relevance, and relative importance of different areas of medical knowledge. This study reports the construction of a map of medical knowledge based on the entire corpus of the MEDLINE database indexing more than 30 million articles published in medical journals since the 19th century. Techniques used in cartography to maximise the visually intelligible differentiation between regions are applied to knowledge clusters identified by a self-organising map to show the structure of published psychiatric evidence and its relationship to non-psychiatric medical domains.

Gender dysphoria: Reconsidering ethical and iatrogenic factors in clinical practice.

OBJECTIVE: To examine the treatment of gender dysphoria described in Bell v Tavistock (UK 2020). Bell documents the treatment and sequelae of a 16-year-old adolescent referred to the Tavistock with gender dysphoria. Her case highlights contrasts between gender affirming care and comprehensive care. CONCLUSIONS: Consistent with other western centres, in the 2010s, the Tavistock began treating patients with gender dysphoria under the 'Dutch protocol' for gender affirming care. Bell reveals concerning lapses of clinical governance influenced by activists and linked to patient harm. The recent suspension of a senior child psychiatrist from an Australian public hospital service after questioning the evidence base and ethical foundation of gender affirming care underlines the need to resolve these uncertainties to address the crisis in the treatment of gender dysphoria.

Advancing psychiatry trainee wellbeing and safety: Building on RANZCP Position Statement 48.

OBJECTIVE: The RANZCP recently released Position Statement 48 on the 'safety and wellbeing of psychiatrists and those in psychiatry training'. This article will examine the five key domains highlighted by this statement and provide suggestions on how this guidance might relate to trainees. The domains covered are (i) safe workplaces free from discrimination, bullying, harassment, and violence; (ii) positive team cultures; (iii) positive professional peer relationships; (iv) supportive supervision and mentorship; and (v) work-life balance. CONCLUSIONS: In the context of the significant and complex demands of psychiatry training, Position Statement 48 helps to provide a framework for trainees and the people and systems that support them to understand, anticipate, and successfully manage the potential risks to trainee wellbeing and safety.

Modelling the rate of trainees transitioning to Fellowship before achieving competence under the RANZCP's Alternative Assessment Pathway to the Objective Structured Clinical Examination.

OBJECTIVE: The Objective Structured Clinical Examination (OSCE) has been removed from the Royal Australian and New Zealand College of Psychiatrists' (RANZCP) training pathway. This decision occurred in the context of an Alternative Assessment Pathway (AAP) necessitated by Covid-19, justified by logistical, methodological and equity concerns. The false positive rate of trainees progressing to Fellowship before achieving competence is a key indicator for evaluating any assessment leading to psychiatric Fellowship. Variations in the statistical properties of the AAP and OSCE were analysed for their impact on pre-competent trainees progressing to Fellowship. METHOD: Starting with the false positive scenario presented to justify discontinuing the OSCE, false positive rates associated with the AAP and OSCE were calculated based on different assumptions about reliability and accuracy. RESULTS: The analyses suggest that less reliable and less accurate alternatives to the OSCE, such as the AAP, increase the number of pre-competent trainees progressing to Fellowship. CONCLUSIONS: Given possible increases in pre-competent trainees progressing to Fellowship while alternatives to the OSCE are finalised, confidence in the RANZCP's training program demands robust public analyses of those alternatives.

The importance of appraising articles and conducting psychiatric journal clubs.

OBJECTIVE: To describe the importance of scientifically rigorous journal clubs in psychiatric education, and to provide a framework to effectively run journal clubs and appraise articles in a journal club format. This paper explores the concept of journal clubs and describes issues with the current state of academic science. It then lists factors associated with effectiveness of journal clubs and outlines a structure for appraising articles relevant to psychiatric practice in a journal club format. CONCLUSIONS: Current models of academic research and publishing, which can reward practices vulnerable to multiple forms of bias, make the consistent and valued use of journal clubs in psychiatric education and continuing professional development more important than ever. The literature shows that journal clubs can provide a valuable forum for mental health clinicians to update themselves on recent medical and scientific knowledge, while practicing and teaching skills in critical appraisal of research, statistics, clinical decision-making and epidemiology.

Thinking clearly about climate change and mental health.

OBJECTIVE: To examine the quality and strength of evidence for an association between temperature increases caused by climate change and suicide used in policy documents to advocate for radical changes to healthcare systems in pursuit of decarbonisation. METHOD: The designs of articles collected in a systematic review which concluded that there was an association between climate change and increased rates of suicide were analysed for their capacity to support this conclusion. Complete US data covering temperatures and suicide rates between 1968 and 2004 was aggregated and analysed using linear regression to evaluate evidence for an association between temperature and suicide. RESULTS: None of the articles collected in the review has a design capable of investigating whether there is an association between temperature increases caused by climate change and rates of suicide. At the national level increased annual US temperatures were associated with a decrease in the rate of suicide, and at the state level it was common for high average temperature states to have low rates of suicide and vice versa. CONCLUSIONS: Policy recommendations for radical changes in healthcare services have been based on misrepresented evidence. Policy makers should beware of recommendations that ignore scientific evidence to pursue faith-based goals.