Differences between medical school and PGY1 learning outcomes: An explanation for new graduates not being "work ready"?

Background: Widespread concerns about new medical graduates' 'work readiness' may reflect, in part, differences in mandatory learning outcomes for medical students and new medical graduates.Purpose: To examine differences between required medical student and PGY1 (first year resident) training program outcomes, and the nature and magnitude of these differences.Method: Comparison, systematic identification and thematic analysis of differences between the graduate outcomes in the Australian Medical Council Standards for the Assessment and Accreditation of Primary Medical Programs and those in the New Zealand Curriculum Framework for Prevocational Training.Results: The relationship between these outcome statements were categorized as: essentially similar; continuity; partial discontinuity; and complete discontinuity of learning trajectory. Areas requiring substantial new learning may reflect medical schools' focus on individual student performance, and on learning and assessments based on single episodes of often uncomplicated illness. This contrasted with a post-graduate focus on integrated health care delivery by teams and management of complex illnesses over the whole patient care journey.Conclusions: Characterizing these marked differences between pre-graduate and postgraduate standards, within a trajectory of learning, explains some of the difficulties in students' preparation for work readiness. These could inform learning interventions to support new graduates' professional development to ensure patient safety. Development and revision of accreditation standards should include formal review against the expectations of the preceding and succeeding phases of learning.

What Do Final Year Medical Students Understand by the Concept of Recovery? A Descriptive Qualitative Study.

OBJECTIVE: Traditional teaching in psychiatry does little to address recovery concepts. The aim of this study was to evaluate the incorporation of a recovery-focused teaching program for medical students in psychiatry. METHODS: Recovery, as understood by medical students who had participated in a recovery-focused teaching program, was assessed by thematic analysis of recovery-focused assessment reflections. RESULTS: Six major themes emerged from the recovery reflections from final year medical students are as follows: (1) recovery as a person-centered approach, (2) the need for social integration, (3) non-diagnostic framing of mental illness, (4) tensions between the medical model and personal recovery, (5) a patient's willingness to engage with mental health services, and (6) the development of a positive sense of self. CONCLUSIONS: A recovery teaching program was associated with students expressing knowledge of recovery principles and positive attitudes towards people with experience of mental illness. Psychiatric placements for medical students may benefit from a recovery focus.

Discovering stigma through recovery teaching.

OBJECTIVE: From the perspective of the tutor, course coordinators and a clinical supervisor, we describe and reflect on our observations of innovative service-user led tutorials on recovery that were delivered to final year medical students as part of their psychiatric module. CONCLUSIONS: Much to our surprise, and in contrast to observations elsewhere during the module, students openly expressed blatant stigmatising attitudes in the tutorials on recovery, particularly after spending time with inpatient services. More specifically, they were pessimistic about the possibility of recovery and they struggled to accept the service user status of the recovery tutor. This prompted us to reflect on what and how we teach psychiatry.

Core dimensions of recovery: a psychometric analysis.

Core recovery dimensions lie between the large general factor of recovery and its underlying components. Identifying these could enhance recovery frameworks, practice and research. In contrast to existing conceptually based taxonomies, we sought to empirically identify the core dimensions of recovery through further psychometric analysis of a robust eleven factor (sub-scale) consumer recovery outcome measure, My Voice, My Life. We subjected the sub-scale scores of 504 consumers to further principal components analyses, beginning with a single unrotated factor and progressing through two to nine factors with varimax rotation. We found the five-factor solution to provide an orderly intermediate configuration with the eleven recovery factors having either aligned and/or disengaged through the process to result in the following core dimensions: (1) Belonging and relating (encompassing the individual factors of spirituality, culture, and relationships); (2) Being and doing (encompassing the individual factors of physical health, day-to-day life, and quality of life); (3) Thinking and feeling (encompassing the individual factors of recovery, mental health, and hope and empowerment); (4) Resources (which maintained its independence); and (5) Satisfaction with Services (which also maintained its independence). We compare this empirical configuration with conceptually based taxonomies.

Capacity of forensic patients to consent to treatment.

OBJECTIVE: Lack of capacity to consent to psychiatric treatment has been promoted as a better basis for compulsion than mental disorder plus risk of harm. Previous research has examined how that legal change would affect acutely unwell inpatients. There is little research on forensic patients. This research aimed to assess capacity to consent in forensic patients at different stages of recovery and to consider the implications of respecting their competent treatment decisions. METHOD: Capacity to consent was assessed in a cross-sectional sample of 109 forensic patients both in hospital and in community settings. RESULTS: The majority of participants (67.6%) had treatment-related decision-making capacity. Very few patients with capacity refused treatment. CONCLUSIONS: Change to a capacity-based legal approach may alter treatment for some forensic patients but would not necessarily increase risk of harm to others. The implications for release decisions are less clear.

Development of a self-assessed consumer recovery outcome measure: my voice, my life.

We report the development of a self-assessed consumer recovery outcome measure by way of a consumer led and focused iterative process, informed by exploratory and confirmatory factor analysis. The process began with a deliberately over-inclusive preliminary measure of 127 items, based on 12 presumptive domains derived from the recovery literature and consumer consultation, being piloted with over 500 mental health consumers. The full 504 participant data set was randomly split into two discrete sets of 300 and 204 to provide one for the initial exploratory factor analysis and another (of independence) for the subsequent confirmatory factor analysis and reliability estimation. Analyses identified and confirmed (using the separate data sets) a robust factor structure, with 11 distinct and relatively independent factors (relationships; day-to-day life; culture; physical health; quality of life; mental health; recovery; hope and empowerment; spirituality; resources; and satisfaction with services) underlying one substantial principal construct (that we refer to as consumer recovery). The measure was refined to 65 items, between three and ten items for each of the 11 domains, the reliabilities for which are uniformly high.

A population study of childhood maltreatment and asthma diagnosis: differential associations between child protection database versus retrospective self-reported data.

OBJECTIVE: Despite growing evidence from longitudinal studies of a link between early-life stress and the development of asthma, very few of these examine one of the most severe types of early-life stress: childhood maltreatment. Cross-sectional studies on this topic have relied on retrospective self-reports of maltreatment. This study investigates associations between childhood maltreatment indicated by child protection agency records versus self-reports and lifetime asthma diagnosis in young adults, adjusting for socioeconomic status and mental disorders. METHODS: A nationally representative general population survey of DSM-IV mental disorders in New Zealand (n = 12,992) obtained information on lifetime diagnoses of chronic physical conditions. Information from a subsample of survey respondents aged 16 to 27 years (n = 1413) was linked with a national child protection database to identify respondents with a history of agency involvement, which was used as a proxy for childhood maltreatment. Retrospective reports of maltreatment were also obtained. RESULTS: Child protection agency history was associated with elevated odds (odds ratio = 2.88 [95% confidence interval = 1.7-4.74]) of a lifetime diagnosis of asthma. After adjusting for a variety of indicators of socioeconomic status, lifetime mental disorders, lifetime smoking, and body mass index, this association remained significantly elevated (odds ratio = 2.26 [95% confidence interval = 1.33-3.83]). Retrospectively self-reported maltreatment in childhood was not associated with asthma. CONCLUSIONS: Childhood maltreatment was associated with elevated odds of asthma diagnosis. These findings are consistent with the possibility that early-life stress may be one of the environmental factors that increase the risk of asthma in genetically vulnerable individuals.

Childhood maltreatment and DSM-IV adult mental disorders: comparison of prospective and retrospective findings.

BACKGROUND: Prior research reports stronger associations between childhood maltreatment and adult psychopathology when maltreatment is assessed retrospectively compared with prospectively, casting doubt on the mental health risk conferred by maltreatment and on the validity of retrospective reports. AIMS: To investigate associations of psychopathology with prospective v. retrospective maltreatment ascertainment. METHOD: A nationally representative sample of respondents aged 16-27 years (n = 1413) in New Zealand completed a retrospective assessment of maltreatment and DSM-IV mental disorders. Survey data were linked with a national child protection database to identify respondents with maltreatment records (prospective ascertainment). RESULTS: Childhood maltreatment was associated with elevated odds of mood, anxiety and drug disorders (odds ratios = 2.1-4.1), with no difference in association strength between prospective and retrospective groups. Prospectively ascertained maltreatment predicted unfavourable depression course involving early onset, chronicity and impairment. CONCLUSIONS: Prospectively and retrospectively assessed maltreatment elevated the risk of psychopathology to a similar degree. Prospectively ascertained maltreatment predicted a more unfavourable depression course.

Learning is what happens between seeing patients: defining clinical access.

The inability to access clinical placements during the COVID-19 pandemic stimulated us to reflect on key elements of the experience, beyond history taking and examination. We were also mindful of concerns about work readiness of new graduates. We identified seven aspects of clinical experience distinct from those requiring direct patient contact. These are: recognise and contribute to the collective competence of multidisciplinary teams; apply project management principles to the complexities of clinical care; integrate personal and team-based clinical reasoning; deliver patient-centred collaborative care; achieve an integrated perspective of clinical care; demonstrate adaptability to health systems; consolidate professional identity formation. We consider that making these aspects explicit in learning objectives and assessments in medical schools is likely to improve the work-readiness of new graduates and should also be reflected in accreditation standards.

The low pass rate in the RANZCP clinical examinations: is the exam the problem?

OBJECTIVES: The aim of this study was to examine the role of supervision during psychiatric training in ensuring that registrars are adequately trained to meet the standards of the RANZCP examinations and to consider the implications for improving examination pass rates. METHOD: Audiotaped recordings of 50 h of supervision involving six supervisors and thirteen trainees, obtained 2000-2003, were transcribed and analysed thematically in a qualitative study, informed by a postmodern, foucaultian perspective. RESULTS: Until an examination loomed, supervisors rarely required evidence of theoretical study or structured case presentations from their trainees. The examination and the examiners served to justify the supervisors requiring such discipline. This enabled the supervisors to remain in a supportive role, while requiring higher standards from trainees. Paradoxically, while requiring higher standards 'for the exam', trainees were told that the examiners expected nothing more than 'good psychiatric practice'. In presenting cases, the attributes of prioritization, thoughtfulness, conciseness and good timing were valued, as reported in both undergraduate and other postgraduate medical training. CONCLUSIONS: Much of supervision bore little relationship to preparation for college examinations until these were imminent. While the daily practice of trainees and supervisors continues to be at variance with the practices required to pass the examination (reflected by reference to 'exam-style' and 'non-exam style' presentations) the pass rates will remain low. If we believe that the standard set in the examination is that required of a practising psychiatrist, change is required to supervision and daily practice standards to reflect these standards.

Constipation screening in people taking clozapine: A diagnostic accuracy study.

OBJECTIVE: Clozapine is the favoured antipsychotic for treatment-refractory schizophrenia but its safe use requires careful adverse-effect management. Clozapine-induced gastrointestinal hypomotility (CIGH or 'slow-gut') is one of the most common and serious of clozapine's adverse effects. CIGH can lead to paralytic ileus, bowel obstruction, gastrointestinal ischaemia, toxic megacolon, and death. Enquiring about constipation is a simple and commonly used screening method for CIGH but its diagnostic accuracy has not previously been assessed. METHODS: First, we examined the reliability of asking about constipation compared with asking about Rome constipation criteria in inpatients treated with clozapine (n = 69). Second, we examined the diagnostic accuracy of (1) self-reported constipation and (2) the Rome criteria, compared with the reference standard of gastrointestinal motility studies. RESULTS: After 30 motility tests, it was clear constipation screening had very poor diagnostic properties in this inpatient group and the study was terminated. Although 73% of participants had objective CIGH on motility testing, only 26% of participants self-reported constipation, with sensitivity of 18% (95% CI: 5-40%). Specificity and positive predictive values were higher (95% CI: 63-100% and 40-100%, respectively). Adding in Rome criteria improved sensitivity to 50% (95% CI: 28.2-71.8%), but half the cases were still missed, making this no more accurate than tossing a coin. CONCLUSIONS: CIGH is often silent, with self-reported constipation having low sensitivity in its diagnosis. Treating CIGH based on self-reported symptoms questions will miss most cases. However, universal bowel motility studies are impractical. In the interests of patient safety, prophylactic laxatives are suggested for people taking clozapine.

Effects of Clozapine on the Gut: Cross-Sectional Study of Delayed Gastric Emptying and Small and Large Intestinal Dysmotility.

BACKGROUND: Gastrointestinal hypomotility in people taking clozapine is common, poorly understood and potentially dangerous. It causes distress and sometimes sudden death, with greater associated morbidity than the better known adverse effect of clozapine, agranulocytosis. Neither the mechanism nor prevalence of clozapine-induced gastrointestinal hypomotility is well understood. Previous studies show clozapine impedes colon transit, likely owing to anticholinergic and anti-serotonergic properties. However, regional gastrointestinal transit times (including gastric and small bowel emptying) have not been quantified. METHODS: We used wireless motility capsules to measure gastric emptying and small and large bowel transit times in clozapine-treated individuals. We tested 17 clozapine-treated patients without any known gastrointestinal dysfunction, and compared data with matched normative transit times. RESULTS: Clozapine-treated participants had significant 'slow gut', with dysmotility in at least one region of the gastrointestinal tract evident in 82%, with 59% experiencing multi-regional dysmotility. Delayed gastric emptying was diagnosed in 41%, delayed small bowel transit in 71% and delayed colon transit in 50%. Only 18% of participants had normal studies. Hypomotility was not correlated with ethnicity, sex or duration of treatment. Subjective reporting of constipation had low sensitivity in predicting dysmotility. Delayed gastric emptying had been unrecognised clinically for all participants. CONCLUSION: Clozapine is associated with significant multi-regional gastrointestinal dysfunction. This is relevant when considering the relationship between clozapine use and conditions such as gastroparesis, choking, aspiration pneumonia, constipation, ileus and intestinal pseudo-obstruction. While the constipating properties of clozapine are now well recognised, this study shows a high degree of vigilance is required for both lower and upper gastrointestinal dysmotility in people taking this antipsychotic.

Predictive Utility of Personality Disorder in Depression: Comparison of Outcomes and Taxonomic Approach.

There is debate around the best model for diagnosing personality disorder, both in terms of its relationship to the empirical data and clinical utility. Four randomized controlled trials examining various treatments for depression were analyzed at an individual patient level. Three different approaches to the diagnosis of personality disorder were analyzed in these patients. A total of 578 depressed patients were included in the analysis. Personality disorder, however measured, was of little predictive utility in the short term but added significantly to predictive modelling of mediumterm outcomes, accounting for more than twice as much of the variance in social functioning outcome as depression psychopathology. Personality disorder assessment is of predictive utility with longer timeframes and when considering social outcomes as opposed to symptom counts. This utility is sufficiently great that there appears to be value in assessing personality; however, no particular approach outperforms any other.

Visual conversion disorder in a harbor pilot leading to sudden loss of control of a large vessel.

We describe an accident caused by the rapid onset of visual impairment in a ship's pilot, who was subsequently diagnosed as having visual conversion disorder (hysterical blindness). This case is documented to draw attention to the unusual cause of sudden incapacitation in transport crew and the consequential threat to transportation safety. Because sudden visual impairment incidents caused by conversion disorder are isolated and rare, they may be under-reported in the scientific literature. While it is unlikely that current systems for medical screening could anticipate and/or prevent crew incapacitation due to conversion disorders, this condition should be borne in mind when consulted by crew who report otherwise unexplained physical symptoms in the context of high levels of personal stress. It should also be considered when investigating possible medical incapacitation in transportation incidents or accidents.

Clozapine-Induced Gastrointestinal Hypomotility: A 22-Year Bi-National Pharmacovigilance Study of Serious or Fatal 'Slow Gut' Reactions, and Comparison with International Drug Safety Advice.

INTRODUCTION: Clozapine is the preferred antipsychotic for treatment-resistant schizophrenia, but has significant adverse effects, including gastrointestinal hypomotility or 'slow gut', which may result in severe constipation, ileus, bowel obstruction, and even death. These gastrointestinal effects remain inadequately recognized. METHODS: We reviewed all reports of serious clozapine-induced gastrointestinal hypomotility (CIGH) submitted to the Australian Therapeutic Goods Administration and New Zealand Pharmacovigilance Centre between 1992 and 2013. We extracted relevant demographic, clinical, and outcome data and derived a numerator from clozapine registries. We examined whether clozapine drug safety information in Australia, New Zealand, the US, and the UK was adequate and consistent with pharmacoepidemiologic evidence. RESULTS: A total of 43,132 people commenced clozapine over the study period. 160 were reported as having serious gastrointestinal hypomotility with clozapine the suspected cause (37/10,000 clozapine users). Of these, 66.3% were male, age range was 17-76 years, clozapine dose range 25-1000 mg/day (mean 439 mg/day) and median duration of clozapine treatment 2.5 years. Few had received laxatives. At least 29 patients died (7/10,000 clozapine users), a reported case fatality rate of 18%. The CIGH prevalence, while similar to other smaller studies, differs significantly from clozapine prescribing information issued by regulators and pharmaceutical companies, none of which mention CIGH, and which report serious gastrointestinal complications at rates of <1/10,000, almost a 40-fold difference. CONCLUSION: This is the largest study to date of serious CIGH. The reported prevalence of serious CIGH was 37/10,000, a likely underestimation of true prevalence. Current prescribing guidelines provide inadequate information on CIGH. This may be contributing to poor awareness and high associated morbidity and mortality. It is time regulators and manufacturers update their guidance.

Spatiotemporal Mapping Techniques Show Clozapine Impairs Neurogenic and Myogenic Patterns of Activity in the Colon of the Rabbit in a Dose-Dependent Manner.

Background: Clozapine, an antipsychotic used in treatment-resistant schizophrenia, has adverse gastrointestinal effects with significant associated morbidity and mortality. However, its effects on defined patterns of colonic contractile activity have not been assessed. Method: We used novel radial and longitudinal spatiotemporal mapping techniques, combined with and monitoring of ambient lumen pressure, in ex vivo preparations of triply and of singly haustrated portions of rabbit colon. We identified the contractile patterns of mass peristalses, fast phasic, and ripple contractions and directly qualified the effects of clozapine, at concentrations of 10 µmol/L, 20 µmol/L, and 30 µmol/L, and of norclozapine, the main metabolite of clozapine, on contractile patterns. The effects of carbachol, serotonin and naloxone on clozapine-exposed preparations were also determined. Tetradotoxin was used to distinguish neurogenic from myogenic contractions. Results: At 10 µmol/L, clozapine temporarily abolished the longitudinal contractile components of mass peristalsis, which on return were significantly reduced in number and amplitude, as was maximal mass peristaltic pressure. These effects were reversed by carbachol (1 µmol/L) and to some extent by serotonin (15 µmol/L). At 10 µmol/L, myogenic ripple contractions were not affected. At 20 µmol/L, clozapine had a similar but more marked effect on mass peristalses with both longitudinal and radial components and corresponding maximal pressure greatly reduced. At 30 µmol/L, clozapine suppressed the radial and longitudinal components of mass peristalses for over 30 min, as well as ripple contractions. Similar dose-related effects were observed on addition of clozapine to the mid colon. At 20 µmol/L, norclozapine had opposite effects to those of clozapine, causing an increase in the frequency of mass peristalsis with slight increases in basal tone. These slightly augmented contractions were abolished on addition of clozapine. Concentrations of norclozapine below 20 µmol/L had no discernible effects. Conclusion: Clozapine, but not norclozapine, has potent effects on the motility of the rabbit colon, inhibiting neurogenic contractions at lower concentrations and myogenic contractions at higher concentrations. This is the likely mechanism for the serious and life-threatening gastrointestinal complications seen in human clozapine-users. These effects appear to be mediated by cholinergic and serotonergic mechanisms. Spatiotemporal mapping is useful in directly assessing the effects of pharmaceuticals on particular patterns of gastrointestinal motility.

The Porirua Protocol in the Treatment of Clozapine-Induced Gastrointestinal Hypomotility and Constipation: A Pre- and Post-Treatment Study.

BACKGROUND: Clozapine, an antipsychotic used in treatment-resistant schizophrenia, causes slow gastrointestinal transit in 50-80% of patients. Clozapine-induced gastrointestinal hypomotility is both common and serious, and potential complications include severe constipation, ileus, bowel obstruction and related complications, with a higher mortality rate than clozapine-related agranulocytosis. Little evidence exists on its prevention and management. METHOD: Using a well-validated radiopaque marker ('Metcalf') method, we compared colonic transit times (CTTs) of clozapine-treated inpatients not receiving laxatives with their transit times when receiving laxatives, with treatment prescribed according to the Porirua Protocol for clozapine-related constipation (docusate and senna augmented by macrogol 3350 in treatment-resistant cases). RESULTS: The median age of participants was 35 years, and median clozapine dose, plasma level and duration of treatment were 575 mg/day, 506 ng/mL and 2.5 years, respectively. Overall, 14 participants (10 male) were enrolled and all completed the study. Transit times improved markedly with laxative treatment. Median colonic transit without laxatives was 110 h (95% confidence interval [CI] 76-144 h), over four times longer than normative values (p < 0.0001). Median CTT with laxatives was 62 h (95% CI 27-96 h), a 2-day reduction in average transit time (p = 0.009). The prevalence of gastrointestinal hypomotility decreased from 86% pre-treatment to 50% post-treatment (p = 0.061). Severe gastrointestinal hypomotility decreased from 64 to 21% (p = 0.031). Subjective reporting of constipation did not correlate well with objective hypomotility, and did not change significantly with treatment. CONCLUSION: Treating clozapine-treated patients with docusate and senna augmented by macrogol appears effective in reducing CTTs in clozapine-induced constipation. Randomised controlled trials are the next step. Australian New Zealand Clinical Trial Registry ACTRN12616001405404 (registered retrospectively).

Clozapine-treated Patients Have Marked Gastrointestinal Hypomotility, the Probable Basis of Life-threatening Gastrointestinal Complications: A Cross Sectional Study.

BACKGROUND: Gastrointestinal side effects are particularly common with clozapine and occur with other antipsychotics, ranging from mild constipation to fatal bowel obstruction and/or ischemia. While this adverse-effect spectrum has been attributed to 'gastrointestinal hypomotility', gastrointestinal transit times in antipsychotic-treated patients have not previously been measured, making this mechanism speculative. METHODS: Using standardized radiopaque marker ('Metcalf') methods we established colonic transit times of antipsychotic-treated psychiatric inpatients and compared them with population normative values. We analyzed results by antipsychotic type, antipsychotic dose equivalent, anticholinergic load, duration of treatment, gender, ethnicity, and age. OUTCOMES: For patients not prescribed clozapine, median colonic transit time was 23 h. For patients prescribed clozapine, median transit time was 104.5 h, over four times longer than those on other antipsychotics or normative values (p < 0.0001). Eighty percent of clozapine-treated patients had colonic hypomotility, compared with none of those prescribed other antipsychotics (olanzapine, risperidone, paliperidone aripiprazole, zuclopenthixol or haloperidol). In the clozapine group, right colon, left colon and rectosigmoid transit times were all markedly abnormal suggesting pan-colonic pathology. Hypomotility occurred irrespective of gender, age, ethnicity, or length of clozapine treatment. Transit times were positively correlated with clozapine plasma level (rho = 0.451, p = 0.045), but not with duration of treatment, total antipsychotic load or demographic factors. INTERPRETATION: Clozapine, unlike the other antipsychotics examined, causes marked gastrointestinal hypomotility, as previously hypothesized. Pre-emptive laxative treatment is recommended when starting clozapine.