Psychiatry Residency Directors' Attitudes Toward and Uses of the Medical Student Performance Evaluation and Other Potential Tools for Residency Selection.

OBJECTIVE: A survey was conducted to determine US psychiatry residency directors' attitudes regarding current measures of medical student performance and their preferences for the future. METHODS: A team of psychiatry medical student educators and residency program directors developed a 23-question survey. In July 2021, links to the survey were sent out to all program directors registered with the American Association of Directors of Psychiatric Residency Training. RESULTS: Seventy program directors out of 223 initiated the survey, resulting in a response rate of 31.4%. Forty percent of respondents reported that the most important use of the Medical Student Performance Evaluation (MSPE) is in screening out applicants for interviews, and only 26.1% reported that the MSPE in its current form could be trusted to provide a valid and reliable assessment of a student's medical school performance. Most respondents agreed that in the absence of United States Medical Licensing Examination (USMLE) step 1 numerical scores, the existing MSPE format/content requirements should be modified, use a set of ranking categories that are uniform across all medical schools, and be supplemented with additional measures of the student's character and ability specific to psychiatry. CONCLUSIONS: US psychiatry program directors are eager for change when it comes to the MSPE and how it reports rankings, grades, and professionalism. The transition of the USMLE step 1 score reporting to pass/fail presents an opportunity to pursue this change and for stakeholders from all medical specialties to work together toward a shared goal of an improved residency selection process.

Aligning Medical Student Workplace-Based Assessments with Entrustable Professional Activities and the RIME Model in a Psychiatry Clerkship.

OBJECTIVE: The authors piloted use of workplace-based assessments of students during the psychiatry clerkship utilizing both entrustable professional activities (EPAs) and the reporter, interpreter, manager, and educator (RIME) model. METHODS: After supervising clinicians conducted assessments of medical students (N=109) during the psychiatry clerkship using a supervisory scale aligned with both EPA and RIME models, each student received individualized formative feedback. Students were then surveyed on the usefulness of this feedback, and participating faculty/residents were surveyed on the ease of completion of the supervisory scale. RESULTS: Students' mean skill profile suggested they no longer needed direct supervision on EPA1 and EPA6. Mean scores on other studied EPAs suggested students were well on their way toward performing these EPAs without direct supervision. Students had mean RIME scores that exceeded the suggested levels identified for a Reporter to start clerkships, for an Interpreter to start clerkships, and for a Manager to transition to the fourth year. Close to half of the students found the feedback helpful in their development as a clinician but most felt their performance should not be shared with residency program directors, either before or after the Match. Almost all responding preceptors felt the supervisory ratings were easy to complete. CONCLUSIONS: This pilot RIME/EPA framework served as a successful step toward a more competency-based medical education in the psychiatry clerkship with relatively little additional faculty time commitment by using workplace-based assessments already in place and a supervisory scale based on EPAs and RIME.

Objective Structured Clinical Examination Skill Station Is Effective for Assessing Acute Opioid Overdose Resuscitation.

Introduction In recent decades, deaths related to heroin, illicit fentanyl, and prescription opioids have risen in the United States. Utilizing new clinical guidelines and non-prescription naloxone, we aimed to develop a competency-based assessment for clinical skills in opioid overdose resuscitation outside of the hospital setting. Methods An assessment of opioid resuscitation skills, consisting of an Objective Structured Clinical Examination (OSCE) skill station-utilizing a simulation mannequin and a standardized patient portraying the patient's relative-followed by a facilitated individual debrief, was added to the fourth year Psychiatry Boot Camp for students entering a psychiatry residency. A survey was given to students to assess the OSCE's believability, value, and impact on confidence in managing out-of-hospital overdose. Results Following the OSCE, 2017-2019 graduating students entering a psychiatry residency (N=10) all agreed or strongly agreed that the OSCE "was realistic and believable" and "was valuable as an educational tool. Most either agreed (N=7) or strongly agreed (N=1) they felt confident of their skill in managing out-of-hospital opioid overdose. A small number (n=2) were neutral in the confidence of their skill in managing out-of-hospital opioid overdose. Discussion Based on early medical student feedback (n=10), this OSCE skill station provides a promising competency-based assessment for opioid overdose resuscitation outside of the hospital setting. Its use could be expanded to other medical disciplines in undergraduate and graduate education.

Assessing Entrustable Professional Activities During the Psychiatry Clerkship.

OBJECTIVE: Within 10 years, the Association of American Medical Colleges envisions graduating medical students will be entrusted by their school to perform 13 core entrustable professional activities (EPAs) without direct supervision. The authors focused on eight EPAs that appear most relevant to clinical training during the psychiatry clerkship at their institution to evaluate whether students assess themselves as making progress in EPAs during this clerkship, to see how students' self-assessments compare with the clerkship director's assessments, and to see if weaknesses in the curriculum were found. METHODS: An EPA-assessment scale was designed (ratings 1 to 5) to assess progress toward entrustment in each EPA. Medical students completed pre- and post-psychiatry clerkship self-assessments. The clerkship director independently assessed each student's progress in EPAs utilizing assessment methods already present in the curriculum. RESULTS: Seventy of 116 students (60.3%) completed both pre- and post-clerkship self-assessments. These ratings increased significantly from pre- to post-clerkship, representing large effect sizes from 0.83 to 1.13. The largest mean rating increase was observed for EPA 2, Prioritize a differential diagnosis following a clinical encounter. Mean post-clerkship self-assessment ratings were significantly higher than mean post-clerkship instructor ratings for seven of the eight EPAs. CONCLUSIONS: The results suggest training during the psychiatry clerkship can contribute to the professional development of medical students in the eight EPAs studied but that student self-assessments tend to be higher than those of the clerkship director. Further study is needed of the relative value and role of student self-assessments versus faculty assessments of progress in EPAs.

Opioid Risk Mitigation Strategies and Overdose Resuscitation.

INTRODUCTION: In the context of an opioid public health crisis, U.S. medical schools have been called upon to strengthen curricula on the appropriate use of opioids, with an emphasis on maximizing benefits while utilizing risk-mitigation strategies to prevent addiction and overdose. METHODS: This self-contained module provides an overview of the opioid crisis and presents recent clinical guidelines on opioid risk mitigation, as well as information regarding prevention and treatment of opioid overdose. This module then gives learners the opportunity to practice these skills by solving an evolving case of back pain. RESULTS: Verbal and written feedback on the module from students revealed that the majority strongly agreed that, overall, the module was valuable as an educational tool. DISCUSSION: This module was created to help medical educators update the training of students in risk mitigation strategies and the steps of opioid overdose resuscitation. The feedback to date from students and faculty has been positive and supports its use in undergraduate medical education.

Outcomes of the first 2 American hand transplants at 8 and 6 years posttransplant.

PURPOSE: The feasibility of hand allotransplantation has been demonstrated. The purpose of the article is to report the (1) functional return, (2) psychosocial outcomes, (3) clinical and histological assessment for rejection, (4) complications, and (5) graft survival in the 2 American hand transplant recipients. METHODS: We present 2 patients 106 and 81 months, respectively, after unilateral transplantation of an allogeneic hand and forearm. We analyzed clinical course, number of rejection episodes, adverse events, function of the allograft, and quality of life. Clinical laboratory results, biopsy histology, and patient clinical examinations were used to compare the clinical course. Standard hand function tests were used to evaluate function. Psychological interviews were used to assess acceptance and quality of life. RESULTS: Our patients have allograft survival with improvements in intrinsic muscle activity, total active motion and return of functional grip, pinch strength, and sensibility. Rejection episodes were restricted primarily to the first 6 months after transplantation, and all responded to treatment. The major posttransplantation complications were a cytomegalovirus infection in patient 1 and osteonecrosis of the hip requiring both hips to be replaced, 1 at year 4 and the other at year 6, as well as transient immunosuppression-related diabetes in patient 2. Recently we have weaned both patients off maintenance steroids. Current Carroll scores are fair for patient 1 (72/99) and fair for patient 2 (55/99), although patient 2 has not had good recovery of intrinsic function. Both patients are back at work and report an excellent quality of life at nearly 9 and 7 years, respectively, after transplantation. CONCLUSIONS: Our intermediate long-term results of hand transplants have demonstrated functional return similar to that of replants. Graft survival and quality of life after hand transplantation has far exceeded initial expectations. We conclude that allogeneic hand transplant is feasible and holds promise as a treatment modality for catastrophic upper extremity loss. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Combining ECT and Antipsychotic Agents: Benefits and Risks.

A comprehensive review describes the benefits and risks of the combination of electroconvulsive therapy (ECT) and antipsychotic agents for patients with psychotic disorders. For some patients, combined treatment may lead to greater rates of response or more rapid improvement than with either therapy alone. Except for reserpine, combining neuroleptics with ECT is safe, but some precautions are suggested. The mechanism of interaction, effect on seizure threshold, the use of ECT for neuroleptic associated motor effects, and additional anesthesia considerations are discussed.

Clozapine, ECT, and Schizoaffective Disorder, Bipolar Type.

Opinions differ regarding the risks and benefits of the concurrent use of antipsychotic medication and ECT. A case example is presented of the safe and effective concurrent use of ECT and the newly available neuroleptic clozapine in a young patient with schizoaffective disorder, bipolar type. The patient's pulse did climb as high as 170-180 beats/min during a few of the seizures. More experience is needed with the combined use of clozapine and ECT.