Make Way for the Learners

never-stop-learning_designAll resident psychiatrists undergo periodic assessments of their patient interviewing and diagnostic skills called Clinical Skills Evaluations (CSEs) which allows experienced faculty to directly observe them conduct psychiatric evaluations of patients unknown to either the teacher or the learner. It’s a vital part of training the next generation of doctors, in whom I have great confidence.

Teachers listen to the residents elicit rapport and ask the patients key questions, but not just that. Following the interview, the trainee must present a summary of the information gleaned from the patient, along with a diagnostic formulation and treatment recommendations. The whole thing takes about an hour and the vast majority of trainees do a great job.

This form of evaluation started in response to the elimination of the live patient interview (as of 2012) as part of the live patient exam (Step 2) as part of the American Board of Psychiatry and Neurology (ABPN) certification examination because Step 2 was considered a poor as well as a very expensive test of a freshly minted psychiatrist’s interview skills.

As a colleague put it, “In the era of competencies—we need to prove our residents know how to do this.” And we need to prove this to the ABPN and the Accreditation Council for Graduate Medical Education (ACGME).

This includes suicide risk assessments, which so far do not include listening for the trainees recommending blood tests for suicide biomarkers. Neither have I listened for recommendations for ketamine to be used in the management of severe suicidality and depression.

Following my CSE session with one of the senior residents (a star performer), I thought about this after reading new articles about both interventions, one in an open access article in Molecular Psychiatry, which touted a combination of genomic blood tests and clinical risk assessments, the latter comprised of a couple of apps. The other was a sort of tongue-in-cheek article about ketamine, a paper written by Caroline Winter, who somehow managed to animate it with psychedelic special effects.

Caveats are in order. The biomarker study is hampered by small sample sizes and probably would overestimate acute suicidality, despite the authors’ admission that the risk factors discussed are relevant for prediction over a year’s time.

And one of the lead authors (A.B. Niculescu) is “listed as inventor on a patent application being filed by Indiana University.” Yet the “authors declare no conflict of interest.” I’m not sure what that means; maybe nothing.

Obvious criticisms and cautions regarding the Niculescu, et al paper help bring us back down to earth.

And I got a big kick out of Caroline Winter’s humorous treatment of the ketamine issue, which I think carries a healthy undercurrent of common sense though I’m all for looking under every rock for methods to prevent suffering and suicide.

By the way, the Urban Dictionary definition for “common sense” is “What I think you should know.”

I don’t think I’ll be requiring residents to be recommending the interventions in this sort of literature just yet on their CSEs.

But if they speculate about them during their presentations—I’ll probably give them credit for open-mindedness and creativity that often enough mark major paradigm-shifting innovations which can move humanity forward.

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