Working with entrustable professional activities in clinical education in undergraduate medical education: a scoping review.

BACKGROUND: Entrustable professional activities (EPAs) are increasingly used in undergraduate medical education (UME). We conducted a scoping review to summarize the evidence for the use of EPAs in clinical rotations in UME. METHODS: We searched multiple databases for scoping reviews based on the PRISMA guidelines for articles reporting qualitative and quantitative research, as well as conceptual and curriculum development reports, on EPAs in UME clinical rotations. RESULTS: We identified 3309 records by searching through multiple databases. After the removal of duplicates, 1858 reports were screened. A total of 36 articles were used for data extraction. Of these, 47% reported on EPA and EPA-based curriculum development for clerkships, 50% reported on implementation strategies, and 53% reported on assessment methods and tools used in clerkships. Validity frameworks for developing EPAs in the context of clerkships were inconsistent. Several specialties reported feasible implementation strategies for EPA-based clerkship curricula, however, these required additional faculty time and resources. Limited exposure to clinical activities was identified as a barrier to relevant learning experiences. Educators used nationally defined, or specialty-specific EPAs, and a range of entrustability and supervision scales. We found only one study that used an empirical research approach for EPA assessment. One article reported on the earlier advancement of trainees from UME to graduate medical education based on summative entrustment decisions. CONCLUSIONS: There is emerging evidence concerning how EPAs can be effectively introduced to clinical training in UME. Specialty-specific, nested EPAs with context-adapted, entrustment-supervision scales might be helpful in better leveraging their formative assessment potential.

Introducing a Psychiatry Clerkship Curriculum Based on Entrustable Professional Activities: an Explorative Pilot Study.

OBJECTIVE: The authors evaluated a reformed psychiatry clerkship curriculum based on entrustable professional activities (EPAs). METHODS: The authors conducted an exploratory pilot study of a reformed clerkship curriculum based on EPAs. A novel workplace-based assessment format including an entrustment-supervision scale and curricular adaptations were introduced. The Kirkpatrick model was used to evaluate outcomes of the reformed clerkship curriculum on three levels (1 = acceptance, 2 = learning, 3 = change of behavior). RESULTS: The pilot student cohort (n = 10) completed a questionnaire, 180 self-assessments (18 per student) on need for supervision, and 63 workplace-based assessments (6.3 per student, in 4 weeks). Level 1: high overall satisfaction with the clerkship (five-point Likert item: average, 4.9; range: 4.0-5.0). Level 2: the overall significant decrease in self-assessed need for supervision before and after the clerkship was two supervision levels (direct to indirect supervision; p < 0.05). The most frequently documented admissions included schizophrenic disorders (n = 11; 28%), affective disorders (n = 10; 25%), substance abuse disorders (n = 5; 13%), and anxiety and stress-related disorders (n = 5; 13%). Level 3: clinical supervisors used history taking, assessing the mental status, and documentation and presentation for workplace-based assessments. According to supervisors' ratings, there was a decreasing need for supervision from the first to last week of the clerkship. CONCLUSIONS: Students reacted positively to the reformed clerkship curriculum. The workplace-based assessments with entrustment ratings appeared to support achievement of competency-based learning objectives. Better understanding of how to cover assessment of all core EPAs in the psychiatry clerkship is needed.

Emerging drugs to treat obsessive-compulsive disorder.

INTRODUCTION: Obsessive-compulsive disorder (OCD) is a chronic and disabling neuropsychiatric disorder with a lifetime prevalence of approximately 1 - 2% and a rate of treatment resistance of 40%. Other disorders have been related to OCD and have been grouped together in a separate DSM-5 chapter, hypothesizing the existence of an 'OC spectrum', showing a paradigm shift in the conceptualization of the disorder. AREAS COVERED: A review of the most important and recent neurobiological findings that sustain the hypothesis of a more sophisticated model of the disorder is provided, together with a brief overview of the most relevant pharmacological animal models of OCD and its first-line treatments. Current research goals, new compounds tested and the rationale behind the development of these new pharmacologic agents are then explained and reviewed. EXPERT OPINION: In the past years, no effective novel compounds have emerged for the treatment of OCD, even if many efforts has been made in the study of its neurobiological underpinnings. Relevant changes in the conceptualization of the disorder, suggested by interesting new neurobiological evidences, may result helpful in the development of new treatments.

Hypochondriasis and obsessive-compulsive disorder in schizophrenic patients treated with clozapine vs other atypical antipsychotics.

OBJECTIVE: The aim of the study was to investigate the prevalence rates of obsessive-compulsive disorder (OCD) and hypochondriasis in schizophrenic patients treated with atypical antipsychotics (AAPs) and to investigate the different comorbidity rates of OCD and hypochondriasis between clozapine-treated patients and patients treated with other AAPs. METHODS: We therefore recruited 60 schizophrenic patients treated with clozapine or other AAPs. We assessed the prevalence rates of OCD or OC symptoms and hypochondriasis or hypochondriac symptoms in the whole group of patients and in clozapine-treated patients versus patients treated with other AAPs. RESULTS: Schizophrenic patients had a higher comorbidity rate of OCD (26.6% vs 1-3%) and hypochondriasis (20% vs 1%) than the general population. These comorbidities were more frequent in schizophrenic patients treated with clozapine versus patients treated with other AAPs (36.7% vs 16.7% and 33.3% vs 6.7%). Clozapine-treated patients showed a higher mean Y-BOCS and HY-BOCS score when compared to patients treated with other AAPs (10.90 vs 5.90, p = .099; 15.40 vs 8.93, p = .166). A statistical significant correlation was found between the Y-BOCS and HY-BOCS scores of the whole group (r = .378, p = 0.03). Furthermore, we found an inverse correlation between the global level of functioning and the diagnosis of hypochondriasis (p = .048) and the severity of hypochondriac symptoms (p = .047). CONCLUSIONS: Hypochondriasis could represent an important clinical feature of schizophrenic patients treated with atypical antipsychotics, and further research is needed in this field.

Anxiety as a core aspect of schizophrenia.

The clinical relevance of anxiety disorders in schizophrenia has been neglected for a long time and has only recently become the subject of a systematic investigation, although its consequences may have a very negative impact on the outcome and considerably worsen the trajectory of the disease. This could be originally related to the hierarchical organization of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and to the lack of assessment instruments. In this article, we will review the most recent literature concerning two of the most impairing anxiety disorders in comorbidity with schizophrenia, such as panic disorder and social anxiety disorder, briefly analyze the role of anxiety in the prodromal phase of psychosis and provide suggestions for the clinical assessment.

rTMS age-dependent response in treatment-resistant depressed subjects: a mini-review.

BACKGROUND: In old age, depressive syndromes often affect people with chronic medical illnesses, cognitive impairment, and disability, which can worsen the outcomes of other medical disorders and promote disability. Repetitive magnetic transcranial stimulation (rTMS) is a simple and effective treatment in patients with treatment-resistant depression. Therefore the use of rTMS could be of particular potential benefit in treatment-resistant elderly patients, who often cannot tolerate the higher doses of drugs needed or show phenomena of intolerance and interaction. However, several studies assessing the efficacy of rTMS found smaller response rates in elderly patients when compared to younger samples. Nevertheless, the correlation between age and response is still a controversial issue, and there is no strong evidence to date. The aim of our study was to retest the effectiveness and safety of low-frequency rTMS in a 3 weeks active treatment in a group of resistant-depressed patients, and to investigate the role of age in the response to stimulation treatment. METHODS: Enrolled in this study were 102 treatment-resistant depressed patients. The patients were treated with low-frequency rTMS over the right dorso-lateral prefrontal cortex (DLPFC) for 3 weeks with a simple protocol (420 pulses per session for 15 sessions). At baseline, at the end of the second week, and at the end of the third week of treatment, the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Anxiety Rating Scale (HAM-A) were administered. RESULTS: Low-frequency rTMS on the prefrontal dorsolateral right area resulted in a statistically significant reduction of mean HAM-D scores in the entire group of patients at the end of treatment. The responder's rate in the whole group at the end of the third week was 56.86%. A significant inverse relationship between HAM-D reduction and age was found in the "older" (>60 years old) group, not in the "younger" (<60 years old) group. CONCLUSION: Results from this study show that low-frequency rTMS over the right DLPFC, with a relatively low number of pulses (420 pulses per session) and a relatively short period of treatment, is effective in the treatment of resistant patients (in a sample also including elderly patients) in a 3-weeks treatment protocol with a low reduction with the progress of age. Furthermore, we found a greater response in younger patients and an inverse correlation between age and treatment response. Adaptations of the protocol according to age are reviewed.

Curriculum Development with the Implementation of an Open-Source Learning Management System for Training Early Clinical Students: An Educational Design Research Study.

BACKGROUND: Learning management systems (LMSs) have not been explored from an educational design research (EDR) perspective for developing clinical curricula and supporting novice clinical students with self-regulated learning during their early clinical rotations. METHODS: An EDR approach was used to inform a de novo implementation of an LMS during an early clinical rotation of medical students. The EDR consisted of three phases: analysis and exploration; design and construction; and evaluation and reflection. Process and evaluation data (including academic years 2018 and 2019) from two student cohorts (total n = 190, 107 without and 83 with LMS exposure) at one academic teaching hospital were analyzed. RESULTS: Learning theories and concepts of self-regulated learning were used to develop and implement an LMS clerkship prototype. For design and construction, the maturing prototype design included flipped-classroom elements, in-class activation, voluntary digital self-assessments, and clinical teaching videos. For evaluation and reflection, global satisfaction improvement was significant (from 3.9 to 4.4 on a 5-point Likert scale, p < 0.05). There was a positive evaluation trend for all evaluation items related to learning climate, self-regulated learning, and perceived usefulness of the LMS prototype; however, these changes were not statistically significant. The teaching hospital also improved its ranking after the introduction of the LMS prototype. Nearly all students (94%) used the LMS material. The average number of times the LMS course was accessed per student was 70 (range: 7-172), and the average duration students spent online was 58 minutes (range: 9-165). CONCLUSION: Our data indicate that using an EDR approach was helpful for systematically introducing an LMS in a clerkship curriculum informed by learning theory. Our evidence-oriented curriculum reform was associated with higher student satisfaction and appeared to support self-regulated learning in the workplace. Further research should explore which elements of an LMS most effectively help to achieve educational outcomes.

Become your own SLEEPexpert: design, implementation, and preliminary evaluation of a pragmatic behavioral treatment program for insomnia in inpatient psychiatric care.

Study Objectives: The majority of patients with mental disorders suffer from insomnia, associated with adverse health outcomes. Cognitive behavioral therapy for insomnia (CBT-I) represents the first-line treatment, but is too complex for severely ill patients and not systematically implemented in inpatient psychiatric care. This project aimed to develop a pragmatic behavioral treatment program that empowers inpatients with severe mental disorders to take care of their own sleep health. Methods: CBT-I was adapted based on implementation research involving 24 inpatients with psychiatric disorders across diagnostic entities and comorbid insomnia and 30 health care providers at the University Hospital of Psychiatry and Psychotherapy, Bern. The program was implemented and evaluated by 15 patients and 22 health care providers based on interviews and questionnaires before participation and prior to discharge. Results: Implementation research resulted in the SLEEPexpert intervention, centering on bedtime restriction and circadian adaptation in three phases; therapist-guided treatment initiation, self-management with nursing support, and self-management. Evaluative pre-post assessments in 15 patients demonstrated feasibility. Time in bed decreased by 60 minutes (520 ± 105.3 vs. 460 ± 78.1, p = 0.031, d = 0.6) and total sleep time increased by around 45 minutes (331 ± 110.6 vs. 375 ± 74.6, p = 0.09, d = 0.5), resulting in increased sleep efficiency (65.3 ± 21.8 vs. 81.9 ± 11.2%, p = 0.011, d = 0.8). Patients improved on the Insomnia Severity Index (18.3 ± 4.6 vs. 11.4 ± 4.4, p < 0.001, d = 1.2) and Pittsburgh Sleep Quality Index (12.9 ± 3.8 vs. 10.3 ± 3.3, p = 0.031, d = 0.6). Conclusions: We propose a new pragmatic behavioral treatment program (SLEEPexpert) customized to the needs of patients and health care providers in inpatient psychiatric care. Data demonstrate feasibility. An improvement of insomnia severity was observed, but a control comparison is needed to further test for efficacy.

Blood perfusion in left inferior and middle frontal gyrus predicts communication skills in schizophrenia.

Schizophrenia is one of the most debilitating mental disorders, severely affecting patients' community functioning. Functional capacity (FC) describes the skills necessary for successful functional outcome (FO), such as financial knowledge or communication skills. We investigated whether resting-state cerebral blood flow (rCBF) measured at baseline with arterial spin labeling (ASL) would predict FC or FO at a 6-months follow-up in 27 schizophrenia patients. A negative linear association was noted between FC and rCBF in the left inferior and middle frontal gyrus, areas involved in language processing, suggesting a potential relationship between cerebral perfusion and prospective FC in schizophrenia.

Psychomotor retardation is linked to frontal alpha asymmetry in major depression.

BACKGROUND: Psychomotor disturbances are a main clinical feature of major depressive disorder (MDD) but little is known about their EEG signature. One of the most replicated EEG findings in MDD is resting frontal asymmetry in the alpha band (FAA), which is thought to be a correlate of withdrawal behavior and reduced approach motivation. The purpose of this study was to assess psychomotor alterations, alpha band power, FAA and investigate the association between them. METHODS: 20 MDD patients and 19 healthy subjects were enrolled. Alpha power and FAA scores were calculated from a resting state EEG. Wrist actigraphy was recorded from the non-dominant arm for 24 h and activity level scores (AL) were extrapolated from the wakeful periods. RESULTS: MDD patients had a left-lateralized frontal alpha activity and lower AL scores when compared to healthy subjects. A significant correlation was found between mean FAA and AL scores. A negative covariance between power in the lower alpha range and AL scores over the motor cortex bilaterally was detected. LIMITATIONS: Relatively small sample size. Patients were pharmacologically treated with antidepressants. CONCLUSIONS: This study replicates the finding of left-lateralized FAA and lower AL scores in MDD patients, and establishes the first evidence of significant correlations between alpha power, FAA scores and measures of motor activity, which may be interpreted as an expression of impaired motivational drive in MDD.

Obsessive-compulsive disorder comorbidity: clinical assessment and therapeutic implications.

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder affecting approximately 1-3% of the population. OCD is probably an etiologically heterogeneous condition. Individuals with OCD frequently have additional psychiatric disorders concomitantly or at some time during their lifetime. Recently, some authors proposed an OCD sub-classification based on comorbidity. An important issue in assessing comorbidity is the fact that the non-response to treatment often involves the presence of comorbid conditions. Non-responsive patients are more likely to meet criteria for comorbid axis I or axis II disorders and the presence of a specific comorbid condition could be a distinguishing feature in OCD, with influence on the treatment adequacy and outcome.

Motor cortex excitability correlates with novelty seeking in social anxiety: a transcranial magnetic stimulation investigation.

Social anxiety disorder (SAD) is characterised by fear of scrutiny by other people, avoidance of social situations and vegetative/motor symptomatology. The correlation between reduced striatal dopaminergic (DA) function, SAD motor symptoms and the high occurrence of SAD in patients with Parkinson's disease (PD), suggests a link between SAD and movement diseases caused by dopamine dysfunction. However, little is known about the electrophysiological aspects of SAD. We applied single- and paired-pulse transcranial magnetic stimulation (TMS) to investigate excitatory and inhibitory mechanisms of the primary motor cortex (M1) in 15 SAD patients and the relationship between these neurophysiological measures and clinical symptoms or temperamental traits. Data were compared with those obtained in 15 age- and sex-matched healthy volunteers. SAD patients showed significantly higher harm avoidance scores and lower novelty seeking scores when compared to controls. TMS measures did not significantly differ between groups. However, in SAD patients the cortical silent period (CSP) duration and the amount of long-interstimulus interval intracortical inhibition were significantly correlated with the NS score. Accordingly with NS reduction and CSP shortening reported in PD, the relationship between NS levels and the excitability of inhibitory circuits of the M1 may support the hypothesis that DA dysfunction could underlie NS deficits in SAD. Furthermore, these data suggest that "trait variables" (i.e., NS) are more closely related to neurophysiological measures than SAD symptoms, which represent "state variables" linked to social performance.