Moonlighting by Psychiatry Residents: a Survey of Residents and Training Directors.

OBJECTIVE: This study sought to assess the prevalence of moonlighting among psychiatry residents; the perceived effects of moonlighting on resident recruitment, education, and liability; and policies and practices governing oversight. METHODS: In 2013, surveys were emailed to all general psychiatry residency programs that were accredited by the Accreditation Council for Graduate Medical Education and had available contact information (n = 183). Resident surveys were emailed to program coordinators with a request to forward the survey link to their residents. RESULTS: Responses were received from 63 program directors (34% response rate) and 238 residents (about 5% of total general psychiatry residents). Most psychiatry program directors (95%) indicated that their programs permit moonlighting. Moonlighting participation increased with each year of training, culminating with 67% of fourth year residents. Most residents and faculty (87%) agreed that moonlighting enhanced resident education. Thirty-seven percent of program directors reported having no oversight procedures in place to monitor moonlighting activities. Thirty-nine percent of resident survey responders reported having no supervision for at least one of their moonlighting activities and only 9% reported always having access to on-site supervision. CONCLUSION: Though limited by a low response rate, this study found that moonlighting seems to remain prevalent among psychiatry residents and widely accepted by psychiatry residency training programs. There appears to be relatively limited program oversight for moonlighting activities, many of which seem to lack close supervision.

A Qualitative Study of Factors Affecting Morale in Psychiatry Residency Training.

OBJECTIVE: Resident morale is an important yet poorly understood aspect of the residency training experience. Despite implications for program quality, resident satisfaction, patient care, and recruitment, little is known about the variables influencing this complex phenomenon. This study sought to identify important factors affecting morale in psychiatry residency training. METHODS: The authors conducted four semi-structured focus groups at a moderately sized, urban, psychiatry residency program during the 2013-2014 academic year. They used qualitative data analysis techniques, including grounded theory and content analysis, to identify key themes affecting resident morale across training levels. RESULTS: Twenty-seven residents participated in the focus groups with equal distribution across post-graduate years (PGY) 1-4. Five major conceptual categories affecting resident morale emerged: Sense of Community, Individual Motivators, Clinical Work, Feeling Cared For, and Trust in the Administration. CONCLUSIONS: Morale is an important topic in residency education. The qualitative results suggest that factors related to a Sense of Community and Individual Motivators generally enhanced resident morale whereas factors related to a lack of Feeling Cared For and Trust in the Administration tended to contribute to lower morale. The authors describe the possible interventions to promote stronger program morale suggested by these findings.

Defragmenting the path to diagnosis for underserved youth with Autism Spectrum Disorder in a community-based health system.

Autism Spectrum Disorder (ASD) is a pervasive neurodevelopmental disorder that affects about 1 out of every 54 youth and is characterized by impairments in social communication and functioning. ASD is a treatable condition though, and early initiation of interventions in the home and community can lead to improved long-term outcomes. Despite the clear benefits of early diagnosis and intervention, many youth, particularly from impoverished and minoritized populations, face tremendous barriers to accessing a timely formal diagnosis and critical early supports. Many of these barriers are inherent features of a fragmented health care system that even the most resourced of families struggle to navigate. Informed by the principles of coproduction of health care, value-based care design, and health equity, we present a quality improvement initiative to defragment the experience of care for underserved families seeking a timely formal diagnosis of ASD in a safety-net community-based health system. Over the course of 2.5 years, we were able to partner with families to create clinical workflows that cut in half the duration of time from first developmental concern to ASD diagnosis, and lowered the median age of ASD diagnosis in our health system by more than 3 years. We share our process and lessons learned in the hopes of helping other health systems pursuing similar goals for patient- and family-centered care design.

Promoting Population Behavioral Health in a Safety-Net Health System During the COVID-19 Pandemic.

The COVID-19 pandemic has been expected to lead to substantial increases in need for behavioral health care. A population health framework can facilitate the development of interventions and policies to promote the equitable distribution of care across the population. This column describes the application of population behavioral health principles in a safety-net health system during the pandemic. The approach includes stepped models of care, interventions to target individuals at high behavioral health risk, and measurement-based care. Early data suggest that these strategies have resulted in expanded behavioral health care capacity.

A Comparison of Health Care Expenditures for Medicaid-Insured Children with Autism Spectrum Disorder and Asthma in an Expanding Accountable Care Organization.

As value-based care continues to expand, more children with autism spectrum disorder (ASD) will be treated by accountable care organizations (ACOs), provider organizations seeking to improve population health while reducing costs. To inform ACO strategies for children with ASD, this study compared health care expenditures of children insured by a Medicaid managed care organization, empaneled to a safety net ACO, with ASD, asthma, and neither diagnosis. Compared to other study groups, children with ASD were more costly, had lower rates of acute care, and had higher rates of "leaked" care provided by home- and community-based mental health agencies outside of the ACO. These findings highlight the need for unique value-based strategies for children with ASD in a public sector ACO.

Discharge antithrombotic strategies among patients with acute coronary syndrome previously on warfarin anticoagulation: physician practice in the CRUSADE registry.

BACKGROUND: Patients experiencing acute coronary syndromes (ACS) with high-risk features frequently undergo percutaneous coronary intervention (PCI) with stent placement, prompting the requisite administration of aspirin and clopidogrel. The current management of ACS patients with a concomitant indication for warfarin anticoagulant therapy is a question of growing interest and clinical relevance. METHODS: We analyzed discharge antithrombotic medication use among all patients with non-ST-segment elevation (NSTE) ACS enrolled in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) initiative who were receiving warfarin at the time of hospital admission. Multivariable logistic regression was used to determine factors associated with a decision to discontinue warfarin at discharge. RESULTS: Among 5673 patients with ACS previously on home warfarin, 1357 (24%) were not discharged on warfarin. In the subset of 1247 patients who underwent coronary stenting, 60% were prescribed triple anticoagulation therapy (aspirin, clopidogrel, and warfarin), 31% were given aspirin and clopidogrel without warfarin, and 3% received warfarin and aspirin without clopidogrel. Factors associated with a decision not to continue warfarin at the time of hospital discharge included in-hospital red blood cell transfusion, non-white race, prior stroke, and discharge clopidogrel use. The decision to continue warfarin at discharge correlated with perceived bleeding risk and was unaffected by patients' stroke risk. CONCLUSION: Physician practices vary with regard to the perceived optimal antithrombotic strategy at time of hospital discharge among patients with ACS with a concomitant indication for warfarin. Decisions are influenced primarily by other medication use and anticipated bleeding risk. Further research is needed to guide patient care based on the safety and efficacy of antiplatelet-anticoagulant combined pharmacotherapy.

Description of a program for social language intervention: "if you can have a conversation, you can have a relationship".

Adolescents with impaired language comprehension and formulation skills often experience difficulty keeping up with the linguistic and social demands of peer interaction. This clinical exchange describes an individualized treatment program designed to increase the conversational skill of an adolescent male with language impairment. Treatment focused on increasing awareness of the listener's needs and on balancing the exchange of conversational turns. Clinical performance, parent report, and client report were used to assess outcomes.

Electroconvulsive therapy for the treatment of refractory mania.

We present the case of a patient with treatment-refractory mania. The patient had been tried on numerous medications, to which she either did not respond well or on which she developed severe side effects, However, the patient improved rapidly when treated with unilateral electropercussive therapy (ECT) following a court order. We outline the legal barriers that have been raised against the use of ECT in patients with mania, who often refuse treatment, and the irony that ECT can be safer than medications for some patients. ECT is underutilized in mania but deserves more frequent consideration. (Journal of Psychiatric Practice. 2011;17:61-66).

Description of a Program for Social Language Intervention: If You Can Have a Conversation, You Can Have a Relationship.

Adolescents with impaired language comprehension and formulation skills often experience difficulty keeping up with the linguistic and social demands of peer interaction. This clinical exchange describes an individualized treatment program designed to increase the conversational skill of an adolescent male with language impairment. Treatment focused on increasing awareness of the listener's needs and on balancing the exchange of conversational turns. Clinical performance, parent report, and client report were used to assess outcomes.