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Introducing a Psychosomatic Medicine Interest Group for Psychiatry Residents Neil Puri, Pierre Azzam, Priya Gopalan

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S0033-3182(13)00168-0 http://dx.doi.org/10.1016/j.psym.2013.08.010 PSYM387

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Psychosomatics

Cite this article as: Neil Puri, Pierre Azzam, Priya Gopalan, Introducing a Psychosomatic Medicine Interest Group for Psychiatry Residents, Psychosomatics, http://dx.doi.org/10.1016/j.psym.2013.08.010 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Introducing a Psychosomatic Medicine Interest Group for Psychiatry Residents  Neil Puri, Pierre Azzam, Priya Gopalan  University of Pittsburgh School of Medicine, Department of Psychiatry    

Corresponding author e‐mail: [email protected] (Neil Puri) 

Introducing a Psychosomatic Medicine Interest Group for Psychiatry Residents Abstract: Background: Having gained subspecialty certification in 2003, the field of psychosomatic medicine (PM) addresses the mental health needs of individuals who suffer from general medical conditions. The rising prevalence of chronic illness, along with trends in medical delivery toward more collaborative models of care, underscore the value of recruitment to PM specialty programs. Objectives: To foster interest and education in PM, we have developed and implemented a Psychosomatic Medicine Interest Group (PMIG) for trainees within a psychiatry residency program. Results: Participants have found the PMIG to be an enjoyable experience that has improved their clinical practice and interest in PM. Discussion: The PMIG has also been a successful vehicle to enhance clinical knowledge and mentoring opportunities during training, while bolstering residents’ desire to pursue a career in PM. Introduction: Interest groups have long united tradesmen, politicians, and professionals for popular representation and the advancement of shared objectives.1 In the arena of medicine, the evolution of clinical practice guidelines, graduate education, and legislation has relied heavily on the work of specialty organizations and interest groups. While graduate medical trainees (i.e., students, residents, fellows) often seek membership to these agencies, few studies have examined the extent to which specialty interest groups address their professional development needs; this includes the process of choosing a medical discipline. Task forces representing internal medicine, family practice, and psychiatry have investigated factors related to specialty decision-making among medical students, while promoting interest for their respective fields.2–6 Studies of career choice among residents in internal medicine, emergency medicine, and radiology cite aspects such as intellectual curiosity, personality, and lifestyle as most influential.7–9 Exploring these factors has aided in efforts to target recruitment for underserved and subspecialty fields.10,11 To our knowledge, only one study has examined the impact of interest groups specifically during residency training. Durning et al investigated whether residents who participated in an internal medicine interest group for medical students perceived benefits from their involvement; the investigators describe a general consensus among residents that the experience was valuable and improved morale and leadership skills.12 To our knowledge, there are no studies that comment on promoting interest in psychosomatic medicine. Objectives: We set out to develop a Psychosomatic Medicine Interest Group (PMIG) that would accomplish for psychiatry residents the following objectives: • Increase interest in psychosomatic medicine (PM)

• • •

Enhance clinical knowledge in PM gained during residency training Facilitate opportunities for mentorship and peer advisorship Encourage recruitment into the field of PM

Methods: The PMIG is open to all psychiatry residents of the Western Psychiatric Institute and Clinic (WPIC) at the University of Pittsburgh Medical Center (UPMC). One resident who is interested in psychosomatic medicine spearheaded the coordination of resident involvement, and two members of the faculty who have expertise in psychosomatic medicine volunteered to serve as the PMIG advisors. An invitation email was sent to all residency classes at the initiation of the group, and again at the start of the following academic year. Trainees who expressed interest in participating were compiled into a separate electronic list to receive PMIG invitations and notifications. The PMIG convenes for two hours, every 4-8 weeks. In an effort to encourage attendance and create an informal environment, meetings are held over dinner at a resident’s or faculty advisor’s home. Each PMIG meeting includes a resident-led clinical case presentation and literature review on a topic relevant to psychosomatic medicine. PMIG meetings follow an organ-system pattern longitudinally (e.g., meeting devoted to renal system with presentation on capacity to refuse hemodialysis; subsequent meeting devoted gastrointestinal system with presentation of chronic recurrent foreign-body ingestion). Residents are encouraged to raise and discuss questions as they arise during the presentation, and they are expected to produce a differential diagnosis by the end of the case presentation. The presenting resident may also pose practical and hypothetical questions to the group during the case (e.g., “What would you have done if the patient asked to leave before completing her course of hemodialysis?”). The case discussion and differential diagnosis are typically followed by a 5-10 minute synopsis on a topic relevant to the case (e.g., presentation about the signs of Korsakoff dementia after a case of new-onset confabulation) and literature review. Faculty advisors attend each meeting to facilitate the case discussions, to answer any clinical questions, and to provide career-related mentorship. Residents volunteer to present cases with which they are familiar in the weeks leading to each meeting, as coordinated by the resident leader of the PMIG. At the end of each meeting, residents completed anonymous surveys to evaluate the session (Table 1). At the six-month mark for the group, an additional survey was given to residents to assess their plans for a career prior to the PMIG and the extent to which the PMIG had: increased their PM knowledge, increased their interest in PM, influenced them to pursue a career in PM, and provided opportunities for PM mentorship. Survey questions were based on a 1-10 Likert scale with one to two representing “strongly disagree” and nine to ten representing “strongly agree.” End of meeting surveys also included free response sections. Individual responses from surveys were averaged, and standard deviations for each survey question (i.e., between meetings) was calculated. For the six-month survey, the responses of those who attended two or fewer sessions were compared to those who attended three or more sessions by a two-tailed t-test. The standard deviation between individual responses was also calculated. Results: During the first six months after its induction, five PMIG meetings were held and covered topics related to: neurology, nephrology, gastroenterology, nutrition, reproduction, and endocrinology (Table 2). On average: 5-6 residents attended each meeting; 75% of residents at each meeting were in their first two years of training; and residents attended three meetings apiece. In end-of-meeting surveys, residents “strongly agreed” that the PMIG meetings were interesting (avg. 9.72/10), had helpful materials (avg. 9.56/10), had well prepared presenters (avg. 9.66/10), offered active and didactic learning (avg. 9.66/10), allowed for discussion (avg. 9.69/10), and helped improve their

clinical practice (avg. 9.53/10) (Table 3). The standard deviation of scores on each survey question between meetings ranged from 0.08 to 0.24. In the free response section of our survey, comments highlighted the interactive aspects of the group and the casual environment with food and opportunities to socialize as enjoyable and noteworthy. Feedback also noted time commitment as a challenge for attendance. The six-month survey revealed that residents “agreed” that participating in the PMIG increased knowledge of PM (avg. 8.11/10), increased interest in PM (avg. 8.67/10), and provided opportunities for mentorship (avg. 8.45/10) (Table 4). Most participants “agreed” they were considering a career in PM prior to joining (avg. 7.78/10) and “agreed” that participating in the PMIG influenced a choice for a career in psychosomatic medicine (avg. 7.89/10). Residents who attended more than three sessions felt more strongly that the PMIG increased their PM knowledge than residents who attended less than three sessions (avg. 9.25/10 vs. 7.2/10, p=0.02) (Table 5). Residents who attended more than three sessions reported a stronger agreement that the PMIG has influenced them to pursue a career in psychosomatic medicine (avg. 9/10 vs. 7/10), though the difference did not reach statistical significance (p=0.24). Overall, residents felt less strongly that the PMIG afforded opportunities to be a mentor (avg. 6.56/10). At the same time, third- and fourth-year residents (N=3) felt more strongly that they had opportunities to provide mentorship through the PMIG (avg. 8.3/10), as compared to first- and second-year residents (avg. 5.67/10). The small number of participants precluded multivariate analysis and limited the detection of statistically significant differences between resident subgroups. Discussion: Amid a surge in the prevalence of chronic medical conditions,13 many of which present with associated affective and behavioral syndromes,14 psychiatrists must gain comfort navigating the line between mental and physical health. The field of psychosomatic medicine (PM) aims to improve the care of individuals with comorbid psychiatric and general medical illness. In 2003, the American Board of Psychiatry and Neurology officiated PM as a subspecialty of psychiatry; by 2011, approximately 1080 certificates in PM had been awarded15. The growing need for PM specialists must be reconciled with data that suggest most psychiatrists do not have an interest in fellowship training, with only 41% pursuing any psychiatry fellowship in 200815. In an effort to promote PM, we have developed a PMIG for psychiatry residents at our institution. Data from surveys obtained during meetings of the PMIG underscore the potential benefits of implementing such an organization for psychiatry residents. Participants found that the PMIG improves their clinical practice and PM knowledge, the latter of which appears to increase significantly with longer participation in the group. The PMIG increases resident exposure to PM-specialized faculty and offers opportunities for mentorship outside of the hospital and classroom settings. The PMIG also serves as a forum for collaboration on academic projects related to PM. Members of the PMIG have worked together to compose manuscripts, develop a recurrent lecture series for internal medicine residents, and fashion a video series on topics salient to general hospital psychiatry. Several challenges are associated with implementation of such a group. As with most extramural activities, time commitment appears to be the largest hurdle. This may explain why there were a relatively small number of attendees at each meeting, and the drop in attendance between the first session and subsequent ones. Commitments to other clinical and extracurricular activities may have also contributed to the relative underrepresentation of senior-level residents. The setting of the PMIG, away from work and over a meal, may mitigate some of the perceived time strain associated with an extracurricular activity.

The PMIG at our institution has continued to be successful past its first year of implementation. Based on survey results, aspects that participants enjoy most are the case-based interactive format and casual environment. As these meetings require careful organization and planning, they promote resident leadership, as well as provide mentoring opportunities for junior faculty. While cumulative data suggest that the PMIG less strongly provides an environment for residents to grow as mentors, this is perhaps explained by the predominance of attendees in early stages of psychiatry training. Approximately 75% are first- and second-year residents, who are less likely to take on mentorship roles in the meeting. Senior residents appear to feel more strongly that the PMIG affords opportunities for them to provide mentorship, though more responses are required to confirm this trend. As residents who joined the PMIG were already interested in PM, it is difficult to ascertain if such an interest group would sway the decision-making of undecided residents. Longitudinal monitoring, evaluation of residents’ eventual career choices, and larger sample sizes would allow for stronger conclusions. Replicating a similar PMIG at other institutions would also allow for greater generalizability. Future plans for the group include expanding membership to incoming residency classes, interfacing with medical students through teaching/mentorship opportunities, shaping career development opportunities, expanding topics of discussion to include other specialized areas in psychosomatic medicine, and assisting other programs in developing their own interest groups. We expect that the initial challenges, especially those related to attendance, will improve with time and exposure; attendance at the two most recent meetings of the PMIG are already increased from the previous year (N=13 and N = 11). By bringing psychiatry residents and faculty together for learning, mentorship, and academic collaboration, the PMIG at the University of Pittsburgh Medical Center has helped to promote clinical knowledge, interest, and scholarly activity in PM. Our experience with the PMIG suggests that interest groups can be effective tools to foster enthusiasm in focused medical fields. Disclosure: The PMIG was awarded a grant by the American Psychosomatic Society during the course of this study.

1.

Walker JL. The Origins and Maintenance of Interest Groups in America. The American Political Science Review. 1983 Jun: 77(2): 390-406.

2.

Hauer KE, Durning SJ, Kernan WN, Fagan MJ, Mintz M, O’Sullivan PS, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA: the journal of the American Medical Association. 2008;300(10):1154–64.

3.

Schwartz MD, Linzer M, Babbott D, Divine GW, Broadhead E. Medical student interest in internal medicine. Initial report of the Society of General Internal Medicine Interest Group Survey on Factors Influencing Career Choice in Internal Medicine. Ann Intern Med. 1991 Jan 1;114(1):6–15.

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Nielsen III AC, Eaton Jr JS. Medical students’ attitudes about psychiatry: implications for psychiatric recruitment. Archives of General Psychiatry. 1981;38(10):1144.

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Cutler J, Alspector S, Harding K, Wright L, Graham M. Medical students’ perceptions of psychiatry as a career choice. Academic Psychiatry. 2006;30(2):144–9.

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Biggs WS, Bieck AD, Pugno PA, Crosley PW. Results of the 2011 National Resident Matching Program: family medicine. Family Medicine-Kansas City. 2011;43(9):619.

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Rahbar L, Moxley G, Carleton D, Barrett C, Brannen J, Thacker L, et al. Correlation of rheumatology subspecialty choice and identifiable strong motivations, including intellectual interest. Arthritis Care & Research. 2010 Dec;62(12):1796–804.

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Arnold RW, Goske MJ, Bulas DI, Benya EC, Ying J, Sunshine JH. Factors Influencing Subspecialty Choice Among Radiology Residents: A Case Study of Pediatric Radiology. Journal of the American College of Radiology. 2009 Sep;6(9):635–42.

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Table 1. End of Meeting Feedback Survey Strongly Disagree Disagree Neutral Agree The meetings was interesting and held my attention: 1 2 3 4 5 6 7 The meetings was a good blend of didactic teaching and active learning: 1 2 3 4 5 6 7 The meetings allowed for discussion/questions as needed: 1 2 3 4 5 6 7 The presenters and facilitators for the meeting appeared to be well-prepared: 1 2 3 4 5 6 7 The materials used in the meeting were helpful: 1 2 3 4 5 6 7 The meeting was useful for me in improving my clinical practice: 1 2 3 4 5 6 7 Free Response Section: What worked well with the group? What could be improved with the group?

Strongly Agree 8

9

10

8

9

10

8

9

10

8

9

10

8

9

10

8

9

10

Table 2. Summary of Meetings Meetin g

Topic

Number of Participants

Clinical Case

1

Neurology

10

60 y/o female with atypical neurological complaints who was found to have Cotard’s Syndrome

2

Renal

5

52 y/o female refusing hemodialysis due to depression

3

GI

6

24 y/o female with borderline personality disorder and recurrent ingestion of foreign objects

4

Nutrition

6

52 y/o male with cognitive decline and thiamine deficiency

5

Reproduction

5

36 y/o female with T6 paraplegia, baclofen pump, and seizure disorder who becomes psychotic post-partum

Table 3. End of Meeting Feedback Question

Session 1 Average Score N = 10

The meeting was interesting and held my attention

9.9

The meeting was a good blend of didactic teaching and active learning

Session 2 Average Score N=5

Session 3 Average Score N =6

Session 4 Average Score N=6

Session 5 Average Score N=5

Average Score across all session

Standard Deviation Between Meetings

9.6

9.67

9.67

9.6

9.72

0.12

9.9

9.6

9.67

9.5

9.4

9.66

0.19

The meeting allowed for discussion/questions as needed

9.8

9.6

9.67

9.67

9.6

9.69

0.08

The presenters/ facilitators for the meeting appeared to be well-prepared

9.8

9.6

9.5

9.5

9.8

9.66

0.15

The materials used in the meeting were helpful

9.7

9.2

9.5

9.83

9.4

9.56

0.24

The meeting was useful for me in improving my clinical practice

9.6

9.6

9.5

9.34

9.4

9.53

0.12

Table 4. Six Month Survey (N=9) Question

Average Score

Standard Deviation between responses

Participating in the PMIG has increased my knowledge of psychosomatic medicine.

8.11

1.45

Prior to joining the PMIG, I was considering a career in psychosomatic medicine.

7.78

3.45

Participating in the PMIG has increased my interest in psychosomatic medicine.

8.67

1.73

Participating in the PMIG has influenced me to pursue a career in psychosomatic medicine.

7.89

2.42

Participating in the PMIG opportunities for mentorship.

has

given

me

8.45

1.81

Participating in the PMIG opportunities to be a mentor.

has

given

me

6.56

2.55

Table 5. Six Month Survey by Frequency of Attendance Question

Attended less than 3 session (N=5)

Attended P-Value more than 3 sessions (N=4)

Participating in the PMIG has increased my knowledge of psychosomatic medicine.

7.2

9.25

0.02

Prior to joining the PMIG, I was considering a career in psychosomatic medicine.

7.8

7.75

0.98

Participating in the PMIG has increased my interest in psychosomatic medicine.

7.8

9.75

0.09

Participating in the PMIG has influenced me to pursue a career in psychosomatic medicine.

7

9

0.24

Participating in the PMIG has given me opportunities for mentorship.

7.8

9.25

0.20

Participating in the PMIG has given me opportunities to be a mentor.

6.4

6.75

0.85

Introducing a psychosomatic medicine interest group for psychiatry residents.

Having gained subspecialty certification in 2003, the field of psychosomatic medicine (PM) addresses the mental health needs of individuals who suffer...
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