Delirium on clozapine: A tale of friend turned foe-A case report.

Treatment resistant schizophrenia (TRS) is often encountered in clinical practice. Clozapine remains the drug of choice in the management of TRS. Several studies have shown that clozapine is the most effective antipsychotic medication to date for TRS. But it is also well known that it has multiple side effects. Some side effects are transient and relatively benign, while other adverse effects are menacing, serious and life-threatening. Delirium may occur with clozapine and is a therapeutic challenge as there is always a risk of precipitating delirium on clozapine rechallenge. Limited management strategies are available as alternatives for the management of psychiatric illness stabilized on clozapine. In this case report, we describe an older adult patient who developed delirium on clozapine. The aims of this case report are to discuss the mechanism by which clozapine leads to delirium, revisit various factors which could possibly lead to delirium, and discuss the different management strategies available for management of psychiatric illness for a patient previously stabilized on clozapine.

Millennials in Psychiatry: Exploring Career Choice Factors in Generation Y Psychiatry Interns.

OBJECTIVE: There is a national shortage of psychiatrists. To grow the workforce, educators must understand the factors that influence the choice of psychiatry as a specialty for medical students in the Generation Y cohort. METHODS: Psychiatry residents born between 1981 and 2000 were recruited from six psychiatry training programs across the USA and were interviewed in the fall of their first year. The interviews were coded and analyzed qualitatively for themes. Career Construction Theory (CCT) was applied to relate the themes within the four domains of Career Adaptability (a focus of CCT): concern, control, curiosity, and confidence. RESULTS: The majority of themes mapped onto the four domains. A fifth domain, "contribution," was created to capture additional themes. Themes associated with choosing psychiatry as a career included Practice Concerns and Economic/Lifestyle Concerns (concern), Changes in Stigma and Changes in Legitimacy (control), Exploring Humanity and Exposures to Psychiatry (curiosity), Abilities Called Upon by the Field, Recognized Qualities in the Participant, and Recognized Qualities in the Faculty/Residents (confidence), and Hoping to Make a Difference and Engaging in Research/Technology (contribution). CONCLUSIONS: With the knowledge generated from this study, educators now have a guide for the kinds of learning experiences that may attract Generation Y students to the field, and can identify those with the background, values, or personality traits most likely to find a career in psychiatry to be attractive.

Modern-Day Relics of Psychiatry.

Constantly shifting cultural views influence public perceptions of psychiatric diagnoses, sometimes accommodated by changes in diagnostic terminology. Evolving scientific knowledge of the era is at times used to justify and support mental illnesses. Too often, however, remasked nomenclatures fail to alter social stigma, in part because political arguments are used. Scientific validations of variant behaviors as symptoms with a pathologic status are unfortunately overshadowed. Examples of cultural bias effects on recurring diagnostic challenges illustrate a need for scientific validation. Renaming fails to improve stigma or diagnostic clarity. For example, neurasthenia, or nervous exhaustion, was attributed to fast-paced urban life through the late 1970s. Its symptoms are now largely, to no real advantage, retitled as chronic fatigue syndrome. Diagnoses like "hysteria" have evolved into histrionic personality disorder and somatoform spectrum disorders, although less as a result of demonic possession or a "wandering uterus." Decriminalized and depathologized homosexuality remains a political football, where religious "sin" conceptualizations have not been displaced by studies documenting healthy adjustments among groups with diverse sexual orientations and preferences. Each of these remains severely socially stigmatized. The pseudoscience of "drapetomania," once used to rationalize and pathologize a slave's freedom, is perceived now as psychiatric incarcerations of mentally healthy individuals, more commonly in totalitarian regimes-a politicization of stigma. Research reviews and funding efforts need to emphasize a sound basis for individuals caught in perpetuated diagnostic challenges, not remedied by simple shifts in nomenclature.

Medical School Factors Associated with Higher Rates of Recruitment into Psychiatry.

OBJECTIVE: The medical school a student attends appears to be a factor in whether students eventually match into psychiatry. Knowledge of which factors are associated with medical schools with higher recruitment rates into psychiatry may assist in developing strategies to increase recruitment. METHODS: Psychiatry leaders in medical student education in the 25 highest and lowest recruiting US allopathic schools were surveyed concerning various factors that could be important such as curriculum, educational leadership, and presence of anti-psychiatry stigma. The relationship between the survey results of high recruiting schools versus those of low recruiting schools was evaluated using Mann-Whitney U tests. RESULTS: Factors significantly associated (p < .05) with higher recruiting schools included better reputation of the psychiatry department and residents, perceived higher respect for psychiatry among non-psychiatry faculty, less perception that students dissuaded other students from pursuing psychiatry, and longer clerkship length. CONCLUSIONS: Educational culture and climate factors may have a significant impact on psychiatry recruitment rates. Clerkship length was associated with higher recruiting schools, but several previous studies with more complete samples have not shown this.

Factors Influencing Medical School Graduates Toward a Career in Psychiatry: Analysis from the 2011-2013 Association of American Medical Colleges Graduation Questionnaire.

OBJECTIVE: Various factors influence choice of medical specialty. Previous research grouped specialties into controllable lifestyle, primary care, and surgical. This study compared factors influencing individuals to choose psychiatry versus other specialties. METHODS: Data came from the 2011-2013 Association of American Medical Colleges Graduation Questionnaire. The authors grouped responses, ranging from no influence to minor, moderate, and strong influence, into psychiatry and controllable lifestyle, primary care, and surgical specialties and analyzed the data using one-way analysis of variance. RESULTS: The analyses included 29,227 students, of which 1329 (4.5%) elected psychiatry; 10,998 (37.6%), controllable lifestyle specialties; 12,320 (42.2%), primary care specialties; and 4580 (15.7%), surgical specialties. Students choosing psychiatry reported less influence of competitiveness, student debt, and salary expectations than those choosing controllable lifestyle and surgical specialties (p < 0.0001) and more influence of work/life balance than those choosing primary care and surgical specialties (p < 0.0001). They reported less influence of family expectations than those choosing controllable lifestyle specialties (p < 0.0001). They reported more influence of fit with personality than controllable lifestyle, primary care, and surgical specialties (p < 0.004). CONCLUSIONS: Students entering psychiatry do not fit the traditional categories of controllable lifestyle, primary care, and surgical profiles, but fall between controllable lifestyle and primary care specialties. Recruitment efforts may need to address this different pattern of influences.

Evidence for validity of a survey to measure the learning environment for professionalism.

BACKGROUND: With the emphasis on professionalism in academic health settings, including recently added accreditation requirements for US medical schools, there is a need for a valid and feasible method to assess the learning environment for professionalism. AIM: This article describes the development and investigation of the validity of a brief measure, the learning environment for professionalism (LEP) survey, designed to assess medical student perceptions of professionalism among residents and faculty during clinical rotations. METHOD: Two successive cohorts of third-year medical students completed the 22-item LEP survey at the conclusion of clerkship rotations, providing a total of 902 responses for scale reliability and principal components factor analysis, as well as assessment of changes in scores over time and correlations with a related clerkship evaluation item. RESULTS: The internal structure of the LEP survey was consistent with intended goals to assess both positive and negative professionalism behaviors. Acceptable internal consistency, sensitivity to change over time, and positive relationships between LEP scores and a concurrent measure of professionalism were observed. CONCLUSIONS: Use of the instrument could help identify clinical learning environments for professionalism that represent either best practices or areas in need of improvement, assess the impact of professionalism initiatives, and help satisfy accreditation requirements.

A randomized controlled trial of behavior change counseling education for medical students.

BACKGROUND: Educating medical students about how to effectively counsel patients with negative health behaviors (i.e., lack of exercise, smoking) is vitally important. Behavior change counseling is a promising method that can be used by physicians to encourage positive changes in health behaviors. PURPOSE: To examine the effectiveness of a 2 h workshop in behavior change counseling for medical students. METHODS: This study used a pre-post control group design with 35 second-year medical students who were randomly assigned to participate in a behavior change counseling intervention or wait-list control group. Student knowledge and attitudes were assessed using multiple choice items and open-ended question prompts. Student skills were assessed via performance in a standardized patient encounter rated using the Behavior Change Counseling Index (BECCI). RESULTS: Student attitudes toward behavior change counseling were positive at both pre- and post-test assessment in both groups. Knowledge scores and BECCI total scores showed significantly greater improvement in the intervention group compared to the wait-list control group. CONCLUSIONS: This study found that a brief educational intervention had a positive impact on medical students' knowledge and skills in behavior change counseling, and that student attitudes about the counseling method were very positive.

Evolving roles of clerkship directors: have expectations changed?

BACKGROUND: Physician educators directing medical student programs face increasingly more complex challenges to ensure students receive appropriate preparation to care for patients. The Alliance for Clinical Education (ACE) defined expectations of and for clerkship directors in 2003. Since then, much has changed in medical education and health care. METHODS: ACE conducted a panel discussion at the 2016 Association of American Medical Colleges Learn Serve Lead conference, soliciting input on these expectations and the changing roles of clerkship directors. Using workshops as a cross-sectional study design, participants reacted to roles and responsibilities of clerkship directors identified in the literature using an audience response system and completing worksheets. RESULTS: The participants represented different disciplines of medicine and ranged from clerkship directors to deans of curriculum. Essential clerkship director qualifications identified by participants included: enthusiasm, experience teaching, and clinical expertise. Essential tasks included grading and assessment and attention to accreditation standards. Participants felt clerkship directors need adequate resources, including budget oversight, full-time clerkship support, and dedicated time to be the clerkship director. To whom clerkship directors report was mixed. Clerkship directors look to their chair for career advice, and they also report to the dean to ensure educational standards are being met. Expectations to meet accreditation standards and provide exemplary educational experiences can be difficult to achieve if clerkship directors' time and resources are limited. CONCLUSIONS: Participant responses indicated the need for a strong partnership between department chairs and the dean's office so that clerkship directors can fulfill their responsibilities. Our results indicate a need to ensure clerkship directors have the time and resources necessary to manage clinical medical student education in an increasingly complex health care environment. Further studies need to be conducted to obtain more precise data on the true amount of time they are given to do that role.

Stability of and Factors Related to Medical Student Specialty Choice of Psychiatry.

OBJECTIVE: Targeted efforts are needed to increase the number of medical students choosing psychiatry, but little is known about when students decide on their specialty or what factors influence their choice. The authors examined the timing and stability of student career choice of psychiatry compared with other specialties and determined what pre- and intra-medical school factors were associated with choosing a career in psychiatry. METHOD: Using survey data from students who graduated from U.S. allopathic medical schools in 2013 and 2014 (N=29,713), the authors computed rates of psychiatry specialty choice at the beginning and end of medical school and assessed the stability of that choice. A multivariate-adjusted logistic regression and recursive partitioning were used to determine the association of 29 factors with psychiatry specialty choice. RESULTS: Choice of psychiatry increased from 1.6% at the start of medical school to 4.1% at graduation. The stability of psychiatry specialty choice from matriculation to graduation, at just over 50%, was greater than for any other specialty. However, almost 80% of future psychiatrists did not indicate an inclination toward the specialty at matriculation. A rating of "excellent" for the psychiatry clerkship (odds ratio=2.66), a major in psychology in college (odds ratio=2.58), and valuing work-life balance (odds ratio=2.25) were the factors most strongly associated with psychiatry career choice. CONCLUSIONS: Students who enter medical school planning to become psychiatrists are likely to do so, but the vast majority of students who choose psychiatry do so during medical school. Increasing the percentage of medical students with undergraduate psychology majors and providing an exemplary psychiatry clerkship are modifiable factors that may increase the rate of psychiatry specialty choice.

Crystal clear or tin ear: how do medical students interpret derogatory comments about patients and other professionals?

PURPOSE: To assess the learning environment at our medical school, third-year medical students complete an 11-item survey called the Learning Environment for Professionalism (LEP) at the end of each clerkship. The LEP survey asks about the frequency of faculty and resident professional and unprofessional behaviors that students observed; two of the items specifically address derogatory comments. This study used focus group methodology to explore how medical students interpret the derogatory comments they reported on the LEP survey. METHODS: Seven focus groups were conducted with 82 medical students after they completed the LEP survey. Analysis of focus group transcripts was performed to better understand the nature and meaning that students ascribe to derogatory comments. RESULTS: The study results provide insights into the types of derogatory comments that medical students heard during their clerkship rotations, why the comments were made and how they were interpreted. Emergent themes, labeled by the authors as 1) 'onstage-offstage', 2) 'one bad apple', and 3) 'pressure cooker environment', highlight the contextual aspects and understandings ascribed by students to the derogatory comments. Incidentally, students felt that the comments were not associated with fatigue, but were associated with cumulative stress and burn-out. CONCLUSIONS: The results suggest students have a clear understanding of the nature of unprofessional comments made by role models during clerkships and point to important systems-related issues that could be leveraged to improve clinical learning environments.

Psychiatry clerkship students' preparation, reflection, and results on the NBME Psychiatry Subject Exam.

OBJECTIVE: Psychiatry clerkship training involves many learning components, one of which is acquisition of scholarly knowledge. The authors investigate the reading materials and learning methods used by clinical clerks in their preparation for the National Board of Medical Examiners (NBME) Psychiatry Subject Exam (PSE). METHODS: Clerkship students from six U.S. medical schools who had recently completed their psychiatry clerkship and PSE were surveyed regarding reading material use, teaching methods encountered, and other relevant resources which may have influenced their PSE scores. RESULTS: The most frequently used PSE preparation material was a "step-or-prep" book, followed by practice questions, handouts, and assigned texts. No single preparation material type or combination proved significantly different in influencing PSE scores. The didactic methods used in clerkships did differ significantly in their influence on PSE scores. Students in the top quartile used slightly more books and different combinations of books than students in the bottom quartile. CONCLUSION: Students exhibited several trends in their preparation for the PSE. The most striking findings were the heavy student reliance on step-or-prep books over other learning resources and that step-or-prep books did not demonstrate significance as a superior preparation resource for the PSE. These trends in third-year psychiatric rotations have important implications for medical student education.

Prolactin levels and erectile function in patients treated with risperidone.

Treatment with risperidone is associated with prolactin (PRL) elevation, and PRL elevations are associated with erectile dysfunction (ED). We evaluated whether the PRL elevations caused by risperidone treatment of subjects with schizophrenia are associated with objective measures of erectile function. Subjects were hospitalized for 2 nights, and serum measurements of PRL, total testosterone, and free and weakly bound testosterone were performed in the morning and afternoon of each day. Risperidone levels, parent compound, and 9-hydroxy metabolite levels were drawn on the first day. Erectile function assessments, using the RigiScan, an instrument that measures nocturnal penile tumescence and rigidity, were performed on both nights. Consistent with previous reports, the correlation between total risperidone level and PRL was very high (r = 0.92, df = 12, P < 0.0001), but risperidone did not appear to affect either testosterone (r = 0.29, df = 5, P = 0.51) or free and weakly bound testosterone (r = -0.11, df = 10, P = 0.72). Contrary to expectations, PRL levels from the second night were positively correlated with erectile function (r = 0.68, df = 9, P = 0.022). Using objective measures, we were unable to confirm a detrimental association between PRL levels and male erectile function. These results are tentative given the small sample.