THORNY ISSUES IN EDUCATING RESIDENTS TO TREAT BPD
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4/8/2021
THORNY ISSUES IN EDUCATING
RESIDENTS TO TREAT BPD
DANIEL PRICE, MD
DIRECTOR OF RESIDENCY TRAINING
MAINE MEDICAL CENTER, DEPARTMENT OF PSYCHIATRY
NASSPD, APRIL 16, 2021
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CONFLICTS OF INTEREST/DISCLOSURES
• I have no relevant conflicts of interest or disclosures to make
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OBJECTIVES
• Coherently advocate with your Residency Training Director to devote
increased time for training about BPD
• Understand how training residents in a generalist approach to BPD can satisfy
a number of ACGME Milestones.
• Describe a 4-year approach to a graded-increase in knowledge and clinical
responsibility in caring for BPD patients.
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THE ACGME MILESTONES 2.0—COMING TO A PSYCHIATRY
RESIDENCY NEAR YOU IN JULY, 2021
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INTRODUCTION TO MILESTONES
• All residencies and fellowships in all specialties have milestones that drive curriculum and
evaluation of residents
• Though the specific content of each set of milestones differs across specialties, all specialties
(including psychiatry) have milestones in 6 broad areas
• Patient Care
• Medical Knowledge
• Systems-Based Practice
• Practice-Based Learning and Improvement
• Professionalism
• Interpersonal Communication Skills
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MILESTONES (CONTINUED)
• They are meant to frame resident learning as a graded-increase in
knowledge and ability
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MILESTONES (CONTINUED
• They are meant to frame resident learning as a graded-increase in
knowledge and ability
• There are NO STATED CUTOFFS for promotion or graduation
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INTRODUCTION TO MILESTONES
• They are meant to frame resident learning as a graded-increase in
knowledge and ability
• There are NO STATED CUTOFFS for promotion or graduation
• Level 5 is meant to be aspirational
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WHAT DO THE MILESTONES SAY ABOUT BPD OR
PERSONALITY DISORDERS?
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THE MILESTONES:
• Do not mention BPD
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THE MILESTONES:
• Do not mention BPD
• Do not mention any Specific Personality Disorder
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THE MILESTONES:
• Do not mention BPD
• Do not mention any Specific Personality Disorder
• Only mention “Personality” once
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SO HOW DO YOU MAKE THE CASE FOR BPD
TRAINING TO YOUR RESIDENCY TRAINING
DIRECTOR?
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THE GOOD NEWS
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THE GOOD NEWS
THE MILESTONES DON’T MENTION ANY SPECIFIC DISORDER.
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WHAT’S THE ELEVATOR PITCH?
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GOOD BPD TRAINING, CARING FOR BPD PATIENTS
MAKES GOOD RESIDENTS
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STEPPED CARE
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HOW DO RESIDENTS LEARN?--ADULT
LEARNING THEORY
Adults (e.g. Residents) learn best when:
▪ They feel respected for what they bring to the situation
▪ They learn material that relates to what they already know
▪ They feel challenged but not threatened
▪ They participate actively
▪ The material is meaningful to the residents, and has immediacy
The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development by Malcolm S. Knowles, Elwood E. Holton III, & Richard A. Swanson, 2005,
.
Burlington, MA: Elsevier
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BPD TRAINING AT MAINE MEDICAL CENTER
• Orientation—Seminar on working with BPD in the ED using a GPM approach—including making the diagnosis, using the
interpersonal hypersensitivity model, risk assessment by attention to Acute on Chronic risk, providing basic psychoeducation
• PGY-1 and PGY-2 Seminars
• Psychopathology Seminar--Providing basic education about neurobiological underpinnings, Genetics, prognosis, symptom recognition,
comorbidity (and prioritizing comorbidity treatment) making the diagnosis
• Psychopharmacology Seminar—Education about limited role for meds, how meds might be used for targeted symptoms, enlisting patients
in
• Psychotherapy seminar—training in basic GPM principles including making diagnosis, using psychoeducation, Case-Management
approach, Interersonal Hypersensitivity, importance of structure, involving families
• Supervision by Rotation Supervising Attendings—modeling GPM, DBT approach in ED, on consult service, and on inpatient units.
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BPD TRAINING AT MAINE MEDICAL CENTER
• PGY-3
• Everyone co-leads an 8 week Psychoeducation group for BPD patients (Graded responsibility)
• Utilizing GPM (with the help of GPM trained supervisors) in managing “psychopharm”
patients
• Optional—Co-lead DBT skills, or MBT group with expert clinician
• PGY-4
• Optional participation in Personality Disorders Clinic Supervision reviewing difficult cases,
and assisting in building the clinics programs and outreach
• Optional Individual MBT, or DBT treatment of BPD or NPD patient.
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EXAMPLE: TEACHING BPD IN THE ED
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IATROGENESIS IN THE ED
Table 1
Possible Iatrogenic Actions While Treating BPD in the Emergency Department
Iatrogenic action Likely causes Potential consequences Productive alternatives
Unnecessary inpatient hospitalizations Reacting to fears of liability, Reinforces hospitalization as Work actively with patients and
emphasizing chronic (over acute) risk the best answer to short-term their families on safety planning
factors, equating self-harm with crises and improving social supports
suicidality
Inadequate safety assessments Staff fatigue, poor transitions of Heightens safety risk and Be aware of provider fatigue,
care, underutilization of collateral increases liability engage in formal sign-outs with
information (e.g., outpatient written recommendations, make
providers and social supports) efforts to contact outpatient
providers and social supports
Excessive use of medications Provider frustration, insufficient Frames medications as the Actively express support,
verbal de-escalation (due to lack of solution, subjects patients to provide psychoeducation
training or time), patient or provider adverse side effects regarding medications in BPD
seeking a “quick fix”
Hostile or dismissive staff behavior Excessive countertransference or Exacerbates patient’s Recognize negative reactions
transference reactions. hopelessness, worsens and adopt a more hopeful,
stigma, increases liability positive attitude
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RELEVANT GPM PRINCIPLES IN THE EMERGENCY
DEPARTMENT
• Engage in psychoeducation about BPD
• Be active and authentic when communicating with the patient
• Imbue therapeutic interactions with the expectation of positive change
• Encourage the patient to actively participate in treatment
• Focus on interpersonal relationships and stressors
• With Permission from Victor Hong
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MEDICATION GUIDELINES FOR TREATING BPD IN THE
EMERGENCY DEPARTMENT: DO’S
(ADAPTED FROM VICTOR HONG, 2016)
Use medications to reduce agitation when danger to self or others
is present
Engage in psychoeducation about the role of medications in BPD
Use medications to reduce anxiety interfering with a thorough
assessmentAttempt verbal de-escalation before resorting to the
use of a calming medication.
Emphasize psychosocial interventions as the mainstay of
treatment, and frame medications as adjunctive at best
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MEDICATION GUIDELINES FOR TREATING BPD IN THE
EMERGENCY DEPARTMENT: DON’TS
(ADAPTED FROM VICTOR HONG, 2016)
Present medications as the treatment of choice for BPD symptoms
Use medications in a hostile or punitive fashion
Offer medications without explaining to the patient why you are doing so
Make recommendations regarding the patient’s medications without collaborating with
his or her outpatient providers
Significantly change medication regimens in the acute crisis setting
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