Forensic Psychiatry Topics Ripe for Teaching in a Collaborative Setting

Dangerousness, informed consent, and capacity for medical decision making were among the forensic psychiatry topics rated as most important by residents from several disciplines who participated in a small pilot program in collaborative training in forensic psychiatry.

The residents—who were trainees in internal medicine, psychiatry, neurology, and pharmacy—were asked to rate the importance of these and other forensic-related topics (including medical liability, civil commitment, confidentiality and responsibility to third persons, capacity for medical decision making suicide risk assessment, informed consent; testimony, managing problem behaviors, and child abuse or neglect) before and after working collaboratively in a patient care model and jointly participating in didactic sessions on the topics. The residents indicated that they found many sessions covered in the pilot to be very important.

“Forensics really lends itself to a collaborative discussion among psychiatrists and other disciplines because the topics transcend medical specialty,” Jennifer Piel, M.D., associate program director for the psychiatry residency program at the University of Washington told Psychiatric News. “Internists need to know, for instance, when to seek consultation with a specialist about patients who may be unable to make decisions about their medical care. It’s really helpful to have those conversations in a collaborative training setting.”

Piel presented her findings in a poster at the March meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT) in Orlando, Fla., and spoke with Psychiatric News after the meeting.

She added that some topics in forensic psychiatry have general applicability to trainees in general psychiatry and other health care disciplines. The American Board of Psychiatry and Neurology (ABPN) milestones, for example, call for general psychiatry residents to understand jurisdictional variation in medical-legal topics.

In the study, pre-and post-didactic surveys were distributed to trainees rotating in the integrated program at the VA Puget Sound in the 2013-2014 and 2014-2015 academic years. Trainees in the integrated program worked collaboratively in a patient care model and jointly participated in didactic sessions. The following disciplines were represented: resident physicians in internal medicine, psychiatry, and neurology; residents in pharmacy; and students in family nurse practitioner and psychiatric nurse practitioner programs.

The pre-didactic survey asked participants to rate the importance of various forensic-related topics and their confidence with the topics. Respondents were also asked to rate types of training modalities, including lecture, panel discussion, small group discussion, reading, role play, and videos. Topics and confidence levels were rated on a four-point scale not important at all (1) to very important (4).

The post-didactic survey asked respondents to rate the importance of topics after the educational modules on a scale of one to five (five being “most important”), rank topic suitability for integrated training, and comment on their impressions of the integrated curriculum in narrative form.

Of the 36 pre-didactic surveys distributed, 26 were returned (72 percent response rate). The majority of respondents (n=17) were resident physicians in the internal medicine training program. The other respondents included: psychiatry residents (six), neurology resident (one), pharmacy resident (one), and psychiatric advanced registered nurse practitioner (one). Twenty-three trainees responded to the post-didactic survey. For the post-test survey, 14 internal medicine trainees responded with no change in numbers for the other disciplines.

Most topics were rated as important, but dangerousness, informed consent, and capacity for medical decision making were given the highest ratings in both pre- and post-test surveys. The post-test ratings of perceived importance of the topic increased from pre-test ratings in several cases and Piel says she believes this is because trainees had underestimated the relevance of the topic in their routine medical practice or realized that they had limited exposure to the topic elsewhere in their training.

The residents rated the topics of testimony, medical liability, and civil commitment laws as least important, but these were also the topics for which residents reported they had the least confidence in their knowledge and skills. “My sense is that those are topics that are regarded by trainees as least clinically relevant and outside the scope of what they need to know, particularly for trainees in specialties outside of psychiatry,” Piel said. “But after exposure to these topics, they also indicated that they recognized the value of learning about these issues.”

When separately analyzed, there was no statistical difference in responses between the psychiatry residents and trainees in other disciplines except in their confidence level in civil commitment procedures, where psychiatry residents rated their confidence much higher than the trainees in other disciplines.

Respondents consistently rated the quality of the sessions as 4.5 on the 5-point scale. Twelve respondents wrote narrative comments about their experience with the integrated didactics series on forensic topics. Themes included being exposed to topics that they do not receive elsewhere in training, having a broader understanding of medical-legal concepts, and commenting on the integrated approach as helping them to better understand the standard of care and when to consult with providers from different disciplines.

Piel said inclusion of forensics in integrated care settings for trainees is a new idea and a good one, and she hopes to expand the pilot. “I would like to include a mock testimony experience so that internal medicine and pharmacy residents could participate while we are teaching psychiatry students about court testimony,” Piel said. ■