February Milestones of the Month--PBLI1 and SBP4

Virtual Journal Club--Week of February 13

Just a couple of short articles about burnout interventions that were sent my way by AADPRT this month. One compares Yoga vs CBT Stress Management, the other compares the effectiveness of organizational interventions vs. individual interventions. Taken together, I'm guessing we should all be doing yoga together!

Yoga vs CBT Stress Management

Controlled Interventions for Burnout

January Milestones of the Month--PBLI2 and SBP1

Happy New Year--January's Milestones address Quality Improvement, which I frequently think is a appropriate topic for January. Like those of us who set New Year's Resolutions, or make other sorts of goals for a calendar year, QI, Systems-Based Practice (SBP) and Practice Based Learning and Improvement (PBLI) are focused on taking stock of our present situation, setting goals to change something, and evaluating our progress.  The PBLI2 Milestone is focused on setting SMART goals and internalizing that approach to continuous improvement of our own practices. Actually moving beyond ourselves to make changes in our systems is extremely challenging--so take advantage of every opportunity to support one another and your teams when hospital initiatives or other projects are going on.

SBP1 is focused specifically on Patient Safety, Error Reporting, and Prevention of Errors.  You should know at a minimum how to report an error in our electronic records systems, and be alert to how patient safety considerations affect the care we give. Finally, don't be afraid when things go wrong! These are powerful learning experiences, and we've all experienced them.

December Milestones of the Month--PC4 and MK4

Gosh, is it December already?

This month's theme is the development of therapy skills. I particularly like how Level 1 begins with "accurately identifies emotions", and the work proceeds through stages of helping our patients use these for constructive change. The associated Medical Knowledge Milestone also predicates a progressively expanded knowledge base regarding the evidence for various therapies, and our sophistication in applying that knowledge. Note also Thread D in PC4: the process of getting supervision is a vital part of providing the therapy, and important at a fairly high level--e.g. supervision is not for "beginners" but for the "proficient" as well. Have you scheduled a meeting with your supervisor this week? Don't neglect it!

Virtual Journal Club--Week of November 21, 2016

This is a new submission from NNCI (National Neuroscience Curriculum Initiative) which I found interesting: Modern Microglia: Novel Targets in PsychiatricNeuroscience, by Jennifer B. Dwyer and David A. Ross.

From the authors: "Neuroscience is all about neurons, right? Psychiatric neuroscience has often viewed the relative health or dysfunction of neurons as the key to mental health or disease. While we've long known about other cells in the brain, we're only now starting to appreciate their potential roles in psychiatric disorders.

Glia were classically considered the support cells of the brain, merely inert structural “glue” as their name suggests. Modern neuroscience, however, has begun to appreciate a more active, and at times critical role, for these cell types in a variety of important neural processes. Here we discuss the function and significance of microglia, particularly as they relate to mental health and disease. These hard working cells provide a new set of possible therapeutic targets and suggest that psychiatric neuroscience is about more than just neurons."

http://www.biologicalpsychiatryjournal.com/article/S0006-3223(16)32667-1/pdf

Virtual Journal Club--Dealing with Patient Suicides

The excellent Morning Report presentation by Dr. Bauer today raised two main issues: 1) the nuts and bolts of detailed suicide assessment, and 2) how do we as psychiatrists cope when despite our best efforts, a patient succumbs to their disease. Most of you have seen the DVD "Collateral Damage", discussing the impact of this event on psychiatrists at all levels of their careers. I also want to upload a very good, wrenchingly personal article from Michael Gitlin, A Psychiatrist’s Reaction to a Patient’s Suicide. I found it quite helpful in working through my first experience with this unfortunate outcome as a senior resident.

Let me also take this opportunity to encourage you all to continue to talk with one another and with your supervisors about how things are really going with your patients. This, especially the supervision time, is a time and place in which it should be safe to express doubts and fears, and OK to be wrong.

Please don't hesitate to approach me or another faculty member with your concerns.

Michael Gitlin, A Psychiatrist’s Reaction to a Patient’s Suicide.

Virtual Journal Club--Week of November 14, 2016

Some heavier reading this week, in keeping with the Milestones for somatic therapies this month.

How do you determinine if an antipsychotic medication will work? What outcome measures will you use? Is there some way to tell whether Medication A will be better than Medication B, and if so how--and how clinically meaningful is that difference.

Attached is a large randomized open trial, Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial, (René S Kahn*, W Wolfgang Fleischhacker*, Han Boter, Michael Davidson, Yvonne Vergouwe, Ireneus P M Keet, Mihai D Gheorghe, Janusz K Rybakowski, Silvana Galderisi, Jan Libiger, Martina Hummer, Sonia Dollfus, Juan J López-Ibor, Luchezar G Hranov, Wolfgang Gaebel, Joseph Peuskens, Nils Lindefors, Anita Riecher-Rössler, Diederick E Grobbee, for the EUFEST study group†.  Lancet 371: 1085-97, 2008), that asks these questions. Note too, the role of adherence and discontinuation in the outcomes. As I've often said, "the best medication for the patient is the one that they actually take".

The second article is a major metaanalysis comparing antipsychotic medications against one another (and placebo). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. (Stefan Leucht, Andrea Cipriani, Loukia Spineli, Dimitris Mavridis, Deniz Örey, Franziska Richter, Myrt. Lancet 382: 951-62, 2013) I'm simply impressed with the scope of this. Who comes out ahead, and why? The exercise is left to the reader, as they say.

Effectiveness of antipsychotic drugs... Kahn, et al.
Comparative Efficacy..., Leucht, et al.