Psychiatry Residency Training Research Articles

Clinical Practice Guidelines for the Therapeutic Use of Repetitive Transcranial Magnetic Stimulation in Neuropsychiatric Disorders.

Clinical Practice Guidelines for the Therapeutic Use of Repetitive Transcranial Magnetic Stimulation in Neuropsychiatric Disorders.

Ensino em psiquiatria cultural: rumo a uma atitude decolonial

Abstract: Introduction: This essay is based on the teaching experience of theTranscultural Psychiatry Program at the University of São Paulo (ProSol,Programa de Psiquiatria Transcultural da Universidade de São Paulo) and on theoretical foundations in the field of cultural psychiatry. Objective: To highlight the importance of teaching cultural psychiatry for the training of psychiatry residents. Results: Brazilian psychiatry, throughout its history, was marked by the incorporation of knowledge from developed countries with little concern for the Brazilian reality. The teaching of cultural aspects, in the psychiatric field, makes it possible to reactivate the importance of Brazilian reality and specificity for the teaching of residents. Conclusion: The central thesis of this essay is that the teaching of cultural psychiatry is a form of decolonization of teaching, insofar as it makes psychiatrists more apt to face the different clinical scenarios in a diverse country full of contradictions such as Brazil.

Integrated Care for Complicated Patients: A Role for Combined Training and Practice

Patients with chronic medical disease frequently have comorbid psychiatric illness, yet mental and physical healthcare is frequently siloed in the United States. Integrated behavioral healthcare models, such as medicine-psychiatry services, are feasible, improve patient outcomes, and reduce costs. The Duke University Hospital medicine-psychiatry service provides holistic patient care and serves as a model for those interested in developing combined services or training programs elsewhere. Combined residency training in psychiatry is a way to provide a workforce of physician-scientist educators adept at providing coordinated, integrated care for complex patients with comorbid illness.

Longitudinality Matters: Qualitative Perspectives on a Longitudinal Clinical Experience in a Psychiatry Residency Training Program.

Longitudinal models of clinical care and education can positively impact the patient and provider experience in terms of health outcomes, satisfaction, and motivation. While residency programs have seen an increase in primary care longitudinal clinical experiences (LCEs), defined as outpatient clinics in which patients are seen by residents over the course of their entire training, less is known about such opportunities in psychiatry residency programs. This qualitative study explores the impact of a longitudinal training model on psychiatric resident skill development, relationships in the clinical learning environment, and professional identity formation. The authors conducted 24 semi-structured interviews of residents, graduates, and faculty in three well-established LCE clinics in a single, multi-site, academic psychiatry residency program. Transcripts were analyzed using inductive thematic analysis techniques. Themes were categorized into benefits and challenges. For benefits, themes included longitudinal relationships, improved feedback, near-peer teaching, early outpatient exposure, graduated independence, skill development, patient population expertise, and solidification of professional identity. For challenges, themes included system logistics, offsite panel management, and intermittent presence of junior trainees. Results suggest that overall, residents and faculty find the LCE a positive learning opportunity that has contributed to their professional development. LCEs do appear to have distinct challenges, largely logistical in nature, which can interfere with the favorability of residents' experiences. Developing strategies up front to minimize these logistical challenges will support the success of a longitudinal program.

2.121 A Needs Assessment of Cyberbullying Curricula in Psychiatry Residency Training

Research indicates that most teens have faced some form of cyberbullying (Anderson, 2018; Cook, 2021). Cyberbullying victims are at higher risk of developing depression, self-harm, suicide attempts, substance abuse, and anxiety (Englander et al, 2017; John et al, 2018; Zhu et al, 2021). It is unclear how much instruction child and adolescent psychiatry trainees are provided on this topic. The purpose of this study is to assess trainees’ comfort in evaluating and treating victims of cyberbullying.

MANAGING INTRAFAMILIAL CONFLICT: “CATCHING THE BULLET” FROM EMOTIONALLY FOCUSED THERAPY

Family engagement and intervention have been associated with improved mental health treatment outcomes for patients of all ages. However, methods by which to prepare psychiatrists to effectively work with families have presented a challenge. Early career psychiatrists reported that family skills were the least taught during residency and among the skills most needed after graduation. To teach a circumscribed, clinically practical family skill with which to more effectively manage intrafamilial conflict, the NewYork-Presbyterian Child and Adolescent Psychiatry Residency Training Program developed a “catching the bullet” workshop, based on emotionally focused therapy (EFT).

Postgraduate Psychiatry Training Programme in Morocco

AimsThe field of psychiatry in Morocco has grown significantly since the 1970s, from less than 10 psychiatrists to the current number of around 400. The increased number of practising psychiatrists has enabled the expansion of local residency training programmes, which has been set up since 1974 to cater for the population needs of more than 36 million population of Morocco. This study is aimed to describe the current medical educational approach of the Moroccan postgraduate psychiatry training programme.MethodsThis descriptive medical educational study was based on official training documents and interviews with local faculty members involved in the training.ResultsThe entry requirement of the four-year Moroccan postgraduate psychiatry residency programme includes the completion of 1 year of foundation training and passing the entrance examination consisting of psychiatric semiology and pharmacology. The postgraduate residency programme is run by the local universities in collaboration with the Ministry of Health and accredited by the Moroccan government. Trainees have the option of taking up a voluntary or contractual position with the government or University Hospitals. All trainees will go through 34 months of general adult outpatient and inpatient, while liaison psychiatry training starts from the second year until the end of the training. On top of the core rotation, a trainee can opt for two months in old age and neuropsychiatry postings. Child and adolescent rotation is currently not available. Addiction psychiatry training is optional and can be done through a university diploma. The 4th year is a 12-month elective posting in any discipline that is relevant to psychiatry, which can be done either locally or abroad. Teaching methodologies involve lectures, seminars, ward rounds, case conferences, journal clubs, and skill training workshops. Formative assessments included case-based discussions and mini-clinical evaluation exercise. There are multiple high stakes summative assessments at year 1, year 2, year 3, and year 4. The summative assessment strategies includes modified essay question, clinical short case and long case. Viva voce is used to assess competency in research. Different mandatory skill competencies include electroconvulsive therapy, psychotherapy, and research.ConclusionThe advancement of local postgraduate psychiatry residency training in Morocco has improved the access of local trainees to quality training. Similar to other developing countries, Morocco requires more psychiatrists to improve the psychiatrists to population ratio so that the mental service can become more accessible to the local population.

Setting Common Standards for Reproductive Psychiatry Education: Effectiveness of the National Curriculum in Reproductive Psychiatry.

The National Curriculum in Reproductive Psychiatry (NCRP) provides standardized education for psychiatry residency training programs. The authors hypothesized that residents' preparedness to treat reproductive psychiatric concerns and their medical knowledge would improve following teaching with the NCRP. Pre- and post-assessments were administered to residents enrolled in two waves of pilot NCRP training (Early-Modules and All-Modules). Data were collected by individual survey, and pre- and post-responses matched via anonymous ID. Statistical analyses were conducted using R version 3.5.3 and included paired Student's t-tests and a chi-square test. Thirty-eight residents completed the Early-Modules survey and 16 the All-Modules survey. In both groups, there was significant improvement in preparedness to treat pregnant and postpartum women with mental illness (p<0.05). Scores on the 29-point knowledge test rose by 2.5 points in the Early-Modules group and 4.3 points in the All-Modules group (p<0.001 for both). In both cohorts, a majority of residents felt reproductive psychiatry was among the top three specialties needed to become competent independent adult psychiatrists. Classroom training with local faculty using a standardized curriculum is feasible and results in substantial and significant improvements in both feelings of preparedness and medical knowledge. Psychiatry trainees view training in reproductive psychiatry as an important and missing aspect of their education. Dissemination of a standardized curriculum may help to forge a path toward subspecialty certification for reproductive psychiatry, and can be used as a model for other specialties.

Sharing perspectives on feedback: a combined resident-faculty workshop

BackgroundFeedback is essential to medical education. Although the need for effective feedback delivery is well known, more recent focus is on understanding and strengthening the faculty-trainee relationship within which the feedback process is carried out. The authors developed and implemented a combined resident-faculty feedback workshop within a psychiatry residency training program to enhance participants’ understanding of challenges residents and faculty experience with the feedback process.MethodsThe one-hour workshop consisted of small group activities and large group discussions, focused on (i) feedback challenges for both residents and faculty and (ii) potential ways to address identified challenges. Participants completed pre-and post-workshop questionnaires to rate their level of understanding of, and answer open-ended questions regarding, feedback challenges. Mixed-methods assessment of questionnaire responses examined quantitative rating changes from pre- to post-workshop, as well as emergent qualitative themes from the open-ended responses.ResultsFrom a pool of 30 workshop participants, 26 completed each of the pre- and post-workshop questionnaires. Overall, participants were satisfied with the programming. Important considerations for the feedback process were (i) specific/constructive/timely feedback, (ii) meeting logistical/administrative feedback requirements, (iii) setting norms/expectations of effective/routine feedback, and (iv) relational/emotional considerations surrounding feedback. It appeared both faculty and residents were able to increase perspective taking about how the other group perceived the feedback process.ConclusionsThis pilot project is one of the first to examine a joint resident-faculty workshop focused on understanding how faculty and residents can interact to better understand each other’s perspective on the feedback process. Further work in this area is needed to identify common misperceptions and design programming to help correct them. Further research is also needed to examine the impact of such programming on the feedback process.

Improving Pharmacologic Management of Behavioral and Psychological Symptoms of Dementia (BPSD): An Algorithm for Real-World Care

The Psychopharmacology Algorithm Project at the Harvard South Shore Psychiatry Residency Training Program (www.psychopharm.mobi) aims to capture the essence of the available evidence on pharmacotherapy treatment of various psychiatric disorders. This presentation focuses on our recently published BPSD algorithm which will be updated to the time of the meeting. Major factors considered in the review included efficacy, side effects, and amount of evidence supporting the medication. Speakers will explain how this algorithm should be interpreted and utilized. Ample time will be available for questions and answers.Geriatric patients with dementia frequently present to psychiatrists and geriatricians with agitation, aggression, psychosis, and other psychological symptoms of dementia. We present an update of our previously published algorithm for the use of psychopharmacology in these patients, taking into account more recent studies and recommendations from meta-analyses, reviews, and other published algorithms. We propose three algorithms: one for BPSD in an emergent setting, one for an urgent setting, and another for non-emergent settings. In the emergent setting, the clinician, patient, or others are in imminent danger due to behaviors related to BPSD and rapid response is required. In the urgent BPSD setting, the patient is symptomatic, but there is the potential to wait for a few days to weeks for improvement. In the non-emergent setting, the patient does not appear to be at imminent risk of putting him/herself or others at harm but has a history of such behaviors which interfere with care or quality of life.Emergency management often requires intramuscular medication (IM) administration., Our first-line recommendation is olanzapine (IM aripiprazole, favored in our previous version, is no longer available). Haloperidol IM is the second choice, followed by consideration of IM benzodiazepine. In the urgent algorithm, when oral treatments are possible, first line recommendations are the second-generation antipsychotics (SGAs) aripiprazole and risperidone. We review the evidence for also considering prazosin and electroconvulsive therapy as alternatives. There are hazards associated with all of these agents, including increased risk of mortality, which are discussed. Dosing strategies, discontinuation considerations, and side effects will also be discussed. In the non-emergent setting, we recommend first decreasing anti-cholinergic load, optimizing pain management, and improving sleep. Medication options are proposed for use in the following order: trazodone, donepezil and memantine, the selective serotonin reuptake inhibitors escitalopram and sertraline, SGAs (aripiprazole and risperidone), prazosin, and carbamazepine. Finally, other emerging options with insufficient evidence to include in the algorithms but with potential future promise are also discussed.

United States of America Child and Adolescent Psychiatrists' Career Satisfaction by Career Stage.

This study sought to examine career satisfaction among United States of America child and adolescent psychiatrists (CAPs) across career stages, identifying predictive factors for their career satisfaction. A total of 526 CAPs responded to a national career satisfaction survey. Satisfaction was assessed via responses to statements about their career on a Likert scale. Career satisfaction was defined as the sum of the scores for satisfaction with their choice of career, career advancement, and career recognition. Responses were disaggregated by the number of years post child and adolescent psychiatry residency training (early career: 0-10years; midcareer: 11-20years; and late career: 21 + years post-training). Stepwise linear regression analyses identified predictive factors of career satisfaction. CAPs' career satisfaction was high (3.95) and increased with career stage. It was most positively correlated with advancement opportunities, job enjoyment, and control of assigned tasks, and most negatively correlated with workload. Job enjoyment was the leading predictive factor of career satisfaction for early career and late career CAPs, with midcareer CAPs identifying task assignment control as the leading contributor to their career satisfaction (all p = .000). Career satisfaction in Child and Adolescent Psychiatry is high, increases with career stage, and is most predicted by advancement opportunities. Further study of the predictive factors of CAPs' career satisfaction is warranted as we focus on increasing the workforce in child and adolescent psychiatry.

The conceptualisation of educational supervision in a National Psychiatry Residency Training Program

Introduction: Development of expertise and counselling skills in psychiatry can be mastered only with effective supervision and mentoring. The conceptualisations of educational supervision amongst supervisors and residents were explored in this study to understand how supervisory roles may have been affected by the adoption of competency-based psychiatry residency training. Methods: A qualitative research approach with thematic analysis was adopted. Individual in-depth interviews using a semi-structured interview guide with a purposive sample of six supervisors and six newly graduated residents were conducted. Transcripts of the interview were analysed and coded using the Atlas Ti software. Results: Four major themes emerged from analysis of the transcripts: (1) Meaning and definition of supervision; (2) Expectations and responsibilities of the educational supervisor; (3) Elusiveness of mentoring elements in educational supervision and (4) Personal and professional development of residents in supervision. Supervisors and residents perceived educational supervision narrowly to be transactional with acquisition of knowledge and skills, but residents yearned for more relational interactions. Conclusion: This study showed that the roles and functions of supervisors in educational supervision were unclear. It also highlighted the lack of a mentoring orientation in supervision in the psychiatry residency training program. An emphasis on assessment of competencies might have contributed to tension in the supervisory relationship and lack of a mentoring role, with concerns on residents’ personal and professional identity development in their psychiatry training.

Person-centred care in psychiatry: a clinical and philosophically informed approach

SUMMARYAfter many years of mental healthcare reform there is still a lot of unease among patients about healthcare workers’ lack of attention to their daily needs and to the tensions and ambiguities that accompany their attempts to integrate their condition into their lives. Person-centred care is often presented as a solution, but the term refers to many differing approaches and needs further specification depending on the problem it aims to resolve. This article presents and discusses a clinical and philosophically informed approach that flexibly focuses on the person- and context-bound aspects of the patient's condition and on the co-regulatory role of the clinician in the patient's attempt to regulate their condition. This approach is a way of thinking, rather than yet another model. It will be shown how this approach can be integrated in the core curriculum of specialty (residency) training in psychiatry.

6.9 Piloting a Video Lecture Series to Improve Training of Future Psychiatrists in Autism Spectrum Disorder and Intellectual Disability

Major gaps exist in training psychiatry residents in the care of individuals with autism spectrum disorder (ASD) and intellectual disability (ID), leaving trainees unprepared to manage these groups' significant mental health needs. To address these gaps, this pilot study assessed whether educational videos could improve knowledge, interest, and comfort in treating these populations among general psychiatry and child and adolescent psychiatry (CAP) trainees. Nine video lectures on the fundamentals of ASD/ID were developed by the AACAP Autism and Intellectual Disability Committee Training Workgroup, whose members have extensive expertise in ASD/ID. Program directors (PDs) of the Accreditation Council for Graduate Medical Education (ACGME)-approved general and CAP programs were invited to enroll in an IRB-approved study to incorporate these videos in their curriculum during the 2019-2020 academic year. Videos were shared with PDs online. Before and after each video, trainees completed brief online surveys on knowledge, interest, and comfort with ASD/ID topics. PDs completed a baseline survey on their trainees' experience in ASD/ID and a follow-up survey on the videos’ effectiveness. Independent samples t tests compared PD ratings of general and CAP trainees. Paired t tests compared trainees’ pre- and postvideo responses. PDs from 25 (10%) of general and 25 (18%) of CAP programs enrolled. At baseline, CAP PDs rated their trainees as having more interest (t36 = 2.07; p = 0.046) and skill (t36 = 3.92; p < 0.001) in patient care for ASD but not ID. Among 34 programs with trainee responses, both general (n = 186) and CAP (n = 89) trainees' knowledge improved after lectures on phenomenology, assessment, pharmacology, and school intervention, with moderate to large effect sizes (Cohen’s d = 0.49-1.39; p < 0.05). General but not CAP trainees endorsed greater comfort with patients with ASD and ID after these lectures (p < 0.05). Neither group endorsed more interest in working with these populations. On a scale of 1 to 5 (5 = excellent), PDs' ratings of video quality and benefit (mean ± SD) were 4.33 ± 1.04 and 4.23 ± 1.04, respectively. Video lectures improved trainees’ knowledge and comfort in working with patients with ASD and ID. Disseminating expert-developed videos in ASD/ID is an accessible strategy to nationally enhance training in this underserved area of psychiatry.

65.1 PSYCHODYNAMIC PSYCHOPHARMACOLOGY CURRICULUM FOR CHILD AND ADOLESCENT PSYCHIATRY

The phenomenon of polypharmacy or inadequate treatment with psychotropic medication is not an uncommon issue in child and adolescent clinical practice. Using psychodynamic theory can guide psychopharmacology treatment, especially when dealing with treatment-resistant patients or when the formulations are very complex. This raised questions about the best way to integrate psychodynamic concepts into psychopharmacology. Through the AACAP Psychodynamic Faculty Training and Mentorship Initiative (PFTMI), the presenter collaborated with his mentor, Horacio Hojman, MD, MBA, Associate Professor at Alpert Medical School at Brown University, Faculty at Boston Psychoanalytic Society and Institute, to develop a psychodynamic psychopharmacology curriculum for children and adolescent psychiatry residency training programs. This curriculum emphasizes the importance of establishing a therapeutic alliance and recognizing the meanings, both conscious and symbolic, of medication to everyone in the system of prescribing medications. Applying psychodynamic understanding and techniques can help child and adolescent psychiatry residents become effective prescribers; the residents will maintain their self-esteem and may experience less burnout. In this way, they can become increasingly motivated to learn psychodynamics and to apply this psychodynamic knowledge in their daily practice in a variety of clinical settings, especially in psychopharmacology. A psychodynamic approach to psychopharmacology can enhance the comprehensive biopsychosocial formulation and may result in better clinical outcomes for children and families.

Development and Implementation of a Chief Resident for Research Role in a Psychiatry Residency Training Program.

Psychiatry residency programs with robust research training can prepare physician-scientists to make contributions that advance the mental health field. Our psychiatry residency developed a chief resident for research position to help provide mentorship, community building, and advising around scholarly activities for residents. We present the process of implementing this new position in our residency to offer a model for engaging psychiatry residents in research.

65.3 DELIVERING PSYCHODYNAMIC PSYCHOTHERAPY SUPERVISION IN CHILD AND ADOLESCENT PSYCHIATRY FELLOWSHIP PROGRAMS

In this presentation, attendees will learn practical approaches to assess and/or improve the quality of psychodynamic supervision within child and adolescent psychiatry residency training programs. Attendees will also identify potential barriers to providing psychodynamic supervision in child and adolescent psychiatry training programs and engage in a discussion about creative solutions to remove these barriers.

Teaching emergency situations during a psychiatry residency programme using a blended learning approach: a pilot study

BackgroundEmergency psychiatry is an essential component in the training of psychiatry residents who are required to make patient-centred orientation decisions. This training calls for specific knowledge as well as skills and attitudes requiring experience. Kolb introduced a theory on experiential learning which suggested that effective learners should have four types of abilities: concrete experience, reflective observation, abstract conceptualisation and active experimentation.We aimed to evaluate a resident training programme that we designed for use in an emergency psychiatry setting based on the experimental learning theory.MethodsWe designed a four-step training programme for all first-year psychiatry residents: (i) theoretical teaching of psychiatric emergency knowledge, (ii) concrete experience of ability teaching involving an initial simulation session based on three scenarios corresponding to clinical situations frequently encountered in emergency psychiatry (suicidal crisis, hypomania and depressive episodes), (iii) reflective observation and abstract conceptualisation teaching based on videos and clinical interview commentary by a senior psychiatrist for the same three scenarios, (iv) active experimentation teaching during a second simulation session based on the same three frequently encountered clinical situations but with different scenarios.Training-related knowledge acquisition was assessed after the second simulation session based on a multiple-choice quiz (MCQ), short-answer questions and a script concordance test (SCT). The satisfaction questionnaire was assessed after the resident had completed his/her initial session in order to evaluate the relevance of teaching in clinical practice. The descriptive analyses were described using the mean (+/- standard deviation). The comparative analyses were conducted with the Wilcoxon or Student’s t tests depending on data distribution.ResultsThe residents’ mean MCQ and short-answer question scores and SCT were 7.25/10 (SD = 1.2) 8.33/10 (SD = 1.4), 77.5/100 (SD = 15.8), respectively. The satisfaction questionnaire revealed that 67 % of residents found the teaching consistent.ConclusionWe designed a blended learning programme that associated, classical theoretical learning to acquire the basic concepts, a learning with simulation training to experiment the clinical situations and a video support to improve learning of interview skills and memory recall. The residents indicate that this training was adequate to prepare them to be on duty. However, despite this encouraging point, this program needs further studies to attest of its efficiency.

Editorial introductions.

Editorial introductions.

Self-confidence in conducting forensic psychiatric evaluations among general psychiatrists in Indonesia

ObjectiveSeveral general psychiatrists experience lack of confidence when they perform forensic psychiatric evaluations that may be due to limited or insufficient training. This study aimed to determine whether structured forensic psychiatry educational modules are associated with general psychiatrists’ self-confidence in conducting forensic psychiatric evaluations in Indonesia. MethodA cross-sectional study was conducted with 246 general psychiatrists. A questionnaire was developed exclusively for this study by a group of experts based on relevant references and it was distributed online. Sample questions included: “How often do you perform forensic psychiatric evaluations?”, “As a general psychiatrist, are you confident in conducting forensic psychiatric evaluations?”, and “Do you experience any difficulties when conducting forensic psychiatric evaluations?” Data were analyzed through SPSS 20 for Windows; a p-value <0.05 indicated statistical significance. ResultsCompared to general psychiatrists who did not study structured forensic psychiatry educational modules during their residency training, those exposed to such modules reported confidence in conducting forensic psychiatric evaluations in the following cases: insanity defense in cases of violence, insanity defense, fitness to stand trial, malingering, capacity to consent to treatment, risk of recidivism, guardianship, and parenting capacity. Furthermore, those with higher self-confidence were less likely to experience difficulties in conducting forensic psychiatric evaluations. ConclusionStructured forensic psychiatry educational modules during general psychiatry residency training played an important role in the development of psychiatrists’ self-confidence.