The Role of Specialty Certification in Career-Long Competence.

Across the medical profession there is broad acceptance of the critical role of continuing medical education (CME) in enabling physicians to adapt to both new information and evolving expectations within the profession. In the presence of widespread participation in CME, some have attempted to question, discredit, or marginalize the role of ongoing lifelong assessment of physician knowledge and skills through specialty continuing certification, advocating instead for a participatory standard based only on engagement with CME. This essay outlines the limitations of physician self-evaluation and clarifies the need for external assessments. Certification boards' role is to set specialty-specific standards for competence, assess to those standards, and assure the public that certified physicians are adequately maintaining their skills and abilities; doing so credibly necessarily requires, in part, independent assessments of physician competence. In these contexts, the specialty boards are taking approaches to identify performance gaps and leverage intrinsic motivation to facilitate physician engagement in targeted learning. Specialty board continuing certification plays a unique role, distinct from and complementary to the CME enterprise. Calls to eliminate continuing certification requirements beyond self-directed CME are contradictory to the evidence and fail the profession and the public.

Institutional Variability in Representation of Women and Racial and Ethnic Minority Groups Among Medical School Faculty.

Importance: Bolstering the ranks of women and underrepresented groups in medicine (URM) among medical faculty can help address ongoing health care disparities and therefore constitutes a critical public health need. There are increasing proportions of URM faculty, but comparisons of these changes with shifts in regional populations are lacking. Objective: To quantify the representation of women and URM and assess changes and variability in representation by individual US medical schools. Design, Setting, and Participants: This retrospective cross-sectional study assessed US medical school faculty rosters for women and URM, including American Indian and Alaska Native, Black, Hispanic, and Native Hawaiian or other Pacific Islander faculty. US allopathic medical schools participating in the Association of American Medical Colleges (AAMC) Faculty Administrative Management Online User System from 1990 to 2019 (updated December 31 for each year), were included. Faculty data were analyzed from yearly cross-sections updated as of December 31 for each year from 1990 to 2019. For census data, decennial census data were used for years 1990, 2000, and 2010. Intercensal estimates were used for all other years from 1990 to 2019. Main Outcomes and Measures: Trends and variability in representation quotient (RQ), defined as representation of a group within an institution's faculty compared to its respective US county. Results: There were 121 AAMC member institutions (72 076 faculty) in 1990, which increased to 144 institutions (184 577 faculty) in 2019. The median RQ of women faculty increased from 0.42 (IQR, 0.37-0.46) to 0.80 (IQR, 0.74-0.89) (slope, +1.4% per year; P < .001). The median RQ of Black faculty increased from 0.10 (IQR, 0.06-0.22) to 0.22 (IQR, 0.14-0.41) (slope, +0.5% per year; P < .001), but remained low. In contrast, the median RQ of Hispanic faculty decreased from 0.44 (IQR, 0.19-1.22) to 0.34 (IQR, 0.23-0.62) (slope, -1.7% per year; P < .001) between 1990 and 2019. Absolute total change in RQ of URM showed an increase; however, the 30-year slope did not differ from zero (+0.1% per year; P = .052). Although RQ of women faculty increased for most institutions (127 [88.2%]), large variability in URM faculty trends were observed (57 institutions [39.6%] with increased RQ and 10 institutions [6.9%] with decreased RQ). Nearly one-quarter of institutions shifted from the top to bottom 50th percentile institutional ranking by URM RQ with county vs national comparisons. Conclusions and Relevance: The findings of this cross-sectional study suggest that representation of women in academic medicine improved with time, while URM overall experienced only modest increases with wide variability across institutions. Among URM, the Hispanic population has lost representational ground. County-based population comparisons provide new insights into institutional variation in representation among medical school faculty.

Advancing Equity in Academic Medicine Through Holistic Review for Faculty Recruitment and Retention.

The Association of American Medical Colleges (AAMC) in 2007 developed the Holistic Review Framework for medical school admissions to increase mission-aligned student diversity. This approach balances an applicant's experiences, attributes, and metrics during the screening, interview, and selection processes. Faculty recruitment provides its own set of challenges, and there is persistent underrepresentation of certain racial and ethnic minority groups and women in faculty and leadership positions in U.S. academic health centers (AHCs). In 2019, the AAMC initiated a pilot program to adapt and implement the framework for use in faculty recruitment at AHCs. In this Invited Commentary, the authors describe the pilot implementation of the Holistic Review Framework for Faculty Recruitment and Retention and share lessons learned to date. Although the pilot proceeded during 2020, institutional implementation was impacted by the COVID-19 pandemic and racial justice movement. Pilot institutions encountered hiring freezes, reductions in funding, and restrictions on in-person meetings due to COVID-19 that resulted in both barriers and opportunities in implementing the framework. Renewed commitment to racial justice was associated with increased momentum and urgency for the implementation of faculty holistic review at the majority of pilot institutions. Common themes from the pilot leads' experiences included the importance of achieving "buy in," having a dedicated implementation team, and being explicit about core values. Other themes included the importance of adaptability and flexibility to meet the needs of different institutions and mission areas. The faculty holistic review framework has shown promise as an approach to advancing faculty diversity goals. The pilot institutions will continue to share best practices, track outcomes, implement quality improvement, and disseminate findings to assist other institutions and health care communities with their endeavors to recruit and retain diverse faculty.

The DSM-5 Clinical and Public Health Committee (CPHC): operations, mechanics, controversies and recommendations.

BACKGROUND: For DSM - 5, the American Psychiatric Association Board of Trustees established a robust vetting and review process that included two review committees that did not exist in the development of prior DSMs, the Scientific Review Committee (SRC) and the Clinical and Public Health Committee (CPHC). The CPHC was created as a body that could independently review the clinical and public health merits of various proposals that would fall outside of the strictly defined scientific process. METHODS: This article describes the principles and issues which led to the creation of the CPHC, the composition and vetting of the committee, and the processes developed by the committee - including the use of external reviewers. RESULTS: Outcomes of some of the more involved CPHC deliberations, specifically, decisions concerning elements of diagnoses for major depressive disorder, autism spectrum disorder, catatonia, and substance use disorders, are described. The Committee's extensive reviews and its recommendations regarding Personality Disorders are also discussed. CONCLUSIONS: On the basis of our experiences, the CPHC membership unanimously believes that external review processes to evaluate and respond to Work Group proposals is essential for future DSM efforts. The Committee also recommends that separate SRC and CPHC committees be appointed to assess proposals for scientific merit and for clinical and public health utility and impact.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia.

(Reprinted with permission from The American Journal of Psychiatry 2020; 177:868-872).

Association of depressive symptoms with health status and markers of uncontrolled severe asthma.

Background: There are limited data that describe the association between markers of asthma control and depressive symptoms in severe asthma. Objective: To evaluate the association between depressive symptoms and markers of asthma control in patients with uncontrolled severe eosinophilic asthma. Methods: Baseline data from the MENSA and SIRIUS studies (N = 681) of mepolizumab intervention in severe eosinophilic asthma was used. We analyzed the relationships between depressive symptom severity by using the Beck Depression Inventory (BDI-II) and quality of life by using the St. George's Respiratory Questionnaire (SGRQ), asthma control questionnaire-5 (ACQ-5), polypharmacy, and sleep symptoms. Results: When compared with patients with less severe depressive symptoms, patients with more severe depressive symptoms were predominantly female (81% versus 54%), had a higher mean body mass index (30.56 versus 27.67 kg/m²), were more likely to have a blood eosinophil count of ≥300 cells/uL within the previous 12 months (81% versus 68%), and to have experienced a near-fatal asthma event (16% versus 7%). The mean SGRQ score was higher in the severe BDI-II category compared with the minimal depressive symptoms category, which indicated a worse quality of life (71.6 versus 41.4, p < 0.001). Eighty-nine percent of the patients in the severe BDI-II category had poorly controlled asthma (ACQ-5 score ≥ 1.5) compared with 63% in the minimal category (p < 0.001). Conclusion: Increased severity of depressive symptoms was associated with worse respiratory-related quality of life and asthma control in the patients with severe eosinophilic asthma. These findings highlight the need for a multidimensional approach for the management of uncontrolled asthma, including timely identification of depressive symptoms. Additional research is needed to further explore the interactions between the two common conditions.Clinical trials NCT01691521 and NCT01619508, www.clinicaltrials.gov.

Health risk prediction models incorporating personality data: Motivation, challenges, and illustration.

The age of "big data" in health has ushered in an era of prediction models promising to forecast individual health events. Although many models focus on enhancing the predictive power of medical risk factors with genomic data, a recent proposal is to augment traditional health predictors with psychosocial data, such as personality measures. In this article we provide a general overview of the medical risk prediction models and then discuss the rationale for integrating personality data. We suggest three principles that should guide work in this area if personality data is ultimately to be useful within risk prediction as it is actually practiced in the health care system. These include (a) prediction of specific, priority health outcomes; (b) sufficient incremental validity beyond established biomedical risk factors; and (c) technically responsible model-building that does not overfit the data. We then illustrate the application of these principles in the development of a personality-augmented prediction model for the occurrence of mild cognitive impairment, designed for a primary care setting. We evaluate the results, drawing conclusions for the direction an iterative, programmatic approach would need to take to eventually achieve clinical utility. Although there is great potential for personality measurement to play a key role in the coming era of risk prediction models, the final section reviews the many challenges that must be faced in real-world implementation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Primary Care and Neurology in Psychiatry Residency Training: a Survey of Early Career Psychiatrists.

OBJECTIVE: A survey of recently certified psychiatrists was conducted to obtain their feedback about the contribution of the primary care and neurology components of residency training to their professional development and to their current needs as practitioners. METHODS: A 22-item survey was developed based on issues discussed at a forum on residency competence requirements and administered electronically to four cohorts of recently certified psychiatrists. RESULTS: The response rate was 17% (1049/6083). Overall, the respondents described both their primary care and neurology experiences as helping them accomplish several goals for their professional development. The majority were satisfied with their primary care training and felt well-prepared to enter practice. The most common suggestions for improving the primary care component were better integration with psychiatry and providing longitudinal experiences and more outpatient experience. They were somewhat less satisfied with their neurology training, and only about half felt well-prepared for the neurologic aspects of psychiatry practice. The most common suggestions for improving neurology training were to provide more time in neurology with experiences that were more relevant to psychiatry such as outpatient and consultation experiences. Some also thought longitudinal experiences would be useful. CONCLUSIONS: These psychiatrists were generally satisfied with the primary care and neurology components of residency training and felt that they had contributed to their professional development. Their suggestions for improvement contribute to the rich discussion among training directors and other psychiatry educators about these components of residency training.

Advanced Research Institute (ARI): An Effective Model for Career Development and Transition to Independence.

The vitality of geriatric mental health research requires an ongoing infusion of new investigators into the career pipeline. This report examines outcomes of the NIMH-funded, Advanced Research Institute (ARI) in Geriatric Mental Health, a national mentoring program supporting the transition of early career researchers to independent investigators. Outcome data for 119 ARI Scholars were obtained from the NIH Reporter database, CVs, and PubMed: 95.0% continue in research, 80.7% had obtained federal grants, and 45.4% had achieved an NIH R01. Among all NIMH mentored K awardees initially funded 2002-2014 (n=901), 60.4% (32/53) of ARI participants vs. 42.0% (356/848) of nonparticipants obtained an R01. Controlling for funding year, ARI participants were 1.9 times more likely to achieve R01 funding than nonparticipants. These data suggest that ARI has helped new generations of researchers to achieve independent funding, become scientific leaders, and conduct high impact research contributing to public health and patient care.

Vignettes and Viewpoints From a Professional Autobiography.

In this professional autobiography, the author describes factors contributing to important decisions in his academic geriatric psychiatry career. Major inflection points included embarking on clinical research and later deciding to focus more on leadership roles in education and in faculty affairs. The discussion then examines themes that have emerged in reviewing this career arc, including the value of: the variety and social connectedness inherent in the academic life; cultivation of interpersonal relationships and best efforts as much as possible; an open mind ready to (collegially) seize new opportunities; and family, friends, and avocational pursuits as complements to one's profession. The author hopes that this public life review is of help to others planning or reflecting on their own career paths. .

WITHDRAWN: Author's Response.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Lessons From the Lives of Celebrated Musicians: What Armstrong, Cash, Dylan, Ellington, Fitzgerald, and Sinatra Can Teach Us About Creative Resilience and Aging.

For a decade the author has delivered presentations using techniques from the humanities, principally biography, to elucidate themes of creative resilience and aging in the lives of well-known musicians, illustrated with excerpted images, audio clips, and videos. The goal has been to stimulate discussions about the potential for creative growth in later years, even in the face of the professional and personal setbacks inevitable in the course of life, with implications for clinical work with older adults and for ourselves as we age. This summary describes key take-home points that have recurred across these varied artists' stories and the interactions they have sparked with audiences and colleagues.

Assessing future care preparation in late life: Two short measures.

The purpose of this article is to introduce 2 short forms of the previously published measure of preparation for future care (PFC). Community-dwelling older adults ages 65-94 who had completed the 29-item Preparation for Future Care Needs scale were randomly divided into scale development (n = 697) and scale validation (n = 690) samples. Fifteen items were selected using exploratory and confirmatory factor analyses on the scale development and scale validation samples, respectively. Consistent with PFC theory, the 5 subscales of the original long-form measure (Awareness, Gathering Information, Decision Making, Concrete Planning, Avoidance of Care Planning) were maintained. A 5-item scale with acceptable score reliability and validity was also developed. Compared to the long form, these short forms are more easily incorporated into epidemiologic studies and can be used in medical, psychology, and social work practice to initiate discussions about long-term care planning. (PsycINFO Database Record

Subspecialty Training and Certification in Geriatric Psychiatry: A 25-Year Overview.

The Institute of Medicine estimated that by 2030, from 10.1 to 14.4 million Americans aged 65 years or older will have mental health or substance use disorders. This article reviews the history and current status of training, certification, and practice in geriatric psychiatry against the backdrop of this "silver tsunami." The American Board of Psychiatry and Neurology (ABPN) administered the first subspecialty examination in geriatric psychiatry in 1991, and through 2015 3,329 certificates were awarded. The Accreditation Council for Graduate Medical Education approved the training requirements in 1993. After a surge in programs and fellows, the numbers appear to have stabilized at about 57 programs and 60-65 trainees per year with fewer than half of the positions filled each year. The majority of graduates seeks and obtains ABPN certification, and the majority of those who were fellowship trained have maintained certification. Despite the unprecedented demand for mental health services for older adults, it must be acknowledged that not enough geriatric psychiatrists can be prepared to meet the needs of an aging U.S. POPULATION: Strategies for addressing the shortage are discussed, including undertaking subspecialty training in the fourth year of psychiatry training, increasing the time devoted to the care of older adults in undergraduate and graduate medical education, and developing alternative training pathways such as mini-fellowships. It is not clear whether more favorable Medicare reimbursement rates for those certified in geriatric psychiatry would increase the numbers seeking fellowship training.

Does formal mentoring for faculty members matter? A survey of clinical faculty members.

BACKGROUND: Mentoring relationships, for all medical school faculty members, are an important component of lifelong development and education, yet an understanding of mentoring among medical school clinical faculty members is incomplete. This study examined associations between formal mentoring relationships and aspects of faculty members' engagement and satisfaction. It then explored the variability of these associations across subgroups of clinical faculty members to understand the status of mentoring and outcomes of mentoring relationships. The authors hypothesised that academic clinical faculty members currently in formal mentoring relationships experience enhanced employee engagement and satisfaction with their department and institution. METHODS: Medical school faculty members at 26 self-selected USA institutions participated in the 2011-2014 Faculty Forward Engagement Survey. Responses from clinical faculty members were analysed for relationships between mentoring status and perceptions of engagement by faculty members. RESULTS: Of the 11 953 clinical faculty respondents, almost one-third reported having a formal mentoring relationship (30%; 3529). Most mentored faculty indicated the relationship was important (86%; n = 3027), and over three-fourths were satisfied with their mentoring experience (77%; n = 2722). Mentored faculty members across ranks reported significantly higher levels of satisfaction and more positive perceptions of their roles in the organisation. Faculty members who were not receiving mentoring reported significantly less satisfaction with their workplace environment and lower overall satisfaction. CONCLUSIONS: Mentored clinical faculty members have significantly greater satisfaction with their department and institution. This multi-institutional study provides evidence that fostering mentoring opportunities may facilitate faculty members' satisfaction and engagement, which, in turn, may help medical schools retain high-quality faculty staff committed to the multidimensional academic mission.

Trait Hope and Preparation for Future Care Needs among Older Adult Primary Care Patients.

We examined associations between trait hope and preparation for future care needs (PFCN) among 66 older adult primary care patients in western New York. Participants completed a questionnaire assessing PFCN (awareness, information gathering, decision-making, concrete planning, and avoidance), and the Adult Trait Hope Scale. In multivariate regressions, lower hope, particularly less agency, was associated with more awareness of needing care, whereas higher hopefulness, particularly pathways thinking, was associated with increased decision-making and concrete planning. Greater hopefulness appears to be linked to goal-directed planning behaviors, although those with lower hope may actually be more aware of the need for planning. Evidence-based programming that encourages learned hopefulness may contribute to enhanced health planning and decision-making among older adult primary care patients.

Circulating endocannabinoids during hematopoietic stem cell transplantation: A pilot study.

OBJECTIVE: Hematopoietic stem cell transplantation (HCT) is a stressful and rigorous medical procedure involving significant emotional and immune challenges. The endocannabinoid (eCB) signaling system is involved in regulation of both the immune system and emotional reactivity, yet little is known about its function during HCT. We investigated the role of the eCB signaling system in a group of HCT recipients. METHODS: A total of 19 HCT recipients were enrolled and provided psychosocial data and blood samples at three peri-transplant time points: prior to transplant, hospital discharge, and approximately 100 days post-transplant. Psychosocial factors, inflammatory molecules, and the eCBs were determined and assessed for changes over this period and association with each other. RESULTS: HCT recipients demonstrated significant changes over the peri- transplant period in inflammatory molecules and psychosocial functioning, but not in circulating concentrations of the eCBs. Associations among these variables were most likely to be present pre-transplant and least likely to be present immediately post-transplant, with depressive symptoms and inflammation most significantly associated. The eCB 2-arachidonoylglycerol (2-AG) was significantly, positively associated with both interleukin (IL)-6 and C-reactive protein (CRP) and negatively associated with depressive symptoms. CONCLUSIONS: The eCB signaling system may have alternative sources and regulatory mechanisms in addition to the immune system. Given the significant associations with inflammatory molecules and depressive symptoms in the peri- transplant period, it is important to better understand this system and its potential implications in the setting of complex and stressful medical procedures such as HCT.