Virtual Journal Club--Week of July 25, 2016

This weeks articles return to the topic of Professionalism, this time from the Physician Health dimension. Tyzuk's review of this subject, Physician health: A review of lifestyle behaviors and preventive health care (BCMJ 54(8): 419-23, 2012), points out that most of the attention to this topic has been given to crisis management with impaired physicians, and little, if any, to overall wellness and prevention strategies.  Perhaps the tide is beginning to turn on this, but the reminder is still relevant. Sleep, nutrition, and fitness are often the first areas of neglect when work load and stressors mount, fundamentally impairing our abilities to manage that work load and stress.  In psychiatry, though we may not usually be subject to the same time demands in number of hours, nor the same pressures in terms of overnight calls or rotating shift, we also face unique stressors of high intensity interpersonal interactions, and often the secondary traumas involved with managing patients in severe emotional crises.

I often tell my patients that if they will eat breakfast and walk 20 minutes each day, they will be "halfway there" with respect to recovery. Stable habits and decent nutrition go a long way toward strengthening our inner selves. We are not exempt as physicians from the need to take adequate care for ourselves*. What are you doing now that works? What do you need to do, or what goals would you like to meet, and how can we as your peers support this for you?

Tyzuk

*[You may notice that this is getting posted while I'm on vacation! That's because I prepared it in advance and scheduled it to post automatically. Trying to set a good example, too! ]

Virtual Journal Club--Week of July 18, 2016

Happy Monday!  This week's article falls into the category of "classics": an interesting, controversial, and thought provoking experiment that might cause us to question some of our foundational ideas about mental health.  On Being Sane in Insane Places, by D. L. Rosenhan (Science 179: 250-258, 1973) examined what might happen if a healthy individual presented, claiming vague symptoms and seeking admission to a psychiatric hospital. Although it was (rightly) criticized as lacking realism, since the "patients" were intending to deceive psychiatrists through their subjective reports, I think that reading this still might make us pause and ask "How do we know what we think we know?" (For one of the major critiques, see Spitzer, Journal of Abnormal Psychology, 84(5): 442, 1975, if you want to dig deeper.)

I found the observations of how patients and staff interactions very interesting as well. Although there are many differences between the psychiatric institutions of 40 years ago and our current inpatient units, I think there is still a real danger that we might easily dismiss or minimize patients' experiences. The subjects of this experiment reported boredom, invasion of privacy, and dehumanization--to say nothing of loss of autonomy--and I think these are still relevant experiences of our patients today. What have you noticed on our units that is similar? Do we really treat patients "better" today? How do we ensure that patients' humanity and dignity is maintained, in spite of their illness and potential endangerment of self or others? It's often been said that the only difference between "Us" and "Them" is that one has the keys. Considering this might cause us to consider how it feels to be on the other side of that door.

Rosenhan

Virtual Journal Club--Week of July 11, 2016

This week's article, A New Intellectual Framework for Psychiatry, by Eric R. Kandel, M.D, was published two months after I finished my med school Psychiatry clerkship. The 1990s had been declared "The Decade of the Brain" by the NIH--and it was a time of rapid discovery, with the advent of functional brain imaging, the start of the Human Genome Project, and new applications of molecular biology to neuroscience. There were a lot of heady claims about what clinical applications might result "any day now" from this research.  I'll leave it as an exercise for the readers to deliberate what, if anything, has changed since that time frame.

Dr. Kandel is one of the true renaissance thinkers of psychiatry--Nobel-winning basic scientist, core textbook editor, art historian (some of us heard him speak at the Minneapolis Institute of Arts a couple of years ago), and analytically-trained psychiatrist.  This article addresses the false dichotomy between psychological and biological paradigms of psychiatry, and offers, I think, insights in how to reconcile the two viewpoints.  I think you might enjoy his reflections on the history of how this developed, as well as his survey of how five basic principles of neuroscience apply to Psychiatry. Given that this article is now pushing 20 years of age--do you think that any more recent knowledge has changed that framework? Can you think of any specific finding of the last 18 years that would make Kandel's 1998 perspective obsolete? How does basic neuroscience knowledge inform or alter your approach to clinical needs of the patient?

[Google drive link: Kandel]

Virtual Journal Club--Week of July 4, 2016

Hello and welcome to our first weekly Virtual Journal Club. I chose to start out the year with two articles this week which relate to one of the Milestones of the Month:  Professionalism. Both of these are qualitative essays, rather than quantitative studies, so an approach to discussion is less about hypothesis testing and quantitative analysis and more about considering the authors' perspectives and what applications they may have to our practices.

First up is Professionalism in medicine: definitions and considerations for teaching, by Lynne M. Kirk.  (Proc (Bayl Univ Med Cent) 2007;20:13–16).  Dr. Kirk explores some of the history of how professionalism became a focus of medical education, and attempts to deliniate how it should be defined, assessed, and taught. Characteristics of professionalism are listed as a set of specific commitments and as measurable behaviors. What do you think of these lists? Are there things that are included that you don't think of as necessary? Are there necessary items left off the list?

Next is The moral foundation of medical leadership: The professional virtues of the physician as fiduciary of the patient, by Frank A. Chervenak, MD, and Laurence B. McCullough, PhD. (Am J Obstet Gynecol: 184(5): 875-880. 2001).  They distill professionalism to a basis of four core virtues:  self-effacement, self-sacrifice, compassion, and integrity. What do these terms mean to you? Do you think that it is still relevant to talk about medical professionalism in terms of "virtues" and "vices" in the modern age of corporate medicine? Why or why not? To what extent do these virtues characterize your life as a physician, and how might you develop them--if possible.

I look forward to your comments and hearing about your discussions. Both papers are available on New Innovations, under Resources/Readings of the Week/07July.

[Added google drive links:  Kirk.  Chervenak.
Unfortunately, these cannot be accessed from Regions or HealthPartners sites. Sorry.]

July Milestones of the Month--PC1 and PROF2

Each month I'm planning to bring one or two of our twenty-two Milestones forward for emphasis.
For July, I chose The Basics:  Psychiatric Evaluation and Accountability to Self, Patients, Colleagues, and the Profession.

Like all of the Milestones, these are organized around a developmental course, from Novice to Expert.  At Level 1, you exhibit the skills and abilities expected of a beginning intern, and by Level 5 you are beginning to exemplify the qualities of experienced attendings.  It should be emphasized that the levels do not correspond to training year, and that they do not represent requirements for program completion. Indeed, we should view Level 5 as aspirational goals--many of us as attendings have to honestly admit that we might not consistently be at that level on all milestones. Instead, these are mostly objective standards that will help us evaluate our own progress in training and practice.  You'll also notice that each Milestone is further subdivided into Threads along which the development occurs and can be more or less objectively observed.  You can visit all of our Milestones at the ACGME, or on New Innovations.

For PC1, Evaluation, there are a couple of things I'd emphasize: First is the paramount importance of patient safety and risk assessment--especially assessing suicidal and homicidal ideation. I'm struck that there is no Level 3, 4, or 5 on this thread. It is foundational to the work of a psychiatrist. Back in the "old days", we were told that a sure way to fail the oral board exam was to fail to complete this task in our patient interview. This is still the most important task we perform, so practice, practice, practice!

The second interesting item is Thread D--the use of our own emotional responses to the patient for their diagnostic value. Whether you call it counter-transference or gut instinct, how it feels to be with a particular patient is often a very important clue to understanding how they relate to the world, or how their symptoms are manifesting themselves. I can't claim to have read all of the Internal Medicine or General Surgery Milestones, but I would not expect to find this Thread there. It is a unique province of our discipline, one to be observed, nurtured, and discussed in supervision. Also, as in the "House of God", where the third law is "At a cardiac arrest, the first procedure is to take your own pulse", it is important that we check ourselves emotionally and are attentive to our inner state when dealing with the extreme levels of emotional disturbance that we encounter in our our patients. I would encourage all of us to avail ourselves of opportunities to learn Mindfulness as a vital skill to build resilience and sustain ourselves for a long career, topics which are addressed further in the next Milestone, Accountability to Self, Patients, Colleagues, and the Profession. 

Again with PROF2, you'll notice the gradual development of Professionalism from beginner to leader--which starts with two foundational items in Thread B: Core Professional Behaviors and Openness to Feedback.  Much has been written about what constitutes "core professional behaviors", and some of this will be included in this month's Virtual Journal Club selections.  The footnotes in the ACGME Milestones refer to overall values of compassion, integrity, responsibility, accountability, and respect for others. The behaviors that manifest these values will include timeliness, reliability, listening, and public behavior, among others. We have assembled some of these in our Program's Compact, which we will discuss in the very near future.  In the meantime, commit yourselves today, at the beginning of this academic year, to adopt the professional character of a psychiatrist in all of your encounters with patients, colleagues, and the community, and to seek to further develop that character in yourself and others. 

Happy New Year!

Welcome to the Hennepin-Regions Psychiatry blog, what I hope will be the "official" social media outlet for our residency program.

July 1 truly counts as New Years Day for the academic world, particularly in medicine. In academic medicine, everyone starts a new job today--medical students become interns, interns and residents step up into higher levels of responsibility and accountability, and yesterday's seniors become today's attendings.  It's also a great time to adopt new attitudes, habits, and routines. This blog, particularly the Virtual Journal Club it will contain, is one of those new routines for me--and I hope it will become one for you as well. I look forward to having you share comments, and suggest content ideas that can be shared with the program. Feel free to send suggestions to either this account: hcmc.regions.pd@gmail.com or to my regular work accounts.

Have a great year!

--SAO