Challenges of Assessing Resident Competency in Well-Being: Development of the Psychiatry Milestones 2.0 Well-Being Subcompetency.

Burnout and depression are major problems facing physicians, with 300-400 physicians dying by suicide each year. In an effort to address this issue, the Accreditation Council for Graduate Medical Education (ACGME) revised the Common Program Requirements for residency and fellowship programs to include a strong emphasis on well-being, and this revision has been extended to including a subcompetency on well-being in the Milestones 2.0. The Psychiatry Milestones 2.0 Work Group was convened to draft updated psychiatry milestones. As part of the open feedback period, the American Association of Directors of Psychiatric Residency Training submitted an organizational letter outlining several points to consider regarding the original draft of the well-being subcompetency. The ACGME was receptive to this feedback and allowed the Psychiatry Milestones 2.0 Work Group to revise the subcompetency. Current research indicates that burnout is largely driven by systemic factors, but well-being literature and initiatives often focus on individual factors and responsibility for burnout rather than systemic change. Program directors tasked with assessing resident well-being can additionally encounter several professionalism concerns, including how to (1) define a subcompetency within a competency that itself has not been well defined; (2) decide the appropriate balance between individual and systemic responsibility for well-being; (3) consider mental health as a parameter of well-being; (4) balance roles as physicians, psychiatrists, and training directors in thinking about the mental health of residents without overstepping boundaries and while maintaining privacy, confidentiality, and resident safety; and (5) measure well-being in a sociocultural context. This article describes how these considerations were incorporated into the revision of the Psychiatry Milestones 2.0 version of the well-being subcompetency, which has subsequently been made available to other specialty work groups for potential use as they develop their specialty-specific Milestones 2.0.

Disparities and Variables Associated With Physical Restraint for Acute Agitation in a Nonpsychiatric Emergency Department.

OBJECTIVE: To determine associations between the rate of physical restraint and demographic variables such as body mass index (BMI), ethnicity, sex, and age in the emergency department (ED) along with clinical variables such as various psychiatric diagnoses and medications. METHODS: This 6-month (October 1, 2016-March 30, 2017) retrospective chart review was conducted in the ED of a community hospital, which is also a teaching institution for medical students and residents but does not have access to psychiatry consultations via phone or in person. A total of 165 agitated patients were included in the study. Agitated patients who were restrained were compared to those who were not physically restrained. RESULTS: Of the patients, 112 (68%) were physically restrained, and those not physically restrained were included as controls (n = 53, 32%). Younger age (P = .03), lower BMI (P = .04), intoxication (P = .001), preexisting diagnosis of depression (P = .02), and antipsychotics as a home medication (P = .03) were associated with physical restraints. In the ED, administration of haloperidol and olanzapine was associated with physical restraints. Current benzodiazepine prescription (P = .001), ED administration of ketamine (P = .001), and ED administration of diazepam (P = .001) were more common in those not physically restrained. CONCLUSIONS: Risk factors for physical restraints can be used to identify high-risk patients early, and other treatments along with behavioral and environmental modifications may then be utilized. Further research to develop protocols using nonpharmacologic and pharmacologic measures to minimize use of restraints is required.