Care Transitions in the Psychiatric Hospital: Focus on Older Adults.

Patients undergoing a care transition are vulnerable to duplication of services, conflicting care recommendations, and errors in medication reconciliation. Older adults may be more vulnerable to care transitions given their relatively higher medical burden, cognitive impairment, and frequent polypharmacy. In this Treatment in Geriatric Mental Health: Research in Action article, we first present the results of a quality improvement study examining the frequency of care transitions to and from the medical hospital among patients admitted to a university-affiliated psychiatric hospital. Among a sample of 50 geriatric adults and 50 nongeriatric adults admitted to the psychiatric hospital, we tallied the number of care transitions to and from the medical hospital. We found that the geriatric cohort was significantly more likely to experience this type of care transition (p = 0.012, Fisher's exact test) compared to the nongeriatric cohort. In the second part of this article, we use a clinical vignette to illustrate the types of medical errors that can occur as a vulnerable and frail older adult moves between acute psychiatric and medical settings. Finally, we list provider-level and systems-level evidence-based recommendations for how care of the patient in the vignette could be improved. The quality improvement study and clinical vignette demonstrate how older adults are at greater risk for care transitions to and from the acute medical setting during psychiatric hospitalization, and that creative solutions are required to improve outcomes.

Self-Assessment of Teaching Skills Among Psychiatric Residents.

OBJECTIVE: Psychiatry residency programs have increasingly emphasized the role of resident-as-teacher; however, little is known about resident self-perceptions of teaching skills. This study reports on psychiatry residents' self-perceived skills in teaching medical students and compares cohort ratings with anonymous medical student evaluations of residents as teachers at our large academic residency program. METHODS: In May-June 2016, 84 residents in our program were surveyed using an anonymous, web-based survey, and this data was then compared to 3 years of aggregate data from anonymous student evaluations of resident teaching at our institution. RESULTS: Forty-seven (47) residents responded to the survey (56% response rate). Residents reported self-perceived deficits in several specific teaching competencies. Medical students consistently rated residents higher with respect to teaching skills than residents rated themselves, and these data were highly statistically significant. CONCLUSION: This study underscores the benefits of resident self-assessment in comparison to medical student evaluations of residents as teachers and this information can be used to inform training programs' resident-as-teacher curricula.

Assessing Career Outcomes of a Resident Academic Administrator, Clinician Educator Track: A Seven-Year Follow-up.

OBJECTIVE: This study reports the academic outcomes, including scholarly productivity, of the graduates of one residency training track for future clinician educators and academic administrators. Since its implementation in 2008, the Academic Administrator, Clinician Educator (AACE) track at Western Psychiatric Institute and Clinic - UPMC has grown in popularity with reports of participants achieving post-graduate academic success; however, there has been no prior assessment of outcomes. METHODS: In 2015 all graduates of the track were surveyed using an anonymous, web-based survey. Twenty-nine total graduates were surveyed RESULTS: Twenty-four graduates responded to the survey (83% response rate). The graduates are very active in academic psychiatry with 23 (96%) holding an academic appointment with different administrative roles, medical director (50%) and training director (17%) being the most frequent. Participants have also been active in pursuing scholarship with 80% presenting their scholarly projects at local and national conferences and producing post-graduate, peer-reviewed articles (50%). CONCLUSION: This study underscores the benefits of a clinician educator track and suggests areas for future growth.

Self-Enucleation and Severe Ocular Injury in the Psychiatric Setting.

BACKGROUND: Although the first medically-reported case of auto-enucleation was described in the mid-19th century, ocular self-gouging has long been depicted in historical legend and mythology. Cases of enucleation have since been identified across various cultures. Though relatively uncommon, this major form of self-mutilation now afflicts approximately 500 individuals per year, and may present more commonly among certain clinical populations. METHODS: We present 2 cases of self-enucleation in patients with psychotic illnesses and review existing literature on the history of enucleation, associated pathology, and management (both medically and psychiatrically) for this serious form of self-injury. RESULTS: Literature review includes a brief historical perspective of auto-enucleation and its context in psychosomatic medicine, with cases to highlight key aspects in the prevention and management of ocular self-injury. Normal eye pathology is described briefly, with a focus on medical care after self-inflicted damage, as pertinent to consultation psychiatrists. Interventions for behavioral and pharmacologic management of agitation and impulsivity are reviewed, including consideration for electroconvulsive therapy, in this particular context. CONCLUSION: Although severe ocular self-injury is uncommon, psychiatrists should be familiar with approaches to prevent and manage auto-enucleation in individuals at risk thereof. Consultation psychiatrists must work closely with ophthalmologists to address affective, behavioral, and cognitive triggers and complications of ocular self-injury.

Physical Examination for the Academic Psychiatrist: Primer and Common Clinical Scenarios.

As clinical psychiatry has evolved to mirror the patient care model followed in other medical specialties, psychiatrists are called upon increasingly to utilize general medical skills in routine practice. Psychiatrists who practice in academic settings are often required to generate broad differential diagnoses that include medical and neurologic conditions and, as a result, benefit from incorporating physical examination into their psychiatric assessments. Physical examination allows psychiatrists to follow and to teach patient-informed clinical practices and comprehensive treatment approaches. In this commentary, the authors encourage routine use of a targeted physical examination and outline common scenarios in which physical examination would be useful for the academic psychiatrist: delirium, toxidromes, and unexplained medical conditions (e.g., somatic symptom disorders).

Introducing a psychosomatic medicine interest group for psychiatry residents.

BACKGROUND: Having gained subspecialty certification in 2003, the field of psychosomatic medicine (PM) addresses the mental health needs of individuals who suffer from general medical conditions. The rising prevalence of chronic illness, along with trends in medical delivery toward more collaborative models of care, underscores the value of recruitment to PM specialty programs. OBJECTIVES: To foster interest and education in PM, we have developed and implemented a Psychosomatic Medicine Interest Group for trainees within a psychiatry residency program. RESULTS: Participants have found the Psychosomatic Medicine Interest Group to be an enjoyable experience that has improved their clinical practice and interest in PM. CONCLUSION: The Psychosomatic Medicine Interest Group has also been a successful vehicle to enhance clinical knowledge and mentoring opportunities during training, while bolstering residents' desire to pursue a career in PM.

Teaching a neuromedical-contextual approach to psychosomatic medicine.

The practice of psychosomatic medicine in the general hospital setting can be challenging, particularly for the inexperienced trainee. Guidance for how to approach a psychiatric consultation can be nonspecific or lacking altogether. In response, we offer a pedagogical model that emphasizes patient-specific neurological, medical, and contextual variables. A stepwise, "ABC" approach to psychiatric consultation is elaborated, beginning with collection of critical history ("Admission, Background, Consultation Question"), followed by both patient encounter ("Appearance, Behavior, Context") and actual patient examination ("Arousal, Brain/Body, Cognitive Assessment"), ultimately informing any given case formulation. Multiple clinical vignettes illustrate this approach and are offered for educational purposes in dissemination to trainees.

Managing benzodiazepine withdrawal during pregnancy: case-based guidelines.

Substance use disorders during pregnancy pose serious risks for both the mother and the fetus, demanding careful monitoring by the patient's medical providers. Sedative-hypnotic use, in particular, is common but remains poorly studied. Management of withdrawal from chronic benzodiazepine use during pregnancy presents unique challenges to the treating physician. We present two pregnant patients with dependence on sedative-hypnotic agents, outline principles of benzodiazepine withdrawal, and suggest guidelines for detoxification during pregnancy.

Longitudinal interdisciplinary neuroscience curriculum.

OBJECTIVE: Enhancing neuroscience education during psychiatry residency training requires the organization of comprehensive and longitudinal pedagogy in various aspects of clinical neuroscience. This process can be complex, and limited structured guidance is available for how to implement such a curriculum. The authors' principal goal was to develop a longitudinal interdisciplinary neuroscience curriculum that spans 4 years, promotes collaboration of educators from multiple departments, and can be generalized to other psychiatry programs. METHODS: The authors implemented a 4-year curriculum in a stepwise manner during psychiatry residency training. They obtained feedback and used it for improvement. RESULTS: Positive feedback was given for the curriculum, with improvement to scores across 2 years. CONCLUSIONS: Development of a clinical neuroscience curriculum at the authors' program provides a potential framework for implementation in other psychiatry residency programs.

Pain in the ICU: a psychiatric perspective.

Pain is abundant in the intensive care unit (ICU). Successful analgesia demands a comprehensive appreciation for the etiologies of pain, vigilant clinical assessment, and personalized treatments. For the critically ill, frequent threats to mental and bodily integrity magnify the experience of pain, challenging clinicians to respond swiftly and thoughtfully. Because pain is difficult to predict and physiologic correlates are not specific, self-report remains the gold standard assessment. When communication is limited by intubation or cognitive deficits, behavioral pain scales prove useful. Patient-tailored analgesia aspires to mitigate suffering while optimizing alertness and cognitive capacity. Mindfulness of the neuropsychiatric features of pain helps the ICU clinician to clarify limits of traditional analgesia and identify alternative approaches to care. Armed with empirical data and clinical practice recommendations to better conceptualize, identify, and treat pain and its neuropsychiatric comorbidities, the authors (psychiatric consultants, by trade) reinforce holistic approaches to pain management in the ICU. After all, without attempts to understand and relieve suffering on all fronts, pain will remain undertreated.