What factors contribute to senior psychiatry residents' interest in geriatric psychiatry? a Delphi study

Gender and Racial Trends among Geriatric Psychiatry Fellows in the USA: A Call to Action

OBJECTIVE

The United States (USA) is a culturally and ethnically diverse country with an estimated 5.6 to 8 million elderly population living with psychiatric and substance use disorders and a dwindling geriatric psychiatry workforce. In this study, we explored the gender and racial trends in USA geriatrics psychiatry fellowship programs from 2007-20, and forecasted the 2030 geriatric psychiatry workforce to identify the gaps and provide recommendations.

METHOD

This retrospective analysis of the Accreditation Council for Graduate Medical Education (ACGME) data included trainees in geriatric psychiatry fellowship programs in the USA from 2007-20. Races were classified as White (Non-Hispanic), Asian/Pacific Islander, Hispanic, Black (Non-Hispanic), Native American/Alaskan, Others, and Unknown. Gender was categorized as Male, Female, and Not Reported.

RESULTS

Amongst the geriatric psychiatry fellowship trainees, there was an overall decrease in the representation of all races from 2011-20. There was a relative decrease of 16%, 8.6% and 2.3% for White (Non-Hispanic), Asian/Pacific Islander, and Black (Non-Hispanics) respectively whereas the Hispanic and Native American/Alaskan trainees remained unchanged. Women relatively increased 28.4% from 2007-20 while men relatively decreased 27.1%. Our projections suggest that without changes in the current health professional recruitment trends and the shortage of geriatric psychiatrists will persist with a shortfall of 1,080 (9.7%) by 2030.

CONCLUSION

There are critical gaps in racial and gender representation in geriatric psychiatry fellowship programs in the USA. An inclusive workforce is required to address diverse communities and bridge gaps in physician workforce gender and racial disparities.

The benefits and harms of open notes in mental health: A Delphi survey of international experts

IMPORTANCE

As of April 5, 2021, as part of the 21st Century Cures Act, new federal rules in the U.S. mandate that providers offer patients access to their online clinical records.

OBJECTIVE

To solicit the view of an international panel of experts on the effects on mental health patients, including possible benefits and harms, of accessing their clinical notes.

DESIGN

An online 3-round Delphi poll.

SETTING

Online.

PARTICIPANTS

International experts identified as clinicians, chief medical information officers, patient advocates, and informaticians with extensive experience and/or research knowledge about patient access to mental health notes.

MAIN OUTCOMES, AND MEASURES

An expert-generated consensus on the benefits and risks of sharing mental health notes with patients.

RESULTS

A total of 70 of 92 (76%) experts from 6 countries responded to Round 1. A qualitative review of responses yielded 88 distinct items: 42 potential benefits, and 48 potential harms. A total of 56 of 70 (80%) experts responded to Round 2, and 52 of 56 (93%) responded to Round 3. Consensus was reached on 65 of 88 (74%) of survey items. There was consensus that offering online access to mental health notes could enhance patients' understanding about their diagnosis, care plan, and rationale for treatments, and that access could enhance patient recall and sense of empowerment. Experts also agreed that blocking mental health notes could lead to greater harms including increased feelings of stigmatization. However, panelists predicted there could be an increase in patients demanding changes to their clinical notes, and that mental health clinicians would be less detailed/accurate in documentation.

CONCLUSIONS AND RELEVANCE

This iterative process of survey responses and ratings yielded consensus that there would be multiple benefits and few harms to patients from accessing their mental health notes. Questions remain about the impact of open notes on professional autonomy, and further empirical work into this practice innovation is warranted.

Predictors for Matriculation into Geriatric Psychiatry Fellowship: Data from a 2019-2020 National Survey of U.S. Program Directors

OBJECTIVE

With the number of geriatric psychiatry fellows declining from a peak of 106 during 2002-2003 to 48 during 2020-2021, this study aims to investigate characteristics of the geriatric psychiatry training requirement across U.S. psychiatry residency programs and to identify specific factors which may influence residents to pursue geriatric psychiatry subspecialty training.

METHODS

The authors queried the American Medical Association's Fellowship and Residency Electronic Interactive Database Access system to compile a list of program directors from the Accreditation Council for Graduate Medical Education sponsored general adult psychiatry residency programs. Program directors were emailed an anonymous multiple-choice survey to ascertain specific characteristics of their program's geriatric psychiatry training experiences. This study's primary outcome was the percentage of residents entering geriatric psychiatry fellowship after completion of general psychiatry training. Linear regression analysis determined which variables may be associated with this primary outcome.

RESULTS

Of 248 surveyed, 60 programs (24%) responded to the survey. Only one of the independent variables revealed a statistically significant association with the percent of residents that became geriatric psychiatry fellows: the number of geriatric psychiatrists at the residents' home institution (p=0.002).

CONCLUSIONS

Consistent with previous data, the presence of geriatric psychiatry faculty members is strongly associated with the decision to pursue subspecialty training in geriatric psychiatry.

Current Educational Practices for Major Neurocognitive Disorders in Psychiatry: a Scoping Review

OBJECTIVE

A scoping review of the literature was performed to examine the current state of education on major neurocognitive disorders within psychiatry, to review influential factors for pursuing a career working with these patients, and to review what has been done in education to address the shortage of providers to care for patients with major neurocognitive disorders.

METHODS

Using the Arksey and O'Malley framework for conducting scoping reviews, twenty-eight studies on education in geriatric psychiatry, neuropsychiatry, and major neurocognitive disorders were selected. Learner groups included medical students, residents, and psychiatrists. The results from the studies were compared, and major themes were presented.

RESULTS

Several studies found that positive clinical experiences with older adult patients and effective teachers in geriatric psychiatry play a role in influencing trainees to pursue a career in geriatric psychiatry. Topics pertaining to major neurocognitive disorders are taught by the majority of medical schools during the psychiatry rotation and are rated as the most important teaching topic in neurology among psychiatry residency program directors. Several interventions have resulted in increased comfort working with geriatric patients and patients who have major neurocognitive disorders among students, but fewer studies have resulted in an increase in interest seeing these patients in practice. There is a lack of research pertaining to psychiatry residents working with patients that have major neurocognitive disorders.

CONCLUSIONS

While research on geriatric psychiatry and neuropsychiatry education exists, more research is needed that focuses specifically on how medical students and psychiatry residents are being taught major neurocognitive disorders.

Geriatric Psychiatry Inpatient Primer for Residents

OBJECTIVE

The authors describe a novel curricular intervention that enhances first- and second-year psychiatry residents' geriatric psychiatry knowledge while preparing them for overnight call.

METHODS

A brief, four-page document covering evaluation and management of common clinical scenarios in older adults, including agitation, falls, insomnia, chest pain, abnormal vital signs, and review of pharmacologic interventions, was presented to first- and second-year psychiatry residents. The residents completed an anonymous survey including their comfort level in answering pages and knowledge-based questions regarding evidence-based interventions both before and after the intervention. The pre-survey and post-survey were analyzed using the Wilcoxon-signed rank test, paired T test, and Mann-Whitney U test.

RESULTS

The residents demonstrated statistically significant changes in first-line medication choices for common clinical scenarios such as non-aggressive agitation and insomnia. They were less likely to choose medications that should be avoided in elderly based on expert panel recommendations.

CONCLUSIONS

Findings support the need for educational interventions designed to help residents taking call with geriatric patients. The results demonstrated an improvement in clinical knowledge following this brief intervention.

Advice on How to Choose a Geriatric Psychiatry Fellowship

The population of older adults with mental health and substance use disorders in the United States is increasing at a significant rate. This growth creates a critical need for trained geriatric psychiatrists. Unfortunately, the number of psychiatrists choosing to receive subspecialty training in geriatric psychiatry has not kept pace with the growing needs of society. Many different methods for enhancing the recruitment of physicians interested in subspecialty training are being discussed nationally. One way to improve recruitment is to provide prospective residents a clear understanding of the process by which one may apply to and select a fellowship program. In this article, we discuss the process by which physicians interested in pursuing fellowship training in geriatric psychiatry can make an informed decision to apply to and choose programs that best fit their needs.

Early Clinical Exposure to Geriatric Psychiatry and Medical Students' Interest in Caring for Older Adults: A Randomized Controlled Trial

OBJECTIVE

In the next 25 years, the population aged 65 and older will nearly double in many countries, with few new doctors wishing to care for older adults. The authors hypothesize that early clinical exposure to elderly patient care could increase student interest in caring for older adults during their future career.

METHODS

The authors conducted a pragmatic medical education randomized controlled trial (RCT) at the Jewish General Hospital and the Douglas Mental Health Institute, McGill University, in Montreal, Canada. Third-year medical students undergoing their mandatory 16-week half-time clerkship rotation in psychiatry were randomly assigned to the equivalent of 2-4 weeks of full-time exposure to clinical geriatric psychiatry (n = 84).

RESULTS

Being randomly assigned to geriatric psychiatry exposure (n = 44 of 84) was associated with increased "comfort in working with geriatric patients and their families" at 16-week follow-up (59.1% versus 37.5%, χ² (1) = 3.9; p = 0.05). However, there was no significant association found between geriatric psychiatry exposure and change "in interest in caring for older adults," or change in "interest in becoming a geriatric psychiatrist."

CONCLUSION

The results of this pragmatic education RCT suggest that exposing third-year medical students to 2-4 weeks of geriatric psychiatry did not increase their interest to care for older adults or become a geriatric psychiatrist. However, it did increase their comfort level in working with older adults and their families. However, more research is necessary to identify potential interventions that could inspire and increase medical student interest in caring for older adults as part of their future careers.

What Makes Residents Interested in Geriatric Psychiatry? A Pan-Canadian Online Survey of Psychiatry Residents

OBJECTIVES

In spite of a rapidly increasing need, there remains a shortage of geriatric psychiatrists in North America. The factors associated with psychiatric residents' interest in geriatric psychiatry have not yet been examined in a nationally representative sample.

DESIGN

Cross-sectional study.

SETTING

Web-based online survey of Canadian psychiatry residents.

PARTICIPANTS

207 psychiatry residents (24.3% response rate).

MEASUREMENTS

The main outcome was interest in becoming a geriatric psychiatrist. Bivariate and multivariate analyses were performed to better understand what demographic, educational, and vocational variables were associated with interest in becoming a geriatric psychiatrist.

RESULTS

A number of respondents had an interest in becoming a geriatric psychiatrist (29.0%, N = 60); in doing a geriatric psychiatry fellowship (20.3%, N = 42); or an interest in doing geriatric psychiatry as a part of the clinical practice (60.0%, N = 124). Demographic characteristics (age, gender, ethnicity) did not correlate with interest in geriatric psychiatry. The variables most robustly associated with interest in geriatric psychiatry were: 1) completion of geriatric psychiatry rotation(s) before the third year of residency (OR: 5.13, 95% CI: 1.23-21.4); 2) comfort working with geriatric patients and their families (OR: 18.6, 95% CI: 2.09-165.3); 3) positive experiences caring for older adults prior to medical school (OR: 12.4, 95% CI: 1.07-144.5); and 4) the presence of annual conferences in the resident's field of interest (OR: 4.50, 95% CI: 1.12-18.2).

CONCLUSION

Exposing medical students and junior psychiatry residents to clinical geriatric psychiatry rotations that increase comfort in working with older adults may be potential future strategies to improve recruitment of geriatric psychiatrists.

Effectiveness of a Formal Mentorship Program in Family Medicine Residency: The Residents’ Perspective

Introduction. Mentoring is a recognized form of teaching learning strategy in postgraduate medical education. This paper describes the effectiveness of a formal mentorship program from the residents’ perspective after a year of implementation. Methods. The Aga Khan University Family Medicine Residency Program is the first program in Pakistan to our knowledge to implement formal mentorship for all four years of residency. A mentorship program was developed, implemented, and evaluated a year later using a rating scale. The 10-point Likert scale consisted of questions on academics, clinical work, research, administrative issues, and personal/social issues. Results. The response rate was 95% (). Eighty percent () were women. Satisfaction level in seeking help was the highest for academics (75%). Residents scored mentorship as low in helping to tackle their personal problems (20%). Barriers reported in rapport building with mentor were time constraints and gender difference. The most useful attributes of the mentor which helped rapport building were accessibility, active listening, support for emotional needs, and trustworthiness. Conclusion. Mentoring has a role in trainees’ personal and professional growth especially when their needs are addressed. The effectiveness of the mentorship program in residency can improve if the residents are allowed to choose their own mentors.

Perceptions of psychiatry of old age amongst psychiatry registrars in Australia and New Zealand

OBJECTIVE

To assess the perceptions of psychiatry registrars of their training experience in Psychiatry of Old Age (POA), and whether factors such as clinical exposure and stage of training correlate with these perceptions.

METHOD

Royal Australian and New Zealand College of Psychiatrists (RANZCP) registrars were surveyed in September 2009. Demographic information, POA exposure and responses to 14 statements related to registrar experience were collected.

RESULTS

From 978 surveys sent, 226 responses were complete enough to be analysed. Themes that emerged included a high level of enjoyment of a POA rotation, favourable views of supervision, the challenging nature of managing medical co-morbidities and concerns regarding the teaching of cognitive assessment. In general, type or duration of POA exposure and demographic variables were not correlated with a significant difference in perceptions of the field.

CONCLUSION

These data may be useful in addressing a shortfall of trainees in POA, which has implications for the health of older Australasians. It may inform service providers and the RANZCP of factors that could be modified or optimised to encourage registrars to consider subspecialty training in the area.

Occupational therapists’ reflection on practice within psychiatric care: A Delphi study

AIM

The aim of this study was to describe the reflections on practice in a group of Swedish occupational therapists in psychiatric care in order to illuminate the present practice and ideas about the future using a Delphi survey of three rounds.

MATERIAL AND METHOD

The sample consisted of 14 occupational therapists in psychiatric care. The answers from the first and second rounds illustrate the wide variation in their practice. The third round points out consensus and disagreements in the domains: professional role, theories in practice, domain of concern, occupational therapy assessment, goal setting/treatment, outcome/evaluation and thoughts about the future. A consensus was reached in all domains, but not regarding competence to treat functional reduction and symptoms, or on the importance of theories for documentation, the choice of a theoretical foundation, and the importance of an evidence-based treatment model, although the theories were seen as supporting practice. Disagreements were found as to the effectiveness of repeated assessments as a means of evaluation. The future for OTs within psychiatric care was looked upon as positive.

DISCUSSION

The results developed from providing a relatively unclear and shallow perspective on OT practice to indicating a depth that shows what occupational therapy within psychiatry can be. During the process it became more and more clear how OTs think and act.

Canadian geriatric psychiatrists: why do they do it? A Delphi study

OBJECTIVE

To generate hypotheses regarding influential factors that have contributed to the practice of geriatric psychiatry by geriatric psychiatrists.

METHOD

Using the Delphi technique, designed to generate ideas and consensus, a sample of members of the Canadian Academy of Geriatric Psychiatry (CAGP) was asked to provide ideas on what factors were influential in their decision to devote a significant part of their practice to geriatric patients. These items were then synthesized into a questionnaire and rated for their degree of influence by the same group of psychiatrists.

RESULTS

A total of 41 items were rated according to their degree of influence. The most influential items were related to geriatric psychiatry residency training experiences that were perceived to be positive or adequate. Supervision characteristics and interest in the medical psychiatric nature of the field were also deemed influential.

CONCLUSIONS

This study generates the hypothesis that the nature of the educational experience during psychiatry residency has a significant influence on the practice of geriatric psychiatry.