The Impact of COVID-19 in Reshaping Graduate Medical Education: Harnessing Hybrid Learning and Virtual Training.

Introduction  At the start of the COVID-19 pandemic, many graduate medical education (GME) programs switched from in-person to virtual training to ensure a safe learning environment. However, the preferences of US residents in the wake of the COVID-19 pandemic are largely unknown. Objective The authors surveyed PGY-2 psychiatry residents about their perception of the pandemic's impact on their clinical skills, didactics experience, training preferences, and future career perceptions. Methods The cross-sectional study was conducted from October 31, 2021, to December 31, 2021. The authors emailed a survey to directors of US general psychiatry residency programs to disseminate to PGY-2 residents. The survey had Likert-scale and open-ended questions about the pandemic's perceived impact on PGY-1 training and future training preferences. The authors used descriptive statistics for Likert-scale questions and reflexive thematic analysis for open-ended questions. Results Out of an estimated 1800 residents, only 116 (6.4%) participated; post-pandemic preferences emerged. A strong preference was expressed for hybrid didactics, combining in-person and virtual learning. Virtual patient evaluations, especially in emergency and inpatient settings, were highly valued. Conversely, entirely virtual didactics and clinical rounds were deemed least preferred, emphasizing the importance of interactive, hands-on learning experiences. Conclusions Respondents emphasized the significance of incorporating hybrid models for both in-patient care and didactic sessions in GME. These preferences signify the need for adaptable and flexible approaches to education in psychiatry residency programs as we emerge from the pandemic.

Outcomes from an interprofessional, dementia-focused, telementoring program: a brief report.

Despite a burgeoning older-adult population, the number of health-care professionals with geriatric expertise continues to lag behind. In 2014, the American Geriatrics Society's position statement encouraged interprofessional training for health-care professionals. Telementoring remotely connects clinicians with specialists for education and group mentoring. This dementia-focused, 11-month, 1-hour each, telementoring program was modeled on the Alzheimer's Association ECHO. Our interprofessional expert panel consisted of a geriatrician, a geriatric psychiatrist, an adult nurse practitioner (with geriatric expertise), two geriatric pharmacists, a licensed social worker (coordinating a dementia day program), and a project coordinator. Learners were residents in family medicine and general psychiatry, physician assistant residents in mental health and geriatric psychiatry fellows (total = 31). There was a significant improvement in learner intentions to change medication prescribing by midpoint assessment (p = 0.04). Learners reported few barriers to incorporating skills they learned. An interprofessional telementoring program can help nongeriatric practitioners improve skills in caring for older adults.

Narrowing the Treatment Gap: A Call to Increase Use of Direct-to-Consumer Marketing in Psychotherapy Practice and Research.

A mental health treatment gap exists in which individuals who would benefit from evidence-based psychotherapies (EBPs) do not receive them. It is critical to take effective actions so that individuals with unmet mental health needs feel empowered to seek treatment. Direct-to-consumer (DTC) marketing meets this objective. DTC marketing is an effective, patient-centered approach that creates patient demand for a product or service by influencing patient behaviors, attitudes, and preferences. While primarily used in the United States and New Zealand to promote prescription drugs, uses and practices for DTC marketing with nonpharmaceutical EBPs are less established. This article highlights the value of leveraging this marketing approach to increase awareness and use of EBPs. Additionally, an illustrative example is presented that describes the use of social marketing and marketing mix principles to develop effective DTC marketing campaigns in psychotherapy practice.

A Systematic Review of Barriers Faced by Older Adults in Seeking and Accessing Mental Health Care.

Older adults in the United States have lower rates of mental health care utilization than young adults. To understand these lower rates of mental health care, we performed a systematic review, in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of barriers that prevent older adults from seeking and accessing treatment. We searched PubMed, PsycINFO, and Clinical Key to identify studies of barriers to mental health treatment in the older adult population (in individuals 50 y of age and older). Thirty-two articles met inclusion criteria (English language and focused on barriers to care in older adults) and exclusion criteria (focus on non-United States populations, focus on younger adults, or no focus on barriers to care). We identified 5 categories of barriers to mental health care in older adults: (1) attitudes and knowledge among older adults; (2) comorbid medical conditions; (3) provider-related factors; (4) other extrinsic barriers (eg, cost, transportation, reliance on caregivers); and (5) unique factors that affect older adults in minority populations. Large studies have primarily identified intrinsic barriers, including negative attitudes toward mental health care and lack of perceived need for treatment, as preventing older adults from seeking mental health care. Minority populations have also been found to face cultural barriers and increased levels of stigma compared with non-Hispanic whites, although several of the identified articles concerning barriers among minority older adults involved qualitative studies with small samples. Larger quantitative studies may help clarify the relative importance of barriers affecting this population. Interventions that have been shown to increase access to mental health services for older adults include community-based care and integrated primary and psychiatric care, but these strategies can be difficult to implement in low-resource settings. More research is needed to determine which interventions and policies are most effective in targeting particular barriers.

Elder Abuse Education Using Standardized Patient Simulation in an Undergraduate Nursing Program.

BACKGROUND: With more than 1 million older adults being abused each year, it is imperative for nurses to be knowledgeable about signs and symptoms of elder abuse, assessment, and interventions. This article describes a three-part learning strategy consisting of lecture, simulation using standardized patients (SPs), and debriefing to educate prelicensure nursing students about how to identify, assess, and report elder abuse. Furthermore, the effects of the teaching strategies were assessed. METHOD: Students received a lecture on elder abuse, followed by a simulation with an SP and debriefing. Pre- and posttests were used to assess knowledge, skills, and attitudes about elder abuse. RESULTS: Significant differences were found in pre- and posttest results for knowledge and skills. There were no significant differences in attitude. Teaching strategies affected learning, and students reported increased knowledge and skills in identifying abuse and advocating for vulnerable older adults. CONCLUSION: Lecture and SP simulation followed by debriefing was an effective approach to educate prelicensure nursing students about elder abuse. [J Nurs Educ. 2020;59(6):331-335.].

Training Residents in High-Value, Cost-Effective Care: a National Survey of Psychiatry Program Directors.

OBJECTIVE: The goal of this study was to explore how prepared psychiatry programs are to teach residents to practice resource management and high-value, cost-effective care. METHODS: An anonymous online survey was sent to 187 psychiatry training directors between July and September 2015. RESULTS: Forty-four percent of training directors responded to the survey. While most training directors who responded (88%) agreed that that graduate medical education has a responsibility to respond to the rising cost of health care, fewer than half agreed that that their faculty members consistently model cost-effective care (48%), that residents have access to information regarding the cost of tests and procedures (32%), and that residents are prepared to integrate the cost of care with available evidence when making medical decisions (44%). Only 11% reported providing training in resource management. Barriers cited to teaching cost-effective care included a lack of information regarding health care costs (45%), a lack of time (24%), a lack of faculty with relevant skills (19%), and competing training demands and priorities (18%). Training directors also noted a lack of available curricular resources and assessment tools (21%). Another 12% cited concerns about cost containment overriding treatment guidelines. Ninety percent of training directors agreed that they would be interested in resources to help teach high-value, cost-effective care. CONCLUSIONS: Most psychiatry programs do not provide formal training in resource management but are interested in resources to teach high-value, cost-effective care. Curricula for residents and faculty may help meet this need.

Development and Dissemination of an Interprofessional Online Dementia Training Curriculum.

OBJECTIVES: Despite the growing number of individuals with dementia, clinicians skilled in caring for people with dementia, especially in rural areas, are lacking. The Program for Advancing Cognitive Disorders Education for Rural Staff (PACERS) was designed to improve clinician competency and comfort when caring for individuals with dementia. Based on an interprofessional needs assessment, six 1-hour training modules were created: (1) Dementia and Delirium, (2) Identifying and Assessing for Dementia, (3) Treating Dementia: Case Studies, (4) Normal Cognitive Aging and Dementia Caregiving, (5) Addressing Decision Making and Safety in Dementia, and (6) Dementia and Driving. Each module is available for free on the Department of Veterans Affairs Talent Management System (TMS) for employees and the free TrainingFinder Real-time Affiliate Integrated Network (TRAIN) platform for clinicians in the community. One continuing education unit is earned upon completion of each module. DESIGN: Posttest. SETTING: Online training at VA TMS and TRAIN. PARTICIPANTS: To date, more than 3000 modules have been completed by interprofessional healthcare learners (eg, nurses, physicians, psychologists, and social workers). MEASUREMENTS: Satisfaction, perceived utility of training, knowledge, skills, and attitudes were assessed. RESULTS: The learners reported high satisfaction (mean [M] > 4) and ability to apply the knowledge and skills learned from the module to their job (M > 4) on a Likert scale (1 = Strongly disagree to 5 = Strongly agree). CONCLUSION: Learners also reported perceived impact on both direct patient care (eg, ability to provide education and support to individuals with dementia and their caregivers) and system-level care (eg, more appropriate referrals). Given the number of users and their evaluation data, PACERS can serve as a model curriculum for online interprofessional dementia training. J Am Geriatr Soc 68:192-197, 2019.

A Systematic Review of Practice Guidelines and Recommendations for Discontinuation of Cholinesterase Inhibitors in Dementia.

Cholinesterase inhibitors (ChEIs) are the primary pharmacological treatment for symptom management of Alzheimer disease (AD), but they carry known risks during long-term use, and do not guarantee clinical effects over time. The balance of risks and benefits may warrant discontinuation at different points during the disease course. Indeed, although there is limited scientific study of deprescribing ChEIs, clinicians routinely face practical decisions about whether to continue or stop medications. This review examined published practice recommendations for discontinuation of ChEIs in AD. To characterize the scientific basis for recommendations, we first summarized randomized controlled trials of ChEI discontinuation. We then identified practice guidelines by professional societies and in textbooks and classified them according to 1) whether they made a recommendation about discontinuation, 2) what the recommendation was, and 3) the proposed grounds for discontinuation. There was no consensus in guidelines and textbooks about discontinuation. Most recommended individualized discontinuation decisions, but there was essentially no agreement about what findings or situations would warrant discontinuation, or even about what domains to consider in this process. The only relevant domain identified by most guidelines and textbooks was a lack of response or a loss of effectiveness, both of which can be difficult to ascertain in the course of a progressive condition. Well-designed, long-term studies of discontinuation have not been conducted; such evidence is needed to provide a scientific basis for practice guidelines. It seems reasonable to apply an individualized approach to discontinuation while engaging patients and families in treatment decisions. .

A Simulation Exercise to Raise Learners' Awareness of the Physical and Cognitive Changes in Older Adults.

OBJECTIVE: The growing number of older adults with cognitive impairment is increasing the need for healthcare services. However, there is a great shortage of geriatric trained primary care providers and psychiatrists. A positive attitude towards people with cognitive impairment is associated with better quality of life among residents of long-term care settings. This led us to develop a simulation exercise to raise learners' awareness of, and attentiveness to, physical and cognitive changes experienced by the aging population. METHODS: Fifty-one learners rotating through Psychiatry at the Michael E. DeBakey VA Medical Center received the 10-min training over 1 year. The Approaches to Dementia Questionnaire was used to measure attitudes towards older persons with cognitive impairment. Pre- and postsimulation data subscores for the Hope, Person-centered, and total score were calculated, and a paired sample t test was conducted. RESULTS: Results of the questionnaire showed statistically significant improvement in the Approaches to Dementia Questionnaire scores among participants after they completed the simulation exercise, indicating an increase in positive attitudes. The mean difference in the total score of the Approaches to Dementia Questionnaire was 3.22, with a 95% CI of 1.67 to 4.74, t = 4.20, df (47), p < .000, r = .64, and a medium effect size of d = .61. CONCLUSIONS: On the basis of these findings, the simulation exercise can be used for improving learners' attitudes towards those with cognitive impairment.

Castaways: addressing hostility and helplessness in severely lonely adults.

Hostility and helplessness are recurrent themes in severely lonely adults, and they can be both causes and effects of subjective feelings of loneliness. Since many lonely patients report a history of abuse, hostile and helpless states of mind may reflect identification with hostile (aggressor) or helpless (passive) attachment figures. Hostile intrusiveness and helpless withdrawal by the parent are 2 distinct patterns of parent-child misattunement that can lead to infant disorganization via disrupted emotional communication and to loneliness later in life. Anxious-ambivalent lonely older adults tend to exhibit hyperactivating hostile behaviors (to deal with a core sense of powerlessness), whereas those with fearful-avoidant attachment styles exhibit deactivating helpless behaviors (to deflect intense underlying feelings of rage). Based on this model, we outline different treatment approaches for lonely persons with different attachment styles by describing the successful treatment of two severely lonely, suicidal veterans. We describe an approach to treating hostile and helpless behaviors in lonely patients, using validation, mentalization, reality orientation, and socialization. Validation provides a sense of safety and rapport. Mentalization allows the lonely individual to better appreciate his or her own mental processes and those of others. Reality orientation provides feedback to lonely individuals on whether their perceptions are accurate and reality-based and helps them appreciate the consequences their behavior may have for self and others. Finally, socialization reduces disenfranchisement by teaching/re-teaching individuals social skills that may have become impaired by prolonged isolation.

Therapy 101: a psychotherapy curriculum for medical students.

OBJECTIVE: This pilot project, designed and taught by a resident, created a curriculum to introduce medical students to the practice of psychotherapy. Medical students who are knowledgeable about psychotherapy can become physicians who are able to refer patients to psychotherapeutic treatments. A search of the literature did not identify a curriculum that introduced psychotherapy, its applications, and evidence for its use. METHODS: The authors worked closely with a faculty mentor to create a course that fulfilled a perceived need for more psychotherapy teaching of medical students. "Therapy 101: An Introduction to Psychotherapy" is a 6-hour curriculum that employs creative teaching techniques such as video clips from TV shows, role play, and recordings of therapy sessions. The series was evaluated using a multiple-choice pre/postcourse test with questions on psychotherapy, written feedback, and perceived knowledge of psychotherapy. RESULTS: The scores from the pre/postcourse test measuring the students' knowledge of psychotherapy did not change significantly. However, students' self-rating of knowledge greatly increased after the series. Written feedback showed substantial enthusiasm for the course. CONCLUSION: Students can benefit from a short and engaging curriculum on psychotherapy. "Therapy 101" was very well accepted by students and has been integrated into the curriculum for students in the mental health pathway. Medical students may benefit from more exposure to psychotherapy as taught by a resident.