Associate residency training directors in psychiatry: demographics, professional activities, and job satisfaction.

OBJECTIVE: The purpose of this study was to characterize associate training director (ATD) positions in psychiatry. METHOD: An on-line survey was e-mailed in 2009 to all ATDs identified through the American Association of Directors of Psychiatric Residency Training (AADPRT). Survey questions elicited information regarding demographics, professional activities, job satisfaction, and goals. RESULTS: Of 170 ATDs surveyed, 73 (42.9%) completed the survey. Most respondents (71.3%) had been in their positions for 3 years or less. Many ATDs indicated that they were involved in virtually all aspects of residency training; 75% of respondents agreed that they were happy with their experience. However, specific concerns included inadequate time and compensation for the ATD role in addition to a lack of mentorship and unclear job expectations. CONCLUSIONS: Thoughtful attention to the construction of the ATD role may improve job satisfaction.

Strategies From 11 U.S. Medical Schools for Integrating Basic Science Into Core Clerkships.

Calls for curricular reform in medical schools and enhanced integration of basic and clinical science have resulted in a shift toward preclerkship curricula that enhance the clinical relevance of foundational science instruction and provide students with earlier immersion in the clinical environment. These reforms have resulted in shortened preclerkship curricula, yet the promise of integrated basic science education into clerkships has not been sufficiently realized because of barriers such as the nature of clinical practice, time constraints, and limited faculty knowledge. As personalized medicine requires that physicians have a more nuanced understanding of basic science, this is cause for alarm. To address this problem, several schools have developed instructional and assessment strategies to better integrate basic science into the clinical curriculum. In this article, faculty and deans from 11 U.S. medical schools discuss the strategies they implemented and the lessons they learned to provide guidance to other schools seeking to enhance basic science education during clerkships. The strategies include program-level interventions (e.g., longitudinal sessions dedicated to basic science during clerkships, weeks of lessons dedicated to basic science interspersed in clerkships), clerkship-level interventions (e.g., case-based learning with online modules, multidisciplinary clerkship dedicated to applied science), bedside-level interventions (e.g., basic science teaching scripts, self-directed learning), and changes to formative and summative assessments (e.g., spaced repetition/leveraging test-enhanced learning, developing customized examinations). The authors discovered that: interventions were more successful when buy-in from faculty and students was considered, central oversight by curricular committees collaborating with faculty was key, and some integration efforts may require schools to provide significant resources. All schools administered the United States Medical Licensing Examination Step 1 exam to students after clerkship, with positive outcomes. The authors have demonstrated that it is feasible to incorporate basic science into clinical clerkships, but certain challenges remain.

Identifying and Supporting Students to Prevent USMLE Step 1 Failures When Testing Follows Clerkships: Insights From 9 Schools.

Several schools have moved the United States Medical Licensing Examination Step 1 exam after core clerkships, and others are considering this change. Delaying Step 1 may improve Step 1 performance and lower Step 1 failure rates. Schools considering moving Step 1 are particularly concerned about late identification of struggling students and late Step failures, which can be particularly problematic due to reduced time to remediate and accumulated debt if remediation is ultimately unsuccessful. In the literature published to date, little attention has been given to these students. In this article, authors from 9 medical schools with a postclerkship Step 1 exam share their experiences. The authors describe curricular policies, early warning and identification strategies, and interventions to enhance success for all students and struggling students in particular. Such learners can be identified by understanding challenges that place them "at risk" and by tracking performance outcomes, particularly on other standardized assessments. All learners can benefit from early coaching and advising, mechanisms to ensure early feedback on performance, commercial study tools, learning specialists or resources to enhance learning skills, and wellness programs. Some students may need intensive tutoring, neuropsychological testing and exam accommodations, board preparation courses, deceleration pathways, and options to postpone Step 1. In rare instances, a student may need a compassionate off-ramp from medical school. With the National Board of Medical Examiner's announcement that Step 1 scoring will change to pass/fail as early as January 2022, residency program directors might use failing Step 1 scores to screen out candidates. Institutions altering the timing of Step 1 can benefit from practical guidance by those who have made the change, to both prevent Step 1 failures and minimize adverse effects on those who fail.

From the Classroom to Entrustment - The Development of Motivational Interviewing Skills as an Entrustable Professional Activity.

This article was migrated. The article was marked as recommended. Introduction The move towards value-based care and population health has highlighted the prominent role of social and behavioral factors in determining health outcomes. Patient-centered behavioral guidance to improve patient self-management is recognized as an evidence-based intervention for a variety of chronic conditions but has yet to be adopted as a core competency or core entrustable professional activity (EPA). Motivational Interviewing (MI) is an evidence-based behavioral intervention involving an integrated set of competencies, featuring reflective listening, affirmation, evocation, and collaborative planning. An MI encounter is an observable, discrete task that can be framed as an EPA. Successful implementation of EPAs in the workplace requires institutional engagement, a thoughtful curricular approach, faculty development, and feasible, valid workplace-based assessment (WBA). Methods We implemented competency-based MI training and assessed competency outcomes for students and faculty. After joining the Association of American Medical Colleges Core EPA Pilot, we applied an iterative group process to develop an EPA and workplace-based assessment based on established MI competencies. Results Drawing upon nine years of developing MI curriculum, we present competency data for a student training study and a faculty coaching study, describe how we transitioned training from the classroom to the clinical setting employing an EPA framework, and present a one-page schematic and related WBA for an EPA based on MI. Conclusion We propose that MI is a core EPA for future physicians practicing value-based care, and offer a roadmap for curriculum implementation.

A Review of Continuous Quality Improvement Processes at Ten Medical Schools.

The Liaison Committee on Medical Education now expects all allopathic medical schools to develop and adhere to a documentable continuous quality improvement (CQI) process. Medical schools must consider how to establish a defensible process that monitors compliance with accreditation standards between site visits. The purpose of this descriptive study is to detail how ten schools in the Association of American Medical Colleges' (AAMC) Southern Group on Educational Affairs (SGEA) CQI Special Interest Group (SIG) are tackling practical issues of CQI development including establishing a CQI office, designating faculty and staff, charging a CQI committee, choosing software for data management, if schools are choosing formalized CQI models, and other considerations. The information presented is not meant to certify that any way is the correct way to manage CQI, but simply present some schools' models. Future research should include defining commonalities of CQI models as well as seeking differences. Furthermore, what are components of CQI models that may affect accreditation compliance negatively? Are there "worst practices" to avoid? What LCME elements are most commonly identified for CQI, and what are the successes and struggles for addressing those elements? What are identifiable challenges relating to use of standard spreadsheet software and engaging information technology for support? How can students be more engaged and involved in the CQI process? Finally, how do these major shifts to a formalized CQI process impact the educational experience?

Socially Accountable Medical Education: An Innovative Approach at Florida International University Herbert Wertheim College of Medicine.

PROBLEM: Despite medical advances, health disparities persist, resulting in medicine's renewed emphasis on the social determinants of health and calls for reform in medical education. APPROACH: The Green Family Foundation Neighborhood Health Education Learning Program (NeighborhoodHELP) at Herbert Wertheim College of Medicine provides a platform for the school's community-focused mission. NeighborhoodHELP emphasizes social accountability and interprofessional education while providing evidence-based, patient- and household-centered care. NeighborhoodHELP is a required, longitudinal service-learning outreach program in which each medical student is assigned a household in a medically underserved community. Students, teamed with learners from other professional schools, provide social and clinical services to their household for three years. Here the authors describe the program's engagement approach, logistics, and educational goals and structure. OUTCOMES: During the first six years of NeighborhoodHELP (September 2010-August 2016), 1,470 interprofessional students conducted 7,452 visits to 848 households with, collectively, 2,252 members. From August 2012, when mobile health centers were added to the program, through August 2016, students saw a total of 1,021 household members through 7,207 mobile health center visits. Throughout this time, households received a variety of free health and social services (e.g., legal aid, tutoring). Compared with peers from other schools, graduating medical students reported more experience with clinical interprofessional education and health disparities. Surveyed residency program directors rated graduates highly for their cultural sensitivity, teamwork, and accountability. NEXT STEPS: Faculty and administrators are focusing on social accountability curriculum integration, systems for assessing and tracking relevant educational and household outcomes, and policy analysis.

Implementing an Entrustable Professional Activities Framework in Undergraduate Medical Education: Early Lessons From the AAMC Core Entrustable Professional Activities for Entering Residency Pilot.

In 2014, the Association of American Medical Colleges (AAMC) published a list of 13 Core Entrustable Professional Activities for Entering Residency (Core EPAs) that medical school graduates might be expected to perform, without direct supervision, on the first day of residency. Soon after, the AAMC commissioned a five-year pilot with 10 medical schools across the United States, seeking to implement the Core EPA framework to improve the transition from undergraduate to graduate medical education.In this article, the pilot team presents the organizational structure and early results of collaborative efforts to provide guidance to other institutions planning to implement the Core EPA framework. They describe the aims, timeline, and organization of the pilot as well as findings to date regarding the concepts of entrustment, assessment, curriculum development, and faculty development. On the basis of their experiences over the first two years of the pilot, the authors offer a set of guiding principles for institutions intending to implement the Core EPA framework. They also discuss the impact of the pilot, its limitations, and next steps, as well as how the pilot team is engaging the broader medical education community. They encourage ongoing communication across institutions to capitalize on the expertise of educators to tackle challenges related to the implementation of this novel approach and to generate common national standards for entrustment. The Core EPA pilot aims to better prepare medical school graduates for their professional duties at the beginning of residency with the ultimate goal of improving patient care.

Predictors of response in depression.

Conflicting or sparse data on predictors of treatment response in depression have resulted in lack of clear guidelines in choosing antidepressant treatment. Critical to treatment outcome are accurate diagnosis and adequate treatment. Other data easy to obtain, such as age, gender, and marital status, have failed to be consistent predictors; more elaborate studies, such as receptor analysis or neuroimaging, are not yet accessible to most clinicians or economically feasible; however, they offer hope for the future, when more biologically based diagnostic distinctions may come to guide treatment choices.

Defining translational research: implications for training.

Because translational research is not clearly defined, developers of translational research programs are struggling to articulate specific program objectives, delineate the knowledge and skills (competencies) that trainees are expected to develop, create an appropriate curriculum, and track outcomes to assess whether program objectives and competency requirements are being met. Members of the Evaluation Committee of the Association for Clinical Research Training (ACRT) reviewed current definitions of translational research and proposed an operational definition to use in the educational framework. In this article, the authors posit that translational research fosters the multidirectional and multidisciplinary integration of basic research, patient-oriented research, and population-based research, with the long-term aim of improving the health of the public. The authors argue that the approach to designing and evaluating the success of translational training programs must therefore be flexible enough to accommodate the needs of individual institutions and individual trainees within the institutions but that it must also be rigorous enough to document that the program is meeting its short-, intermediate-, and long-term objectives and that its trainees are meeting preestablished competency requirements. A logic model is proposed for the evaluation of translational research programs.

Phosphodiesterase genes and antidepressant treatment response: a review.

Depression results in a tremendous burden to individuals suffering from the disorder and to the global health economy. Available pharmacologic treatments for depression target monoamine levels and monoamine receptors. However, delayed onset of effect, partial or inadequate treatment response, and side-effects are significant limitations of current therapies. The search for a better understanding of mechanisms of depression and for new treatment targets has turned attention to intracellular mediators. Phosphodiesterases (PDEs) are enzymes that break down the intracellular second messenger mononucleotides cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). Recent data from animal and human studies indicate that PDEs may play a role in depression and in related stress conditions. PDE genes have been linked directly to depression and to other genes associated with psychiatric disorders.

Elevated stress-hemoconcentration in major depression is normalized by antidepressant treatment: secondary analysis from a randomized, double-blind clinical trial and relevance to cardiovascular disease risk.

BACKGROUND: Major depressive disorder (MDD) is an independent risk factor for cardiovascular disease (CVD); the presence of MDD symptoms in patients with CVD is associated with a higher incidence of cardiac complications following acute myocardial infarction (MI). Stress-hemoconcentration, a result of psychological stress that might be a risk factor for the pathogenesis of CVD, has been studied in stress-challenge paradigms but has not been systematically studied in MDD. METHODS: Secondary analysis of stress hemoconcentration was performed on data from controls and subjects with mild to moderate MDD participating in an ongoing pharmacogenetic study of antidepressant treatment response to desipramine or fluoxetine. Hematologic and hemorheologic measures of stress-hemoconcentration included blood cell counts, hematocrit, hemoglobin, total serum protein, and albumin, and whole blood viscosity. FINDINGS: Subjects with mild to moderate MDD had significantly increased hemorheologic measures of stress-hemoconcentration and blood viscosity when compared to controls; these measures were correlated with depression severity. Measures of stress-hemoconcentration improved significantly after 8 weeks of antidepressant treatment. Improvements in white blood cell count, red blood cell measures and plasma volume were correlated with decreased severity of depression. CONCLUSIONS: Our secondary data analyses support that stress-hemoconcentration, possibly caused by decrements in plasma volume during psychological stress, is present in Mexican-American subjects with mild to moderate MDD at non-challenged baseline conditions. We also found that after antidepressant treatment hemorheologic measures of stress-hemoconcentration are improved and are correlated with improvement of depressive symptoms. These findings suggest that antidepressant treatment may have a positive impact in CVD by ameliorating increased blood viscosity. Physicians should be aware of the potential impact of measures of hemoconcentration and consider the implications for cardiovascular risk in depressed patients.

Leptin replacement improves cognitive development.

BACKGROUND: Leptin changes brain structure, neuron excitability and synaptic plasticity. It also regulates the development and function of feeding circuits. However, the effects of leptin on neurocognitive development are unknown. OBJECTIVE: To evaluate the effect of leptin on neurocognitive development. METHODOLOGY: A 5-year-old boy with a nonconservative missense leptin gene mutation (Cys-to-Thr in codon 105) was treated with recombinant methionyl human leptin (r-metHuLeptin) at physiologic replacement doses of 0.03 mg/kg/day. Cognitive development was assessed using the Differential Ability Scales (DAS), a measure of general verbal and nonverbal functioning; and selected subtests from the NEPSY, a measure of neuropsychological functioning in children. PRINCIPAL FINDINGS: Prior to treatment, the patient was morbidly obese, hypertensive, dyslipidemic, and hyperinsulinemic. Baseline neurocognitive tests revealed slower than expected rates of development (developmental age lower than chronological age) in a majority of the areas assessed. After two years, substantial increases in the rates of development in most neurocognitive domains were apparent, with some skills at or exceeding expectations based on chronological age. We also observed marked weight loss and resolution of hypertension, dyslipidemia and hyperinsulinemia. CONCLUSIONS: We concluded that replacement with r-metHuLeptin is associated with weight loss and changes in rates of development in many neurocognitive domains, which lends support to the hypothesis that, in addition to its role in metabolism, leptin may have a cognitive enhancing role in the developing central nervous system. TRIAL REGISTRATION: ClinicalTrials.gov NCT00659828.

Changes in insulin sensitivity during leptin replacement therapy in leptin-deficient patients.

Leptin replacement rescues the phenotype of morbid obesity and hypogonadism in leptin-deficient adults. However, leptin's effects on insulin resistance are not well understood. Our objective was to evaluate the effects of leptin on insulin resistance. Three leptin-deficient adults (male, 32 yr old, BMI 23.5 kg/m(2); female, 42 yr old, BMI 25.1 kg/m(2); female, 46 yr old, BMI 31.7 kg/m(2)) with a missense mutation of the leptin gene were evaluated during treatment with recombinant methionyl human leptin (r-metHuLeptin). Insulin resistance was determined by euglycemic hyperinsulinemic clamps and by oral glucose tolerance tests (OGTTs), whereas patients were on r-metHuLeptin and after treatment was interrupted for 2-4 wk in the 4th, 5th, and 6th years of treatment. At baseline, all patients had normal insulin levels, C-peptide, and homeostatic model assessment of insulin resistance index, except for one female diagnosed with type 2 diabetes. The glucose infusion rate was significantly lower with r-metHuLeptin (12.03 +/- 3.27 vs. 8.16 +/- 2.77 mg.kg(-1).min(-1), P = 0.0016) but did not differ in the 4th, 5th, and 6th years of treatment when all results were analyzed by a mixed model [F(1,4) = 0.57 and P = 0.5951]. The female patient with type 2 diabetes became euglycemic after treatment with r-metHuLeptin and subsequent weight loss. The OGTT suggested that two patients showed decreased insulin resistance while off treatment. During an off-leptin OGTT, one of the patients developed a moderate hypoglycemic reaction attributed to increased posthepatic insulin delivery and sensitivity. We conclude that, in leptin-deficient adults, the interruption of r-metHuLeptin decreases insulin resistance in the context of rapid weight gain. Our results suggest that hyperleptinemia may contribute to mediate the increased insulin resistance of obesity.