Author's Accepted Manuscript
Readings on psychosomatic medicine: survey of Resources for trainees Mladen Nisavic MD, John L. Shuster MD, David Gitlin MD, Linda Worley MD, Theodore A. Stern MD
PII: DOI: Reference:
S0033-3182(14)00232-1 http://dx.doi.org/10.1016/j.psym.2014.12.006 PSYM524
To appear in:
Psychosomatics
Cite this article as: Mladen Nisavic MD, John L. Shuster MD, David Gitlin MD, Linda Worley MD, Theodore A. Stern MD, Readings on psychosomatic medicine: survey of Resources for trainees, Psychosomatics, http://dx.doi.org/10.1016/j. psym.2014.12.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Readings on Psychosomatic Medicine: Survey of Resources for Trainees
Authors: Mladen Nisavic MD, John L. Shuster MD, David Gitlin, MD, Linda Worley MD, Theodore A. Stern, MD
Abstract: Background: As systems of care become more complex and co-morbid medical and psychiatric illness becomes more evident, it is essential to prepare psychiatric trainees for practice in more integrated models of care. Objective: We sought to identify readings available for residency training in ConsultationLiaison (C-L) psychiatry/Psychosomatic Medicine (PM), with the intent to help educators and trainees identify appropriate and essential learning resources within the field. Methods: We reviewed readings available to the residents (including commonly-used textbooks in C-L psychiatry, and C-L training programs’ required reading lists) and identified areas of consensus regarding the topics germane to the care of patients with co-morbid medical and psychiatric illness (namely depression, dementia, delirium) and the education of trainees. Results: There was considerable variation in the references cited by well-regarded textbooks and by reading lists created for trainees in C-L psychiatry. In the four textbooks reviewed, there were 83 shared citations on delirium (including 10 citations that were common to all four textbooks and 17 citations shared by three textbooks). Markedly less overlap was noted in the chapters on depression (only 2 references cited in all of the textbooks with relevant content) and dementia (only 7 shared references).
1
Conclusion: Given the paucity of overlap of citations in commonly-used textbooks, we recommend that practical topical reviews or textbook chapters be used as core (required) or recommended readings for residents on C-L Psychiatry rotations, supplemented by a small number of studies or case series that illustrate key teaching points on each essential topic.
2
Introduction: Psychosomatic Medicine (PM)/Consultation-Liaison (C-L) psychiatry is a sub-specialty of psychiatry centered on the identification, diagnosis, and management of patients with comorbid medical/obstetrical/surgical and psychiatric conditions. As medical knowledge in this area has burgeoned, and as active efforts in healthcare reform place a growing emphasis on the integration of medical and psychiatric care, it is increasingly important to expose psychiatric trainees to core content. Moreover, as systems of care become more complex it is essential to enhance the education and to facilitate the competence of psychiatric trainees, who may then provide excellent care to patients with co-existing medical and psychiatric conditions.1
The Accreditation Council for Graduate Medical Education (ACGME), which oversees the training and education for psychiatric residents and fellows in the United States, requires that training programs expose residents to C-L psychiatry. However, few specific recommendations have been offered on how this should be achieved beyond a “two-month full-time equivalent rotation in which residents provide supervised consultations on medical and surgical services.”2 Furthermore, the ACGME has established six core requirements (i.e., patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) that cover essential educational components for all trainees in psychiatry.2 Since the Academy for Psychosomatic Medicine (APM) was established in 1953, it has focused on the education and training of PM/C-L psychiatrists. In 1993, the Academy created a Task Force focused on the development of recommendations for C-L training within adult 3
psychiatry residency programs. Those guidelines, published in 1996, reviewed structural (e.g., prerequisite, length of C-L rotations, faculty supervision, and the PGY training number for C-L trainees) as well as content-based aspects of the C-L rotation (e.g., clinical topics of importance, skills, attitudes, learning resources).3 An emphasis was placed on the creation of standardized training settings across psychiatry residency programs, and on assisting programs with the development of a unified educational curriculum for rotating residents. In 2007, a European Association of Consultation-Liaison Psychiatry (EACLP) workgroup provided guidelines for C-L residency training based on a 2001 survey of 20 C-L experts from 16 European countries.4 Much as in the United States, training was highly variable with respect to most of the aspects of PM/C-L training (e.g., whether C-L training was mandatory or recommended, and whether a specific number of cases should be required), as well as specific guidelines regarding knowledge/skill needed by trainees. A paucity of full-time, C-Ltrained psychiatrists to supervise and teach trainees was noted, as was a marked heterogeneity in the quality of the teaching provided. Similar to the 1996 APM Task Force recommendations, the EACLP’s report concluded with guidelines that intended to facilitate a consistent approach across training programs, and outlined specific areas of knowledge, skills, and attitudes thought to be essential for training in C-L psychiatry. More recently (2013), Heinrich et. al surveyed United States-based psychiatry residency program directors to review the status of C-L training practices, and assessed how closely training practices approximated those proposed by the APM’s 1996 guidelines.5 Of the 206 directors of general psychiatry and combined residency programs invited to participate, 92 (45%) responded to the survey. Similar to the 1996 report, they noted a significant variation in the requirements for C-L training, including discrepancies in the duration of training required, the 4
year of training in which C-L Psychiatry was done, and the overall structure of the C-L rotation. While most of the programs met the ACGME requirement of minimum of 2 months allocated for C-L psychiatry training, only 58% of the programs surveyed met the 3-month 1996 APM recommendations. Similarly, marked discrepancies were noted in the quality and content of the education provided. While 77% of the programs surveyed described having a formal curriculum in C-L psychiatry, there was significant variation noted regarding the amount of time dedicated to C-L-based educational activities. Didactics dedicated to C-L specific educational content varied between 1-5 hours to 41-50 hours within the four years of training (average 11-15 hours). Only 36% of programs described resident involvement in C-L-focused journal club activities, and only 64% of the programs noted that their trainees participated in C-L psychiatry clinical case conferences. Following this survey, the APM presented revised and updated residency training recommendations in early 2014.6 These recommendations included specific guidelines on structural issues (e.g., length of rotation, the ideal year for the C-L rotation, the preferred clinical volume of cases, rotation sites, and faculty supervision), educational guidelines, and core competencies (i.e., patient care, medical knowledge, interpersonal/communication skills, professionalism, practice-based learning and improvement, and systems-based practice). With regard to the content of medical knowledge needed during the C-L rotation, the authors identified six broad knowledge areas considered as essential for the education of psychiatry residents and three advanced knowledge areas considered optional for resident education. Table 1 summarizes the 2014 APM recommended knowledge areas alongside the 2007 EACLPP recommendations.
5
Overall, despite the existence of recent guidelines, it is clear that significant variability remains with regard to the content and quality of teaching provided to residents during their C-L rotations. In an effort to explore this issue further, we reviewed several of the learning resources available to residents during their C-L rotations, including: national and international guidelines and recommendations (outlined above), commonly-used textbooks in C-L psychiatry, and C-L training programs required reading lists. We examined the content areas covered by these various resources and sought to establish areas of consensus regarding the topics covered. Our evaluation sought to clarify whether the available reading resources reflect on the knowledge areas important for residency training in C-L psychiatry, and to identify appropriate and essential learning resources (e.g., specific textbook chapters, review articles, online articles) for trainees.
Topics Covered by Textbooks in PM/C-L Psychiatry The content of PM/C-L Psychiatry textbooks was examined, searching for agreement on topics of core knowledge. To identify the textbooks, we performed an electronic search of the general psychiatry textbooks available at the library of a large and renowned medical school using combinations of search terms “C-L”, “consultation liaison”, psychosomatic” and “psychiatry.” Online-only resources, as well as traditional physical textbooks were both included in the search. Furthermore, to avoid possible bias pertaining to libraries stocking older/out-dated versions of the textbooks, each physical resource identified was also accompanied by a search of the online catalog to verify for possible newer editions of the textbooks. We excluded those texts considered to be general psychiatry textbooks and opted to focus on textbooks published and marketed specifically for trainees in PM/C-L psychiatry.
6
Overall, we identified the following resources as the most frequently used reference texts for the residents/trainees (listed alphabetically) that have been published over the past 15 years: A. Blumenfield M, Strain JJ: Psychosomatic Medicine, Lippincott Williams & Wilkins (2006) B. Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) C. Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012) D. Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) E. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry, First Edition. Mosby/Elsevier (2008) F. Stoudemire A, Fogel BS, Greenberg D: Psychiatric Care of the Medical Patient, New York, Oxford University Press (2000) We are aware that our list does not represent a complete list of textbook resources available within the field, and that it may reflect some degree of institutional preference. This said, we found most of the resources listed above to be nationally recognized as important textbooks in CL psychiatry, and thus likely to be represented in similar libraries across the country, which should reduce institutional as well as content-based bias.
As is illustrated in Tables 2-4,
numerous topics were considered as important, as reflected by the tables of contents and section 7
titles of the textbooks selected. Overall there was considerable consensus between the topics covered by these textbooks, and the general areas of knowledge recommended by both the EACLP and the APM (and described above).4,6-7 None of the textbooks covered all of the recommended content areas, and there was significant variability among the textbooks with regards to how the information was presented (e.g., based on presenting symptoms or diagnostic categories) and the depth of information provided within each topic covered (e.g., Neurology may be covered as a single chapter or as a series of chapters that focused on specific topics). This variability between the resources sampled is further illustrated by our attempts to examine the references cited in selected chapters from these textbooks. Our initial hypothesis was that the chapters on key content areas would share similar resources/references, thus reflecting concordance between what the chapter authors deemed as essential resources for the topic. To evaluate this, we reviewed the reference lists for the chapters on three commonlyencountered topics of major importance in C-L training (i.e., delirium, dementia, and depression), and evaluated them for agreement on key studies and reviews cited. We focused on textbooks published within the past 7 years (2008-2014) to exclude textbooks with potentially outdated references. As textbooks may take years between first drafts and publication, we felt that examining textbooks published over a 7-year period would help keep the references within a more conventional 10-year span. Amongst the four textbooks falling within these criteria, three had chapters dedicated to all of the topics noted. All four had a chapter on delirium. Lloyd and Guthrie’s text did not include chapters on depression or dementia. The reference lists of all ten chapters on these three topics were evaluated, and 1339 individual citations were identified. Our approach has a number of potential limitations: Even with a small sample size (4 textbooks) there was considerable variation in how the references were presented, with some 8
textbooks providing a brief list of key references, and others providing a more comprehensive reference list. Furthermore, given the stylistic and organizational differences among the textbooks examined, it is likely that some of the references pertinent to each topic may have been presented across multiple chapters (rather than within a dedicated chapter). Lastly, two of the textbooks examined were prepared by similar editorial teams, with significant overlap with regards to textbook chapter authors, as well as the references the authors deemed essential. In general, these textbooks had significantly greater overlap in regards to number of identical references cited compared to the other two textbooks examined. These limitations non-withstanding, the variability was huge (with regards to key studies referenced across all three topics sampled), as illustrated in Table 5. Despite the relatively large number of references cited across the three topics, there was surprisingly little overlap. Of 1339 individual references identified, only 154 references were cited by more than one of these textbooks, and once we excluded the two textbooks prepared by similar editorial teams, this number dropped further (to 96 individual references cited by more than one of these textbooks). Additional variability was noted across the three content areas sampled, with chapters on delirium providing overall more shared citations than those on depression and dementia. Across the four textbooks, there were 83 shared citations on delirium (including 10 citations14-24 that were shared by all four textbooks, 17 citations shared by three textbooks25-41 and 56 citations shared between two of the textbooks). Markedly less overlap was noted on our evaluation of the chapters on depression (only 2 shared references across all three textbooks with a chapter on depression16, 42) and dementia (only 7 shared references across all three textbooks with a chapter on dementia16, 20, 43-47). As with chapters on delirium, significant overlap in references cited was
9
noted between the two textbooks that shared similar chapter authors (e.g., greater than 90% concordance on the depression reference list). Across all three of these content areas, specific patterns were noted with regard to the types of references that were most likely to be shared amongst the multiple sources. Most frequently, shared citations included disease-specific diagnostic criteria (e.g., Diagnostic and Statistical Manual of Mental Disorders16, ICD-1024), formal treatment guidelines, and screening tools (e.g., the mini-mental state examination20), followed by book chapters and case studies. Little consensus was observed regarding cross-referencing of seminal review articles and primary research studies pertaining to the topic areas. An additional pattern noted was that the chapter authors would cite multiple publications by similar research groups (rather than specific papers), possibly indicating that essential information may be been presented across a number of papers, rather than in a single seminal study. Lastly, we reviewed whether the shared citations listed by all the textbooks were likely to be more recent vs. reflective of older (and seminal) papers in the field; however, no clear correlation was noted across the three subject areas sampled. For example, looking at the seven shared citations on dementia, three were published within past ten years, two within past 20 years, and two prior to that. Similarly, the 10 shared citations on delirium were evenly distributed, with three published in past 10 years, three in past 20 years, and four prior to that. Reading Lists Provided by C-L Psychiatry Residency Programs In addition to reviewing these C-L psychiatry textbooks, we contacted selected program directors of United States-based C-L Programs (including residency training directors, C-L fellowship directors, and nationally-known C-L physicians) on two separate occasions (1994,
10
2011) regarding their recommended/required reading lists for the program and examined these for a general agreement regarding key references. Our first attempt (1994), yielded only 16 responses, and a total of 999 unique articles/reading resources were identified. Much like with our evaluation of the key textbook chapters, there was relatively little overlap between the reading resources recommended by the various programs. Only 52 of the 999 articles were cited by more than one program, and only 10 articles were cited by four or more C-L programs.48-57 Most of the articles recommended by multiple programs were reports of studies, with less consensus regarding topical review articles or textbook chapters. Our attempt to replicate this questionnaire in 2011 met with even less success, as only a handful of responses were obtained. Despite the limitations imposed by meager response rates, our efforts raise the questions of whether formal reading lists exist at most of the C-L residency training programs in the US, and whether consensus exists between the existing resource lists recommended by the various training sites. The latter appears consistent with the recent (2012) survey of C-L residency training program directors that indicated minimal consistency between the programs sampled regarding the access to teaching resources, formal opportunities for teaching (including journal clubs, didactics) and time dedicated to resident education.5
Conclusion Significant variability exists between the available educational resources used for PM/CL psychiatry trainees and the guidelines proposed by the APM and the EACLP. On one hand, all of the textbooks reviewed for this article presented content consistent with the six major and three advanced knowledge areas proposed by the 2014 APM guidelines. However, our review 11
indicates that there is little consensus and/or consistency among these textbooks with regards to the depth of coverage provided, the number of topics presented within each knowledge area, and the organization/presentation strategy of covered topics. Given thousands of articles published each year and the expansion of knowledge in psychiatry over last few decades, perhaps it should not be a surprise that it is so challenging to identify a small number of seminal studies. . This said, given the abundance of resources and options available to most current psychiatry trainees (e.g., multiple textbooks, online databases, Internet resources), we find it peculiar that most of the commonly-recommended articles involved diagnostic classification criteria, rating scales, and reports of studies. The general psychiatry resident rotating through a C-L service primarily needs practical instruction on the management of psychiatric problems in medical and surgical patients. Most of the commonly-cited articles did not offer such information. For this reason, we recommend that practical topical review articles or textbook chapters be used as a core of a required or recommended reading list for resident’s C-L Psychiatry rotations, supplemented by a small number of studies or case series reports illustrating key teaching points pertaining to the topic. However, given the variety observed across the various educational resources surveyed, it is impossible for us to recommend one textbook over another, and we ultimately find that it is up to the individual educator to choose the specific educational resources that best meets the needs of his or her trainees.
12
References: 1.
Gitlin DF, Levenson JL, Lyketsos CG. Psychosomatic Medicine: A new psychiatric subspecialty. Acad Psychiatry 2004; 28(1):4-11
2.
Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Last accessed August 19, 2014
3.
Gitlin DF, Schindler BA, Stern TA, et al. Recommended guidelines for consultation-liaison psychiatric training in psychiatry residency programs. A report from the Academy of Psychosomatic Medicine Task Force on Psychiatric Resident Training in Consultation-Liaison Psychiatry. Psychosomatics, 1996; 37 (1): 3–11
4.
Söllner, WF. Creed F, European Association of Consultation-Liaison Psychiatry and Psychosomatics Workgroup on Training in Consultation-Liaison (2007) European guidelines for training in consultationliaison psychiatry and psychosomatics: Report of the EACLPP Workgroup on Training in ConsultationLiaison Psychiatry and Psychosomatics. J Psychosom Res, 2007; 62 (4):501–509
5.
Heinrich TW, Schwartz AC, Zimbrean PC, Lolak S, Wright MT, Academy of Psychosomatic Medicine′s Residency Education Subcommittee. The state of the service: A survey of psychiatry resident education in psychosomatic medicine. Psychosomatics, 2013; 54 (6):560–566
6.
Heinrich TW, Schwartz AC, Zimbrean PC, Lolak S, Wright MT, Brooks KB, Ernst CL, Gitlin DF. Recommendations for training psychiatry residents in Psychosomatic Medicine. Psychosomatics.pii: S0033-3182(13)00248-X; 2014
7.
Leentjens AFG, Rundell JR, Diefenbacher A, Kathol R, Guthrie E. Psychosomatic Medicine and Consultation-Liaison Psychiatry: Scope of Practice, Processess and Competencies for Psychiatrists or Psychosomatic Medicine Specialists: A Consensus Statement of the European Association of Consultation Liaison Psychiatry and the Academy of Psychosomatic Medicine. Psychosomatics. 2011; 52 (1):19-25
8.
Blumenfield M, Strain JJ (editors): Psychosomatic Medicine, Lippincott Williams & Wilkins,2006
9.
Levenson JL (editor): The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association, Washington, DC, 2011
13
10. Lloyd GG, Guthrie E (editors): Handbook of Liaison Psychiatry, Cambridge University Press, 2012 11. Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF (editors): Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier, Philadelphia,2010 12. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL (editors): Massachusetts General Hospital Comprehensive Clinical Psychiatry, First Edition. Mosby/Elsevier, Philadelphia, 2008 13. Stoudemire A, Fogel BS, Greenberg D (editors): Psychiatric Care of the Medical Patient, New York, Oxford University Press, 2000 14. Cremens MC, Calabrese LV, Shuster JL Jr., Stern TA. The Massachusetts General Hospital annotated bibliography. For residents training in consultation-liaison psychiatry. Psychosomatics 1995; 36 (3): 217235 15. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Delirium. Am J Psychiatry 1999; 156 (5 suppl):1-20 16. American Psychiatric Association. Diagnosis and Statistical Manual of Mental Disorders, IV Edition, Text Revision. Washington DC: American Psychiatric Association, 2000 17. Breitbart W, Gibson C, Tremblay A The delirium experience: Delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics, 2002; 183194 18. Engel GL, Romano J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis 1958; 9:260-277 19. Farrell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Arch Int Med 1995; 155:2459-2464 20. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State Examination: A practical method for grading the cognitive state of patients for clinicians. J Psychosom Res 1975; 11: 189-198 21. Franco K., Litaker D, Locala J, et al. The cost of deliriu in the surgical patient. Psychosomatics 2001; 42: 68-73 22. Stern TA. Continuous infusion of physostigmine in anticholinergic delirium: a case report. J Clin Psychiatry 1983; 44: 463-464 23. Webster R., Holroyd S. Prevalence of psychotic symptoms in delirium. Psychosomatics 2002; 41: 519-522
14
24. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992 25. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291:1753-1762 26. Milbrandt EB, Deppen S, Harrison PL, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2005; 9: R375-R381 27. McNicoll L, Pisani MA, Zhang Y, et al. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc 2003; 51: 591-598 28. Liptzin B, Levkoff SE. An empirical study of delirium subtypes. Br J Psychiatry 1992; 161: 843-845 29. Jacobson S, Jerrier H. EEG in delirium. Semin Clin Neuropsychiatry 2000; 5: 86-92 30. Menza MA, Murray GB, Holmes VF, et al. Decreased extrapyramidal symptoms with intravenous haloperidol. J Clin Psychiatry 1987; 48: 278-280 31. Tesar GE, Murray GB, Cassem NH. Use of high-dose intravenous haloperidol in the treeatment of agitated cardiac patients. J Clin Psychopharmacol 1985; 5:344-347 32. Sanders KM, Stern TA, O’Gara PT, et al. Delirium after intra-aortic balloon pump therapy. Psychosomatics 1992; 33: 35-41 33. Metzger E, Friedman R. Prolongation of the corrected QT and torsades de pointes cardiac arrhythmia associated with intravenous haloperidol in the medically ill. J Clin Psychopharmacol 1993; 13: 128-132 34. Wilt JL, Minnema AM, Johnson RF, et al. Torsades de pointes associated with the use of intravenous haloperidol. Ann Intern Med 1993; 119: 391-394 35. Schwartz TL, Masand PS. The role of atypical antipsychotics in the treatment of delirium. Psychosomatics 2002; 43: 171-174 36. Leso L, Schwartz TL. Ziprasidone treatment of delirium. Psychosomatics 2002; 43: 175-182 37. Breitbart W, Tremblay A, Gibson C. An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients. Psychosomatics 2002; 43: 175-182 38. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005; 53: 1658-1666
15
39. Fernandez F, Levy JK, Mansell PWA. Management of delirium in terminally ill AIDS patients. Int J Psychiatr Med 1989; 19:165-172 40. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying Confusion: the confusion assessment method. A new method for detection of delirium. Ann Int Med 1990; 113: 941-948 41. Trzepacs PT, Baker RW, Greenhouse J. A symptom rating scale for delirium. Psychiatry Res 1988; 23: 8997 42. Dr Groot M, Anderson R, Freedland KE, et al. Association of depression and diabetes complications: a meta-analysis. Psychosom Med 2001; 63 (4):619-630 43. Petersen Rc. Mild cognitive impairment as a diagnostic entity. J Intern Med 2004; 256:183-194 44. McKhann G, Drachman D, Folstein M, et al. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services task force on Alzheimer’s disease. Neurology 1984; 34:939-944 45. McKeith IG, Galasko D, Kosaka K, et al. Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy Bodies (DLB): report of the consortium on DLB international workshop. Neurology 1996; 47: 1113-1124 46. McKeith IG, Disckson DW, Lowe J, et al. Diagnosis and management of dementia with Lewy bodies: third report of the DLB consortium. Neurology 2005; 65: 1863-1872 47. Ferri CP, Prince M, Brayne C, et al. Alzheimer’s disease international: Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366(9503): 2112-2117 48. Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med 1988; 319: 1635-1638 49. Drugs that cause psychiatric symptoms. The Medical Letter 1993. 35: 65-70 50. Garrick TR, Stotland NL. How to write a psychiatric consultation. Am J Psychiatry 1982; 139:849-855 51. Groves JE. Taking care of the hateful patient. N Engl J Med 1978; 298:883-887 52. Groves JE. Patients with borderline personality disorder, in Cassem NH, ed. Massachusetts General Hospital Handbook of General Hospital Psychiatry, Third edition. St Louis, Mosby Year Book, 1991; pp. 191-215
16
53. Kahana RF, Bibring GL. Personality types in medical management, in Psychiatry & Medical Practice in the General Hospital, International Universities Press, 1964; pp 108-123 54. Mahler J, Perry S. Assessing competency in the physically ill: guidelines for psychiatric consultants. Hosp Comm Psychiatry 1988; 39: 856-861 55. Perry SW. Organic mental disorders caused by HIV: update on early diagnosis and treatment. Am J Psychiatry 1990; 147:696-710 56. Rodin G, Voshart K. Depression in the medically ill: an overview. Am J Psychiatry 1986; 143: 696-705 57. Stoudemire A, Moran MG, Fogel BS. Psychotropic drug use in the medically ill, part I. Psychosomatics 1990; 31: 377-391
17
Table 1: Knowledge Areas Considered Essential for Education of Psychiatry Trainees in C-L Psychiatry based on APM (2014) and EACLPP (2007) Guidelines and Recommendations APM 2014 Recommendations
EACLPP 2007 Guidelines
Knowledge Areas:
Knowledge Areas:
1. 2. 3. Essential Knowledge Areas: 1. 2. 3. 4.
5.
6.
General psychiatric illness in the medical setting; Psychiatric illnesses that occur primarily in the medical setting (e.g., somatic symptom disorder); Psychiatric manifestations of medical/surgical illness (e.g., delirium); Psychiatric co-morbidities associated with specific medical/surgical illness or treatment of such illness (e.g., cancer/chemotherapy); Psychiatric treatment modalities in the medical setting (e.g., pharmacology, electroconvulsive therapy); Legal aspects of the C-L psychiatry;
Advanced knowledge areas (considered optional): 7. 8. 9.
Liaison work (psychiatric practice in specific medical/surgical setting); C-L psychiatry in the outpatient setting; Pediatric C-L psychiatry);
Awareness of different theoretical models (e.g., bipsychological model); Ethical and medico-legal issues; Assessment and management of: Delirium/Dementia and other psychiatric diagnoses with organic causes; Somatization; Depression and anxiety in medically ill patients; Suicide/Self-harm; Addiction problems in mental setting; Abnormal illness behavior in somatically ill patients; Coping with chronical and terminal illness; Chronic pain; Gender-specific disorders, sexual dysfunction in medically ill patients; Sexual abuse in specific patient populations; Child and adolescent C-L psychiatry; Management of patients with psychiatric disorders in need of medical and/or surgical care;
18
Table 2: Topics on Psychiatric Illness in the General Medical Setting (as covered by the commonly used textbooks in C-L psychiatry)
A
B
C
D
E
F
Psychiatric Illness in the General Medical Setting Alcohol Use Disorder
x
Anxiety Disorders
x
Child and Adolescent Psychiatry
x x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Delirium
x
x
Dementia and Neurocognitive Disorders
x
x
x
x
x
Deception Syndromes: Factitious Disorders, Malingering
x
x
x
x
x
Depression and Related Disorders
x
x
x
x
x
Eating Disorders
x
x
x
x
x
x
x
x
x
x
x
Geriatric Psychiatry Mania/Bipolar Disorder
x
Personality Disorders
x
x
PTSD/Trauma
x
x
Schizophrenia and Psychotic Disorders
x
x
Somatization and Somatoform Disorders
x
x
x
x
x
x
x
x
x
x
x
Sleep Disorders
x
Sexual Disorders
x
x
x
x
x
Substance Use Disorders, Intoxication and Withdrawal
x
x
x
x
x
x
Suicide
x
x
x
x
x
x
Textbook Key: (A) Blumenfield M, Strain JJ: Psychosomatic Medicine, Lippincott Williams & Wilkins (2006) (B) Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) (C) Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012) (D) Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) (E) Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry , First Edition. Mosby/Elsevier (2008) (F) Stoudemire A, Fogel BS, Greenberg D: Psychiatric Care of the Medical Patient, New York, Oxford University Press (2000)
19
Table 3: Topics Pertaining to Psychiatry in the General Medical/Surgical Setting (as covered by the commonly used textbooks in C-L psychiatry) A
B
C
D
F
E
Topics Pertaining to Psychiatry In General Medical/Surgical Settings Internal Medicine and Sub-Specialties Cardiology
x
Dermatology Diabetes/Endocrinology
x
x
x
x
x
x
x
x
x
x
x
Immunology Intensive Care Medicine
x
x x
x
Infectious Disease/HIV/AIDS
x
x
x
Gastroenterology
x
x
x
x
Nephrology
x
x
x
x
Oncology
x
x
x
x
x
x
x
x x
Outpatient medicine Pain Medicine
x
x
Pulmonology
x
x
Rheumatology and Connective Tissue Disease
x
x
x
x
x x x
x
x
Toxicology Surgery and Sub-Specialities:
x
Anesthesiology Cosmetic/Reconstructive Surgery
x
x
x x
General Surgery
x x
HEENT Neurosurgery
x x
x
Obstetrics/Gynecology
x
x
Trauma, Burns and Orthopedic Surgery
x
Transplant Surgery
x
x
Coping with Chronic Illness/Psychological Response to Illness
x
x
Death/Dying/Terminal Illness
x
Neurology
x
x x
x x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Other Medical Specialities/Topics:
Pediatrics
x
x
Physical Medicine/Rehabilitation
x
x
x x
x
Textbook Key: (A) Blumenfield M, Strain JJ: Psychosomatic Medicine, Lippincott Williams & Wilkins (2006) (B) Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) (C) Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012)
20
(D) Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) (E) Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry, First Edition. Mosby/Elsevier (2008) (F) Stoudemire A, Fogel BS, Greenberg D: Psychiatric Care of the Medical Patient, New York, Oxford University Press (2000)
21
Table 4: Treatment Options and Advanced Topics in C-L Psychiatry (as covered by the commonly used textbooks in C-L psychiatry)
A
B
C
D
E
F
Treatment Resources and Other Topics In C-L Psychiatry x
Aggression and Violence Capacity, Competency and Surrogate Decision Making
x
Catatonia, NMS, Serotonin Syndrome
x
x
x
x
x
x
x
x
Culture and Psychiatry
x
x
x
Genetics
x
x
x
x
Examination/Testing (including Neuropsychiatric Testing)
x
x
x
x
x
x
x
x
x
Emergency Psychiatry Ethics
x
x
x
Forensic Psychiatry and Legal Issues
x
x
x
x
International Psychiatry Laboratory Assessment
x
x
x
x
x x
x
Major Disaster Planning
x
Neuroimaging and Other Imaging in Psychiatry
x
x
x x
x
x
x
x
x
x
x
x
x
x
x
x
Psychiatric Treatment in General Medical Setting and C-L Psychiatry: Complementary and Alternative Treatment ECT
x
Hypnosis Psychopharmacology/Drug-Drug Interactions
x
x
Therapy (Individual, including cognitive-behavioral therapy)
x
x
x
x
x
x
x
x
x
x
x
x
x
Academic/Clinical Research In C-L Psychiatry
x
x
x
History of C-L psychiatry
x
Therapy (Couples, Group and/or Family) Reproductive Medicine and Psychiatry
x
Topics Pertaining to Development/Organization of C-L Service:
x
Future of C-L psychiatry Organization of C-L service Outpatient C-L psychiatry and Integration with Primary Care
x
x x
x
x
x
x
x
x
x
22
Textbook Key: (A) Blumenfield M, Strain JJ: Psychosomatic Medicine, Lippincott Williams & Wilkins (2006) (B) Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) (C) Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012) (D) Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) (E) Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry, First Edition. Mosby/Elsevier (2008) (F) Stoudemire A, Fogel BS, Greenberg D: Psychiatric Care of the Medical Patient, New York, Oxford University Press (2000)
23
Table 5: Multiple-Cited References from C-L Psychiatry Textbooks. (based upon four textbooks, published within a 7- year period (2008-2014) . Textbook:
B
C
D
E
Delirium
400 89
92
79
Dementia
252 n/a
85
97
Depression
254 n/a
134 62
Number of references reported per content area:
Total number of individual references identified in the sample: Delirium
537
Dementia
388
Depression
414
Number of references cited by more than one textbook:
Delirium
83 (10 with four citations, 17 with three citations; 56 with two citations)
Dementia
37 (7 with three citations; 30 with two citations) (19 of these are shared citations between two MGH textbooks)
Depression
34 (2 with three citations; 32 with two citations) (27 of these are shared citations between two MGH textbooks)
(B) Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) (C) Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012) (D) Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) (E) Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry , First Edition. Mosby/Elsevier (2008)
24
Readings on psychosomatic medicine: survey of Resources for trainees Mladen Nisavic MD, John L. Shuster MD, David Gitlin MD, Linda Worley MD, Theodore A. Stern MD
PII: DOI: Reference:
S0033-3182(14)00232-1 http://dx.doi.org/10.1016/j.psym.2014.12.006 PSYM524
To appear in:
Psychosomatics
Cite this article as: Mladen Nisavic MD, John L. Shuster MD, David Gitlin MD, Linda Worley MD, Theodore A. Stern MD, Readings on psychosomatic medicine: survey of Resources for trainees, Psychosomatics, http://dx.doi.org/10.1016/j. psym.2014.12.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Readings on Psychosomatic Medicine: Survey of Resources for Trainees
Authors: Mladen Nisavic MD, John L. Shuster MD, David Gitlin, MD, Linda Worley MD, Theodore A. Stern, MD
Abstract: Background: As systems of care become more complex and co-morbid medical and psychiatric illness becomes more evident, it is essential to prepare psychiatric trainees for practice in more integrated models of care. Objective: We sought to identify readings available for residency training in ConsultationLiaison (C-L) psychiatry/Psychosomatic Medicine (PM), with the intent to help educators and trainees identify appropriate and essential learning resources within the field. Methods: We reviewed readings available to the residents (including commonly-used textbooks in C-L psychiatry, and C-L training programs’ required reading lists) and identified areas of consensus regarding the topics germane to the care of patients with co-morbid medical and psychiatric illness (namely depression, dementia, delirium) and the education of trainees. Results: There was considerable variation in the references cited by well-regarded textbooks and by reading lists created for trainees in C-L psychiatry. In the four textbooks reviewed, there were 83 shared citations on delirium (including 10 citations that were common to all four textbooks and 17 citations shared by three textbooks). Markedly less overlap was noted in the chapters on depression (only 2 references cited in all of the textbooks with relevant content) and dementia (only 7 shared references).
1
Conclusion: Given the paucity of overlap of citations in commonly-used textbooks, we recommend that practical topical reviews or textbook chapters be used as core (required) or recommended readings for residents on C-L Psychiatry rotations, supplemented by a small number of studies or case series that illustrate key teaching points on each essential topic.
2
Introduction: Psychosomatic Medicine (PM)/Consultation-Liaison (C-L) psychiatry is a sub-specialty of psychiatry centered on the identification, diagnosis, and management of patients with comorbid medical/obstetrical/surgical and psychiatric conditions. As medical knowledge in this area has burgeoned, and as active efforts in healthcare reform place a growing emphasis on the integration of medical and psychiatric care, it is increasingly important to expose psychiatric trainees to core content. Moreover, as systems of care become more complex it is essential to enhance the education and to facilitate the competence of psychiatric trainees, who may then provide excellent care to patients with co-existing medical and psychiatric conditions.1
The Accreditation Council for Graduate Medical Education (ACGME), which oversees the training and education for psychiatric residents and fellows in the United States, requires that training programs expose residents to C-L psychiatry. However, few specific recommendations have been offered on how this should be achieved beyond a “two-month full-time equivalent rotation in which residents provide supervised consultations on medical and surgical services.”2 Furthermore, the ACGME has established six core requirements (i.e., patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) that cover essential educational components for all trainees in psychiatry.2 Since the Academy for Psychosomatic Medicine (APM) was established in 1953, it has focused on the education and training of PM/C-L psychiatrists. In 1993, the Academy created a Task Force focused on the development of recommendations for C-L training within adult 3
psychiatry residency programs. Those guidelines, published in 1996, reviewed structural (e.g., prerequisite, length of C-L rotations, faculty supervision, and the PGY training number for C-L trainees) as well as content-based aspects of the C-L rotation (e.g., clinical topics of importance, skills, attitudes, learning resources).3 An emphasis was placed on the creation of standardized training settings across psychiatry residency programs, and on assisting programs with the development of a unified educational curriculum for rotating residents. In 2007, a European Association of Consultation-Liaison Psychiatry (EACLP) workgroup provided guidelines for C-L residency training based on a 2001 survey of 20 C-L experts from 16 European countries.4 Much as in the United States, training was highly variable with respect to most of the aspects of PM/C-L training (e.g., whether C-L training was mandatory or recommended, and whether a specific number of cases should be required), as well as specific guidelines regarding knowledge/skill needed by trainees. A paucity of full-time, C-Ltrained psychiatrists to supervise and teach trainees was noted, as was a marked heterogeneity in the quality of the teaching provided. Similar to the 1996 APM Task Force recommendations, the EACLP’s report concluded with guidelines that intended to facilitate a consistent approach across training programs, and outlined specific areas of knowledge, skills, and attitudes thought to be essential for training in C-L psychiatry. More recently (2013), Heinrich et. al surveyed United States-based psychiatry residency program directors to review the status of C-L training practices, and assessed how closely training practices approximated those proposed by the APM’s 1996 guidelines.5 Of the 206 directors of general psychiatry and combined residency programs invited to participate, 92 (45%) responded to the survey. Similar to the 1996 report, they noted a significant variation in the requirements for C-L training, including discrepancies in the duration of training required, the 4
year of training in which C-L Psychiatry was done, and the overall structure of the C-L rotation. While most of the programs met the ACGME requirement of minimum of 2 months allocated for C-L psychiatry training, only 58% of the programs surveyed met the 3-month 1996 APM recommendations. Similarly, marked discrepancies were noted in the quality and content of the education provided. While 77% of the programs surveyed described having a formal curriculum in C-L psychiatry, there was significant variation noted regarding the amount of time dedicated to C-L-based educational activities. Didactics dedicated to C-L specific educational content varied between 1-5 hours to 41-50 hours within the four years of training (average 11-15 hours). Only 36% of programs described resident involvement in C-L-focused journal club activities, and only 64% of the programs noted that their trainees participated in C-L psychiatry clinical case conferences. Following this survey, the APM presented revised and updated residency training recommendations in early 2014.6 These recommendations included specific guidelines on structural issues (e.g., length of rotation, the ideal year for the C-L rotation, the preferred clinical volume of cases, rotation sites, and faculty supervision), educational guidelines, and core competencies (i.e., patient care, medical knowledge, interpersonal/communication skills, professionalism, practice-based learning and improvement, and systems-based practice). With regard to the content of medical knowledge needed during the C-L rotation, the authors identified six broad knowledge areas considered as essential for the education of psychiatry residents and three advanced knowledge areas considered optional for resident education. Table 1 summarizes the 2014 APM recommended knowledge areas alongside the 2007 EACLPP recommendations.
5
Overall, despite the existence of recent guidelines, it is clear that significant variability remains with regard to the content and quality of teaching provided to residents during their C-L rotations. In an effort to explore this issue further, we reviewed several of the learning resources available to residents during their C-L rotations, including: national and international guidelines and recommendations (outlined above), commonly-used textbooks in C-L psychiatry, and C-L training programs required reading lists. We examined the content areas covered by these various resources and sought to establish areas of consensus regarding the topics covered. Our evaluation sought to clarify whether the available reading resources reflect on the knowledge areas important for residency training in C-L psychiatry, and to identify appropriate and essential learning resources (e.g., specific textbook chapters, review articles, online articles) for trainees.
Topics Covered by Textbooks in PM/C-L Psychiatry The content of PM/C-L Psychiatry textbooks was examined, searching for agreement on topics of core knowledge. To identify the textbooks, we performed an electronic search of the general psychiatry textbooks available at the library of a large and renowned medical school using combinations of search terms “C-L”, “consultation liaison”, psychosomatic” and “psychiatry.” Online-only resources, as well as traditional physical textbooks were both included in the search. Furthermore, to avoid possible bias pertaining to libraries stocking older/out-dated versions of the textbooks, each physical resource identified was also accompanied by a search of the online catalog to verify for possible newer editions of the textbooks. We excluded those texts considered to be general psychiatry textbooks and opted to focus on textbooks published and marketed specifically for trainees in PM/C-L psychiatry.
6
Overall, we identified the following resources as the most frequently used reference texts for the residents/trainees (listed alphabetically) that have been published over the past 15 years: A. Blumenfield M, Strain JJ: Psychosomatic Medicine, Lippincott Williams & Wilkins (2006) B. Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) C. Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012) D. Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) E. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry, First Edition. Mosby/Elsevier (2008) F. Stoudemire A, Fogel BS, Greenberg D: Psychiatric Care of the Medical Patient, New York, Oxford University Press (2000) We are aware that our list does not represent a complete list of textbook resources available within the field, and that it may reflect some degree of institutional preference. This said, we found most of the resources listed above to be nationally recognized as important textbooks in CL psychiatry, and thus likely to be represented in similar libraries across the country, which should reduce institutional as well as content-based bias.
As is illustrated in Tables 2-4,
numerous topics were considered as important, as reflected by the tables of contents and section 7
titles of the textbooks selected. Overall there was considerable consensus between the topics covered by these textbooks, and the general areas of knowledge recommended by both the EACLP and the APM (and described above).4,6-7 None of the textbooks covered all of the recommended content areas, and there was significant variability among the textbooks with regards to how the information was presented (e.g., based on presenting symptoms or diagnostic categories) and the depth of information provided within each topic covered (e.g., Neurology may be covered as a single chapter or as a series of chapters that focused on specific topics). This variability between the resources sampled is further illustrated by our attempts to examine the references cited in selected chapters from these textbooks. Our initial hypothesis was that the chapters on key content areas would share similar resources/references, thus reflecting concordance between what the chapter authors deemed as essential resources for the topic. To evaluate this, we reviewed the reference lists for the chapters on three commonlyencountered topics of major importance in C-L training (i.e., delirium, dementia, and depression), and evaluated them for agreement on key studies and reviews cited. We focused on textbooks published within the past 7 years (2008-2014) to exclude textbooks with potentially outdated references. As textbooks may take years between first drafts and publication, we felt that examining textbooks published over a 7-year period would help keep the references within a more conventional 10-year span. Amongst the four textbooks falling within these criteria, three had chapters dedicated to all of the topics noted. All four had a chapter on delirium. Lloyd and Guthrie’s text did not include chapters on depression or dementia. The reference lists of all ten chapters on these three topics were evaluated, and 1339 individual citations were identified. Our approach has a number of potential limitations: Even with a small sample size (4 textbooks) there was considerable variation in how the references were presented, with some 8
textbooks providing a brief list of key references, and others providing a more comprehensive reference list. Furthermore, given the stylistic and organizational differences among the textbooks examined, it is likely that some of the references pertinent to each topic may have been presented across multiple chapters (rather than within a dedicated chapter). Lastly, two of the textbooks examined were prepared by similar editorial teams, with significant overlap with regards to textbook chapter authors, as well as the references the authors deemed essential. In general, these textbooks had significantly greater overlap in regards to number of identical references cited compared to the other two textbooks examined. These limitations non-withstanding, the variability was huge (with regards to key studies referenced across all three topics sampled), as illustrated in Table 5. Despite the relatively large number of references cited across the three topics, there was surprisingly little overlap. Of 1339 individual references identified, only 154 references were cited by more than one of these textbooks, and once we excluded the two textbooks prepared by similar editorial teams, this number dropped further (to 96 individual references cited by more than one of these textbooks). Additional variability was noted across the three content areas sampled, with chapters on delirium providing overall more shared citations than those on depression and dementia. Across the four textbooks, there were 83 shared citations on delirium (including 10 citations14-24 that were shared by all four textbooks, 17 citations shared by three textbooks25-41 and 56 citations shared between two of the textbooks). Markedly less overlap was noted on our evaluation of the chapters on depression (only 2 shared references across all three textbooks with a chapter on depression16, 42) and dementia (only 7 shared references across all three textbooks with a chapter on dementia16, 20, 43-47). As with chapters on delirium, significant overlap in references cited was
9
noted between the two textbooks that shared similar chapter authors (e.g., greater than 90% concordance on the depression reference list). Across all three of these content areas, specific patterns were noted with regard to the types of references that were most likely to be shared amongst the multiple sources. Most frequently, shared citations included disease-specific diagnostic criteria (e.g., Diagnostic and Statistical Manual of Mental Disorders16, ICD-1024), formal treatment guidelines, and screening tools (e.g., the mini-mental state examination20), followed by book chapters and case studies. Little consensus was observed regarding cross-referencing of seminal review articles and primary research studies pertaining to the topic areas. An additional pattern noted was that the chapter authors would cite multiple publications by similar research groups (rather than specific papers), possibly indicating that essential information may be been presented across a number of papers, rather than in a single seminal study. Lastly, we reviewed whether the shared citations listed by all the textbooks were likely to be more recent vs. reflective of older (and seminal) papers in the field; however, no clear correlation was noted across the three subject areas sampled. For example, looking at the seven shared citations on dementia, three were published within past ten years, two within past 20 years, and two prior to that. Similarly, the 10 shared citations on delirium were evenly distributed, with three published in past 10 years, three in past 20 years, and four prior to that. Reading Lists Provided by C-L Psychiatry Residency Programs In addition to reviewing these C-L psychiatry textbooks, we contacted selected program directors of United States-based C-L Programs (including residency training directors, C-L fellowship directors, and nationally-known C-L physicians) on two separate occasions (1994,
10
2011) regarding their recommended/required reading lists for the program and examined these for a general agreement regarding key references. Our first attempt (1994), yielded only 16 responses, and a total of 999 unique articles/reading resources were identified. Much like with our evaluation of the key textbook chapters, there was relatively little overlap between the reading resources recommended by the various programs. Only 52 of the 999 articles were cited by more than one program, and only 10 articles were cited by four or more C-L programs.48-57 Most of the articles recommended by multiple programs were reports of studies, with less consensus regarding topical review articles or textbook chapters. Our attempt to replicate this questionnaire in 2011 met with even less success, as only a handful of responses were obtained. Despite the limitations imposed by meager response rates, our efforts raise the questions of whether formal reading lists exist at most of the C-L residency training programs in the US, and whether consensus exists between the existing resource lists recommended by the various training sites. The latter appears consistent with the recent (2012) survey of C-L residency training program directors that indicated minimal consistency between the programs sampled regarding the access to teaching resources, formal opportunities for teaching (including journal clubs, didactics) and time dedicated to resident education.5
Conclusion Significant variability exists between the available educational resources used for PM/CL psychiatry trainees and the guidelines proposed by the APM and the EACLP. On one hand, all of the textbooks reviewed for this article presented content consistent with the six major and three advanced knowledge areas proposed by the 2014 APM guidelines. However, our review 11
indicates that there is little consensus and/or consistency among these textbooks with regards to the depth of coverage provided, the number of topics presented within each knowledge area, and the organization/presentation strategy of covered topics. Given thousands of articles published each year and the expansion of knowledge in psychiatry over last few decades, perhaps it should not be a surprise that it is so challenging to identify a small number of seminal studies. . This said, given the abundance of resources and options available to most current psychiatry trainees (e.g., multiple textbooks, online databases, Internet resources), we find it peculiar that most of the commonly-recommended articles involved diagnostic classification criteria, rating scales, and reports of studies. The general psychiatry resident rotating through a C-L service primarily needs practical instruction on the management of psychiatric problems in medical and surgical patients. Most of the commonly-cited articles did not offer such information. For this reason, we recommend that practical topical review articles or textbook chapters be used as a core of a required or recommended reading list for resident’s C-L Psychiatry rotations, supplemented by a small number of studies or case series reports illustrating key teaching points pertaining to the topic. However, given the variety observed across the various educational resources surveyed, it is impossible for us to recommend one textbook over another, and we ultimately find that it is up to the individual educator to choose the specific educational resources that best meets the needs of his or her trainees.
12
References: 1.
Gitlin DF, Levenson JL, Lyketsos CG. Psychosomatic Medicine: A new psychiatric subspecialty. Acad Psychiatry 2004; 28(1):4-11
2.
Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Last accessed August 19, 2014
3.
Gitlin DF, Schindler BA, Stern TA, et al. Recommended guidelines for consultation-liaison psychiatric training in psychiatry residency programs. A report from the Academy of Psychosomatic Medicine Task Force on Psychiatric Resident Training in Consultation-Liaison Psychiatry. Psychosomatics, 1996; 37 (1): 3–11
4.
Söllner, WF. Creed F, European Association of Consultation-Liaison Psychiatry and Psychosomatics Workgroup on Training in Consultation-Liaison (2007) European guidelines for training in consultationliaison psychiatry and psychosomatics: Report of the EACLPP Workgroup on Training in ConsultationLiaison Psychiatry and Psychosomatics. J Psychosom Res, 2007; 62 (4):501–509
5.
Heinrich TW, Schwartz AC, Zimbrean PC, Lolak S, Wright MT, Academy of Psychosomatic Medicine′s Residency Education Subcommittee. The state of the service: A survey of psychiatry resident education in psychosomatic medicine. Psychosomatics, 2013; 54 (6):560–566
6.
Heinrich TW, Schwartz AC, Zimbrean PC, Lolak S, Wright MT, Brooks KB, Ernst CL, Gitlin DF. Recommendations for training psychiatry residents in Psychosomatic Medicine. Psychosomatics.pii: S0033-3182(13)00248-X; 2014
7.
Leentjens AFG, Rundell JR, Diefenbacher A, Kathol R, Guthrie E. Psychosomatic Medicine and Consultation-Liaison Psychiatry: Scope of Practice, Processess and Competencies for Psychiatrists or Psychosomatic Medicine Specialists: A Consensus Statement of the European Association of Consultation Liaison Psychiatry and the Academy of Psychosomatic Medicine. Psychosomatics. 2011; 52 (1):19-25
8.
Blumenfield M, Strain JJ (editors): Psychosomatic Medicine, Lippincott Williams & Wilkins,2006
9.
Levenson JL (editor): The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association, Washington, DC, 2011
13
10. Lloyd GG, Guthrie E (editors): Handbook of Liaison Psychiatry, Cambridge University Press, 2012 11. Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF (editors): Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier, Philadelphia,2010 12. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL (editors): Massachusetts General Hospital Comprehensive Clinical Psychiatry, First Edition. Mosby/Elsevier, Philadelphia, 2008 13. Stoudemire A, Fogel BS, Greenberg D (editors): Psychiatric Care of the Medical Patient, New York, Oxford University Press, 2000 14. Cremens MC, Calabrese LV, Shuster JL Jr., Stern TA. The Massachusetts General Hospital annotated bibliography. For residents training in consultation-liaison psychiatry. Psychosomatics 1995; 36 (3): 217235 15. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Delirium. Am J Psychiatry 1999; 156 (5 suppl):1-20 16. American Psychiatric Association. Diagnosis and Statistical Manual of Mental Disorders, IV Edition, Text Revision. Washington DC: American Psychiatric Association, 2000 17. Breitbart W, Gibson C, Tremblay A The delirium experience: Delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics, 2002; 183194 18. Engel GL, Romano J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis 1958; 9:260-277 19. Farrell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Arch Int Med 1995; 155:2459-2464 20. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State Examination: A practical method for grading the cognitive state of patients for clinicians. J Psychosom Res 1975; 11: 189-198 21. Franco K., Litaker D, Locala J, et al. The cost of deliriu in the surgical patient. Psychosomatics 2001; 42: 68-73 22. Stern TA. Continuous infusion of physostigmine in anticholinergic delirium: a case report. J Clin Psychiatry 1983; 44: 463-464 23. Webster R., Holroyd S. Prevalence of psychotic symptoms in delirium. Psychosomatics 2002; 41: 519-522
14
24. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992 25. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291:1753-1762 26. Milbrandt EB, Deppen S, Harrison PL, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2005; 9: R375-R381 27. McNicoll L, Pisani MA, Zhang Y, et al. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc 2003; 51: 591-598 28. Liptzin B, Levkoff SE. An empirical study of delirium subtypes. Br J Psychiatry 1992; 161: 843-845 29. Jacobson S, Jerrier H. EEG in delirium. Semin Clin Neuropsychiatry 2000; 5: 86-92 30. Menza MA, Murray GB, Holmes VF, et al. Decreased extrapyramidal symptoms with intravenous haloperidol. J Clin Psychiatry 1987; 48: 278-280 31. Tesar GE, Murray GB, Cassem NH. Use of high-dose intravenous haloperidol in the treeatment of agitated cardiac patients. J Clin Psychopharmacol 1985; 5:344-347 32. Sanders KM, Stern TA, O’Gara PT, et al. Delirium after intra-aortic balloon pump therapy. Psychosomatics 1992; 33: 35-41 33. Metzger E, Friedman R. Prolongation of the corrected QT and torsades de pointes cardiac arrhythmia associated with intravenous haloperidol in the medically ill. J Clin Psychopharmacol 1993; 13: 128-132 34. Wilt JL, Minnema AM, Johnson RF, et al. Torsades de pointes associated with the use of intravenous haloperidol. Ann Intern Med 1993; 119: 391-394 35. Schwartz TL, Masand PS. The role of atypical antipsychotics in the treatment of delirium. Psychosomatics 2002; 43: 171-174 36. Leso L, Schwartz TL. Ziprasidone treatment of delirium. Psychosomatics 2002; 43: 175-182 37. Breitbart W, Tremblay A, Gibson C. An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients. Psychosomatics 2002; 43: 175-182 38. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005; 53: 1658-1666
15
39. Fernandez F, Levy JK, Mansell PWA. Management of delirium in terminally ill AIDS patients. Int J Psychiatr Med 1989; 19:165-172 40. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying Confusion: the confusion assessment method. A new method for detection of delirium. Ann Int Med 1990; 113: 941-948 41. Trzepacs PT, Baker RW, Greenhouse J. A symptom rating scale for delirium. Psychiatry Res 1988; 23: 8997 42. Dr Groot M, Anderson R, Freedland KE, et al. Association of depression and diabetes complications: a meta-analysis. Psychosom Med 2001; 63 (4):619-630 43. Petersen Rc. Mild cognitive impairment as a diagnostic entity. J Intern Med 2004; 256:183-194 44. McKhann G, Drachman D, Folstein M, et al. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services task force on Alzheimer’s disease. Neurology 1984; 34:939-944 45. McKeith IG, Galasko D, Kosaka K, et al. Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy Bodies (DLB): report of the consortium on DLB international workshop. Neurology 1996; 47: 1113-1124 46. McKeith IG, Disckson DW, Lowe J, et al. Diagnosis and management of dementia with Lewy bodies: third report of the DLB consortium. Neurology 2005; 65: 1863-1872 47. Ferri CP, Prince M, Brayne C, et al. Alzheimer’s disease international: Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366(9503): 2112-2117 48. Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med 1988; 319: 1635-1638 49. Drugs that cause psychiatric symptoms. The Medical Letter 1993. 35: 65-70 50. Garrick TR, Stotland NL. How to write a psychiatric consultation. Am J Psychiatry 1982; 139:849-855 51. Groves JE. Taking care of the hateful patient. N Engl J Med 1978; 298:883-887 52. Groves JE. Patients with borderline personality disorder, in Cassem NH, ed. Massachusetts General Hospital Handbook of General Hospital Psychiatry, Third edition. St Louis, Mosby Year Book, 1991; pp. 191-215
16
53. Kahana RF, Bibring GL. Personality types in medical management, in Psychiatry & Medical Practice in the General Hospital, International Universities Press, 1964; pp 108-123 54. Mahler J, Perry S. Assessing competency in the physically ill: guidelines for psychiatric consultants. Hosp Comm Psychiatry 1988; 39: 856-861 55. Perry SW. Organic mental disorders caused by HIV: update on early diagnosis and treatment. Am J Psychiatry 1990; 147:696-710 56. Rodin G, Voshart K. Depression in the medically ill: an overview. Am J Psychiatry 1986; 143: 696-705 57. Stoudemire A, Moran MG, Fogel BS. Psychotropic drug use in the medically ill, part I. Psychosomatics 1990; 31: 377-391
17
Table 1: Knowledge Areas Considered Essential for Education of Psychiatry Trainees in C-L Psychiatry based on APM (2014) and EACLPP (2007) Guidelines and Recommendations APM 2014 Recommendations
EACLPP 2007 Guidelines
Knowledge Areas:
Knowledge Areas:
1. 2. 3. Essential Knowledge Areas: 1. 2. 3. 4.
5.
6.
General psychiatric illness in the medical setting; Psychiatric illnesses that occur primarily in the medical setting (e.g., somatic symptom disorder); Psychiatric manifestations of medical/surgical illness (e.g., delirium); Psychiatric co-morbidities associated with specific medical/surgical illness or treatment of such illness (e.g., cancer/chemotherapy); Psychiatric treatment modalities in the medical setting (e.g., pharmacology, electroconvulsive therapy); Legal aspects of the C-L psychiatry;
Advanced knowledge areas (considered optional): 7. 8. 9.
Liaison work (psychiatric practice in specific medical/surgical setting); C-L psychiatry in the outpatient setting; Pediatric C-L psychiatry);
Awareness of different theoretical models (e.g., bipsychological model); Ethical and medico-legal issues; Assessment and management of: Delirium/Dementia and other psychiatric diagnoses with organic causes; Somatization; Depression and anxiety in medically ill patients; Suicide/Self-harm; Addiction problems in mental setting; Abnormal illness behavior in somatically ill patients; Coping with chronical and terminal illness; Chronic pain; Gender-specific disorders, sexual dysfunction in medically ill patients; Sexual abuse in specific patient populations; Child and adolescent C-L psychiatry; Management of patients with psychiatric disorders in need of medical and/or surgical care;
18
Table 2: Topics on Psychiatric Illness in the General Medical Setting (as covered by the commonly used textbooks in C-L psychiatry)
A
B
C
D
E
F
Psychiatric Illness in the General Medical Setting Alcohol Use Disorder
x
Anxiety Disorders
x
Child and Adolescent Psychiatry
x x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Delirium
x
x
Dementia and Neurocognitive Disorders
x
x
x
x
x
Deception Syndromes: Factitious Disorders, Malingering
x
x
x
x
x
Depression and Related Disorders
x
x
x
x
x
Eating Disorders
x
x
x
x
x
x
x
x
x
x
x
Geriatric Psychiatry Mania/Bipolar Disorder
x
Personality Disorders
x
x
PTSD/Trauma
x
x
Schizophrenia and Psychotic Disorders
x
x
Somatization and Somatoform Disorders
x
x
x
x
x
x
x
x
x
x
x
Sleep Disorders
x
Sexual Disorders
x
x
x
x
x
Substance Use Disorders, Intoxication and Withdrawal
x
x
x
x
x
x
Suicide
x
x
x
x
x
x
Textbook Key: (A) Blumenfield M, Strain JJ: Psychosomatic Medicine, Lippincott Williams & Wilkins (2006) (B) Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) (C) Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012) (D) Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) (E) Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry , First Edition. Mosby/Elsevier (2008) (F) Stoudemire A, Fogel BS, Greenberg D: Psychiatric Care of the Medical Patient, New York, Oxford University Press (2000)
19
Table 3: Topics Pertaining to Psychiatry in the General Medical/Surgical Setting (as covered by the commonly used textbooks in C-L psychiatry) A
B
C
D
F
E
Topics Pertaining to Psychiatry In General Medical/Surgical Settings Internal Medicine and Sub-Specialties Cardiology
x
Dermatology Diabetes/Endocrinology
x
x
x
x
x
x
x
x
x
x
x
Immunology Intensive Care Medicine
x
x x
x
Infectious Disease/HIV/AIDS
x
x
x
Gastroenterology
x
x
x
x
Nephrology
x
x
x
x
Oncology
x
x
x
x
x
x
x
x x
Outpatient medicine Pain Medicine
x
x
Pulmonology
x
x
Rheumatology and Connective Tissue Disease
x
x
x
x
x x x
x
x
Toxicology Surgery and Sub-Specialities:
x
Anesthesiology Cosmetic/Reconstructive Surgery
x
x
x x
General Surgery
x x
HEENT Neurosurgery
x x
x
Obstetrics/Gynecology
x
x
Trauma, Burns and Orthopedic Surgery
x
Transplant Surgery
x
x
Coping with Chronic Illness/Psychological Response to Illness
x
x
Death/Dying/Terminal Illness
x
Neurology
x
x x
x x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Other Medical Specialities/Topics:
Pediatrics
x
x
Physical Medicine/Rehabilitation
x
x
x x
x
Textbook Key: (A) Blumenfield M, Strain JJ: Psychosomatic Medicine, Lippincott Williams & Wilkins (2006) (B) Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) (C) Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012)
20
(D) Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) (E) Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry, First Edition. Mosby/Elsevier (2008) (F) Stoudemire A, Fogel BS, Greenberg D: Psychiatric Care of the Medical Patient, New York, Oxford University Press (2000)
21
Table 4: Treatment Options and Advanced Topics in C-L Psychiatry (as covered by the commonly used textbooks in C-L psychiatry)
A
B
C
D
E
F
Treatment Resources and Other Topics In C-L Psychiatry x
Aggression and Violence Capacity, Competency and Surrogate Decision Making
x
Catatonia, NMS, Serotonin Syndrome
x
x
x
x
x
x
x
x
Culture and Psychiatry
x
x
x
Genetics
x
x
x
x
Examination/Testing (including Neuropsychiatric Testing)
x
x
x
x
x
x
x
x
x
Emergency Psychiatry Ethics
x
x
x
Forensic Psychiatry and Legal Issues
x
x
x
x
International Psychiatry Laboratory Assessment
x
x
x
x
x x
x
Major Disaster Planning
x
Neuroimaging and Other Imaging in Psychiatry
x
x
x x
x
x
x
x
x
x
x
x
x
x
x
x
Psychiatric Treatment in General Medical Setting and C-L Psychiatry: Complementary and Alternative Treatment ECT
x
Hypnosis Psychopharmacology/Drug-Drug Interactions
x
x
Therapy (Individual, including cognitive-behavioral therapy)
x
x
x
x
x
x
x
x
x
x
x
x
x
Academic/Clinical Research In C-L Psychiatry
x
x
x
History of C-L psychiatry
x
Therapy (Couples, Group and/or Family) Reproductive Medicine and Psychiatry
x
Topics Pertaining to Development/Organization of C-L Service:
x
Future of C-L psychiatry Organization of C-L service Outpatient C-L psychiatry and Integration with Primary Care
x
x x
x
x
x
x
x
x
x
22
Textbook Key: (A) Blumenfield M, Strain JJ: Psychosomatic Medicine, Lippincott Williams & Wilkins (2006) (B) Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) (C) Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012) (D) Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) (E) Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry, First Edition. Mosby/Elsevier (2008) (F) Stoudemire A, Fogel BS, Greenberg D: Psychiatric Care of the Medical Patient, New York, Oxford University Press (2000)
23
Table 5: Multiple-Cited References from C-L Psychiatry Textbooks. (based upon four textbooks, published within a 7- year period (2008-2014) . Textbook:
B
C
D
E
Delirium
400 89
92
79
Dementia
252 n/a
85
97
Depression
254 n/a
134 62
Number of references reported per content area:
Total number of individual references identified in the sample: Delirium
537
Dementia
388
Depression
414
Number of references cited by more than one textbook:
Delirium
83 (10 with four citations, 17 with three citations; 56 with two citations)
Dementia
37 (7 with three citations; 30 with two citations) (19 of these are shared citations between two MGH textbooks)
Depression
34 (2 with three citations; 32 with two citations) (27 of these are shared citations between two MGH textbooks)
(B) Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, American Psychiatric Association (2011) (C) Lloyd GG, Guthrie E: Handbook of Liaison Psychiatry, Cambridge University Press (2012) (D) Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF: Massachussets General Hospital Handbook of General Hospital Psychiatry, Sixth Edition. Saunders/Elsevier (2010) (E) Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL: Massachusetts General Hospital Comprehensive Clinical Psychiatry , First Edition. Mosby/Elsevier (2008)
24
