Findings from the Harvard Medical School Cambridge Integrated Clerkship, a Year-Long Longitudinal Psychiatry Experience.

OBJECTIVE: The Harvard Medical School Cambridge Integrated Clerkship is a longitudinal integrated clerkship that has provided an alternative clinical model for medical education in psychiatry since its inception in 2004. This study was undertaken in an effort to better understand the student experience of the Cambridge Integrated Clerkship and how it may have impacted students' perceptions of and interest in psychiatry, as well as performance. METHODS: Qualitative surveys were sent via e-mail to the first 11 student cohorts who had completed the Cambridge Integrated Clerkship (from 2004 to 2014) and for whom we had e-mail addresses (N = 100), and the free-text responses were coded thematically. All available standardized scoring data and residency match data for Cambridge Integrated Clerkship graduates were obtained. RESULTS: From 2006 to 2014, 12 out of 73 Cambridge Integrated Clerkship students who entered the match chose a psychiatry residency (16.4%), four times more than students in traditional clerkships at Harvard Medical School (3.8% of 1355 students) or the national average (4.1% of 146,066 US applicants). Thirty of the 100 surveyed Cambridge Integrated Clerkship graduates (30%) responded to the qualitative survey with free-text remarks on a number of themes. CONCLUSIONS: Cambridge Integrated Clerkship students compared positively to their classmates in terms of standardized test performance. Their fourfold higher match rate into psychiatry compared to other students raises intriguing questions as to what role a longitudinal clerkship might have played in developing interest in psychiatry as a career.

Availability of Buprenorphine Treatment in the 10 States With the Highest Drug Overdose Death Rates in the United States.

OBJECTIVE: The objective of this study was to assess the accuracy of the Substance Abuse and Mental Health Services Administration (SAMHSA) database for patients who use it to seek buprenorphine treatment. DESIGN AND MEASUREMENTS: Buprenorphine providers within a 25-mile radius of the county with the highest drug-related death rates within the 10 states with the highest drug-related death rates were identified and called to determine whether the provider worked there, prescribed buprenorphine, accepted insurance, had appointments, or charged for visits. RESULTS: The number of providers listed in each county ranged from 1 to 166, with 5 counties having <10 providers. In 3 counties no appointments were obtained, and another 3 counties had ≤3 providers with availability. Of the 505 providers listed, 355 providers (70.3%) were reached, 310 (61.4%) of the 505 listings were correct numbers, and 195 (38.6%) of the 505 providers in the listings provided buprenorphine. Of the 173 clinics that provided buprenorphine and were asked about insurance, 131 (75.7%) accepted insurance. Of the 167 clinics that provided buprenorphine and were asked about Medicaid, 105 (62.9%) accepted it. Wait times for appointments ranged from 1 to 120 days, with an average of 16.8 days for those that had a waitlist. Among the 39 providers who reported out-of-pocket costs, the average cost was $231 (range: $90 to $600). One hundred forty of the 505 providers listed in the database had appointments available (27.7%). Three hundred sixty-five of the 505 providers did not have appointments available (72.3%) for various reasons, including the fact that 120 providers (32.9% of the 365 providers) could not be reached, and 137 of the numbers (37.5% of the 365 listed numbers) were wrong. Other reasons appointments could not be obtained included the fact that providers did not treat outpatients, were not accepting new patients, were out of office, or required a referral. CONCLUSION: Although the SAMHSA buprenorphine practitioner locator is used by patients and providers to locate treatment options, only a small portion of clinicians in the database ultimately offered initial appointments, implying that the database is only marginally useful for patients.

Availability of Outpatient Mental Health Care by Pediatricians and Child Psychiatrists in Five U.S. Cities.

The authors sought to assess the availability of outpatient mental health care through pediatrician and child psychiatrist offices in the United States and to characterize differences in appointment availability by location, provider type, and insurance across five cities. To do so, the authors posed as parents of a 12-year-old child with depression, gave a predetermined insurance type, and asked to make the first available appointment with the specified provider. They called the offices of 601 individual pediatricians and 312 child psychiatrists located in five U.S. cities and listed as in-network by Blue Cross Blue Shield, one of the largest private insurers in the United States. Appointments were obtained with 40% of the pediatricians and 17% of the child psychiatrists. The mean wait time for psychiatry appointments was 30 days longer than for pediatric appointments. Providers were less likely to have available appointments for children on Medicaid, which is public insurance for low-income people. The most common reason for being unable to make an appointment was that the listed phone number was incorrect. Pediatricians were twice as likely to see new patients and to see them sooner than child psychiatrists. Increasing the number of both types of providers may be necessary to increase access to mental health care for children.

Exploratory hydrocarbon drilling impacts to Arctic lake ecosystems.

Recent attention regarding the impacts of oil and gas development and exploitation has focused on the unintentional release of hydrocarbons into the environment, whilst the potential negative effects of other possible avenues of environmental contamination are less well documented. In the hydrocarbon-rich and ecologically sensitive Mackenzie Delta region (NT, Canada), saline wastes associated with hydrocarbon exploration have typically been disposed of in drilling sumps (i.e., large pits excavated into the permafrost) that were believed to be a permanent containment solution. However, failure of permafrost as a waste containment medium may cause impacts to lakes in this sensitive environment. Here, we examine the effects of degrading drilling sumps on water quality by combining paleolimnological approaches with the analysis of an extensive present-day water chemistry dataset. This dataset includes lakes believed to have been impacted by saline drilling fluids leaching from drilling sumps, lakes with no visible disturbances, and lakes impacted by significant, naturally occurring permafrost thaw in the form of retrogressive thaw slumps. We show that lakes impacted by compromised drilling sumps have significantly elevated lakewater conductivity levels compared to control sites. Chloride levels are particularly elevated in sump-impacted lakes relative to all other lakes included in the survey. Paleolimnological analyses showed that invertebrate assemblages appear to have responded to the leaching of drilling wastes by a discernible increase in a taxon known to be tolerant of elevated conductivity coincident with the timing of sump construction. This suggests construction and abandonment techniques at, or soon after, sump establishment may result in impacts to downstream aquatic ecosystems. With hydrocarbon development in the north predicted to expand in the coming decades, the use of sumps must be examined in light of the threat of accelerated permafrost thaw, and the potential for these industrial wastes to impact sensitive Arctic ecosystems.