Coaching in Postgraduate Competency-Based Medical Education: a Qualitative Exploration of Three Models.

OBJECTIVE: As postgraduate medical education increasingly transitions to competency-based models, there is a growing need for faculty to help residents process increasing amounts of assessment data. It has been recommended that a designated resident advisor or coach take on this faculty role, but the literature surrounding coaching in medical education is sparse. The authors evaluated the implementation of different coaching models in a postgraduate psychiatry program to identify drivers and barriers to effective coaching. METHODS: The authors conducted semi-structured interviews in September 2019 with focus groups of residents and faculty to understand their experiences of coaching under different models. They identified major themes through a qualitative analysis of the transcribed focus groups, which took place from September to December 2020. RESULTS: The authors identified four key themes associated with the implementation of coaching within a competency-based framework, namely role ambiguity, educational alliance, the "idealized coach," and burden. CONCLUSIONS: While these findings highlight the barriers that can interfere with effective coaching, particularly in the context of widespread curriculum change, they also illuminate opportunities for the coaching role moving forward. Thus, they offer valuable guidance for present and upcoming competency-based programs as they implement coaching and seek to optimize the learning experience for residents.

Impact of standardizing care for agitation in dementia using an integrated care pathway on an inpatient geriatric psychiatry unit.

OBJECTIVES: This study examined the effectiveness of an integrated care pathway (ICP), including a medication algorithm, to treat agitation associated with dementia. DESIGN: Analyses of data (both prospective and retrospective) collected during routine clinical care. SETTING: Geriatric Psychiatry Inpatient Unit. PARTICIPANTS: Patients with agitation associated with dementia (n = 28) who were treated as part of the implementation of the ICP and those who received treatment-as-usual (TAU) (n = 28) on the same inpatient unit before the implementation of the ICP. Two control groups of patients without dementia treated on the same unit contemporaneously to the TAU (n = 17) and ICP groups (n = 36) were included to account for any secular trends. INTERVENTION: ICP. MEASUREMENTS: Cohen Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory Questionnaire (NPIQ), and assessment of motor symptoms were completed during the ICP implementation. Chart review was used to obtain length of inpatient stay and rates of psychotropic polypharmacy. RESULTS: Patients in the ICP group experienced a reduction in their scores on the CMAI and NPIQ and no changes in motor symptoms. Compared to the TAU group, the ICP group had a higher chance of an earlier discharge from hospital, a lower rate of psychotropic polypharmacy, and a lower chance of having a fall during hospital stay. In contrast, these outcomes did not differ between the two control groups. CONCLUSIONS: These preliminary results suggest that an ICP can be used effectively to treat agitation associated with dementia in inpatients. A larger randomized study is needed to confirm these results.

Using simulation to explore medical students' understanding of integrated care within geriatrics.

BACKGROUND: Given the increasing evidence and expansion of integrated care (IC) in healthcare, new IC curricula introduced early in undergraduate medical education (UME) are needed. Building on a pilot IC simulation called "Getting to Know Patients' System of Care" (GPS-Care), we aimed to explore students' understanding of patients' complex physical and mental health needs, and to increase our understanding of how students learned in this simulation. METHODS: 177 of 259 first-year medical students participated in GPS-Care at the University of Toronto. Students role-played an elderly patient or caregiver within 5 simulated healthcare professional appointments. Students completed written reflections and 7 students participated in one-on-one interviews. A thematic analysis of the reflections and transcripts was conducted and descriptive data was generated for questionnaires. RESULTS: Data saturation was reached at 43 reflections and 7 transcripts and the following themes emerged: a) students reflected on patients' complex care experiences, b) students reflected on of the healthcare system needs care, c) students increased understanding of IC, and d) students desire to improve the care of IC patients within the healthcare system. CONCLUSIONS: In addition to confirming previous pilot study themes, the results from this study identified the role of productive struggle to provide students with a deeper understanding of patients' IC care needs. Moreover, GPS-Care resulted in a transformative learning experience resulting in new insights into the importance of IC early in UME training.

Collaborative Care for Psychiatric Disorders in Older Adults: A Systematic Review.

OBJECTIVE: To evaluate the mode of implementation, clinical outcomes, cost-effectiveness, and the factors influencing uptake and sustainability of collaborative care for psychiatric disorders in older adults. DESIGN: Systematic review. SETTING: Primary care, home health care, seniors' residence, medical inpatient and outpatient. PARTICIPANTS: Studies with a mean sample age of 60 years and older. INTERVENTION: Collaborative care for psychiatric disorders. METHODS: PubMed, MEDLINE, Embase, and Cochrane databases were searched up until October 2016. Individual randomized controlled trials and cohort, case-control, and health service evaluation studies were selected, and relevant data were extracted for qualitative synthesis. RESULTS: Of the 552 records identified, 53 records (from 29 studies) were included. Very few studies evaluated psychiatric disorders other than depression. The mode of implementation differed based on the setting, with beneficial use of telemedicine. Clinical outcomes for depression were significantly better compared with usual care across settings. In depression, there is some evidence for cost-effectiveness. There is limited evidence for improved dementia care and outcomes using collaborative care. There is a lack of evidence for benefit in disorders other than depression or in settings such as home health care and general acute inpatients. Attitudes and skill of primary care staff, availability of resources, and organizational support are some of the factors influencing uptake and implementation. CONCLUSIONS: Collaborative care for depressive disorders is feasible and beneficial among older adults in diverse settings. There is a paucity of studies on collaborative care in conditions other than depression or in settings other than primary care, indicating the need for further evaluation.

Psychological distress in mothers of children admitted to a nutritional rehabilitation unit in Malawi - a comparison with other paediatric wards.

In a previous study we found a very high prevalence of psychological distress in mothers of children admitted to a nutritional rehabilitation unit (NRU) in Malawi, Africa. The objective of this study was to compare the prevalence and severity of maternal distress within the NRU with that in other paediatric wards. Given the known association between poor maternal psychological well-being and child undernutrition in low- and middle-income countries, we hypothesised that distress would be higher among NRU mothers. Mothers of consecutive paediatric inpatients in a NRU, a high-dependency (and research) unit and an oncology ward were assessed for psychological distress using the Self-Reporting Questionnaire (SRQ). Two hundred sixty-eight mothers were interviewed (90.3% of eligible). The prevalence of SRQ score ≥8 was 35/150 {23.3% [95% confidence interval (CI) 16.8- 30.9%]} on the NRU, 13/84 [15.5% (95% CI 8.5-25.0%)] on the high-dependency unit and 7/34 [20.6% (95% CI 8.7-37.9%)] on the oncology ward (χ(2) = 2.04, P = 0.36). In linear regression analysis, the correlates of higher SRQ score were child diarrhoea on admission, child diagnosed with tuberculosis, and maternal experience of abuse by partner; child height-for-age z-score fell only just outside significance (P = 0.05). In summary, we found no evidence of greater maternal distress among the mothers of severely malnourished children within the NRU compared with mothers of paediatric inpatients with other severe illnesses. However, in support of previous research findings, we found some evidence that poor maternal psychological well-being is associated with child stunting and diarrhoea.

Are Opioids Agitating? A Data Analysis of Baseline Data from the STAN Study.

 Agitation, a common dementia symptom often arising from untreated pain, lacks comprehensive research on its connection with opioids prescribed for long-term pain. This study investigated the relationship between opioid use and agitation in dementia patients. Participants (n = 188) were categorized into opioid, acetaminophen PRN, or no-pain medication groups. Despite higher reported pain levels in the opioid group, no significant differences in agitation were observed among the groups. In conclusion, opioid use for pain management in older adults with dementia did not significantly impact agitation, emphasizing the ongoing importance of proper pain management in improving dementia care and addressing agitation in this population.

A survey on knowledge of female genital mutilation guidelines.

The increase in immigration from countries with a high prevalence of female genital mutilation (FGM) has highlighted the need for knowledge and sensitivity in this area of healthcare in high-resource countries. We have surveyed with an online questionnaire 607 members, fellows and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG) on knowledge about the RCOG guidelines for FGM. Completed training and more practical experience with women affected by FGM significantly increased knowledge. Many respondents were not aware of specialist services locally (22.9%) or how to access them (52.3%). Some areas of insufficient knowledge were identified, in particular in relation to psychiatric morbidity, HIV, hepatitis B and pelvic infection. More specialized training efforts might improve this aspect.

The Rationale and Design of Behavioral Interventions for Management of Agitation in Dementia in a Multi-Site Clinical Trial.

BACKGROUND: Agitation and aggression are common in patients with Alzheimer's disease and related dementias and pose a significant burden on patients, caregivers, and the healthcare systems. Guidelines recommend personalized behavioral interventions as the first-line treatment; however, these interventions are often underutilized. The Standardizing Care for Neuropsychiatric Symptoms and Quality of Life in Dementia (StaN) study (ClinicalTrials.gov Identifier # NCT0367220) is a multisite randomized controlled trial comparing an Integrated Care Pathway, that includes a sequential pharmacological algorithm and structured behavioral interventions, with treatment-as-usual to treat agitation in dementia in long-term care and inpatient settings. OBJECTIVE: To describe the rationale and design of structured behavioral interventions in the StaN study. METHODS: Structured behavioral interventions are designed and implemented based on the following considerations: 1) personalization, 2) evidence base, 3) dose and duration, 4) measurement-based care, and 5) environmental factors and feasibility. RESULTS: The process to design behavioral interventions for each individual starts with a comprehensive assessment, followed by personalized, evidence-based interventions delivered in a standardized manner with ongoing monitoring of global clinical status. Measurement-based care is used to tailor the interventions and integrate them with pharmacotherapy. CONCLUSION: Individualized behavioral interventions in patients with dementia may be challenging to design and implement. Here we describe a process to design and implement individualized and structured behavioral interventions in the context of a multisite trial in long-term care and inpatient settings. This process can inform the design of behavioral interventions in future trials and in clinical settings for the treatment of agitation in dementia.

Sequential drug treatment algorithm for agitation and aggression in Alzheimer's and mixed dementia.

INTRODUCTION: Behavioural and psychological symptoms of dementia (BPSD) include agitation and aggression in people with dementia. BPSD is common on inpatient psychogeriatric units and may prevent individuals from living at home or in residential/nursing home settings. Several drugs and non-pharmacological treatments have been shown to be effective in reducing behavioural and psychological symptoms of dementia. Algorithmic treatment may address the challenge of synthesizing this evidence-based knowledge. METHODS: A multidisciplinary team created evidence-based algorithms for the treatment of behavioural and psychological symptoms of dementia. We present drug treatment algorithms for agitation and aggression associated with Alzheimer's and mixed Alzheimer's/vascular dementia. Drugs were appraised by psychiatrists based on strength of evidence of efficacy, time to onset of clinical effect, tolerability, ease of use, and efficacy for indications other than behavioural and psychological symptoms of dementia. RESULTS: After baseline assessment and discontinuation of potentially exacerbating medications, sequential trials are recommended with risperidone, aripiprazole or quetiapine, carbamazepine, citalopram, gabapentin, and prazosin. Titration schedules are proposed, with adjustments for frailty. Additional guidance is given on use of electroconvulsive therapy, optimization of existing cholinesterase inhibitors/memantine, and use of pro re nata medications. CONCLUSION: This algorithm-based approach for drug treatment of agitation/aggression in Alzheimer's/mixed dementia has been implemented in several Canadian Hospital Inpatient Units. Impact should be assessed in future research.