Perceptions of Supervision in an Outpatient Psychiatry Clinic.

OBJECTIVES: There is little guidance regarding best practices in supervision of psychiatric residents. As a result, expectations for both supervisors and trainees are often unclear. This study explored the experiences of trainees and supervisors in outpatient supervision, in order to identify areas for potential improvement. METHODS: The authors conducted focus groups of residents and faculty members. The sessions were transcribed and analyzed via established methods of qualitative data analysis. RESULTS: A number of themes emerged. In general, residents desire an explicit structure to supervisory sessions, with more specific and concrete instruction. Attendings prefer to let residents lead discussion in supervision and focus on interpersonal aspects, such as the mentor-mentee relationship. Findings were situated within an established model of skill acquisition, the five-stage progression described by Dreyfus and Dreyfus. CONCLUSIONS: The differing experiences of trainees and supervisors reflect their respective stages of skill development as ambulatory psychiatrists. Potential interventions to improve the educational value of supervision include explicit agenda-setting at the beginning of supervision, regular bidirectional feedback, and more frequent opportunities for residents to observe attending interviews with patients.

Psychosomatic medicine training as a bridge to practice: training and professional practice patterns of early career psychosomatic medicine specialists.

BACKGROUND: The number of interested candidates for psychosomatic medicine (PM) training programs has not matched the growing need for psychiatrists trained to care for complex medically ill patients. The reasons for this lack of growth may be found in the experience of new entrants into the subspecialty. OBJECTIVE: To investigate this issue, we conducted a survey of early career psychiatrists (ECPs) practicing PM to identify the personal and professional characteristics of ECP PM specialists and to examine the relevance of PM training to professional practice. METHODS: ECPs who attended the 2012 Academy of Psychosomatic Medicine annual meeting or who were registered members of the Academy of Psychosomatic Medicine completed a survey on training and work experiences. Decisional factors associated with pursuit of subspecialty fellowship education and professional practice patterns were identified using descriptive statistics and chi-square tests. RESULTS: A total of 102 ECPs completed the survey. Of the respondents, 67 (67%) had completed a PM fellowship. Motivating factors for pursuing fellowship training included (1) obtaining additional clinical training, (2) developing a special interest in PM training, and (3) improving job candidacy. Overall, 80% of ECPs desired inpatient consultation-liaison positions at the time of fellowship graduation. Overall, 22% reported difficulty in obtaining employment in PM after training. Chi-square tests between subjects who pursued a PM fellowship and those who did not proved nonsignificant. CONCLUSIONS: PM fellowship training remains relevant and important to ECPs in this sample. The survey results can be used to shape institutional and professional supports to better meet early career transition needs for PM psychiatrists.

The Short-Answer Vignette Examination (SAVE): an assessment tool for the core psychiatry clerkship.

OBJECTIVE: This study aims to develop a vignette-based assessment tool for medical students on the psychiatry clerkship, with the goal of capturing knowledge and clinical reasoning. METHODS: The Short-Answer Vignette Exam (SAVE), four case vignettes with open-ended questions regarding assessment, differential diagnosis, management, and treatment, was developed for and administered to medical students rotating through psychiatry at a university medical school over one academic year (n = 169). The correlation of SAVE scores to resident/faculty evaluations (clinical rating) and Shelf exam scores were analyzed. RESULTS: SAVE scores were significantly correlated with scores on both the Shelf and Clinical Rating. By contrast, Shelf scores were not significantly related to Clinical Rating. CONCLUSION: The SAVE may measure aspects of clinical decision making not measured by the Shelf, without being redundant in what is assessed by the Clinical Rating. The SAVE provides an additional potentially useful assessment tool to evaluate medical students on the psychiatry clerkship.

C-L Case Conference: The Case of a 34-Year-Old Male Veteran with Suicidal Ideation in the Context of Alcohol Intoxication.

We describe the case of a 34-year-old male veteran who presents to the emergency department with suicidal ideation while intoxicated on alcohol. From his progression from intoxication through sobriety, this case details changes in his suicide risk during the sobering process. Consultation-liaison psychiatrists present guidance for this clinical scenario based on their experiences and a review of the available literature. The following important concepts for managing suicide risk among patients with alcohol intoxication are considered: evaluating for medical risk, timing the suicide risk assessment, anticipating withdrawal, diagnosing other disorders, and achieving a safe disposition.

Trainees as teachers in team-based learning.

OBJECTIVE: Team-based learning is an active learning modality that is gaining popularity in medical education. The authors studied the effect of using trainees as facilitators of team-based learning sessions. METHODS: Team-based learning modules were developed and implemented by faculty members and trainees for the third-year medical student clerkship in psychiatry in the 2007-2008 academic year. Evaluation forms were used to elicit student opinions about the team-based learning sessions. Scores for trainee and faculty facilitators were compared using Student's t tests. RESULTS: Overall scores were positive, reflecting acceptability of this form of instruction. Eight of nine comparisons showed no difference in students' ratings of faculty versus trainee facilitators. The other comparison showed a modest preference for faculty facilitators. CONCLUSION: Team-based learning modules can be led as effectively by trainees as by faculty members to teach medical students in the classroom setting.

Assessing Residents' Veteran-Centered Care Skills in the Clinical Setting.

BACKGROUND: Despite their placement in Veterans Health Administration centers nationwide, residents' training and assessment in veteran-centered care is variable and often insufficient. OBJECTIVE: We assessed residents' ability to recognize and address mental health issues that affect US military veterans. METHODS: Two unannounced standardized patient (SP) cases were used to assess internal medicine residents' veteran-centered care skills from September 2014 to March 2016. Residents were assessed on 7 domains: military history taking, communication skills, assessment skills, mental health screening, triage, and professionalism, using a 36-item checklist. After each encounter, residents completed a questionnaire to assess their ability to recognize knowledge deficits. Residents' mean scores were compared across training levels, between the 2 cases, and by SP gender. We conducted analysis of variance (ANOVA) tests to analyze mean performance differences across training levels and descriptive statistics to analyze self-assessment questionnaire results. RESULTS: Ninety-eight residents from 2 internal medicine programs completed the encounter and 53 completed the self-assessment questionnaire. Residents performed best on professionalism (0.92 ± 0.20, percentage of the maximal score) and triage (0.87 ± 0.17), and they scored lowest on posttraumatic stress disorder (0.52 ± 0.30) and military sexual trauma (0.33 ± 0.39). Few residents reported that they sought out training to enhance their knowledge and skills in the provision of services and support to military and veteran groups beyond their core curriculum. CONCLUSIONS: This study suggests that additional education and assessment in veteran-centered care may be needed, particularly in the areas of posttraumatic stress disorder and military sexual trauma.

Where Do Soldiers Really Come From? A Faculty Development Workshop on Veteran-Centered Care.

PROBLEM: Addressing the medical concerns of veterans in both civilian health care systems and the Veterans Affairs (VA) health care system, where staff are familiar with issues of military reintegration, remains difficult but is increasingly important. APPROACH: In 2013, the authors developed and implemented a faculty development workshop for practicing clinicians using the documentary Where Soldiers Come From. The workshop included topics on unconscious bias, the service member trajectory, health care disparities, and strategies for overcoming barriers to treating veterans with posttraumatic stress disorder and traumatic brain injury. The workshop engaged faculty in the following active-learning techniques: images in education; trigger video; critical thinking and reflective writing; think-pair-share; and large-group discussion. The workshop has been conducted at three locations with 46 health care professionals. OUTCOMES: Thirty-one of 37 (84%) participants who completed the workshop evaluation were VA employees. The evaluation results show 25/32 (78.1%) participants indicated the workshop activities changed their knowledge, attitudes, and/or skills; 22/34 (64.7%) stated they had a better understanding of how to develop a care plan for veterans; and 27/34 (79.4%) stated they gained a better understanding of how to prepare for issues around returning veterans. NEXT STEPS: To address the issue of veteran-centered care education more broadly, the authors have developed a massive open online course for health professionals, using most of the content from this workshop, which will be offered in spring 2016. Another important next step will be to deliver this workshop to and collect evaluation data from non-VA providers.