For Residents

This article exhibits key pediatric dermatology pearls garnered at the 2017 Annual Meeting of the American Academy of Dermatology (AAD) in Orlando, Florida (March 3–7, 2017). Highlights from both the Society for Pediatric Dermatology pre-AAD meeting (March 2, 2017) and the AAD general meeting sessions are included. This discussion is intended to help maximize care of our pediatric patients in dermatology and present high-yield take-home points from the AAD that can be readily transferred to our patient care.

“New Tools for Your Therapeutic Toolbox” by Erin Mathes, MD (University of California, San Francisco)

During this lecture at the Society for Pediatric Dermatology meeting, Dr. Mathes discussed a randomized controlled trial that took place in 2014 in both the United States and the United Kingdom to assess skin barrier enhancement to reduce the incidence of atopic dermatitis (AD) in 124 high-risk infants.¹ The high-risk infants had either a parent or sibling with physician-diagnosed AD, asthma, or rhinitis, or a first-degree relative with an aforementioned condition. Full-body emollient therapy was applied at least once daily within 3 weeks of birth for 6 months, while the control arm did not use emollient. Parents were allowed to choose from the following emollients: sunflower seed oil, moisturizing cream, or ointment. The primary outcome was the incidence of AD at 6 months. The authors found a 43% incidence of AD in the control group compared to 22% in the emollient group, amounting to a relative risk reduction of approximately 50%.¹

Emollients in AD are hypothesized to help through the enhanced barrier function and decreased penetration of irritant substances and allergens. This study is vital given the ease of use of emollients and the foreseeable substantial impact on reduced health care costs associated with the decreased incidence of AD.

Take-Home Point
Full-body emollient therapy within 3 weeks of birth may reduce the incidence of AD in high-risk infants.

Dr. Mathes also discussed the novel topical phosphodiesterase 4 inhibitor crisaborole and its emerging role in AD. She reviewed the results of a large phase 3 trial of crisaborole therapy for patients aged 2 years or older with mild to moderate AD.² Crisaborole ointment was applied twice daily for 28 days. The primary outcome measured was an investigator static global assessment score of clear or almost clear, which is a score for AD based on the degree of erythema, presence of oozing and crusting, and presence of induration or papulation. Overall, 32.8% of patients treated with crisaborole achieved success compared to 25.4% of vehicle-treated patients. The control patients were still given a vehicle to apply, which can function as therapy to help repair the barrier of AD and thus theoretically reduced the percentage gap between patients who met success with and without crisaborole therapy. Furthermore, only 4% of patients reported adverse effects such as burning and stinging with application of crisaborole in contrast to topical calcineurin inhibitors, which can elicit symptoms up to 50% of the time.² In summary, this lecture reviewed the first new topical treatment for AD in 15 years.

Take-Home Point
Crisaborole ointment is a novel topical phosphodiesterase 4 inhibitor approved for mild to moderate AD in patients 2 years of age and older.

“The Truth About Pediatric Contact Dermatitis” by Sharon Jacob, MD (Loma Linda University, California)

In this session, Dr. Jacob discussed how she approaches pediatric patients with suspected contact dermatitis and elaborated on the common allergens unique to this patient population. Furthermore, she explained the substantial role of nickel in pediatric contact dermatitis, citing a study performed in Denmark and the United States, which tested 212 toys for nickel using the dimethylglyoxime test and found that 34.4% of toys did in fact release nickel.³ Additional studies have shown that nickel released from children’s toys is deposited on the skin, even with short contact times such as 30 minutes on one or more occasions within 2 weeks.^3,4 She is currently evaluating the presence of nickel in locales frequented by children such as schools, libraries, and supermarkets. Interestingly, she anecdotally found that a pediatric eczematous eruption in a spiralized distribution of the legs can be attributed to the presence of nickel in school chairs, and the morphology is secondary to children wrapping their legs around the chairs. In conclusion, she reiterated that nickel continues to be the top allergen among pediatric patients, and states that additional allergens for patch testing in this population are unique to their adult counterparts.

Take-Home Point
Nickel is an ubiquitous allergen for pediatric contact dermatitis; additionally, the list of allergens for patch testing should be tailored to this patient population.

“When to Image, When to Sedate” by Annette Wagner, MD (Northwestern Medicine, Chicago, Illinois)

This lecture was a 3-part discussion on the safety of general anesthesia in children, when to image children, and when sedation may be worth the risk. Dr. Wagner shared her pearls for when children younger than 3 years may benefit from dermatologic procedures that involve general anesthesia. Large congenital lesions of the scalp or face that require tissue expansion or multiple stages may be best performed at a younger age due to the flexibility of the infant scalp, providing the best outcome. Additional considerations include a questionable malignant diagnosis in which a punch biopsy is not enough, rapidly growing facial lesions, Spitz nevi of the face, congenital lesions with no available therapy, and nonhealing refractory lesions causing severe pain. The general rule proposed was intervention for single procedures lasting less than 1 hour that otherwise would result in a worse outcome if postponed. Finally, she concluded to always advocate for your patient, to wait if the outcome will be the same regardless of timing, and to be frank about not knowing the risks of general anesthesia in this population. The resource, SmartTots (http://smarttots.org) provides current consensus statements and ongoing research on the use and safety of general anesthesia in children.

Take-Home Point
General sedation may be considered for short pediatric procedures that will result in a worse outcome if postponed.

“Highlights From the Pediatric Literature” by Katherine Marks, DO (Geisinger, Danville and Wilkes-Barre, Pennsylvania)

Dr. Marks discussed numerous emerging pediatric dermatology articles. One article looked at 40 infants with proliferating infantile hemangiomas (IHs) who had timolol gel 0.5% applied twice daily.⁵ The primary outcomes were the urinary excretion and serum levels of timolol as well as the clinical response to therapy measured by a visual analog scale at monthly visits. A urinalysis collected 3 to 4 hours after timolol application was found to be positive in 83% (20/24) of the tested patients; the first 3 positive infants were then sent to have their serum timolol levels drawn and also were found to be positive, though substantially small levels (median, 0.16 ng/mL). The 3 patients tested had small IHs on the face with no ulceration. None of these patients experienced adverse effects and all of the IHs significantly (P<.001) improved with therapy. The authors stated that even though the absorption was minimal, it is wise to be cognizant about the use of timolol in certain patient demographics such as preterm or young infants with large ulcerating IHs.⁵

Take-Home Point
Systemic absorption with topical timolol occurs, albeit substantially small; be judicious about giving this medication in select patient populations with ulcerated hemangiomas.

Acknowledgment
The author thanks the presenters for their review and contributions to this article.

This article exhibits key pediatric dermatology pearls garnered at the 2017 Annual Meeting of the American Academy of Dermatology (AAD) in Orlando, Florida (March 3–7, 2017). Highlights from both the Society for Pediatric Dermatology pre-AAD meeting (March 2, 2017) and the AAD general meeting sessions are included. This discussion is intended to help maximize care of our pediatric patients in dermatology and present high-yield take-home points from the AAD that can be readily transferred to our patient care.

“New Tools for Your Therapeutic Toolbox” by Erin Mathes, MD (University of California, San Francisco)

During this lecture at the Society for Pediatric Dermatology meeting, Dr. Mathes discussed a randomized controlled trial that took place in 2014 in both the United States and the United Kingdom to assess skin barrier enhancement to reduce the incidence of atopic dermatitis (AD) in 124 high-risk infants.¹ The high-risk infants had either a parent or sibling with physician-diagnosed AD, asthma, or rhinitis, or a first-degree relative with an aforementioned condition. Full-body emollient therapy was applied at least once daily within 3 weeks of birth for 6 months, while the control arm did not use emollient. Parents were allowed to choose from the following emollients: sunflower seed oil, moisturizing cream, or ointment. The primary outcome was the incidence of AD at 6 months. The authors found a 43% incidence of AD in the control group compared to 22% in the emollient group, amounting to a relative risk reduction of approximately 50%.¹

Emollients in AD are hypothesized to help through the enhanced barrier function and decreased penetration of irritant substances and allergens. This study is vital given the ease of use of emollients and the foreseeable substantial impact on reduced health care costs associated with the decreased incidence of AD.

Take-Home Point
Full-body emollient therapy within 3 weeks of birth may reduce the incidence of AD in high-risk infants.

Dr. Mathes also discussed the novel topical phosphodiesterase 4 inhibitor crisaborole and its emerging role in AD. She reviewed the results of a large phase 3 trial of crisaborole therapy for patients aged 2 years or older with mild to moderate AD.² Crisaborole ointment was applied twice daily for 28 days. The primary outcome measured was an investigator static global assessment score of clear or almost clear, which is a score for AD based on the degree of erythema, presence of oozing and crusting, and presence of induration or papulation. Overall, 32.8% of patients treated with crisaborole achieved success compared to 25.4% of vehicle-treated patients. The control patients were still given a vehicle to apply, which can function as therapy to help repair the barrier of AD and thus theoretically reduced the percentage gap between patients who met success with and without crisaborole therapy. Furthermore, only 4% of patients reported adverse effects such as burning and stinging with application of crisaborole in contrast to topical calcineurin inhibitors, which can elicit symptoms up to 50% of the time.² In summary, this lecture reviewed the first new topical treatment for AD in 15 years.

Take-Home Point
Crisaborole ointment is a novel topical phosphodiesterase 4 inhibitor approved for mild to moderate AD in patients 2 years of age and older.

“The Truth About Pediatric Contact Dermatitis” by Sharon Jacob, MD (Loma Linda University, California)

In this session, Dr. Jacob discussed how she approaches pediatric patients with suspected contact dermatitis and elaborated on the common allergens unique to this patient population. Furthermore, she explained the substantial role of nickel in pediatric contact dermatitis, citing a study performed in Denmark and the United States, which tested 212 toys for nickel using the dimethylglyoxime test and found that 34.4% of toys did in fact release nickel.³ Additional studies have shown that nickel released from children’s toys is deposited on the skin, even with short contact times such as 30 minutes on one or more occasions within 2 weeks.^3,4 She is currently evaluating the presence of nickel in locales frequented by children such as schools, libraries, and supermarkets. Interestingly, she anecdotally found that a pediatric eczematous eruption in a spiralized distribution of the legs can be attributed to the presence of nickel in school chairs, and the morphology is secondary to children wrapping their legs around the chairs. In conclusion, she reiterated that nickel continues to be the top allergen among pediatric patients, and states that additional allergens for patch testing in this population are unique to their adult counterparts.

Take-Home Point
Nickel is an ubiquitous allergen for pediatric contact dermatitis; additionally, the list of allergens for patch testing should be tailored to this patient population.

“When to Image, When to Sedate” by Annette Wagner, MD (Northwestern Medicine, Chicago, Illinois)

This lecture was a 3-part discussion on the safety of general anesthesia in children, when to image children, and when sedation may be worth the risk. Dr. Wagner shared her pearls for when children younger than 3 years may benefit from dermatologic procedures that involve general anesthesia. Large congenital lesions of the scalp or face that require tissue expansion or multiple stages may be best performed at a younger age due to the flexibility of the infant scalp, providing the best outcome. Additional considerations include a questionable malignant diagnosis in which a punch biopsy is not enough, rapidly growing facial lesions, Spitz nevi of the face, congenital lesions with no available therapy, and nonhealing refractory lesions causing severe pain. The general rule proposed was intervention for single procedures lasting less than 1 hour that otherwise would result in a worse outcome if postponed. Finally, she concluded to always advocate for your patient, to wait if the outcome will be the same regardless of timing, and to be frank about not knowing the risks of general anesthesia in this population. The resource, SmartTots (http://smarttots.org) provides current consensus statements and ongoing research on the use and safety of general anesthesia in children.

Take-Home Point
General sedation may be considered for short pediatric procedures that will result in a worse outcome if postponed.

“Highlights From the Pediatric Literature” by Katherine Marks, DO (Geisinger, Danville and Wilkes-Barre, Pennsylvania)

Dr. Marks discussed numerous emerging pediatric dermatology articles. One article looked at 40 infants with proliferating infantile hemangiomas (IHs) who had timolol gel 0.5% applied twice daily.⁵ The primary outcomes were the urinary excretion and serum levels of timolol as well as the clinical response to therapy measured by a visual analog scale at monthly visits. A urinalysis collected 3 to 4 hours after timolol application was found to be positive in 83% (20/24) of the tested patients; the first 3 positive infants were then sent to have their serum timolol levels drawn and also were found to be positive, though substantially small levels (median, 0.16 ng/mL). The 3 patients tested had small IHs on the face with no ulceration. None of these patients experienced adverse effects and all of the IHs significantly (P<.001) improved with therapy. The authors stated that even though the absorption was minimal, it is wise to be cognizant about the use of timolol in certain patient demographics such as preterm or young infants with large ulcerating IHs.⁵

Take-Home Point
Systemic absorption with topical timolol occurs, albeit substantially small; be judicious about giving this medication in select patient populations with ulcerated hemangiomas.

Acknowledgment
The author thanks the presenters for their review and contributions to this article.

This article exhibits key pediatric dermatology pearls garnered at the 2017 Annual Meeting of the American Academy of Dermatology (AAD) in Orlando, Florida (March 3–7, 2017). Highlights from both the Society for Pediatric Dermatology pre-AAD meeting (March 2, 2017) and the AAD general meeting sessions are included. This discussion is intended to help maximize care of our pediatric patients in dermatology and present high-yield take-home points from the AAD that can be readily transferred to our patient care.

“New Tools for Your Therapeutic Toolbox” by Erin Mathes, MD (University of California, San Francisco)

During this lecture at the Society for Pediatric Dermatology meeting, Dr. Mathes discussed a randomized controlled trial that took place in 2014 in both the United States and the United Kingdom to assess skin barrier enhancement to reduce the incidence of atopic dermatitis (AD) in 124 high-risk infants.¹ The high-risk infants had either a parent or sibling with physician-diagnosed AD, asthma, or rhinitis, or a first-degree relative with an aforementioned condition. Full-body emollient therapy was applied at least once daily within 3 weeks of birth for 6 months, while the control arm did not use emollient. Parents were allowed to choose from the following emollients: sunflower seed oil, moisturizing cream, or ointment. The primary outcome was the incidence of AD at 6 months. The authors found a 43% incidence of AD in the control group compared to 22% in the emollient group, amounting to a relative risk reduction of approximately 50%.¹

Emollients in AD are hypothesized to help through the enhanced barrier function and decreased penetration of irritant substances and allergens. This study is vital given the ease of use of emollients and the foreseeable substantial impact on reduced health care costs associated with the decreased incidence of AD.

Take-Home Point
Full-body emollient therapy within 3 weeks of birth may reduce the incidence of AD in high-risk infants.

Dr. Mathes also discussed the novel topical phosphodiesterase 4 inhibitor crisaborole and its emerging role in AD. She reviewed the results of a large phase 3 trial of crisaborole therapy for patients aged 2 years or older with mild to moderate AD.² Crisaborole ointment was applied twice daily for 28 days. The primary outcome measured was an investigator static global assessment score of clear or almost clear, which is a score for AD based on the degree of erythema, presence of oozing and crusting, and presence of induration or papulation. Overall, 32.8% of patients treated with crisaborole achieved success compared to 25.4% of vehicle-treated patients. The control patients were still given a vehicle to apply, which can function as therapy to help repair the barrier of AD and thus theoretically reduced the percentage gap between patients who met success with and without crisaborole therapy. Furthermore, only 4% of patients reported adverse effects such as burning and stinging with application of crisaborole in contrast to topical calcineurin inhibitors, which can elicit symptoms up to 50% of the time.² In summary, this lecture reviewed the first new topical treatment for AD in 15 years.

Take-Home Point
Crisaborole ointment is a novel topical phosphodiesterase 4 inhibitor approved for mild to moderate AD in patients 2 years of age and older.

“The Truth About Pediatric Contact Dermatitis” by Sharon Jacob, MD (Loma Linda University, California)

In this session, Dr. Jacob discussed how she approaches pediatric patients with suspected contact dermatitis and elaborated on the common allergens unique to this patient population. Furthermore, she explained the substantial role of nickel in pediatric contact dermatitis, citing a study performed in Denmark and the United States, which tested 212 toys for nickel using the dimethylglyoxime test and found that 34.4% of toys did in fact release nickel.³ Additional studies have shown that nickel released from children’s toys is deposited on the skin, even with short contact times such as 30 minutes on one or more occasions within 2 weeks.^3,4 She is currently evaluating the presence of nickel in locales frequented by children such as schools, libraries, and supermarkets. Interestingly, she anecdotally found that a pediatric eczematous eruption in a spiralized distribution of the legs can be attributed to the presence of nickel in school chairs, and the morphology is secondary to children wrapping their legs around the chairs. In conclusion, she reiterated that nickel continues to be the top allergen among pediatric patients, and states that additional allergens for patch testing in this population are unique to their adult counterparts.

Take-Home Point
Nickel is an ubiquitous allergen for pediatric contact dermatitis; additionally, the list of allergens for patch testing should be tailored to this patient population.

“When to Image, When to Sedate” by Annette Wagner, MD (Northwestern Medicine, Chicago, Illinois)

This lecture was a 3-part discussion on the safety of general anesthesia in children, when to image children, and when sedation may be worth the risk. Dr. Wagner shared her pearls for when children younger than 3 years may benefit from dermatologic procedures that involve general anesthesia. Large congenital lesions of the scalp or face that require tissue expansion or multiple stages may be best performed at a younger age due to the flexibility of the infant scalp, providing the best outcome. Additional considerations include a questionable malignant diagnosis in which a punch biopsy is not enough, rapidly growing facial lesions, Spitz nevi of the face, congenital lesions with no available therapy, and nonhealing refractory lesions causing severe pain. The general rule proposed was intervention for single procedures lasting less than 1 hour that otherwise would result in a worse outcome if postponed. Finally, she concluded to always advocate for your patient, to wait if the outcome will be the same regardless of timing, and to be frank about not knowing the risks of general anesthesia in this population. The resource, SmartTots (http://smarttots.org) provides current consensus statements and ongoing research on the use and safety of general anesthesia in children.

Take-Home Point
General sedation may be considered for short pediatric procedures that will result in a worse outcome if postponed.

“Highlights From the Pediatric Literature” by Katherine Marks, DO (Geisinger, Danville and Wilkes-Barre, Pennsylvania)

Dr. Marks discussed numerous emerging pediatric dermatology articles. One article looked at 40 infants with proliferating infantile hemangiomas (IHs) who had timolol gel 0.5% applied twice daily.⁵ The primary outcomes were the urinary excretion and serum levels of timolol as well as the clinical response to therapy measured by a visual analog scale at monthly visits. A urinalysis collected 3 to 4 hours after timolol application was found to be positive in 83% (20/24) of the tested patients; the first 3 positive infants were then sent to have their serum timolol levels drawn and also were found to be positive, though substantially small levels (median, 0.16 ng/mL). The 3 patients tested had small IHs on the face with no ulceration. None of these patients experienced adverse effects and all of the IHs significantly (P<.001) improved with therapy. The authors stated that even though the absorption was minimal, it is wise to be cognizant about the use of timolol in certain patient demographics such as preterm or young infants with large ulcerating IHs.⁵

Take-Home Point
Systemic absorption with topical timolol occurs, albeit substantially small; be judicious about giving this medication in select patient populations with ulcerated hemangiomas.

Acknowledgment
The author thanks the presenters for their review and contributions to this article.

As psychiatrists, we do not often encounter situations in which we need to inform patients and their families that they have a life-threatening diagnosis. Nonetheless, on the rare occasions when we work with such patients, new psychiatrists may find their clinical skills challenged. Breaking bad news remains an aspect of clinical training that is often overlooked by medical schools.

Here I present a case that illustrates the challenges residents and medical students face when they need to deliver bad news and review the current literature on how to present patients with this type of information.

Case
Bizarre behavior, difficult diagnosis

Mr. C, age 59, with a 1-year history of major depressive disorder, was brought to the emergency department by his wife for worsening depression and disorganized behavior over the course of 3 weeks. Mr. C had obsessive thoughts about arranging things in symmetrical patterns, difficulty sleeping, loss of appetite, and anhedonia. His wife reported that his bizarre, disorganized behavior further intensified in the previous week; he was urinating on the rug, rubbing his genitals against the bathroom counter, staring into space without moving for prolonged periods of time, and arranging his food in symmetrical patterns. Mr. C has no reported substance use or suicidal or homicidal ideation.

Strategies for delivering bad news

Initially, I struggled when I realized I would have to deliver the news of this potentially life-threatening diagnosis to the patient and his wife because I had not received any training on how to do so. However, I took time to look into the literature and used the skills that we as psychiatrists have, including empathy, listening, and validation. My experience with Mr. C and his family made me realize that delivering bad news with empathy and being involved in the struggle that follows can make a significant difference to their suffering.

There are various models and techniques for breaking bad news to patients. Two of the most commonly used models in the oncology setting are the SPIKES (Set up, Perception, Interview, Knowledge, Emotions, Strategize and Summarize) model (Table 1²) and Kaye’s model (Table 2³).

• Choose a setting with adequate privacy, use simple language that distills medical facts into appreciable pieces of information, and give the recipients ample space and time to process the implications. Doing so will foster better understanding and facilitate their acceptance of the bad news.
• Although physicians can rarely appreciate the patient’s feelings at a personal level, make every effort to validate their thoughts and offer emotional support. In such situations, it is often appropriate to move closer to the recipient and make brief physical gestures, such as laying a hand on the shoulder, which might comfort them.
• In the aftermath of such encounters, it is important to remain active in the patient’s emotional journey and available for further clarification, which can mitigate uncertainties and facilitate the difficult process of coming to terms with new realities.^4,5

As psychiatrists, we do not often encounter situations in which we need to inform patients and their families that they have a life-threatening diagnosis. Nonetheless, on the rare occasions when we work with such patients, new psychiatrists may find their clinical skills challenged. Breaking bad news remains an aspect of clinical training that is often overlooked by medical schools.

Here I present a case that illustrates the challenges residents and medical students face when they need to deliver bad news and review the current literature on how to present patients with this type of information.

Case
Bizarre behavior, difficult diagnosis

Mr. C, age 59, with a 1-year history of major depressive disorder, was brought to the emergency department by his wife for worsening depression and disorganized behavior over the course of 3 weeks. Mr. C had obsessive thoughts about arranging things in symmetrical patterns, difficulty sleeping, loss of appetite, and anhedonia. His wife reported that his bizarre, disorganized behavior further intensified in the previous week; he was urinating on the rug, rubbing his genitals against the bathroom counter, staring into space without moving for prolonged periods of time, and arranging his food in symmetrical patterns. Mr. C has no reported substance use or suicidal or homicidal ideation.

Strategies for delivering bad news

Initially, I struggled when I realized I would have to deliver the news of this potentially life-threatening diagnosis to the patient and his wife because I had not received any training on how to do so. However, I took time to look into the literature and used the skills that we as psychiatrists have, including empathy, listening, and validation. My experience with Mr. C and his family made me realize that delivering bad news with empathy and being involved in the struggle that follows can make a significant difference to their suffering.

There are various models and techniques for breaking bad news to patients. Two of the most commonly used models in the oncology setting are the SPIKES (Set up, Perception, Interview, Knowledge, Emotions, Strategize and Summarize) model (Table 1²) and Kaye’s model (Table 2³).

• Choose a setting with adequate privacy, use simple language that distills medical facts into appreciable pieces of information, and give the recipients ample space and time to process the implications. Doing so will foster better understanding and facilitate their acceptance of the bad news.
• Although physicians can rarely appreciate the patient’s feelings at a personal level, make every effort to validate their thoughts and offer emotional support. In such situations, it is often appropriate to move closer to the recipient and make brief physical gestures, such as laying a hand on the shoulder, which might comfort them.
• In the aftermath of such encounters, it is important to remain active in the patient’s emotional journey and available for further clarification, which can mitigate uncertainties and facilitate the difficult process of coming to terms with new realities.^4,5

As psychiatrists, we do not often encounter situations in which we need to inform patients and their families that they have a life-threatening diagnosis. Nonetheless, on the rare occasions when we work with such patients, new psychiatrists may find their clinical skills challenged. Breaking bad news remains an aspect of clinical training that is often overlooked by medical schools.

Here I present a case that illustrates the challenges residents and medical students face when they need to deliver bad news and review the current literature on how to present patients with this type of information.

Case
Bizarre behavior, difficult diagnosis

Mr. C, age 59, with a 1-year history of major depressive disorder, was brought to the emergency department by his wife for worsening depression and disorganized behavior over the course of 3 weeks. Mr. C had obsessive thoughts about arranging things in symmetrical patterns, difficulty sleeping, loss of appetite, and anhedonia. His wife reported that his bizarre, disorganized behavior further intensified in the previous week; he was urinating on the rug, rubbing his genitals against the bathroom counter, staring into space without moving for prolonged periods of time, and arranging his food in symmetrical patterns. Mr. C has no reported substance use or suicidal or homicidal ideation.

Strategies for delivering bad news

Initially, I struggled when I realized I would have to deliver the news of this potentially life-threatening diagnosis to the patient and his wife because I had not received any training on how to do so. However, I took time to look into the literature and used the skills that we as psychiatrists have, including empathy, listening, and validation. My experience with Mr. C and his family made me realize that delivering bad news with empathy and being involved in the struggle that follows can make a significant difference to their suffering.

There are various models and techniques for breaking bad news to patients. Two of the most commonly used models in the oncology setting are the SPIKES (Set up, Perception, Interview, Knowledge, Emotions, Strategize and Summarize) model (Table 1²) and Kaye’s model (Table 2³).

• Choose a setting with adequate privacy, use simple language that distills medical facts into appreciable pieces of information, and give the recipients ample space and time to process the implications. Doing so will foster better understanding and facilitate their acceptance of the bad news.
• Although physicians can rarely appreciate the patient’s feelings at a personal level, make every effort to validate their thoughts and offer emotional support. In such situations, it is often appropriate to move closer to the recipient and make brief physical gestures, such as laying a hand on the shoulder, which might comfort them.
• In the aftermath of such encounters, it is important to remain active in the patient’s emotional journey and available for further clarification, which can mitigate uncertainties and facilitate the difficult process of coming to terms with new realities.^4,5

Timolol is a nonselective β-adrenergic receptor antagonist indicated for treating glaucoma, heart attacks, hypertension, and migraine headaches. It is made in both an oral and ophthalmic form. In dermatology, the beta-blocker propranolol is approved for the treatment of infantile hemangiomas (IHs). The exact mechanism of action of beta-blockers for the treatment of IHs is not yet completely understood, but it is postulated that they inhibit growth by at least 4 distinct mechanisms: (1) vasoconstriction, (2) inhibition of angiogenesis or vasculogenesis, (3) induction of apoptosis, and (4) recruitment of endothelial progenitor cells to the site of the hemangioma.¹

Scar cosmesis can be calculated using the visual analog scale (VAS), which is a subjective scar assessment scored from poor to excellent. The multidimensional VAS is a photograph-based scale derived from evaluating standardized digital photographs in 4 dimensions—pigmentation, vascularity, acceptability, and observer comfort—plus contour. It uses the sum of the individual scores to obtain a single overall score ranging from excellent to poor.² In this study, we sought to determine if the use of topical timolol after excision or Mohs micrographic surgery (MMS) treatment of nonmelanoma skin cancers improved the overall cosmesis of the scar.

Methods

The study protocol was approved by the institutional review board at Roger Williams Medical Center (Providence, Rhode Island). Eligibility criteria included patients who required excision or MMS for their nonmelanoma skin cancer located below the patella and those who agreed to allow their wounds to heal by secondary intention when given options for closure of their wounds. Patients were randomized to either the timolol (study medication) group or the saline (placebo) group. The initial defects were measured and photographed. Patients were educated on how to apply the study medication. All patients were prescribed 40 mm Hg compression stockings to wear following application of the study medication. Patients were asked to return at 1 and 5 weeks postsurgery and then every 1 to 2 weeks for wound assessment and measurement until their wounds had healed or at 13 weeks, depending on which came first. A healed wound was defined as having no exudate, exhibiting complete reepithelialization, and being stable for 1 week.

Healed wounds were assessed by a blinded outside dermatologist who examined photographs of the wounds and then completed the VAS for each participant’s scar.

Results

A total of 9 participants were enrolled in the study. Three participants were lost to follow-up; 6 completed the study (4 females, 2 males). The mean age was 70 years (age range, 46–89 years). The average wound size was 2×2 cm with a depth of 1 mm. Three participants were in the active medication group and 3 were in the control group.

A VAS was completed for each participant’s scar by an outside blinded dermatologist. Based on the VAS, wounds treated with timolol resulted in more cosmetically favorable scars (scored higher on the VAS) compared to control (mean [SD]: 6.5±0.9 vs 2.5±0.7; P<0.05). See Figures 1 and 2 for representative results.

Comment

Dermatologists create acute wounds in patients on a daily basis. Ensuring that patients achieve the most desirable cosmetic outcome is a primary goal for dermatologists and an important component of patient satisfaction. A number of studies have examined patient satisfaction following MMS.^3,4 Patient satisfaction is an especially important outcome measure in dermatology, as dermatologic diseases affect cosmetic appearance and are related to quality of life.^3,4

Timolol is a nonselective β-adrenergic receptor antagonist that is used in dermatology to treat IHs. In this preliminary study, the authors sought to determine if topical timolol applied to acute wounds following surgical removal of nonmelanoma skin cancers could improve the overall cosmetic outcome of acute surgical scars. The results showed that compared to control, topical timolol resulted in a more cosmetically favorable scar. The results are preliminary, and it would be of future interest to further study the effects of topical timolol on acute surgical wounds from a wound-healing standpoint as well as to further test its effects on the cosmesis of these wounds.

Timolol is a nonselective β-adrenergic receptor antagonist indicated for treating glaucoma, heart attacks, hypertension, and migraine headaches. It is made in both an oral and ophthalmic form. In dermatology, the beta-blocker propranolol is approved for the treatment of infantile hemangiomas (IHs). The exact mechanism of action of beta-blockers for the treatment of IHs is not yet completely understood, but it is postulated that they inhibit growth by at least 4 distinct mechanisms: (1) vasoconstriction, (2) inhibition of angiogenesis or vasculogenesis, (3) induction of apoptosis, and (4) recruitment of endothelial progenitor cells to the site of the hemangioma.¹

Scar cosmesis can be calculated using the visual analog scale (VAS), which is a subjective scar assessment scored from poor to excellent. The multidimensional VAS is a photograph-based scale derived from evaluating standardized digital photographs in 4 dimensions—pigmentation, vascularity, acceptability, and observer comfort—plus contour. It uses the sum of the individual scores to obtain a single overall score ranging from excellent to poor.² In this study, we sought to determine if the use of topical timolol after excision or Mohs micrographic surgery (MMS) treatment of nonmelanoma skin cancers improved the overall cosmesis of the scar.

Methods

The study protocol was approved by the institutional review board at Roger Williams Medical Center (Providence, Rhode Island). Eligibility criteria included patients who required excision or MMS for their nonmelanoma skin cancer located below the patella and those who agreed to allow their wounds to heal by secondary intention when given options for closure of their wounds. Patients were randomized to either the timolol (study medication) group or the saline (placebo) group. The initial defects were measured and photographed. Patients were educated on how to apply the study medication. All patients were prescribed 40 mm Hg compression stockings to wear following application of the study medication. Patients were asked to return at 1 and 5 weeks postsurgery and then every 1 to 2 weeks for wound assessment and measurement until their wounds had healed or at 13 weeks, depending on which came first. A healed wound was defined as having no exudate, exhibiting complete reepithelialization, and being stable for 1 week.

Healed wounds were assessed by a blinded outside dermatologist who examined photographs of the wounds and then completed the VAS for each participant’s scar.

Results

A total of 9 participants were enrolled in the study. Three participants were lost to follow-up; 6 completed the study (4 females, 2 males). The mean age was 70 years (age range, 46–89 years). The average wound size was 2×2 cm with a depth of 1 mm. Three participants were in the active medication group and 3 were in the control group.

A VAS was completed for each participant’s scar by an outside blinded dermatologist. Based on the VAS, wounds treated with timolol resulted in more cosmetically favorable scars (scored higher on the VAS) compared to control (mean [SD]: 6.5±0.9 vs 2.5±0.7; P<0.05). See Figures 1 and 2 for representative results.

Comment

Dermatologists create acute wounds in patients on a daily basis. Ensuring that patients achieve the most desirable cosmetic outcome is a primary goal for dermatologists and an important component of patient satisfaction. A number of studies have examined patient satisfaction following MMS.^3,4 Patient satisfaction is an especially important outcome measure in dermatology, as dermatologic diseases affect cosmetic appearance and are related to quality of life.^3,4

Timolol is a nonselective β-adrenergic receptor antagonist that is used in dermatology to treat IHs. In this preliminary study, the authors sought to determine if topical timolol applied to acute wounds following surgical removal of nonmelanoma skin cancers could improve the overall cosmetic outcome of acute surgical scars. The results showed that compared to control, topical timolol resulted in a more cosmetically favorable scar. The results are preliminary, and it would be of future interest to further study the effects of topical timolol on acute surgical wounds from a wound-healing standpoint as well as to further test its effects on the cosmesis of these wounds.

Timolol is a nonselective β-adrenergic receptor antagonist indicated for treating glaucoma, heart attacks, hypertension, and migraine headaches. It is made in both an oral and ophthalmic form. In dermatology, the beta-blocker propranolol is approved for the treatment of infantile hemangiomas (IHs). The exact mechanism of action of beta-blockers for the treatment of IHs is not yet completely understood, but it is postulated that they inhibit growth by at least 4 distinct mechanisms: (1) vasoconstriction, (2) inhibition of angiogenesis or vasculogenesis, (3) induction of apoptosis, and (4) recruitment of endothelial progenitor cells to the site of the hemangioma.¹

Scar cosmesis can be calculated using the visual analog scale (VAS), which is a subjective scar assessment scored from poor to excellent. The multidimensional VAS is a photograph-based scale derived from evaluating standardized digital photographs in 4 dimensions—pigmentation, vascularity, acceptability, and observer comfort—plus contour. It uses the sum of the individual scores to obtain a single overall score ranging from excellent to poor.² In this study, we sought to determine if the use of topical timolol after excision or Mohs micrographic surgery (MMS) treatment of nonmelanoma skin cancers improved the overall cosmesis of the scar.

Methods

The study protocol was approved by the institutional review board at Roger Williams Medical Center (Providence, Rhode Island). Eligibility criteria included patients who required excision or MMS for their nonmelanoma skin cancer located below the patella and those who agreed to allow their wounds to heal by secondary intention when given options for closure of their wounds. Patients were randomized to either the timolol (study medication) group or the saline (placebo) group. The initial defects were measured and photographed. Patients were educated on how to apply the study medication. All patients were prescribed 40 mm Hg compression stockings to wear following application of the study medication. Patients were asked to return at 1 and 5 weeks postsurgery and then every 1 to 2 weeks for wound assessment and measurement until their wounds had healed or at 13 weeks, depending on which came first. A healed wound was defined as having no exudate, exhibiting complete reepithelialization, and being stable for 1 week.

Healed wounds were assessed by a blinded outside dermatologist who examined photographs of the wounds and then completed the VAS for each participant’s scar.

Results

A total of 9 participants were enrolled in the study. Three participants were lost to follow-up; 6 completed the study (4 females, 2 males). The mean age was 70 years (age range, 46–89 years). The average wound size was 2×2 cm with a depth of 1 mm. Three participants were in the active medication group and 3 were in the control group.

A VAS was completed for each participant’s scar by an outside blinded dermatologist. Based on the VAS, wounds treated with timolol resulted in more cosmetically favorable scars (scored higher on the VAS) compared to control (mean [SD]: 6.5±0.9 vs 2.5±0.7; P<0.05). See Figures 1 and 2 for representative results.

Comment

Dermatologists create acute wounds in patients on a daily basis. Ensuring that patients achieve the most desirable cosmetic outcome is a primary goal for dermatologists and an important component of patient satisfaction. A number of studies have examined patient satisfaction following MMS.^3,4 Patient satisfaction is an especially important outcome measure in dermatology, as dermatologic diseases affect cosmetic appearance and are related to quality of life.^3,4

Timolol is a nonselective β-adrenergic receptor antagonist that is used in dermatology to treat IHs. In this preliminary study, the authors sought to determine if topical timolol applied to acute wounds following surgical removal of nonmelanoma skin cancers could improve the overall cosmetic outcome of acute surgical scars. The results showed that compared to control, topical timolol resulted in a more cosmetically favorable scar. The results are preliminary, and it would be of future interest to further study the effects of topical timolol on acute surgical wounds from a wound-healing standpoint as well as to further test its effects on the cosmesis of these wounds.

App overload is a challenge for both providers and patients. As of September 2015, the number of health apps in the US Apple iTunes and Google Play stores exceeded 165,000, with approximately 7% focused on women's health and pregnancy.¹ Clinicians express interest in promoting the use of health apps with their patients and seek guidance about making app recommendations.² In my prior articles in this "App review" series, I have recommended due date calculator and drug reference apps.

One area in which an app may enhance your patient care is in menstrual cycle tracking. Patients may be more honest with their phones than with their health care professionals, and the results are more accurate than paper questionnaires and calendars.³ Of note, menstrual cycle tracking apps are the fourth most popular health app among adults and likely even more popular if limited to adult women.⁴

Dr. Paula Castano and her team systematically identified and evaluated free menstrual cycle tracking apps.⁵ The accuracy of each app was determined by menstrual cycle predictions based on average cycle lengths of at least 3 previous cycles, ovulation predicted at 13 to 15 days prior to the start of the next cycle, and qualification that the application contained no misinformation.⁵

The top 3 recommended menstrual cycle tracking apps from Dr. Castano and colleagues' study are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁶ I hope this column will allow you to feel more comfortable recommending these "vetted" apps to your patients.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

App overload is a challenge for both providers and patients. As of September 2015, the number of health apps in the US Apple iTunes and Google Play stores exceeded 165,000, with approximately 7% focused on women's health and pregnancy.¹ Clinicians express interest in promoting the use of health apps with their patients and seek guidance about making app recommendations.² In my prior articles in this "App review" series, I have recommended due date calculator and drug reference apps.

One area in which an app may enhance your patient care is in menstrual cycle tracking. Patients may be more honest with their phones than with their health care professionals, and the results are more accurate than paper questionnaires and calendars.³ Of note, menstrual cycle tracking apps are the fourth most popular health app among adults and likely even more popular if limited to adult women.⁴

Dr. Paula Castano and her team systematically identified and evaluated free menstrual cycle tracking apps.⁵ The accuracy of each app was determined by menstrual cycle predictions based on average cycle lengths of at least 3 previous cycles, ovulation predicted at 13 to 15 days prior to the start of the next cycle, and qualification that the application contained no misinformation.⁵

The top 3 recommended menstrual cycle tracking apps from Dr. Castano and colleagues' study are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁶ I hope this column will allow you to feel more comfortable recommending these "vetted" apps to your patients.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

App overload is a challenge for both providers and patients. As of September 2015, the number of health apps in the US Apple iTunes and Google Play stores exceeded 165,000, with approximately 7% focused on women's health and pregnancy.¹ Clinicians express interest in promoting the use of health apps with their patients and seek guidance about making app recommendations.² In my prior articles in this "App review" series, I have recommended due date calculator and drug reference apps.

One area in which an app may enhance your patient care is in menstrual cycle tracking. Patients may be more honest with their phones than with their health care professionals, and the results are more accurate than paper questionnaires and calendars.³ Of note, menstrual cycle tracking apps are the fourth most popular health app among adults and likely even more popular if limited to adult women.⁴

Dr. Paula Castano and her team systematically identified and evaluated free menstrual cycle tracking apps.⁵ The accuracy of each app was determined by menstrual cycle predictions based on average cycle lengths of at least 3 previous cycles, ovulation predicted at 13 to 15 days prior to the start of the next cycle, and qualification that the application contained no misinformation.⁵

The top 3 recommended menstrual cycle tracking apps from Dr. Castano and colleagues' study are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁶ I hope this column will allow you to feel more comfortable recommending these "vetted" apps to your patients.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

The term psychiatry is derived from the Greek words “pskhe” and “iatreia” which mean “healing of the soul.”¹ The desire to heal souls from different ethnicities, religions, and languages can be overwhelming for a trainee resident who is new to U.S. culture. The fear of having difficulty in building rapport with patients because of cultural bias and the dread of not understanding accents, slang, jokes, and nonverbal communication can be so frustrating that it overrides the intense desire of becoming an empathetic and successful physician.² During this critical period of training, residents need a training director who nudges them forward through the darkness and peels away the superficial and suffocating layers of incompetency that may keep them from reaching their full potential.

I started my residency training in 2014 without any substantial scholarly work in my background or clinical experience in the United States. However, I had a great learning experience at my training program and would like to express my gratitude by recognizing my program director’s (Panagiota Korenis, MD) role in helping me accomplish my career goals. She believed in me when I was not able to believe in myself, and helped me overcome a helpless feeling of isolation and desperation during my intern year. Because of her mentorship and supervision, I presented 20 posters and oral presentations; published 5 works; drafted guidelines for training residents, including course material on the health care disparities faced by the Lesbian, Gay Bisexual, Transgender, Queer community; created a tool to predict readmissions in an inpatient psychiatric setting; received many prestigious awards, including Resident of the Year, a Certificate of Academic Excellence, a Young Scholar Award, and an American Psychiatric Association Diversity Leadership Fellowship for 2017-2019; and was accepted for a child and adolescent psychiatry fellowship in one of my dream programs, Boston Children’s Hospital.

I strongly believe that the impact of an inspiring, motivating, and encouraging program director on a resident’s life is monumental. Here are some of the qualities I believe make a great program director who can significantly transform a trainee’s life:

A positive attitude.

• Encourage trainees to believe in their abilities, even if they stumble.
• Unleash and nurture their talents, and help them recognize their strengths and confidence.
• Foster a warm, welcoming, and supportive environment that enables residents to strive to reach their potential and goals.
• Boost confidence, acknowledge genuine efforts, and praise achievements.
• Encourage involvement in future projects.

Empathy and generosity.

• Treat residents with respect and care, while recognizing their strengths and weaknesses.
• Understand them at both a professional and personal level.
• Support meaningful and suitable projects that residents are passionate about and at which they excel.
• Influence residents by helping them understand the impact they have on patients and the program.
• Demonstrate sensitivity to the individual needs of each resident and provide constructive feedback.

Easy accessibility.

• Build good rapport with residents.
• Listen carefully to the residents’ ideas and feedback.
• Reassure residents that they can ask any questions or raise any issues they want to address.

Leadership.

• Color/BlackUndertake a leadership role within multidisciplinary teams, and collaborate effectively with other medical specialties for continuity of care, mutual support, Color/Blackand interdisciplinary education and communication.
• Assert authority when needed, and make important decisions for the program.
• Manage conflicts effectively and timely.
• Strictly monitor duty hours.³

Education.

• Design an educational curriculum relevant to all clinical settings.
• Provide protected time for didactics and scholarlyColor/Black activities.
• Ensure that residents develop a comprehensive understanding of the field.
• Actively involve residents in teaching, and modify the curriculum based on residents’ input and feedback.
• Schedule classes for in-service exams (eg, Psychiatry Residency In-Service Training Exam) and for the board exam preparation.⁴
• Promote residents’ autonomy and sense of competence.

Promote residents well-being.

• Encourage a work–life balance.
• Focus on team building and communication, and organize process groups.
• Adopt innovative ways to enable residents in managing stress.
• Organize social events and group activities, and provide support groups.
• Ensure adequate sleep hours and time away from work to prevent burnout.

Career development.

• Provide career guidance, and connect residents to appropriate resources for further professional development.
• Recognize that mentoring is a lifelong activity that does not end with the completion of residency training.

The term psychiatry is derived from the Greek words “pskhe” and “iatreia” which mean “healing of the soul.”¹ The desire to heal souls from different ethnicities, religions, and languages can be overwhelming for a trainee resident who is new to U.S. culture. The fear of having difficulty in building rapport with patients because of cultural bias and the dread of not understanding accents, slang, jokes, and nonverbal communication can be so frustrating that it overrides the intense desire of becoming an empathetic and successful physician.² During this critical period of training, residents need a training director who nudges them forward through the darkness and peels away the superficial and suffocating layers of incompetency that may keep them from reaching their full potential.

I started my residency training in 2014 without any substantial scholarly work in my background or clinical experience in the United States. However, I had a great learning experience at my training program and would like to express my gratitude by recognizing my program director’s (Panagiota Korenis, MD) role in helping me accomplish my career goals. She believed in me when I was not able to believe in myself, and helped me overcome a helpless feeling of isolation and desperation during my intern year. Because of her mentorship and supervision, I presented 20 posters and oral presentations; published 5 works; drafted guidelines for training residents, including course material on the health care disparities faced by the Lesbian, Gay Bisexual, Transgender, Queer community; created a tool to predict readmissions in an inpatient psychiatric setting; received many prestigious awards, including Resident of the Year, a Certificate of Academic Excellence, a Young Scholar Award, and an American Psychiatric Association Diversity Leadership Fellowship for 2017-2019; and was accepted for a child and adolescent psychiatry fellowship in one of my dream programs, Boston Children’s Hospital.

I strongly believe that the impact of an inspiring, motivating, and encouraging program director on a resident’s life is monumental. Here are some of the qualities I believe make a great program director who can significantly transform a trainee’s life:

A positive attitude.

• Encourage trainees to believe in their abilities, even if they stumble.
• Unleash and nurture their talents, and help them recognize their strengths and confidence.
• Foster a warm, welcoming, and supportive environment that enables residents to strive to reach their potential and goals.
• Boost confidence, acknowledge genuine efforts, and praise achievements.
• Encourage involvement in future projects.

Empathy and generosity.

• Treat residents with respect and care, while recognizing their strengths and weaknesses.
• Understand them at both a professional and personal level.
• Support meaningful and suitable projects that residents are passionate about and at which they excel.
• Influence residents by helping them understand the impact they have on patients and the program.
• Demonstrate sensitivity to the individual needs of each resident and provide constructive feedback.

Easy accessibility.

• Build good rapport with residents.
• Listen carefully to the residents’ ideas and feedback.
• Reassure residents that they can ask any questions or raise any issues they want to address.

Leadership.

• Color/BlackUndertake a leadership role within multidisciplinary teams, and collaborate effectively with other medical specialties for continuity of care, mutual support, Color/Blackand interdisciplinary education and communication.
• Assert authority when needed, and make important decisions for the program.
• Manage conflicts effectively and timely.
• Strictly monitor duty hours.³

Education.

• Design an educational curriculum relevant to all clinical settings.
• Provide protected time for didactics and scholarlyColor/Black activities.
• Ensure that residents develop a comprehensive understanding of the field.
• Actively involve residents in teaching, and modify the curriculum based on residents’ input and feedback.
• Schedule classes for in-service exams (eg, Psychiatry Residency In-Service Training Exam) and for the board exam preparation.⁴
• Promote residents’ autonomy and sense of competence.

Promote residents well-being.

• Encourage a work–life balance.
• Focus on team building and communication, and organize process groups.
• Adopt innovative ways to enable residents in managing stress.
• Organize social events and group activities, and provide support groups.
• Ensure adequate sleep hours and time away from work to prevent burnout.

Career development.

• Provide career guidance, and connect residents to appropriate resources for further professional development.
• Recognize that mentoring is a lifelong activity that does not end with the completion of residency training.

The term psychiatry is derived from the Greek words “pskhe” and “iatreia” which mean “healing of the soul.”¹ The desire to heal souls from different ethnicities, religions, and languages can be overwhelming for a trainee resident who is new to U.S. culture. The fear of having difficulty in building rapport with patients because of cultural bias and the dread of not understanding accents, slang, jokes, and nonverbal communication can be so frustrating that it overrides the intense desire of becoming an empathetic and successful physician.² During this critical period of training, residents need a training director who nudges them forward through the darkness and peels away the superficial and suffocating layers of incompetency that may keep them from reaching their full potential.

I started my residency training in 2014 without any substantial scholarly work in my background or clinical experience in the United States. However, I had a great learning experience at my training program and would like to express my gratitude by recognizing my program director’s (Panagiota Korenis, MD) role in helping me accomplish my career goals. She believed in me when I was not able to believe in myself, and helped me overcome a helpless feeling of isolation and desperation during my intern year. Because of her mentorship and supervision, I presented 20 posters and oral presentations; published 5 works; drafted guidelines for training residents, including course material on the health care disparities faced by the Lesbian, Gay Bisexual, Transgender, Queer community; created a tool to predict readmissions in an inpatient psychiatric setting; received many prestigious awards, including Resident of the Year, a Certificate of Academic Excellence, a Young Scholar Award, and an American Psychiatric Association Diversity Leadership Fellowship for 2017-2019; and was accepted for a child and adolescent psychiatry fellowship in one of my dream programs, Boston Children’s Hospital.

I strongly believe that the impact of an inspiring, motivating, and encouraging program director on a resident’s life is monumental. Here are some of the qualities I believe make a great program director who can significantly transform a trainee’s life:

A positive attitude.

• Encourage trainees to believe in their abilities, even if they stumble.
• Unleash and nurture their talents, and help them recognize their strengths and confidence.
• Foster a warm, welcoming, and supportive environment that enables residents to strive to reach their potential and goals.
• Boost confidence, acknowledge genuine efforts, and praise achievements.
• Encourage involvement in future projects.

Empathy and generosity.

• Treat residents with respect and care, while recognizing their strengths and weaknesses.
• Understand them at both a professional and personal level.
• Support meaningful and suitable projects that residents are passionate about and at which they excel.
• Influence residents by helping them understand the impact they have on patients and the program.
• Demonstrate sensitivity to the individual needs of each resident and provide constructive feedback.

Easy accessibility.

• Build good rapport with residents.
• Listen carefully to the residents’ ideas and feedback.
• Reassure residents that they can ask any questions or raise any issues they want to address.

Leadership.

• Color/BlackUndertake a leadership role within multidisciplinary teams, and collaborate effectively with other medical specialties for continuity of care, mutual support, Color/Blackand interdisciplinary education and communication.
• Assert authority when needed, and make important decisions for the program.
• Manage conflicts effectively and timely.
• Strictly monitor duty hours.³

Education.

• Design an educational curriculum relevant to all clinical settings.
• Provide protected time for didactics and scholarlyColor/Black activities.
• Ensure that residents develop a comprehensive understanding of the field.
• Actively involve residents in teaching, and modify the curriculum based on residents’ input and feedback.
• Schedule classes for in-service exams (eg, Psychiatry Residency In-Service Training Exam) and for the board exam preparation.⁴
• Promote residents’ autonomy and sense of competence.

Promote residents well-being.

• Encourage a work–life balance.
• Focus on team building and communication, and organize process groups.
• Adopt innovative ways to enable residents in managing stress.
• Organize social events and group activities, and provide support groups.
• Ensure adequate sleep hours and time away from work to prevent burnout.

Career development.

• Provide career guidance, and connect residents to appropriate resources for further professional development.
• Recognize that mentoring is a lifelong activity that does not end with the completion of residency training.

UV radiation from sun exposure is a risk factor for most types of skin cancer.¹ Despite comprising only 1% of the body's surface area, the periocular region is the location of approximately 5% to 10% of skin cancers described in one US study.² The efficacy of sunscreen in preventing skin cancer is widely accepted, and the American Academy of Dermatology recommends application of broad-spectrum UVA/UVB sunscreen with a sun protection factor of 30 or higher to help prevent skin cancer.^3-5

RELATED ARTICLE: Sun Protection for Infants: Parent Behaviors and Beliefs

Reducing the risk of skin cancer from sun exposure relies on many factors, including completeness of application. A number of studies have demonstrated incomplete sunscreen application on the hairline, ears, neck, and dorsal feet.^6-8 The purpose of this study was to assess the completeness of facial sunscreen self-application in oculofacial surgery patients using UV photography.

Methods

This single-site, cross-sectional, qualitative study assessed the completeness of facial sunscreen self-application among patients from a single surgeon's (J.A.W.) cosmetic and tertiary-care oculofacial surgery practice at the Duke Eye Center (Durham, North Carolina) between March 2016 and May 2016. Approval from the Duke University institutional review board was obtained, and the research adhered to the tenets of the Declaration of Helsinki and complied with the Health Insurance Portability and Accountability Act. Informed consent was obtained from all patients, and patients could elect to provide specific written consent for publication of photographs in scientific presentations and publications. Patients younger than 18 years of age; those with known sensitivity to sunscreen or its ingredients; and those with an active lesion, rash, or open wound were excluded from the study.

After obtaining informed consent, patients were photographed using a camera with a UV lens in natural outdoor lighting, first without sunscreen and again after self-application of a sunscreen of their choosing using their routine application technique. Completeness of sunscreen application was graded independently by 3 oculofacial surgeons (N.A.L., J.L., J.A.W.) as complete, partial, none, or cannot determine for 15 facial regions. The majority response was used for analysis.

Results

Forty-four patients were enrolled in the study. Six patients were disqualified due to use of mineral-based formulations (zinc oxide and/or titanium dioxide), as these sunscreens could not be visualized using UV photography. The age range of the remaining 38 patients was 28 to 74 years; 26% (10/38) were men and 74% (28/38) were women.

Complete sunscreen application was most frequently performed on the cheeks (97% [37/38]), chin (95% [36/38]), forehead (92% [35/38]), and temples (92% [35/38]). Complete absence of sunscreen coverage was most common on the lower eyelid margin (84% [32/38]), upper eyelid margin (82% [31/38]), medial canthus (71% 27/38]), and upper eyelid (66% [25/38])(Table)(Figure).

Comment

UV radiation-related skin cancers frequently occur in the periocular area, presumably because it is a frequent site of UV exposure. Clothing, sunglasses, and hats can be used to aid in protection from UV radiation, but these products are only regulated by the US Food and Drug Administration if the product claims to prevent skin cancer. Sunscreen is a proven method of protection from UV radiation and the prevention of skin cancer but must be properly applied for it to be effective.^1,2,5,6 Incomplete sunscreen application has been demonstrated in numerous studies. Lademann et al7 studied sunscreen application among 60 beachgoers in Germany and found they typically missed the hairline, ears, and dorsal feet. In a study of 10 women with photosensitivity in England who were asked to apply sunscreen in their routine manner, Azurdia et al⁶ found the posterior neck, lateral neck, temples, and ears, respectively, were the most frequently missed sites. Yang et al⁸ assessed sunscreen application in 39 dermatologists and 41 photosensitive patients in China and found the neck, ears, dorsal hands, hairline, temples, and perioral region, respectively, were most commonly left unprotected.

Our study investigated detailed facial self-application of sunscreen and found excellent coverage of the larger facial units such as the forehead, cheeks, chin, and temples. The brow, medial canthus, lateral canthus, and upper and lower eyelids and eyelid margins were infrequently protected with sunscreen during routine application. Our opinion is that patients are unaware that eyelid sunscreen application is important. They may be afraid that the products will sting or cause damage if they get in the eyes. Although some products do sting if they get into the eyes, there is no evidence that sunscreens cause injury to the eyes. The US Food and Drug Administration does not have clear guidelines about applying sunscreens in the periocular area, but in general, mineral blocks are recommended because they have less chance of irritation. Several companies make such products that are designed to be applied to the eyelids.

Limitations of our study included a small sample size and a majority female demographic, which may have affected the results, as women generally are more familiar with the application of lotions to the face. Additionally, the patients were recruited from a tertiary-care clinic and may have had periocular malignancy or may have previously received counseling on the importance of sunscreen use.

Conclusion

Cancer reconstruction of the periocular area is challenging, and even in the best of hands, a patient's quality of life may be negatively affected by postreconstructive appearance or suboptimal function, resulting in ocular exposure. The authors recommend counseling patients on the importance of good sun protection habits, including daily application of sunscreen to the face and periocular region to prevent malignancy in these delicate areas.

UV radiation from sun exposure is a risk factor for most types of skin cancer.¹ Despite comprising only 1% of the body's surface area, the periocular region is the location of approximately 5% to 10% of skin cancers described in one US study.² The efficacy of sunscreen in preventing skin cancer is widely accepted, and the American Academy of Dermatology recommends application of broad-spectrum UVA/UVB sunscreen with a sun protection factor of 30 or higher to help prevent skin cancer.^3-5

RELATED ARTICLE: Sun Protection for Infants: Parent Behaviors and Beliefs

Reducing the risk of skin cancer from sun exposure relies on many factors, including completeness of application. A number of studies have demonstrated incomplete sunscreen application on the hairline, ears, neck, and dorsal feet.^6-8 The purpose of this study was to assess the completeness of facial sunscreen self-application in oculofacial surgery patients using UV photography.

Methods

This single-site, cross-sectional, qualitative study assessed the completeness of facial sunscreen self-application among patients from a single surgeon's (J.A.W.) cosmetic and tertiary-care oculofacial surgery practice at the Duke Eye Center (Durham, North Carolina) between March 2016 and May 2016. Approval from the Duke University institutional review board was obtained, and the research adhered to the tenets of the Declaration of Helsinki and complied with the Health Insurance Portability and Accountability Act. Informed consent was obtained from all patients, and patients could elect to provide specific written consent for publication of photographs in scientific presentations and publications. Patients younger than 18 years of age; those with known sensitivity to sunscreen or its ingredients; and those with an active lesion, rash, or open wound were excluded from the study.

After obtaining informed consent, patients were photographed using a camera with a UV lens in natural outdoor lighting, first without sunscreen and again after self-application of a sunscreen of their choosing using their routine application technique. Completeness of sunscreen application was graded independently by 3 oculofacial surgeons (N.A.L., J.L., J.A.W.) as complete, partial, none, or cannot determine for 15 facial regions. The majority response was used for analysis.

Results

Forty-four patients were enrolled in the study. Six patients were disqualified due to use of mineral-based formulations (zinc oxide and/or titanium dioxide), as these sunscreens could not be visualized using UV photography. The age range of the remaining 38 patients was 28 to 74 years; 26% (10/38) were men and 74% (28/38) were women.

Complete sunscreen application was most frequently performed on the cheeks (97% [37/38]), chin (95% [36/38]), forehead (92% [35/38]), and temples (92% [35/38]). Complete absence of sunscreen coverage was most common on the lower eyelid margin (84% [32/38]), upper eyelid margin (82% [31/38]), medial canthus (71% 27/38]), and upper eyelid (66% [25/38])(Table)(Figure).

Comment

UV radiation-related skin cancers frequently occur in the periocular area, presumably because it is a frequent site of UV exposure. Clothing, sunglasses, and hats can be used to aid in protection from UV radiation, but these products are only regulated by the US Food and Drug Administration if the product claims to prevent skin cancer. Sunscreen is a proven method of protection from UV radiation and the prevention of skin cancer but must be properly applied for it to be effective.^1,2,5,6 Incomplete sunscreen application has been demonstrated in numerous studies. Lademann et al7 studied sunscreen application among 60 beachgoers in Germany and found they typically missed the hairline, ears, and dorsal feet. In a study of 10 women with photosensitivity in England who were asked to apply sunscreen in their routine manner, Azurdia et al⁶ found the posterior neck, lateral neck, temples, and ears, respectively, were the most frequently missed sites. Yang et al⁸ assessed sunscreen application in 39 dermatologists and 41 photosensitive patients in China and found the neck, ears, dorsal hands, hairline, temples, and perioral region, respectively, were most commonly left unprotected.

Our study investigated detailed facial self-application of sunscreen and found excellent coverage of the larger facial units such as the forehead, cheeks, chin, and temples. The brow, medial canthus, lateral canthus, and upper and lower eyelids and eyelid margins were infrequently protected with sunscreen during routine application. Our opinion is that patients are unaware that eyelid sunscreen application is important. They may be afraid that the products will sting or cause damage if they get in the eyes. Although some products do sting if they get into the eyes, there is no evidence that sunscreens cause injury to the eyes. The US Food and Drug Administration does not have clear guidelines about applying sunscreens in the periocular area, but in general, mineral blocks are recommended because they have less chance of irritation. Several companies make such products that are designed to be applied to the eyelids.

Limitations of our study included a small sample size and a majority female demographic, which may have affected the results, as women generally are more familiar with the application of lotions to the face. Additionally, the patients were recruited from a tertiary-care clinic and may have had periocular malignancy or may have previously received counseling on the importance of sunscreen use.

Conclusion

Cancer reconstruction of the periocular area is challenging, and even in the best of hands, a patient's quality of life may be negatively affected by postreconstructive appearance or suboptimal function, resulting in ocular exposure. The authors recommend counseling patients on the importance of good sun protection habits, including daily application of sunscreen to the face and periocular region to prevent malignancy in these delicate areas.

UV radiation from sun exposure is a risk factor for most types of skin cancer.¹ Despite comprising only 1% of the body's surface area, the periocular region is the location of approximately 5% to 10% of skin cancers described in one US study.² The efficacy of sunscreen in preventing skin cancer is widely accepted, and the American Academy of Dermatology recommends application of broad-spectrum UVA/UVB sunscreen with a sun protection factor of 30 or higher to help prevent skin cancer.^3-5

RELATED ARTICLE: Sun Protection for Infants: Parent Behaviors and Beliefs

Reducing the risk of skin cancer from sun exposure relies on many factors, including completeness of application. A number of studies have demonstrated incomplete sunscreen application on the hairline, ears, neck, and dorsal feet.^6-8 The purpose of this study was to assess the completeness of facial sunscreen self-application in oculofacial surgery patients using UV photography.

Methods

This single-site, cross-sectional, qualitative study assessed the completeness of facial sunscreen self-application among patients from a single surgeon's (J.A.W.) cosmetic and tertiary-care oculofacial surgery practice at the Duke Eye Center (Durham, North Carolina) between March 2016 and May 2016. Approval from the Duke University institutional review board was obtained, and the research adhered to the tenets of the Declaration of Helsinki and complied with the Health Insurance Portability and Accountability Act. Informed consent was obtained from all patients, and patients could elect to provide specific written consent for publication of photographs in scientific presentations and publications. Patients younger than 18 years of age; those with known sensitivity to sunscreen or its ingredients; and those with an active lesion, rash, or open wound were excluded from the study.

After obtaining informed consent, patients were photographed using a camera with a UV lens in natural outdoor lighting, first without sunscreen and again after self-application of a sunscreen of their choosing using their routine application technique. Completeness of sunscreen application was graded independently by 3 oculofacial surgeons (N.A.L., J.L., J.A.W.) as complete, partial, none, or cannot determine for 15 facial regions. The majority response was used for analysis.

Results

Forty-four patients were enrolled in the study. Six patients were disqualified due to use of mineral-based formulations (zinc oxide and/or titanium dioxide), as these sunscreens could not be visualized using UV photography. The age range of the remaining 38 patients was 28 to 74 years; 26% (10/38) were men and 74% (28/38) were women.

Complete sunscreen application was most frequently performed on the cheeks (97% [37/38]), chin (95% [36/38]), forehead (92% [35/38]), and temples (92% [35/38]). Complete absence of sunscreen coverage was most common on the lower eyelid margin (84% [32/38]), upper eyelid margin (82% [31/38]), medial canthus (71% 27/38]), and upper eyelid (66% [25/38])(Table)(Figure).

Comment

UV radiation-related skin cancers frequently occur in the periocular area, presumably because it is a frequent site of UV exposure. Clothing, sunglasses, and hats can be used to aid in protection from UV radiation, but these products are only regulated by the US Food and Drug Administration if the product claims to prevent skin cancer. Sunscreen is a proven method of protection from UV radiation and the prevention of skin cancer but must be properly applied for it to be effective.^1,2,5,6 Incomplete sunscreen application has been demonstrated in numerous studies. Lademann et al7 studied sunscreen application among 60 beachgoers in Germany and found they typically missed the hairline, ears, and dorsal feet. In a study of 10 women with photosensitivity in England who were asked to apply sunscreen in their routine manner, Azurdia et al⁶ found the posterior neck, lateral neck, temples, and ears, respectively, were the most frequently missed sites. Yang et al⁸ assessed sunscreen application in 39 dermatologists and 41 photosensitive patients in China and found the neck, ears, dorsal hands, hairline, temples, and perioral region, respectively, were most commonly left unprotected.

Our study investigated detailed facial self-application of sunscreen and found excellent coverage of the larger facial units such as the forehead, cheeks, chin, and temples. The brow, medial canthus, lateral canthus, and upper and lower eyelids and eyelid margins were infrequently protected with sunscreen during routine application. Our opinion is that patients are unaware that eyelid sunscreen application is important. They may be afraid that the products will sting or cause damage if they get in the eyes. Although some products do sting if they get into the eyes, there is no evidence that sunscreens cause injury to the eyes. The US Food and Drug Administration does not have clear guidelines about applying sunscreens in the periocular area, but in general, mineral blocks are recommended because they have less chance of irritation. Several companies make such products that are designed to be applied to the eyelids.

Limitations of our study included a small sample size and a majority female demographic, which may have affected the results, as women generally are more familiar with the application of lotions to the face. Additionally, the patients were recruited from a tertiary-care clinic and may have had periocular malignancy or may have previously received counseling on the importance of sunscreen use.

Conclusion

Cancer reconstruction of the periocular area is challenging, and even in the best of hands, a patient's quality of life may be negatively affected by postreconstructive appearance or suboptimal function, resulting in ocular exposure. The authors recommend counseling patients on the importance of good sun protection habits, including daily application of sunscreen to the face and periocular region to prevent malignancy in these delicate areas.

Over the past 10 years, the VHA has been a national leader in primary care-mental health integration (PC-MHI) within patient aligned care teams (PACTs).^1,2 Studies of the PC-MHI collaborative care model consistently have shown increased access to MH services, higher levels of MH treatment engagement, improved MH treatment outcomes, and high patient and provider satisfaction.^3-7 Primary care-mental health integration relies heavily on interprofessional team-based practice with providers from diverse educational and clinical backgrounds who work together to deliver integrated mental and behavioral health services within PACTs. This model requires a unique blending of professional cultures and communication and practice styles.

To sustain PC-MHI in PACT, health care professionals (HCPs) must be well trained to work effectively in interprofessional teams. Across health care organizations, training in collaborative interprofessional team-based practice has been identified as an important and challenging task.^8-11

Integrating educational experiences among different HCP learners is an approach to developing competency in interprofessional collaboration early in training. The World Health Organization defined interprofessional education (IPE) as occurring “when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”⁹ Fundamental to this definition is the belief that interaction among learners from different disciplines during their training develops competency in subsequent effective collaborative practice. Studies of IPE in MH professional training have found that prelicensure IPE contributes to increased knowledge of roles and responsibilities of different disciplines, improved interprofessional communication and attitudes, and increased willingness to work in teams.^12-17

Interprofessional education is a valuable training model, but developing interprofessional learning experiences in a system of diverse and often siloed training programs is difficult. More information about design and implementation of IPE training experiences is needed, particularly in outpatient settings in which integration of traditionally separate discipline-specific care is central to the health care mission. The VA PACT PC-MHI is a strong team-based care model that represents a unique opportunity for training across disciplines in interprofessional collaborative care.

To find innovative approaches to meeting the need for IPE in PACT PC-MHI, the authors developed a new IPE program in PC-MHI at the William S. Middleton Memorial Veterans Hospital (WSMMVH) in Madison, Wisconsin. This article reviews the development, implementation, and first-year evaluation of the training program and discusses the challenges and the IPE areas in need of improvement in PACT PC-MHI.

Methods

In 2012, the VHA launched phase 1 of the Mental Health Education Expansion Initiative (MHEEI), a collaboration of the Office of Academic Affiliations (OAA), VHA Mental Health Services (VHA-MHS), and the Office of Mental Health Operations (OMHO).¹⁸ The MHEEI was intended to “increase expertise in critical areas of need, expand the recruitment pipeline of well-trained, highly qualified health care providers in behavioral and mental health disciplines, and promote the utilization of interprofessional team-based care.”¹⁸ In response, WSMMVH organized a planning committee and submitted a funding request through the section of MHEEI called PACT With Integrated Behavioral Health Providers. The planning committee included training program directors and staff from psychiatry, pharmacy, social work, psychology, and primary care. The authors received funding for trainees in psychiatry (postgraduate year 4 [PGY-4]), pharmacy/MH residency (PGY-2), pharmacy/ambulatory care (PGY-1), and social work (interns).

Curriculum Development

The planning committee met regularly for 6 months to develop the organization, learning objectives, educational strategies, and implementation plan for the IPE program. The program was organized as a 4- to 12-month clinical rotation with the PC-MHI team in PACT, combined with 12 months of protected weekly IPE time (Table 1).

Learning Objectives

To better understand the educational needs and foci for learning objectives, the interprofessional planning committee reviewed guidelines on training in integrated care and collaborative team-based practice.^2,9,10,19-21 These guidelines were compared with existing training opportunities for each discipline to identify training gaps and needs.

Learning objectives were organized into 3 domains: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Table 2 outlines the shared learning objectives linked to each domain that were common to the psychiatry, pharmacy, and social work disciplines. Although many of the learning objectives were shared among all disciplines, each trainee also had discipline-specific clinical activities and learning objectives. Psychiatry and pharmacy residents focused on primary care psychiatric medication consultation and care management for antidepressant medication starts. Social work interns focused on psychosocial and functional assessment and brief problem-focused psychotherapies. Learning objectives were met through direct veteran care in the primary care clinic as part of the PACT PC-MHI team and through interprofessional learning activities during protected weekly education time.

Implementation

Critical stakeholders in implementing the IPE program involved themselves early and throughout the planning process. Stakeholders included VAMC leadership, primary care and MH service line chiefs and clinic managers, training program directors, and PACT staff. Planning committee members gave presentations on the IPE program at MH service line and PACT meetings in the 2 months before program initiation in order to orient staff to learning objectives, program structure, and impact on PACT PC-MHI operations. Throughout the first year, the planning committee continued to meet every 2 weeks to review progress, solve implementation problems, and revise learning objectives and activities.

Trainee Clinical Activities

A wide range of educational strategies were planned to meet learning objectives across the 3 domains. There was strong emphasis on experiential learning through daily PACT and PC-MHI clinical work, team huddles and meetings, and trainee-led program improvement projects.

Psychiatry and PGY-2 pharmacy/MH residents focused on direct and indirect medication consultation and problem-focused assessments. Their clinical activities included PC-MHI medication evaluation and follow-up visits; chart reviews and e-consults for medication recommendations to PACT providers; reviews of care management data and consultations on veterans enrolled in depression and anxiety care management; “curbside consultations” for providers in PACT huddles and meetings and throughout the clinic day; and “warm handoffs,” same-day initial PC-MHI problem-focused assessments performed on PACT provider request. The residents were part of a pool of staff and trainees who performed these assessments.

PGY-1 pharmacy residents made care management phone calls for antidepressant trials for depression and anxiety. These residents were trained in motivational interviewing (MI). They applied their MI skills during care management calls focused on medication adherence and behavioral interventions for depression (eg, exercise, planning pleasurable activity) and during other clinical rotations, including tobacco cessation and medication management for diabetes and hypertension. Particularly challenging veteran cases from these clinics were cosupervised with medication management and PC-MHIstaff for added consultation on engagement, behavior change, and treatment plan adherence.

Social work interns completed initial PC-MHI psychosocial and functional assessments by phone and directly by same-day warm handoffs from PACT staff. The PC-MHI therapies they provided included problem-solving therapy, behavioral activation, stress management based on cognitive behavioral therapy, and brief alcohol interventions.

Group IPE Activities

All trainees had a weekly protected block of 3 hours during which they came together for group IPE that was designed to elicit active participation; facilitate interprofessional communication; and develop an understanding of and respect for the knowledge, culture, and practice style of the different disciplines.

Trainees participated in a Herrmann Brain Dominance Instrument (HBDI) workshop focused on developing a better understanding of individual differences in thinking and problem solving, with the goal of improving communication and learning within teams.²² In a seminar series on professionalism and boundaries in health care, trainees from each discipline gave a presentation on the traditional structure and content of their discipline’s training and discussed similarities and differences in their disciplines’ professional oaths, codes of ethics, and boundary guidelines.

Motivational interviewing training was conducted early in the year so trainees would be prepared to apply MI skills in their daily PACT PC-MHI clinical work. Motivational inteviewing is a patient-centered approach to engaging patients in health promoting behavior change. It is defined as a “directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”²³

Trainees recorded MI sessions with at least 2 live-patient visits and at least 2 simulated-patient interviews (with staff serving as patient actors). The structure of MI training and supervision was deliberately designed to facilitate interprofessional communication and learning. In accord with a group supervision model for MI recorded reviews, the trainees presented their tapes to the entire learning group in the presence of a facilitating supervisor. Trainees had the opportunity to observe different interview styles and exchange feedback within a peer group of interprofessional learners.

Seminars were focused on core PC-MHI clinical content (eg, depression, anxiety, alcohol use disorders) and organized around case-based learning. Trainees divided into small teams in which representatives of each discipline offered their perspective on how to approach planning patient assessment and treatment. During the seminars, the authors engaged trainees as teachers and leaders whenever possible. All trainees presented on a topic in which they had some discipline expertise. For example, social work interns led a seminar on support and social services for victims of domestic violence, and PGY-1 pharmacy/ambulatory care residents led seminars and a panel management project focused on diabetes and depression.

Trainees participated in several PACT PC-MHI projects focused on population- and measurement-based care, panel management, and program improvement (Table 3). Protected IPE time was used to teach trainees about population health principles and different tools for process improvement (eg, Vision-Analysis Team-Aim-Map-Measure-Change-Sustain) and provide a forum in which trainees could share their work with one another.

Evaluations

Several tools were used for trainee and program evaluations. Clinical skills were evaluated during daily supervision. Trainees began the year with PC-MHI staff directly observing all their clinical contacts with veterans. Staff evaluated and offered feedback on trainee clinical interviewing and on assessment and treatment planning skills. Once they were assessed to be ready to see veterans on their own, trainees were advanced by staff to “drop-in” direct supervision: Toward the end of a veteran’s visit, a staff preceptor entered the room to review relevant clinical findings, assessment and finalized treatment planning with the trainee and veteran. When appropriate for trainee competence level, clinical contacts were indirectly supervised: Trainees discussed their assessment and treatment plan with a staff supervisor at the end of the day.

Motivational interviewing recordings were reviewed during group supervision. To objectively evaluate MI skills, supervisors who were VA-certified in MI used the Motivational Interviewing Treatment Integrity (MITI) coding tool to review and code both the live- and simulated-patient recordings.²⁴ The MITI coding involves quantitative and qualitative analysis using standardized coding items.

Quantitative items included percentage of open-ended questions (Proficiency: 50%; competency: 70%); percentage of reflections considered complex reflections, or reflective statements adding substantial meaning or emphasis and conveying a deeper or more complex picture of what patients say (Proficiency: 40%; competency: 50%); reflection-to-question ratio (Proficiency: 1:1; competency: 2:1); and percentage of MI-adherent provider statements (Proficiency: 90%; competency: 100%).

Qualitative coding items were a global rating of therapist “empathy,” which evaluated the extent to which the trainee understood or made an effort to grasp the patient’s perspective, and “MI spirit.” This coding intended to capture the overall competence of the trainee in emphasizing collaboration, patient autonomy, and evocation of the patient experience (Proficiency score: 5; competency score: 6).

The PC-MHI teaching staff met midyear and end of year as a team to complete trainee evaluations focused on the 3 areas of learning objectives: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Patient-centered PC-MHI involves direct observation and supervision of trainee clinical contacts with veterans, including assessment and treatment planning, clinical documentation, and review of live- and simulated-patient MI recordings. Collaborative team-based practice involves review of trainee participation in day-to-day teamwork, huddles, team meetings, and IPE activities. Population health and program improvement involves review of trainee work on a panel measurement-based care management or program improvement project. In each learning objectives area, trainees were rated on a 3-point scale: needs improvement (1); satisfactory (2); achieved (3). Core knowledge about PC-MHI evidence base, structure, and clinical topics was assessed with case-based written examination at midyear and end of year.

Surveys and qualitative interviews were used to assess trainee perceptions about the IPE program. A midyear and end-of-year survey assessed trainee satisfaction and perceived efficacy of the IPE training program in meeting core learning objectives. A midyear survey designed by pharmacy residents as part of their program improvement project evaluated attitudes around interprofessional learning and team practice. Trainees met individually with the PC-MHI IPE director at midyear and end of year to gather qualitative feedback on the IPE program.

Outcomes

All trainees advanced to the expected level of supervision for clinical contacts (drop-in or indirect clinical supervision). Over the year, there was significant improvement in trainees’ MI skills as measured by MITI coding of at least 2 live-patient or 2 simulated-patient recordings (Figures 1A and 1B). By end of year, most trainees had reached proficiency or competency in several MITI coded items: percentage of open-ended questions (4/12 proficient, 8/12 competent), percentage of complex reflections (2/12 less than proficient, 3/12 proficient, 7/12 competent), MI adherence (1/12 proficient, 11/12 competent), global empathy rating (2/12 proficient, 10/12 competent), and global MI spirit rating (12/12 competent). Average reflection-to-question ratio for the trainee group increased from 0.63 to 0.96 from midyear to end of year, but only 3 of 12 trainees reached the proficiency level of a 1:1 ratio, and no trainee reached the competency level of a 2:1 ratio.

According to the PC-MHI team’s midyear evaluation, most trainees were already making satisfactory progress in the 3 domains of learning objectives for the training program. At end of year, 13 of 14 trainees were assessed as competent in all 3 domains (Figures 2A and B). All trainees passed the midyear and end-of-year written examinations with overall high scores (average score, 82%) demonstrating acquisition of core PC-MHI clinical knowledge.

Trainee evaluations of the IPE program were overall highly favorable at both midyear and at end of year. Trainees rated the program effective or extremely effective in developing their skills in patient-centered care, interprofessional communication, and collaborative team-based practice. They also rated the program highly effective in preparing them to use team-based practice skills in other settings. On a midyear survey, trainees moderately to strongly agreed with several positive beliefs and attitudes about team-based care.

In qualitative interviews at program completion, trainees across disciplines rated the MI training with group supervision as one of their most valuable interprofessional learning experiences. Other highly valued training experiences were PACT PC-MHI panel management projects, team-based clinical case reviews, and cross-disciplinary supervision.

Discussion

This article describes the successful development and implementation of a VA-based IPE program in PACT PC-MHI. Interprofessional clinical training and educational experiences were highly valued, and trainees identified positive attitudes and improved skills related to team-based care. These findings support previous findings that IPE is associated with high satisfaction and positive attitudes toward team-based collaborative practice.^{12-17 P}rogram implementation presented several challenges: nonsynchronous academic calendars and rotation schedules, cross-disciplinary supervision regulations, variations in clinical and supervisory requirements for accreditation standards, the traditional health care hierarchy, and measurement of the impact of IPE experiences.^11,25,26

Rotation schedules and academic calendars varied across the psychiatry, pharmacy, and social work home programs. Organizing different trainee rotation schedules was a significant challenge. Collaboration with training directors and support staff was crucial in planning rotations that offered a longitudinal training experience in PACT PC-MHI. Given the participants’ different starting dates, protected IPE time early in the calendar year was focused on developing clinical skills specific to the pharmacy and psychiatry trainees who would be starting in July, and IPE activities that required the presence of all trainee disciplines (eg, MI training, HBDI) were planned for after the September start of the social work interns.

Cross-disciplinary supervision was highly valued by trainees because it offered exposure to the disciplines’ different communication styles and approaches to clinical assessment and decision making. Throughout the year, however, trainees encountered several obstacles to cross-disciplinary supervision, with respect to coding/billing and home program supervisory policies. The authors worked closely with the VA administration and each training program to develop and revise supervising policies and procedures to meet the necessary administrative and program supervisory requirements for accreditation standards.

In some cases, this work resulted in dual supervision by a preceptor of the same discipline (to meet requirements for coding/billing and home program supervision) and clinical supervision by a preceptor of a different discipline (eg, in team meetings or in clinical case reviews during protected IPE time). Preceptors from each discipline met regularly to discuss challenges in cross-disciplinary supervision, review scope-of-practice issues, share information on discipline-specific training, and revise supervisory procedures.

Interprofessional education activities during weekly protected time were designed to improve collaboration and to challenge trainees to examine traditional hierarchical roles and patterns of communication in health care. An emphasis on case-based learning in small groups encouraged trainees to share perspectives on their discipline-specific approach to assessment and treatment planning. Motivational interviewing training, one of the IPE experiences most valued by trainees and staff, created the opportunity for a truly shared learning environment, as trainees largely started at about the same skill level despite having different educational backgrounds. Group supervision of MI recordings offered trainees the opportunity to learn from each other and develop comfort in offering and receiving interprofessional constructive feedback.

Limitations

There were considerable methodologic limitations in the authors’ efforts to evaluate the impact of this training program on trainee attitudes and skills in collaborative team-based practice. Although trainee surveys revealed highly positive attitudes and beliefs about team-based care as well as perceived competence in collaborative practice, these were not validated surveys, and changes could not be accurately measured over time (trainees were not assessed at baseline). Trainees also were involved in other clinical teams within the VA during the year, and it is difficult to assess the specific impact of their PC-MHI IPE experiences. The PC-MHI staff evaluations of trainee competence in collaborative team-based practice were largely observational and potentially vulnerable to biases, as the staff evaluating trainee competence also were part of the IPE program planning process and invested in its success.

To address these limitations in the future, the authors will use better assessment tools at baseline and end of year to more effectively evaluate the impact of the training program on teamwork skills as well changes in attitudes and beliefs about interprofessional learning and teamwork. The Attitudes Toward Interprofessional Health Care Teams Scale and the Perceptions of Effective Interpersonal Teams Scale should be considered as they have published reliability and validity.^27,28 The authors could improve the reliability and depth of trainee evaluations with use of a “360-degree evaluation” model for trainee evaluations that includes other PACT members (beyond PC-MHI staff) as well as veterans.

Assessment of MI skills and competency was limited by use of both live- and simulated-patient recordings. Simulation is a valuable learning tool but often does not accurately represent actual clinical situations and challenges. To appropriately assess MI competence, future MI training should emphasize live-patient recordings over simulated-patient visits. Furthermore, whereas trainees reached competency in several MI coding items, none reached competency in the reflection-to-question ratio, and only about half reached competency in percentage of complex reflections. Future MI training will need to focus on further development of reflection skills.

Trainee intentions to remain involved in program improvement and collaborative team-based care in future professional work were core attitudinal learning objectives, but neither was adequately assessed in end-of-year surveys. Ideally, future evaluations will assess subjective trainee intentions and goals around team-based work and objectively measure future professional choices and activities. For example, it would be interesting to determine whether trainees who participated in this program will choose to practice in an interprofessional team-based model or participate in program improvement activities.

Last, the absence of psychology interns was considered a weakness in the learning environment, resulting in a relatively “prescriber-heavy” balance in discipline perspectives for IPE-focused case discussions and other training. Furthermore, the discipline representation in the IPE program did not exemplify the typical PC-MHI team in most VA clinic settings and community practices in which psychology has a strong presence. Adding psychology trainees was an important goal for the IPE program leadership. In 2015, WSMMVH was awarded additional funding for a PACT PC-MHI predoctoral psychology intern through the phase 4 MHEEI. The PC-MHI track psychology intern joined the IPE program in the 2016-2017 training year.

Conclusion

There is broad consensus that interprofessional team-based practice is crucial for providers in the VA and all health care systems. Primary care-mental health integration is an area of VA care in which interprofessional collaboration is uniquely important to implementation and sustainability of the model. Interprofessional education is an effective approach for preparing HCPs for team-based practice, but implementation is challenging. Several factors crucially contributed to the successful implementation of this program: collaboration of the interprofessional planning team with representation from key stakeholders in different departments and training programs; a well-established PACT PC-MHI team with experience in collaborative team-based care; a curriculum structure that emphasized experiential educational strategies designed to promote interprofessional learning and communication; VA leadership support at the national level (MHEEI funding) and local level; and PACT PC-MHI clinical staff committed to teaching and to the IPE mission.

Over the past 10 years, the VHA has been a national leader in primary care-mental health integration (PC-MHI) within patient aligned care teams (PACTs).^1,2 Studies of the PC-MHI collaborative care model consistently have shown increased access to MH services, higher levels of MH treatment engagement, improved MH treatment outcomes, and high patient and provider satisfaction.^3-7 Primary care-mental health integration relies heavily on interprofessional team-based practice with providers from diverse educational and clinical backgrounds who work together to deliver integrated mental and behavioral health services within PACTs. This model requires a unique blending of professional cultures and communication and practice styles.

To sustain PC-MHI in PACT, health care professionals (HCPs) must be well trained to work effectively in interprofessional teams. Across health care organizations, training in collaborative interprofessional team-based practice has been identified as an important and challenging task.^8-11

Integrating educational experiences among different HCP learners is an approach to developing competency in interprofessional collaboration early in training. The World Health Organization defined interprofessional education (IPE) as occurring “when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”⁹ Fundamental to this definition is the belief that interaction among learners from different disciplines during their training develops competency in subsequent effective collaborative practice. Studies of IPE in MH professional training have found that prelicensure IPE contributes to increased knowledge of roles and responsibilities of different disciplines, improved interprofessional communication and attitudes, and increased willingness to work in teams.^12-17

Interprofessional education is a valuable training model, but developing interprofessional learning experiences in a system of diverse and often siloed training programs is difficult. More information about design and implementation of IPE training experiences is needed, particularly in outpatient settings in which integration of traditionally separate discipline-specific care is central to the health care mission. The VA PACT PC-MHI is a strong team-based care model that represents a unique opportunity for training across disciplines in interprofessional collaborative care.

To find innovative approaches to meeting the need for IPE in PACT PC-MHI, the authors developed a new IPE program in PC-MHI at the William S. Middleton Memorial Veterans Hospital (WSMMVH) in Madison, Wisconsin. This article reviews the development, implementation, and first-year evaluation of the training program and discusses the challenges and the IPE areas in need of improvement in PACT PC-MHI.

Methods

In 2012, the VHA launched phase 1 of the Mental Health Education Expansion Initiative (MHEEI), a collaboration of the Office of Academic Affiliations (OAA), VHA Mental Health Services (VHA-MHS), and the Office of Mental Health Operations (OMHO).¹⁸ The MHEEI was intended to “increase expertise in critical areas of need, expand the recruitment pipeline of well-trained, highly qualified health care providers in behavioral and mental health disciplines, and promote the utilization of interprofessional team-based care.”¹⁸ In response, WSMMVH organized a planning committee and submitted a funding request through the section of MHEEI called PACT With Integrated Behavioral Health Providers. The planning committee included training program directors and staff from psychiatry, pharmacy, social work, psychology, and primary care. The authors received funding for trainees in psychiatry (postgraduate year 4 [PGY-4]), pharmacy/MH residency (PGY-2), pharmacy/ambulatory care (PGY-1), and social work (interns).

Curriculum Development

The planning committee met regularly for 6 months to develop the organization, learning objectives, educational strategies, and implementation plan for the IPE program. The program was organized as a 4- to 12-month clinical rotation with the PC-MHI team in PACT, combined with 12 months of protected weekly IPE time (Table 1).

Learning Objectives

To better understand the educational needs and foci for learning objectives, the interprofessional planning committee reviewed guidelines on training in integrated care and collaborative team-based practice.^2,9,10,19-21 These guidelines were compared with existing training opportunities for each discipline to identify training gaps and needs.

Learning objectives were organized into 3 domains: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Table 2 outlines the shared learning objectives linked to each domain that were common to the psychiatry, pharmacy, and social work disciplines. Although many of the learning objectives were shared among all disciplines, each trainee also had discipline-specific clinical activities and learning objectives. Psychiatry and pharmacy residents focused on primary care psychiatric medication consultation and care management for antidepressant medication starts. Social work interns focused on psychosocial and functional assessment and brief problem-focused psychotherapies. Learning objectives were met through direct veteran care in the primary care clinic as part of the PACT PC-MHI team and through interprofessional learning activities during protected weekly education time.

Implementation

Critical stakeholders in implementing the IPE program involved themselves early and throughout the planning process. Stakeholders included VAMC leadership, primary care and MH service line chiefs and clinic managers, training program directors, and PACT staff. Planning committee members gave presentations on the IPE program at MH service line and PACT meetings in the 2 months before program initiation in order to orient staff to learning objectives, program structure, and impact on PACT PC-MHI operations. Throughout the first year, the planning committee continued to meet every 2 weeks to review progress, solve implementation problems, and revise learning objectives and activities.

Trainee Clinical Activities

A wide range of educational strategies were planned to meet learning objectives across the 3 domains. There was strong emphasis on experiential learning through daily PACT and PC-MHI clinical work, team huddles and meetings, and trainee-led program improvement projects.

Psychiatry and PGY-2 pharmacy/MH residents focused on direct and indirect medication consultation and problem-focused assessments. Their clinical activities included PC-MHI medication evaluation and follow-up visits; chart reviews and e-consults for medication recommendations to PACT providers; reviews of care management data and consultations on veterans enrolled in depression and anxiety care management; “curbside consultations” for providers in PACT huddles and meetings and throughout the clinic day; and “warm handoffs,” same-day initial PC-MHI problem-focused assessments performed on PACT provider request. The residents were part of a pool of staff and trainees who performed these assessments.

PGY-1 pharmacy residents made care management phone calls for antidepressant trials for depression and anxiety. These residents were trained in motivational interviewing (MI). They applied their MI skills during care management calls focused on medication adherence and behavioral interventions for depression (eg, exercise, planning pleasurable activity) and during other clinical rotations, including tobacco cessation and medication management for diabetes and hypertension. Particularly challenging veteran cases from these clinics were cosupervised with medication management and PC-MHIstaff for added consultation on engagement, behavior change, and treatment plan adherence.

Social work interns completed initial PC-MHI psychosocial and functional assessments by phone and directly by same-day warm handoffs from PACT staff. The PC-MHI therapies they provided included problem-solving therapy, behavioral activation, stress management based on cognitive behavioral therapy, and brief alcohol interventions.

Group IPE Activities

All trainees had a weekly protected block of 3 hours during which they came together for group IPE that was designed to elicit active participation; facilitate interprofessional communication; and develop an understanding of and respect for the knowledge, culture, and practice style of the different disciplines.

Trainees participated in a Herrmann Brain Dominance Instrument (HBDI) workshop focused on developing a better understanding of individual differences in thinking and problem solving, with the goal of improving communication and learning within teams.²² In a seminar series on professionalism and boundaries in health care, trainees from each discipline gave a presentation on the traditional structure and content of their discipline’s training and discussed similarities and differences in their disciplines’ professional oaths, codes of ethics, and boundary guidelines.

Motivational interviewing training was conducted early in the year so trainees would be prepared to apply MI skills in their daily PACT PC-MHI clinical work. Motivational inteviewing is a patient-centered approach to engaging patients in health promoting behavior change. It is defined as a “directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”²³

Trainees recorded MI sessions with at least 2 live-patient visits and at least 2 simulated-patient interviews (with staff serving as patient actors). The structure of MI training and supervision was deliberately designed to facilitate interprofessional communication and learning. In accord with a group supervision model for MI recorded reviews, the trainees presented their tapes to the entire learning group in the presence of a facilitating supervisor. Trainees had the opportunity to observe different interview styles and exchange feedback within a peer group of interprofessional learners.

Seminars were focused on core PC-MHI clinical content (eg, depression, anxiety, alcohol use disorders) and organized around case-based learning. Trainees divided into small teams in which representatives of each discipline offered their perspective on how to approach planning patient assessment and treatment. During the seminars, the authors engaged trainees as teachers and leaders whenever possible. All trainees presented on a topic in which they had some discipline expertise. For example, social work interns led a seminar on support and social services for victims of domestic violence, and PGY-1 pharmacy/ambulatory care residents led seminars and a panel management project focused on diabetes and depression.

Trainees participated in several PACT PC-MHI projects focused on population- and measurement-based care, panel management, and program improvement (Table 3). Protected IPE time was used to teach trainees about population health principles and different tools for process improvement (eg, Vision-Analysis Team-Aim-Map-Measure-Change-Sustain) and provide a forum in which trainees could share their work with one another.

Evaluations

Several tools were used for trainee and program evaluations. Clinical skills were evaluated during daily supervision. Trainees began the year with PC-MHI staff directly observing all their clinical contacts with veterans. Staff evaluated and offered feedback on trainee clinical interviewing and on assessment and treatment planning skills. Once they were assessed to be ready to see veterans on their own, trainees were advanced by staff to “drop-in” direct supervision: Toward the end of a veteran’s visit, a staff preceptor entered the room to review relevant clinical findings, assessment and finalized treatment planning with the trainee and veteran. When appropriate for trainee competence level, clinical contacts were indirectly supervised: Trainees discussed their assessment and treatment plan with a staff supervisor at the end of the day.

Motivational interviewing recordings were reviewed during group supervision. To objectively evaluate MI skills, supervisors who were VA-certified in MI used the Motivational Interviewing Treatment Integrity (MITI) coding tool to review and code both the live- and simulated-patient recordings.²⁴ The MITI coding involves quantitative and qualitative analysis using standardized coding items.

Quantitative items included percentage of open-ended questions (Proficiency: 50%; competency: 70%); percentage of reflections considered complex reflections, or reflective statements adding substantial meaning or emphasis and conveying a deeper or more complex picture of what patients say (Proficiency: 40%; competency: 50%); reflection-to-question ratio (Proficiency: 1:1; competency: 2:1); and percentage of MI-adherent provider statements (Proficiency: 90%; competency: 100%).

Qualitative coding items were a global rating of therapist “empathy,” which evaluated the extent to which the trainee understood or made an effort to grasp the patient’s perspective, and “MI spirit.” This coding intended to capture the overall competence of the trainee in emphasizing collaboration, patient autonomy, and evocation of the patient experience (Proficiency score: 5; competency score: 6).

The PC-MHI teaching staff met midyear and end of year as a team to complete trainee evaluations focused on the 3 areas of learning objectives: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Patient-centered PC-MHI involves direct observation and supervision of trainee clinical contacts with veterans, including assessment and treatment planning, clinical documentation, and review of live- and simulated-patient MI recordings. Collaborative team-based practice involves review of trainee participation in day-to-day teamwork, huddles, team meetings, and IPE activities. Population health and program improvement involves review of trainee work on a panel measurement-based care management or program improvement project. In each learning objectives area, trainees were rated on a 3-point scale: needs improvement (1); satisfactory (2); achieved (3). Core knowledge about PC-MHI evidence base, structure, and clinical topics was assessed with case-based written examination at midyear and end of year.

Surveys and qualitative interviews were used to assess trainee perceptions about the IPE program. A midyear and end-of-year survey assessed trainee satisfaction and perceived efficacy of the IPE training program in meeting core learning objectives. A midyear survey designed by pharmacy residents as part of their program improvement project evaluated attitudes around interprofessional learning and team practice. Trainees met individually with the PC-MHI IPE director at midyear and end of year to gather qualitative feedback on the IPE program.

Outcomes

All trainees advanced to the expected level of supervision for clinical contacts (drop-in or indirect clinical supervision). Over the year, there was significant improvement in trainees’ MI skills as measured by MITI coding of at least 2 live-patient or 2 simulated-patient recordings (Figures 1A and 1B). By end of year, most trainees had reached proficiency or competency in several MITI coded items: percentage of open-ended questions (4/12 proficient, 8/12 competent), percentage of complex reflections (2/12 less than proficient, 3/12 proficient, 7/12 competent), MI adherence (1/12 proficient, 11/12 competent), global empathy rating (2/12 proficient, 10/12 competent), and global MI spirit rating (12/12 competent). Average reflection-to-question ratio for the trainee group increased from 0.63 to 0.96 from midyear to end of year, but only 3 of 12 trainees reached the proficiency level of a 1:1 ratio, and no trainee reached the competency level of a 2:1 ratio.

According to the PC-MHI team’s midyear evaluation, most trainees were already making satisfactory progress in the 3 domains of learning objectives for the training program. At end of year, 13 of 14 trainees were assessed as competent in all 3 domains (Figures 2A and B). All trainees passed the midyear and end-of-year written examinations with overall high scores (average score, 82%) demonstrating acquisition of core PC-MHI clinical knowledge.

Trainee evaluations of the IPE program were overall highly favorable at both midyear and at end of year. Trainees rated the program effective or extremely effective in developing their skills in patient-centered care, interprofessional communication, and collaborative team-based practice. They also rated the program highly effective in preparing them to use team-based practice skills in other settings. On a midyear survey, trainees moderately to strongly agreed with several positive beliefs and attitudes about team-based care.

In qualitative interviews at program completion, trainees across disciplines rated the MI training with group supervision as one of their most valuable interprofessional learning experiences. Other highly valued training experiences were PACT PC-MHI panel management projects, team-based clinical case reviews, and cross-disciplinary supervision.

Discussion

This article describes the successful development and implementation of a VA-based IPE program in PACT PC-MHI. Interprofessional clinical training and educational experiences were highly valued, and trainees identified positive attitudes and improved skills related to team-based care. These findings support previous findings that IPE is associated with high satisfaction and positive attitudes toward team-based collaborative practice.^{12-17 P}rogram implementation presented several challenges: nonsynchronous academic calendars and rotation schedules, cross-disciplinary supervision regulations, variations in clinical and supervisory requirements for accreditation standards, the traditional health care hierarchy, and measurement of the impact of IPE experiences.^11,25,26

Rotation schedules and academic calendars varied across the psychiatry, pharmacy, and social work home programs. Organizing different trainee rotation schedules was a significant challenge. Collaboration with training directors and support staff was crucial in planning rotations that offered a longitudinal training experience in PACT PC-MHI. Given the participants’ different starting dates, protected IPE time early in the calendar year was focused on developing clinical skills specific to the pharmacy and psychiatry trainees who would be starting in July, and IPE activities that required the presence of all trainee disciplines (eg, MI training, HBDI) were planned for after the September start of the social work interns.

Cross-disciplinary supervision was highly valued by trainees because it offered exposure to the disciplines’ different communication styles and approaches to clinical assessment and decision making. Throughout the year, however, trainees encountered several obstacles to cross-disciplinary supervision, with respect to coding/billing and home program supervisory policies. The authors worked closely with the VA administration and each training program to develop and revise supervising policies and procedures to meet the necessary administrative and program supervisory requirements for accreditation standards.

In some cases, this work resulted in dual supervision by a preceptor of the same discipline (to meet requirements for coding/billing and home program supervision) and clinical supervision by a preceptor of a different discipline (eg, in team meetings or in clinical case reviews during protected IPE time). Preceptors from each discipline met regularly to discuss challenges in cross-disciplinary supervision, review scope-of-practice issues, share information on discipline-specific training, and revise supervisory procedures.

Interprofessional education activities during weekly protected time were designed to improve collaboration and to challenge trainees to examine traditional hierarchical roles and patterns of communication in health care. An emphasis on case-based learning in small groups encouraged trainees to share perspectives on their discipline-specific approach to assessment and treatment planning. Motivational interviewing training, one of the IPE experiences most valued by trainees and staff, created the opportunity for a truly shared learning environment, as trainees largely started at about the same skill level despite having different educational backgrounds. Group supervision of MI recordings offered trainees the opportunity to learn from each other and develop comfort in offering and receiving interprofessional constructive feedback.

Limitations

There were considerable methodologic limitations in the authors’ efforts to evaluate the impact of this training program on trainee attitudes and skills in collaborative team-based practice. Although trainee surveys revealed highly positive attitudes and beliefs about team-based care as well as perceived competence in collaborative practice, these were not validated surveys, and changes could not be accurately measured over time (trainees were not assessed at baseline). Trainees also were involved in other clinical teams within the VA during the year, and it is difficult to assess the specific impact of their PC-MHI IPE experiences. The PC-MHI staff evaluations of trainee competence in collaborative team-based practice were largely observational and potentially vulnerable to biases, as the staff evaluating trainee competence also were part of the IPE program planning process and invested in its success.

To address these limitations in the future, the authors will use better assessment tools at baseline and end of year to more effectively evaluate the impact of the training program on teamwork skills as well changes in attitudes and beliefs about interprofessional learning and teamwork. The Attitudes Toward Interprofessional Health Care Teams Scale and the Perceptions of Effective Interpersonal Teams Scale should be considered as they have published reliability and validity.^27,28 The authors could improve the reliability and depth of trainee evaluations with use of a “360-degree evaluation” model for trainee evaluations that includes other PACT members (beyond PC-MHI staff) as well as veterans.

Assessment of MI skills and competency was limited by use of both live- and simulated-patient recordings. Simulation is a valuable learning tool but often does not accurately represent actual clinical situations and challenges. To appropriately assess MI competence, future MI training should emphasize live-patient recordings over simulated-patient visits. Furthermore, whereas trainees reached competency in several MI coding items, none reached competency in the reflection-to-question ratio, and only about half reached competency in percentage of complex reflections. Future MI training will need to focus on further development of reflection skills.

Trainee intentions to remain involved in program improvement and collaborative team-based care in future professional work were core attitudinal learning objectives, but neither was adequately assessed in end-of-year surveys. Ideally, future evaluations will assess subjective trainee intentions and goals around team-based work and objectively measure future professional choices and activities. For example, it would be interesting to determine whether trainees who participated in this program will choose to practice in an interprofessional team-based model or participate in program improvement activities.

Last, the absence of psychology interns was considered a weakness in the learning environment, resulting in a relatively “prescriber-heavy” balance in discipline perspectives for IPE-focused case discussions and other training. Furthermore, the discipline representation in the IPE program did not exemplify the typical PC-MHI team in most VA clinic settings and community practices in which psychology has a strong presence. Adding psychology trainees was an important goal for the IPE program leadership. In 2015, WSMMVH was awarded additional funding for a PACT PC-MHI predoctoral psychology intern through the phase 4 MHEEI. The PC-MHI track psychology intern joined the IPE program in the 2016-2017 training year.

Conclusion

There is broad consensus that interprofessional team-based practice is crucial for providers in the VA and all health care systems. Primary care-mental health integration is an area of VA care in which interprofessional collaboration is uniquely important to implementation and sustainability of the model. Interprofessional education is an effective approach for preparing HCPs for team-based practice, but implementation is challenging. Several factors crucially contributed to the successful implementation of this program: collaboration of the interprofessional planning team with representation from key stakeholders in different departments and training programs; a well-established PACT PC-MHI team with experience in collaborative team-based care; a curriculum structure that emphasized experiential educational strategies designed to promote interprofessional learning and communication; VA leadership support at the national level (MHEEI funding) and local level; and PACT PC-MHI clinical staff committed to teaching and to the IPE mission.

Over the past 10 years, the VHA has been a national leader in primary care-mental health integration (PC-MHI) within patient aligned care teams (PACTs).^1,2 Studies of the PC-MHI collaborative care model consistently have shown increased access to MH services, higher levels of MH treatment engagement, improved MH treatment outcomes, and high patient and provider satisfaction.^3-7 Primary care-mental health integration relies heavily on interprofessional team-based practice with providers from diverse educational and clinical backgrounds who work together to deliver integrated mental and behavioral health services within PACTs. This model requires a unique blending of professional cultures and communication and practice styles.

To sustain PC-MHI in PACT, health care professionals (HCPs) must be well trained to work effectively in interprofessional teams. Across health care organizations, training in collaborative interprofessional team-based practice has been identified as an important and challenging task.^8-11

Integrating educational experiences among different HCP learners is an approach to developing competency in interprofessional collaboration early in training. The World Health Organization defined interprofessional education (IPE) as occurring “when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”⁹ Fundamental to this definition is the belief that interaction among learners from different disciplines during their training develops competency in subsequent effective collaborative practice. Studies of IPE in MH professional training have found that prelicensure IPE contributes to increased knowledge of roles and responsibilities of different disciplines, improved interprofessional communication and attitudes, and increased willingness to work in teams.^12-17

Interprofessional education is a valuable training model, but developing interprofessional learning experiences in a system of diverse and often siloed training programs is difficult. More information about design and implementation of IPE training experiences is needed, particularly in outpatient settings in which integration of traditionally separate discipline-specific care is central to the health care mission. The VA PACT PC-MHI is a strong team-based care model that represents a unique opportunity for training across disciplines in interprofessional collaborative care.

To find innovative approaches to meeting the need for IPE in PACT PC-MHI, the authors developed a new IPE program in PC-MHI at the William S. Middleton Memorial Veterans Hospital (WSMMVH) in Madison, Wisconsin. This article reviews the development, implementation, and first-year evaluation of the training program and discusses the challenges and the IPE areas in need of improvement in PACT PC-MHI.

Methods

In 2012, the VHA launched phase 1 of the Mental Health Education Expansion Initiative (MHEEI), a collaboration of the Office of Academic Affiliations (OAA), VHA Mental Health Services (VHA-MHS), and the Office of Mental Health Operations (OMHO).¹⁸ The MHEEI was intended to “increase expertise in critical areas of need, expand the recruitment pipeline of well-trained, highly qualified health care providers in behavioral and mental health disciplines, and promote the utilization of interprofessional team-based care.”¹⁸ In response, WSMMVH organized a planning committee and submitted a funding request through the section of MHEEI called PACT With Integrated Behavioral Health Providers. The planning committee included training program directors and staff from psychiatry, pharmacy, social work, psychology, and primary care. The authors received funding for trainees in psychiatry (postgraduate year 4 [PGY-4]), pharmacy/MH residency (PGY-2), pharmacy/ambulatory care (PGY-1), and social work (interns).

Curriculum Development

The planning committee met regularly for 6 months to develop the organization, learning objectives, educational strategies, and implementation plan for the IPE program. The program was organized as a 4- to 12-month clinical rotation with the PC-MHI team in PACT, combined with 12 months of protected weekly IPE time (Table 1).

Learning Objectives

To better understand the educational needs and foci for learning objectives, the interprofessional planning committee reviewed guidelines on training in integrated care and collaborative team-based practice.^2,9,10,19-21 These guidelines were compared with existing training opportunities for each discipline to identify training gaps and needs.

Learning objectives were organized into 3 domains: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Table 2 outlines the shared learning objectives linked to each domain that were common to the psychiatry, pharmacy, and social work disciplines. Although many of the learning objectives were shared among all disciplines, each trainee also had discipline-specific clinical activities and learning objectives. Psychiatry and pharmacy residents focused on primary care psychiatric medication consultation and care management for antidepressant medication starts. Social work interns focused on psychosocial and functional assessment and brief problem-focused psychotherapies. Learning objectives were met through direct veteran care in the primary care clinic as part of the PACT PC-MHI team and through interprofessional learning activities during protected weekly education time.

Implementation

Critical stakeholders in implementing the IPE program involved themselves early and throughout the planning process. Stakeholders included VAMC leadership, primary care and MH service line chiefs and clinic managers, training program directors, and PACT staff. Planning committee members gave presentations on the IPE program at MH service line and PACT meetings in the 2 months before program initiation in order to orient staff to learning objectives, program structure, and impact on PACT PC-MHI operations. Throughout the first year, the planning committee continued to meet every 2 weeks to review progress, solve implementation problems, and revise learning objectives and activities.

Trainee Clinical Activities

A wide range of educational strategies were planned to meet learning objectives across the 3 domains. There was strong emphasis on experiential learning through daily PACT and PC-MHI clinical work, team huddles and meetings, and trainee-led program improvement projects.

Psychiatry and PGY-2 pharmacy/MH residents focused on direct and indirect medication consultation and problem-focused assessments. Their clinical activities included PC-MHI medication evaluation and follow-up visits; chart reviews and e-consults for medication recommendations to PACT providers; reviews of care management data and consultations on veterans enrolled in depression and anxiety care management; “curbside consultations” for providers in PACT huddles and meetings and throughout the clinic day; and “warm handoffs,” same-day initial PC-MHI problem-focused assessments performed on PACT provider request. The residents were part of a pool of staff and trainees who performed these assessments.

PGY-1 pharmacy residents made care management phone calls for antidepressant trials for depression and anxiety. These residents were trained in motivational interviewing (MI). They applied their MI skills during care management calls focused on medication adherence and behavioral interventions for depression (eg, exercise, planning pleasurable activity) and during other clinical rotations, including tobacco cessation and medication management for diabetes and hypertension. Particularly challenging veteran cases from these clinics were cosupervised with medication management and PC-MHIstaff for added consultation on engagement, behavior change, and treatment plan adherence.

Social work interns completed initial PC-MHI psychosocial and functional assessments by phone and directly by same-day warm handoffs from PACT staff. The PC-MHI therapies they provided included problem-solving therapy, behavioral activation, stress management based on cognitive behavioral therapy, and brief alcohol interventions.

Group IPE Activities

All trainees had a weekly protected block of 3 hours during which they came together for group IPE that was designed to elicit active participation; facilitate interprofessional communication; and develop an understanding of and respect for the knowledge, culture, and practice style of the different disciplines.

Trainees participated in a Herrmann Brain Dominance Instrument (HBDI) workshop focused on developing a better understanding of individual differences in thinking and problem solving, with the goal of improving communication and learning within teams.²² In a seminar series on professionalism and boundaries in health care, trainees from each discipline gave a presentation on the traditional structure and content of their discipline’s training and discussed similarities and differences in their disciplines’ professional oaths, codes of ethics, and boundary guidelines.

Motivational interviewing training was conducted early in the year so trainees would be prepared to apply MI skills in their daily PACT PC-MHI clinical work. Motivational inteviewing is a patient-centered approach to engaging patients in health promoting behavior change. It is defined as a “directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”²³

Trainees recorded MI sessions with at least 2 live-patient visits and at least 2 simulated-patient interviews (with staff serving as patient actors). The structure of MI training and supervision was deliberately designed to facilitate interprofessional communication and learning. In accord with a group supervision model for MI recorded reviews, the trainees presented their tapes to the entire learning group in the presence of a facilitating supervisor. Trainees had the opportunity to observe different interview styles and exchange feedback within a peer group of interprofessional learners.

Seminars were focused on core PC-MHI clinical content (eg, depression, anxiety, alcohol use disorders) and organized around case-based learning. Trainees divided into small teams in which representatives of each discipline offered their perspective on how to approach planning patient assessment and treatment. During the seminars, the authors engaged trainees as teachers and leaders whenever possible. All trainees presented on a topic in which they had some discipline expertise. For example, social work interns led a seminar on support and social services for victims of domestic violence, and PGY-1 pharmacy/ambulatory care residents led seminars and a panel management project focused on diabetes and depression.

Trainees participated in several PACT PC-MHI projects focused on population- and measurement-based care, panel management, and program improvement (Table 3). Protected IPE time was used to teach trainees about population health principles and different tools for process improvement (eg, Vision-Analysis Team-Aim-Map-Measure-Change-Sustain) and provide a forum in which trainees could share their work with one another.

Evaluations

Several tools were used for trainee and program evaluations. Clinical skills were evaluated during daily supervision. Trainees began the year with PC-MHI staff directly observing all their clinical contacts with veterans. Staff evaluated and offered feedback on trainee clinical interviewing and on assessment and treatment planning skills. Once they were assessed to be ready to see veterans on their own, trainees were advanced by staff to “drop-in” direct supervision: Toward the end of a veteran’s visit, a staff preceptor entered the room to review relevant clinical findings, assessment and finalized treatment planning with the trainee and veteran. When appropriate for trainee competence level, clinical contacts were indirectly supervised: Trainees discussed their assessment and treatment plan with a staff supervisor at the end of the day.

Motivational interviewing recordings were reviewed during group supervision. To objectively evaluate MI skills, supervisors who were VA-certified in MI used the Motivational Interviewing Treatment Integrity (MITI) coding tool to review and code both the live- and simulated-patient recordings.²⁴ The MITI coding involves quantitative and qualitative analysis using standardized coding items.

Quantitative items included percentage of open-ended questions (Proficiency: 50%; competency: 70%); percentage of reflections considered complex reflections, or reflective statements adding substantial meaning or emphasis and conveying a deeper or more complex picture of what patients say (Proficiency: 40%; competency: 50%); reflection-to-question ratio (Proficiency: 1:1; competency: 2:1); and percentage of MI-adherent provider statements (Proficiency: 90%; competency: 100%).

Qualitative coding items were a global rating of therapist “empathy,” which evaluated the extent to which the trainee understood or made an effort to grasp the patient’s perspective, and “MI spirit.” This coding intended to capture the overall competence of the trainee in emphasizing collaboration, patient autonomy, and evocation of the patient experience (Proficiency score: 5; competency score: 6).

The PC-MHI teaching staff met midyear and end of year as a team to complete trainee evaluations focused on the 3 areas of learning objectives: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Patient-centered PC-MHI involves direct observation and supervision of trainee clinical contacts with veterans, including assessment and treatment planning, clinical documentation, and review of live- and simulated-patient MI recordings. Collaborative team-based practice involves review of trainee participation in day-to-day teamwork, huddles, team meetings, and IPE activities. Population health and program improvement involves review of trainee work on a panel measurement-based care management or program improvement project. In each learning objectives area, trainees were rated on a 3-point scale: needs improvement (1); satisfactory (2); achieved (3). Core knowledge about PC-MHI evidence base, structure, and clinical topics was assessed with case-based written examination at midyear and end of year.

Surveys and qualitative interviews were used to assess trainee perceptions about the IPE program. A midyear and end-of-year survey assessed trainee satisfaction and perceived efficacy of the IPE training program in meeting core learning objectives. A midyear survey designed by pharmacy residents as part of their program improvement project evaluated attitudes around interprofessional learning and team practice. Trainees met individually with the PC-MHI IPE director at midyear and end of year to gather qualitative feedback on the IPE program.

Outcomes

All trainees advanced to the expected level of supervision for clinical contacts (drop-in or indirect clinical supervision). Over the year, there was significant improvement in trainees’ MI skills as measured by MITI coding of at least 2 live-patient or 2 simulated-patient recordings (Figures 1A and 1B). By end of year, most trainees had reached proficiency or competency in several MITI coded items: percentage of open-ended questions (4/12 proficient, 8/12 competent), percentage of complex reflections (2/12 less than proficient, 3/12 proficient, 7/12 competent), MI adherence (1/12 proficient, 11/12 competent), global empathy rating (2/12 proficient, 10/12 competent), and global MI spirit rating (12/12 competent). Average reflection-to-question ratio for the trainee group increased from 0.63 to 0.96 from midyear to end of year, but only 3 of 12 trainees reached the proficiency level of a 1:1 ratio, and no trainee reached the competency level of a 2:1 ratio.

According to the PC-MHI team’s midyear evaluation, most trainees were already making satisfactory progress in the 3 domains of learning objectives for the training program. At end of year, 13 of 14 trainees were assessed as competent in all 3 domains (Figures 2A and B). All trainees passed the midyear and end-of-year written examinations with overall high scores (average score, 82%) demonstrating acquisition of core PC-MHI clinical knowledge.

Trainee evaluations of the IPE program were overall highly favorable at both midyear and at end of year. Trainees rated the program effective or extremely effective in developing their skills in patient-centered care, interprofessional communication, and collaborative team-based practice. They also rated the program highly effective in preparing them to use team-based practice skills in other settings. On a midyear survey, trainees moderately to strongly agreed with several positive beliefs and attitudes about team-based care.

In qualitative interviews at program completion, trainees across disciplines rated the MI training with group supervision as one of their most valuable interprofessional learning experiences. Other highly valued training experiences were PACT PC-MHI panel management projects, team-based clinical case reviews, and cross-disciplinary supervision.

Discussion

This article describes the successful development and implementation of a VA-based IPE program in PACT PC-MHI. Interprofessional clinical training and educational experiences were highly valued, and trainees identified positive attitudes and improved skills related to team-based care. These findings support previous findings that IPE is associated with high satisfaction and positive attitudes toward team-based collaborative practice.^{12-17 P}rogram implementation presented several challenges: nonsynchronous academic calendars and rotation schedules, cross-disciplinary supervision regulations, variations in clinical and supervisory requirements for accreditation standards, the traditional health care hierarchy, and measurement of the impact of IPE experiences.^11,25,26

Rotation schedules and academic calendars varied across the psychiatry, pharmacy, and social work home programs. Organizing different trainee rotation schedules was a significant challenge. Collaboration with training directors and support staff was crucial in planning rotations that offered a longitudinal training experience in PACT PC-MHI. Given the participants’ different starting dates, protected IPE time early in the calendar year was focused on developing clinical skills specific to the pharmacy and psychiatry trainees who would be starting in July, and IPE activities that required the presence of all trainee disciplines (eg, MI training, HBDI) were planned for after the September start of the social work interns.

Cross-disciplinary supervision was highly valued by trainees because it offered exposure to the disciplines’ different communication styles and approaches to clinical assessment and decision making. Throughout the year, however, trainees encountered several obstacles to cross-disciplinary supervision, with respect to coding/billing and home program supervisory policies. The authors worked closely with the VA administration and each training program to develop and revise supervising policies and procedures to meet the necessary administrative and program supervisory requirements for accreditation standards.

In some cases, this work resulted in dual supervision by a preceptor of the same discipline (to meet requirements for coding/billing and home program supervision) and clinical supervision by a preceptor of a different discipline (eg, in team meetings or in clinical case reviews during protected IPE time). Preceptors from each discipline met regularly to discuss challenges in cross-disciplinary supervision, review scope-of-practice issues, share information on discipline-specific training, and revise supervisory procedures.

Interprofessional education activities during weekly protected time were designed to improve collaboration and to challenge trainees to examine traditional hierarchical roles and patterns of communication in health care. An emphasis on case-based learning in small groups encouraged trainees to share perspectives on their discipline-specific approach to assessment and treatment planning. Motivational interviewing training, one of the IPE experiences most valued by trainees and staff, created the opportunity for a truly shared learning environment, as trainees largely started at about the same skill level despite having different educational backgrounds. Group supervision of MI recordings offered trainees the opportunity to learn from each other and develop comfort in offering and receiving interprofessional constructive feedback.

Limitations

There were considerable methodologic limitations in the authors’ efforts to evaluate the impact of this training program on trainee attitudes and skills in collaborative team-based practice. Although trainee surveys revealed highly positive attitudes and beliefs about team-based care as well as perceived competence in collaborative practice, these were not validated surveys, and changes could not be accurately measured over time (trainees were not assessed at baseline). Trainees also were involved in other clinical teams within the VA during the year, and it is difficult to assess the specific impact of their PC-MHI IPE experiences. The PC-MHI staff evaluations of trainee competence in collaborative team-based practice were largely observational and potentially vulnerable to biases, as the staff evaluating trainee competence also were part of the IPE program planning process and invested in its success.

To address these limitations in the future, the authors will use better assessment tools at baseline and end of year to more effectively evaluate the impact of the training program on teamwork skills as well changes in attitudes and beliefs about interprofessional learning and teamwork. The Attitudes Toward Interprofessional Health Care Teams Scale and the Perceptions of Effective Interpersonal Teams Scale should be considered as they have published reliability and validity.^27,28 The authors could improve the reliability and depth of trainee evaluations with use of a “360-degree evaluation” model for trainee evaluations that includes other PACT members (beyond PC-MHI staff) as well as veterans.

Assessment of MI skills and competency was limited by use of both live- and simulated-patient recordings. Simulation is a valuable learning tool but often does not accurately represent actual clinical situations and challenges. To appropriately assess MI competence, future MI training should emphasize live-patient recordings over simulated-patient visits. Furthermore, whereas trainees reached competency in several MI coding items, none reached competency in the reflection-to-question ratio, and only about half reached competency in percentage of complex reflections. Future MI training will need to focus on further development of reflection skills.

Trainee intentions to remain involved in program improvement and collaborative team-based care in future professional work were core attitudinal learning objectives, but neither was adequately assessed in end-of-year surveys. Ideally, future evaluations will assess subjective trainee intentions and goals around team-based work and objectively measure future professional choices and activities. For example, it would be interesting to determine whether trainees who participated in this program will choose to practice in an interprofessional team-based model or participate in program improvement activities.

Last, the absence of psychology interns was considered a weakness in the learning environment, resulting in a relatively “prescriber-heavy” balance in discipline perspectives for IPE-focused case discussions and other training. Furthermore, the discipline representation in the IPE program did not exemplify the typical PC-MHI team in most VA clinic settings and community practices in which psychology has a strong presence. Adding psychology trainees was an important goal for the IPE program leadership. In 2015, WSMMVH was awarded additional funding for a PACT PC-MHI predoctoral psychology intern through the phase 4 MHEEI. The PC-MHI track psychology intern joined the IPE program in the 2016-2017 training year.

Conclusion

There is broad consensus that interprofessional team-based practice is crucial for providers in the VA and all health care systems. Primary care-mental health integration is an area of VA care in which interprofessional collaboration is uniquely important to implementation and sustainability of the model. Interprofessional education is an effective approach for preparing HCPs for team-based practice, but implementation is challenging. Several factors crucially contributed to the successful implementation of this program: collaboration of the interprofessional planning team with representation from key stakeholders in different departments and training programs; a well-established PACT PC-MHI team with experience in collaborative team-based care; a curriculum structure that emphasized experiential educational strategies designed to promote interprofessional learning and communication; VA leadership support at the national level (MHEEI funding) and local level; and PACT PC-MHI clinical staff committed to teaching and to the IPE mission.

As lifelong learners, physicians are encouraged and expected to share their knowledge base with budding residents and students. Effective communication is essential to the utmost delivery of clinical knowledge and pearls. Lecture delivery is important for all stages of learning, and adapting efficient techniques early in one's career is critical for the transmission of ideas and teaching points. These tips were created to help formulate guidelines for physician presentations and are open for interpretation. These well-meaning suggestions can be integrated into one's toolbox to foster an enthusiastic educational arena.

Step 1: Know Your Key Message 

First and foremost, one should ruminate over the overall message of the lecture. Consider at least 3 main points you want the learner to gain and remember on completion of the lecture. Additionally, it is crucial to think about the audience who will be present for your message and how to deliver your ideas clearly and effectively. Be cognizant of the knowledge base of your listeners and gauge how much initial background information is needed; conversely, if the audience is familiar with the material, excessive introductory material may be unnecessary and cause inattentiveness. Simplicity, both within the inherent message itself and the content and layout, can ameliorate the transmission of data regardless of the audience. A mentor once told me that no slide should contain more than 13 lines of text. Furthermore, if you are counting the number of lines, then you likely need to reduce the text and simplify the slide. Each slide should contain a maximum of 3 or 4 bullet points.¹ Convoluted figures should be avoided and key points should be highlighted. Overall, know your take-home message and provide the listener with simplistic text and images to convey the key ideas at their educational level.

Step 2: Prepare

Preparation is of utmost importance. Reading over the slides several times prior to the presentation is vital. You are the assumed expert on the topic and meticulously knowing the subject matter helps with the confidence of your delivery. Ease of subject matter also helps you, as the presenter, to rely less on verbatim reading of the slides and allows you to interact more with your audience. It is important to be familiar with the order of your presentation as well as the phrases and figures provided.² Flipping back and forth through slides can be distracting to the audience and can make the order of your presentation seem incongruous, presenting as a hastily constructed lecture. If you are prepared, you can engage your audience and provide additional information that is not on the slides to maintain interest. Remember that reading the slides can reduce your voice to a monotone, subtracting enthusiasm and energy from the delivery of your talk.² Rehearsal helps give you the freedom to confidently and proudly present your subject material.

Step 3: Be Animated 

You are the main attraction and the performer of this lecture. Radiate the confidence you gained from being prepared with the ability to engage in eye contact and gestures as needed to convey your point. Regularly shift your focus around the room to attempt to involve as many people as possible in your talk.² Your main focus should be your audience and not your slides; the slides should simply help guide your talk.³ During your presentation, you also can ask rhetorical questions that you can then answer to keep the group engaged (eg, "So, what does this tell us?" or "What would you do next?"). These questions demonstrate to your audience that you are interested in their attention and can help reciprocate the enthusiasm. Use language that involves your audience as a group participant. For example, when looking at visual aids, introduce them by saying "If we look at this table, we can see that . . ." or "This figure shows us that . . ."^2,3 Additionally, be cognizant of the volume and pace of your voice. During key points, you may want to slightly raise your voice and slow your pace for emphasis. Anxiety can make all presenters speed through their material; however, try to be mindful of the rhythm of your speech. With preparation you should be able to accurately gauge the length of your presentation but also adapt to the necessary time constraints if too much time is spent on one point early on. Most would believe that all good lectures end at least a few minutes early to allow for questions and comprehension of the material as well as to provide your audience with time to move on to their next engagement or clinical duty. 

Step 4: Encourage Active Participation

Active audience participation is shown by a multitude of studies to provide the highest level of comprehension.^4,5 In a crossover study conducted by Bleske et al,⁴ 30 students were divided into 2 groups and were taught 6 therapeutic topics, with 3 topics provided by conventional lecture and 3 topics taught by team-based learning. At the end of the educational series, the students were surveyed to evaluate their confidence and attitudes. Students demonstrated not only higher examination scores with team-based learning but higher confidence in their ability to transmit the information garnered through therapeutic recommendations.⁴ Although small, this study highlights the intuitive notion that active learning with subject material, either by sharing ideas with colleagues or having small brainstorming discussions throughout lectures, helps consolidate the information for long-term memory and comprehension.

Additionally, teaching in a medical environment can present unique challenges, as participants may feel anxiety over having right or wrong answers due to fear of inadequacy among their scholarly peers. Neher et al⁶ proposed a 5-step "microskills" model for teaching young physicians, and although it is intended for a clinical setting, it also can be applied to engaging and answering questions from a medical audience in general. Their model focuses on the teacher, or in our case the lecturer, asking a question and then applying the following model: (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done right, and (5) correct mistakes.⁶ After asking your question, the student commits to an answer and must then provide supporting details for their choice, thus feeling more responsible for their collaborative role in problem-solving. Based on their answer, you can then teach your general rule, provide positive feedback on what the student said accurately, and ultimately correct any erroneous information. This prototype of learning is best utilized in the clinical setting but also can enhance participant engagement in lectures while maintaining an inviting educational environment. 

Step 5: Summarize 

Lastly, conclude your presentation with at least 3 memorable points. What was the point of the presentation? What message do you want your audience to take with them and apply to clinical care? Reiterating the key points through repetition is crucial for long-term memory. Leave the audience with additional thoughts for exploration and subsequent discussion. How can your work or topic be further translated into additional projects for investigation? If the lecture material contains abundant clinical information beyond 3 points, a handout can be helpful to avoid having learners struggling to keep up with notes. This piece of take-home material can serve as a tool for subsequent study and to stimulate enhanced memory of the subject material provided. A strong concluding message can consolidate and remind learners of the scope of the topic and highlight the vital information that should be retained.

Final Thoughts

In summary, the clinical lecturer provides a unique teaching experience, and all physicians should feel proficient in formulating and delivering an educational lecture. These simple tips that call for the teacher to know and prepare his/her key message to deliver an animated and engaged presentation and then to summarize key findings are suggestions for the utmost transmission of data and ideas for all learners.

Acknowledgment
A special thank you to Joan E. St. Onge, MD (Miami, Florida), for her help providing resources for this topic. 

As lifelong learners, physicians are encouraged and expected to share their knowledge base with budding residents and students. Effective communication is essential to the utmost delivery of clinical knowledge and pearls. Lecture delivery is important for all stages of learning, and adapting efficient techniques early in one's career is critical for the transmission of ideas and teaching points. These tips were created to help formulate guidelines for physician presentations and are open for interpretation. These well-meaning suggestions can be integrated into one's toolbox to foster an enthusiastic educational arena.

Step 1: Know Your Key Message 

First and foremost, one should ruminate over the overall message of the lecture. Consider at least 3 main points you want the learner to gain and remember on completion of the lecture. Additionally, it is crucial to think about the audience who will be present for your message and how to deliver your ideas clearly and effectively. Be cognizant of the knowledge base of your listeners and gauge how much initial background information is needed; conversely, if the audience is familiar with the material, excessive introductory material may be unnecessary and cause inattentiveness. Simplicity, both within the inherent message itself and the content and layout, can ameliorate the transmission of data regardless of the audience. A mentor once told me that no slide should contain more than 13 lines of text. Furthermore, if you are counting the number of lines, then you likely need to reduce the text and simplify the slide. Each slide should contain a maximum of 3 or 4 bullet points.¹ Convoluted figures should be avoided and key points should be highlighted. Overall, know your take-home message and provide the listener with simplistic text and images to convey the key ideas at their educational level.

Step 2: Prepare

Preparation is of utmost importance. Reading over the slides several times prior to the presentation is vital. You are the assumed expert on the topic and meticulously knowing the subject matter helps with the confidence of your delivery. Ease of subject matter also helps you, as the presenter, to rely less on verbatim reading of the slides and allows you to interact more with your audience. It is important to be familiar with the order of your presentation as well as the phrases and figures provided.² Flipping back and forth through slides can be distracting to the audience and can make the order of your presentation seem incongruous, presenting as a hastily constructed lecture. If you are prepared, you can engage your audience and provide additional information that is not on the slides to maintain interest. Remember that reading the slides can reduce your voice to a monotone, subtracting enthusiasm and energy from the delivery of your talk.² Rehearsal helps give you the freedom to confidently and proudly present your subject material.

Step 3: Be Animated 

You are the main attraction and the performer of this lecture. Radiate the confidence you gained from being prepared with the ability to engage in eye contact and gestures as needed to convey your point. Regularly shift your focus around the room to attempt to involve as many people as possible in your talk.² Your main focus should be your audience and not your slides; the slides should simply help guide your talk.³ During your presentation, you also can ask rhetorical questions that you can then answer to keep the group engaged (eg, "So, what does this tell us?" or "What would you do next?"). These questions demonstrate to your audience that you are interested in their attention and can help reciprocate the enthusiasm. Use language that involves your audience as a group participant. For example, when looking at visual aids, introduce them by saying "If we look at this table, we can see that . . ." or "This figure shows us that . . ."^2,3 Additionally, be cognizant of the volume and pace of your voice. During key points, you may want to slightly raise your voice and slow your pace for emphasis. Anxiety can make all presenters speed through their material; however, try to be mindful of the rhythm of your speech. With preparation you should be able to accurately gauge the length of your presentation but also adapt to the necessary time constraints if too much time is spent on one point early on. Most would believe that all good lectures end at least a few minutes early to allow for questions and comprehension of the material as well as to provide your audience with time to move on to their next engagement or clinical duty. 

Step 4: Encourage Active Participation

Active audience participation is shown by a multitude of studies to provide the highest level of comprehension.^4,5 In a crossover study conducted by Bleske et al,⁴ 30 students were divided into 2 groups and were taught 6 therapeutic topics, with 3 topics provided by conventional lecture and 3 topics taught by team-based learning. At the end of the educational series, the students were surveyed to evaluate their confidence and attitudes. Students demonstrated not only higher examination scores with team-based learning but higher confidence in their ability to transmit the information garnered through therapeutic recommendations.⁴ Although small, this study highlights the intuitive notion that active learning with subject material, either by sharing ideas with colleagues or having small brainstorming discussions throughout lectures, helps consolidate the information for long-term memory and comprehension.

Additionally, teaching in a medical environment can present unique challenges, as participants may feel anxiety over having right or wrong answers due to fear of inadequacy among their scholarly peers. Neher et al⁶ proposed a 5-step "microskills" model for teaching young physicians, and although it is intended for a clinical setting, it also can be applied to engaging and answering questions from a medical audience in general. Their model focuses on the teacher, or in our case the lecturer, asking a question and then applying the following model: (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done right, and (5) correct mistakes.⁶ After asking your question, the student commits to an answer and must then provide supporting details for their choice, thus feeling more responsible for their collaborative role in problem-solving. Based on their answer, you can then teach your general rule, provide positive feedback on what the student said accurately, and ultimately correct any erroneous information. This prototype of learning is best utilized in the clinical setting but also can enhance participant engagement in lectures while maintaining an inviting educational environment. 

Step 5: Summarize 

Lastly, conclude your presentation with at least 3 memorable points. What was the point of the presentation? What message do you want your audience to take with them and apply to clinical care? Reiterating the key points through repetition is crucial for long-term memory. Leave the audience with additional thoughts for exploration and subsequent discussion. How can your work or topic be further translated into additional projects for investigation? If the lecture material contains abundant clinical information beyond 3 points, a handout can be helpful to avoid having learners struggling to keep up with notes. This piece of take-home material can serve as a tool for subsequent study and to stimulate enhanced memory of the subject material provided. A strong concluding message can consolidate and remind learners of the scope of the topic and highlight the vital information that should be retained.

Final Thoughts

In summary, the clinical lecturer provides a unique teaching experience, and all physicians should feel proficient in formulating and delivering an educational lecture. These simple tips that call for the teacher to know and prepare his/her key message to deliver an animated and engaged presentation and then to summarize key findings are suggestions for the utmost transmission of data and ideas for all learners.

Acknowledgment
A special thank you to Joan E. St. Onge, MD (Miami, Florida), for her help providing resources for this topic. 

As lifelong learners, physicians are encouraged and expected to share their knowledge base with budding residents and students. Effective communication is essential to the utmost delivery of clinical knowledge and pearls. Lecture delivery is important for all stages of learning, and adapting efficient techniques early in one's career is critical for the transmission of ideas and teaching points. These tips were created to help formulate guidelines for physician presentations and are open for interpretation. These well-meaning suggestions can be integrated into one's toolbox to foster an enthusiastic educational arena.

Step 1: Know Your Key Message 

First and foremost, one should ruminate over the overall message of the lecture. Consider at least 3 main points you want the learner to gain and remember on completion of the lecture. Additionally, it is crucial to think about the audience who will be present for your message and how to deliver your ideas clearly and effectively. Be cognizant of the knowledge base of your listeners and gauge how much initial background information is needed; conversely, if the audience is familiar with the material, excessive introductory material may be unnecessary and cause inattentiveness. Simplicity, both within the inherent message itself and the content and layout, can ameliorate the transmission of data regardless of the audience. A mentor once told me that no slide should contain more than 13 lines of text. Furthermore, if you are counting the number of lines, then you likely need to reduce the text and simplify the slide. Each slide should contain a maximum of 3 or 4 bullet points.¹ Convoluted figures should be avoided and key points should be highlighted. Overall, know your take-home message and provide the listener with simplistic text and images to convey the key ideas at their educational level.

Step 2: Prepare

Preparation is of utmost importance. Reading over the slides several times prior to the presentation is vital. You are the assumed expert on the topic and meticulously knowing the subject matter helps with the confidence of your delivery. Ease of subject matter also helps you, as the presenter, to rely less on verbatim reading of the slides and allows you to interact more with your audience. It is important to be familiar with the order of your presentation as well as the phrases and figures provided.² Flipping back and forth through slides can be distracting to the audience and can make the order of your presentation seem incongruous, presenting as a hastily constructed lecture. If you are prepared, you can engage your audience and provide additional information that is not on the slides to maintain interest. Remember that reading the slides can reduce your voice to a monotone, subtracting enthusiasm and energy from the delivery of your talk.² Rehearsal helps give you the freedom to confidently and proudly present your subject material.

Step 3: Be Animated 

You are the main attraction and the performer of this lecture. Radiate the confidence you gained from being prepared with the ability to engage in eye contact and gestures as needed to convey your point. Regularly shift your focus around the room to attempt to involve as many people as possible in your talk.² Your main focus should be your audience and not your slides; the slides should simply help guide your talk.³ During your presentation, you also can ask rhetorical questions that you can then answer to keep the group engaged (eg, "So, what does this tell us?" or "What would you do next?"). These questions demonstrate to your audience that you are interested in their attention and can help reciprocate the enthusiasm. Use language that involves your audience as a group participant. For example, when looking at visual aids, introduce them by saying "If we look at this table, we can see that . . ." or "This figure shows us that . . ."^2,3 Additionally, be cognizant of the volume and pace of your voice. During key points, you may want to slightly raise your voice and slow your pace for emphasis. Anxiety can make all presenters speed through their material; however, try to be mindful of the rhythm of your speech. With preparation you should be able to accurately gauge the length of your presentation but also adapt to the necessary time constraints if too much time is spent on one point early on. Most would believe that all good lectures end at least a few minutes early to allow for questions and comprehension of the material as well as to provide your audience with time to move on to their next engagement or clinical duty. 

Step 4: Encourage Active Participation

Active audience participation is shown by a multitude of studies to provide the highest level of comprehension.^4,5 In a crossover study conducted by Bleske et al,⁴ 30 students were divided into 2 groups and were taught 6 therapeutic topics, with 3 topics provided by conventional lecture and 3 topics taught by team-based learning. At the end of the educational series, the students were surveyed to evaluate their confidence and attitudes. Students demonstrated not only higher examination scores with team-based learning but higher confidence in their ability to transmit the information garnered through therapeutic recommendations.⁴ Although small, this study highlights the intuitive notion that active learning with subject material, either by sharing ideas with colleagues or having small brainstorming discussions throughout lectures, helps consolidate the information for long-term memory and comprehension.

Additionally, teaching in a medical environment can present unique challenges, as participants may feel anxiety over having right or wrong answers due to fear of inadequacy among their scholarly peers. Neher et al⁶ proposed a 5-step "microskills" model for teaching young physicians, and although it is intended for a clinical setting, it also can be applied to engaging and answering questions from a medical audience in general. Their model focuses on the teacher, or in our case the lecturer, asking a question and then applying the following model: (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done right, and (5) correct mistakes.⁶ After asking your question, the student commits to an answer and must then provide supporting details for their choice, thus feeling more responsible for their collaborative role in problem-solving. Based on their answer, you can then teach your general rule, provide positive feedback on what the student said accurately, and ultimately correct any erroneous information. This prototype of learning is best utilized in the clinical setting but also can enhance participant engagement in lectures while maintaining an inviting educational environment. 

Step 5: Summarize 

Lastly, conclude your presentation with at least 3 memorable points. What was the point of the presentation? What message do you want your audience to take with them and apply to clinical care? Reiterating the key points through repetition is crucial for long-term memory. Leave the audience with additional thoughts for exploration and subsequent discussion. How can your work or topic be further translated into additional projects for investigation? If the lecture material contains abundant clinical information beyond 3 points, a handout can be helpful to avoid having learners struggling to keep up with notes. This piece of take-home material can serve as a tool for subsequent study and to stimulate enhanced memory of the subject material provided. A strong concluding message can consolidate and remind learners of the scope of the topic and highlight the vital information that should be retained.

Final Thoughts

In summary, the clinical lecturer provides a unique teaching experience, and all physicians should feel proficient in formulating and delivering an educational lecture. These simple tips that call for the teacher to know and prepare his/her key message to deliver an animated and engaged presentation and then to summarize key findings are suggestions for the utmost transmission of data and ideas for all learners.

Acknowledgment
A special thank you to Joan E. St. Onge, MD (Miami, Florida), for her help providing resources for this topic. 

On December 13, 2016, the VA announced a change in its medical regulations to permit full practice authority for all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.This amendment removed the stipulation requiring physician supervision or collaboration for APRNs. Many states across the U.S. have similar statutes for APRNs.

Not surprisingly, the regulatorychange was met with resistance fromof the physician establishment. “TheAmerican Medical Association (AMA) is disappointed by the Department of Veterans Affairs’ unprecedented proposal to allow advanced practice nurses within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law,” Stephen R. Permut, MD, JD, AMA immediate past-chair wrote in a statement.

The American Academy of Physician Assistants (AAPA) then announced that it was “actively working with senior officials at the VA to institute a similar rule for PAs (physician assistants).” The well-intentioned AAPA statement seems misguided. It implies that PAs should be granted full practice authority because APRNs were granted the authority.

No matter the rational for granting APRNs full practice authority, the VA should not pursue similar regulations for PAs only because APRNs were granted the privilege. If the VA should institute a new amendment granting full practice authority to PAs, this action should be done independent of actions taken by any other nonphysician profession. Full practice authority for PAs should be based on training, clinical experience, and competency. Rather than adjusting the previously established threshold to obtain full practice authority to meet current PA standards, PAs should pursue further training and certification to earn this privilege. Physician assistant didactic and clinical training is based on the same model as training for medical doctors.

Physician assistant programs generally have 1 year of didactic training and 1 year of clinical training before trainees are eligible to take the Physician Assistant National Certifying Exam. Many schools, such as my alma mater, George Washington University School of Medicine, have PA students in the same lecture hall training side by side with medical students.

Medical doctor training generally includes 2 years of didactic training, 2 years of clinical training in medical school, and 3 years of clinical training in residency (for internal medicine) before trainees are eligible to take the American Board of Internal Medicine (ABIM) exam. The didactic training in PA programs mirrors that of medical doctor programs. The real difference in education and preparation is the duration of clinical training; 1 year of clinical training for PAs vs 5 years of clinical training for MDs.

Therefore, my suggestion would be that leaders within the PA profession should work with the ABIM to create a pathway in which PAs who work in the VA could take the ABIM exam after 4 years of clinical experience. If a PA employed by the VA passes the ABIM exam, they would be granted full practice authority within their scope of practice at the VA. This requirement would validate that these PAs warrant this privilege and subsequently satisfy physician concerns by showing that they have passed the same exam required of physicians. Moreover, this additional level of preparation and testing would increase the competency of PAs and the quality of care they provide to the veterans they serve.

On December 13, 2016, the VA announced a change in its medical regulations to permit full practice authority for all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.This amendment removed the stipulation requiring physician supervision or collaboration for APRNs. Many states across the U.S. have similar statutes for APRNs.

Not surprisingly, the regulatorychange was met with resistance fromof the physician establishment. “TheAmerican Medical Association (AMA) is disappointed by the Department of Veterans Affairs’ unprecedented proposal to allow advanced practice nurses within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law,” Stephen R. Permut, MD, JD, AMA immediate past-chair wrote in a statement.

The American Academy of Physician Assistants (AAPA) then announced that it was “actively working with senior officials at the VA to institute a similar rule for PAs (physician assistants).” The well-intentioned AAPA statement seems misguided. It implies that PAs should be granted full practice authority because APRNs were granted the authority.

No matter the rational for granting APRNs full practice authority, the VA should not pursue similar regulations for PAs only because APRNs were granted the privilege. If the VA should institute a new amendment granting full practice authority to PAs, this action should be done independent of actions taken by any other nonphysician profession. Full practice authority for PAs should be based on training, clinical experience, and competency. Rather than adjusting the previously established threshold to obtain full practice authority to meet current PA standards, PAs should pursue further training and certification to earn this privilege. Physician assistant didactic and clinical training is based on the same model as training for medical doctors.

Physician assistant programs generally have 1 year of didactic training and 1 year of clinical training before trainees are eligible to take the Physician Assistant National Certifying Exam. Many schools, such as my alma mater, George Washington University School of Medicine, have PA students in the same lecture hall training side by side with medical students.

Medical doctor training generally includes 2 years of didactic training, 2 years of clinical training in medical school, and 3 years of clinical training in residency (for internal medicine) before trainees are eligible to take the American Board of Internal Medicine (ABIM) exam. The didactic training in PA programs mirrors that of medical doctor programs. The real difference in education and preparation is the duration of clinical training; 1 year of clinical training for PAs vs 5 years of clinical training for MDs.

Therefore, my suggestion would be that leaders within the PA profession should work with the ABIM to create a pathway in which PAs who work in the VA could take the ABIM exam after 4 years of clinical experience. If a PA employed by the VA passes the ABIM exam, they would be granted full practice authority within their scope of practice at the VA. This requirement would validate that these PAs warrant this privilege and subsequently satisfy physician concerns by showing that they have passed the same exam required of physicians. Moreover, this additional level of preparation and testing would increase the competency of PAs and the quality of care they provide to the veterans they serve.

On December 13, 2016, the VA announced a change in its medical regulations to permit full practice authority for all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.This amendment removed the stipulation requiring physician supervision or collaboration for APRNs. Many states across the U.S. have similar statutes for APRNs.

Not surprisingly, the regulatorychange was met with resistance fromof the physician establishment. “TheAmerican Medical Association (AMA) is disappointed by the Department of Veterans Affairs’ unprecedented proposal to allow advanced practice nurses within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law,” Stephen R. Permut, MD, JD, AMA immediate past-chair wrote in a statement.

The American Academy of Physician Assistants (AAPA) then announced that it was “actively working with senior officials at the VA to institute a similar rule for PAs (physician assistants).” The well-intentioned AAPA statement seems misguided. It implies that PAs should be granted full practice authority because APRNs were granted the authority.

No matter the rational for granting APRNs full practice authority, the VA should not pursue similar regulations for PAs only because APRNs were granted the privilege. If the VA should institute a new amendment granting full practice authority to PAs, this action should be done independent of actions taken by any other nonphysician profession. Full practice authority for PAs should be based on training, clinical experience, and competency. Rather than adjusting the previously established threshold to obtain full practice authority to meet current PA standards, PAs should pursue further training and certification to earn this privilege. Physician assistant didactic and clinical training is based on the same model as training for medical doctors.

Physician assistant programs generally have 1 year of didactic training and 1 year of clinical training before trainees are eligible to take the Physician Assistant National Certifying Exam. Many schools, such as my alma mater, George Washington University School of Medicine, have PA students in the same lecture hall training side by side with medical students.

Medical doctor training generally includes 2 years of didactic training, 2 years of clinical training in medical school, and 3 years of clinical training in residency (for internal medicine) before trainees are eligible to take the American Board of Internal Medicine (ABIM) exam. The didactic training in PA programs mirrors that of medical doctor programs. The real difference in education and preparation is the duration of clinical training; 1 year of clinical training for PAs vs 5 years of clinical training for MDs.

Therefore, my suggestion would be that leaders within the PA profession should work with the ABIM to create a pathway in which PAs who work in the VA could take the ABIM exam after 4 years of clinical experience. If a PA employed by the VA passes the ABIM exam, they would be granted full practice authority within their scope of practice at the VA. This requirement would validate that these PAs warrant this privilege and subsequently satisfy physician concerns by showing that they have passed the same exam required of physicians. Moreover, this additional level of preparation and testing would increase the competency of PAs and the quality of care they provide to the veterans they serve.