Acad Psychiatry DOI 10.1007/s40596-015-0294-0
IN DEPTH ARTICLE: COMMENTARY
21st Century Training in Psychosis John Lauriello
Received: 17 September 2014 / Accepted: 23 January 2015 # Academic Psychiatry 2015
It is much more important to know what sort of a patient has a disease than what sort of disease a patient has. —Sir William Osler It was 1985; I sat at a table, playing cards with a fellow medical student, and two patients admitted to our assigned psychiatry clerkship service. One of the patients, an affable young African American man, was roughly my age. We talked about what led to his hospitalization, and he spoke of the prejudice he had encountered at the large state university he had attended, failing school and suffering a “nervous breakdown.” The conversation alternated between lucid insights into his experience and overt paranoia and anger about his old school and people in general. During my month-long rotation, we talked, played cards and chess (well, he played chess—I tried to keep up), and got to know each other. He was not just a case to discuss in a daily progress note; he was a person, not unlike me, whose life had taken a different path. He had encountered the stress of being an outcast at school and, due to his illness, was unable to complete school or work a full-time job. Several times he said to me, “I could have been a doctor like you.” Today, I have forgotten the specifics of his diagnosis and treatment, but I remember the man: a funny, frightened, and sometimes frightening person. In this issue of Academic Psychiatry, there are several excellent articles on training learners in interviewing and assessment during medication management visits, discussing the diagnosis and prognosis of schizophrenia,
J. Lauriello (*) University of Missouri Columbia, Columbia, MO, USA e-mail: [email protected]
and providing education on medication management of second-generation antipsychotics. Each has applications to our everyday training of medical students and residents. There is a common theme in these articles, reflecting the current movement in medicine. Reduce variability, employ testable algorithms, and use state-of-the-art simulation to prepare for the real thing. Psychiatry lags in this current standardization effort and could benefit from more attention to this from our discipline and the field of medicine in general. For example, the Centers for Medicare and Medicaid Services’ “Partnership for Patients” has identified 10 indicators for preventing hospitalizations and readmissions, and none are specifically related to psychiatry [1]. In pursuit of this, Phelps et al. [2] demonstrate how a structured approach to the psychiatric medication management visit can elicit information, include psychotherapeutic principles, and allow the patient and family more input into the visit. Their model employed at the University of South Carolina is comprehensive, and I would guess superior to the current “nonspecific model” used in most clinics. In our outpatient resident clinics, we have variability in residents’ competency and rapport with patients. In some cases, the resident is overwhelmed by the workload and pace or not very attune to the patient’s struggles because of cultural or socioeconomic differences. The benefit of a structured approach, like the one Phelps et al. present, is that it allows a comprehensive approach (i.e., the six Es—Elicit, Externalize, Exceptions, Empathy, Enactment, and Education) in the limited available time. The six Es attempt to improve information gathering while showing empathy and fostering interaction with the patient and family. This is certainly the direction we would like our residents to learn. There is some risk, especially starting out, that such a process might be applied too concretely, that making sure everything is covered (all the Es are “met”) may
Acad Psychiatry
impede simply talking to and getting to know the patient. It is already difficult for residents to develop a deep connection with their patients because as residents, they are only going to be the doctor for a limited period, usually a year. We see the effect of this every day in our outpatient clinics; the patients often feel they have to “start all over again” each year with a new resident. Often, a patient will develop a good therapeutic alliance with a resident and regret the inevitable turnover. I have found that, as a clinic supervisor, one of my roles is to bridge the gap from resident to resident. In this way, the diagnostic and treatment history gleaned by successive residents is faithfully carried by the attending. The attending is able to provide a personal, in the moment, handoff to the incoming resident, and the patient feels that his or her care has continuity despite the year-to-year resident change. One can envision that using the six Es approach coupled with continuity via the attending could improve management and patient satisfaction. A significant challenge for both trainees and newly graduated residents is sharing a serious diagnosis and prognosis with a patient and his or her family. In a very comprehensive survey of 550 mental health care facilities in the Czech Republic, Motlová et al. [3] examined the availability of psycho education about schizophrenia in that country. As in many other parts of the world, they found gaps in educating patients and families about diagnosis, the need for continuous treatment, and warning signs of relapse. They followed up the survey with focus groups and individual interviews. In addition to the need for more efforts in this area, the authors report that there was a mismatch between the allocated time the educators gave to subject matter and the information the patients and relatives wanted. As might be expected, the clinical team concentrated on medications and treatment options, whereas the families wanted more “practical training on recognition and management of relapse.” Lecturing on treatment is a comfortable practice for most providers; it is more difficult and complex to discuss the possibility (in some expert opinions, inevitability) of a relapse and how to intervene early enough to prevent or shorten a relapse episode. Similarly, Outram et al. [4] from the University of Newcastle in Australia recruited a number of mental health clinicians to better understand their belief system and experiences on how to communicate a diagnosis of schizophrenia. Similar to the Czech report [3], these authors report that communicating diagnostic information about schizophrenia to families was generally unplanned and inconsistent [4]. This lack of planning led to “tension” between different members of the multidisciplinary team, especially on who should take the lead in discussions with patient and family. In order to address this type of problem, Loughland et al. [5], from the University of Newcastle, describe a simulation model that focuses on an existing training module (the ComSkil) that incorporates intensive role-playing for trainees with simulated patients that allows practice and feedback on how to discuss
the diagnosis and prognosis of patients with early presentation of schizophrenia. Simulation has become an integral part of medical student training, allowing practice to occur without undo “practicing on the patient.” Students can make some rather blatant mistakes when they start out, and making those mistakes with an actor may prevent them in the actual clinical setting. Simulation may also ensure that the most important clinical conditions are covered by all students, who may have variable and limited experiences on their clinical rotations. Students and residents today, however, spend less and less time with patients, and simulation, while attempting to fill this gap, may give one a false sense of competency. It is understandable that duty-hour restrictions, ever growing paperwork (more accurately, computer work) pull the student and resident away from the bedside [6]. Today, many learners have limited physical contact with patients; they do not draw blood as often or perform as many procedures (e.g., administer chemotherapy) that necessitated being at the bedside. It is very hard to avoid talking to patients when one is pushing intravenous medication, to ask about their family, or for them to bring up their fear of getting sick from the chemotherapy or even dying. Twenty-five years ago, psychiatry residents might have spent up to a month with the average inpatient, and today, that length of stay is usually less than a week. Whereas clinical simulation exercises are a relatively new practice, medical handbooks have been available for a long time, including the MGH/McLean Hospital Residency Handbook of Psychiatry and the Harriet Lane Handbook for pediatric residents [7, 8]. These handbooks help operationalize practice and break down a large and daunting practice into digestible bits. Gibson et al. [9] report on an educational handbook they developed on the use of antipsychotics in children. The handbook focused on secondgeneration antipsychotics use in children and adolescents, and the authors employed pre- and post-testing to evaluate the effectiveness of their method. Their results were mixed; the handbook was shown to improve learning in some, but not all, areas of care. In a 2013 issue of this journal, Freudenreich et al. [10] described a successful intensive teaching model for prescribing clozapine, with similar pre- and post-testing. Developing clinical manuals with pre- and post-testing appears to help standardize and reinforce essential learning points but may not be practical for covering all areas of study. The future may lay in accessing information, not memorizing it. With information available at one’s digital fingertips, teaching learners to efficiently look up material may be the best approach. Yes, some information, used repetitively, will sink in, but even that information needs continuous updating. So, what is the best way to train students and residents? Providing simulation, manuals, and practice algorithms have value. More research and study on the use of simulation, education manuals, and pre- and post-testing should advance our teaching and practice. In these efforts, I hope we will not
Acad Psychiatry
neglect the value of just spending time with patients. I learned more from “hanging out” with my patients during my psychiatry clerkship than anything I read. It is not a coincidence that some of our best residents are individuals who previously worked with people with mental illness in nonmedical positions. Should we set aside time for trainees to spend time in the day room, playing cards with psychiatric patients; to help with meals in a nursing home; or to visit patients in their homes? I think that might go a long way.
4.
5.
6.
Disclosure The author states that there is no conflict of interest. 7.
References 8. 1. Centers for Medicare & Medicaid Services. Partnership for Patients. Available at http://partnershipforpatients.cms.gov/about-thepartnership/what-is-the-partnership-about/lpwhat-the-partnership-isabout.html. Accessed 21 Jan 2015. 2. Phelps K, Bullard C, Helps S, Getz A. Building strengths with the six Es of medication management. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0164-1. 3. Motlová LB, Dragomirecká E, Blabolová A, Španiel F, Slováková A. Psychoeducation for schizophrenia in the Czech Republic:
9.
10.
curriculum modification based on opinions of service users and providers. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0234-4. Outram S, Harris G, Kelly B, Cohen M, Bylund CL, Landa Y, et al. Contextual barriers to discussing a schizophrenia diagnosis with patients and families: need for leadership and teamwork training in psychiatry. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0226-4. Loughland C, Kelly B, Ditton-Phare P, Sandhu H, Vamos M, Outram S, et al. Improving clinician competency in communication about schizophrenia: a pilot educational program for psychiatry trainees. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0195-7. Block L, Habicht R, Wu AW, Desai SV, Wang K, Silva KN, et al. In the wake of the 2003 and 2011 duty hour’s regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013;28:1042–7. Rosenquist J, Nykiel S, Chang T, Sanders K, editors. MGH/Mclean residency handbook of psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2010. Tschudy M, Arcara K. The Harriet Lane Handbook: A Manual for Pediatric House officers. Elsevier Mosby. 2012. Gibson J, Nguyen D, Davidson J, Panagiotopoulos C. Effectiveness of an educational handbook in improving psychiatry resident knowledge of second-generation antipsychotics. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0177-9. Freudenreich O, Henderson DC, Sanders KM, Goff DC. Training in a clozapine clinic for psychiatry residents: a plea and suggestions for implementation. Acad Psychiatry. 2013;37:27–30.
IN DEPTH ARTICLE: COMMENTARY
21st Century Training in Psychosis John Lauriello
Received: 17 September 2014 / Accepted: 23 January 2015 # Academic Psychiatry 2015
It is much more important to know what sort of a patient has a disease than what sort of disease a patient has. —Sir William Osler It was 1985; I sat at a table, playing cards with a fellow medical student, and two patients admitted to our assigned psychiatry clerkship service. One of the patients, an affable young African American man, was roughly my age. We talked about what led to his hospitalization, and he spoke of the prejudice he had encountered at the large state university he had attended, failing school and suffering a “nervous breakdown.” The conversation alternated between lucid insights into his experience and overt paranoia and anger about his old school and people in general. During my month-long rotation, we talked, played cards and chess (well, he played chess—I tried to keep up), and got to know each other. He was not just a case to discuss in a daily progress note; he was a person, not unlike me, whose life had taken a different path. He had encountered the stress of being an outcast at school and, due to his illness, was unable to complete school or work a full-time job. Several times he said to me, “I could have been a doctor like you.” Today, I have forgotten the specifics of his diagnosis and treatment, but I remember the man: a funny, frightened, and sometimes frightening person. In this issue of Academic Psychiatry, there are several excellent articles on training learners in interviewing and assessment during medication management visits, discussing the diagnosis and prognosis of schizophrenia,
J. Lauriello (*) University of Missouri Columbia, Columbia, MO, USA e-mail: [email protected]
and providing education on medication management of second-generation antipsychotics. Each has applications to our everyday training of medical students and residents. There is a common theme in these articles, reflecting the current movement in medicine. Reduce variability, employ testable algorithms, and use state-of-the-art simulation to prepare for the real thing. Psychiatry lags in this current standardization effort and could benefit from more attention to this from our discipline and the field of medicine in general. For example, the Centers for Medicare and Medicaid Services’ “Partnership for Patients” has identified 10 indicators for preventing hospitalizations and readmissions, and none are specifically related to psychiatry [1]. In pursuit of this, Phelps et al. [2] demonstrate how a structured approach to the psychiatric medication management visit can elicit information, include psychotherapeutic principles, and allow the patient and family more input into the visit. Their model employed at the University of South Carolina is comprehensive, and I would guess superior to the current “nonspecific model” used in most clinics. In our outpatient resident clinics, we have variability in residents’ competency and rapport with patients. In some cases, the resident is overwhelmed by the workload and pace or not very attune to the patient’s struggles because of cultural or socioeconomic differences. The benefit of a structured approach, like the one Phelps et al. present, is that it allows a comprehensive approach (i.e., the six Es—Elicit, Externalize, Exceptions, Empathy, Enactment, and Education) in the limited available time. The six Es attempt to improve information gathering while showing empathy and fostering interaction with the patient and family. This is certainly the direction we would like our residents to learn. There is some risk, especially starting out, that such a process might be applied too concretely, that making sure everything is covered (all the Es are “met”) may
Acad Psychiatry
impede simply talking to and getting to know the patient. It is already difficult for residents to develop a deep connection with their patients because as residents, they are only going to be the doctor for a limited period, usually a year. We see the effect of this every day in our outpatient clinics; the patients often feel they have to “start all over again” each year with a new resident. Often, a patient will develop a good therapeutic alliance with a resident and regret the inevitable turnover. I have found that, as a clinic supervisor, one of my roles is to bridge the gap from resident to resident. In this way, the diagnostic and treatment history gleaned by successive residents is faithfully carried by the attending. The attending is able to provide a personal, in the moment, handoff to the incoming resident, and the patient feels that his or her care has continuity despite the year-to-year resident change. One can envision that using the six Es approach coupled with continuity via the attending could improve management and patient satisfaction. A significant challenge for both trainees and newly graduated residents is sharing a serious diagnosis and prognosis with a patient and his or her family. In a very comprehensive survey of 550 mental health care facilities in the Czech Republic, Motlová et al. [3] examined the availability of psycho education about schizophrenia in that country. As in many other parts of the world, they found gaps in educating patients and families about diagnosis, the need for continuous treatment, and warning signs of relapse. They followed up the survey with focus groups and individual interviews. In addition to the need for more efforts in this area, the authors report that there was a mismatch between the allocated time the educators gave to subject matter and the information the patients and relatives wanted. As might be expected, the clinical team concentrated on medications and treatment options, whereas the families wanted more “practical training on recognition and management of relapse.” Lecturing on treatment is a comfortable practice for most providers; it is more difficult and complex to discuss the possibility (in some expert opinions, inevitability) of a relapse and how to intervene early enough to prevent or shorten a relapse episode. Similarly, Outram et al. [4] from the University of Newcastle in Australia recruited a number of mental health clinicians to better understand their belief system and experiences on how to communicate a diagnosis of schizophrenia. Similar to the Czech report [3], these authors report that communicating diagnostic information about schizophrenia to families was generally unplanned and inconsistent [4]. This lack of planning led to “tension” between different members of the multidisciplinary team, especially on who should take the lead in discussions with patient and family. In order to address this type of problem, Loughland et al. [5], from the University of Newcastle, describe a simulation model that focuses on an existing training module (the ComSkil) that incorporates intensive role-playing for trainees with simulated patients that allows practice and feedback on how to discuss
the diagnosis and prognosis of patients with early presentation of schizophrenia. Simulation has become an integral part of medical student training, allowing practice to occur without undo “practicing on the patient.” Students can make some rather blatant mistakes when they start out, and making those mistakes with an actor may prevent them in the actual clinical setting. Simulation may also ensure that the most important clinical conditions are covered by all students, who may have variable and limited experiences on their clinical rotations. Students and residents today, however, spend less and less time with patients, and simulation, while attempting to fill this gap, may give one a false sense of competency. It is understandable that duty-hour restrictions, ever growing paperwork (more accurately, computer work) pull the student and resident away from the bedside [6]. Today, many learners have limited physical contact with patients; they do not draw blood as often or perform as many procedures (e.g., administer chemotherapy) that necessitated being at the bedside. It is very hard to avoid talking to patients when one is pushing intravenous medication, to ask about their family, or for them to bring up their fear of getting sick from the chemotherapy or even dying. Twenty-five years ago, psychiatry residents might have spent up to a month with the average inpatient, and today, that length of stay is usually less than a week. Whereas clinical simulation exercises are a relatively new practice, medical handbooks have been available for a long time, including the MGH/McLean Hospital Residency Handbook of Psychiatry and the Harriet Lane Handbook for pediatric residents [7, 8]. These handbooks help operationalize practice and break down a large and daunting practice into digestible bits. Gibson et al. [9] report on an educational handbook they developed on the use of antipsychotics in children. The handbook focused on secondgeneration antipsychotics use in children and adolescents, and the authors employed pre- and post-testing to evaluate the effectiveness of their method. Their results were mixed; the handbook was shown to improve learning in some, but not all, areas of care. In a 2013 issue of this journal, Freudenreich et al. [10] described a successful intensive teaching model for prescribing clozapine, with similar pre- and post-testing. Developing clinical manuals with pre- and post-testing appears to help standardize and reinforce essential learning points but may not be practical for covering all areas of study. The future may lay in accessing information, not memorizing it. With information available at one’s digital fingertips, teaching learners to efficiently look up material may be the best approach. Yes, some information, used repetitively, will sink in, but even that information needs continuous updating. So, what is the best way to train students and residents? Providing simulation, manuals, and practice algorithms have value. More research and study on the use of simulation, education manuals, and pre- and post-testing should advance our teaching and practice. In these efforts, I hope we will not
Acad Psychiatry
neglect the value of just spending time with patients. I learned more from “hanging out” with my patients during my psychiatry clerkship than anything I read. It is not a coincidence that some of our best residents are individuals who previously worked with people with mental illness in nonmedical positions. Should we set aside time for trainees to spend time in the day room, playing cards with psychiatric patients; to help with meals in a nursing home; or to visit patients in their homes? I think that might go a long way.
4.
5.
6.
Disclosure The author states that there is no conflict of interest. 7.
References 8. 1. Centers for Medicare & Medicaid Services. Partnership for Patients. Available at http://partnershipforpatients.cms.gov/about-thepartnership/what-is-the-partnership-about/lpwhat-the-partnership-isabout.html. Accessed 21 Jan 2015. 2. Phelps K, Bullard C, Helps S, Getz A. Building strengths with the six Es of medication management. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0164-1. 3. Motlová LB, Dragomirecká E, Blabolová A, Španiel F, Slováková A. Psychoeducation for schizophrenia in the Czech Republic:
9.
10.
curriculum modification based on opinions of service users and providers. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0234-4. Outram S, Harris G, Kelly B, Cohen M, Bylund CL, Landa Y, et al. Contextual barriers to discussing a schizophrenia diagnosis with patients and families: need for leadership and teamwork training in psychiatry. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0226-4. Loughland C, Kelly B, Ditton-Phare P, Sandhu H, Vamos M, Outram S, et al. Improving clinician competency in communication about schizophrenia: a pilot educational program for psychiatry trainees. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0195-7. Block L, Habicht R, Wu AW, Desai SV, Wang K, Silva KN, et al. In the wake of the 2003 and 2011 duty hour’s regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013;28:1042–7. Rosenquist J, Nykiel S, Chang T, Sanders K, editors. MGH/Mclean residency handbook of psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2010. Tschudy M, Arcara K. The Harriet Lane Handbook: A Manual for Pediatric House officers. Elsevier Mosby. 2012. Gibson J, Nguyen D, Davidson J, Panagiotopoulos C. Effectiveness of an educational handbook in improving psychiatry resident knowledge of second-generation antipsychotics. Acad Psychiatry. 2014. doi:10.1007/s40596-014-0177-9. Freudenreich O, Henderson DC, Sanders KM, Goff DC. Training in a clozapine clinic for psychiatry residents: a plea and suggestions for implementation. Acad Psychiatry. 2013;37:27–30.
