Acad Psychiatry 31:65-67, February 2007
doi: 10.1176/appi.ap.31.1.65
© 2007 Academic Psychiatry
Achieving Competency in Electroconvulsive Therapy: A Model Curriculum
Tamara J. Dolenc, M.D. and
Kemuel L. Philbrick, M.D.
Received June 29, 2005; revised December 22, 2005; accepted January 5, 2006. Dr. Dolenc was affiliated with the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota at the time this article was written, and is currently affiliated with the Department of Psychiatry, Duluth Clinic, Duluth, Minnesota. Dr. Philbrick is affiliated with the Mayo Clinic, Rochester, Minnesota. Address correspondence to Dr. Dolenc, 400 East Third Street, Duluth, MN 55905; tdolenc{at}smdc.org (e-mail).
|
ABSTRACT
|
OBJECTIVE: This article illustrates a model electroconvulsive therapy (ECT) curriculum with specific parameters of both practice-based learning and medical knowledge. METHOD: The authors review the recommendations of the APA Task Force on ECT as they relate to training in ECT in psychiatry residency programs, and discuss diverse educational experiences across American psychiatry residencies. RESULTS: The authors present objective methods for assessment of factual knowledge germane to ECT practice, including an objective structured clinical examination. CONCLUSIONS: The ECT curriculum allows residents to become familiar with the theory and practice of ECT. Guided study, informed observation, and hands-on learning ensure that residents become skillful in executing pre-ECT psychiatric and medical assessment, ECT procedure, and immediate post-ECT care.
|
INTRODUCTION
|
Electroconvulsive therapy is a potent therapeutic tool that deserves mastery by every psychiatry resident and practicing psychiatrist. In an era of increasing competition for psychiatry, it is imperative that trainees maintain a clear identity as physicians even as they acquire particular skills in psychotherapy. The assessment of potential candidates for electroconvulsive therapy (ECT), followed by informed administration or referral and subsequent aftercare, requires both specific training and firm clinical footing.
The views on ECT have varied, from clinicians who are skeptical about its effects and concerned about brain damage to those who believe it is the most effective and safe psychiatric treatment. A recent systematic literature review and meta-analysis of published work concluded that ECT is an effective short-term treatment for depression (1). The use of ECT in vulnerable populations, such as children, mentally retarded, and demented patients, has provoked ethical controversy. Though some clinicians are appalled that this procedure should be offered to such patient populations, others argue that it is inhumane to withhold this effective treatment.
An informal survey of psychiatrists utilizing ECT in American psychiatry residencies revealed diverse educational experiences, ranging from brief, elective observation to expectations for participation in a prescribed number of treatment cases (2). The interest and initiative of the trainee appeared likely to have been a determinative influence on the extent of training in many programs. This curious, inconsistent commitment to acquiring expertise in one of our most effective treatments is perhaps not surprising given the almost inverse endorsement of the Accreditation Council for Graduate Medical Education (ACGME): "electroconvulsive therapy, a somatic therapy that is viewed as so important that its absence must be justified" (3).
APA’s Task Force on ECT (4) recommends that psychiatry residency programs provide comprehensive training in ECT to all residents. The same report suggests that each resident actively participate in at least 10 electroconvulsive therapy treatments involving at least three separate patients, and also participate in the care of at least three patients during ECT workup, treatment course, and post-ECT management. In programs where no qualified or privileged ECT clinicians are available, the APA Task Force recommends using consultants or appropriate community practitioners.
We illustrate the specific parameters of both practice-based learning and medical knowledge that will equip psychiatry trainees to demonstrate appropriate competency in the care of patients who are well served by ECT.
ECT Curriculum
In our adult residency program, all PGY-4 residents complete a 1-month ECT rotation. Residents rotate one at a time, 4 days a week, to allow for focused teaching and an intense learning experience, including the participation in approximately 400 treatments.
Each day, residents are assigned a mentor who is an experienced member of the ECT team. The ECT team at our medical center consists of a psychiatrist, anesthesiologist, physician assistant, respiratory therapist, nurse, and recovery nurse. The ECT psychiatrist is the team leader and plays a pivotal role in resident education by reviewing basic and advanced ECT topics, teaching the clinical pearls of ECT practice, and delineating prerequisites of successful teamwork. Comprehensive readings are provided in the key areas of medical knowledge (4, 5).
The role of the physician assistant is to provide pre-ECT medical evaluations and initial risk assessment for all outpatients receiving ECT. The anesthesiologist is responsible for ECT-specific anesthesia, comprising the administration of anticholinergic and anesthetic agents, a muscle relaxant, and modifiers of cardiovascular hemodynamic response. The ECT nurse is responsible for the application of stimulus and recording electrodes and appropriate electrode contact during stimulus administration. The recovery nurse monitors the patient’s post-procedure vital signs, level of alertness, cognitive status, and any adverse effects of treatment. Although the residents spend a majority of time acquiring the necessary psychiatric knowledge and experience, they are also assigned to spend at least 1 day with each of the team members. In this way, the resident is obliged to view the patient through the lens of each discipline that contributes to the safe care of the patient. A thorough understanding of each team member’s role fosters mutual respect and effective team leadership skills for the senior psychiatry resident who may soon be called upon to build his or her own ECT team after graduation.
|
Discussion
|
By working closely with experienced ECT team members, residents become intimately familiar with the theory and practice of ECT. Hands-on learning experience fosters proficiency and assumption of progressively increasing responsibilities. Under supervision of the ECT psychiatrist, residents eventually become responsible for skillfully executing pre-ECT psychiatric and medical assessments, ECT procedure, and immediate post-treatment care and are expected to act as the ECT team leader (Appendix 1).
To provide an objective assessment of factual knowledge germane to ECT practice, our residency program will implement pre- and post-ECT rotation tests, using multiple-choice questions patterned after the PRITE (Psychiatry Resident-In-Training Examination) and ABPN (American Board of Psychiatry and Neurology) Part 1 examinations. Also, an objective structured clinical examination (OSCE) at the conclusion of the rotation shall provide a realistic assessment of the practical skills essential for safe administration of ECT. Lastly, we will survey pre- and post-curriculum attitudes of the residents toward the use of ECT.
Almost a hundred years ago, Sir William Osler commented on the quintessential role of practice-based learning: "To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all." Targeted exposure to allied disciplines, informed observation of seasoned psychiatrists, hands-on experience, and guided self-study over successive weeks to ensure adequate familiarity with a clinically varied and often intensely ill population enables the psychiatric physician to preserve a patient-centered appreciation for the salient considerations across multiple medical disciplines in the safe and effective administration of ECT.
|
REFERENCES
|
- The UK ECT Review Group: Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361:799–808[CrossRef][Medline]
- Personal communication: Association of Convulsive Therapy E-mail Listserv, 2002
- Accreditation Council of Graduate Medical Education: Program Requirements for Residency Training in Psychiatry, 2004. Available at http://www.acgme.org/acWebsite/downloads/RRC_progReg/400pr1104.pdf
- Weiner RD, Coffey C, Fochtmann L: The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, 2nd ed. Washington, DC, American Psychiatric Press, 2001
- Abrams R: Electroconvulsive therapy, 4th ed. New York, Oxford University Press, 2002
Get information about faster international access.
Privacy Policy
Copyright © 2007
Academic Psychiatry.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
