Update on medical student education and teaching psychiatry

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Update on medical student education and teaching
psychiatry

• Tony Guerrero, M.D.
• Associate Chair for Education and Training,
  Department of Psychiatry

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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

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Why talk about undergraduate education?
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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.

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Reason 2 Without medical students, we wouldnt
have a department
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Reason 3 I needed something fun to present
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Reason 4 We should care about communitys
needs and the future of our specialty
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Your thoughts when you hear of a medical student
interested in psychiatry

1. This is great! Another potential new student to
   meet the communitys need.
2. Darn! Another person to compete for business
   with.
3. Why on earth is this student interested in this
   specialty?

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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
  Generals report (AACAP, 2000), the current
  supply of less than 7000 child and adolescent
  psychiatrists is up to 23,000 short of whats
  actually needed
• Unfilled residency positions in psychiatry
  (including specialties)

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Workforce needs (local)

• Federally designated (HPSA) Mental Health
  Shortage areas Puna, Kau (Big Island)
  Molokai 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)

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Recruitment trends bottom lines

• Nationally, 4 of medical school graduates choose
  psychiatry.
• In Hawaii, we overall do better, but still are
  we where we ought to be?

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Why dont 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?

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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

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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

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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

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The general scheme at JABSOM
Unit 1(health/illness) Unit 2(cardio/pulm/renal)
Unit 3(endo/heme/GI) Unit 4 (locomotor/neuro/beh
avior) Unit 5 (life cycle) Unit 6
clerkships (FP, medicine, peds, ob/gyn,
PSYCHIATRY, surgery) Unit 7 electives/career
differentiation
Year 1 Year 2 Year 3 Year 4
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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

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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

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Interfaces psychiatry clerkship

• Components
• Inpatient (QMC, HSH)
• Outpatient (QCS, QEC, KMCWC OPD)
• Child/adolescent (FTC)
• Emergency/on-call (QMC)
• PBL tutorials
• Videotape conferences

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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

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Clerkship goals

• Attitudes
• To be empathetic and professionally responsible
  towards patients with mental health needs
• To respectfully collaborate with others involved
  in patient care
•  
• Skills
• 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
  patients 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
• 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.
• To be familiar with the mental health needs and
  resources specific to the Hawaii community.
• To be familiar with the scope and practice of
  psychiatry.
•  

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Clerkship organization implications for weekly
schedules, other planning
 
Clerkship handbook http//dop.hawaii.edu
 
 
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Clinical experiences

• 1. Participating in the care of a patient with
  symptoms of depression and/or anxiety in an
  outpatient (e.g., clinic) or general medical
  (e.g., emergency room, consultation-liaison,
  etc.) setting.
• 2. 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.)
• 3. Participating in the care of a patient with a
  major mood disorder presenting in an acute
  setting.
• 4. Participating in the care of a patient with a
  substance use disorder.
• 5. Participating in the care of a patient with a
  psychotic disorder presenting in an acute
  setting.
• 6. Participating in the assessment of a child or
  adolescent patient.
• 7. Participating in the care of three patients
  who are followed-up several times.
• 8. Observing electro-convulsive therapy.
• 9. Performing two patient interviews supervised
  by and discussed with the attending or chief
  resident.

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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).

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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.)

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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.

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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.

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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

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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

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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

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Resident Supervision(ACGME Bulletin)

• Good supervision
• Good patient care
• Good education, that cultivates good supervisors
• Good business sense
• Better morale

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Resident Supervision(ACGME Bulletin)

• Direct observation
• Structured, predictable
• Feedback
• Appropriate content
• Appropriate process

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A bit more about feedback

• Feedback vs. evaluation
• Tips on giving feedback
• Timeliness
• For the receivers benefit
• Objective descriptions of behavior (vs.
  subjective conclusions)

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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.

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Resident Supervision(ACGME Bulletin)

• Competency-based evaluations (6 competencies)
• Portfolio-based assessments

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Training medical students and residents

• New methods, with growing body of evidence-based
  support
• Problem-based learning
• Team-based learning

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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

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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

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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)

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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)

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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)

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PBL at JABSOM

• Good USMLE performance relative to national norms
  (Kasuya et al, 2003)
• Successful residency matching
• LCME accreditation full 7 years

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Teaching according to PBL principles

• Process of identifying facts/problems, hypotheses
  (including mechanisms), additional information,
  learning issues
• Active role not teaching, but facilitating
  process

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Facilitating the PBL ProcessInitial Problem
Encounter

• Any other facts or problems you see in this
  case?
• Any other hypotheses, or possible mechanisms,
  for the problem(s) youve 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?

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Use of the Mechanistic Case Diagram to Generate
Hypotheses
Hypotheses
Additional Info.
Learning Issues
Problems
respiratory arrest
hypoxemia
cardiac dysrhythmia
vital signs, heart rate
1. Anatomy and physiology of consciousness
energy production
loss of consciousness
poor perfusion
cardiac output
cerebrovascular atherosclerosis
lack of substrate
disruption of the brain
hypoglycemia
insulin overdose
pallor
tumor
?
mass lesion
trauma
physical impingement
intracranial bleed
ICP
meningitis
Na
seizure
abnormal neurotransmission
hepatic failure
neurotoxins
drug abuse
further history about drug use (e.g., what
drug?)
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Facilitating the PBL ProcessGroup Functioning

• I notice that most (or some) people are quiet.
  Im wondering what other people are thinking at
  this point.
• Thats a good clarifying question that you asked
  your colleague.
• It seems like theres some disagreement here.
  Any suggestions about how to resolve this?
• Any feedback about todays session what worked
  well, what could have been done better?

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Facilitating the PBL ProcessIntegrating Knowledge

• How would you apply the knowledge youve learned
  back to the patients presentation?
• How does the information youve presented relate
  to what your colleague(s) just presented?
• It sounds like youve identified a gap in
  knowledge, and youre wondering if I know the
  answer. I actually dont 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?

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Use of the Mechanistic Case Diagram to Summarize
a PBL Case
adolescence
goal of independence
recent emigration
reward/ reinforcement
peer vs. family pressure
risk-taking behavior
self- fragmentation
unemployment
dopamine activity
methamphetamine abuse
depressive- equivalent behavior
dopamine release
release of epinephrine and norepinephrine
sensitive receptor
myocardial demand
genetic factor
functional ischemia
other family members with substance abuse
diffuse cardiac necrosis
non-functioning ionic pumps
poor contractility
partial AV node damage
contractile force
abnormal atrial automaticity
intracellular calcium
cardiomyopathy via echocardiogram
cardiac output
slow pathway
Digoxin
AV conduction
conduction of impulse
poor perfusion
vagal tone
diastolic filling
re-entry through fast pathway
energy production
pallor

tachycardia
reticulocortical disruption
PSVT via EKG
loss of consciousness
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Condition affecting Brain functioning
Specific parts of the brain influencing social
connectedness
0-3 services Special ed.
Parts of the higher brain
Social disconnectedness
Relatively less natural motivation to
learn adaptive skills
Weaknesses in multiple areas of functioning
discrete trial training, etc.
Tendency to repetitive and sterotypic behaviors
Significant delays in language and communication
development
MENTAL RETARDATION
AUTISTIC DISORDER?
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Selected PBL cases
vitamin B1 Genetic factors nutrient vitamin
B1 decreased glutamate malabsorption deficien
cy glucose neurotoxicity utilization Abnor
mal reward systems vestibular
nuclei pontine gaze center hippocampus CN6
nuclei dorsomedial thalamus Alcohol
use nystagmus lateral gaze defects anterograde
amnesia Mesolimbic pyridoxine, peripheral
nerve longest tracks weakness dopamine
release pantothenate dysfunction decreased
sensation B12, folate hands/feet Thalamo-
orbitofrontal overactivity Confusion,
hallucinations

• Greg Primo (Unit 4) Wernicke-Korsakoffs
  syndrome
• Pathophysiological mechanisms
• Anatomic/clinical correlations

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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 acute dystonia/ basal
ganglia stiff jaw Neuronal migration
errors risperidone DA receptor
blockade Cytoarchitectural Inappropriate
Increased dopamine Poor cortical Delusions, abno
rmalities mesolimbic dopamine tone filtering tan
gentiality release hallucinations Maldeve
lopment flat/inappropriate Frontal
lobe affect practical help Poor
judgment limited access to
care poverty homelessness injury to
feet cellulitis Inability to work
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Mood disorders
Lithium thyroid effects elevated
TSH goiter Genetic factors increased
functional dopamine systems antipsychotics neuro
transmission Abnormal 2nd
messengers prefrontal cortex limbic
system hypothalamus reticular activating Receptor
amygdala (which parts?) system desensitizatio
n poor judgment mania decreased sleep poor
concentration aggression decreased
appetite restlessness Decreased weight
loss neurotransmission Increased
inhibitory neurotransmitters Increased
catecholamines Hypothalamus, ECT Limbic
system Increased serotonin Depression,
motor SSRIs retardation

• Bipolar disorder (Unit 4)
• Pathophysiological mechanisms
• Anatomic/clinical correlations

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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 infection
dehydration e.g., anticholinergic abnormal
electrolytes Cell death Accumulation
of Plaques and tangles cholinesterase
donepezil disruption of inhibition reticul
ar activating Cholinergic neurons system
Decreased cholinergic impaired
alertness function and concentration
Hippocampus Motor pathways acute
confusion agitation Nucleus basalis Impaire
d memory Frontal release emergence of
encoding primitive reflexes
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Anxiety Disorders
benzodiazepine GABA/Cl channel facilit
ation Genetic factors oversensitive inappropria
te homeostatic receptors/ locus ceruleus
desensitization brainstem nuclei firing
oversensitive 5HT receptor reticulospinal
limbic activation corticolimbic path pathw
ay 5HT receptor Increased synaptic downregulatio
n sympathetic fear kindling prefrontal
cortex serotonin discharge
tachycardia chronic SSRI 5HT3
agonism palpiatations anticipatory sweating
anxiety agoraphobia increased
respiratory demand GI side effects
Mary Kaweli (Unit 4) Panic Disorder
with Anticipatory anxiety and agoraphobia
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Potential Application to the Biopsychosocial
Formulation
Biological Psychological Social/Cultural Hea
d trauma age 59 Cortical dysfunction generat
ivity vs. stagnation Alcohol job
dysfunction Genetic factors Loss of
father Medication effects Depression Loss
of girlfriend Limited family contact Sleep
difficulty Lonely Others who drink
around (chief complaint) Risk of relapse
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Evaluations

• Evaluation 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.

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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.

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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.

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Everyones well-being

• Education and patient care are both optimized if
  we all look out for each others well-being
• Its everyones job to look out for each others
  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.

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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

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Whom can you call?

• Dan Alicata, M.D.
• Psychiatry Clerkship Director
• AlicataD_at_dop.hawaii.edu
• Tony Guerrero, M.D.
• Vice-Chair for Education and Training,
  Department of Psychiatry
• GuerreroA_at_dop.hawaii.edu

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THANK YOU FOR YOUR ATTENTION!