Journal Article Annotations
2017, 2nd Quarter
Annotations by Diana Robinson, MD
Also of interest:
The authors describe a three-part approach for resident education on identifying and managing deceptive patients including didactics, process rounds, and clinical experience. The didactics component includes three lecture hours spread out during the PGY1, PGY2, and PGY3/4 training years. The process rounds component is recommended to be carried out at least once per week on high intensity services such as consult-liaison, inpatient, and emergency psychiatry. At the author’s institution, they are done 2-3 times a week directly after morning sign-out and are facilitated by a faculty member facilitator that is not the unit director or program director. Finally, the “see one, do one, teach one” approach is used with junior residents accompanying attendings during confronting patients with attending support and debriefing. This system of teaching the residents to “think dirty” helps residents be aware of potential pathological and nonpathological reasons for patient deception, to manage their countertransference, to reduce resident burnout, and improve their empathy for patients. This is relevant to C-L because patient deception is commonly encountered in emergency and inpatient C-L services and can lead to strong physician countertransference that can increase physician burnout and reduce patient empathy if not productively managed.
The finding: The authors conducted a survey of pediatric hospitalists and pediatric C-L psychiatrists in order to characterize how practice and training experience in PAABE were similar or different based on specialty and to determine if there were existing screening, communication, and evaluation and management strategies that were formalized in pediatric inpatient settings. A total of 47 responses from 38 North American academic children’s hospitals in 20 states were included. The most common associated factors of PAABE were primary mental illness (27%) followed by medical illness (22%), multifactorial (16%), autism spectrum disorder (14%), and developmental disability (12.4%). Interventions were highly varied including behavioral response teams (n=3), active guideline development (n=9), protocols for specific patient populations (n=3), and consultation with psychiatry (n=4), social work (n=2), and Child Life (n=2).
Strength and weaknesses: Strengths of this study were obtaining data in an area where there is minimal literature with little consensus. Limitations included a low response rate to the non-incentivized survey through two professional listservs and a short one-month window of response. The small sample size limited statistical analysis with subgroup analysis showing trends but no statistical significance.
Relevance: Despite the common occurrence and perceived importance of pediatric acute agitation in the inpatient setting, there is minimal formal training, screening, preventative strategies, interprofessional communication, and management strategies to target PAABE. C-L psychiatrists in hospital settings are commonly consulted for treatment recommendations for acute agitation and may even be part of organized inpatient agitation response teams, so it is valuable to get a sense of the current systems that are in place at hospitals nationwide.