An Article-Based Format for Medical Specialty and Subspecialty Maintenance of Certification.

INTRODUCTION: This article describes an article-based alternative for maintenance of certification that the American Board of Psychiatry and Neurology developed and began pilot testing in 2019. The rationale for and components of the pilot program are presented along with data on participant performance and feedback from the first year of implementation in three primary specialties (neurology, child neurology, and psychiatry) and one subspecialty (child and adolescent psychiatry). METHODS: Evaluation of the pilot program was guided by a widely used validity framework. Data were collected that addressed the five categories of validity evidence: content, response process, internal structure, relation to other variables, and consequences. RESULTS: Enrollment ranged from 66.7% for psychiatrists to 75.3% for child neurologists. For the 2019 cohort, the pass rates ranged from 92.6% for child and adolescent psychiatry to 98.7% for neurology, and very small numbers of diplomates failed or did not complete the process. For psychiatrists, there was a modest, but significant, relationship between performance on previous and subsequent maintenance of certification examinations. Ninety percent or more agreed that: the articles were easy to access and helpful to their practices; the mini-tests were a fair assessment of their understanding of the articles; and their test-taking experience was satisfactory. DISCUSSION: Most eligible diplomates participated in the article-based pilot project, and they strongly preferred this format to the traditional multiple-choice examinations. Most important, the pilot was perceived to be a meaningful and relevant learning activity that had a positive effect on patient care.

Make a Joyful Noise: Integrating Music into Child Psychiatry Evaluation and Treatment.

Music is a significant part of daily life for most youth, affording clinical opportunities to cultivate positive emotions, engagement, relationships, meaning, and accomplishment. Clinical inquiry into what types of music elicit different emotions, how music fits into daily life routines, how music connects one to others, and how music anchors life events can improve the clinician-patient alliance and patient well-being practices. Music may be useful in home and school settings to help youth manage diverse moods. Practicing an instrument effectively accelerates accomplishment and pleasure, which applies to other life activities.

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.

Does Acute Propranolol Treatment Prevent Posttraumatic Stress Disorder, Anxiety, and Depression in Children with Burns?

OBJECTIVE: This study examined whether acute propranolol treatment prevented posttraumatic stress disorder (PTSD), anxiety, and depression in children hospitalized in the pediatric intensive care unit for large burns. We hypothesized that the prevalence of PTSD, anxiety, and depression would be significantly less in the propranolol than nonpropranolol groups. METHODS: Children who had previously participated in a randomized controlled clinical trial of acute propranolol and nonpropranolol controls were invited to participate in long-term follow-up interviews. Eligible participants from 1997 to 2008 were identified from the electronic medical records, and data were collected in 2010-2011. Measures included the Missouri Assessment of Genetics Interview for Children to assess lifetime PTSD, Revised Children's Manifest Anxiety Scale to assess anxiety, and two depression inventories Children's Depression Inventory and Beck Depression Inventory-II. RESULTS: Of 202 participants, 89 were in the propranolol group and 113 were nonpropranolol controls. Children were an average of 7 years postburn. The average total body surface area burned was 56.4 + 15.1% (range = 24%-99%). The mean dose of propranolol was 3.64 ± 3.19 mg/kg per day (range = 0.36-12.12). The duration of propranolol inpatient treatment days varied, mean days 26.5 ± 19.8. The prevalence of lifetime PTSD in the propranolol group was 3.5% and controls 7.2%, but this difference was not statistically significant. We controlled for administration of pain medications, anxiolytics, and antidepressants overall and no significant differences were detected in the rates of PTSD, anxiety, or depression. CONCLUSIONS: The prevalence of PTSD, anxiety, and depression was similar in children who received propranolol acutely and those who did not. This may be influenced by the standard of care that all children received timely pharmacotherapy for pain and anxiety management and psychotherapy beginning in their acute phase of treatment.

Navigating the Perfect Storm: Ethical Guidance for Conducting Research Involving Participants with Multiple Vulnerabilities.

The development of ethical guidelines and regulations regarding human subjects research has focused upon protection of vulnerable populations by relying on a categorical approach to vulnerability. This results in several challenges: First, Institutional Review Boards (IRBs) struggle to interpret and apply the regulations because they are often vague and inconsistent. Second, applying the regulations to subjects who fit within multiple categories of vulnerability can lead to contradictions and the rejection of research that would be permissible if only one category were applicable. Finally, some potential subjects have social and other context-based vulnerabilities that are not described in the federal regulations and therefore not considered in IRB deliberations. IRBs and investigators lack guidance on how to address the problem of multiple vulnerabilities in a way that strikes a balance between protection and respect for persons. In this essay, we evaluate the acceptability of the existing federal regulations with respect to research participants with multiple vulnerabilities, offer strategies for rethinking the concept of vulnerability, and outline a context-based normative framework to account for the compounding effects of multiple vulnerabilities.

The Road Ahead in Education: Milestones for Geriatric Psychiatry Subspecialty Training.

OBJECTIVE: The Accreditation Council of Graduate Medical Education (ACGME) Milestone Project is the next step in a series of changes revamping the system of graduate medical education. In 2013 the ACGME completed the general psychiatry milestones. The ACGME then pursued creation of milestones for accredited psychiatric subspecialty fellowships. This article documents the work of the geriatric psychiatry subspecialty milestones work group. It reports the history and rationale supporting the milestones, the milestone development process, and the implications for geriatric psychiatry fellowship training. METHODS: In consultation with the American Association for Geriatric Psychiatry, the American Board of Psychiatry and Neurology, and the ACGME Psychiatry Residency Review Committee, the ACGME appointed a working group to create the geriatric psychiatry milestones using the general psychiatry milestones as a guide. CONCLUSION: The geriatric psychiatry milestones are the result of an iterative process resulting in the definition of the characteristics vital to a fellowship-trained geriatric psychiatrist. It is premature to assess their effect on psychiatric training. The true impact of the milestones will be determined as each training director uses the milestones to re-evaluate their program curriculum and the educational and clinical learning environment. The ACGME is currently collecting the information about the milestone performance of residents and fellows to further refine and determine how the milestones can best be used to assist programs in improving training.

Epigenetics and Child Psychiatry: Ethical and Legal Issues.

Epigenetics has the potential to revolutionize diagnosis and treatment in psychiatry, especially child psychiatry, as it may offer the opportunity for early detection and prevention, as well as development of new treatments. As with the previous introduction of genetic research in psychiatry, there is also the problem of unrealistic expectations and new legal and ethical problems. This article reviews the potential contributions and problems of epigenetic research in child psychiatry. Previous legal and ethical issues in genetic research serve as a guide to those in epigenetic research. Recommendations for safeguards and guidelines on the use of epigenetics with children and adolescents are outlined based on the identified issues.

The milestones for psychosomatic medicine subspecialty training.

BACKGROUND: The Accreditation Council of Graduate Medical Education Milestones project is a key element in the Next Accreditation System for graduate medical education. On completing the general psychiatry milestones in 2013, the Accreditation Council of Graduate Medical Education began the process of creating milestones for the accredited psychiatric subspecialties. METHODS: With consultation from the Academy of Psychosomatic Medicine, the Accreditation Council of Graduate Medical Education appointed a working group to create the psychosomatic medicine milestones, using the general psychiatry milestones as a starting point. RESULTS: This article represents a record of the work of this committee. It describes the history and rationale behind the milestones, the development process used by the working group, and the implications of these milestones on psychosomatic medicine fellowship training. CONCLUSIONS: The milestones, as presented in this article, will have an important influence on psychosomatic medicine training programs. The implications of these include changes in how fellowship programs will be reviewed and accredited by the Accreditation Council of Graduate Medical Education and changes in the process of assessment and feedback for fellows.

Introduction and commentary on the psychiatry milestones.

OBJECTIVE: The Psychiatry Milestones are a major change in the accreditation of residency training and evaluation of residents and programs. This introduction provides an overview of the papers in this issue describing the Psychiatry Milestones and a commentary on the process of their development. METHODS: The author describes the challenges and experiences in creating the Psychiatry Milestones as a member of the Working Group and Advisory Group. RESULTS: While there were many potential obstacles in development, the Psychiatry Milestones were created due to the efforts of all those involved. CONCLUSION: The inclusive and participatory process was successful and serves as a model for the implementation and further development of the Psychiatry Milestones.

Phase II trial of adjuvant oral thalidomide following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface disease from colorectal/appendiceal cancer.

PURPOSE: This phase II single-institution trial of adjuvant thalidomide after cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with appendiceal and colorectal malignancies sought to detect an improvement in progression-free survival (PFS) from 7 to 12 months. METHODS: Eligible patients received CS, HIPEC, and baseline imaging, followed by pretreatment thalidomide counseling. All participants were then started on a 28-day regimen of thalidomide, 100 mg by mouth at bedtime, followed by 200 mg for 4 weeks, followed by 300 mg as the final maintenance dose, as tolerated. RESULTS: Twenty-seven eligible patients (median age 52 years; 52% appendiceal/48% colorectal) were enrolled on this trial and included in the analysis, and 26 were evaluable for response. Eighteen patients demonstrated stable disease on adjuvant thalidomide, while eight showed evidence of progression. Approximately 30% of the patients withdrew due to toxicity. Grade 3/4 toxicities included neurological disorders (16%), nausea (12%), vomiting (8%), and thromboembolism (8%). Median overall survival (OS) and PFS were 43.0 and 9.3 months, respectively, and median follow-up was 40.4 months. Multivariate modeling showed significant improvements in PFS and OS for appendiceal patients and those with R0 or R1 resections. On an intent-to-treat analysis, the PFS of the study group was 9 months. CONCLUSIONS: Based on these findings, thalidomide cannot be recommended as adjuvant therapy after CS and HIPEC for gastrointestinal malignancies. Further research is needed to identify active agents in this population.

Self-perceptions of young adults who survived severe childhood burn injury.

The transition of pediatric burn survivors into adulthood is accompanied by a reformulation of their self-concept. To anticipate the need for and guide development of appropriate psychosocial interventions, this study examines how young adults who were burned as children perceive themselves and how this perception might affect their self-esteem. Eighty-two young adult burn survivors (45 male, 37 female) were assessed using the Tennessee Self-Concept Scale, 2nd edition (TSCS2) to determine how the participants perceive themselves and their interaction with society. To gain insight into the possible effects of these self-concept scores, relationships were analyzed between self-concept, a behavioral assessment (Young Adult Self-Report [YASR]), and a psychiatric symptom assessment (Structured Clinical Interview for DSM-IV Axis I Disorders [SCID I]). This group of burn survivors scored significantly lower in self-concepts, reflected in TSCS2 subscale scores of physical function, appearance, and sexuality, moral conduct, personal values, academics and work, and identity, than did the reference population. Pearson correlation coefficients showed that as moral, personal, family, and social aspects of self-concept decreased, clinical problems endorsed on the YASR subscales increased, including anxiety, somatic, attention, intrusive, and aggressive. Persons with lower self-concept scores on the TSCS2 personal, family, and social scales were more withdrawn on the YASR. Similarly, those with lower TSCS2 scores on the personal and family scales endorsed significantly more thought problems on the YASR. TSCS2 total self-concept, personal, and all of the supplementary scale scores were significantly lower for the group with an affective disorder. Those whose SCID I scores were consistent with a current anxiety disorder had significantly lower scores for the TSCS2 total self-concept and personal. Lower self-concept was associated with endorsement of SCID symptoms. In summary, the significantly lower self-concept scores on the TSCS2 physical scale are consistent with the physical disfigurement and handicaps common with major burn injuries, and a strong indication of this group's perception of the first impression made when interacting with others. The survivors seem to feel worthwhile within the contexts of family and friends. Although the major limitation of this study using the TSCS2 is the lack of a matched reference population to compare the burn survivors, the TSCS2 does help in gaining insight into the self-esteem issues of the burn survivor population.

Personality disorders in young adult survivors of pediatric burn injury.

OBJECTIVE: Life experience shapes personality and chronic trauma in childhood has been associated with risk for development of subsequent personality disorder. The purpose of this study is to determine the prevalence and character of personality disorders and traits in young adult survivors of severe pediatric burn injury. METHOD.: SCID-II and 16PF were completed by 98 young adult survivors of pediatric burn trauma. RESULTS: 48 (49%) met criteria for one or more personality disorders. The most frequent personality disorders were Paranoid (19.4%), Passive Aggressive (18.4%), Antisocial (17.3%), Depressive (11.2%), and Borderline (9.2%). Diagnosis with a personality disorder was associated with comorbid Axis I diagnoses and strongly correlated with personality traits as measured by the 16PF. CONCLUSIONS: Pediatric burn trauma is similar to other chronic traumas of childhood in significant correlation with subsequent personality disorder.