Professionally responsible intrapartum management of patients with major mental disorders

Pregnant women with major mental disorders present obstetricians with a range of clinical challenges, which are magnified when a psychotic or agitated patient presents in labor and there is limited time for decision making. This article provides the obstetrician with an algorithm to guide professionally responsible decision making with these patients. We searched for articles related to the intrapartum management of pregnant patients with major mental disorders, using 3 main search components: pregnancy, chronic mental illness, and ethics. No articles were found that addressed the clinical ethical challenges of decision making during the intrapartum period with these patients. We therefore developed an ethical framework with 4 components: the concept of the fetus as a patient; the presumption of decision-making capacity; the concept of assent; and beneficence-based clinical judgment. On the basis of this framework we propose an algorithm to guide professionally responsible decision making that asks 5 questions: (1) Does the patient have the capacity to consent to treatment?; (2) Is there time to attempt restoration of capacity?; (3) Is there an opportunity for substituted judgment?; (4) Is the patient accepting treatment?; (5) Is there an opportunity for active assent?; and (6) coerced clinical management as the least worst alternative. The algorithm is designed to support a deliberative, clinically comprehensive, preventive-ethics approach to guide obstetricians in decision making with this challenging population of patients.

Responsibly managing students' learning experiences in student-run clinics: a virtues-based ethical framework

BACKGROUND

Many medical schools now offer students a distinctive clinical and learning opportunity, the student-run clinic (SRC), in which generalist physicians often play the major role. Although SRCs have become popular, they pose as-yet unexplored ethical challenges for the learning experiences of students. In SRCs students not only take on a significant administrative role especially in coordinating care, but also provide direct patient care for a clinically challenging, biopsychosocially vulnerable, medically indigent population of patients. SRCs provide an exemplar of the ethical challenges of care for such patients.

SUMMARY

The ethical framework proposed in this article emphasizes that these valued learning opportunities for students should occur in the context of professional formation, with explicit attention to developing the professional virtues, with faculty as role models for these virtues.

CONCLUSIONS

The valued learning opportunities for students in SRCs should occur in the context of professional formation, with explicit attention to developing the professional virtues of integrity, compassion, self-effacement, self-sacrifice, and courage, which are required for the appropriate care of the vulnerable populations served by SRCs.

Prevalence and treatment of frotteurism in the community: a systematic review

This article describes a systematic review of prevalence studies on frotteurism. We searched the following databases for previously published, peer-reviewed studies that used suitable diagnostic methods in adult nonclinical samples: Ovid MEDLINE, PsycINFO, Pubmed, AccessMedicine, Cochrane Library, Books@Ovid, DynaMed, Micromedex, Science Direct, and SciVerse Scopus. We conducted multiple searches using the following terms: frotteu*, frottage, frotteurism, paraphilia, paraphilic, courtship disorder, prevalence, treatment, diagnosis, and chikan, and we evaluated the articles by using a six-point epidemiologic quality tool. We identified four prevalence studies, all of which were of limited methodological quality. Limitations included small sample sizes, the use of local rather than national samples, the failure to apply DSM or ICD-9 diagnostic criteria, and the lack of assessment regarding the reliability of diagnostic tools. One small study, a statistical outlier, reported a prevalence of 35 percent. In the three other studies, the prevalence of frotteurism was 7.9 percent, 9.1 percent, and 9.7 percent. We found no studies addressing treatment that met our inclusion criteria. Our findings reveal a need to develop more rigorous research on this topic.

Methodologies and study designs relevant to medical education research

Research is an important part of educational scholarship. Knowledge of research methodologies is essential for both conducting research as well as determining the soundness of the findings from published studies. Our goals for this paper therefore are to inform medical education researchers of the range and key components of educational research designs. We will discuss both qualitative and quantitative approaches to educational research. Qualitative methods will be presented according to traditions that have a distinguished history in particular disciplines. Quantitative methods will be presented according to an evidence-based hierarchy akin to that of evidence-based medicine with the stronger designs (systematic reviews and well conducted educational randomized controlled trials) at the top, and weaker designs (descriptive studies without comparison groups, or single case studies) at the bottom. It should be appreciated, however, that the research question determines the study design. Therefore, the onus is on the researcher to choose a design that is appropriate to answering the question. We conclude with an overview of how educational researchers should describe the study design and methods in order to provide transparency and clarity.

A systematic review of stress-management programs for medical students

OBJECTIVE

Because medical students experience a considerable amount of stress during training, academic leaders have recognized the importance of developing stress-management programs for medical students. The authors set out to identify all controlled trials of stress-management interventions and determine the efficacy of those interventions.

METHOD

The authors searched the published English-language articles on PsycINFO and PubMed, using a combination of the following search terms: stress-management, distress, burnout, coping, medical student, wellness. Both randomized, controlled trials and controlled, non-randomized trials of stress-management programs were selected and critically appraised.

RESULTS

A total of 13 randomized, controlled trials or controlled, non-randomized trials were identified. Interventions included self-hypnosis, meditation, mindfulness-based stress-reduction, feedback on various health habits, educational discussion, changes in the length and type of curriculum, and changes in the grading system. Only one study was identified to be of very high quality, although several had described group differences at baseline, used blinding, had good follow-up, and used validated assessment tools. There was a wide heterogeneity of outcome measures used. Interventions that were supported by a reduction in stress and anxiety in medical students included mindfulness-based stress-reduction or meditation techniques, self-hypnosis, and pass/fail grading.

CONCLUSIONS

Significant opportunities to advance educational research in this field exist by developing more high-quality studies with particular attention to randomization techniques and standardizing outcome measures.

Writing for academia: getting your research into print: AMEE Guide No. 74

The authors identify and describe strategies for success in writing for publication, including how to choose an educational research topic, define the question and choose the correct design, know the anatomy of a research paper, write each of the sections, optimize the writing before publication, choose a journal, and respond to editors and reviewers. The research question should be focused, modest, and achievable given the constraints of the setting, significant, and appropriately imbedded in the available literature. The choice of methods is determined by the nature of the educational research question and should conform to ethical standards. Specific strategies for writing include starting where it is easiest to do so, spontaneously and uncritically writing the first paragraphs through, minimizing external impediments to the work, and knowing how each section of a manuscript is routinely structured. All papers require a number of revisions with careful attention to accuracy and detail as well as to specific requirements of the target journal before submission. Authors should respond positively, not defensively, and in detail to all of the editor's and reviewers' suggestions for revision. Writing for success is therefore a disciplined and systematic process following prescribed steps, which, although hard work, is rewarding.

Survey of threats and assaults by patients on psychiatry residents

OBJECTIVE

The authors sought to determine the prevalence of threats and assaults by patients on psychiatry residents, their consequences, and the perceived adequacy of supports and institutional responses.

METHOD

Authors conducted an anonymous survey of 519 psychiatry residents in 13 psychiatry programs across the United States. The survey questionnaire inquired about residents' experiences of threats and assaults by patients during their residency training.

RESULTS

The response rate for this survey was 39% (N=204). Residents were most commonly threatened (N=175; 86%), physically intimidated (N=145; 71%) or received unwanted advances (N=118; 58%). One-quarter (N=51; 25%) were physically assaulted. Most of the incidents occurred in inpatient settings (N=92; 45%).

CONCLUSION

This study, like previous studies on this topic, calls attention to the high number of residents that are affected by violence during their training, and it underscores the need to protect the safety of psychiatry residents and to support those who have been victimized.

Teaching sexual history-taking: a systematic review of educational programs

PURPOSE

Because of the importance of sexual history-taking, the authors attempted to identify all randomized controlled trials on teaching this topic and reviewed the methods used for teaching and the efficacy of the educational interventions.

METHOD

From June to November 2010, the authors searched the published English-language literature indexed in PubMed, PsycINFO, and SCOPUS, using the key terms sexual history-taking, teaching, medical students, residents, sexual health, sexually transmitted infections, HIV, and AIDS. The authors selected and critically appraised randomized controlled trials and controlled nonrandomized trials of educational programs designed to enhance sexual history-taking skills.

RESULTS

Of 11 trials identified, 7 included medical students, 2 included residents, 1 involved community-based physicians, and 1 involved attendings, fellows, and residents. The educational interventions and outcome measures were heterogeneous, and the quality of study methodologies varied widely. The authors judged only 1 study to be of very high quality, although 8 studies explicitly mentioned at least one of the following: group differences at baseline, blinding, follow-up, and validated measurement tools. In the highest-quality study, primary care physicians who were mailed educational materials and received an unannounced instructor visit performed better in risk assessment and counseling than two comparison groups. Evidence also supported interactive workshops over didactic presentations.

CONCLUSIONS

The dearth of high-quality controlled studies hampers the development of sexual history-taking curricula for medical students and residents. The available literature supports formal opportunities to directly practice and receive feedback on interviewing skills. More rigorous research on sexual history-taking education is needed.

Hard to swallow: a systematic review of deliberate foreign body ingestion

OBJECTIVE

Deliberate foreign body ingestion (DFBI) is often impulsively driven, repetitive and refractory to intervention and frequently necessitates multiple medical interventions. As such, the frustrations among health care providers are great, and the financial toll on health care is significant. Nevertheless, the literature on DFBI is sparse, and suggestions for treatment planning and management are limited. The authors sought to investigate and uncover efficacious treatments and strategies for preventing reoccurrence in DFBI. We build on earlier work by offering both broad and diagnosis-specific management strategies.

METHOD

A literature review was performed addressing the presentation, management and prevention of reoccurrences of DFBI. Four cases of DFBI are presented illustrating those psychiatric diagnoses (psychosis, malingering, obsessive-compulsive disorder and borderline personality disorder) most frequently encountered in hospital practice. Both broad and specific treatment approaches are presented.

RESULTS

Patients engaging in DFBI are best managed through a multidisciplinary approach, following acute medical management. Successful strategies for the prevention of reoccurrences of DFBI are inconclusive.

CONCLUSION

Understanding the function of this behavior is critical in developing treatment for patients who engage in these dangerous, potentially life-threatening, self-injurious behaviors. An amalgam of medical, pharmacological and cognitive-behavioral interventions is recommended, as is additional research.

Focus on patient management: responsibly managing psychiatric inpatient refusal of medical or surgical diagnostic work-up

This column uses the tools of normative ethics-analysis and argument-to provide a reasoned account of and to identify ethically justified responses by the psychiatrist to psychiatric inpatients' refusal of medical or surgical diagnostic work-up. There are three relevant ethical considerations when psychiatric inpatients refuse medical or surgical diagnostic tests: balancing autonomy with beneficence, surrogate decision making and confidentiality, and managing strong feelings. Assisted decision making and assent are key management strategies for promoting patients' autonomy and for protecting against adverse consequences of decision making.

Toolbox for evaluating residents as teachers

OBJECTIVE

The authors review existing assessment tools related to evaluating residents' teaching skills and teaching effectiveness.

METHODS

PubMed and PsycInfo databases were searched using combinations of keywords including "residents," "residents as teachers," "teaching skills," and "assessments" or "rating scales."

RESULTS

Eleven evaluation tools that utilized self-reports, learner evaluations, or observed structured teaching evaluations were found. These varied in length from one to 58 items, most of which were both valid and reliable. Additional evaluation tools were found that utilized direct audio- or videotaped recordings of teaching.

CONCLUSION

This toolbox should facilitate program directors and others in assessing residents' teaching skills and should promote rigorously conducted research on residents as teachers.

Evaluating the quality of learning-team processes in medical education: development and validation of a new measure

BACKGROUND

Measurement of the quality of team processes in medical education, particularly in classroom-based teaching settings, has been limited by a lack of measurement instruments. Therefore, the purpose of this study was to develop and test an instrument to measure the quality of team interactions.

METHOD

The authors created 30 items and reduced these to 18 items using factor analysis. They distributed the scale to 309 second-year medical students (RR = 95%) in a course that used teams and measured internal consistency, validity, and differences in scores between teams.

RESULTS

Cronbach's alpha for the scale was 0.97. Team ratings were variable, with a mean score of 95.7 (SD 8.5) out of 108. Team Performance Scale (TPS) scores correlated inversely with the spread of peer evaluation scores (r = -0.38, P = .003). Differences between teams were statistically significant (P < .001, eta = 0.33).

CONCLUSIONS

The TPS was short, had evidence of reliability and validity, and exhibited the capacity to distinguish between teams. This instrument can provide a measure of the quality of team interactions. More work is needed to provide further evidence of validity and generalizability.

Evaluating the quality of learning-team processes in medical education: development and validation of a new measure

BACKGROUND

Measurement of the quality of team processes in medical education, particularly in classroom-based teaching settings, has been limited by a lack of measurement instruments. Therefore, the purpose of this study was to develop and test an instrument to measure the quality of team interactions.

METHOD

The authors created 30 items and reduced these to 18 items using factor analysis. They distributed the scale to 309 second-year medical students (RR = 95%) in a course that used teams and measured internal consistency, validity, and differences in scores between teams.

RESULTS

Cronbach's alpha for the scale was 0.97. Team ratings were variable, with a mean score of 95.7 (SD 8.5) out of 108. Team Performance Scale (TPS) scores correlated inversely with the spread of peer evaluation scores (r = -0.38, P = .003). Differences between teams were statistically significant (P < .001, eta = 0.33).

CONCLUSIONS

The TPS was short, had evidence of reliability and validity, and exhibited the capacity to distinguish between teams. This instrument can provide a measure of the quality of team interactions. More work is needed to provide further evidence of validity and generalizability.

When should psychiatrists seek criminal prosecution of assaultive psychiatric inpatients?

This Open Forum commentary reviews the ethical considerations relevant to the question of prosecuting assaultive psychiatric patients, with particular attention to the significance that should be attached to the arguments generated by those considerations. A comprehensive literature search was conducted incorporating the terms "assaultive patients," "ethics," "psychiatric inpatients," and "law." The literature of professional medical ethics was applied to identify relevant domains of ethical argument. Five domains were identified: fiduciary obligations of physicians to assaultive and other patients; obligations to staff members; professional virtues of compassion, self-sacrifice, and self-effacement; retributive justice; and the patient's right to confidentiality. The content of each domain is explained, and guidance is provided on how to assess the relative strengths of ethical argument within each domain. All five domains must be explicitly addressed in order to make ethically disciplined judgments about whether to seek prosecution. A distinctive feature of this ethical analysis is the central importance of the professional virtues.

Prepublication review of medical ethics research: cause for concern

PURPOSE

Although medical ethics research is frequently published in medical journals, little is known about the prepublication review such articles receive. The authors sought to describe the prepublication review of medical ethics research at major medical journals and medical ethics journals. They also sought to compare the ethics backgrounds of editors at both journal types and editors' attitudes concerning the training necessary for reviewers of ethics research.

METHOD

In November 2006, the authors distributed a 19-item survey via the Internet and mail to editors of major medical journals, specialty medical journals, and medical ethics journals. The survey collected data on the use of peer review, importance of peer review, ethics training of editors, and editors' attitudes regarding the appropriate training for reviewers. Multiple-choice and open-response questions measured peer review use characteristics, and questions weighted with a five-point scale measured editor attitudes.

RESULTS

Medical journals and medical ethics journals almost always peer reviewed articles examining topics in medical ethics and considered this review important to enhancing the quality of published ethics research. However, medical journals were less likely to have an editor with advanced training in ethics as compared with medical ethics journals (7% versus 100%, P < .001), and their editors viewed specialized training in ethics as less important for a reviewer than did medical ethics journal editors (2.56 versus 3.88, P = .035).

CONCLUSIONS

Physicians should be aware that ethics articles in prominent medical journals may not have been appropriately reviewed by a reviewer with specialized training in ethics.

What do we teach psychiatric residents about suicide? A national survey of chief residents

OBJECTIVE

Because of the clinical significance of patient suicide for trainees and current limited information on this essential educational subject, the authors sought to determine what topics involving the care of suicidal patients were taught to residents in psychiatry training programs.

METHODS

Chief residents of psychiatry training programs across the United States (response rate 59%) anonymously completed questions on what and how the care of suicidal patients was taught. Topics that required more attention and barriers to teaching were also identified.

RESULTS

A vast majority of the national programs (91%) offered formal teaching on suicide care; grand rounds (85%) and case conferences (80%) were also popular methods for teaching. Even the topics most commonly taught, such as risk factors, recognizing early warning signs, and standards of clinical care, were judged to warrant more attention by many residents. Commonly identified barriers to teaching included the lack of audio or video teaching materials and relevant texts. Only 19% of chief residents reported that they felt prepared for the possibility of having to manage the aftermath of a patient suicide.

CONCLUSION

The chief residents identified a need for programs to focus even more attention on teaching of the care of suicidal patients in training programs.

Residents-as-teachers programs in psychiatry: a systematic review

OBJECTIVES

Because psychiatry residents have important roles as teachers and significant opportunities to contribute to medical student education, we set out to: identify all randomized control trials (RCT) for residents' teaching skills programs in psychiatry and to identify the efficacy of those interventions for improving teaching skills; identify the strengths and weaknesses of the available studies across medical disciplines; and identify currently available methods for enhancing residents' teaching skills for residents training in psychiatry.

METHODS

The published English-language literature was searched using PubMed, Social Sciences Index, and PsycINFO databases, with key search words including: residents, teaching skills, residents as teachers, psychiatry, and assessments. Both RCT and controlled, nonrandomized trials of residents' teaching programs directed to enhance residents' teaching skills were selected and critically appraised.

RESULTS

Of 13 trials identified and reviewed, most included residents in internal medicine. Only one included psychiatry residents and assessed their ability to teach interviewing skills to medical students. Along with other studies, this study demonstrated improvement in residents' teaching skills. Overall, interventions and outcome measures were heterogeneous while the quality of methodologies varied. Five studies were of higher quality, representing examples of quality educational research. Several described group differences, blinding, good follow-up, and use of valid, reliable tools.

CONCLUSIONS

Only one trial exists that incorporated psychiatry residents. Significant opportunity to advance educational research in this field exists. Psychiatry residency program directors should incorporate high-quality methodologies and can benefit from the findings of trials in other disciplines.