Monitoring the Meeting: Resident Takeaways From the October 2015 APA Mental Health Services Conference

Roberto E. Montenegro, M.D., Ph.D., Department of Psychiatry, Yale School of Medicine, New Haven, Conn.

Hector Colon-Rivera, M.D., Department of Psychiatry, Boston University Medical Center, Boston.

This symposium focused on elucidating the very real and pervasive modern forms of subtle and unintentional exclusion based on social differences. Unlike the traditional definition of microaggressions, defined as “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults that potentially have harmful or unpleasant psychological impact on the target person or group” (1), this workshop emphasized how microaggressions go beyond race. There is both established and emerging literature that shows how microaggressions extend into other socially constructed identities that embody privilege in different ways, such as income, social capital, religion, ableness, sex, and sexual orientation (2). The impact that microaggressions can have on the well-being of individuals is indeed cumulative (3). The panelists shared experiences that aimed to increase awareness and accountability of the impact that microaggressions can have on the well-being of trainees. By sharing their experiences, they demonstrated how microaggressions are very complex and often a challenge to identify, examine, and even confront. For example, such subtleties as “you speak English really well” (despite being born and raised in the United States), or “are you a nurse?” (to a female resident), or “you look too masculine” (to a self-identified lesbian resident) are often confusing, shocking, frustrating, and hurtful. More importantly, however, this session emphasized how it is even more difficult to acknowledge and be accountable for the microaggressions we ourselves commit. It is absolutely critical that we recognize the fact that most of us, including people in positions of power, alternate between being the “recipient” of a microaggression and actually “committing” a microaggression. Recognizing that we all have implicit biases is important in facilitating an environment where we can discuss and deal with difficult topics, such as microaggressions and implicit bias (4). The following were key points made by the panelists:

Brian Hurley, M.D., M.B.A., Robert Wood Johnson Foundation Clinical Scholars Program, David Geffen School of Medicine of the University of California, Los Angeles.

Kristen Eckstrand, M.D., Ph.D., Department of Psychiatry, University of Pittsburgh Medical Center and Western Psychiatric Institute and Clinic.

Dr. Hurley chaired a workshop addressing medical education competencies on sexual orientation, gender identity, and sex development. The session began by defining terminology for a diverse set of patients, including lesbian, gay, bisexual, and transgender (LGBT) people and those born with differences of sex development (DSD). These populations experience a greater degree of mood and anxiety disorders, suicide, trauma, and substance abuse (6) (7), and the minority stress model describes specific stressors and coping mechanisms that significantly affect these mental health outcomes (8). The workshop highlighted the valuable role community and public psychiatrists play in supporting the optimal mental health of these populations (9), as well as the significant variability in the training received with respect to these patient populations. During the workshop, educational strategies that optimize care for individuals who are LGBT and/or those born with DSD that are essential to the modern practice of community and public psychiatry were reviewed.

The session introduced the audience to competency-based medical education, specific competencies addressing sexual orientation, gender identity, and sex development, and the work of the Association of American Medical Colleges (AAMC) Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development. Competency-based medical education is an educational framework beginning in medical school to support effective learning for the development of knowledge, skills, attitudes, and behaviors necessary for clinical practice. Achieving and assessing competence extends into postmedical graduate education. The AAMC created an advisory committee in 2012 to promote LGBT and DSD health through advancement of medical education on sexual orientation, gender identity, and sex development. The committee developed competencies specific to these populations and mapped them to the preexisting framework of competency-based medical education.

The AAMC Advisory Committee authored a publication (10) that describes how to 1) integrate these competencies into existing medical curricula, 2) promote the necessary institutional climate change across levels of experience, including faculty and administrators, and 3) assess the achievement of physician competence in these areas. During the workshop, participants were presented with a roadmap to the application of these initiatives, which included the use of hypothetical questions/discussions within existing didactics, cases, and rotations, increasing faculty awareness of relevance to other topics, and an emphasis on understanding the key differences between populations. All individuals have an important role to play in promoting the integration of these issues into curricula and training, and there are opportunities within all modalities to integrate the competencies across domains. Participants were encouraged not to ignore spontaneous opportunities teaching to raise issues pertaining to sex, sexuality, and gender. Given that these competencies map onto the domains used by the Accreditation Council on Graduate Medical Education, session participants highlighted the applicability of this work to psychiatric graduate medical education. The workshop also reviewed the hidden curriculum and tools, specifically including the AAMC Graduate Questionnaire, Human Rights Campaign Foundation’s Healthcare Equality Index, Campus Pride Index, Outlists, SafeZone programs, and other LGBT-specific events as tools for assessing the climate of colleges of medicine and other educational environments.

The session concluded by encouraging participants to download the AAMC publication, Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators, which is available at www.aamc.org/lgbtdsd. (View the Faculty Development Video Series available at www.aamc.org/axis, and you can contribute to and utilize the resources available at MedEdPORTAL: An Integrated Learning Platform, via www.mededportal.org.)

Tanuja Gandhi, M.D., Department of Psychiatry, Einstein Healthcare Network, Philadelphia

I truly wish that I never had to ask the question in the title, but it is a part of modern-day reality and, therefore, safety assessments in psychiatry. Indeed, it is essential to talk about gun safety, as access to guns has become ubiquitous and firearm-related injuries are a major public health problem (11). The speakers described quite succinctly the challenges faced by clinicians in having the gun safety conversation. The talk highlighted that while as mental health professionals we screen for gun access, easy access to guns remains a reality, with many people probably owning guns for home security and self-defense. While emphasizing the importance of having this conversation (12), the speakers suggested an alternative to the uncomfortable and often difficult “do you have a gun” in your home conversation. That is, by asking open-ended questions inviting a discussion on this topic.

During the workshop, Drs. Soliman and Jain emphasized that “engagement can be a better goal than predetermined outcomes.” The myriad number of ways clinicians could talk about guns with patients and their families surprised me. They presented an “AEIOU” mnemonic-based approach, an excellent tool for residents to ensure a comprehensive safety assessment. “A” stands for “access to weapons,” “E” is “experience with weapons,” “I” stands for “ideation or intent to carry out an assault,” “O” is for “operational plan on how to access weapons,” and “U” is for “unconcerned with consequences, suicidal, or hopeless.” Furthermore, Dr. Rozel drew our attention to the tendency to focus on removal of guns than the overall safety conversation. He discussed the importance of gun awareness among clinicians in order to obtain better gun use history and open the discussion about “safer storage” of guns (13). Dr. Rozel also noted that “parents often tend to overestimate their gun safety measures at home,” an important issue that hit home with the video of “3-year-old ‘Toby’ opening a gun safe,” which was played during the presentation.

So how do we have effective gun safety conversations? The speakers described the significance of using motivational interviewing techniques to have this conversation with unwilling and resistant patients and their families. The stages of change model can be used to understand the issues around accepting and implementing healthy behaviors in terms of gun safety. Toward the end of the session, Dr. Rozel addressed some of the legal and political challenges that clinicians tend to face while addressing the gun safety issues and the importance of being acquainted with the gun laws of your own state.

In summary, this session offered a new outlook on discussing guns through a motivational interview-based approach. While our efforts to remove guns from the home may not yield successful outcomes in all cases, having an open discussion about gun access, safe storage, and other safety measures would definitely enhance public awareness about the risks and responsibilities that come with gun access and ownership. Psychiatrists are in a unique position to advocate for gun safety and reduce stigmatization of the mentally ill (14).

The comprehensive handout describing “The Gun Talk” is a valuable resource for any mental health professional.