Longitudinality Matters: Qualitative Perspectives on a Longitudinal Clinical Experience in a Psychiatry Residency Training Program.

OBJECTIVE: Longitudinal models of clinical care and education can positively impact the patient and provider experience in terms of health outcomes, satisfaction, and motivation. While residency programs have seen an increase in primary care longitudinal clinical experiences (LCEs), defined as outpatient clinics in which patients are seen by residents over the course of their entire training, less is known about such opportunities in psychiatry residency programs. This qualitative study explores the impact of a longitudinal training model on psychiatric resident skill development, relationships in the clinical learning environment, and professional identity formation. METHODS: The authors conducted 24 semi-structured interviews of residents, graduates, and faculty in three well-established LCE clinics in a single, multi-site, academic psychiatry residency program. Transcripts were analyzed using inductive thematic analysis techniques. RESULTS: Themes were categorized into benefits and challenges. For benefits, themes included longitudinal relationships, improved feedback, near-peer teaching, early outpatient exposure, graduated independence, skill development, patient population expertise, and solidification of professional identity. For challenges, themes included system logistics, offsite panel management, and intermittent presence of junior trainees. CONCLUSION: Results suggest that overall, residents and faculty find the LCE a positive learning opportunity that has contributed to their professional development. LCEs do appear to have distinct challenges, largely logistical in nature, which can interfere with the favorability of residents' experiences. Developing strategies up front to minimize these logistical challenges will support the success of a longitudinal program.

Drainage Percutaneous Endoscopic Gastrostomy for Malignant Bowel Obstruction in Gastrointestinal Cancers: Prognosis and Implications for Timing of Palliative Intervention.

BACKGROUND: Malignant bowel obstruction (MBO) is a frequent complication in patients with advanced solid tumors. Palliative relief may be achieved by the use of a drainage percutaneous endoscopic gastrostomy (dPEG) tube, although optimal timing of placement remains unknown. OBJECTIVES: To determine median survival after diagnosis of MBO and dPEG placement, factors associated with worse survival in MBO, factors associated with receipt of dPEG, and association of timing of dPEG placement on survival. METHODS: This observational retrospective cohort study examined 439 patients with MBO on a gastrointestinal medical oncology inpatient service. Patients were characterized by age, gender, race, primary cancer type, length of stay, readmission, complications (aspiration pneumonia or bowel perforation), and receipt of dPEG. Select factors were analyzed to examine overall survival (OS) and dPEG placement. RESULTS: Median survival from diagnosis of first MBO was 2.5 months. Median survival after dPEG placement was 37 days. In univariate analysis, dPEG placement, complications, longer length of stay, and readmissions were significantly associated with worse OS. Receipt of dPEG was significantly associated with younger age, longer length of stay at first admission, and shorter interval to readmission. In patients who received dPEG, longer interval from MBO diagnosis to dPEG placement did not affect OS. CONCLUSION: We found that prognosis following diagnosis of MBO in patients with gastrointestinal malignancies remains poor. Our data suggest that timing of dPEG placement in MBO does not affect OS and, therefore, earlier intervention with this procedure may allow earlier and prolonged palliative relief.