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The new JNC guidelines were released today.
A quick summary:
Joint National Committee (JNC 8) — raises the recommended blood pressure threshold to determine the need for drug therapy in many patients.
For most hypertensive individuals 60 or older, pharmacologic treatment should be started when the systolic pressure is 150 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher, with the goal of achieving readings below those cutoffs, according to the new recommendations.
For younger hypertensive patients and for those with chronic kidney disease or diabetes — regardless of age — treatment should be initiated when the systolic pressure is 140 or higher or the diastolic pressure is 90 or higher.
For the initial choice of agent, the authors made the following recommendations:
A New Model of Comprehensive Care and Opportunity for Internal Medicine-Family Medicine-Psychiatry Physicians
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Course of Illness and Vasculopathy in Mood Disorders – A Case for Integrated Care
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The Mind-Skin Connection Everything About Psychocutaneous Medicine that You Have Been Itching to Know
Since 2007, more women have died from drug overdoses than from motor vehicle traffic injuries, and in 2010, four times as many died as a result of drug overdose as were victims of homicide. Men are more likely than women to die from drug overdose; however, between 1999 and 2010, the percentage increase in the rate of overdose deaths was greater for women (151%) than for men (85%). The prescribing of controlled substances, drug overdose deaths, and drug misuse- and abuse-related ED visits among women have risen despite numerous recommendations over the past decade for more cautious use of OPR and efforts to curb abuse and prevent deaths.
Between 1999 and 2010, OPR overdose deaths increased more than fivefold among women (a total of 47,935 OPR overdose deaths during that period). Abuse of OPR is a particular problem for women of childbearing age. Given the risk for neonatal abstinence syndrome as a result of OPR abuse during pregnancy (16), and the potential effects of OPR on an embryo during the first trimester (17), health-care providers should include discussions of pregnancy plans within the context of treatment and monitoring of patients taking OPR for medical or nonmedical reasons. Women treated for OPR abuse should be counseled regarding risks to the fetus of OPR abuse during pregnancy. The risks and benefits of treatment of chronic conditions with OPR during pregnancy should be weighed carefully (18). Use of benzodiazepines and antidepressants during pregnancy, or at any time in combination with OPR, also should be considered carefully by women and their health-care providers. Psychological conditions, which might co-occurr with pain or substance abuse (19), need to be assessed and addressed within a treatment regime.
The findings in this report are subject to at least four limitations. First, vital statistics underestimate the rates of drug involvement in deaths because the type of drug is not specified on many death certificates. Second, injury mortality data might underestimate by up to 35% the actual numbers of deaths for American Indian/Alaskan Natives and certain other racial/ethnic populations (e.g., Hispanics) because of the misclassification of race/ethnicity of decedents on death certificates (20). Third, all the drugs involved in ED visits might not be identified. Fourth, information on the motivation for use might be incomplete; some ED visits might have resulted from suicide attempts. Finally, distinguishing between drugs taken for nonmedical and medical reasons is not always possible, especially when multiple drugs are involved.
Public health interventions to reduce prescription drug overdose must strike a balance between reducing misuse and abuse and safeguarding legitimate access to treatment. Health-care providers who treat women for pain should follow prescribing guidelines. Providers should screen all their patients for psychological disorders and for use of psychotherapeutic drugs, either with or without a prescription. Checking state prescription drug monitoring programs before long-term prescribing of controlled substances should be a standard of care. Communities should try to increase access for women, especially pregnant women, to substance abuse treatment services. Medicaid programs, which enroll disproportionate numbers of young women, should ensure that the prescribing of controlled substances to their clients meets established guidelines. Overdose deaths and ED visits related to prescription drugs, especially OPR, continue to be unacceptably high, and targeted efforts are needed to reduce the number of deaths in this epidemic.
A rethink is needed in terms of how we view mental illness, stated National Institute of Mental Health Director Thomas Insel, M.D., in a recent . at the California Institute of Technology (Caltech) in Pasadena.
Deaths from medical causes such as leukemia and heart disease have decreased over the past 30 years. The same cannot be said of the suicide rate, which has remained the same. A vast majority of suicides—90 percent—are related to mental illnesses such as depression and schizophrenia.
Insel believes part of the problem is that mental illness is referred to either as a mental or behavioral disorder. “We need to think of these as brain disorders,” he said, adding that for these brain disorders, behavior is the last thing to change.
Insel walked the audience through recent advances in neuroscience, including the Human Connectome, which indicates that mental illness may be more of a neuronal connection or circuit disorder. The earlier these circuits are identified, he said, the earlier preventive treatments could be used to save the lives of people with mental illnesses.
“If we waited for the ‘heart attack,’ we would be sacrificing 1.1 million lives every year in this country,” he said. “That is precisely what we do today when we decide that everyone with one of these brain disorders, brain circuit disorders, has a behavior disorder. We wait until the behavior emerges. That’s not early detection, that’s not early prevention.”
The American Board of Internal Medicine and the American Board of Psychiatry and Neurology offer dual Certification in internal medicine and psychiatry. A combined residency must include at least five years of coherent education integral to residencies in the two disciplines. Participating residencies must be in the same institution.
To meet eligibility requirements for dual Certification, the resident must satisfactorily complete 60 months of combined education, which must be verified by the directors of both programs. The written certifying examinations cannot be taken until all required years in both specialties are satisfactorily completed.
Internists and psychiatrists have traditionally been trained in the physical and emotional aspects of patient care. Psychiatrists have been expected to be familiar with organic illnesses presenting as psychiatric disorders, while internists have been trained to recognize physical manifestations of psychiatric disease. Acknowledging the large overlap in the domains of these two specialties, and the increasing need for specialists trained to treat the broad spectrum of adult illness shared by internal medicine and psychiatry, the two specialties have agreed to offer combined training leading to dual Certification. The American Boards of Internal Medicine (ABIM) and Psychiatry and Neurology (ABPN) will not consider proposals on behalf of individual candidates entering training after July 1, 1995.
The objective of combined training in internal medicine and psychiatry is to produce physicians with broad-based training in both specialties and specific expertise in such areas as geriatrics/geriatric psychiatry, substance and alcohol abuse, diagnosis and treatment of depression, delirium, eating disorders, panic disorders and neurotic and somatizing behavior. Graduates of combined training may be expected to develop practices which take advantage of the joint training experience, serve as consultants in liaison psychiatry or consultative medicine, or be actively involved in research or administration in internal medicine and psychiatry.
The strengths of the residencies in internal medicine and psychiatry should complement each other to provide an optimal educational experience to trainees.
Combined training includes the components of categorical internal medicine and psychiatry residencies which are accredited respectively by the Residency Review Committee for Internal Medicine and by the Residency Review Committee for Psychiatry, both of which function under the auspices of the Accreditation Council for Graduate Medical Education. While combined training programs will not be independently accredited, the accreditation status of the core psychiatry and internal medicine programs shall influence a trainee’s admission to the certifying examinations of each Board. Residents for combined training should not be recruited if either program has probationary or provisional status. Proposals for combined residencies must be submitted to ABIM and ABPN for approval before a candidate can be accepted into joint training.
A combined residency in internal medicine and psychiatry must include at least five years of coherent training integral to residencies in the two disciplines which meet the Program Requirements for accreditation by the RRC-IM and the RRC-Psychiatry, respectively.
It is required that combined training be in the same institution. Documentation of hospital and faculty commitment to and institutional goals of the combined training must be available in signed agreements. Affiliated institutions must be located close enough to facilitate cohesion among the program’s house staff, promote attendance at weekly continuity clinics and integrated conferences, and encourage participation in faculty exchanges of curriculum, evaluation, administration and related matters.
Ideally, at least two residents should be enrolled in combined training each year. If no trainees are in a combined program for a period of three years, the program will not be listed as approved in the AMA’s Graduate Medical Education Directory.
At the conclusion of 60 months of training in internal medicine and psychiatry, residents should have had experience and instruction in the prevention, detection and treatment of acute and chronic medical and psychiatric illness presenting in both inpatient and ambulatory settings. Trainees should be exposed to the psychiatric and medical problems in patients from adolescence to old age and receive training in socioeconomics of illness, the ethical care of patients, and in the team approach to the provision of patient care.
The training of residents while on internal medicine rotations is the responsibility of the internal medicine faculty and while on psychiatry rotations, the responsibility of the psychiatry faculty. Vacations, leave and meeting time will be shared equally by both training programs. Absences from training (vacation, leave) exceeding five months of the 60 months should be made up.
Except for the following provisions, combined residencies must conform to the Program Requirements for accreditation of residencies in internal medicine and psychiatry.
Residents should enter combined training at the R-1 level, but may enter as late as the beginning of the R-2 level only if the R-1 year was served in a categorical (or preliminary) residency in internal medicine in the same academic health center. Under unusual circumstances and with the permission of both Boards, the Boards will consider accepting individuals who have trained in other accredited programs. Entry after completion of an R-1 year in psychiatry which involved less than eight months of internal medicine training requires prospective approval of each Board. Residents may not enter combined training beyond the R-2 level. Transfer between combined programs must have prospective approval of both Boards, and is allowed only once during the five-year training period. In a transfer between combined programs, residents must be offered and complete a fully integrated curriculum. A resident transferring from combined training to straight internal medicine or psychiatry training should have prospective approval of the receiving Board.
Transitional year training shall receive no credit toward the requirements of either Board unless eight months or more have been completed under the direction of a training director of an ACGME-accredited sponsoring residency in internal medicine.
Training in each discipline must incorporate progressive responsibility for patient care, supervision and the teaching of medical students and junior residents throughout the training period.
Combined residencies must be coordinated by a designated full-time director or co-directors who can devote time and effort to the educational program. An overall training director must be appointed from either specialty, or co-directors from both specialties. If a single training director is appointed, an associate director from the other specialty must be named to ensure both integration of the training and supervision in the discipline. An exception to the above requirements would be a single director who is certified and/or residency trained in both specialties and has an academic appointment in each department. The two directors must embrace similar values and goals for their program. The supervising directors from both specialties must document meetings with one another at least quarterly to monitor the progress of each resident and the overall success of the program.
Training requirements for credentialing for the certifying examination of each Board will be fulfilled by 60 months of training in an approved combined program. A total credit of 12 months over that required for two separate residencies is possible due to overlap of curriculum and training requirements. The requirement of 36 months of internal medicine training is met by 30 months of internal medicine training with six months credit for training appropriate to internal medicine obtained during the 30 months of psychiatry training. Likewise, the 36 months of psychiatry training requirement is met by 30 months of psychiatry training with six months credit for training appropriate to psychiatry obtained during the 30 months of internal medicine training.
A clearly described written curriculum must be available to residents, faculty and both Residency Review Committees. The curriculum must assure a cohesive, planned educational experience and not simply comprise a series of rotations between the two specialties. Duplication of clinical experiences between the two specialties should be avoided and periodic review of the training curriculum must be performed. This review must include the training directors from both departments, in consultation with faculty and residents from both departments.
Each year of the residency should include both internal medicine rotations and psychiatry residency rotations. Except where stated in the Program Requirements for each specialty, specific rotations must be at least four weeks long and consecutive rotations not less than three months in each specialty. Care must be exercised to avoid unnecessary duplication of educational experiences to provide as many clinical/educational opportunities as possible. In each of the five years, no less than four months should be spent in each specialty.
Joint educational conferences involving residents from internal medicine and psychiatry is recommended and should specifically include the participation of all residents in the combined training program. Availability of faculty from both specialties for consultation during clinical rotations, and especially during continuity clinic, is encouraged.
During the 30 months of internal medicine training, each resident must obtain 20 months of experience with direct responsibility for patients with illnesses in the domain of internal medicine, including geriatric medicine. Each resident shall have a one-month experience during years 1 or 2 in the emergency room with first contact responsibility for the diagnosis and management of adults. The resident’s responsibility must include direct participation in reaching decisions about admissions.
Each resident will be assigned to the care of patients with various illnesses in critical care (e.g., intensive care, cardiac care, respiratory care) for three to four weeks during years R-1 or R-2 and again during years R-3, R-4 or R-5 during the 30 months of internal medicine training. At least 33 percent of the 30 months in internal medicine must involve ambulatory experiences. Continuity clinic should occur during the entire 30 months of internal medicine training. Continuity clinic may be in internal medicine every week (10 percent ambulatory time), every other week if alternating with a psychiatry continuity clinic (five percent ambulatory time), or every week as a combined medicine/psychiatry clinic (five percent ambulatory time). Each resident should have at least two months of block ambulatory experience (seven percent), which might include additional work in continuity clinic, walk-in-clinics or subspecialty clinics, or brief experiences in appropriate interdisciplinary areas such as dermatology, office gynecology, orthopedics, otorhinolaryngology or ophthalmology. The remaining ambulatory time can be obtained in additional continuity clinics, subspecialty clinics, emergency department rotations and other ambulatory experiences scheduled as partial or full months rotations. A month of ambulatory experience counts as 3.5 percent; one-half day a week during a month-long rotation counts as 0.4 percent. Some arrangement should be made to allow residents to follow their patients while on psychiatry rotations. Health maintenance, prevention and rehabilitation should be emphasized. Residents should work with other professionals such as social workers, nurse practitioners, physician assistants, behavioral scientists and dietitians in the clinics.
Subspecialty experiences must be provided to every resident for at least four months. Some of this must include experience as a consultant. Significant exposure to inpatient cardiology exclusive of coronary care unit assignments is necessary. Subspecialty experience may be inpatient, outpatient, or a combination thereof.
Residents must regularly attend morning report, medical grand rounds work rounds, and mortality and morbidity conferences when on internal medicine rotations.
During the 30 months of psychiatry, a minimum of two months of neurology – or its full-time equivalent on a part-time basis – is required. A maximum of one month of neurology training may be completed in child neurology. The training in neurology should have sufficient didactic and clinical experience for residents to develop expertise in the diagnosis of those neurological disorders/conditions that might reasonably be expected to be encountered in psychiatric practice and that must be considered in the differential diagnosis of psychiatric disorders/conditions.
Each resident must assume significant responsibility for an appropriate number and variety of psychiatric inpatients for a period of not less than nine months but no more than 18 months. Up to three months of rotations on specialized clinical services, such as addiction psychiatry, adolescent psychiatry, forensic psychiatry, geriatric psychiatry, research units, and day and/or partial hospitalization may be applied to the minimum nine-month requirement. However, no portion of this experience may be counted to meet the timed requirement in child and adolescent psychiatry.
Clinical experience must also include at least 12 months in an organized, continuous, supervised experience in the assessment, diagnosis and treatment of outpatients that emphasizes a developmental and biopsychosocial approach to outpatient treatment. At least 90% of this experience must be with adult patients. A minimum of 20 percent of the overall experience (clinical time and patient volume) must be continuous and followed for a duration of at least one year. The outpatient requirement must include experience with a wide variety of disorders, patients, and treatment modalities, with experience in both brief and long-term care of patients using individual psychotherapy (including psychodynamic, cognitive, behavioral, supportive, brief), and biological treatments and psychosocial rehabilitation approaches to outpatient treatment. Long-term psychiatry experience must include a sufficient number of patients, seen at least weekly for at least one year, under supervision. Other long-term treatment experiences should include patients with differing disorders and patients who are chronically mentally ill. No portion of this experience may be counted to meet the timed requirements in child and adolescent psychiatry.
A minimum of two months full-time equivalent (FTE) in the evaluation, diagnosis and treatment of children, adolescents, and families is required. While adolescent inpatient units may be used to satisfy a portion of this requirement, rotations to student health services may not.
Also required is a minimum of two months full-time equivalent supervised psychiatric consultation/liaison responsibility involving medical and surgical patients. Up to one month of pediatric consultation/liaison psychiatry may be credited toward the two-month requirement.
There must be one month of FTE-supervised clinical management of geriatric patients with a variety of psychiatric disorders. This requirement may be fulfilled as part of the inpatient or outpatient requirement.
One month of FTE supervised evaluation and clinical management of patients with addictive disorders is also required. The resident must gain familiarity with rehabilitation and self-help groups. This requirement may be fulfilled as part of the inpatient or outpatient requirement.
Residents must also have supervised responsibility on an organized 24-hour emergency service; supervised experience in both community psychiatry and forensic psychiatry; collaboration with other mental health professionals; experience with common psychological test procedures; and supervised experience in the evaluation and treatment of couples, families, and groups.
There must be adequate, ongoing evaluation of the knowledge, skills and performance of the residents. Entry evaluation assessment, interim testing and periodic reassessment, as well as other modalities for evaluation, should be utilized. There must be a method of documenting the procedures that are performed by the residents. Such documentation must be maintained by the program, be available for review by the RRCs, ABPN, ABIM, and site visitors, and be used to provide documentation for future hospital privileges.
The faculty must provide a written evaluation of each resident after each rotation, and these must be available for review by the resident and site visitors. Written evaluation of each resident’s knowledge, skills, professional growth and performance, using appropriate criteria and procedures, must be accomplished at least semiannually and communicated to and discussed with the resident in a timely manner.
Residents should be advanced to positions of higher responsibility only on the basis of evidence of their satisfactory progressive scholarship and professional growth.
The program must maintain a permanent record of evaluation for each resident and make it available to the resident and other authorized personnel. The training director and faculty are responsible for the provision of a written final evaluation for each resident who completes the program. This evaluation must include a review of the resident’s performance during the final period of training and should verify that the resident has demonstrated sufficient professional ability to practice competently and independently. This final evaluation should be part of the resident’s permanent record maintained by the institution.
To meet eligibility for dual Certification, the resident must satisfactorily complete 60 months of combined training, and which must be verified by both training directors. The written certifying examinations may not be taken until all required years of training in both specialties are satisfactorily completed. Lacking verification of acceptable clinical competence and performance in both specialties in combined training, the resident must satisfactorily complete the training requirements as required by each specialty.
Approved November 1996
Revised: February 1999
Revised: February 2002
We only matched 1 of 2 spots.
Learn who it is this Friday…
Watch for the email from Debbie on Friday!
This renewal session will be held at the Psych clinic Thursday from 1-4 PM. Check your email for further details.
Thanks to all who helped with the residency interviews – especially Debbie Medlin – who puts a lot of effort into this. Thanks also to Irene, Raj, and Melissa who made it to all of the dinners. We had a lot of great candidates and look forward to filling our 2 slots with excellent residents. We will have our annual “ranking” meeting in January. You will receive an email with the information.