Emergency Psychiatry Training Research Articles

How we developed an emergency psychiatry training course for new residents using principles of high-fidelity simulation

New psychiatry residents must rapidly acquire new clinical skills and learn to work effectively with new colleagues. In medical and surgical specialties, high-fidelity simulation with structured debriefing is widely used, but so far this has not been applied to psychiatry. We have developed a one-day simulation-based training course for emergency psychiatry which incorporates clinical and team-working skills training. Five scenarios covering key psychiatric emergencies are delivered in a purpose-built simulation facility. Patients are played by an actor or a high-fidelity manikin. Each scenario is followed by a 45-minute group debrief. Evaluation of a pilot group found that the course was well received and improved participants' workplace confidence. We are now planning to expand the course, provide it to all new residents and conduct further evaluation.

A Preliminary Report on Resident Emergency Psychiatry Training From a Survey of Psychiatry Chief Residents

The Accreditation Council for Graduate Medical Education (ACGME) requirements stipulate that psychiatry residents need to be educated in the area of emergency psychiatry. Existing research investigating the current state of this training is limited, and no research to date has assessed whether the ACGME Residency Review Committee requirements for psychiatry residency training are followed by psychiatry residency training programs. We administered, to chief resident attendees of a national leadership conference, a 24-item paper survey on the types and amount of emergency psychiatry training provided by their psychiatric residency training programs. Descriptive statistics were used in the analysis. Of 154 surveys distributed, 111 were returned (72% response rate). Nearly one-third of chief resident respondents indicated that more than 50% of their program's emergency psychiatry training was provided during on-call periods. A minority indicated that they were aware of the ACGME program requirements for emergency psychiatry training. While training in emergency psychiatry occurred in many programs through rotations-different from the on-call period-direct supervision was available during on-call training only about one-third of the time. The findings suggest that about one-third of psychiatry residency training programs do not adhere to the ACGME standards for emergency psychiatry training. Enhanced knowledge of the ACGME requirements may enhance psychiatry residents' understanding on how their programs are fulfilling the need for more emergency psychiatry training. Alternative settings to the on-call period for emergency psychiatry training are more likely to provide for direct supervision.

Postgraduate Year-1 Residency Training in Emergency Psychiatry: An Acute Care Psychiatric Clinic at a Community Mental Health Center

The purpose of this study was to determine resident satisfaction with an acute care psychiatric clinic designed in collaboration with a nearby community mental health center. We also sought to demonstrate that this rotation helps meet program requirements for emergency psychiatry training, provides direct assessments of resident interviewing skills and clinical knowledge in the postgraduate year-1, and provides exposure to public sector systems of care. We developed a resident satisfaction questionnaire and fielded it to each of the residents who participated in the clinic over the first 3years. Data were collected, organized, and analyzed. Of the 15 residents in the acute care psychiatric clinic, 12 completed and returned the satisfaction questionnaires. Educational aspects of the clinic experience were rated favorably. This postgraduate year-1 acute care psychiatric clinic provides a mechanism for the fulfillment of emergency psychiatry training as well as direct supervision of clinical encounters, which is a satisfactory and useful educational experience for trainees.

Emergency Psychiatry Training for Third-Year Medical Students as Reported by Directors of Medical Student Education in Psychiatry

Background: Physicians can expect to confront a variety of psychiatric emergencies during their careers. However, medical schools are not required to teach emergency psychiatry and little is known about the content of existing instruction.Purposes: We conducted this survey to better understand the emergency psychiatry experiences provided to 3rd-year medical students.Methods: Directors of medical student education in psychiatry at U.S. medical schools were mailed a 1-page questionnaire about their school's instruction in emergency psychiatry.Results: We received 74 responses from the 122 U.S. medical schools (61%). All but 4 reported emergency psychiatry instruction. The number of hours and type of settings students were on-call varied greatly from school to school, as did the scope of faculty supervision.Conclusions: Most schools provide emergency psychiatry instruction, but methods vary among institutions. Given its importance, medical schools should work to provide uniformity in the way emergency psychiatry is taught.

Residency Training in Emergency Psychiatry

Independent random samples of residency training programs were surveyed in 1980 and in 1990 about their emergency psychiatry training. A larger percentage of the programs required daytime emergency service duty in 1990 (80%), compared with 1980 data (50%), and a larger percentage offered a daytime block training rotation, defined as at least 5 days a week of emergency psychiatry for at least 4 weeks (48%), compared with 23% in 1980. Each sample reported that the most important topics in emergency psychiatry were being taught. In 1990, two trends were noted: 1) more faculty psychiatrist time allocated to the emergency service, and 2) more emergency patient visits per shift. In 1990, the residents said they felt more stressed by the heavy patient load and lack of disposition facilities than in 1980, but less stressed by the lack of faculty interest and backup. Based on the data, the interpretation was made that emergency psychiatry training had improved over this period; however, it was indicated that further improvement was also needed.

Emergency Psychiatry Training and the Decision to Hospitalize

To assess the impact of a 6-month emergency psychiatry training program on emergency psychiatric decision making, we studied 577 emergency psychiatric patient evaluations conducted by 15 first-year psychiatry residents. By their fifth month of training, the residents' rates of emergency patient hospitalization declined from 33% to 19%. For residents in the early training phase, various clinical features, including psychosis, thought disorder, schizophrenic diagnosis, dangerousness, and overall symptoms, were associated with higher rates of patient hospitalization. By the end of training, only dangerousness and overall symptoms remained significantly related to the hospitalization decision. Specific training in emergency psychiatry may affect psychiatric decision-making practices as early as the first year of residency training.

Weaknesses in Emergency Psychiatric Education: A Solution

Emergency psychiatry training is beset by various problems although it is recognized as essential for psychiatrists. Trainees often function under such adverse circumstances that constructive learning is impossible. An important case of these problems is the lack of integration of emergency room training with other departmental activities. In an attempt to address this difficulty an off-hours volunteer teaching program was developed. The author describes this aspect of a large training program in emergency psychiatry which has had numerous benefits, including the integration of the emergency service with the rest of the department, the education of the faculty about emergency psychiatry and the promotion of the feeling in trainees that their work is appreciated and important. Under such positive circumstances, effective learning can and does take place.

Emergency psychiatry training: The new old problem

Unevenness in emergency psychiatry training is still an issue as borne out by a recent literature review. An emergency setting in a general hospital is described with its attendant problem areas for psychiatric residents' function and learning. An adaptable curriculum is reported that takes into account limits of time, finances, and faculty.

Psychiatric Residency Training in the Management of Emergencies

As a psychiatry resident on the Emergency Service or on call at night, the resident learns to function on several levels, as consultant, liaison, colleague, and occasionally as primary physician. At the outset, the resident needs to know that he or she is not expected to know all that yet. It is especially necessary to emphasize to a beginning resident that it is acceptable and important to ask for help. The resident is never the only physician caring for an emergency department patient. There should always be other psychiatry residents, psychiatry attending physicians, other house staff, and emergency medicine attending physicians who can help and often have an interest in each patients. The resident has an obligation to involve other physicians if there is uncertainty about the proper moves to make, and an obligation to discuss the management of a patient with the physician who initially consulted, as well as any other doctors responsible for the patient. Emergency cases can be discussed at morning rounds as well as at various seminars. The resident should also know that an interested or helpful ear can always be found among more experienced residents and attending physicians. The supervisor may present the option to the resident that he or she is available to see the patient with the resident, afterwards, or not at all, and can teach by watching and commenting, by modeling, and by supervision of the observations and reactions that the resident presents. There are a number of benefits to these models of emergency psychiatry training. In the first place, all of the drawbacks seen in present systems are addressed or avoided. The psychiatry resident retains his or her identity as a physician, working in consultation and cooperation with other physicians in a medical facility, rather than in a community clinic or psychiatric hospital. When a resident sees an emergency patient in revisit one or two days later, the resident has the opportunity to observe the effect of the psychotherapeutic intervention. One outcome of this observation is a decreased reliance on medication, and an increased use of outpatient modalities. The resident also gains an appreciation of the mental health system as he or she must work with many agencies and many levels of care.