Distributed Medical Education (DME) in psychiatry: perspectives on facilitators, obstacles, and factors affecting psychiatrists' willingness to engage in teaching activities.

BACKGROUND: Distributed Medical Education (DME), a decentralized model focused on smaller cities and communities, has been implemented worldwide to bridge the gap in psychiatric education. Faculty engagement in teaching activities such as clinical teaching, supervision, and examinations is a crucial aspect of DME sites. Implementing or expanding DME sites requires careful consideration to identify enablers that contribute to success and barriers that need to be addressed. This study aims to examine enablers, barriers, and factors influencing psychiatrists' willingness to start or continue participating in teaching activities within Dalhousie University's Faculty of Medicine DME sites in two provinces in Atlantic Canada. METHODOLOGY: This cross-sectional study was conducted as part of an environmental scan of Dalhousie Faculty of Medicine's DME programs in Nova Scotia (NS) and New Brunswick (NB), Canada. In February 2023, psychiatrists from seven administrative health zones in these provinces anonymously participated in an online survey. The survey, created with OPINIO, collected data on sociodemographic factors, practice-related characteristics, medical education, and barriers to teaching activities. Five key outcomes were assessed, which included psychiatrists' willingness to engage in (i) clinical training and supervision, (ii) lectures or skills-based teaching, (iii) skills-based examinations, (iv) training and supervision of Canadian-trained psychiatrists, and (v) training and supervision of internationally trained psychiatrists. The study employed various statistical analyses, including descriptive analysis, chi-square tests, and logistic regression, to identify potential predictors associated with each outcome variable. RESULTS: The study involved 60 psychiatrists, primarily male (69%), practicing in NS (53.3%), with international medical education (69%), mainly working in outpatient services (41%). Notably, 60.3% lacked formal medical education training, yet they did not perceive the lack of training as a significant barrier, but lack of protected time as the main one. Despite this, there was a strong willingness to engage in teaching activities, with an average positive response rate of 81.98%. The lack of protected time for teaching/training was a major barrier reported by study participants. Availability to take the Royal College of Physicians and Surgeons of Canada Competency by Design training was the main factor associated with psychiatrists' willingness to participate in the five teaching activities investigated in this study: willingness to participate in clinical training and supervision of psychiatry residents (p = .01); provision of lectures or skills-based teaching for psychiatry residents (p < .01); skills-based examinations of psychiatry residents (p < .001); training/supervision of Canadian-trained psychiatrists (p < .01); and training and supervision of internationally trained psychiatrists (p < .01). CONCLUSION: The study reveals a nuanced picture regarding psychiatrists' engagement in teaching activities at DME sites. Despite a significant association between interest in formal medical education training and willingness to participate in teaching activities, clinicians do not consider the lack of formal training as a barrier. Addressing this complexity requires thoughtful strategies, potentially involving resource allocation, policy modifications, and adjustments to incentive structures by relevant institutions.

The Goldilocks of Social Justice Education: Balint Groups as a Curricular Intervention to Support Equitable Health Care.

While there is consensus within the medical profession on the importance of ensuring future physicians are well versed in issues of social justice, there is little consensus on how to best achieve this. Traditional methods of didactic lectures or case-based learning, with an emphasis on the transmission of knowledge, run the risk of reinforcing the very inequities they are aiming to disrupt. The classroom experiences do not call on trainees to act on issues of social justice beyond discussing imagined actions in a carefully constructed case. Balint Groups offer an alternate pedagogy that align with a more interpretative style of teaching and offer an opportunity for meaningful engagement with issues of social justice. In Balint Groups, students are engaged in cases where the presenter has participated directly in the clinical encounter. While these cases tend to focus on relational dilemmas between the doctor and patient, the dilemma can also highlight an internal dilemma between competing professional identities - such as the biomedical expert and the socially conscious professional. Imagined agency is removed and the group is tasked with reflecting on the dissonance created by these two competing identities. While the use of Balint Groups as a curricular intervention offers exciting opportunities to promote social justice, there are cautions. First, Balint Groups operate within the dominant discourse of medical education and facilitators must be sensitive to how this may position the presenter; second, it cannot be forced - it must arise from the case presented.

The Juice is Worth the Squeeze: Psychiatry Residents' Experience of Balint Group.

INTRODUCTION: Balint Groups provide physicians with a forum to develop their capacity to empathically engage with patients, through exploring patient-provider relationships. The Dalhousie University Department of Psychiatry implemented a mandatory Balint Group as part of the junior resident curriculum. The purpose of this study is to explore how residents describe their experience of participating in this Balint Group. METHODS: Psychiatry residents in their first year of training participated in a focus group to discuss their experiences of the Balint Group. Data was analyzed using content analysis. RESULTS: Three main categories were identified: the purpose of, the process of, and participation in the Balint Group. Process was subdivided into Balint Frame and Institutional Factors. Participation was further subdivided into vulnerability, reflection, fellowship, and validation. CONCLUSION: Residents attributed fellowship with their peers, self-efficacy and hope in their work to their participation in the Balint Group. While there was an adjustment period, residents grew to accept, and even appreciate the group. Lack of problem-solving became accepted as part of the purpose of the group and this acceptance was attributed to having other avenues within the program to address problems raised in the discussion. Feeling disconnected when the session ended was described and was related to the abrupt termination of the virtual session or having to exit the group early to return to clinical duties. While the virtual nature of the group was not explicitly identified as a challenge, having to leave early was. While these institutional factors can be mitigated through programmatic implementation, they are not a deal breaker to implementing a Balint Group in a residency training program. Even in a lunch hour or virtual environment our data suggests that the juice is worth the squeeze.

Evolution of a biological thermocouple by adaptation of cytochrome c oxidase in a subterrestrial metazoan, Halicephalobus mephisto.

In this study, we report a biological temperature-sensing electrical regulator in the cytochrome c oxidase of the Devil Worm, Halicephalobus mephisto. This extremophile metazoan was isolated 1.3 km underground in a South African goldmine, where it adapted to heat and potentially to hypoxia, making its mitochondrial sequence a likely target of adaptational change. We obtained the complete mitochondrial genome sequence of this organism and show through dN/dS analysis evidence of positive selection in H. mephisto cytochrome c oxidase subunits. Seventeen of these positively selected amino acid substitutions were located in proximity to the H- and K-pathway proton channels of the complex. Surprisingly, the H. mephisto cytochrome c oxidase completely shuts down at low temperatures (20 °C), leading to a 4.8-fold reduction in the transmembrane proton gradient (ΔΨm) compared to optimal temperature (37 °C). Direct measurement of oxygen consumption found a corresponding 4.6-fold drop at 20 °C compared to 37 °C. Correspondingly, the lifecycle of H. mephisto takes four times longer at low temperature than at higher. This elegant evolutionary adaptation creates a finely-tuned mitochondrial temperature sensor, allowing this ectothermic organism to maximize its reproductive success across varying environmental temperatures.

Evolution of a biological thermocouple by adaptation of cytochrome c oxidase in a subterrestrial metazoan.

In this study we report a naturally evolved temperature-sensing electrical regulator in the cytochrome c oxidase of the Devil Worm, Halicephalobus mephisto. This extremophile metazoan was isolated 1.3 km underground in a South African goldmine, where it adapted to heat and potentially to hypoxia, making its mitochondrial sequence a likely target of adaptational change. We obtained the full mitochondrial genome sequence of this organism, and show through dN/dS analysis statistically robust evidence of positive selection in H. mephisto cytochrome c oxidase subunits. Seventeen of these positively-selected amino acid substitutions were localized in proximity to the H- and K-pathway proton channels of the complex. Surprisingly, the H. mephisto cytochrome c oxidase proton pump completely shuts down at low temperatures (20°C) leading to approximately a 4.8-fold reduction in the transmembrane proton gradient voltage (ΔΨm) compared to optimal temperature (37°C). Direct measurement of oxygen consumption found a corresponding 4.7-fold drop at 20°C compared to 37°C. Correspondingly, the lifecycle of H. mephisto takes four-fold longer at the low temperature compared to higher. This elegant evolutionary adaptation creates a finely-tuned mitochondrial temperature sensor, allowing this ectothermic organism to maximize its reproductive success in varying environmental temperatures. Our study shows that evolutionary innovation may remodel core metabolism to make it more accurately map onto environmental variation.

Exploring Current Practices, Needs, and Barriers for Expanding Distributed Medical Education and Scholarship in Psychiatry: Protocol for an Environmental Scan Using a Formal Information Search Approach and Explanatory Design.

BACKGROUND: Distributed medical education (DME) offers manifold benefits, such as increased training capacity, enhanced clinical learning, and enhanced rural physician recruitment. Engaged faculty are pivotal to DME's success, necessitating efforts from the academic department to promote integration into scholarly and research activities. Environmental scanning has been used to gather, analyze, and apply information for strategic planning purposes. It helps organizations identify current practices, assess needs and barriers, and respond to emerging risks and opportunities. There are process models and conceptual frameworks developed for environmental scanning in the business and educational sectors. However, the literature lacks methodological direction on how to go about designing and implementing this strategy to guide research and practice in DME, especially in the psychiatry field. OBJECTIVE: This paper presents a protocol for an environmental scanning that aims to understand current practices and identify needs and barriers that must be addressed to facilitate the integration of psychiatrists from the Dalhousie University Faculty of Medicine's distributed education sites in Nova Scotia and New Brunswick into the Department of Psychiatry, contributing for the expansion of DME in both provinces and informing strategic planning and decision-making within the organization. METHODS: This protocol adopts an innovative approach combining a formal information search and an explanatory design that includes quantitative and qualitative data. About 120 psychiatrists from 8 administrative health zones of both provinces will be invited to complete an anonymous web-based survey with questions about demographics, participants' experience and interest in undergraduate, postgraduate, and continuing medical education, research and scholarly activities, quality improvement, and knowledge translation. Focus group sessions will be conducted with a purposive sample of psychiatrists to collect qualitative data on their perspectives on the expansion of DME. RESULTS: Results are expected within 6 months of data collection and will inform policy options for expanding Dalhousie University's psychiatry residency and fellowship programs using the infrastructure and human resources at distributed learning sites, leveraging opportunities regionally, especially in rural areas. CONCLUSIONS: This paper proposes a comprehensive environmental scan procedure adapted from existing approaches. It does this by collecting important characteristics that affect psychiatrists' desire to be involved with research and scholarly activities, which is crucial for the DME expansion. Furthermore, its concordance with the literature facilitates interpretation and comparison. The protocol's new method also fills DME information gaps, allowing one to identify insights and patterns that may shape psychiatric education. This environmental scan's results will answer essential questions about how training programs could involve therapists outside the academic core and make the most of training experiences in semiurban and rural areas. This could help other psychiatry and medical units outside tertiary care establish residency and fellowship programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46835.