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2010 Annual Meeting
SESSION DETAILS - WORKSHOPS & SYMPOSIA

SESSIONS BY DATE / TIME

Thursday, November 11 1:45–3:45pm Workshops 1–6 Symposia 1–2
Friday, November 12 9:30–11:30am Workshops 7–10 Symposia 3–5
1:30–3:30pm Workshops 11–15 Symposia 6–7
3:40–5:40pm Workshops 16–20 Symposia 8–9
Saturday, November 13 2:15–4:15pm Workshops 21–24 Symposia 10–12
4:30–6:30pm Workshops 25–27 Symposia 13–16

SESSIONS BY PROGRAM TRACK
W=Workshop, S=Symposium

  Care Models (CM) Early Career (EC) Educating Trainees (ET) Ethical & Management Challenges (EMC) Potpourri (P) PM Sub-
specialties (PS)
Therapeutics (T)
Thursday, 1:45–3:45 W5 W3 W2 W1 and S2 W4 S1 W6
Friday, 9:30–11:30 W8 W7 W9 S5 W10 S3 S4
Friday, 1:30–3:30 S6 W11 W13 W14 W12 S7 W15
Friday, 3:40–5:40 W16 W18 S8 W20 W17 W19 S9
Saturday, 2:15–4:15 S10 W22 W21 W24 W23 S11 S12
Saturday, 4:30–6:30 S13 S15 W25 S16 S14 W27 W26

 

THURSDAY, NOVEMBER 11, 2010     1:45–3:45 PM     Workshops 1–6, Symposia 1–2

WORKSHOP 1:
Forensic Issues in the General Hospital: Educational Approaches and Effective Management

Program Track: Ethical and Management Challenges (EMC)

Chair & Moderator: Theodore A. Stern, MD, FAPM

Presenters:

Marlynn Wei, MD, JD: Capacity and Informed Consent

Rebecca Brendel, MD, JD, FAPM: Capacity Assessments for Guardianship and Surrogate Decision-Making

Judith Edersheim, MD, JD: Suicide Risk, Violence Risk Assessment, and the Duty to Warn/Protect

Anna Glezer, MD: Medical and Psychiatric Use of Restraints

Abstract:

Forensic issues arise frequently in the practice of psychosomatic medicine. Medical and surgical colleagues often consult psychiatrists for legal and quasi-legal questions such as a patient's decision-making capacity, the need for a surrogate decision-maker, a patient's risk of violence or harm, and the use of physical restraints. While these topics arise frequently in practice, they may generate confusion and inconsistency from institution to institution and among psychosomatic psychiatrists and other physicians within the same institutions.

This workshop identifies four commonly encountered forensic topics in the general hospital setting, and practical strategies for identification and management of these topics will be presented, as outlined below.  In addition, the workshop will present core concepts and strategies for presenting and understanding the material that may be employed in teaching about these core legal concepts in psychosomatic medicine to trainees and colleagues alike.

  • In the first portion of this workshop, Dr. Wei will review the clinical assessment of capacity for medical decision-making and address the legal principles surrounding the importance of capacity as a requirement for informed consent.  The clinical and legal underpinnings of capacity and informed consent will be synthesized into a practical model for psychosomatic medicine practice and a concise and consistent model for teaching.
  • While psychosomatic psychiatrists are generally familiar with the evaluation of capacity to make medical decisions, capacity evaluations for the purpose of identifying, assigning or appointing, and invoking substitute decision-makers require a comprehensive evaluation for cognitive and well as functional abilities. Dr. Brendel will present a clinical and conceptual model for use in practice and in education.
  • Drawing on her vast experience in teaching about and evaluating patients related to risk of harm to self and to others, Dr. Edersheim will present an approach to violence in the general hospital incorporating clinical pearls, bedside techniques, and tools for teaching about these assessments.
  • Psychiatrists are generally familiar with the use of physical restraints for behavioral purposes in psychiatric settings.  However, physical restraint is now more widespread in general hospital settings than on psychiatric inpatient units and is regulated by different principles and regulations than behavioral restraint. Dr. Glezer will review the clinical, legal, and regulatory underpinnings of physical restraint for psychiatric and medical purposes.

WORKSHOP 2:
Integrating Educational Programs into Outpatient Psychosomatic Medicine Settings: How We Teach Our Colleagues and Trainees

Program Track: Educating Trainees (EC)

Presenters:

Pamela N. Diefenbach, MD, FAPM: Primary Care and Mental Health Collaboration: A Multi-Discipline Teaching Program

Nehama Dresner, MD, FAPM: Embedding and Recreating: Women's Mental Health in the Hospital and Private Setting

Robert C. Joseph, MD, MS, FAPM: Psychiatry Training in Public Sector Integrated Medical Clinics

Wayne J. Katon, MD, FAPM: Teaching Behavioral Sciences in a Family Medicine Program: A 30 year Experience

Leopoldo Pozuelo, MD, FAPM and Elias Khawam, MD: Outpatient Psychosomatic Clinic: The Trainee's Perspective

James R. Rundell, MD, FAPM: Differentiating Educational Goals when Psychosomatic Medicine Fellows, Psychiatry Residents, and Medical Students Are Training Together in a Team-based Outpatient Psychosomatic Medicine Practice

Abstract:

This workshop will focus on educational programs in outpatient psychosomatic settings. The presenters work in a variety of outpatient settings, diverse psychosomatic sites, different supported backgrounds including private sector, government and academic institutions, and all have developed training programs at their sites. During this workshop, the presenters will describe their models of outpatient consultation, the groups to whom they offer the education, and how the education is integrated into the outpatient consultation and liaison process. This workshop should be helpful for those who are in the process of developing programs as well as offering additional educational ideas for existing programs. There will be time for audience participation to share their experiences and to ask questions of the presenters.

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WORKSHOP 3:
Research Success and Academic Advancement through Psychosomatic Medicine

Program Track: Early Career (EC)

Presenters:

Linda Ganzini, MD, MPH, FAPM: Overview

E. Sherwood Brown, MD, PhD: Funding for Research in Psychosomatic Medicine

Stephen J. Ferrando, MD, FAPM: Protocol-driven Research in Medically Ill Populations

Teresa Rummans, MD, FAPM: Career Development and Mentoring in Academic Psychiatry

Abstract:

In this workshop members of the APM research committee will discuss funding for research, conducting research, and advancing academically in psychosomatic medicine. Dr. Ganzini (chair) will begin with a brief overview of the topic. Dr. Brown will discuss funding sources (NIH/DOD, Foundations, Industry), grant writing and the NIH review process. Dr. Ferrando will discuss how to conduct protocol-driven research in a medically ill population, including study design. Dr. Rummans will review academic career development, mentoring, leadership opportunities and adaptation to the academic environment. The workshop is designed to be interactive with substantial time for questions and discussions.

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WORKSHOP 4:
Dynamic Bedside Psychiatry

Program Track: Potpourri (P)

Presenters:

Kemuel Philbrick, MD, FAPM

Wolfgang Soellner, MD, PhD

Kristin Somers, MD

Paul Summergrad, MD, FAPM

Abstract:

A brief historical review of the perceived relevance and role of psychodynamically informed consultative psychiatry followed by the atrophy of this element in psychosomatic medicine training programs during the "decade of the brain" will set the stage to address three questions:

  1. How does dynamically informed consultation provide added value for patients, colleagues, and trainees?
  2. Is inclusion of this skill set a worthwhile goal for training programs?
  3. How might this be accomplished?

Although early consultation psychiatrists were steeped in analytically informed assessment, this is an implicit, rather than explicit, goal in recent American and European efforts to delineate recommended objectives of psychosomatic medicine fellowship training programs. Faced with multiple competing pressures to efficiently care for ill medical/surgical patients, residents and fellows will better meet the needs of their patients when they are equipped to listen and think through the whole meaning of the patient's illness and suffering.

We will address these issues through presentation and panel discussion of three cases that illustrate the advantage provided by dynamically attuned consultation.

Case 1:  A patient whose personal dilemma or conflict is expressed in the here-and-now of an acute medical illness but which derives from important developmental and interpersonal history.

Case 2:  A patient and primary team whose shared conflict and consequent threat to effective medical care is a reflection of, and amplified by, antecedent psychological issues that do not adhere tidily to DSM categorization or permit a pharmacologic panacea.

Case 3:  A patient and/or family who elicits powerful responses in the primary medical team and/or the consulting psychiatry trainee, enabling fruitful examination of transference and counter-transference phenomena.

Further exploration of the thesis that cultivating dynamically informed assessment and formulation in psychosomatic training programs is worthwhile will be provided by a panel of C-L psychiatrists representing different vantage points, including: a recently-graduated fellow; a practicing consultation psychiatrist involved in education; and, experienced and analytically trained psychiatrists.

In conclusion, a review of methods whereby residency and fellowship programs can potentially strengthen the ability and comfort of trainees to integrate dynamic formulation into their consultative work will be shared.

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WORKSHOP 5:
Consultative/Collaborative Care for the Treatment of Perinatal Women with Mental Illness

Program Track: Care Models (CM)

Chair: Stacey Gramann DO, MPH

Presenters:

Rebecca Lundquist MD

Nancy Byatt DO, MBA

Jane Payne MD

Abstract:

Objectives: At the conclusion of this workshop session, the participant should be able to:

  • Discuss the various collaborative-care models providing mental health services within the primary care setting.
  • Describe the main components involved in creating a collaborative/consultative care approach to the care of perinatal women with mental illness.
  • Understand the role of the psychosomatic medicine psychiatrist in improving mental health delivery within the obstetric setting.

In the United States, the primary source of health care for women of reproductive age (18-44 yrs) is the primary care provider. Women comprise 68% of primary care clinician office visits, and often have limited access to mental health services. Often, the primary care clinician lacks training in screening, diagnosis, and treatment of mental illness. As a result, common psychiatric disorders such as postpartum depression are often undetected or mismanaged.

Growing evidence suggests collaborative-care treatment results in improved medication compliance, enhanced functional outcomes up to 5 years following treatment, and increased patient and provider satisfaction. This suggests that the development of a perinatal psychiatry consultative/collaborative care model could improve quality of care by providing convenient and timely access to psychiatric consultation for both patients and obstetrical providers, and engage perinatal women in psychiatric care. 

Drs. Gramann, Lundquist, Byatt, and Payne will lead a presentation and panel discussion reviewing the various collaborative-care models in primary care with a focus on the provision of psychiatric consultation within the obstetric clinic setting. They will share their experiences in developing women's mental health consultation clinics at the University of Massachusetts and Oregon Health Sciences University, providing an overview of the challenges and components of creating such a clinic.

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WORKSHOP 6:
Motivational Interviewing for Psychosomatic Medicine

Program Track: Therapeutics (T)

Presenters:

Steven Cole, MD, FAPM

Joji Suzuki, MD

Abstract:

Motivational Interviewing (MI) is, most recently, defined as a "collaborative, patient-centered form of guiding to elicit and strengthen motivation for change." There are 11 books on MI, over 800 publications and 180 clinical trials, 1200 trainers in 27 languages, and dozens of international, federal, state, and foundation research and dissemination grants. Four meta-analyses demonstrate effectiveness across multiple areas of patient behavior including substance abuse, smoking, obesity, and medication non-adherence. New data confirm the relevance of MI for psychiatrists and, especially, for psychomatic medicine: the life-expectancy of patients with severe mental illness is 32 years less than age and sex-matched controls and the risk of death from CV disease is 2-3x higher than controls. Despite this evidence and the compelling relevance of MI for psychosomatic medicine, most psychosomatic medicine physicians still have little appreciation of the principles and practice of MI.

Using interactive lectures, six high-definition video demonstration vignettes, and role-play techniques, this workshop offers psychosomatic physicians the opportunity to learn the core concepts of MI, as well as 7 basic and 13 advanced MI techniques. The workshop will also introduce participants to the use of an innovative motivational tool, Brief Action Planning (formerly UB-PAP), developed by the facilitator (who is a member of MINT: Motivational Interviewing Network of Trainers). Research on Brief Action Planning (B.A.P.) was presented at the First International Conference on MI (Interlaken, Switzerland 2008), as well at the Institute of Psychiatric Services (2009), the CDC (2009), and the HRSA Office of Rural Health Policy (2009).  The B.A.P. Checklist was published by the American Medical Association in its 2008 "Tipsheet for Physician Self-Management Support."

Participants will learn how to utilize the three core questions and seven basic skills of Brief Action Planning in a manner consistent with the "spirit of motivational interviewing." For patients with PUB (persistent unhealthy behavior), attendees will practice 13 additional evidence-based interventions from the Dr. Cole's textbook on communication, The Medical Interview: The Three Function Approach and/or from the robust repertoire of MI skills. The 3 core questions of Brief Action Planning supplemented by 17 additional communication skills represent an integrated set of "comprehensive motivational interventions" (CMI) which are relevant for patients across the full spectrum of readiness to change. Though designed as a basic course, the program will also be useful to practitioners with intermediate or advanced experience in MI (or other behavior change skills) because they will learn how to integrate Brief Action Planning and MI for clinical interventions and/or training purposes.

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SYMPOSIUM 1:
Psychiatric Consultation on Surgical Intensive Care Services

Program Track: Psychosomatic Subspecialties (PS)

Presenters:

Lawrence Park, MD

John Findley, MD

Shamim Nejad, MD

Gregory Fricchione, MD, FAPM

Patrick Aquino, MD

Thomas Cummings, MD

Abstract:

Psychiatric consultation on surgical intensive care services offers a unique challenge in clinical practice. While it is tempting to defer psychiatric involvement in an unresponsive and uncommunicative patient, a psychosomatic approach can add significant value to the care of patients in the surgical ICU. The pertinent knowledge base and clinical skill set of the psychiatric consultant in this setting varies greatly from other medical settings. The consulting psychiatrist may be required to treat severely injured/ill patients with multi-system involvement, receiving invasive treatments, who may be limited in their level of consciousness or ability to communicate. This symposium proposes addressing the following topics:

  • The role of the psychiatrist on the surgical intensive care service
  • Assessment of mental state in the unconscious or intubated patient
  • Psychiatric aspects of ventilator management
  • Management of pain, sedation and consciousness
  • Assessment and management of substance dependence and withdrawal
  • Management of traumatic brain injury

In addition, the need for the development of a psychosomatic surgical intensive care training program will be discussed.

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SYMPOSIUM 2:
Cancer’s Not Sexy: Psychological Impact of Sexual, Hormonal, and Reproductive Function in the Context of Cancer Treatment

Program Track: Ethical and Management Challenges (EMC)

Presenters:

Elizabeth A. Davis, MD

Ilana Braun, MD

Carlos Fernandez-Robles, MD

Donna Greenberg, MD, FAPM

Abstract:

Talking to patients about sexual health and functioning in the setting of cancer treatment is often foremost on the minds of patients, but challenging for providers to address. Specific issues that face patients undergoing cancer treatment include loss of fertility and libido, premature menopause, negative surgical outcomes, impotence, and change in body image.

This symposium will present a conceptual framework and practical model for obtaining a sexual history in the context of cancer treatment, identifying areas of concern regarding sexual image and function, and engaging patients in a therapeutic alliance to address sexual wellness during cancer treatment. This presentation will also present an approach to psychiatric evaluation and diagnosis in the setting of androgen deprivation and menopause-inducing therapies. Finally, the panelists will present preliminary data about characteristics, prevalence, and management of issues related to the sexual health, self-image, and functioning of their patients.

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FRIDAY, NOVEMBER 12, 2010     9:30–11:30AM     Workshops 7–10, Symposia 3–5

WORKSHOP 7:
Writing and Publishing 101

Program Track: Early Career (EC)

Presenters:

Thomas Wise, MD, FAPM

Maryland Pao, MD, FAPM

Lewis Cohen, MD, FAPM

Abstract:

"I get a fine warm feeling when I'm doing well, but that pleasure is pretty much negated by the pain of getting started each day. Let's face it, writing is hell."
    ...William Styron

"A writer is someone for whom writing is more difficult than it is for other people."
    ...Thomas Mann

"The secret to being a writer is that you have to write. It's not enough to think about writing or to study literature or plan a future life as an author. You really have to lock yourself away, alone, and get to work."
    ...Augusten Burroughs

This workshop is designed for both beginning and more experienced members of the Academy who have a desire to write and publish. While much of the focus will be on preparing papers, chapters, and books for an academic audience, it is also intended to convey lessons for those who aspire to write for the general public.

Dr. Wise was the editor of Psychosomatics for two decades, during which time he had a substantial opportunity to judge the elements of successful submissions to the Academy’s journal. He will describe from an editor’s perspective how authors can submit articles that cry out to be published, or alternatively, the common flaws and errors that contribute to rejections.

Dr. Pao is the clinical director of NIMH at the NIH Clinical Research Center in Bethesda. In addition to being an author or co-author of more than 60 medical publications, she has mentored numerous residents and fellows as they attempted to prepare manuscripts for publication. She will describe what she has learned about organizing and compiling research findings and other valuable tips for novice authors.

Dr. Cohen is a professor of psychiatry from Tufts University School of Medicine, who acquired a Guggenheim Fellowship that allowed him this year to publish his first non-fiction book for the general public. He will describe the process of preparing a formal proposal, securing the services of a literary agent, and working with a lay publishing company.

The workshop will be shaped by the questions, experiences, and interests of the audience, but topics will likely include: determination of authorship order, resolution of conflicts, selection of a journal, and how to acquire a lay publisher. Given William Styron’s quotation above, the workshop will also attempt to answer why we are driven to write!

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WORKSHOP 8:
Using Telemedicine to Provide Psychiatric Consultation to Underserved and Vulnerable Populations

Program Track: Care Models (CM)

Presenters:

Terry Rabinowitz, MD, FAPM

Katharine Murphy, RN, PhD

Harry Clark, MSMIIT

Stephen Taylor

Abstract:

Although a videoconference approach to delivering healthcare has been in use for many decades, its use for psychiatric consultations has been limited. This underutilization is due to several factors including: 1) lack of information about its availability; 2) so-called "technophobia" on the part of would-be users; 3) concern about high start-up and maintenance costs; 4) a paucity of well-designed studies demonstrating its effectiveness; and 5) the belief that psychiatric care delivered by videoconference can never be as good as that delivered face-to-face.

We recently reported our findings regarding the benefits of telepsychiatry consultations for rural nursing home residents that demonstrated significant cost and time savings as well as patient and provider satisfaction with this modality (Rabinowitz et al, Telemed J E-Health, 2010). In addition, discussions with other consultation psychiatrists have led us to conclude that the time is ripe and the technology so good, that high-quality telepsychiatry consultations can become a part of virtually every consulting psychiatrist's armamentarium, increasing the number of patients who might be served and bringing psychiatric services to many who might not otherwise receive it.

This workshop will have two main components:

  1. Two to four short presentations (about 45 minutes total) by experienced telemedicine clinicians and technicians that will introduce participants to consultation telepsychiatry and will address the potential impediments to its use listed above.
  2. An opportunity for all participants to use telemedicine equipment on-site and to interact with the clinicians and telemedicine technical experts.

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WORKSHOP 9:
Enhancing the Education of Residents and Medical Students on Psychosomatic Medicine Services (APM Education Committee Workshop)

Program Track: Educating Trainees (ET)

Moderator: Jorge Sotelo, M.D.

Presenters:

Kristen Brooks, MD

Lucy A. Epstein, MD

Thomas Heinrich, MD

Michael Marcangelo, MD

Theodore A. Stern, MD, FAPM

Abstract:

Psychosomatic medicine (PSM) services provide a unique opportunity for comprehensive training in psychiatry. Multidisciplinary collaborations related to the care of medical and surgical patients provide fertile ground for exposure to, and mastery of, core competencies in psychiatry, particularly with regard to medical knowledge, professionalism, and systems-based practice. Diagnosis and treatment of common conditions (e.g., depression, delirium, dementia, pain, substance abuse, anxiety, and psychosis) form the backbone of the rotation. Simultaneously, there is exposure to subspecialty experiences within psychiatry (e.g., perinatal psychiatry and transplantation) and end-of-life care.

Dr. Stern will discuss educational goals on these services as well as challenges confronted by trainees (e.g., varied caseloads, less structured daily schedules, consulting to services with different knowledge bases and experience levels, difficult ethical and clinical dilemmas, disagreements with other services, and consultation requests that may not appear psychiatric in nature). Dr. Heinrich will review outcome data on evaluations of the educational experience on these services and the state of psychosomatic medicine training in general adult psychiatry training programs across the country. Dr. Brooks will present an innovative curriculum for PSM training for psychiatry residents. Dr. Marcangelo will discuss the challenges of medical student education in psychiatry on PSM services, and Dr. Epstein will present recommendations for the optimization of the education experience for undergraduate trainees. Trainees, early career psychiatrists, and psychiatric educators will be encouraged to provide their perspectives to create an interactive and innovative workshop.

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WORKSHOP 10:
Facebook, Twitter, and Other Online Sources: How Should These Be Used in a Psychiatric Consultation?

Program Track: Potpourri (P)

Presenters:

Lois E. Krahn, MD, FAPM

Paul M. Berkowitz, MD

J. Michael Bostwick, MD, FAPM

Abstract:

In recent months there have been several examples of the venerable suicidal note becoming supplanted because, instead, suicidal and homicidal intent has been posted on the web. In March 2010, ten days after statements appeared on a Facebook posting indicating that a man may be suicidal, a murder-suicide is discovered in NC. Also in March 2010, after family members found an email confirming a purchase from a firing range, they attempted to alert police that their mentally ill son was unstable and armed.  Days later he opened fire without any additional warning at the entrance of the Pentagon. In February 2010, after posting a suicide note on the web and setting fire to his house, a man crashed his plane into the IRS offices in Austin, TX.

In a different context, patients presenting for a pretransplantation evaluation at times seek to enhance their acceptability by providing selective information to the transplant team.  Their family members also may hide data to present a favorable picture.

The internet can provides a searchable resource with many different types of data including personal communication (Facebook, Twitter), media accounts (local newspapers), government files (court records), and professional activities (Board of Medical Practice), among others.  Many of these sources can be accessed without any cost or permission.  When available, many users do not maximize the privacy settings to create password protection.

The conventional psychiatric assessment includes a patient interview and contact with family members to gain collateral information.  Family members may or may not be aware of the material readily available on the Internet. This workshop will examine several cases where online information was potentially available to the psychiatric consultation team. The objectives of this workshop are to examine the value of collateral data available on the Internet, processes for searching for this data, the reliability of this type of information, the impact of this data in cases with court or selection committees involvement, and the effect on the relationship between the patient and the psychiatric consultation team of additional data not disclosed by the patient directly. The presenters have experience in consultation in both public and private medical centers.

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SYMPOSIUM 3:
Educating Clinicians about HIV-Associated Dementia (APM AIDS Psychiatry SIG Symposium)

Program Track: Psychosomatic Subspecialties (PS)

Chair: Mary Ann Cohen, MD, FAPM

Discussant: Harold W. Goforth, MD, FAPM

Presenters:

Jordi Blanch, MD: Risk Factors for HIV-Associated Neurocognitive Disorders (HAND)

Adriana Carvalhal, MD, MSc, PhD: Early Recognition of HIV-Associated Dementia: Differential Diagnosis

Stephen J. Ferrando, MD, FAPM: Early Recognition of HAD: Complexities of Assessment and Screening

Andrew Angelino, MD and John Grimaldi, MD: Developing Screening Tools for HAD and Assessing Current Practices

John Grimaldi, MD and Andrew Angelino, MD: Prevention and Treatment of HAD and HAND: What Works and What Does Not Work

Abstract:

The transformation of AIDS from a rapidly fatal and acute illness to a chronic complex and severe medical illness for persons with access to competent medical care and combination antiretroviral therapy (CART) has resulted in the need for heightened attention to the preservation of neurocognitive function to enable persons with AIDS to live healthy and meaningful lives. Since HIV has a special affinity for brain and neural tissue, it enters the brain early during the course of illness and can affect cognition. This symposium presents strategies for the education of clinicians on how to prevent, recognize, and treat HIV-associated dementia (HAD) and HIV-associated neurocognitive disorders (HAND).

We discuss educational strategies from five different perpectives:

  1. We present the major factors that have been identified as significant contributors to the progression of neurocognitive impairment in persons with HIV and those that have a neuroprotective function.
  2. Cognitive impairment in persons with HIV and AIDS may be multifactorial and may be related to toxic, metabolic, infectious, neoplastic, hypoxic, endocrine, renal, hepatic other factors. We present a differential diagnosis of HIV-related and HIV-unrelated causes of cognitive impairment.
  3. We then discuss the use of special screening tools designed to detect early HAD and present those used in clinical practice.
  4. We provide an in-depth discussion of the complexities involved in the assessment and screening for HAD and HAND.
  5. Clinicians will learn the most effective preventive and therapeutic strategies in the care of persons with HIV-associated dementia.

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SYMPOSIUM 4:
New Developments in Preventing Delirium in Critical Care Settings: A Role for Dexmedetomidine

Program Track: Therapeutics (T)

Discussant: Paula T. Trzepacz, MD, FAPM

Presenters:

Amanda Wilson MD: Review of the Research Findings of Increased Postdischarge Mortality Reported by Wesley Ely, MD and Colleagues

Hannah Wunsch MD, MSc: Pharmacology and Proposed Mechanisms of Action in Reducing Delirium Occurrence

Jose Maldonado MD, FAPM: Review of the Literature on the Use of Other Pharmacological Interventions to Reduce Delirium Incidence

Abstract:

Delirium in critical care settings ranges between 60-80% and is associated with higher lengths of stay, and an increased rate of post-discharge cognitive decline and mortality even when controlling for severity of illness. It may also be a marker for unrecognized premorbid cognitive impairment and a risk for subsequent cognitive decline. Further, there is evidence to suggest that the longer the delirious the episode, the worse the prognosis.

Given these data, intensivists, anesthesiologists, and C-L psychiatrists are now combining efforts toward improving recognition, prevention, and management of delirium. Three panelists representing each of these disciplines will discuss newer findings on delirium in intensive care settings including data suggesting that dexmedetomidine may help to reduce the delirium burden in these settings as compared to other traditionally used medications like propofol.

Dr. Wilson, consulting C-L psychiatrist to the Vanderbilt ICU, will review the research findings of increased post-discharge mortality reported by Wesley Ely, MD and colleagues; Dr. Wunsch of the Anesthesiology Department at Columbia and author of last year's JAMA editorial on the promise of dexmedetomidine will discuss its pharmacology and proposed mechanisms of action in reducing delirium occurrence; Dr. Maldonado will review the literature on the use of other pharmacological interventions to reduce delirium incidence, and his own research with dexmedetomidine at Stanford University School of Medicine. Dr. Trzepacz will serve as discussant of the presentations and offer her unique perspective as one of the world's leading delirium researchers on vulnerability and causality for ICU delirium and its outcomes, including moderating and mediating factors of delirium prevention and treatment strategies.

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SYMPOSIUM 5:
Multidisciplinary Management of Difficult Behavior in Oncology Outpatients

Program Track: Ethical and Management Challenges (EMC)

Presenters:

Fremonta L. Meyer, MD

John R. Peteet, MD

Rachel Y. Lynn, MD

Courtney Davis, MSW

Abstract:

Angry, threatening, or otherwise disruptive behavior by patients can interfere with necessary oncologic treatment, sometimes to the point of rendering continued care impossible. This APOS-sponsored symposium offers mental health clinicians guidance in dealing with difficult outpatients by discussing the differential diagnosis and multidisciplinary management of treatment-disrupting behavior in the ambulatory oncology setting. We review the existing literature on dealing with difficult patients and present our clinical experiences at comprehensive cancer centers where formalized, institutional processes for responding to disruptive outpatients were developed.

A structured, multidisciplinary approach to deal with difficult behavior in oncology outpatients can improve care and staff morale. By this approach, staff identify causes of treatment-disrupting behavior, develop and implement appropriate behavior plans, facilitate communication, address mental health issues, and ensure that decisions to terminate the relationship to a patient are ethical, clinically justified, and supported by due process. Ancillary departments at each institution, such as Patient and Family Relations and Risk Management, are integral to an organized plan of action. They respond to patient and staff concerns, schedule team and patient meetings, and if necessary help draft letters from the team and/or institution to the patient setting forth behavioral expectations, consequences, and options for transferring care elsewhere. We will invite the audience to participate in a multidisciplinary panel discussion of approaches to difficult behavior.

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FRIDAY, NOVEMBER 12, 2010   1:30–3:30 pm  Workshops 11–15, Symposia 6–7

WORKSHOP 11:
Rounds in the General Hospital: See One, Do One, Teach One?

Program Track: Early Career (EC)

Chair: Theodore A. Stern, MD, FAPM

Presenters:

John L. Shuster, Jr., MD, FAPM

Anne F. Gross, MD

Scott Beach, MD

Donald L. Rosenstein, MD, FAPM

Abstract:

Rounds serve as a core training experience for all trainees and staff on Psychosomatic Medicine services. However, the manner in which they are carried out differs widely, as does the scope of the material covered (with varying emphasis placed on biological, psychological, social, and existential factors).  Moreover, the tenor set by the leader of rounds shapes both the lyrics and the music of rounds, as well as the interactivity and involvement of the participants.  By seeing how rounds can be run during this workshop (and by presenting cases at these rounds), attendees will have the opportunity to observe in real-time how clinicians approach complex cases and how they attempt to impart knowledge to others.  In addition, the outline for a case report/case conference (based on a case presented) will be generated by the end of the symposium, and be written and fine-tuned by the participants by the end of the APM meeting.

Learning objectives:

  1. To learn effective strategies for presenting and framing cases.
  2. To learn methods for running rounds more effectively.
  3. To learn methods for how to generate ideas for further inquiry (and publication).

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WORKSHOP 12:
Spiritual Assessment in Medical Settings: Approaching and Assessing Spiritual and Religious Issues & Experiences in the Medically Ill

Program Track: Potpourri (P)

Presenters:

Gregory Fricchione, MD, FAPM: A Review of the Recent Literature on the Impact of Spirituality

Bernard Vaccaro, MD, FAPM: Approaches Toward and Methods of Assessing Spiritual Issues

John Peteet, MD: The Difficulty Around Encountering Patients Whose Values and Belief Systems Are Different from Our Own

Abstract:

The goals of this workshop are to prepare the participants for assessment of psychospiritual issues in patients in medical settings.

Dr. Fricchione will begin our discussion by a review of the recent literature on the impact of spirituality and spiritual beliefs in medical settings, looking at both psychological and physiological outcomes of this research.

Dr. Vaccaro will follow up with a discussion of approaches towards and methods of assessing spiritual issues, will review several instruments that have been validated, and will discuss ways of incorporating spirituality into hospital care. Dr. Vaccaro will also discuss approaching anomolous experiences of patients, how to understand and explore reports of patients about thier personal prayer experiences, which may include visions, near death experiences, and similar events.

Dr. Peteet will discuss the difficulty around encountering patients whose values and belief systems are different than our own. We will discuss the ways in which our personal countertransference can interfere with our ability to connect with and be helpful to patients who are in crisis in the medical setting, and ways to become aware of our countertransference issues and use them as cues to improving our interactions with patients.

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WORKSHOP 13:
Teaching Psychosomatic Medicine Topics in the Small Group Setting and Session Planning Techniques

Program Track: Educating Trainees (ET)

Presenters:

Paula DelRegno, MD

Zhanna Elberg, MD

Abstract:

Objectives:  After attending this workshop participants will be able to:

  1. Formulate measurable objectives for teaching sessions.
  2. Create a session plan useful in the small group setting.
  3. Apply small group teaching techniques in the didactic setting.

Psychosomatic Medicine is often the main setting in which medical student clerks, residents, and professionals in other fields get a glimpse of the clinical practice and importance of psychiatry. Despite the importance of didactic teaching in the educational process, few if any faculty receive formal training in instructional methods. Effective teaching in Psychosomatic Medicine allows physicians from all disciplines to better address the emotional and psychosocial needs of their medically ill patients.

In addition to clinical teaching, teaching in the classroom setting remains an integral part of medical education. Most didactic teaching during medical school clerkships and residency occurs in small groups of 25 students or less. Small group teaching helps students consolidate and enhance their understanding of the topic, develop their capacity for thinking critically and analytically, to learn to communicate effectively with others, to learn to collaborate and work as an effective group, to give and receive feedback, and to take progressively greater responsibility for their learning.

Both presenters will participate in the teaching of these skills and serve as small group facilitators in this hands-on workshop that introduces the concept of session-planning and highlights the importance of having organized and structured sessions. As part of this process, participants will learn how to create measurable objectives for their teaching sessions. They will learn critical facilitator skills and techniques to promote student participation and learning in small groups. These skills include adequate planning to determine appropriate seating arrangements, the use of handouts, and other media, overall session structure, and dealing with challenging learners. Participants will also learn about a variety of effective facilitator activities such as brainstorming, buzz groups, circular interviewing, "the line-up" and reflection. Materials will be provided to help participants plan effective teaching sessions and practice a variety of small-group teaching methods. This workshop will provide participants with take-home tools to enhance their skills for teaching Psychosomatic Medicine, or any topic in the small group setting.

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WORKSHOP 14:
This Is Not Your Analyst’s Tavistock: An Interactive Exercise in Untangling a “Messy” Consult

Program Track: Ethical and Management Challenges (EMC)

Presenters:

Sandra Rackley, MD

Kristin Somers, MD

J. Michael Bostwick, MD, FAPM

Abstract:

Group relations theory offers a lens through which to see challenging clinical scenarios more clearly. Rather than specifically pathologizing individuals, this theory considers the behavior and interactions of the group as a whole and the inevitable tensions that arise around boundaries, authority, and role. In the domain of consultation-liaison psychiatry, the model helps the psychiatrist "diagnose" where points of tension lie in problematic cases and then describe these to patient and care team in practical, non-pejorative terms as a first step toward overcoming the impasse and finding a resolution.

This fun, interactive workshop will begin with a brief introduction to the Tavistock model of group relations and a simple mnemonic — BARTAP — for remembering important aspects of this model. The majority of the workshop time will then be spent engaged in an applied Tavistock exercise built around a medical scenario that contains the kind of complicated dilemma psychosomatic psychiatrists encounter. Participants will be divided into small groups, with each group assigned a role of a "player" in the drama. Facilitators will act as consultants to the unfolding exercise. The groups will interact with each other with the task of reaching consensus on the most appropriate next steps in the case dilemma. Workshop participants will have the dual task of participating in the decision-making process while also observing the interactions of the group and describing points of tension. An after-exercise discussion will focus on what participants have learned and how they can apply the model to use in teaching Professionalism and Systems-Based Practice skills at their home institutions.

Because of the interactive nature of the exercise, participants will maximize their learning by arriving on time, but latecomers will also be accommodated. We have presented a successful workshop along similar lines in the past, but will be using a new case scenario this year, so that those who have participated in the workshop previously can have another opportunity to hone their skills.

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WORKSHOP 15:
Benzodiazepine Failure: What Treatments Should Be Tried Next (And Why) for Critically Ill Patients with Severe Alcohol Withdrawal Syndrome?

Program Track: Therapeutics (T)

Presenters:

Joshua Straus, MD, FAPM

Paul Berkowitz, MD

Shamim Nejad, MD

Abstract:

This workshop will utilize an interactive teaching format to illustrate key elements for timely recognition, diagnosis, effective treatment and stabilization of the critically ill patient with severe alcohol withdrawal syndrome (AWS).  The standard management of AWS in major textbooks of medicine, psychiatry and specialties in medicine has changed relatively little in nearly 50 years.   In the last few years scientific data has quietly accrued but not yet changed clinical best practices for treating this common clinical scenario.

Substantial numbers of basic science, animal, and human clinical studies in peer-reviewed journals provide a rational basis for interventions of acceptable risk when benzodiazepines fail to adequately stabilize a critically ill patient with AWS.  This presentation will summarize and rank the evidence for second-line treatments: some (but not all) anti-epileptic drugs; appropriate route and dose for thiamine (commonly given at an inadequate dose by the wrong route); evidence for NMDA glutamatergic mechanisms as crucial to understanding the development and progression of severe AWS and delirium tremens (DTs); role of GABA-B agonists and the possible beneficial role of calcium homo-taurine (acamprosate).

The presenters will outline their approach to risk/benefit assessment and documentation for these high risk AWS cases, as well as their experiences in working with critical care teams and pharmacy and therapeutics committees.  Common systems barriers, legal and ethical issues will be discussed. An overview of the U.S. Uniform Accident and Sickness Policy Provision Law (UPPL) will be presented, along with a summary of how it has discouraged for almost 50 years adequate emergency screening and evaluation for patients at the greatest risk for AWS.

The first hour will consist of a composite case, elaboration of the data supporting the proposed interventions, and will solicit opinions and discussion from participants. The second hour will consist of further detailed presentations of the basic and clinical science supporting the interventions suggested in the first hour, with time for questions and facilitated discussion with emphasis on sound and reasonable clinical practice approaches and methods where no definitive guidelines or evidence currently exists.

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SYMPOSIUM 6:
A European Perspective on C-L Psychiatry

Program Track: Care Models (CM)

Chairs: Wolfgang Soellner, PhD; Albert Leentjens, MD

Presenters:

Albert Leentjens, MD: The History and Diversity of C-L Psychiatry in Europe

Wolfgang Soellner, PhD: Training in C-L Psychiatry and Psychosomatics Across Europe

Silvia Ferrari, MD: C-L Psychiatry Inside and Outside the General Hospital: The Modena Model

Carsten Leue, MD: A Transmural Treatment Facility for Patients with Medically Unexplained Symptoms: The Maastricht Experience

Abstract:

To date, the European Union (EU) consists of 27 countries, with 23 official languages, 12 different currencies, and political and economical situations that vary widely between its member states. A number of well-known countries are not part of the EU, such as Norway and Switzerland. Between these countries there are large differences in health care organization, in the organizational level of the national psychiatric and psychosomatic associations, the scientific infrastructure, and postgraduate medical specialist training schemes. These differences pose a great challenge to efforts for international collaboration and harmonization between European countries. At the same time this diversity is a good fertilizer for exchange of ideas, as well as for diverse and innovative initiatives in health care organization. Some examples of this are the collaboration of C-L psychiatry with primary care in the north of Italy, or between hospital-based multidisciplinary care and community-based psychiatric care in Maastricht, the Netherlands.

As far as the level of organization of professional associations and the scientific infrastructure are concerned, some countries have set out on extensive guideline development and implementation programmes, with financial and scientific support of "national institutes of clinical excellence." Quality enhancing strategies including the development of quality indicators, routine outcome monitoring, accreditation of institutes and services, have been made into political targets with the aim of improving national health care. Countries fulfilling a leading role in this area are the United Kingdom, the Netherlands, and Germany. Although international associations such as the [C-L section of the] European Psychiatric Association (EPA) and the European Association of C-L Psychiatry and Psychosomatics (EACLPP) lobby towards more collaboration between countries and sharing expertise, in these front-runner countries the focus remains largely national, much to the disadvantage of those European countries that are less affluent and professionally less well organized.

In the field of postgraduate medical training, there is a tendency for increasing harmonization. Basic qualifications as a medical doctor are recognized throughout the EU, and the Union of European Medical Specialists has set up basic requirements for medical specialist training that are mandatory in member states. The ultimate aim is to come to a medical specialist certification that is acknowledged throughout the EU, and it is likely that this will be realized in the near future.

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SYMPOSIUM 7:
Update and Review of Emergency Psychiatry

Program Track: Psychosomatic Subspecialties (PS)

Chair: Seth Powsner, MD, FAPM

Presenters:

Carin Van Gelder, MD: Prehospital Care

Leslie Zun, MD: Medical Cearance

Rachel Glick, MD: Agitation

Divy Ravindranath, MD: Education

Abstract:

Emergent psychiatric consultation & evaluation is a critical component of mental health care in the US. Many psychiatric episodes present first to a general emergency department in a general hospital where they will be seen by C-L Psychiatry. This symposium will focus on consultation in a general emergency department because efficient and effective evaluation and intervention is key to patient care, to reducing emergency department gridlock, and to the safety of staff and patients. Unfortunately, emergency department consultation is often treated as an unwanted burden by C-L and Emergency Medicine departments alike.

This update and review will start by addressing three initial phases of emergent psychiatric care:

  • Prehospital care (CVG) — How do ambulance crews handle patients in extremis? Restraints? Medications? Who makes up an ambulance "crew"? What are they trained to handle? Who supervises? What can be improved? Could they determine which patients to deliver directly to psychiatric or substance abuse treatment?
  • Medical clearance (LZ) — What does "medically clear" mean? What elements of history, physical exam, and laboratory testing are pertinent? How do Emergency Medicine and Psychiatry decide who should have primary responsibility for a patient? Can we collaborate better, especially around treating psychiatric patients "boarding" in an emergency department?
  • Agitation (RLG — What does agitation really mean? What are the current alternatives over "5-2-1" (haloperidol et al)? What's the evidence for one pharmacologic intervention over another?

    And then consider:
  • Education (DV) — How do we effectively teach around an emergency department consultation? It is a setting rich in bio-psycho-social pathology. It is also a setting of greater acuity, greater chaos, and greater noise than most consultations. Traditional bedside rounds may be impossible; but, teachable moments should be common. Can we capitalize on this? Can we effectively teach Emergency Medicine residents and attendings? Could we go further? Could we expand our scope into the free standing PES (psychiatric emergency service), just as traditional C-L has expanded its scope into the outpatient clinic?

Our presenters will offer answers to these questions. This symposium aims to be the first collaborative effort between the American Association for Emergency Psychiatry (AAEP) and the Academy of Psychosomatic Medicine (APM). Three of us (Glick, Powsner, Ravindranath) have been members of both organizations, and there is a definite overlap of interests. We aim not only to update members of the audience who may have been too busy to keep up with changes in emergency psychiatric care, and answer their questions, but also to spur further collaborative meetings.

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FRIDAY, NOVEMBER 12, 2010   3:40–5:40 pm  Workshops 16–20, Symposia 8–9

WORKSHOP 16:
Erasing the Mystery of Medicare Documentation: Utilizing the CMS Scorecard to Review Compliance of Consultation and Progress Notes

Program Track: Care Models (CM)

Moderator: Christine Skotzko, MD FAPM

Facilitators: APM Clinical Practice Committee Members

Abstract:

As Medicare increases its auditing to uncover fraud, many psychosomatic medicine practitioners are faced with increased scrutiny of documentation utilized in their day to day clinical care. Those who work for academic and other healthcare organizations may now routinely be " audited " and told that they are incorrectly submitting charges for services rendered. This can be extremely frustrating as each of us works to provide competent, compassionate, and timely care to our patients in hospital, rehabilitation/NCF and outpatient sites. Those who practice privately and provide services to Medicare beneficiaries (opting into Medicare) are also subject to documentation audits.

While mystical to some, the tools that Medicare utilizes to review documentation are available to practitioners. Once familiar with the "scorecard" utilized, streamlining documentation can facilitate clinical care and improve reimbursement while decreasing risk of a negative audit outcome.

This workshop, supported and staffed by the Clinical Practice Committee, will allow clinicians to review consultation and progress notes utilizing the actual scorecards that coders utilize in auditing our records. Demystifying the standards against which we are measured should allow increased comfort completing documentation that will support services billed for while allowing the opportunity to reviewtemplates that others currently employ.

  • Introduction and welcome: overview of current Medicare audits with data regarding common documentation issues
  • Introduction of scorecard: review of components
  • Exercises utilizing the scorecard with examples of documentation; initial group participation will be followed by individual review for compliance with charges submitted.
  • Wrap up: education and empowerment of participants to contact their local Medicare mediators when questions arise in their geographic area.

At the end of this workshop participants should be much more familiar with standards currently being utilzed to evaluate documentation and billing.

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WORKSHOP 17:
What's Up Doc? Perspectives on Culture and Consultation Psychiatry

Program Track: Potpourri (P)

Presenters:

Rita Hargrave, MD

Jon Streltzer, MD, FAPM

Abstract:

This workshop focuses on how the cultural identity, belief systems, and emotions of healthcare providers affect how they work with patients in primary care and mental health treatment settings. Faculty and workshop participants will share their experiences and expertise through a three part educational program consisting of:

  1. Lecture and 15 minute video which demonstrates the use of the cultural genogram by a group of psychology trainees and nursing staff. This segment is designed to promote cultural self-awareness and sensitivity among providers.
  2. Viewing and discussion of a 15 minute vignette from "No Soy Loco/I'm Not Crazy: Understanding the Stigma of Mental Illness in Latinos." The group discussion will focus on clarifying cultural elements of the relationship between the patient and the clinician. Workshop participants will asked to respond to the following questions
    1. How important is it to understand the clinician's own cultural identity?
    2. What are the similarities in the cultural identity variables between the patient and clinician? What are the differences?
    3. How is relationship (rapport, communication, transference, counter-transference, etc.) affected by similarities/differences in the cultural identity variables between the patient and clinician?
    4. What types of positive emotional responses influenced by culture have viewers experienced in their work with patients?
    5. What types of negative emotional responses influenced by culture have viewers experienced in their work with patients?
  3. Lecture and slide presentation on how cultural values and beliefs influence medical practice and routines. Examples include expectations for recovery from myocardial infarction and beliefs about pain response and pain management.

Goal: To provide and health care professionals with an increased awareness of how culture, beliefs and behaviors of the patients and providers impact the quality and effectiveness of mental health/medical care of patients.

Objectives: Participants in this workshop will:

  1. Become aware of how their cultural identities and health beliefs influence their perceptions of patients.
  2. Become aware of the types of positive/negative emotional responses influenced by culture have workshop participants have experienced int their work with patients.
  3. Learn strategies to work with the socio-cultural issues and manage the stigma of mental illness as part of an overall culturally competent approach to assessment and treatment.
  4. Become aware of the culturally determined influences on medical practice.
  5. Learn educational strategies and clinical interventions that improve the efficacy of consultation-liaison interventions by taking culture into account.

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WORKSHOP 18:
Making Your Presentation More Interactive: A Better Way!

Program Track: Early Career (EC)

Presenter:

Jon Davine, MD, FAPM

Abstract:

Educational literature has shown us that traditional presentations usually are not effective in ultimately changing physician performance. Conversely, interactive learning techniques, particularly in smaller group settings, have been shown to be much more effective.

In this workshop, we look at factors that can enhance interaction, including room arrangements, proper needs assessment, and methods to facilitate interactive discussions. The group will have an interactive component, which will involve participating in different group activities, such as "Buzz Groups," "Think-Pair-Share," and "Stand Up and Be Counted," which enhance small group interaction. The use of commercial films to enhance educational presentations has been coined "cinemeducation." We will discuss techniques to help use films as teaching tools, along with having an experiential component involving the direct viewing and discussion of a film clip. We will also comment on how to maximize the use of audiovisual tapes of patient encounters as a teaching tool. This will also involve direct viewing of an audiovisual tape to illustrate these principles.

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WORKSHOP 19:
Training in Pediatric Psychosomatic Medicine (Essentials VI)

Program Track: Psychosomatic Subspecialties (PS)

Moderator: Maryland Pao MD, FAPM

Presenters:

Paul Jones, MD: Working with Families: What PM Fellows Need to Learn

Sandra Rackley, MD: Impact of Medical Illness on Adolescent Sexual Development

Audrey Walker, MD: Pediatric Psychosomatic Fellowship Track - Creating the Pathway and the Curriculum

Abstract:

In July 2007, the first AGCME-approved fellowship track in pediatric psychosomatic medicine was created at Montefiore Medical Center. The process of developing a pediatric psychosomatic medicine fellowship track will be presented with specific recommendations for the curriculum and syllabus. Alternative training pathways such as the Triple Board Program and Pediatric Portal will be discussed. These experiences suggest that formalizing pediatric psychosomatic education is a valuable and useful training experience to incorporate into Psychosomatic Medicine programs and will strengthen the clinical competencies of all Psychosomatic Medicine trainees in pediatric psychosomatic medicine.

Consultation-Liaison psychiatrists are expected to provide care to patients of all ages but may be unfamiliar or uncomfortable when working with adolescents and their families. Two additional areas of pediatric education for adult PM fellows will be highlighted in this symposium: 1) A review of child psychiatry principles of working with families as relevant to diagnoses and crisis management in PM consultations with child and adolescent patients, and 2) A review of what we know about the way medical illness impacts adolescent sexual development, both physically (such as in vaginal agenesis or premature ovarian failure) and psychologically (such as in serious chronic illness).

This symposium will provide participants useful information on collaboration with other pediatric services to develop and enhance PM services. Upon completion of this symposium, participants should be able to describe how to develop a pediatric PM fellowship track, the impact of medical illness on young women with sexual development concerns, and family approaches to working with children and adolescents with both medical and psychiatric symptoms.

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WORKSHOP 20:
Psychiatrists and Organ Donation: Are We Robin Hood to the People or Are We Hoods Robbin' the People?

Program Track: Ethical and Management Challenges (EMC)

Moderator: Philip R. Muskin, MD, FAPM

Presenters:

Peter A. Shapiro, MD, FAPM: What About Possible Donors Who Do Not Wish to Donate?

Silvia Hafliger, MD: To Take or Not to Take

Lewis Cohen, MD, FAPM: Organ Donation and the Sanctity of Life Coalition

Ilona Wiener, MD: The Altruistic Paired Kidney Exchange versus Altruistic Kidney Donation

Abstract:

Numerous ethical and legal issues encumber organ donation and transplantation. Is every life “saved” by a transplanted organ more worthwhile than a one not saved? Should any measures that will lead to the patient receiving an organ be taken? This workshop will focus upon the many issues faced by transplantation psychiatrists during evaluation of potential donors and recipients.

Dr. Shapiro will examine the possible repercussions for individuals who plausibly might become donation candidates but do not wish to donate an organ. How helpful is “the medical excuse” in preserving the individual’s status within his/her social matrix?

Dr. Hafliger: Transplant psychiatrists are given the task of evaluating living liver donors (altruistic and emotionally connected donors), with the goal to protect the donor from psychological or psychiatric morbidity resulting from the donation. This task is very daunting as the donors hide any imperfections, weaknesses, fears, conflicts in order to be given a "passing grade." This is particularly evident in the evaluation of an altruistic donor, where the stakes to convince the team of his/her psychological fitness is even greater. We will discuss the strong feelings/counter transference/conflicts that arise in the living donor team during evaluation of a pediatric liver living donor. We will discuss the concept of gift exchange where there usually is reciprocity and how this impacts a recipient of altruistic donation.

Dr. Cohen: There are literally millions of Americans who identify with the various organizations that constitute a “Sanctity of Life Coalition” and who are deeply skeptical about the use of advance directives, and efforts on the part of various state motor vehicle licensing bureaus to facilitate organ donation. One belief is that organized medicine and physicians profit by organ transplantation, which is an underlying motive behind the campaign to encourage people to complete advance directives. The Coalition consists of sincere individuals who belong to prolife/anti-abortion groups, conservative Christian churches, and segments of the disability rights movement; they constituted the ranks of protestors who came together at Terri Schiavo’s death, and are opposed to the legalization of physician-assisted dying.

Dr. Wiener: Altruistic paired kidney exchanges facilitate kidney transplants for patients with incompatible live donors,whereas altriustic kidney donation does not involve a designated recipient. We want to examine what factors contribute to being an altruistic donor and whether a personal, psychological gain negates the wish to donate.

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SYMPOSIUM 8:
The Value of Introducing Palliative Medicine Curricula into Psychiatry Training

Program Track: Educating Trainees (ET)

Presenters:

Scott A. Irwin, MD, PhD

Michelle Weckmann, MD, MS

Janeta Tansey, MD, PhD

Abstract:

Chronic and life-threatening illnesses often have psychosocial sequelae which cause intense suffering. While both psychiatry and palliative medicine are asked to respond to these sequelae, palliative medicine particularly focuses on an interdisciplinary and values-oriented dialogue about how suffering will be addressed in treatment planning. We believe the curricula in palliative medicine could be satisfyingly adapted to meet educational goals in general psychiatric education and practice, as well as to introduce psychiatric trainees to rewarding psychosomatic careers as consultants to interdisciplinary palliative medicine teams. Collaboration between palliative medicine and psychiatry can strengthen both fields of study and practice.

This interactive symposium will:

  1. Define palliative medicine and the potential roles for psychosomatic medicine within this field.
  2. Present data showing that palliative medicine education is highly valued among psychiatry residents who receive it, review the limited opportunities for education about palliative medicine in psychiatry training, and discuss how even brief exposure to palliative medicine training significantly improves confidence and knowledge about practicing in this setting.
  3. Discuss the significant overlap in the ACGME Program Requirements for Graduate Medical Education in Psychiatry, and for Fellows in both Palliative and Psychosomatic Medicine, with attention to the potential benefits of using palliative medicine curricula to improve psychiatric training.
  4. Briefly present two specific learning issues from which psychiatric trainees would benefit by exposure to palliative medicine: 1) learning how to effectively break bad news; and 2) adapting models of integrative medicine and values-theory into treatment plans.

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SYMPOSIUM 9:
Toxic Pharmacology: An Update on Psychosomatic Drug Syndromes

Program Track: Therapeutics (T)

Panelists:

Daniel M. Lugassy, MD: Serotonin Toxicity

Kamal Sachdeva, MD: Anticholinergic Syndrome

J.J. Rasimas, MD, PhD: Dopaminergic Drug Toxicity

Abstract:

Taken together, medication and drug effects are a leading cause for outpatient appointments, emergency department visits, and hospital admissions. Delirium and a host of psychosomatic signs and symptoms may be precipitated by chemicals. Commonalities between symptoms of mental illness and psychobehavioral effects of exposures, therefore, demand that consultation-liaison psychiatrists serve as de facto toxicologists in the clinic and at the bedside.

Teaching in medical toxicology is, in fact, a formal requirement for specialization in psychiatry. Although psychiatric education offers some expertise in clinical pharmacology to inform differential diagnostic considerations of medication and substance toxicity, adequate toxicology training in psychiatry residency is rare.

We offer this symposium to review manifestations of toxicity from the major classes of psychotropic medications and highlight key aspects of their diagnosis and management. Serotonergic signs appear on a continuum from mild to severe — astute examination is required to differentiate their etiology from other medical conditions and treat them appropriately. Anticholinergic activity is ubiquitous across multiple classes of pharmaceuticals, thus predisposing patients to delirium that demands rapid diagnosis and specific management. Medications affecting dopamine neurotransmission produce both acute and chronic toxicities; they require different treatment strategies, particularly when precipitated by drugs with other receptor activities, as well.

Following the didactic sessions on serotonergic, cholinergic, and dopaminergic drug syndromes, the symposium will conclude with an interactive discussion of key concepts in medical toxicology and clinical pearls regarding other toxins and overdoses.

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SATURDAY, NOVEMBER 13, 2010   2:15–4:15 pm   Workshops 21–24, Symposia 10–12

WORKSHOP 21:
How to Maximize the Fellowship Liaison Experience – Starting with the End in Mind

Program Track: Educating Trainees (ET)

NOTE: Bring your cell phone for this workshop's audience response system!

Moderator: Ronit K. Dedesma, MD

Discussant: David Gitlin, MD, FAPM

Presenters:

Ronit K. Dedesma, MD: Survey of Fellows and Fellowship Directors: Results

Jessica Daniels, MD: Are All Liaison Experiences Created Equal? The Translatability of the Liaison

Amy Bauer, MD, MS: Training PM Psychiatrists to Liaison with Primary Care: A Unique Clinical Model

Abstract:

There are 46 ACGME-accredited psychosomatic medicine fellowships in the United States and all of them provide a unique combination of liaison experiences, determined primarily by the services offered at the hospitals where the programs are located. Many PM psychiatrists are not practicing inpatient C-L psychiatry in tertiary care hospitals but instead serve in an array of roles as liaisons to fields of medicine other than the ones in which they trained. Each of the specialized liaison roles may require distinct content in the evaluation. The number of specialized evaluations that could be learned far exceeds the number of experiences a PM fellow can have during one year of training. Many fellowship programs are located in hospitals that do not have certain medical services. However, is any liaison experience better than no experience in training PM psychiatrists to perform unrelated specialty evaluations?

In this workshop, we will be asking how fellows and fellowship directors can structure liaison experiences to maximize their value and generalizability and foster the development of a universal skill set. We will explore the idea that despite differences, there are translatable skills that can be learned from training as a liaison, such as building the liaison relationship, performing focused evaluations and developing niche areas of expertise. To stimulate discussion, some personal examples of this will be discussed. We will be presenting the results of a survey of current fellows, recent graduates and fellowship directors on their liaison training and contrast this to the occupational settings where recent graduates are employed. We will engage the attendants in an interactive brainstorming session on how to benefit from the liaison experiences available and to amplify their usefulness during the transition to practice. Participants will be encouraged to share their experiences from both their own fellowship and independent clinical practice. This workshop is expected to be of particular value to residents, fellows, early career psychiatrists and training directors.

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WORKSHOP 22:
The Art of Consultant as Educator

Program Track: Early Career (EC)

Moderator: Robert Boland, MD, FAPM

Presenters:

Kristen Brooks, MD

Jason Caplan, MD

Lucy Epstein, MD

Divy Ravindranath, MD

Abstract:

One of the essential tasks of a psychosomatic medicine specialist is to provide consultation to other medical providers when they are confronted with clinical situations beyond their basic training in mental health. As such, each consultation is an opportunity to revisit and deepen the consulting physician's understanding of mental health concepts, particularly as they apply to patients in the general hospital setting. This is a challenging task that requires the consulting psychiatrist to rapidly assess the consulting doctor's baseline level of knowledge and to tactfully educate them in areas of knowledge deficit.  It can be especially challenging for early career psychosomatic medicine specialists, who may focus on efficiently addressing the patient care issue at the expense of providing education to the requesting physician.  Moreover, a newly minted PSM specialist may feel hesitant about teaching when the consultation question comes from a more seasoned medical specialist.  If effectively done, then this education will serve the needs of the patient in question and patients in similar situations in the future.  At times, consulting psychiatrists will also be called upon to teach clinically applicable concepts to groups of providers from non-mental health disciplines, moving the educational opportunity from one-on-one to a system-wide context.  Thus, education in the clinical context can advance the field of psychosomatic medicine as a whole.

This workshop will be conducted under the premise that opportunities for consultation are also opportunities for education.  We will review the literature about teaching as a consultant and contextual learning.  We will also review the basics of diplomatic communication. After identifying some of the challenging situations and teaching opportunities encountered by consultants, we will invite the audience to participate in applying these concepts to participant-generated clinical scenarios.  We invite trainees, early career psychiatrists, and senior clinicians to put their learning into practice and develop their skills as consultant-educators.

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WORKSHOP 23:
ADVOCACY 101: Leadership and Legislative Skills

Program Track: Potpourri (P)

Presenters:

Mary Helen Davis, MD

Nicholas M. Meyers

Thomas N Wise, MD, FAPM

Carol L Alter, MD, FAPM

Abstract:

In an era of healthcare reform and change, issues of public policy can dramatically impact the delivery of mental health care. This workshop will provide opportunities to discuss issues facing psychiatric leadership that include everything from delivery of care, healthcare disparities, scope of practice, and parity, to health care reform and reimbursement. We will explore the role of our professional organizations, the American Psychiatric Association and the Academy of Psychosomatic Medicine, in terms of updating members and educating both the public and decision makers on key issues impacting mental health care and treatment. Presenters will focus on issues related to PM, including concepts of acountable care organizations (ACOs), the medical home, mental health care financing, and comparative effectiveness research. Participants will gain an awareness of resources for leadership development, media training, and coalition building. There will be opportunities for mentorship development and networking strategies for members in-training and early career psychiatrists.

Dr. Meyers from the American Psychiatric Association will provide a historical perspective and overview of APA's advocacy agenda on the previously named issues as well as the development of grassroots advocacy. He will describe the federal advocacy agenda as well as district branch and state association outreach. Dr. Meyers will overview the Patient Protection and Affordable Care Act (HR 3590) from the perspective of health reform's impact on psychiatrists and patients.

The passing of health care reform legislation hallmarks a transition in health care delivery. We will explore future trends that may impact professional practice. A number of issues relevant to psychosomatic medicine are included in health care reform and parity legislation. Dr. Alter will provide an update on current health policy initiatives related to psychosomatic medicine.

The workshop will conclude with a panel discussion on how to sort through the topics presented and the process for ongoing dialogue to prioritize the development of our future advocacy agendas. Specifically, we will look at potential policy and advocacy strategies that can be utilized to address psychosomatic medicine's issues.

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WORKSHOP 24:
Does This Man Deserve Another Kidney? The Role of Personality and Noncompliance in Renal Transplant Decision-Making

Program Track: Ethical and Management Challenges (EMC)

Presenters:

Reba F. King, MD

J. Michael Bostwick, MD, FAPM

Philip Muskin, MD, FAPM

Maryland Pao, MD, FAPM

Abstract:

We present a young man in his early 20s, a childhood diabetic, who has lost through noncompliance the kidney he received from his father in his late teens. In a series of video clips filmed in a dialysis unit, he describes the conflicted circumstances under which he accepted the kidney transplantation, the troubled (and troubling) behaviors he has exhibited throughout his adolescence and early adulthood, and his desire to receive another transplanted kidney. He is entitled, self-absorbed, and ultimately pathetic in his hostile dependency on the medical system to keep him alive.

The case raises many disturbing questions: The young man clearly has a personality disorder. Does the presence of this diagnosis affect his capacity to make decisions for himself? Was he essentially coerced into receiving the first kidney by parents who were figuratively — and literally — paternalistic in their approach to the detriment of the patient? Should a character like him ever have been given a valuable and limited commodity like a donor kidney in the first place, let alone a second time when he would presumably receive an organ from a non-family member? Was the behavior that led to the rejection of his kidney suicidal?

We anticipate this case will provoke spirited discussion and debate about diverse ethical issues, including noncompliance, limited resources, problematic personality styles, coercion, and paternalism. The panel of discussants includes experts in clinical ethics, pediatric and adult consultation liaison psychiatry. Each discussant will comment on the provocative issues that the case illuminates and offer any evidence based literature that assists in the management of such complex cases. Discussion with audience regarding theses issues, as stated, will be a primary goal of presentation.

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SYMPOSIUM 10:
Integrated Care in Primary Care and Specialty Care Settings: Models and Financing

Program Track: Care Models (CM)

Presenters:

Mark Williams, MD: Integrated Care in Primary Care Settings: Clinical Outcomes and Financial Considerations

James R. Rundell, MD, FAPM: Integrated Care in Specialty Care Settings: Models and Financing. Mayo Clinic Has Over 20 Team Approaches to Providing Mental Health Services in Specialty Care Settings

Kurt Kroenke, MD: The SAD Triad: Integrating Care of Somatic, Anxiety, and Depressive Symptoms in Primary and Specialty Care Settings

Jeffrey P. Staab, MD: Example of a Specialty Care Integrated Program: Evaluation of Dizzy Patients

Roger Kathol MD, FAPM: Mechanics of Setting Up Sustainable Mental Condition Services in Primary and Specialty Care Settings, Successes and Challenges

Abstract:

Psychosomatic Medicine (PM) services are increasingly delivered in outpatient integrated care settings. Conceptual models and financing of multi-specialty, integrated care vary across primary and specialty clinical settings. Many integrated care models focus on depression in primary care patients, with data to support effectiveness. Increasing attention is being given to anxiety and living with undiagnosed symptoms. Financing integrated care is challenging. Models based on cost and reimbursement need to be refined to reflect the impact of screening and integrated management on broader financial measures such as costs of health care and lost days of work. This workshop will present models of integrated care relevant to PM and paradigms for potential financial viability.

Dr. Williams will review models of psychiatric participation in screening and care management-based programs in primary care, and will summarize funding mechanisms. A state-wide effort to sustain an evidence-based model will be reviewed, with current outcomes, challenges, and next steps described.
Dr. Rundell will discuss Mayo Clinic's >20 team approaches to providing mental health services in specialty care settings. Four basic conceptual models include traditional consultation, collaborative team care in a psychiatric setting, non-colocated integrated (multi-specialty) care, and integrated care colocated in a specialty clinic. Financial arrangements in these settings range from reimbursement-based to consolidated financial accounting within an institutional program (e.g., transplant).
Dr. Kroenke will discuss the SAD Triad. Undiagnosed symptoms, anxiety, and depression are the most frequent psychiatric presentations in virtually every medical-surgical setting. They account for considerable morbidity and cost, and respond to integrated management.
Dr. Staab will give an example of a specialty care integrated program. Otolaryngology, Psychiatry and Neurology at Mayo Clinic coordinate standard clinical evaluations with consolidated patient recommendations that focus on functional improvement and treatment of interacting medical and psychiatric etiologies and contributors
Dr. Kathol will describe the mechanics of setting up sustainable mental condition services in primary and specialty care settings, its successes and challenges. Considerable experience with integrated program development informs predictors of successful clinical and financial outcomes.

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SYMPOSIUM 11:
From Mechanisms to Treatment in Depression in Cardiovascular Disease: From Bench to Bedside

Program Track: Psychosomatic Subspecialties (PS)

Chair & Moderator: Hochang Benjamin Lee, MD

Discussant: Wayne Katon, MD, FAPM

Presenters:

Lawson Wulsin, MD, FAPM: Autonomic Imbalance and the Metabolic Syndrome

François Lespérance, MD: The Inflammation and Oxidative Stress Hypothesis of Depression

Hochang Benjamin Lee, MD: Vascular Depresssion Hypothesis of Post-CABG Depression

Abstract:

Negative impact of depression on cardiac morbidity and mortality is well-established based on findings from numerous clinical and community-based studies. Several biologic mechanisms (e.g., autonomic instability, proinflammatory factors, abnormal platelet reactivity, and HPA-axis hyperactivity) have been proposed to underlie the depression-CVD relationship, but their potential roles in design of clinical trials and treatment of depression in CVD have remained elusive. In this symposium, each of the presenters will address different putative biological aspects of depression-CVD relationship based on recent literature and the latest findings from his own studies as following:

Dr. Wulsin will review the evidence in support of autonomic imbalance as a key mechanism linking clinical depression and all eight major cardiac risk factors, as well as cardiac morbidity and mortality. He will discuss the data from primary care patient records which suggest that high average resting heart rate is associated with high rates of metabolic syndrome, and therefore, may serve as an early identifier of those at high risk for coronary heart disease.

Dr. Lespérance will review animal and clinical studies supporting the key roles of inflammation and oxidative stress as potential common pathways to depression and coronary artery disease and discuss the implications for treatment of depression in patients with coronary artery disease.

Dr. Lee will compare the features of geriatric, late-onset depression and post-coronary artery bypass graft surgey (CABG) depression and propose the vascular depression hypothesis of post-CABG depression. In testing this hypothesis, he will also present the recent data on the role of pre-CABG CVD risk factors and intra-and extra-cranial atherosclerosis on incident post-CABG depression and the use of pre-CABG transcranial doppler to predict incident post-CABG depression.

Dr. Katon will discuss the potential implications of the above putative biological mechanisms on future clinical trial designs and treatment of depression in CVD in light of other established behavioral risk factors (e.g. smoking, obesity, and poor adherence to medication).

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SYMPOSIUM 12:
Non-Pharmacological Treatment Alternatives in the Acute Medical Setting for Psychosomatic Medicine Practitioners

Program Track: Therapeutics (T)

Chair & Moderator: José Maldonado, MD, FAPM

Presenters:

Tomer Levin, MD, FAPM: Cognitive Therapy for Patients in Acute Medical Settings

Sermsak Lolak, MD: Brief Bedside Psychotherapy in the Medically Ill

Joji Suzuki, MD: Motivational Interviewing in the Acute Medical Setting

Jose Maldonado, MD, FAPM: Hypnosis: Principles and Applications in the Acute Medical Setting

Abstract:

This symposium will cover the basics of four non-pharmacological treatment interventions to be used in the acute medical setting: CBT, Brief Psychotherapy, Motivational Interviewing, and Hypnosis. The presenters will focus on the basic principles associated with, the possible applications, and available evidence-based uses for each treatment intervention.

The principles of Cognitive Behavioral Therapy in acutely ill medical patients will be outlined with an emphasis on how a case is formulated from the cognitive therapy perspective. Efficacy data for Cognitive Therapy in P-M will be reviewed by Dr. Levin. Strategies such as problem solving, behavioral activation and relaxation/breathing exercises will also be considered. Specific techniques will be discussed from a practical perspective illustrated by case vignettes.

Brief psychotherapy at the bedside is not only possible, but invaluable in some hospitalized medical-surgical patients. Despite limited time and privacy, many patients respond quickly and preferably to psychotherapeutic techniques delivered by psychosomatic medicine practitioners. In his talk, Dr. Lolak will review the general principle and practical steps of how to deliver such therapy efficiently and effectively.

Motivational interviewing (MI) is an interviewing style that can improve empathic understanding between the clinician and patient, fostering a collaborative approach to the medical decision-making process and facilitating change in harmful behaviors. Dr. Suzuki will introduce the basic principles of MI, briefly review the literature, and describe how this approach can be adapted as a brief intervention for consultants in the general hospital setting, with a special emphasis on substance use disorders.

Hypnosis, the oldest Western form of psychotherapy, is also one of the newest means of helping people cope with the rigors of high-tech medicine. Hypnosis utilizes a patient's ability to focus attention to help with many medically related problems such as anxiety management, pain control, habit control, somatic conditions (e.g., warts), and psychosomatic disorders (e.g., asthma, psoriasis, conversion disorders). Dr. Maldonado will cover the basis of the mechanisms of hypnosis, how to measure hypnotizability, and the evidence for its usefulness in the acute medical setting.

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SATURDAY, NOVEMBER 13, 2010   4:30–6:30 pm   Workshops 25–27, Symposia 13–16

WORKSHOP 25:
Professionalism in Psychosomatic Medicine: A Focus on Education

Program Track: Educating Trainees (ET)

Presenters:

Ann Schwartz, MD

Wendy Baer, MD

Raymond Kotwicki, MD, MPH

Abstract:

Developing an understanding of professionalism during medical education is an essential aspect of the development of a physician. Most medical educators would agree that learning how to deliver care in a professional manner is as necessary as learning the core scientific data, and that professionalism is no longer a peripherally acquired skill. Professionalism can and should be clearly defined and taught rather than retroactively responding to infractions after they occur.

In this workshop, we will first review the important attributes defining professionalism, including altruism, accountability, excellence, duty, honor, integrity, and respect for others. Given that the consultation-liaison psychiatrist may be the only exposure that other physicians and hospitalized patients have to mental health care or psychotherapy, the C-L psychiatrist must be able to quickly and simply define the role of psychiatry in medicine and to educate other physicians and patients about the connections between the mind and the body. This responsibility as a steward of the field best fits under the category of professionalism and will be addressed in this workshop.

Development of a culture of professionalism among the faculty and other trainers is an essential element so that these behaviors will be uniformly modeled to trainees. In addition, constructive feedback is an essential component of medical and psychiatric education. However, commenting on a trainee's performance in a useful way is not always easily done and faculty must consciously consider how best to help the trainee understand their performance and how to improve. Participants will be encouraged to share their own experiences that exemplify successful and unsuccessful efforts at providing feedback, and session leaders will share "best practices" of proactive, constructive, formative feedback.

The disciplinary process for lapses in professionalism can be murky and cumbersome. Initial faculty assertions of misbehavior or incompetence may evaporate, arrive after submission of a passing evaluation, or get lost in the shuffle among rotations and sites. When confronted with problematic behavior, trainees may experience a range of emotions which will need to be effectively managed so to achieve the goal of positive change. Suggested strategies for assisting trainees through a disciplinary process will be outlined.

Facebook, Twitter, Skype and YouTube are an everyday part of life for most young people; medical students and psychiatric residents and fellows are no exception. Once a trainee leaves the hospital or clinic, they may feel comfortable speaking, acting or posting in a way that they would not in front of supervisors or patients. The possibility for professional lapses using technology is endless. Guidelines for communicating to trainees the importance of caution when using web-based media and teaching professional boundaries through formal psychiatric training will be discussed.

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WORKSHOP 26:
Managing Opioid Use Disorders in the Acute Medical Setting

Program Track: Therapeutics (T)

Presenters:

Joji Suzuki MD: Teaching Strategies for the Assessment and Management of Opioid Use Disorders

Dwayne Heitmiller MD: Evaluating Patients with Pain and Opioid Dependence

Eliza Park MD: Evaluating the Pregnant Patient with Opioid Dependence

Charles Surber MD: The Use of Buprenorphine in Hospitalized Patients

Abstract:

Workshop Objectives:

  1. Increase participant's knowledge of opioid use disorders in the medical setting.
  2. Participants will be able to apply the information to their clinical practice, notably with opioid dependent patients who have pain, are pregnant, or are on agonist treatment with buprenorphine.
  3. Provide participants with ideas on how to create educational opportunities for psychosomatic fellows to improve knowledge and clinical competence in treating opioid use disorders.

Relevance to the audience:
Opioid use disorders are frequently encountered by consultation-liaison psychiatrists in the acute medical setting. This presentation hopes to increase participant's knowledge about this patient population.

Description of workshop:
Following a brief overview of opioid use disorders, each presenter will spend approximately 15-20 minute on their topics. The remaining 45-60 minutes will be an interactive discussion with the audience for questions and answers about caring for patients with opioid use disorders in the hospital setting. The speakers will also highlight ways to improve education of psychosomatic medicine fellows about opioid use disorders.

Description of topics:

Dr. Suzuki: Strategies to improve psychosomatic medicine fellows' competence in the assessment and management of addictive disorders will be discussed, with an emphasis on opioid use disorders. The speaker will focus on such issues as the importance of identifying an addiction faculty, use of structured assessment tools, interpretation of urine toxicology results, and offering education in buprenorphine and brief interventions.

Dr. Heitmiller: Psychiatrists traditionally have little if any training in pain management issues, yet a frequent reason for consultation from the medical and surgical teams concerns patients with pain and the question of possible opioid dependence. The discussion will include an approach for evaluating such patients, as well as informing the consultee with practical and useful knowledge to guide subsequent care.

Dr. Park: This presentation will give an overview of opioid use in pregnancy, available treatment options, and a discussion of special considerations when managing this patient population.

Dr. Surber: The management of the hospitalized patient taking buprenorphine/naloxone for opiate dependence will be discussed. This will include a brief review of the pharmacology of buprenorphine/naloxone, strategies for managing pain, and re-induction prior to discharge.

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WORKSHOP 27:
“In Sickness and in Health”: Treating Sleep Disorders to Improve Quality of Life

Program Track: Psychosomatic Subspecialties (PS)

Moderator: Elisabeth Kunkel, MD, FAPM

Presenters:

Dimitri Markov, MD: Sleep Disorders in Cancer Patients

Dimitri Markov, MD: Normal Sleep and Sleep Disorders in Older Adults

Jessica Mosier, MD: Effects of Psychiatric Medications on Sleep

Lex Denisenko, MD: Cognitive Behavioral Therapy of Insomnia

Abstract:

In recent years, there has been a great expansion of knowledge about sleep disorders, the importance of sleep and health consequences of chronic sleep deprivation. This knowledge, however, has not been fully implemented into clinical practice. Many physicians can recognize common sleep disorders. However, more needs to be done to educate physicians about diagnosing and treating sleep disorders in order to improve the physical and psychological health and quality of life of their patients.

As people age, they commonly experience sleep-wake cycle changes and sleep architectural disturbances. In the setting of cancer treatment, patients experience many symptoms, including alterations in sleep patterns. These symptoms are rarely addressed outright, as other concerns, such as morbidity and mortality, appear to take precedence. Yet sleep disturbance is three times more common among cancer patients than in general population and up to two-thirds of older adults report problems sleeping. Sleep disturbance in these patients may persist over time, take the form of hypersomnia or insomnia, and the cause of chronic sleep difficulties is multifaceted.

Untreated sleep disorders can frequently complicate medical problems. During a psychiatric consultation, the psychiatrist can provide valuable input by diagnosing and addressing unrecognized sleep disorders.

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SYMPOSIUM 13:
Expanding Collaborative Care to Patients with Comorbid Medical Illness and Community-Based Primary Care Practices

Program Track: Care Models (CM)

Presenters:

Wayne Katon, MD, FAPM: Evaluation of a Collaborative Treat-to-Target Intervention for Complex Chronic Disease Patients with Comorbid Depression

Michael Sharpe, MD, FAPM: Challenges in Delivering Collaborative Care for Depression to People with Lung Cancer: An Interim Report from the Smart Oncology 3 Trial

Kurt Kroenke, MD: INCPAD Trial: Telecare Management of Pain and Depression in Cancer Patients

Jurgen Unützer, MD, MPH: Collaborative Care: Moving from Research to Practice

Abstract:

This symposium will describe both adaptations of collaborative care to enhance care of patients with comorbid depression and medical illness as well as large-scale collaborative care dissemination efforts that are being implemented in Minnesota and Washington State.

Dr. Katon will present results from a randomized trial of collaborative care aimed at improving both depression and medical disease control in patients with diabetes and/or heart disease and poor disease control (PHQ-9 >10 and HbA1c >8.5%, LDL >130, or systolic blood pressure >140). Dr. Sharpe will describe adaptations of collaborative care for patients with depression and lung cancer. Dr. Kroenke will describe the results of a randomized trial that tested an intervention aimed at improving the quality of care for both depression and pain in patients with cancer. Dr. Unützer will describe the results of large scale dissemination efforts to integrate collaborative care into multiple community-based primary care practices in Minnesota, Texas, and Washington State.

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SYMPOSIUM 14:
The Proposed Classification of Somatic Symptom Disorder or Functional Somatic Disorders in the DSM-V from an International Perspective

Program Track: Potpourri (P)

Presenters:

Per Fink, MD, Phd, FAPM: Does the Bodily Distress Syndrome (BDS) Diagnosis Unify the Functional Somatic Syndromes and Somatoform Disorders?

Brian Fallon, MD, MPH: Health Anxiety With and Without Prominent Somatization: Findings from 190 Individuals with DSM-IV Hypochondriasis

James Rundell, MD, FAPM: APM Membership Survey on Opinions About the Proposed DSM-V Classification for Somatic Symptom Disorders

James Levenson, MD, FAPM: DSM-V Proposal for Classification of Somatic Symptoms Causing Significant Psychological Distress

Abstract:

Medically unexplained or functional physical symptoms are a major challenge for the general health care system, but their classification is hampered by an outdated diagnostic system. A revision of the classification of somatoform disorders is pending, and the DSM-V work group has presented a draft of "somatic symptom disorders." The aim of the symposium is to discuss the classification of these disorders on the basis of perspectives from many different countries.

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SYMPOSIUM 15:
Tiaras, Tantrums, and Tears: Administrative Psychiatry During C-L Training

Program Track: Early Career (EC)

Presenters:

Sanjeev Sockalingam, MD: Developing an Administrative Psychiatry Curriculum: Lessons Learned

Adrienne Tan, MD: Tiaras, Tantrums and Tears: Leadership During C-L Fellowship

Susan Abbey, MD, FAPM: Teaching Program Planning and Development: Keeping It Clinical

Abstract:

C-L psychiatrists often practice within intricate health care matrices requiring knowledge and skills in administration. Many of these skills fall within the ACGME Systems-Based Practice (SBP) core competency for psychiatry residency training. Administrative training is often part of the “hidden curriculum”; however, few formal administrative curricula have been developed for psychiatry trainees. If psychomatic medicine fellowship training programs hope to develop tomorrow’s leaders in C-L psychiatry, appropriate training in leadership, quality improvement and knowledge of the health care system is essential.

This symposium will illustrate an approach to teaching key administrative skills within a psychosomatic training program. Dr. Sockalingam will present data on a novel curriculum in administrative psychiatry for senior residents and fellows including methods for delivering contextual quality improvement training. The implementation of this curriculum in C-L psychiatry will be discussed including past successes and challenges. Dr. Tan will discuss the role of leadership within C-L psychiatry and provide a framework for teaching leadership and administrative skills to fellows during psychosomatic training. Dr. Abbey will outline how concepts of program planning and evaluation can be integrated into daily clinical practice. Methods for teaching junior faculty about program development and managing change with their hospital system will be discussed in this symposium.

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SYMPOSIUM 16:
Neuropsychological Assessment: An Important C-L Tool for Resolving Diagnostic Dilemmas and Interspecialty Disagreements in Cases of Complicated Patient Presentations

Program Track: Ethical and Management Challenges (EMC)

Presenters:

Saba Syed, MD

Robert Dasher, MD

Hope Goldberg, PhD

Jaroslava Salman, MD

Abstract:

Objective: To illustrate how, in some medically ill patients, dysregulated behavior can be secondary to underlying infectious, inflammatory, or autoimmune diseases, rather than due to primary psychiatric illness. To demonstrate the utility of neuropsychological assessment and testing in diagnostic clarification, resolving conflicting clinical opinions regarding etiology, and guiding effective treatment planning and implementation.

Method: Literature review and presentation of three cases including results of neuropsychological testing.

Results: In these three cases neuropsychological testing not only facilitated an accurate differential diagnosis, but also clarified the treatment modality and its duration. None of the three patients had prior psychiatric illness, and the consulted teams differed in their opinions in regards to initial diagnosis. Neuropsychological testing provided inarguable results that behavioral dysregulation was due to primary cognitive impairments related to underlying medical conditions and not primary psychiatric illness.

Case 1:  Hashimoto encephalopathy — 19 y/o Hispanic male presenting initially with confusion, disorientation, agitation, combative behavior, and blank staring spells. Initial comprehensive clinical, laboratory and imaging work up failed to reveal the underlying diagnosis.

Case 2:  Lupus Cerebritis — 23 y/o Hispanic male presenting with acute changes in behavior, hallucinations, and episodes of confusion, fever, headache and urinary incontinence.

Case 3:  Lyme disease — 22 y/o Caucasian male with history of tick bite five years prior to his presentation for progressive cognitive decline, visual disturbances, gradual social withdrawal, depression, insomnia and significant obsessive-compulsive behaviors.

Conclusion: There are a number of systemic illnesses that can initially present with behavioral symptoms that strongly suggest a primary psychiatric condition. Such presentations can lead to diagnostic disagreements between treating and consulting teams, and subsequently delay employment of appropriate treatment interventions. Use of neuropsychological assessment and testing in these cases is an important means in clarifying complicated differential diagnosis and substantially contributes to the development of effective treatment plans and improved patient outcomes.

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