Online medical student OSCE examinations during the first three years of the COVID-19 pandemic compared to three years pre-pandemic: An Australian experience in psychiatry and addiction medicine.

PURPOSE: We have evaluated the final-year Psychiatry and Addiction Medicine (PAM) summative Objective Structured Clinical Examination (OSCE) examinations in a four-year graduate medical degree program, for the previous three years as a baseline comparator, and during three years of the COVID-19 pandemic (2020-2022). METHODS: A de-identified analysis of medical student summative OSCE examination performance, and comparative review for the 3 years before, and for each year of the pandemic. RESULTS: Internal reliability in test scores as measured by R-squared remained the same or increased following the start of the pandemic. There was a significant increase in mean test scores after the start of the pandemic compared to pre-pandemic for combined OSCE scores for all final-year disciplines, as well as for the PAM role-play OSCEs, but not for the PAM mental state examination OSCEs. CONCLUSIONS: Changing to online OSCEs during the pandemic was related to an increase in scores for some but not all domains of the tests. This is in line with a nascent body of literature on medical teaching and examination following the start of the pandemic. Further research is needed to optimise teaching and examination in a post-pandemic medical school environment.

A level playing field? Evaluation of the virtual Objective Structured Clinical Examination in Psychiatry and Addiction Medicine: A mixed methods study.

OBJECTIVE: The Objective Structured Clinical Examination (OSCE) has been used for clinical assessment of a broad range of medical student competencies in Psychiatry and Addiction Medicine. However, there has been little research into online assessments. We investigated the virtual OSCE (v-OSCE) from the user perspective to better understand its acceptability, usefulness, benefits, challenges and potential improvements. METHODS: At the conclusion of the v-OSCE, all participants (medical students, examiners and simulated patients) were invited to participate in a brief online survey, based on the Technology and Acceptance Model. Freeform qualitative feedback was also obtained to explore participants' experiences and attitudes. RESULTS: Participants reported the v-OSCE was acceptable, efficient, convenient and easy to use. It was perceived as useful for demonstrating students' interviewing skills and interacting with the simulated patient. Benefits included greater convenience, reduced stress and travel time. Challenges were similar to those experienced in 'real world' telepsychiatry, primarily related to assessment of non-verbal cues and emotional prosody. CONCLUSIONS: Our findings inform recommendations for improving online examinations. These include increased preparation, practice and professionalism, to better simulate the in-person experience. Study credibility was strengthened by the triangulation of qualitative, quantitative and psychometric data.

Psychiatric electronic health records in the era of data breaches - What are the ramifications for patients, psychiatrists and healthcare systems?

OBJECTIVE: To update psychiatrists and trainees on the realised risks of electronic health record data breaches. METHODS: This is a selective narrative review and commentary regarding electronic health record data breaches. RESULTS: Recent events such as the Medibank and Australian Clinical Labs data breaches demonstrate the realised risks for electronic health records. If stolen identity data is publicly released, patients and doctors may be subject to blackmail, fraud, identity theft and targeted scams. Medical diagnoses of psychiatric illness and substance use disorder may be released in blackmail attempts. CONCLUSIONS: Psychiatrists, trainees and their patients need to understand the inevitability of electronic health record data breaches. This understanding should inform a minimised collection of personal information in the health record to avoid exposure of confidential information and identity theft. Governmental regulation of electronic health record privacy and security is needed.

Healthcare provider data breaches - framework for crisis communication and support of patients and healthcare workers in mental healthcare.

Increasing numbers of healthcare data breaches highlight the need for structured organisational responses to protect patients, trainees and psychiatrists against identity theft and blackmail. Evidence-based guidance that is informed by the COVID-19 pandemic response includes: timely and reliable information tailored to users' safety, encouragement to take protective action, and access to practical and psychological support. For healthcare organisations which have suffered a data breach, insurance essentially improves access to funded cyber security responses, risk communication and public relations. Patients, trainees and psychiatrists need specific advice on protective measures. Healthcare data security legislative reform is urgently needed.

Psychiatrist and trainee moral injury during the organisational long COVID of Australian acute psychiatric inpatient services.

OBJECTIVE: This paper provides a commentary on the risk of moral injury amongst psychiatrists and trainees working in the acute psychiatric hospital sector, during the third winter of the COVID-19 pandemic. CONCLUSIONS: Moral injuries arise from observing, causing or failing to prevent adverse outcomes that transgress core ethical and moral values. Potentially, morally injurious events (PMIEs) are more prevalent and potent while demand on acute hospitals is heightened with the emergence of highly infectious SARS-CoV-2-Omicron subvariants (BA.4 and BA.5). Acute hospital inpatient services were already facing extraordinary stresses in the context of increasingly depleted infrastructure and staffing related to the pandemic. These stresses have a high potential to be morally injurious. It is essential to immediately fund additional staff and resources and address workplace health and safety, to seek to arrest a spiral of moral injury and burnout amongst psychiatrists and trainees. We discuss recommended support strategies.

Considering patient narrative-based and medico-scientific epistemologies in framing psychiatric care.

OBJECTIVE: Personal narratives of lived experience with psychiatric illness and distress remain central in the epistemology of mental illness. We provide a commentary on this potential bridging of patient narrative-based epistemology, and medico-scientific epistemology used by psychiatrists used for diagnosis, formulation, prognosis and treatment. CONCLUSION: Discussion and planning of psychiatric care can be framed by understanding the narrative-based epistemology of a patient's illness as highlighted by five key questions to explore the patient's illness explanatory models. We propose five key questions for the psychiatrist's complementary consideration of medico-scientific epistemology that frame conceptual models of aetiology, pathophysiology, diagnosis, formulation, prognosis and treatment, which are embedded in the predominant socio-cultural environment. These questions assist in bridging patient narrative and medico-scientific explanatory models to facilitate more effective collaborative care planning.

Commentary on alignment of medical student assessment and vocational training in psychiatry and addiction medicine.

OBJECTIVE: To comment upon the potential for alignment of medical student assessment and vocational specialist training through the RANZCP-CanMEDS model of Entrustable Professional Activities (EPAs) and Workplace-Based Assessments (WBAs). We discuss a specific post hoc example of such an alignment in an Australian graduate medical school in Psychiatry and Addiction Medicine. CONCLUSIONS: Vocational training models of assessment, such as the RANZCP specialist training program for psychiatrists, can potentially be mapped to medical student education in formative and summative assessment through CanMEDs-based EPAs and WBAs, to assist in transition to specialist training.

Grasping the nettle of danger: a commentary on how people perceive their health risks, impacting on their health behaviours.

OBJECTIVE: To provide a commentary review, for psychiatrists and trainees, on the clinical relevance of risk perception for health behaviours and outcomes. CONCLUSIONS: The core dimensions of risk perception are how a person perceives the likelihood and severity of an adverse outcome in the face of a threat. The two fundamental modes of how a threat is perceived are a rapid, intuitive, affective response followed by a slower, deliberate, cognitive appraisal. Risk perception regarding health threats is influenced by: level of trust in the information source; immediacy; voluntariness; perceived consequences of the threat; an affective response of fear, especially a feeling of dread; familiarity with the threat, including past exposure; and factual knowledge of the threat. Perception of risk may by distorted by cognitive biases (heuristics), including optimistic bias. There is a strong and consistent link between risk perception and health behaviours, and, therefore, health outcomes.

Moral injury and psychiatrists in public community mental health services.

OBJECTIVES: This study aims to provide a clinical update on moral injury from the perspective of a public sector community psychiatrist, and to outline approaches to addressing the issues raised. CONCLUSIONS: Although not considered a mental illness, moral injury is an important condition for psychiatrists to have an awareness of, as it is associated with psychological distress and/or impairments in emotional, social or behavioural functioning. Potentially morally injurious events (PMIEs) for community psychiatrists may include staff shortages and deficient resources rendering it difficult to provide an acceptable standard of professional care; time constraints negatively impacting teaching, supervising and mentoring medical students; cost-prohibition regarding preferred medication choices; lack of gender and cultural diversity of available psychiatrists; and work environments not conducive to psychiatrists speaking out about their concerns. The COVID-19 pandemic has exposed and exacerbated PMIEs for some community psychiatrists. Whether or not a PMIE transitions to a moral injury may be influenced by the individual's resilience and the quality of emotional, psychological and administrative support they receive before, during and after the potentially precipitating event. Preventative strategies to mitigate susceptibility to a moral injury may be implemented at both a systems level and individual level, and include collective healthcare advocacy action.

Risk perception research informing recommendations for COVID-19 preventative health measures and public messaging.

OBJECTIVE: To provide a commentary on evidence-based recommendations for COVID-19 pandemic risk communication for more effective public health measures. METHOD: We apply the principles of risk communication to address key issues in the COVID-19 pandemic. RESULTS: Risk perception and communication research usefully informs preventative health education and public messaging during disease outbreaks such as the current COVID-19 pandemic, especially for those with severe mental illness. CONCLUSIONS: Key recommendations for pandemic public health risk communication are: clear, timely and balanced information from a reputable source; accurate and non-sensationalised depiction of infection, morbidity and mortality rates; awareness of fear as a powerful motivator for adoption of protective measures against the causative virus; promotion of self-efficacy and sense of control in terms of mitigating the health threats associated with a pandemic; correction of mis- and disinformation regarding the pandemic and associated protective measures; and messaging may need to be modified for people with a mental illness to avoid exacerbations of depressive and anxiety symptoms.

Medicare-subsidised mental health services from the beginning of Better Access in 2006-2007 to 2019-2020: Descriptive analysis by state, profession and consultation profile.

OBJECTIVE: Since 2006, the Australian Federal Government has aimed at expanding mental healthcare through the 'Better Access' programme of Medicare-subsidised services by private practitioners. We comment on population access to subsidised mental health treatment via health professionals in Australia. METHODS: We descriptively analysed Australian Institute of Health and Welfare (AIHW) data. RESULTS: Increasing percentages of the Australian population of people received Medicare-subsidised services from 2008-09 to 2019-20. Population access to mental health treatment increased from 5.7% to 10.7%. In 2019-20, psychiatrists provided services for 1.7% of the population, while GPs provided for 8.8%, clinical psychologists 2.2%, registered psychologists 2.9%, and other allied health providers 0.4%. Over the period, numbers of Australian psychiatrists providing services increased, but the numbers of patients seen per year, and other indicators, have either been flat or declined. GP, Psychologist, Clinical Psychologist and other allied health consultations increased overall, but again the numbers of sessions have decreased. CONCLUSIONS: Medicare-subsidised private practice has greatly increased population access to mental health treatment. However, there appear to be a relatively limited number of consultations per patient for most provider groups. Further research is required on the effectiveness of treatment through collecting data on casemix and outcomes.

Penumbra of the pandemic workplace for psychiatrists and trainees in Australia.

OBJECTIVE: A commentary on the workforce, infrastructure and health of psychiatrists and trainees providing psychiatric care during the COVID-19 pandemic in Australia. CONCLUSIONS: The wide-ranging workplace, health system and societal changes necessitated by the SARS-CoV-2 virus have altered the practice and working lives of psychiatrists, trainees and other healthcare workers, as well as the general population. There have been workplace innovations, recalibrations and losses. There is a new baseline upon which to build better psychiatric services, as the pandemic's penumbra recedes.

The single-item Self-Rated Mental Health Question in women with gestational diabetes mellitus.

OBJECTIVE: This study aims to explore whether the single-item Self-Rated Mental Health Question (SRMHQ) may be an indicator of the need for further mental health assessment and investigation in women with gestational diabetes mellitus (GDM). METHOD: Women with GDM (n = 159) were recruited from outpatient clinics in the Australian Capital Territory prior to a GDM information session (mean gestational age = 26, SD = 4.5). Participants were aged 20-45 (mean = 33, SD = 4.2) and completed a single-item Self-Rated Health Question (SRHQ), single-item Self-Rated Mental Health Question (SRMHQ), Kessler 10-item Psychological Distress Scale (K-10), and Edinburgh Depression Scale (EDS), as well as demographic, psychiatric, and general health items. Multiple regression was used to explore whether there was an association between SRMHQ responses and K-10 or EDS total scores. RESULTS: Regression analysis revealed that the SRMHQ was a statistically significant predictor of K-10 and EDS total scores, while controlling for key potential confounders. When mental health was rated as "poor" compared to "excellent," this was associated with an additional 12 and 9 points on K-10 and EDS total scores, respectively. CONCLUSION: The SRMHQ may have a role as an indicator of the need for further mental health assessment and investigation in women with gestational diabetes mellitus.

There's no sugar-coating psychological distress and illness perceptions in gestational diabetes mellitus: depression and anxiety are associated with negative illness perceptions.

OBJECTIVE: To gain an understanding of how women with gestational diabetes perceive their illness, and whether depressive/anxiety symptoms and/or psychological distress influence these illness perceptions. METHOD: A cross-sectional study was conducted with 159 pregnant women aged 18-44 attending gestational diabetes clinics. Participants completed a questionnaire, which included the Edinburgh Depression Scale (EDS), Kessler 10-item Psychological Distress Scale (K-10), Brief Illness Perception Questionnaire (BIPQ), and psychiatric/general health items. Multiple regression was used to explore the relationship between EDS (total and anxiety subscale) scores and BIPQ scores, as well as between K-10 (total and anxiety subscale) scores and BIPQ scores. RESULTS: Regression analysis revealed a positive association between EDS total/anxiety subscale scores and BIPQ total score, as well as between K-10 total/anxiety subscale scores and BIPQ total score, controlling for potentially confounding variables. There was a strong positive correlation between EDS total score and K-10 total score. The most frequently expressed concern about GDM was an adverse effect on their baby's health. A poor diet was the most frequently reported perceived 'cause' of GDM. CONCLUSION: Greater severity of depressive and anxiety symptoms, and psychological distress, is associated with more negative illness perceptions of GDM in pregnant women.

Psychiatrist and trainee burnout: Commentary and recommendations on management.

OBJECTIVE: To comment upon the evidence-base regarding psychiatrist and trainee burnout and provide recommendations on management. CONCLUSIONS: Burnout has been conceptualised as a specific stress-related response, primarily related to work. There is a high prevalence of burnout amongst both trainees and psychiatrists internationally, with substantial consequences for personal and family wellbeing, organisational efficiency and patient care. We summarise the evidence on organisational and individual approaches to addressing burnout.

Final-year medical student Psychiatry and Addiction Medicine synchronous summative tele-assessments during a COVID-19 Delta-variant stay-at-home lockdown.

OBJECTIVE: We describe the planning, process and evaluation of final-year Psychiatry and Addiction Medicine summative assessments in a four-year graduate medical degree program, during a COVID-19 Delta-variant public health stay-at-home lockdown. CONCLUSIONS: We conducted separate written and clinical synchronous (real-time simultaneous) tele-assessments. We used online assessment technology with students, examiners and simulated patients, all in different physical locations. Medical students' examination performance showed a good range. This was comparable to other discipline stations, and performance in previous years. There was no differential performance of students through the day of the assessments.

Clinical update on managing media exposure and misinformation during COVID-19: recommendations for governments and healthcare professionals.

OBJECTIVES: To provide a clinical update on the mechanisms of, and potential population mental health risks of, excessive media exposure and misinformation regarding the COVID-19 pandemic. To outline guidance for government, health services, psychiatrists and health professionals in managing mental health effects of COVID-19 media exposure. CONCLUSIONS: Social and traditional media businesses attract interest by reporting threats and negativity, and heavy media exposure during disasters is associated with increased depressive and post-traumatic symptoms. There are three main recommendations for mitigation of the adverse population mental health effects of excessive media exposure and misinformation. Clear, authoritative communication from governments, health authorities and health professionals is essential, combined with correction of misinformation and addressing mistrust. Specific warnings by governments, health authorities and clinicians of the potential adverse mental health consequences of excessive COVID-19 media consumption are needed. Limitation of exposure to media and disinformation regarding COVID-19 is crucial - the less, the better. Healthcare professionals can advise patients to check information once daily, and be guided by reliable public health authorities, as part of interventions for managing the mental health impact of COVID-19.

Nothing to sneeze at - uptake of protective measures against an influenza pandemic by people with schizophrenia: willingness and perceived barriers.

OBJECTIVES: To examine willingness to adopt protective behaviours, and perceived barriers, during a pandemic influenza, in people with schizophrenia. METHODS: A cross-sectional study using a questionnaire was conducted exploring the responses of 71 adults with schizophrenia and 238 adults without schizophrenia attending a general practice setting, regarding willingness and perceived barriers to adopting protective measures against the 2009 swine influenza pandemic in Australia. RESULTS: The majority of participants with schizophrenia reported that they would be at least moderately willing to be vaccinated (74.2%), isolate themselves (73.2%), wear a face mask (54.9%) and increase hand washing (88.6%). However, 71.8% were concerned about "catching" flu from vaccination. Predictors of willingness to adopt protective actions included self-efficacy (vaccination, face mask, isolation), perceived likelihood of contracting swine flu (vaccination), educational status (face mask) and perceived overall risk from swine flu (face mask). Key modifiable perceived barriers to adopting protective measures were identified, including cost and need for transport assistance for vaccination. CONCLUSIONS: People with schizophrenia report being generally willing to adopt protective measures, especially increased hand washing, during a pandemic influenza. Understanding perceived barriers may enable development of effective interventions to increase uptake of protective measures.

A sense of dread: affect and risk perception in people with schizophrenia during an influenza pandemic.

OBJECTIVE: To explore the role of affect in risk perception and intention to adopt protective measures against pandemic swine influenza in people with schizophrenia. METHODS: A cross-sectional study was conducted exploring the responses of 71 adults with schizophrenia and 238 adults attending general practice settings without schizophrenia. Participants completed a questionnaire that included items relating to: self-predicted affect (affective forecast) were they to contract swine influenza; perceived risk from swine influenza; and willingness to adopt protective measures against swine influenza. The 10-item Kessler Psychological Distress Scale (K10) and a single-item Self-Rated Health Question (SRHQ) were also included as measures. RESULTS: In people with schizophrenia, higher levels of predicted fear were associated with increased likelihood of perceived substantive risk from swine influenza and self-reported willingness to adopt protective measures against it. However, higher K10 anxiety subscale scores, reflecting greater concurrent anxiety, were associated with reduced likelihood of perceived substantive risk from swine influenza in people with schizophrenia. CONCLUSION: Affect appears to play a role in risk perception of influenza and willingness to take protective measures against it in people with schizophrenia.