Universal Journal of Medical Science 2(3): 31-35, 2014 DOI: 10.13189/ujmsj.2014.020302
http://www.hrpub.org
The Current State and Need for Education in Transplant Psychiatry Gabriela Balf Soran1,2, Rani Hoff2, Paula Zimbrean2,* 1
Sanford Behavioral Health, Bismark, North Dakota 2 Yale University, New Haven, CT *Corresponding Author:
[email protected]
Copyright © 2014 Horizon Research Publishing All rights reserved.
Abstract Objective. The Authors Examined The Perceived Adequacy Of Current Training In Transplant Psychiatry (TP).Methods: An anonymous web-based survey was distributed to all US Psychiatry Residency programs (N=182) and Psychosomatic Medicine Fellowship programs (N=46).Results: Sixty one (33.5%) Psychiatry Residency Directors and 24 (52%) Directors of Psychosomatic Medicine completed the survey. Sixty eight percent of Psychiatry Residency programs do not provide specific TP training and 79.4% of residents had never performed a TP evaluation. Among the Psychosomatic Medicine Programs, 91.3% provide TP training; however only 14.3% of fellows are involved in TP evaluations. Giving the news of a negative determination of eligibility was listed as a main source of anxiety about TP. 68.6% of the PRD considered more training in TP necessary, specifically regarding medication interactions and substance abuse issues. Conclusions: Given this perceived need, psychiatry and psychosomatic medicine residency and fellowship programs should consider supplementing their existing curricula with more TP-related training. Keywords Psychiatry Residency Training, Transplant Psychiatry, Transplantation, Psychosomatic Medicine Main Messages: 1. 2.
3.
In teaching hospitals, there is an significant involvement of Psychiatrists in the setting of organ transplantation. There is a perceived need for more training in Transplant Psychiatry in the US Psychiatry Residencies and Psychosomatic Fellowship programs The Transplant Psychiatry topics about which more training is required are the role of the psychiatrist in the transplant process, transplant pharmacology, the nature of medical co-morbidities and the impact of personality disorder in these cases.
Current Research Questions:
What is the optimal training curriculum in Transplant Psychiatry (as clinical experience or formal teaching) for Psychiatry residents? What is the optimal training curriculum in Transplant Psychiatry (as clinical experience or formal teaching) for fellows in Psychosomatic Medicine? What type of training offers adequate preparation of Psychiatry residents for the practice of integrated care?
1. Introduction The overall number of transplants is increasing as reflected in the data provided by the United Network for Organ Sharing (UNOS) 1. There is also growing evidence regarding the impact of mental health upon the outcomes of organ transplantation 2-6 5 . In this context, psychiatrists are playing an increasing role in the transplantation setting by participating in patient selection and by providing care to organ recipients and donors. The psychiatric consultation for transplant patients differs from regular psychiatric consultation for general hospital patients in important ways7-10 . Some psychiatric evaluations of the transplant candidates are done in urgent situations (e.g. acute liver failure) when the patient is critically ill and the clinical interview, the main diagnostic tool for a psychiatrist, is not feasible. The high motivation for being listed as a transplant candidate may lead some patients to withhold information, thus posing further challenges to the psychiatrist 11 . In addition, the findings of the psychiatric evaluation are often used for candidate selection, which may raise ethical challenges for the consultant. The multidisciplinary nature of the transplantation impacts classical confidentiality rules, since information is typically shared among multiple members of the transplantation team. Finally, evaluating living donors includes an assessment of the possible impact of an elective surgical procedure upon a healthy individual 2,12-14. In addition to the role in candidate selection, psychiatrists are increasingly involved in post-transplant care. Untreated mood disorders, psychotic illnesses, severe personality disorders and ongoing substance abuse may interfere with
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The Current State and Need for Education in Transplant Psychiatry
transplant outcomes, mostly through non-adherence with medical treatment 3,15-17. Depression is the most common psychiatric disorder present following organ transplantation, with incidence ranging from 5 to 25 % 4 . Stable psychiatric disorders may decompensate immediately pre or post transplantation, due to the stress of the illness and surgery or due to medication changes (e.g. interactions between psychotropic medications and immunosuppressant drugs). Despite growing evidence for the importance and complex nature of the transplant psychiatric consultation, to our knowledge, there has been no attempt to describe or standardize the psychiatric training in this field. The purpose of our survey was to characterize the current state of training in TP during psychiatry residency training and psychosomatic medicine fellowships.
2. Methods We distributed an 11-question anonymous web-based survey (Survey Monkey ™) to all US Psychiatry Residency Program Directors (182 programs) and all Psychosomatic Medicine Fellowships (46 programs) and along with a request to fill it out and also forward it to their residents and fellows. A second request was sent two weeks later. The study was considered exempt from review by our institutional Human Investigation Committee. The main domains of the questionnaire were: 1.Characteristics of the general consultation liaison (CL)
training at the particular institution (year of residency when CL training is completed, presence or absence of an outpatient setting during the CL training, presence of an organ transplant service); 2.Exposure to TP (presence and type of formal training, likelihood to be asked to perform a TP evaluation, actual experience with transplant consultation); 3.Anticipated sources of anxiety surrounding the transplant evaluation and preferred sources of information about TP; and 4.Perceived need for training in TP. We performed a descriptive analysis of the results.
3. Results 33.5% (61/182) of the Psychiatry Residency Program Directors (PRDs), 52% (24/46) of the Psychosomatic Medicine Fellowship Directors (PMFDs), 74 Psychiatry Residents and 8 Psychosomatic Fellows returned the completed surveys.
Characteristics of the institutional CL training: 43.1% of the residency programs reported that their CL rotation occurs during the second year, while 37.3% reported a spread over more than one year of training. The majority of the residency programs do not expose their residents to the outpatient CL setting, as opposed to 91.3% of the fellowship programs who do offer outpatient CL experience to their trainees.
Exposure to Transplant Psychiatry is summarized in table 1 Table 1. Exposure to Transplant Psychiatry Feature
Psychiatry Residency Programs (N=61)
Psychosomatic Fellowship Programs (N=24)
Organ Transplant Program present at the institution
76.5%
91.3%
Training in Transplant Psychiatry offered
38%
91.3%
Clinical exposure during general consultation-liaison rotation
86.7%
95%
Transplant Psychiatry lecture(s)
52.2%
85%
Transplant Psychiatry Elective
21.7%
35%
Likely to participate in an evaluation
79.1%
100%
79.4% of the Psychiatry Residents and 14.3% of the Psychosomatic Medicine Fellows reported that they had not participated in a TP evaluation.
Universal Journal of Medical Science 2(3): 31-35, 2014
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Sources of anticipated anxiety around TP evaluations (Table 2). Table 2. Perceptions about Transplant Psychiatry training, per respondent categories. Psychiatry Residency Program Directors (n=61)
Psychiatry Residents (n=74)
Anxiety sources
Psychosomatic Fellowship Program Directors (n=24)
Psychosomatic Fellows (n=8)
Average Anxiety Score (0-10 ; 10 highest)
Novelty of the situation
5.8
5.9
4.1
2.3
Being the team’s consultant
4.2
4.4
2.6
1.7
Giving negative news
6.1
4.5
4.8
3.5
6.3
6.6
3.7
4.4
6.3
6.2
3.9
3.4
6.0
6.3
3.6
3.3
Familiarity with the transplant process Familiarity with contraindications to transplant Familiarity with psychopharmacology Sources of information
Importance Score (0-100; 100 highest)
Psychosomatic Textbook
72
46
81
71
Program’s Curriculum
19
20
89
46
Internet Based
72
89
86
86
Senior Colleague
70
91
91
100
Most PRDs thought that the familiarity (or lack thereof) with the transplant evaluation process and its contraindications is the most significant source of anxiety for residents, followed by the possibility of needing to give a patient the news of a negative determination. Residents thought that the psychopharmacology aspect is important as well. PMFDs felt that the main source of anxiety would be giving the news of a negative determination. Their fellows, however, listed the overall degree of familiarity with the transplant evaluation process and the urgent nature of some evaluations as the main anxiety-inducing factors. Need for specific TP training. 68.6% of the PRDs thought that additional TP training is needed during residency and is best delivered during the Consultation Liaison rotation. 73.7% of the PMFDs also indicated that more training in TP is needed. One particularly thoughtful comment was: “I think that this degree of sub-sub specialization should be individually rather than programmatically (or nationally/organizationally) driven. To perform transplant evaluations adequately, a psychiatrist must have specific training and mentoring with multiple cases. It is probably not realistic to expect that all fellows graduating from CL fellowships will be competent to perform transplant evaluations.” Medications interactions and side effects, as well as medical co-morbidities were listed by all parties as areas in which more training would be useful (Table 3). Table 3. Perceived Transplant Psychiatry areas in which more training is needed (Importance score 0-10, 10 highest) Psychiatry Residency Program Directors (n=61) Medication 8.4 interactions Medication side effects 8.0 Substance abuse management Axis I disorders management Axis II disorders management Medical comorbidities
Psychiatry Residents (n=74)
Psychosomatic Fellowship Program Directors (n=24)
Psychosomatic Fellows (n=8)
7.6
8.1
7.3
7.6
8.0
6.1
7.2
7.1
8.2
6.7
7.0
7.2
7.7
4.9
7.2
6.5
7.5
7.1
7.7
7.6
7.7
6.6
Regarding preferred TP sources of information, residents, fellows and PMFDs indicated a senior colleague as the main source. Internet-based sources were also preferred by trainees.
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The Current State and Need for Education in Transplant Psychiatry
4. Discussion The majority of the respondents indicated a need for more TP training, which mirrors the proportion of the institutions that do have transplant programs. There was a difference between the perceived likelihood that residents will be involved in a TP consultation and the actual exposure, which was rather low. The low rate of exposure of residents to TP may be related to the generally low level of involvement in outpatient CL. The size of the sample was too low to pursue any statistical correlations. It was interesting to note that, on average, PRDs rated high as an anxiety source the possibility of giving negative news, although in routine practice, the consultation does not comprise communicating a negative determination to the patient or family. Surprisingly enough, this finding replicates in the Psychosomatic Fellowship Program Directors answers, whom one would expect to be more familiar with the role of the psychiatrist in the transplant setting. It is reassuring to notice that the PRDs are quite attuned to their residents’ perceived needs and sources of anxiety; their answers coincided with those of the residents’ in many respects, particularly regarding the degree of anxiety that their residents expect to encounter during such evaluations. Despite the smaller size of the program and presumably increased contact between DPMF and their fellows, there was more discrepancy noted regarding the fellows’ predicted sources of anxiety. This may reflect some ambiguity surrounding the role of the Psychiatrist in the transplant process, which can vary from being a distant consultant to being the main educator of the organ recipient or donor. Most of the responders indicated that more knowledge is needed about pharmacology and medical co-morbidities in TP. Management of Axis I disorders was also rated as a topic of interest in this setting, likely due to concern for drug-to-drug interactions and risk of organ damage from psychotropic medications in the post transplant setting. Fellows, however, also rated high the need for more information about the role of Personality Disorders in TP, which may reflect a deeper level of understanding of the impact of this diagnosis upon outcomes in chronic medical illnesses. The discrepancies between the recommended references are also interesting: the directors recommended the textbook or program’s curricula, whereas their fellows value more a senior attending opinion, or internet-based resources. Recent recommendations from the Academy of Psychosomatic Medicine (APM) for residency training in valuable Psychosomatic Medicine 18 emphasize the experience residents may have during a TP rotation, through participation in multidisciplinary meetings and liaison work. Our survey indicates a high variability between programs in regards to the structure of the training in TP. This may be the result of a high variability in the practice of TP worldwide and the need for further clinical
guidelines. The main limitation of the study is the low response rate, in context of an Internet-based research landscape of intense competition from pharmaceutical or other research firms that offer reimbursement for physician’s time 19 . Another limitation is the potential for respondent bias; programs that have increased contact with Transplant Psychiatry may have been more likely to respond to the survey. In the current context of the United States healthcare system emphasizing the medical home model, integrated mental health care and embedded psychiatric care are anticipated to expand, and psychiatrists will be seen more and more practicing in close relationship, often co-located with, other medical specialties 20. This survey illustrates some of the challenges waiting ahead in regards to training residents to practice in this new system of healthcare delivery: lack of exposure, misperceptions of the psychiatrist’s role and beliefs that interdisciplinary work is reserved for advanced training. Future research directions in TP education could approach the practitioners in the field to inquire about how their view their own training in TP and perceived needs for improvement. Furthermore, structured educational programs could be tested for feasibility and efficacy.
5. Conclusions There is a perceived need for more training in TP during Psychiatry Residency and Psychosomatic Medicine Training. The topics about which more information is required are the role of the psychiatrist in the transplant process, transplant pharmacology, the nature of medical co-morbidities and the impact of personality disorder in these cases.
Acknowledgments Authors thank Dr. Esperanza Diaz and Dr. Vinod Srihari for their helpful comments on the manuscript.
Disclosures In reference to this article the authors have no conflict of interests
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