Assessment of Brief Online Approaches for Teaching Neuroscience in Psychiatry.

OBJECTIVE: The goal of this study was to assess an online collection of brief educational resources (videos, case studies, articles) for teaching a broad range of concepts relating to neuroscience in psychiatry. METHODS: A national sample of 52 psychiatrists enrolled in the study. Forty (77%) completed an assessment before and after having access to the educational resources for 4 weeks. Pre- and post-assessments were compared using paired t-tests. Fifteen participants were randomly selected to participate in a semi-structured interview. RESULTS: The mean knowledge score increased on a multiple-choice quiz from 46.9 to 86.4% (p < .01). Based on a 5-point Likert rating, participants reported significant gains in self-confidence in their ability to integrate a neuroscience perspective into their clinical work (p = .03) and to discuss neuroscience with their patients (p = .008). Participants rated the extent that they applied neuroscience concepts (such as neurotransmitters, genetics, epigenetics, synaptic plasticity, and neural circuitry) to their overall case formulation and treatment plan over the past typical work week and how often they discussed these elements with patients. Significant gains were noted across all elements (p ≤ .001). Overall satisfaction with the resources were high: participants agreed that the content was useful and relevant (100%) and the teaching resources were engaging (95%). On semi-structured interviews, participants appreciated the mixed teaching approaches and the brief format. Many commented on how the resources impacted their clinical practice. CONCLUSIONS: Brief online teaching resources may be an effective approach for enhancing neuroscience education among psychiatrists and may help facilitate the integration of neuroscience into clinical practice.

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.

Transforming Psychiatry from the Classroom to the Clinic: Lessons from the National Neuroscience Curriculum Initiative.

OBJECTIVE: Individual residency programs often struggle to keep pace with scientific advances and new training requirements. Integrating a modern neuroscience perspective into the clinical practice of psychiatry is particularly emblematic of these challenges. The National Neuroscience Curriculum Initiative (NNCI) was established in 2013 to develop a comprehensive set of shared, open-access resources for teaching neuroscience in psychiatry. METHODS: The NNCI developed a collaborative, team-based approach with a peer-review process for generating and reviewing content. Teaching resources have included interactive sessions for the classroom paired with a comprehensive facilitator's guide. Brief accessible reviews and short videos have been developed for self-study and teaching in clinical settings. Dissemination efforts have included hands-on training for educators through national workshops. All resources are freely available on the NNCI website. Outcome measures have included the number of educational resources developed, feedback from workshop attendees, the number of US psychiatry residency programs who have adopted NNCI resources, as well as analytics from the NNCI website. RESULTS: To date, the NNCI has developed over 150 teaching sessions, reflecting the work of 129 authors from 49 institutions. The NNCI has run over 50 faculty development workshops in collaboration with numerous national and international organizations. Between March 2015 and June 2019, the website (www.NNCIonline.org) has hosted 48,640 unique users from 161 countries with 500,953 page views. More than 200 psychiatry training programs have reported implementing NNCI teaching materials. CONCLUSIONS: This multisite collaborative provides a model for integrating cutting-edge science into medical education and the practice of medicine more broadly.

Psychiatry Residents' Perspectives of Primary Care in the Psychiatric Setting.

OBJECTIVE: Given the growing interest in integrated care, this study sought to investigate the perception of psychiatry residents towards managing general medical conditions in their psychiatric patients. METHODS: Between July-October 2017, all 46 residents at an adult psychiatry program were asked to complete an online survey. RESULTS: Sixty-seven percent responded. Most residents (81%) indicated they were knowledgeable and/or comfortable in managing medical conditions with supervision/consultation from a primary care provider. Residents also indicated that they would "like to" (48%) and/or "should" be able to (71%) manage the general medical conditions of their patients in the future with supervision/consultation from a primary care provider. An additional 26% indicated that they would like to and/or should be able to independently manage both behavioral and general medical conditions for their patients. Nicotine dependence, hypertension, dyslipidemias, and non-insulin-dependent diabetes were among the top conditions residents felt they should be able to manage (≥ 74%). A lack of knowledge, experience, training, and supervision were the most frequent barriers residents listed in providing general medical care to patients (71%). Residents noted that supervision from a primary care physician (29%) and additional education (54%) would help increase their comfort in managing medical conditions. CONCLUSIONS: Psychiatry residents were generally interested in managing basic medical issues. Opportunities to expand residency training in integrated care should be considered. With new models of integrated care emerging, future studies should explore how resident attitudes might evolve over time, as well as the attitudes and opinions of practicing psychiatrists and supervisors on this topic.

Moonlighting by Psychiatry Residents: a Survey of Residents and Training Directors.

OBJECTIVE: This study sought to assess the prevalence of moonlighting among psychiatry residents; the perceived effects of moonlighting on resident recruitment, education, and liability; and policies and practices governing oversight. METHODS: In 2013, surveys were emailed to all general psychiatry residency programs that were accredited by the Accreditation Council for Graduate Medical Education and had available contact information (n = 183). Resident surveys were emailed to program coordinators with a request to forward the survey link to their residents. RESULTS: Responses were received from 63 program directors (34% response rate) and 238 residents (about 5% of total general psychiatry residents). Most psychiatry program directors (95%) indicated that their programs permit moonlighting. Moonlighting participation increased with each year of training, culminating with 67% of fourth year residents. Most residents and faculty (87%) agreed that moonlighting enhanced resident education. Thirty-seven percent of program directors reported having no oversight procedures in place to monitor moonlighting activities. Thirty-nine percent of resident survey responders reported having no supervision for at least one of their moonlighting activities and only 9% reported always having access to on-site supervision. CONCLUSION: Though limited by a low response rate, this study found that moonlighting seems to remain prevalent among psychiatry residents and widely accepted by psychiatry residency training programs. There appears to be relatively limited program oversight for moonlighting activities, many of which seem to lack close supervision.

Broadening the Lens of System-Based Practice: From Micro to Macro and Basic to Complex in Residency Training.

OBJECTIVE: This paper aimed to develop a model for understanding the various dimensions of system-based practice (SBP) and determine the extent to which psychiatry residents perform behaviors along these dimensions. METHODS: Sixty-one supervisors from seven psychiatry programs rated resident performance of SBP behaviors using a 60-item instrument. Multi-dimensional scaling and cluster analysis were conducted to determine how the instrument items related to one another and the larger concept of SBP. Average supervisor ratings between clusters were compared to determine resident performance along the identified SBP dimensions. RESULTS: The data supports a model of SBP defined along two dimensions: (1) from micro (patient) to macro (population-based) interventions and (2) from low to high system complexity. Residents were more likely to perform behaviors at the patient level compared to those at the population-based level. CONCLUSIONS: Training in SBP remains predominately focused on the doctor-patient level and not the greater system of health-care delivery.

Trends in MD/PhD Graduates Entering Psychiatry: Assessing the Physician-Scientist Pipeline.

OBJECTIVE: The goal of this study was to identify trends in MD/PhD graduates entering psychiatry, to compare these trends with other specialties, and to review strategies for enhancing the physician-scientist pipeline. METHODS: Data on 226,588 medical students graduating from Liaison Committee on Medical Education accredited programs between 1999 and 2012 (6626 MD/PhDs) were used to evaluate the number, percentage, and proportion of MD/PhDs entering psychiatry in comparison with other specialties (neurology, neurosurgery, internal medicine, family medicine, and radiation oncology). Linear regression and multiple linear regression determined whether these values increased over time and varied by sex. RESULTS: Over 14 years, an average of 18 MD/PhDs (range 13-29) enrolled in psychiatry each year. The number of MD/PhDs going into psychiatry significantly increased, although these gains were modest (less than one additional MD/PhD per year). The proportion of students entering psychiatry who were MD/PhDs varied between 2.9 and 5.9 per 100 residents, with no significant change over time. There was also no change in the percentage of MD/PhDs entering psychiatry from among all MD/PhD graduates. The rate of increase in the number of MD/PhDs going into psychiatry did not differ significantly from other specialties except for family medicine, which is decreasing. The rate of MD/PhDs going into psychiatry was higher for women, suggesting closure of the sex gap in 17 years. CONCLUSIONS: Despite the increase in the number of MD/PhDs entering psychiatry, these numbers remain low. Expanding the cohort of physician-scientists dedicated to translational research in psychiatry will require a multipronged approach.

Challenges and Opportunities in Global Mental Health: a Research-to-Practice Perspective.

PURPOSE OF REVIEW: Globally, the majority of those who need mental health care worldwide lack access to high-quality mental health services. Stigma, human resource shortages, fragmented service delivery models, and lack of research capacity for implementation and policy change contribute to the current mental health treatment gap. In this review, we describe how health systems in low- and middle-income countries (LMICs) are addressing the mental health gap and further identify challenges and priority areas for future research. RECENT FINDINGS: Common mental disorders are responsible for the largest proportion of the global burden of disease; yet, there is sound evidence that these disorders, as well as severe mental disorders, can be successfully treated using evidence-based interventions delivered by trained lay health workers in low-resource community or primary care settings. Stigma is a barrier to service uptake. Prevention, though necessary to address the mental health gap, has not solidified as a research or programmatic focus. Research-to-practice implementation studies are required to inform policies and scale-up services. Four priority areas are identified for focused attention to diminish the mental health treatment gap and to improve access to high-quality mental health services globally: diminishing pervasive stigma, building mental health system treatment and research capacity, implementing prevention programs to decrease the incidence of mental disorders, and establishing sustainable scale up of public health systems to improve access to mental health treatment using evidence-based interventions.

Evaluating an Advisor Program for Psychiatry Residents.

PURPOSE: A formal residency advisory program was instituted in 2010 to assist psychiatry residents in achieving academic and personal goals and to help identify additional mentors. In this project the authors sought to evaluate and improve resident and faculty satisfaction with the residency advisory program. METHODS: At the end of the 2013-2014 academic period, residents completed an anonymous survey to determine baseline satisfaction with the residency advisory program. A series of interventions were then implemented including the addition of a resident liaison to the program, formal recognition of faculty advisors, and email reminders regarding regular residency advisory meetings. Eight months later a follow-up survey was distributed to assess the impact of the interventions on resident and faculty satisfaction with the residency advisory program and mentoring within the residency program. RESULTS: There were notable improvements in overall satisfaction with a 58% increase (p<0.05) in residents meeting with their advisors. After the intervention, residents were more likely to seek their resident advisor for help in facilitating relationships with potential career mentors (28% vs 72%, OR=6.64, 95% CI =1.83-24.08). Although 87% of all residents reported having mentors outside of the formal residency advisory program, approximately half of those who are in their first year post medical school (PGY1s) reported having no mentors outside of the residency advisory program (notably all women). CONCLUSIONS: Resident advisory programs benefit from continuous evaluation and quality improvement with enhanced structure, including a senior resident position, leading to improved satisfaction. Residency advisory programs may be particularly useful in helping to facilitate relationships with other mentors, which may be particularly important for women early in their training.

Thinking Outside of Outpatient: Underutilized Settings for Psychotherapy Education.

OBJECTIVE: Although psychiatry residents are expected to achieve competency in conducting psychotherapy during their training, it is unclear how psychotherapy teaching is integrated across diverse clinical settings. METHODS: Between January and March 2015, 177 psychiatry residency training directors were sent a survey asking about psychotherapy training practices in their programs, as well as perceived barriers to psychotherapy teaching. RESULTS: Eighty-two training directors (44%) completed the survey. While 95% indicated that psychotherapy was a formal learning objective for outpatient clinic rotations, fifty percent or fewer noted psychotherapy was a learning objective in other settings. Most program directors would like to see psychotherapy training included (particularly supportive psychotherapy and cognitive behavioral therapy) on inpatient (82%) and consultation-liaison settings (57%). The most common barriers identified to teaching psychotherapy in these settings were time and perceived inadequate staff training and interest. CONCLUSIONS: Non-outpatient rotations appear to be an underutilized setting for psychotherapy teaching.

Smartphones, Smart Feedback: Using Mobile Devices to Collect In-the-Moment Feedback.

OBJECTIVE: The goal of this study was to streamline the collection of resident feedback in order to support faculty development and program improvement in psychiatry training. METHODS: The authors developed and implemented a brief, free, mobile survey to track resident feedback and class attendance. RESULTS: Prior to instituting this system, resident feedback was obtained semi-annually for each course (n = 90) and not each individual class. In comparison, this new system allowed the authors to collect feedback on 477 of the 519 classes held over the 2014-15 academic year (92 %). Written comments about the curriculum increased over tenfold from 42 in 2013-14 to 541 during a comparative time period in 2014-15. One year after instituting this new system, resident participation increased to 81 % on average (compared to 64 % previously). CONCLUSION: Mobile devices may provide an inexpensive and relatively untapped mechanism for improving the process of collecting resident feedback and tracking class attendance.

Teaching Dialectical Behavior Therapy to Psychiatry Residents: The Columbia Psychiatry Residency DBT Curriculum.

OBJECTIVE: Dialectical behavior therapy (DBT) is an evidence-based psychosocial treatment with efficacy in reducing self-harm behaviors in borderline personality disorder (BPD). This study describes and evaluates a clinical curriculum to teach DBT to psychiatry residents, developed at a large urban university hospital. The curriculum objectives are to (1) have psychiatry residents achieve basic understanding of DBT theory and clinical skill, (2) increase residents' ability and confidence in treating self-harm behaviors (both suicidal behavior and non-suicidal self-injury), and (3) enhance residents' willingness to treat individuals with BPD. METHODS: In addition to a 6-week didactic course on DBT offered to all residents (n = 62), 25 elected to enroll in a year-long DBT clinical training curriculum over the course of a 5-year period. The DBT clinical training consisted of 15 h of additional didactics, ongoing conduct of individual therapy and group DBT skills training, videotaping of individual therapy sessions, and weekly supervision meetings utilizing videotape to provide feedback. Residents participating in the clinical training program videotaped baseline and later sessions, which were rated for DBT adherence. All 62 graduates of the program were surveyed regarding the impact of the training on their practice of psychiatry. RESULTS: Upon graduation, a high percentage (87 % in the curriculum and 70 % in the didactic course only) reported incorporating DBT into their psychiatry practice, as well as willingness and confidence in treating BPD and self-harm behaviors. Residents participating in the clinical training demonstrated significant improvement in their ability to utilize DBT interventions, particularly in structuring sessions, problem assessment, problem solving, and using validation and dialectical strategies. CONCLUSION: This DBT curriculum was effective in preparing psychiatrists-in-training to incorporate evidence-based practices for effective treatment of BPD and self-harm behaviors and can serve as a model for teaching DBT during psychiatry residency training. Limitations include a small sample size and lack of baseline survey measurement of attitudes for pre- and post-curriculum comparison.

The Use of a Small Private Online Course to Allow Educators to Share Teaching Resources Across Diverse Sites: The Future of Psychiatric Case Conferences?

OBJECTIVE: The authors sought to demonstrate the feasibility of integrating small private online course (SPOC) technology with flipped classroom techniques in order to improve neuroscience education across diverse training sites. METHODS: Post-graduate medical educators used SPOC web conferencing software and video technology to implement an integrated case conference and in-depth neuroscience discussion. RESULTS: Ten psychiatry training programs from across the USA and from two international sites took part in the conference. Feedback from participants was largely positive. CONCLUSION: This pilot demonstrated the feasibility of such a program and provided a diverse audience with the opportunity to engage in an interactive learning experience with expert faculty discussants. This may be a useful model for programs with limited local expertise to expand their teaching efforts in a wide range of topics.

Psychopharmacology Prescribing Workshops: A Novel Method for Teaching Psychiatry Residents How to Talk to Patients About Medications.

OBJECTIVE: Traditional, lecture-based methods of teaching pharmacology may not translate into the skills needed to communicate effectively with patients about medications. In response, the authors developed an interactive course for third-year psychiatry residents to reinforce prescribing skills. METHODS: Residents participate in a facilitated group discussion combined with a role-play exercise where they mock-prescribe medication to their peers. Each session is focused on one medication or class of medications with an emphasis on various aspects of informed consent (such as describing the indication, dosing, expected benefits, potential side effects, and necessary work-up and follow up). In the process of implementing the course at a second site, the original format was modified to include self-assessment measures and video examples of experienced faculty members prescribing to a simulated patient. RESULTS: The course was initially developed at one site and has since been disseminated to a number of other institutions. Between 2010 and 2016, 144 residents participated in the course at the authors' two institutions. Based upon pre/post surveys conducted with a subset of residents, the course significantly improved comfort with various aspects of prescribing. Although residents may also gain comfort in prescribing with experience (as the course coincides with the major outpatient clinical training year), improvement in comfort-level was also noted for medications that residents had relatively little experience initiating. At the end of the year, half of the residents indicated the course was one of their top three preferred methods for learning psychopharmacology in addition to direct clinical experience and supervision (with none listing didactics). CONCLUSION: An interactive prescribing workshop can improve resident comfort with prescribing and may be preferred over a traditional, lecture-based approach. The course may be particularly helpful for those medications that are less commonly used. Based upon our experience, this approach can be easily implemented across institutions..

Recommendations for Primary Care Provided by Psychiatrists.

Recent studies have shown that people with severe mental illness have a dramatically lower life expectancy than the general population. Psychiatrists have not traditionally been very attentive to or involved with physical health issues and there has been growing emphasis on integrated care for physical and mental health and access to primary care for all members of the population. This paper examines the role of psychiatrists in the provision of primary care to the patients they treat. Some recommendations are offered for their involvement in the provision of primary care at three levels of complexity: Level 1--Universal Basic Psychiatric Primary Care; Level 2--Enhanced Psychiatric Primary Care; and Level 3--Fully Integrated Primary Care and Psychiatric Management. Some of the obstacles to the provision of primary care by psychiatrists are considered along with some suggestions for overcoming them.