Transcript Medical Student Resident Orientation 2007

Update on medical student education
and teaching psychiatry
Tony Guerrero, M.D.
Associate Chair for Education and
Training, Department of Psychiatry
Objectives
 To
review current trends in psychiatric
recruitment, nationally and locally
 To provide an update on medical
student education at UH-JABSOM
 To review innovations in psychiatric
education
Why talk about undergraduate
education?
Reason #1: Thank you

Participation by academic and clinical faculty
and residents
 Admissions committee, PBL tutors, clinical
skills preceptors, community medicine
preceptors, resource people, colloquium
lecturers, clerkship faculty, oral examiners,
elective preceptors, student advisors, other
mentors and role models.
Reason #2: Without medical
students, we wouldn’t have a
department
Reason #3: I needed
something fun to present
Reason #4: We should care
about community’s needs and
the future of our specialty
Your thoughts when you hear of a medical
student interested in psychiatry:
a)
b)
c)
This is great! Another potential new
student to meet the community’s need.
Darn! Another person to compete for
business with.
Why on earth is this student interested
in this specialty?
Correct answer:

A)
 There are significant unmet needs for
psychiatrists in nearly all specialties and in
nearly all communities, including in Hawaii.
 For example: according to the U.S. Surgeon
General’s report (AACAP, 2000), the current
supply of less than 7000 child and adolescent
psychiatrists is up to 23,000 short of what’s
actually needed
 Unfilled residency positions in psychiatry
(including specialties)
Workforce needs (local)
 Federally
designated (HPSA) Mental
Health Shortage areas: Puna, Ka`u
(Big Island); Moloka`i; Kalihi Valley
 Various consent decrees (Felix, DOJ,
possibly others)
 Just look at our own experiences
 Our graduates have a much easier time
finding jobs (vs. other specialties)
Recruitment trends: bottom
lines
 Nationally,
4% of medical school
graduates choose psychiatry.
 In Hawai`i, we overall do better, but still:
are we where we ought to be?
14
12
10
8
6
4
2
0
Year
20
07
20
05
20
03
20
01
19
99
19
97
19
95
Percentage of MS4 students
matching into psychiatry
(categorical and combined)
19
93
19
91
Percentage
Psychiatry Recruitment at UH-JABSOM (1991-2007)
Percentage of MS4 students
matching into UH psychiatry
programs (categorical and tripleboard)
Why don’t medical students
choose psychiatry?
 Cutler,
2000: Students may perceive
psychiatry to be a “stressful” specialty.
 Are there actually more students who
are “excellent fits” for psychiatry who
end up choosing a less optimal
specialty?
Are there other factors?
 Clardy
et al, 2000: Higher interest with
clerkship experiences in outpatient
psychiatry.
 “Meaningful contribution to patient
care.”
 Waterman and Schwartz, 2000: High
prevalence of “mind-body dualistic
fallacies”
Are there other factors?
Malhi et al, 2002, 2003 (Australia):
 “The least attractive aspects of psychiatry were
its lack of prestige among the medical
community and a perceived absence of a
scientific foundation.”
 “In comparison with other disciplines, psychiatry
was regarded as… lacking a scientific foundation,
not being enjoyable and failing to draw on training
experiences.”
 “…identified image problems need to be
corrected…”
Medical student teaching and
recruitment is high priority

Part of the UH-DOP strategic plan since 2001
 We have recently started the JABSOM
Psychiatry Student Interest Group (JPSIG) to
identify and foster interest early on in medical
school



Stigma confronted, media examined
Guest speakers, career-related videos
Brain/behavior correlations
The general scheme at
JABSOM
Year 1
Unit 1(health/illness) Unit 2(cardio/pulm/renal) Unit 3(endo/heme/GI)
Year 2
Unit 4 (locomotor/neuro/behavior)
Year 3
Unit 6 clerkships (FP, medicine, peds, ob/gyn, PSYCHIATRY, surgery)
Year 4
Unit 7 electives/career differentiation
Unit 5 (life cycle)
Interfaces: first and second-year
students
 PBL curriculum:
biological, behavioral,
populational, and clinical perspectives.
 Humanism in medicine
 Small-group tutors, resource people,
“white coat ceremony” participants
Interfaces: second-year medical
students
 Clinical
skills preceptorship during
“Brain and Behavior” subunit.
 3 hours/week for 4 weeks (late
November to mid-December)
 Teach a group of 5-6 medical students
the basic mental status exam
 Extremely well-received by students
and enjoyed by faculty
Interfaces: psychiatry clerkship
Components:
 Inpatient (QMC, HSH)
 Outpatient (QCS, QEC, KMCWC OPD)
 Child/adolescent (FTC)
 Emergency/on-call (QMC)
 PBL tutorials
 Videotape conferences
What does the clerkship try to
emphasize?
 Relatively
high prevalence of psychiatric
conditions
 Morbidity and mortality of psychiatric
conditions
 Treatability of psychiatric conditions
 Basic psychiatric interview: essential
tool of the safe physician
Clerkship goals
Attitudes:
1.
To be empathetic and professionally responsible towards patients with mental health needs
2.
To respectfully collaborate with others involved in patient care
Skills:
1.
2.
3.
4.
5.
6.
7.
8.
To establish and maintain rapport with patients in various contexts, and to manage emotions
which arise in the course of patient care.
To assess for conditions that could threaten the safety of the patient or others.
To perform a comprehensive history and mental status examination
To generate broad-based differential diagnoses for psychiatric symptoms
To identify the biological, psychological, social, and cultural factors that influence a patient’s
presentation, and to apply knowledge of such factors to patient care.
To document and communicate information effectively.
To access resources needed to manage patients with psychiatric conditions.
To utilize the medical literature for the benefit of patients with psychiatric conditions.
Knowledge:
1.
To be familiar with: cognitive, substance-related, psychotic, mood, anxiety, somatoform,
dissociative, eating, sexual, sleep, personality disorders; child and adolescent and geriatric
psychiatry; psychopharmacology; and psychotherapies.
2.
To be familiar with the mental health needs and resources specific to the Hawaii community.
3.
To be familiar with the scope and practice of psychiatry.
Clerkship organization: implications for
weekly schedules, other planning
Inpatient acute general hospital psychiatry at Queen’s Medical
Center (3-4 weeks)
Inpatient public psychiatry at Hawaii State Hospital (3-4
weeks)
Child and adolescent psychiatry at Queen’s Medical Center
Outpatient psychiatry at Queen’s Medical Center or Kapi‘olani
Medical Center for Women and Children
On-call/emergency psychiatry (7 weeks)
Orientation/
Interviewing
Tutorial
introduction/
PBL Case 1
PBL Case
1&2
PBL Case
2&3
PBL Case
3&4
PBL Case
4&5
PBL Case
5&6
PDA logs
due
Mid-term
review/
Interviewing
2
Interviewing
3
PBL Case
6&7
PBL Case
7&8
Finish cases
Wrap-up
PDA logs
due
Experiences
checklist due
Write-up
#1
Write-up #2
Mid-term
exam
NBME exam
Oral exam
Clerkship handbook: http://dop.hawaii.edu
Clinical experiences
1. Participating in the care of a patient with symptoms of depression and/or
2.
3.
4.
5.
6.
7.
8.
9.
anxiety in an outpatient (e.g., clinic) or general medical (e.g.,
emergency room, consultation-liaison, etc.) setting.
Participating in the care of a patient with a cognitive disorder presenting
in an acute setting (e.g., emergency room, acute inpatient,
consultation-liaison, etc.)
Participating in the care of a patient with a major mood disorder
presenting in an acute setting.
Participating in the care of a patient with a substance use disorder.
Participating in the care of a patient with a psychotic disorder
presenting in an acute setting.
Participating in the assessment of a child or adolescent patient.
Participating in the care of three patients who are followed-up several
times.
Observing electro-convulsive therapy.
Performing two patient interviews supervised by and discussed with the
attending or chief resident.
Other issues re: clinical care
 Weekends
for Kekela medical students:
round on their own patients, choose
either Saturday or Sunday. No need do
new admissions/stay late unless
extremely low census.
 Medical students can and should write
progress notes (need to be reviewed).
Interfaces: beyond third-year
 Career
advising; fourth-year planning
 Numerous fourth-year electives relevant
for all medical specialties (e.g., child
and adolescent, consult-liaison,
addiction, psychiatric aspects of ob/gyn,
etc.)
Suggestions:
 Interface
with medical students early in
careers.
 Role model: humanism in medicine and
effective management of emotional
issues arising from patient care.
 Role model: importance of the
biopsychosocial approach; enthusiasm
about the neuroscience of behavior.
Suggestions (continued):
 Enable
students to have, with
supervision, experiences in which they
meaningfully contribute to the care of
psychiatric patients (including
documentation)
 Allow students to have an accurate
picture of what a psychiatric career is.
Overall…
 Be
educated about current trends in
education
 Strive for continuous quality
improvement in all aspects of education
 A strong educational culture will improve
residency teaching and faculty
development as well
Trends in medical student
education

Innovations in teaching (e.g., PBL,
information technology) and evaluating (e.g.,
OSCE) medical students


Implications for faculty development
Desirability of other utilizing a wider variety of
settings other than inpatient for clinical
exposure

Implications for how we design academic clinical
services
Trends in resident education
 Competency-based
(not just time-cards)
 80-hour work week (context: need to
improve patient safety)
 Higher degree of structure and
accountability
Resident Supervision
(ACGME Bulletin)
 Good
supervision:
 Good
patient care
 Good education, that cultivates good
supervisors
 Good business sense
 Better morale
Resident Supervision
(ACGME Bulletin)
 Direct
observation
 Structured,
predictable
 Feedback
 Appropriate
content
 Appropriate process
A bit more about feedback
 “Feedback”
vs. evaluation
 Tips on giving feedback
 Timeliness
 For
the receiver’s benefit
 Objective descriptions of behavior (vs.
subjective conclusions)
Resident Supervision
(ACGME Bulletin)
 “Practice
without informed, deliberate
coaching to address non-optimal
components may make poor
performance `permanent,’ as bad habits
become more ingrained with repetitive
use. Practice thus does not always
make performance `perfect.’”
Resident Supervision
(ACGME Bulletin)
 Competency-based
evaluations (6
competencies)
 Portfolio-based assessments
Training medical students and
residents
 New
methods, with growing body of
evidence-based support:
 Problem-based
learning
 Team-based learning
Teaching
Various types of teaching:
 Didactic lectures
 Interactive conferences
 Case-based teaching
 Problem-based learning*

“Closed-loop reiterative problem-based learning”
(Barrows)
Bedside preceptorship*
 Mentorship*

PBL Clerkship tutorial topics

Specific conditions: delirium, dementia,
psychosis, mood disorders (depression,
bipolar), substance abuse, personality
disorders, pervasive developmental
disorders, ADHD, OCD, etc.
 Treatments: psychopharmacology,
psychotherapy
 Age groups: child/adolescent, adult, geriatric
 Covers entire didactic content of psychiatry
Rationale
 Studies
suggest better performance
(shelf exams) with PBL-based (vs.
didactic-based) clerkship curriculum
(Washington et al, 1999; McGrew et al,
1999; Curtis et al, 2001; Nalesnik et al,
2004)
A few more words about PBL
 Used
at McMaster University Medical
School since 1969
 Evidence amassed over the years
shows no disadvantage to PBL for the
general curriculum, in multiple outcome
measures (Colliver, 2000)
PBL…

Evidence (Norman and Schmidt, 1992) that,
compared with traditional methods, PBL:




Enhances application of concepts to clinical
situations
Increases long-term retention
Fosters life-long interest in learning.
Some evidence, even, of improved board
scores (Blake, 2000)
PBL at JABSOM
 Good
USMLE performance relative to
national norms (Kasuya et al, 2003)
 Successful residency matching
 LCME accreditation: full 7 years
Teaching according to PBL
principles
 Process
of identifying facts/problems,
hypotheses (including mechanisms),
additional information, learning issues
 Active role: not teaching, but facilitating
process
Facilitating the PBL Process:
Initial Problem Encounter
“Any other facts or problems you see in this
case?”
 “Any other hypotheses, or possible
mechanisms, for the problem(s) you’ve
identified?”
 “Was what you said more a fact or a
hypothesis?”
 “Based on that hypothesis, any other
additional information?”
 “Did you have a new hypothesis, based on
the additional information you just
requested?”

Use of the Mechanistic Case Diagram to Generate Hypotheses
Hypotheses
Problems
respiratory
arrest
hypoxemia
energy
production
loss of
consciousness
disruption
of “the brain”
poor
perfusion
cardiac
dysrhythmia
Additional Info.
Learning Issues
vital signs, heart rate
1. Anatomy and physiology of consciousness
cardiac
output
cerebrovascular
atherosclerosis
lack of
substrate
hypoglycemia
insulin
overdose
pallor
tumor
?
mass lesion
trauma
physical
impingement
intracranial
bleed
ICP
meningitis
Na
abnormal
neurotransmission
“drug abuse”
seizure
neurotoxins
hepatic
failure
further history about drug use
(e.g., what drug?)
Facilitating the PBL Process
Group Functioning
“I notice that most (or some) people are quiet.
I’m wondering what other people are thinking
at this point.”
 “That’s a good clarifying question that you
asked your colleague.”
 “It seems like there’s some disagreement
here. Any suggestions about how to resolve
this?”
 “Any feedback about today’s session: what
worked well, what could have been done
better?”

Facilitating the PBL Process
Integrating Knowledge
“How would you apply the knowledge you’ve
learned back to the patient’s presentation?”
 “How does the information you’ve presented
relate to what your colleague(s) just
presented?”
 “It sounds like you’ve identified a gap in
knowledge, and you’re wondering if I know
the answer. I actually don’t know the answer,
but how does the group think I would go
about finding it? What mechanisms or basic
information do you think you need to learn
about to help you find the answer?”

Use of the Mechanistic Case Diagram to Summarize a PBL Case
adolescence*
goal of
independence
reward/
reinforcement
peer vs.
family
pressure
risk-taking
behavior
dopamine
activity
recent
emigration*
selffragmentation
methamphetamine
abuse
dopamine
release
sensitive
receptor
depressiveequivalent
behavior
release of epinephrine
and norepinephrine
myocardial
demand
genetic
factor*
functional
ischemia
other family
members with
substance abuse
diffuse cardiac
necrosis
poor
contractility
“cardiomyopathy”
via echocardiogram
cardiac
output
poor
perfusion
pallor
energy
production
reticulocortical
disruption
loss of
consciousness
non-functioning
ionic pumps
contractile
force
partial AV
node damage
intracellular
calcium
slow
pathway
Digoxin
AV
conduction
diastolic
filling
vagal
tone
abnormal atrial
automaticity
conduction of
impulse
re-entry through
fast pathway
tachycardia
“PSVT”
via EKG
unemployment
Condition affecting
Brain functioning
Parts of the
“higher brain”
Specific parts of the
brain influencing
social connectedness
0-3 services
Special ed.
Social
disconnectedness
Weaknesses in
multiple areas of
functioning
Relatively less natural
motivation to learn
adaptive skills
“MENTAL
RETARDATION”
Significant delays in language
and communication development
“discrete trial
training,” etc.
“AUTISTIC
DISORDER?”
Tendency to repetitive
and sterotypic
behaviors
Selected PBL cases
vitamin B1
Genetic factors*
nutrient
malabsorption
vitamin B1
deficiency
decreased
glucose
utilization
glutamate
neurotoxicity
vestibular nuclei
CN6 nuclei
pontine gaze center
dorsomedial thalamus
hippocampus
nystagmus
lateral gaze defects
anterograde amnesia
peripheral nerve
dysfunction
longest tracks
weakness
decreased sensation
hands/feet
Abnormal
reward systems
Alcohol use
Mesolimbic
dopamine release
pyridoxine,
pantothenate
B12, folate
Thalamo-orbitofrontal
overactivity
Confusion, hallucinations
Greg Primo (Unit 4): Wernicke-Korsakoff’s syndrome
•Pathophysiological mechanisms
•Anatomic/clinical correlations
Schizophrenia/psychotic
disorders
Remember Larry Klaus (Unit 4)? Remember Phil Collins (Unit 1)?
•Relationship between psychosocial factors and
overall general medical health
Genetic, environmental
factors*
benztropine
DA/Ach imbalance
basal ganglia
risperidone
DA receptor blockade
Cytoarchitectural
abnormalities
Inappropriate
mesolimbic dopamine
release
Increased dopamine
tone
Maldevelopment
Frontal lobe
flat/inappropriate
affect
acute dystonia/
stiff jaw
Neuronal
migration errors
Poor cortical
filtering
Delusions,
tangentiality
hallucinations
injury to feet
cellulitis
practical help
Poor judgment
limited access
to care
poverty
Inability to work
homelessness
Mood disorders
Genetic factors*
Lithium
thyroid effects
elevated TSH
goiter
increased functional
neurotransmission
dopamine systems
antipsychotics
prefrontal cortex
limbic system
amygdala
hypothalamus
(which parts?)
reticular activating
system
mania
aggression
decreased sleep
decreased appetite
weight loss
poor concentration
restlessness
Abnormal
2nd messengers
Receptor
desensitization
poor judgment
Decreased
neurotransmission
Increased inhibitory
neurotransmitters
Increased
catecholamines
Hypothalamus,
Limbic system
ECT
Increased serotonin
Depression, motor
retardation
SSRI’s
Bipolar disorder (Unit 4)
•Pathophysiological mechanisms
•Anatomic/clinical correlations
Cognitive disorders
Recurrent theme: pathophysiology, anatomical correlations
Delirium (e.g., Flora Dutton, Unit 5; Momi Johnson, Unit 5; Lance Kealoha, Unit 3 –cancer)
versus dementia (e.g., Lotta Pukas, Unit 4; Leilani Kapena, Unit 5)
Genetic factors*
Aging*
medications
e.g., anticholinergic
infection
donepezil
Cholinergic neurons
disruption of
reticular activating
system
Decreased cholinergic
function
impaired alertness
and concentration
dehydration
abnormal electrolytes
Cell death
Accumulation of
Plaques and tangles
cholinesterase
inhibition
Hippocampus
Nucleus basalis
Motor pathways
Impaired memory
encoding
Frontal release
acute confusion
emergence of
primitive reflexes
agitation
Anxiety Disorders
Genetic factors*
SSRI
GABA/Cl channel
facilitation
inappropriate
locus ceruleus
desensitization
firing
reticulospinal
path
limbic activation
corticolimbic
pathway
sympathetic
discharge
fear
prefrontal cortex
oversensitive
homeostatic receptors/
brainstem nuclei
oversensitive
5HT receptor
Increased synaptic
serotonin
benzodiazepine
5HT receptor
downregulation
5HT3 agonism
tachycardia
palpiatations
sweating
increased respiratory demand
kindling
chronic
anticipatory
anxiety
agoraphobia
GI side effects
Mary Kaweli (Unit 4): Panic Disorder with
Anticipatory anxiety and agoraphobia
Potential Application to the Biopsychosocial Formulation
Biological
Psychological
Social/Cultural
Head trauma
age 59
Cortical dysfunction
generativity vs. stagnation
Alcohol
job dysfunction
Genetic factors
Medication effects
Sleep difficulty
(chief complaint)
Loss of father
“Depression”
Loss of girlfriend
Limited family contact
Lonely
Others who drink around
Risk of relapse
Evaluations
forms – mid-unit, end-unit,
grading, time frames
 Write-ups, oral exams
 “Honors” = globally outstanding and
clearly superior to other third-year
medical students, and functioning at the
level of a strong junior resident in
psychiatry.
 Evaluation
Evaluations

Write-ups: can find a sample honors write-up
and grading criteria sheet in the handbook
 Oral exam: ABPN Part II format


Please try to find an adult patient that is unknown
to both you and the student.
Please refer to criteria in the grading sheet.
Please refer to the handbook (or refer students
to the handbook) if there are any questions
about expectations, grading, etc.
Remember
 Through
medical student education, we
provide the psychiatric education for the
96% of students who go into other
specialties.
 Through medical student education, we
can have a lasting impact on the future
of our specialty, and on our ability to
meet community needs in the long run.
Everyone’s well-being

Education and patient care are both
optimized if we all look out for each other’s
well-being
 It’s everyone’s job to look out for each other’s
safety and physical and emotional well-being,
and to insure compliance with regulations that
look out for these very things (e.g., OSHA,
ACGME 80 hour work week, etc.)
 Please let us know if you have any questions
or concerns about this.
In closing…

Your diligence and excellence in medical
student teaching will be recognized and
greatly appreciated! 
 Medical student teaching is an important part
of resident/faculty evaluations
 Please be prompt in turning in evaluation
forms on students you supervise
Whom can you call?
 Dan Alicata,
M.D.
Psychiatry Clerkship Director
[email protected]
 Tony Guerrero, M.D.
Vice-Chair for Education and Training,
Department of Psychiatry
[email protected]
THANK YOU FOR YOUR
ATTENTION!