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Byars-Winston A, Womack VY, Butz AR, McGee R, Quinn SC, Utzerath E, Saetermoe CL, Thomas SB. Pilot Study of an Intervention to Increase Cultural Awareness in Research Mentoring: Implications for Diversifying the Scientific Workforce. J Clin Transl Sci 2018; 2:86-94. [PMID: 30338131 PMCID: PMC6191051 DOI: 10.1017/cts.2018.25] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 03/05/2018] [Accepted: 03/12/2018] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Innovative evidence-based-interventions are needed to equip research mentors with skills to address cultural diversity within research mentoring relationships. A pilot study assessed initial outcomes of a culturally tailored effort to create and disseminate a novel intervention titled Culturally Aware Mentoring (CAM) for research mentors. INTERVENTION Intervention development resulted in four products: a 6hr CAM training curriculum, a facilitator guide, an online pre-training module, and metrics to evaluate the effectiveness of CAM training. METHOD Participants were 64 research mentors from three US research-intensive universities. Quantitative pre and post-training evaluation survey data were collected. RESULTS Participants found high value and satisfaction with the CAM training, reported gains in personal cultural awareness and cultural skills, and increased intentions and confidence to address cultural diversity in their mentoring. CONCLUSIONS Study findings indicate that the CAM training holds promise to build research mentors' capacity and confidence to engage directly with racial/ethnic topics in research mentoring relationships.
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Affiliation(s)
- Angela Byars-Winston
- Department of Medicine, Center for Women’s Health Research, University of Wisconsin – Madison, Madison, WI, USA
| | | | - Amanda R. Butz
- Department of Kinesiology, University of Wisconsin – Madison, Madison, WI, USA
| | - Richard McGee
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandra C. Quinn
- Department of Family Science, Maryland Center for Health Equity, University of Maryland, College Park, MD, USA
| | - Emily Utzerath
- Institute for Clinical and Translational Research, University of Wisconsin – Madison, Madison, WI, USA
| | - Carrie L. Saetermoe
- Department of Psychology, California State University, Northridge, Los Angeles, CA, USA
| | - Stephen B. Thomas
- Health Services Administration, Maryland Center for Health Equity, University of Maryland, College Park, MD, USA
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Crowshoe L, Dannenbaum D, Green M, Henderson R, Hayward MN, Toth E. Type 2 Diabetes and Indigenous Peoples. Can J Diabetes 2018; 42 Suppl 1:S296-S306. [DOI: 10.1016/j.jcjd.2017.10.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 12/16/2022]
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Crowshoe LL, Han H, Calam B, Henderson R, Jacklin K, Walker L, Green ME. Impacts of Educating for Equity Workshop on Addressing Social Barriers of Type 2 Diabetes With Indigenous Patients. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2018; 38:49-59. [PMID: 29432332 DOI: 10.1097/ceh.0000000000000188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Health education about Indigenous populations in Canada (First Nations, Inuit, and Métis people) is one approach to enable health services to mitigate health disparities faced by Indigenous peoples related to a history of colonization and ongoing social inequities. This evaluation of a continuing medical education workshop, to enhance family physicians' clinical approach by including social and cultural dimensions within diabetes management, was conducted to determine whether participation in the workshop improved self-reported knowledge, skills, and confidence in working with Indigenous patients with type 2 diabetes. METHODS The workshop, developed from rigorous national research with Indigenous patients, diabetes care physicians, and Indigenous health medical educators, was attended by 32 family physicians serving Indigenous populations on three sites in Northern Ontario. A same-day evaluation survey assessed participants' satisfaction with workshop content and delivery. Preworkshop and postworkshop surveys consisting of 5-point Likert and open-ended questions were administered 1 week before and 3 month after the workshop. Descriptive statistics and t test were performed to analyze Likert scale questions; thematic analysis was used to elicit and cluster themes from open-ended responses. RESULTS Participants reported high satisfaction with all aspects of the workshop. Reporting improved understanding of socioeconomic (P = .002), psychosocial, and cultural factors (P = .001), participants also described adapting their clinical approach to more actively incorporating social and cultural factors and focusing on patient-centered care. DISCUSSION The workshop was effective in shifting physician's self-reported knowledge, attitudes, and skills resulting in clinical approach modifications within social, psychosocial, and cultural domains for their Indigenous patients with diabetes.
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Affiliation(s)
- Lynden Lindsay Crowshoe
- Dr. Crowshoe: Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada. Dr. Han: Department of Family Medicine, Queen's University, Kingston, Ontario, Canada. Dr. Calam: Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada. Dr. Henderson: Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada. Dr. Jacklin: University of Minnesota Medical School, Duluth, Minnesota. Ms. Walker: School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. Dr. Green: Departments of Family Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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Sharma M, Pinto AD, Kumagai AK. Teaching the Social Determinants of Health: A Path to Equity or a Road to Nowhere? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:25-30. [PMID: 28445214 DOI: 10.1097/acm.0000000000001689] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Medical schools are increasingly called to include social responsibility in their mandates. As such, they are focusing their attention on the social determinants of health (SDOH) as key drivers in the health of the patients and communities they serve. However, underlying this emphasis on the SDOH is the assumption that teaching medical students about the SDOH will lead future physicians to take action to help achieve health equity. There is little evidence to support this belief. In many ways, the current approach to the SDOH within medical education positions them as "facts to be known" rather than as "conditions to be challenged and changed." Educators talk about poverty but not oppression, race but not racism, sex but not sexism, and homosexuality but not homophobia. The current approach to the SDOH may constrain or even incapacitate the ability of medical education to achieve the very goals it lauds, and in fact perpetuate inequity. In this article, the authors explore how "critical consciousness" and a recentering of the SDOH around justice and inequity can be used to deepen collective understanding of power, privilege, and the inequities embedded in social relationships in order to foster an active commitment to social justice among medical trainees. Rather than calling for minor curricular modifications, the authors argue that major structural and cultural transformations within medical education need to occur to make educational institutions truly socially responsible.
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Affiliation(s)
- Malika Sharma
- M. Sharma is an infectious diseases physician and Canadian Institutes of Health Research (CIHR) Canadian HIV Trials Network (CTN)/Canadian Foundation for AIDS Research (CANFAR) postdoctoral fellow, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. A.D. Pinto is a family physician and public health specialist, Department of Family and Community Medicine, St. Michael's Hospital, assistant professor, Department of Family and Community Medicine, Faculty of Medicine and Dalla Lana School of Public Health, University of Toronto, clinician-scientist, Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, and director, The Upstream Lab, Toronto, Ontario, Canada. A.K. Kumagai is endocrinologist, professor, and vice chair of education, Department of Medicine, University of Toronto, and F.M. Hill Chair in Humanism Education, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
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Karani R, Varpio L, May W, Horsley T, Chenault J, Miller KH, O'Brien B. Commentary: Racism and Bias in Health Professions Education: How Educators, Faculty Developers, and Researchers Can Make a Difference. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:S1-S6. [PMID: 29065016 DOI: 10.1097/acm.0000000000001928] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The Research in Medical Education (RIME) Program Planning Committee is committed to advancing scholarship in and promoting dialogue about the critical issues of racism and bias in health professions education (HPE). From the call for studies focused on underrepresented learners and faculty in medicine to the invited 2016 RIME plenary address by Dr. Camara Jones, the committee strongly believes that dismantling racism is critical to the future of HPE.The evidence is glaring: Dramatic racial and ethnic health disparities persist in the United States, people of color remain deeply underrepresented in medical school and academic health systems as faculty, learner experiences across the medical education continuum are fraught with bias, and current approaches to teaching perpetuate stereotypes and insufficiently challenge structural inequities. To achieve racial justice in HPE, academic medicine must commit to leveraging positions of influence and contributing from these positions. In this Commentary, the authors consider three roles (educator, faculty developer, and researcher) represented by the community of scholars and pose potential research questions as well as suggestions for advancing educational research relevant to eliminating racism and bias in HPE.
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Affiliation(s)
- Reena Karani
- R. Karani is senior associate dean for undergraduate medical education and curricular affairs and professor of medical education, medicine and geriatrics and palliative medicine, Icahn School of Medicine at Mount Sinai, New York, New York. L. Varpio is associate professor, Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland. W. May is director and professor, Clinical Skills Education and Evaluation Center, Keck School of Medicine of USC, Los Angeles, California. T. Horsley is associate director, Research Unit, Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada. J. Chenault is associate professor, Reference Department, Kornhauser Health Sciences Library, University of Louisville, Louisville, Kentucky. K.H. Miller is 2017 chair, Research in Medical Education Program Planning Committee, and associate professor of graduate medical education, University of Louisville School of Medicine, Louisville, Kentucky. B. O'Brien is associate professor, Department of Medicine, University of California, San Francisco, San Francisco, California
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Ahmad NJ, Shi M. The Need for Anti-Racism Training in Medical School Curricula. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:1073. [PMID: 28742569 DOI: 10.1097/acm.0000000000001806] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- N Jia Ahmad
- Third-year medical student, Johns Hopkins University School of Medicine, Baltimore, Maryland; ; ORCID: http://orcid.org/0000-0002-0658-5340. Third-year medical student, Johns Hopkins University School of Medicine, Baltimore, Maryland; ORCID: http://orcid.org/0000-0003-3301-6781
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Blanchet Garneau A, Browne AJ, Varcoe C. Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing. Nurs Inq 2017; 25. [PMID: 28685947 DOI: 10.1111/nin.12211] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2017] [Indexed: 01/24/2023]
Abstract
Although nursing has a unique contribution to advancing social justice in health care practices and education, and although social justice has been claimed as a core value of nursing, there is little guidance regarding how to enact social justice in nursing practice and education. In this paper, we propose a critical antidiscriminatory pedagogy (CADP) for nursing as a promising path in this direction. We argue that because discrimination is inherent to the production and maintenance of inequities and injustices, adopting a CADP offers opportunities for students and practicing nurses to develop their capacity to counteract racism and other forms of individual and systemic discrimination in health care, and thus promote social justice. The CADP we propose has the following features: it is grounded in a critical intersectional perspective of discrimination, it aims at fostering transformative learning, and it involves a praxis-oriented critical consciousness. A CADP challenges the liberal individualist paradigm that dominates much of western-based health care, and the culturalist and racializing processes prevalent in nursing education. It also situates nursing practice as responsive to health inequities. Thus, a CADP is a promising way to translate social justice into nursing practice and education through transformative learning.
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Affiliation(s)
| | - Annette J Browne
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Colleen Varcoe
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
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Affiliation(s)
- Daytheon Sturges
- Daytheon Sturges, MPAS, PA-C, is an assistant professor and clinical coordinator in the Department of Physician Assistant Studies at the University of Texas Southwestern School of Health Professions, Dallas, Texas
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Neff J, Knight KR, Satterwhite S, Nelson N, Matthews J, Holmes SM. Teaching Structure: A Qualitative Evaluation of a Structural Competency Training for Resident Physicians. J Gen Intern Med 2017; 32:430-433. [PMID: 27896692 PMCID: PMC5377882 DOI: 10.1007/s11606-016-3924-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 10/03/2016] [Accepted: 11/03/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The influence of societal inequities on health has long been established, but such content has been incorporated unevenly into medical education and clinical training. Structural competency calls for medical education to highlight the important influence of social, political, and economic factors on health outcomes. AIM This article describes the development, implementation, and evaluation of a structural competency training for medical residents. SETTING A California family medicine residency program serving a patient population predominantly (88 %) with income below 200 % of the federal poverty level. PARTICIPANTS A cohort of 12 residents in the family residency program. PROGRAM DESCRIPTION The training was designed to help residents recognize and develop skills to respond to illness and health as the downstream effects of social, political, and economic structures. PROGRAM EVALUATION The training was evaluated via qualitative analysis of surveys gathered immediately post-training (response rate 100 %) and a focus group 1 month post-training (attended by all residents not on service). DISCUSSION Residents reported that the training had a positive impact on their clinical practice and relationships with patients. They also reported feeling overwhelmed by increased recognition of structural influences on patient health, and indicated a need for further training and support to address these influences.
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Affiliation(s)
- Joshua Neff
- Joint Medical Program, UC Berkeley-UCSF, Berkeley, CA, USA
| | - Kelly R Knight
- Department of Anthropology, History, and Social Medicine, UCSF, San Francisco, CA, USA
| | - Shannon Satterwhite
- Medical Scientist Training Program, UCSF, San Francisco, CA, USA
- Joint Program in Medical Anthropology, UC Berkeley-UCSF, San Francisco, CA, USA
| | - Nick Nelson
- Department of Medicine, Highland Hospital, Oakland, CA, USA
- Department of Medicine, UCSF, San Francisco, CA, USA
| | - Jenifer Matthews
- Department of Adolescent Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Seth M Holmes
- Joint Medical Program, UC Berkeley-UCSF, Berkeley, CA, USA.
- Department of Anthropology, History, and Social Medicine, UCSF, San Francisco, CA, USA.
- Medical Scientist Training Program, UCSF, San Francisco, CA, USA.
- Joint Program in Medical Anthropology, UC Berkeley-UCSF, San Francisco, CA, USA.
- Department of Medicine, Highland Hospital, Oakland, CA, USA.
- School of Public Health, UC Berkeley, Berkeley, CA, USA.
- University of California Berkeley, 50 University Hall, MC 7360, Berkeley, CA, 94720, USA.
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Ripp K, Braun L. Race/Ethnicity in Medical Education: An Analysis of a Question Bank for Step 1 of the United States Medical Licensing Examination. TEACHING AND LEARNING IN MEDICINE 2017; 29:115-122. [PMID: 28051889 DOI: 10.1080/10401334.2016.1268056] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
UNLABELLED Phenomenon: There is growing concern over racial/ethnic bias in clinical care, yet how best to reduce bias remains challenging, in part because the sources of bias in medical education are poorly understood. One possible source is the routinized use of race/ethnicity in lectures, assessment, and preparatory materials, including question banks for licensing examinations. Because students worldwide use question banks to prepare for the United States Medical Licensing Examination, we examined how race/ethnicity was used in one of the most commonly recommended question banks. APPROACH We analyzed the use of race/ethnicity in all 2,211 questions in a question bank for Step 1 of the United States Medical Licensing Examination for the following: the frequency of mentions of racial/ethnic groups, whether the use of race/ethnicity was merely descriptive or was central to any part of the question, and whether the question associated race/ethnicity with genetic difference. FINDINGS In sum, 455 of the 2,011 (20.6%) of the questions in the question bank referred to race/ethnicity in the question stem, answer, or educational objective. The frequency of mentions of racial/ethnicity was disproportionate to the U.S. POPULATION 85.8% referred to White/Caucasians, 9.70% to Black/African Americans, 3.16% to Asian, 0.633% to Hispanics, and 0.633% to Native Americans. No cases referred to Native Hawaiians/Pacific Islanders. The proportion of mentions of race/ethnicity classified as either a routine descriptor or central to the case varied by racial/ethnic category. The association between genetics and disease in cases also varied by racial/ethnic category. Insights. The routinized use of race/ethnicity with no specific goal in preparation materials, such as question banks, risks contributing to racial bias. The implications of routinized use extend to assessment in medical education. Race/ethnicity should be used only when referring to social experiences of groups relevant to their health, not as a proxy for genetics, social class, or culture.
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Affiliation(s)
- Kelsey Ripp
- a Brown University Warren Alpert Medical School , Providence , Rhode Island , USA
| | - Lundy Braun
- b Pathology and Laboratory Medicine and Africana Studies, Brown University Warren Alpert Medical School , Providence , Rhode Island , USA
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Acosta D, Ackerman-Barger K. Breaking the Silence: Time to Talk About Race and Racism. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:285-288. [PMID: 27655050 DOI: 10.1097/acm.0000000000001416] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Recent events in the United States have catalyzed the need for all educators to begin paying attention to and discovering ways to dialogue about race. No longer can health professions (HP) educators ignore or avoid these difficult conversations. HP students are now demanding them. Cultural sensitivity and unconscious bias training are not enough. Good will and good intentions are not enough. Current faculty development paradigms are no longer sufficient to meet the educational challenges of delving into issues of race, power, privilege, identity, and social justice.Engaging in such conversations, however, can be overwhelmingly stressful for untrained faculty. The authors argue that before any curriculum on race and racism can be developed for HP students, and before faculty members can begin facilitating conversations about race and racism, faculty must receive proper training through intense and introspective faculty development. Training should cover how best to engage in, sustain, and deepen interracial dialogue on difficult topics such as race and racism within academic health centers (AHCs). If such faculty development training-in how to conduct interracial dialogues on race, racism, oppression, and the invisibility of privilege-is made standard at all AHCs, HP educators might be poised to actualize the real benefits of open dialogue and change.
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Affiliation(s)
- David Acosta
- D. Acosta is associate vice chancellor, Diversity and Inclusion, University of California Davis Health System, senior associate dean, Equity, Diversity and Inclusion, and health sciences clinical professor, Department of Family and Community Medicine, University of California Davis School of Medicine, Sacramento, California. K. Ackerman-Barger is assistant adjunct professor, assistant director, Master's Entry Program for Nurses, and codirector, Interprofessional Teaching Scholars Program, University of California Davis Betty Irene Moore School of Nursing, Sacramento, California
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Sklar DP. Reaching Out Beyond the Health Care System to Achieve a Healthier Nation. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:271-273. [PMID: 28221221 DOI: 10.1097/acm.0000000000001555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Medlock M, Weissman A, Wong SS, Carlo A, Zeng M, Borba C, Curry M, Shtasel D. Racism as a Unique Social Determinant of Mental Health: Development of a Didactic Curriculum for Psychiatry Residents. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2017; 13:10618. [PMID: 29387786 PMCID: PMC5788030 DOI: 10.15766/mep_2374-8265.10618] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 06/26/2017] [Indexed: 05/14/2023]
Abstract
INTRODUCTION Mental health disparities based on minority racial status are well characterized, including inequities in access, symptom severity, diagnosis, and treatment. For African Americans, racism may affect mental health through factors such as poverty and segregation, which have operated since slavery. While the need to address racism in medical training has been recognized, there are few examples of formal didactic curricula in the psychiatric literature. Antiracism didactics during psychiatry residency provide a unique opportunity to equip physicians to address bias and racism in mental health care. METHODS With advocacy by residents in the Massachusetts General Hospital/McLean Psychiatry residency program, the Division of Public and Community Psychiatry developed a curriculum addressing racial inequities in mental health, particularly those experienced by African Americans. Four 50-minute interactive didactic lectures were integrated into the required didactic curriculum (one lecture per postgraduate training class) during the 2015-2016 academic year. RESULTS Of residents who attended lectures and provided anonymous feedback, 97% agreed that discussing racism in formal didactics was at least "somewhat" positive, and 92% agreed that it should "probably" or "definitely" remain in the curriculum. Qualitative feedback centered on a need for more time to discuss racism as well as a desire to learn more about minority mental health advocacy in general. DISCUSSION Teaching about racism as part of required training conveys the explicit message that this is core curricular material and critical knowledge for all physicians. These lectures can serve as a springboard for dissemination and provide scaffolding for similar curriculum development in medical residency programs.
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Affiliation(s)
- Morgan Medlock
- Fourth-year Psychiatry Resident, Massachusetts General Hospital
| | - Anna Weissman
- Fourth-year Psychiatry Resident, Massachusetts General Hospital
| | | | - Andrew Carlo
- Fourth-year Psychiatry Resident, Massachusetts General Hospital
| | - Mary Zeng
- Fourth-year Psychiatry Resident, Massachusetts General Hospital
| | - Christina Borba
- Director of Research, Department of Psychiatry, Boston University School of Medicine
| | - Michael Curry
- Director of Legislative Affairs, Massachusetts League of Community Health Centers
- Board Member, National Association for the Advancement of Colored People (NAACP)
| | - Derri Shtasel
- Director, Division of Public and Community Psychiatry, Massachusetts General Hospital
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