Update on medical student education and teaching psychiatry

Tony Guerrero, M.D.

Associate Chair for Education and Training, Department of Psychiatry

ObjectivesTo review current trends in psychiatric

recruitment, nationally and locallyTo provide an update on medical

student education at UH-JABSOMTo review innovations in psychiatric

education

Why talk about undergraduate education?

Reason #1: Thank you Participation by academic and clinical faculty

and residents Admissions committee, PBL tutors, clinical

skills preceptors, community medicine preceptors, resource people, colloquium lecturers, clerkship faculty, oral examiners, elective preceptors, student advisors, other mentors and role models.

Reason #2: Without medical students, we wouldn’t have a department

Reason #3: I needed something fun to present

Reason #4: We should care about community’s needs and the future of our specialty

Your thoughts when you hear of a medical student interested in psychiatry:

a) This is great! Another potential new student to meet the community’s need.

b) Darn! Another person to compete for business with.

c) Why on earth is this student interested in this specialty?

Correct answer: A) There are significant unmet needs for

psychiatrists in nearly all specialties and in nearly all communities, including in Hawaii.

For example: according to the U.S. Surgeon General’s report (AACAP, 2000), the current supply of less than 7000 child and adolescent psychiatrists is up to 23,000 short of what’s actually needed

Unfilled residency positions in psychiatry (including specialties)

Workforce needs (local)Federally designated (HPSA) Mental

Health Shortage areas: Puna, Ka`u (Big Island); Moloka`i; Kalihi Valley

Various consent decrees (Felix, DOJ, possibly others)

Just look at our own experiencesOur graduates have a much easier time

finding jobs (vs. other specialties)

Recruitment trends: bottom linesNationally, 4% of medical school

graduates choose psychiatry. In Hawai`i, we overall do better, but still:

are we where we ought to be?

Psychiatry Recruitment at UH-JABSOM (1991-2007)

0

24

68

1012

14

Year

Per

cen

tag

e Percentage of MS4 studentsmatching into psychiatry(categorical and combined)

Percentage of MS4 studentsmatching into UH psychiatryprograms (categorical and triple-board)

Why don’t medical students choose psychiatry?Cutler, 2000: Students may perceive

psychiatry to be a “stressful” specialty. Are there actually more students who

are “excellent fits” for psychiatry who end up choosing a less optimal specialty?

Are there other factors?Clardy et al, 2000: Higher interest with

clerkship experiences in outpatient psychiatry.

“Meaningful contribution to patient care.”

Waterman and Schwartz, 2000: High prevalence of “mind-body dualistic fallacies”

Are there other factors?Malhi et al, 2002, 2003 (Australia):

“The least attractive aspects of psychiatry were its lack of prestige among the medical community and a perceived absence of a scientific foundation.”

“In comparison with other disciplines, psychiatry was regarded as… lacking a scientific foundation, not being enjoyable and failing to draw on training experiences.”

“…identified image problems need to be corrected…”

Medical student teaching and recruitment is high priority Part of the UH-DOP strategic plan since 2001 We have recently started the JABSOM

Psychiatry Student Interest Group (JPSIG) to identify and foster interest early on in medical school Stigma confronted, media examined Guest speakers, career-related videos Brain/behavior correlations

The general scheme at JABSOM

Unit 1(health/illness) Unit 2(cardio/pulm/renal) Unit 3(endo/heme/GI)

Unit 4 (locomotor/neuro/behavior) 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

Interfaces: first and second-year students

PBL curriculum: biological, behavioral, populational, and clinical perspectives.

Humanism in medicineSmall-group tutors, resource people,

“white coat ceremony” participants

Interfaces: second-year medical students

Clinical skills preceptorship during “Brain and Behavior” subunit.

3 hours/week for 4 weeks (late November to mid-December)

Teach a group of 5-6 medical students the basic mental status exam

Extremely well-received by students and enjoyed by faculty

Interfaces: psychiatry clerkship

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

What does the clerkship try to emphasize?

Relatively high prevalence of psychiatric conditions

Morbidity and mortality of psychiatric conditions

Treatability of psychiatric conditionsBasic psychiatric interview: essential

tool of the safe physician

Clerkship goalsAttitudes:1. To be empathetic and professionally responsible towards patients with mental health needs2. To respectfully collaborate with others involved in patient care Skills:1. To establish and maintain rapport with patients in various contexts, and to manage emotions which arise in the

course of patient care.2. To assess for conditions that could threaten the safety of the patient or others.3. To perform a comprehensive history and mental status examination 4. To generate broad-based differential diagnoses for psychiatric symptoms5. To identify the biological, psychological, social, and cultural factors that influence a patient’s presentation, and to

apply knowledge of such factors to patient care.6. To document and communicate information effectively.7. To access resources needed to manage patients with psychiatric conditions.8. To utilize the medical literature for the benefit of patients with psychiatric conditions. Knowledge:1. To be familiar with: cognitive, substance-related, psychotic, mood, anxiety, somatoform, dissociative, eating,

sexual, sleep, personality disorders; child and adolescent and geriatric psychiatry; psychopharmacology; and psychotherapies.

2. To be familiar with the mental health needs and resources specific to the Hawaii community.3. To be familiar with the scope and practice of psychiatry. 

Clerkship organization: implications for weekly schedules, other planning

 

Inpatient acute general hospital psychiatry at Queen’s Medical Center (3-4 weeks)

 

Inpatient public psychiatry at Hawaii State Hospital (3-4 weeks)

Child and adolescent psychiatry at Queen’s Medical Center

Outpatient psychiatry at Queen’s Medical Center or Kapi‘olani Medical Center for Women and Children

On-call/emergency psychiatry (7 weeks)

Orientation/Interviewing

Tutorial introduction/PBL Case 1PBL Case 1&2

PBL Case 2&3PBL Case 3&4

PBL Case 4&5PBL Case 5&6

Mid-term review/Interviewing 2Interviewing 3

PBL Case 6&7PBL Case 7&8

Finish casesWrap-up

      PDA logs due

    PDA logs due

            Experiences checklist due

      Write-up #1

    Write-up #2

      Mid-term exam

    NBME exam

            Oral exam

Clerkship handbook: http://dop.hawaii.edu

Clinical experiences1. 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.

Other issues re: clinical careWeekends for Kekela medical students:

round on their own patients, choose either Saturday or Sunday. No need do new admissions/stay late unless extremely low census.

Medical students can and should write progress notes (need to be reviewed).

Interfaces: beyond third-year

Career advising; fourth-year planningNumerous fourth-year electives relevant

for all medical specialties (e.g., child and adolescent, consult-liaison, addiction, psychiatric aspects of ob/gyn, etc.)

Suggestions: Interface with medical students early in

careers.Role model: humanism in medicine and

effective management of emotional issues arising from patient care.

Role model: importance of the biopsychosocial approach; enthusiasm about the neuroscience of behavior.

Suggestions (continued):Enable students to have, with

supervision, experiences in which they meaningfully contribute to the care of psychiatric patients (including documentation)

Allow students to have an accurate picture of what a psychiatric career is.

Overall…Be educated about current trends in

educationStrive for continuous quality

improvement in all aspects of educationA strong educational culture will

improve residency teaching and faculty development as well

Trends in medical student education Innovations in teaching (e.g., PBL,

information technology) and evaluating (e.g., OSCE) medical students Implications for faculty development

Desirability of other utilizing a wider variety of settings other than inpatient for clinical exposure Implications for how we design academic clinical

services

Trends in resident educationCompetency-based (not just time-cards)80-hour work week (context: need to

improve patient safety)Higher degree of structure and

accountability

Resident Supervision(ACGME Bulletin)Good supervision:

Good patient care Good education, that cultivates good

supervisors Good business sense Better morale

Resident Supervision(ACGME Bulletin)Direct observation

Structured, predictableFeedback

Appropriate content Appropriate process

A bit more about feedback “Feedback” vs. evaluationTips on giving feedback

Timeliness For the receiver’s benefit Objective descriptions of behavior (vs.

subjective conclusions)

Resident Supervision(ACGME Bulletin) “Practice without informed, deliberate

coaching to address non-optimal components may make poor performance `permanent,’ as bad habits become more ingrained with repetitive use. Practice thus does not always make performance `perfect.’”

Resident Supervision(ACGME Bulletin)Competency-based evaluations (6

competencies)Portfolio-based assessments

Training medical students and residentsNew methods, with growing body of

evidence-based support: Problem-based learning Team-based learning

TeachingVarious types of teaching: Didactic lectures Interactive conferences Case-based teaching Problem-based learning*

“Closed-loop reiterative problem-based learning” (Barrows)

Bedside preceptorship*

Mentorship*

PBL Clerkship tutorial topics Specific conditions: delirium, dementia,

psychosis, mood disorders (depression, bipolar), substance abuse, personality disorders, pervasive developmental disorders, ADHD, OCD, etc.

Treatments: psychopharmacology, psychotherapy

Age groups: child/adolescent, adult, geriatric Covers entire didactic content of psychiatry

RationaleStudies suggest better performance

(shelf exams) with PBL-based (vs. didactic-based) clerkship curriculum (Washington et al, 1999; McGrew et al, 1999; Curtis et al, 2001; Nalesnik et al, 2004)

A few more words about PBLUsed at McMaster University Medical

School since 1969Evidence amassed over the years

shows no disadvantage to PBL for the general curriculum, in multiple outcome measures (Colliver, 2000)

PBL… Evidence (Norman and Schmidt, 1992) that,

compared with traditional methods, PBL: Enhances application of concepts to clinical

situations Increases long-term retention Fosters life-long interest in learning.

Some evidence, even, of improved board scores (Blake, 2000)

PBL at JABSOMGood USMLE performance relative to

national norms (Kasuya et al, 2003)Successful residency matchingLCME accreditation: full 7 years

Teaching according to PBL principlesProcess of identifying facts/problems,

hypotheses (including mechanisms), additional information, learning issues

Active role: not teaching, but facilitating process

Facilitating the PBL Process:Initial Problem Encounter “Any other facts or problems you see in this case?” “Any other hypotheses, or possible mechanisms,

for the problem(s) you’ve identified?” “Was what you said more a fact or a hypothesis?” “Based on that hypothesis, any other additional

information?” “Did you have a new hypothesis, based on the

additional information you just requested?”

Problems Hypotheses Additional Info. Learning Issues

loss ofconsciousness

pallor

“drug abuse”

disruptionof “the brain”

energyproduction

hypoxemiarespiratoryarrest

poorperfusion

cardiacoutput

cardiacdysrhythmia

cerebrovascularatherosclerosislack of

substrate

hypoglycemia

insulinoverdose

physicalimpingement

mass lesion

ICP

meningitis

Na

tumor

intracranialbleed

trauma

abnormalneurotransmission

seizure

neurotoxins

hepaticfailure

?

vital signs, heart rate

further history about drug use (e.g., what drug?)

1. Anatomy and physiology of consciousness

Use of the Mechanistic Case Diagram to Generate Hypotheses

Facilitating the PBL ProcessGroup Functioning “I notice that most (or some) people are quiet.

I’m wondering what other people are thinking at this point.”

“That’s a good clarifying question that you asked your colleague.”

“It seems like there’s some disagreement here. Any suggestions about how to resolve this?”

“Any feedback about today’s session: what worked well, what could have been done better?”

Facilitating the PBL ProcessIntegrating Knowledge “How would you apply the knowledge you’ve

learned back to the patient’s presentation?” “How does the information you’ve presented

relate to what your colleague(s) just presented?” “It sounds like you’ve identified a gap in

knowledge, and you’re wondering if I know the answer. I actually don’t know the answer, but how does the group think I would go about finding it? What mechanisms or basic information do you think you need to learn about to help you find the answer?”

adolescence*

goal of independence

risk-takingbehavior

peer vs. familypressure

methamphetamineabuse

release of epinephrineand norepinephrine

functional ischemia

diffuse cardiacnecrosis

poor contractility

“cardiomyopathy”via echocardiogram

cardiacoutput

poorperfusion

pallorenergy production

reticulocortical disruption

loss ofconsciousness

partial AVnode damage

slow pathway

non-functioningionic pumps

abnormal atrialautomaticity

conduction ofimpulse

re-entry throughfast pathway

“PSVT”via EKG

diastolicfilling

vagaltone

Digoxin

contractileforce

intracellularcalcium

AVconduction

dopaminerelease

dopamineactivity

reward/reinforcement

sensitivereceptor

geneticfactor*

recentemigration*

self-fragmentation

depressive-equivalentbehavior

unemployment

other familymembers withsubstance abuse

tachycardia

myocardialdemand

Use of the Mechanistic Case Diagram to Summarize a PBL Case

Condition affectingBrain functioning

Parts of the“higher brain”

Weaknesses inmultiple areas of functioning

“MENTAL RETARDATION”

Specific parts of thebrain influencingsocial connectedness

Socialdisconnectedness

Relatively less naturalmotivation to learnadaptive skills

Significant delays in languageand communication development

Tendency to repetitiveand sterotypicbehaviors

“AUTISTICDISORDER?”

0-3 servicesSpecial ed.

“discrete trialtraining,” etc.

Selected PBL casesvitamin B1

Genetic factors* nutrient vitamin B1 decreased glutamatemalabsorption deficiency glucose neurotoxicity

utilizationAbnormal reward systems

vestibular nuclei pontine gaze center hippocampusCN6 nuclei dorsomedial thalamus

Alcohol use nystagmus lateral gaze defects anterograde amnesia

Mesolimbic pyridoxine, peripheral nerve longest tracks weaknessdopamine release pantothenate dysfunctiondecreased sensation

B12, folate hands/feet

Thalamo-orbitofrontaloveractivity

Confusion, hallucinations

Greg Primo (Unit 4): Wernicke-Korsakoff’s syndrome•Pathophysiological mechanisms•Anatomic/clinical correlations

Schizophrenia/psychotic disorders

Genetic, environmental factors*

benztropine DA/Ach imbalance acute dystonia/basal ganglia stiff jaw

Neuronalmigration errors

risperidone DA receptor blockade

Cytoarchitectural Inappropriate Increased dopamine Poor corticalDelusions,abnormalities mesolimbic dopamine tone filtering tangentiality

release hallucinations

Maldevelopment flat/inappropriate Frontal lobe affect

practical helpPoor judgment limited access

to care

poverty homelessness injury to feet cellulitis

Inability to work

Remember Larry Klaus (Unit 4)? Remember Phil Collins (Unit 1)?•Relationship between psychosocial factors and

overall general medical health

Mood disordersLithium thyroid effects elevated TSH goiter

Genetic factors* increased functional dopamine systems antipsychoticsneurotransmission

Abnormal 2nd messengers

prefrontal cortex limbic system hypothalamus reticular activatingReceptor amygdala (which parts?) systemdesensitization poor judgment mania decreased sleep poor concentration

aggression decreased appetite restlessnessDecreased weight lossneurotransmission Increased inhibitory

neurotransmittersIncreased catecholamines

Hypothalamus, ECTLimbic system

Increased serotonin

Depression, motor SSRI’sretardation

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

Cognitive disorders

Genetic factors* Aging* medications infection dehydratione.g., anticholinergic abnormal electrolytes

Cell death

Accumulation ofPlaques and tangles

cholinesterase donepezil disruption of inhibition reticular activating

Cholinergic neurons system

Decreased cholinergic impaired alertnessfunction and concentration

Hippocampus Motor pathways acute confusion agitationNucleus basalis

Impaired memory Frontal release emergence of encoding primitive reflexes

Recurrent theme: pathophysiology, anatomical correlationsDelirium (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)

Anxiety Disordersbenzodiazepine GABA/Cl channel

facilitationGenetic factors* oversensitive inappropriate

homeostatic receptors/ locus ceruleus desensitizationbrainstem nuclei firing

oversensitive5HT receptor reticulospinal limbic activation corticolimbic

path pathway5HT receptor

Increased synaptic downregulation sympathetic fear kindling prefrontal cortexserotonin discharge

tachycardia chronicSSRI 5HT3 agonism palpiatations anticipatory

sweating anxiety agoraphobiaincreased respiratory demand

GI side effects

Mary Kaweli (Unit 4): Panic Disorder withAnticipatory anxiety and agoraphobia

Biological Psychological Social/Cultural

Head trauma age 59

Cortical dysfunction generativity 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

Potential Application to the Biopsychosocial Formulation

EvaluationsEvaluation forms – mid-unit, end-unit,

grading, time framesWrite-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.

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.

RememberThrough medical student education, we

provide the psychiatric education for the 96% of students who go into other specialties.

Through medical student education, we can have a lasting impact on the future of our specialty, and on our ability to meet community needs in the long run.

Everyone’s well-being Education and patient care are both

optimized if we all look out for each other’s well-being

It’s everyone’s job to look out for each other’s safety and physical and emotional well-being, and to insure compliance with regulations that look out for these very things (e.g., OSHA, ACGME 80 hour work week, etc.)

Please let us know if you have any questions or concerns about this.

In closing… Your diligence and excellence in medical

student teaching will be recognized and greatly appreciated!

Medical student teaching is an important part of resident/faculty evaluations

Please be prompt in turning in evaluation forms on students you supervise

Whom can you call?Dan Alicata, M.D.

Psychiatry Clerkship Director

AlicataD@dop.hawaii.eduTony Guerrero, M.D.

Vice-Chair for Education and Training, Department of Psychiatry

GuerreroA@dop.hawaii.edu

THANK YOU FOR YOUR ATTENTION!