Clinical Care of Patients with Neurocognitive Disorders: A Qualitative Study of the Psychiatric Residency Training Experience.

OBJECTIVE: Few data describe how general psychiatry residencies prepare trainees to care for individuals with neurocognitive disorders (NCDs), despite increasing recognition of the need for psychiatrists to provide care for the growing numbers of patients with NCD. This study aims to identify training needs and approaches, as the resident experience is one important perspective that can be added to others, such as milestones developed by expert educators. METHODS: The authors conducted three focus groups of third- and fourth-year general adult psychiatry residency trainees from three different training programs in May and June of 2021. Focus groups consisted of three to eight unique participants per group. Qualitative data analysis techniques derived in grounded theory were utilized to identify themes. RESULTS: Four main themes emerged from the focus groups: unique challenges of NCD care, intrinsic rewards of working with families, perceived gaps in educational experiences, and limited comfort in future practice. CONCLUSIONS: Participants expressed that aspects of NCD care were fundamentally different than care for other mental health conditions encountered in psychiatry residency. They found the progressive nature of the disease to be particularly challenging, and they also expressed challenges with clinical interviews and establishing rapport with individuals with NCDs. However, working with families was especially rewarding. Regardless of training program, participants expressed a need for additional longitudinal and diversified training opportunities to prepare them for future practice in this area.

"He Bore it Like a Scarlet Letter": Medical Student Reflections on Substance Use Disorders.

OBJECTIVE: Substance abuse in the context of the opioid crisis presents a major public health concern. Despite some evidence that medical students' attitudes towards substance use disorders worsen during medical school, very few studies have examined how students' early clinical experiences with substance use disorders shape their views of this clinical population. This study uses student reflective essays to explore these formative educational experiences. METHODS: Using content analysis, the authors analyzed a collection of 802 medical student reflective essays written during core clerkships (excluding Psychiatry), coding for ethical and professional themes as well as descriptions of substance use disorders. In addition to the qualitative identification of themes, the authors used chi-square analysis to determine which themes had statistically significant associations with substance use disorders. RESULTS: Fifty-three essays described patients with substance use disorders. The most common substances described were opioids (n = 25), alcohol (n = 18), and cocaine (n = 11). There were five themes statistically associated with substance use disorders (p < 0.05): (1) adequate treatment, (2) pain, (3) difficult patient, (4) jumping to conclusions, and (5) malingering. CONCLUSIONS: In the sample, students found the treatment of pain to be a significant ethical challenge related to substance use disorders. In considering a comprehensive educational plan, medical educators may need to consider educational venues outside of the Psychiatry clerkship to address substance use disorders.

Addicts and Admits: Metonymy in Medical Students' Reflective Writing.

Phenomenon: Metonymy refers to the substitution of the name of an attribute or adjunct for the name of the object or person being described. In medical contexts, this may involve referring to a person as a disease, body part, or other health-related noun. In this study, we explore the use of metonymy in medical students' reflective writing. Approach: Using content analysis, we identified all usages of metonymy in a sample of 802 medical student reflective essays. We analyzed them for associated themes and used the Fisher's exact test to compare frequencies of clinical ethics themes that occurred in the essays with metonymy to those without metonymy. Findings: Metonymy was used 60 times in the essays. The uses were grouped into thematic clusters of substance abuse (n = 27), illness (n = 9), body part (n = 4), clinical status (n = 6), reproductive health (n = 5), challenging clinical situations (n = 6), and other thoughts on patients as people (n = 3). Several ethical themes associated with essays using metonymy (p < .05): moral distress, substance abuse, adequate treatment, jumping to conclusions, awakening, and pain. Insights: Metonymy was relatively uncommon, and some students explicitly described the practice as dehumanizing to patients. Even so, metonymy did present in a variety of forms and was used most frequently to describe individuals with substance use disorders. Essays involving metonymy were more likely to describe a scenario that elicited moral distress in the students, which may indicate that metonymy occurs more frequently in some troubling situations.

Medical student reflections on geriatrics: Moral distress, empathy, ethics and end of life.

Medical students' early clinical encounters may influence their perceptions of geriatrics. This study examines reflective essays written by 3rd-year medical students on required clinical rotations. Using content analysis, the authors analyzed the essays' thematic content. The authors then used chi-squared analysis to compare themes with geriatric patients (age 60+) to themes with other age groups. One hundred twenty out of 802 essays described a geriatric patient. The most common geriatric themes were (1) death and dying, (2) decision making, (3) meaningful physician-patient interactions, (4) quality of care, and (5) professional development. Geriatric essays were more likely to discuss death/dying and risk-benefit themes and less likely to discuss abuse. Geriatric essays were more likely to describe students' moral distress. Geriatric essays with moral distress were more likely to include empathy themes compared to geriatric essays without moral distress. Geriatric patients may pose unique ethical challenges for early clinical students.

Religion and spirituality in psychiatric practice.

PURPOSE OF REVIEW: The role of religion and spirituality in psychiatric practice has long been a topic of discussion among mental health providers, patients, and faith communities. This review examines the recent findings in the literature that shape current dialogues on this topic and provide implications for patient care. RECENT FINDINGS: An increasing body of evidence correlates certain aspects of religion/spirituality with mental and physical health outcomes, and researchers continue to explore how and when psychiatrists should intervene in matters of faith. As this topic is inherently multidisciplinary, many encourage approaches that incorporate neurobiology, faith, and psychology for enhanced understanding of patient experience. Many also stress the importance of effective interpersonal communication between providers and patients, using a person-centered framework. In all of these dialogues, implications for patient care are highlighted. SUMMARY: The proper role of religion and spirituality in psychiatry continues as a matter of debate. However, current publications attempt to clarify issues that may lead to more evidence-based and empathic care in this area.

Older adults' preferences for religion/spirituality in treatment for anxiety and depression.

OBJECTIVES: To examine patient preferences for incorporating religion and/or spirituality into therapy for anxiety or depression and examine the relations between patient preferences and religious and spiritual coping styles, beliefs and behaviors. METHOD: Participants (66 adults, 55 years or older, from earlier studies of cognitive-behavioral therapy for late-life anxiety and/or depression in primary care) completed these measures by telephone or in-person: Geriatric Anxiety Inventory, Client Attitudes Toward Spirituality in Therapy, Patient Interview, Brief Religious Coping, Religious Problem Solving Scale, Santa Clara Strength of Religious Faith, and Brief Multidimensional Measure of Religiousness and Spirituality. Spearman's rank-order correlations and ordinal logistic regression examined religious/spiritual variables as predictors of preferences for inclusion of religion or spirituality into counseling. RESULTS: Most participants (77-83%) preferred including religion and/or spirituality in therapy for anxiety and depression. Participants who thought it was important to include religion or spirituality in therapy reported more positive religious-based coping, greater strength of religious faith, and greater collaborative and less self-directed problem-solving styles than participants who did not think it was important. CONCLUSION: For individuals like most participants in this study (Christians), incorporating spirituality/religion into counseling for anxiety and depression was desirable.