Acad Psychiatry (2014) 38:109–110 DOI 10.1007/s40596-013-0030-6
FEATURE: LETTER TO THE EDITOR
Increasing Clozapine Use Through Residency Training: Knowledge and Clinical Proficiency Are Necessary but Not Sufficient Paul R. Falzer & D. Melissa Garman
Published online: 10 January 2014 # Academic Psychiatry 2014
To the editor: A recent article in this journal [1] proposed a training curriculum that encourages clozapine use by developing knowledge about its efficacy, indications, risks, and management. We concur with the paper's principal claims—clozapine has unsurpassed efficacy for treatment-refractory schizophrenia, and the evidence base warrants its inclusion in current treatment guidelines. Notwithstanding its efficacy and demonstrable effectiveness, clozapine is persistently underused. The article describes an educational intervention that is integrated into a residency training program, a PGY-II community rotation designed to meet two goals: becoming clinically proficient in the use of clozapine and acquiring knowledge about the clozapine literature. The program is a good start, but it does not address a significant contributor to clozapine's underuse. With proficiency, clinicians can elicit general and case-specific information about the patient's disorder and condition. Two other proficiencies that are de-emphasized in standard clinical examinations are crucial to increasing the clinically appropriate use of clozapine: eliciting the patient's own perspective on the illness and its treatment and incorporating this perspective through shared decision making. Studies and essays have discussed the importance of shared decision making for psychiatry, specifically for patients with schizophrenia [2, 3]. In treating patients who are eligible for clozapine, shared decision making assists clinicians in overcoming their tendency to avoid raising the prospect of a clozapine switch because they mistakenly believe that the patient will resist [4]. There is evidence that this tendency
P. R. Falzer (*) VA Connecticut Healthcare System, New Haven, CT, USA e-mail: [email protected] D. M. Garman State of Connecticut, New Haven, CT, USA
is at least partly responsible for delaying the introduction of clozapine for up to five years [5]. Shared decision making has a variety of meanings. With greater knowledge about clozapine therapy, physicians are better able to give information to patients. However, genuine sharing is an interactive process that involves more than merely conveying information [6]. If it is done well, the process can overcome what Kleinman [7] calls the “explanatory discrepancy”—the fact that patients and physicians understand illness and treatment in dramatically different ways. Our own work has documented the impact of this discrepancy on clozapine treatment recommendations [8]. These findings led to proposing a four-level practice-based learning framework that includes skills in eliciting patients' perspectives and incorporating them into treatment discussions [9]. The benefits of clozapine therapy can be realized more fully if efforts to increase knowledge and develop clinical proficiency are elements of a similar framework.
References 1. 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(1):27–30. 2. Hamann J, Langer B, Winkler V, Busch R, Cohen R, Leucht S, et al. Shared decision making for in-patients with schizophrenia. Acta Psychiatr Scand. 2006;114(4):265–73. 3. Fenton WS. Shared decision making: a model for the physician–patient relationship in the 21st century? Acta Psychiatr Scand. 2003;107(6): 401–2 [editorial]. 4. Kane JM. A user' guide to clozapine. Acta Psychiatr Scand. 2011;123(6): 407–8. 5. Taylor DM, Young C, Paton C. Prior antipsychotic prescribing in patients current receiving clozapine: a case note review. J Clin Psychiatry. 2003;64(1):30–4.
110 6. Braddock CH. Supporting shared decision making when clinical evidence is low. Med Care Res Rev. 2013;70(1 Suppl): 129S–40S. 7. Kleinman A. Explanatory models in health-care relationships: a conceptual frame for research on family-based health-care activities in relation to folk and professional forms of clinical care. In: Stoeckle JD,
Acad Psychiatry (2014) 38:109–110 editor. Encounters between patients and doctors: an anthology. Boston MA: MIT Press; 1987. p. 273–86. 8. Falzer PR, Garman DM. Optimizing clozapine through clinical decision making. Acta Psychiatr Scand. 2012;126(1):47–58. 9. Falzer PR, Garman DM. Evidence-based decision making as a practicebased learning skill: a pilot study. Acad Psychiatry. 2012;36:104–9.
FEATURE: LETTER TO THE EDITOR
Increasing Clozapine Use Through Residency Training: Knowledge and Clinical Proficiency Are Necessary but Not Sufficient Paul R. Falzer & D. Melissa Garman
Published online: 10 January 2014 # Academic Psychiatry 2014
To the editor: A recent article in this journal [1] proposed a training curriculum that encourages clozapine use by developing knowledge about its efficacy, indications, risks, and management. We concur with the paper's principal claims—clozapine has unsurpassed efficacy for treatment-refractory schizophrenia, and the evidence base warrants its inclusion in current treatment guidelines. Notwithstanding its efficacy and demonstrable effectiveness, clozapine is persistently underused. The article describes an educational intervention that is integrated into a residency training program, a PGY-II community rotation designed to meet two goals: becoming clinically proficient in the use of clozapine and acquiring knowledge about the clozapine literature. The program is a good start, but it does not address a significant contributor to clozapine's underuse. With proficiency, clinicians can elicit general and case-specific information about the patient's disorder and condition. Two other proficiencies that are de-emphasized in standard clinical examinations are crucial to increasing the clinically appropriate use of clozapine: eliciting the patient's own perspective on the illness and its treatment and incorporating this perspective through shared decision making. Studies and essays have discussed the importance of shared decision making for psychiatry, specifically for patients with schizophrenia [2, 3]. In treating patients who are eligible for clozapine, shared decision making assists clinicians in overcoming their tendency to avoid raising the prospect of a clozapine switch because they mistakenly believe that the patient will resist [4]. There is evidence that this tendency
P. R. Falzer (*) VA Connecticut Healthcare System, New Haven, CT, USA e-mail: [email protected] D. M. Garman State of Connecticut, New Haven, CT, USA
is at least partly responsible for delaying the introduction of clozapine for up to five years [5]. Shared decision making has a variety of meanings. With greater knowledge about clozapine therapy, physicians are better able to give information to patients. However, genuine sharing is an interactive process that involves more than merely conveying information [6]. If it is done well, the process can overcome what Kleinman [7] calls the “explanatory discrepancy”—the fact that patients and physicians understand illness and treatment in dramatically different ways. Our own work has documented the impact of this discrepancy on clozapine treatment recommendations [8]. These findings led to proposing a four-level practice-based learning framework that includes skills in eliciting patients' perspectives and incorporating them into treatment discussions [9]. The benefits of clozapine therapy can be realized more fully if efforts to increase knowledge and develop clinical proficiency are elements of a similar framework.
References 1. 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(1):27–30. 2. Hamann J, Langer B, Winkler V, Busch R, Cohen R, Leucht S, et al. Shared decision making for in-patients with schizophrenia. Acta Psychiatr Scand. 2006;114(4):265–73. 3. Fenton WS. Shared decision making: a model for the physician–patient relationship in the 21st century? Acta Psychiatr Scand. 2003;107(6): 401–2 [editorial]. 4. Kane JM. A user' guide to clozapine. Acta Psychiatr Scand. 2011;123(6): 407–8. 5. Taylor DM, Young C, Paton C. Prior antipsychotic prescribing in patients current receiving clozapine: a case note review. J Clin Psychiatry. 2003;64(1):30–4.
110 6. Braddock CH. Supporting shared decision making when clinical evidence is low. Med Care Res Rev. 2013;70(1 Suppl): 129S–40S. 7. Kleinman A. Explanatory models in health-care relationships: a conceptual frame for research on family-based health-care activities in relation to folk and professional forms of clinical care. In: Stoeckle JD,
Acad Psychiatry (2014) 38:109–110 editor. Encounters between patients and doctors: an anthology. Boston MA: MIT Press; 1987. p. 273–86. 8. Falzer PR, Garman DM. Optimizing clozapine through clinical decision making. Acta Psychiatr Scand. 2012;126(1):47–58. 9. Falzer PR, Garman DM. Evidence-based decision making as a practicebased learning skill: a pilot study. Acad Psychiatry. 2012;36:104–9.
