So today we're going to be talking about teaching decision-making capacity in a workshop model. Can you all hear me okay? So my name's Kara Angelotta. I'm Vice Chair for Education and the Program Director for the Residency Program at Northwestern University, and I'll introduce my colleague, Brittany Goldstein. Hi, I'm Brittany Goldstein. I'm a third-year resident at Northwestern University Psychiatry Program, and as you can see, no disclosures, at least not yet. So we're going to start with just want to get to know who the audience is so we can adjust the workshop based on your needs. So if you can go ahead and get out your phones and do this quick, just a couple of questions so we know a little bit about your background. The first part of the workshop, we're going to talk about the curriculum overview. Then we'll actually practice what we do in the workshop with our medical students and other trainees, and then we'll talk about how to replicate it in other settings. Okay, cool. Thank you for filling that out. So it looks like our audience is primarily psychiatry residents and attending psychiatrists, and most folks want to learn new tools for teaching capacity assessment, and we have a combination of folks in academic hospitals, community hospitals, private practice, with inpatient being the main setting that people are working in, or most common setting. All right, so we're going to review what the capacity curriculum is that we've been using with our medical students, and the way that it's organized is both asynchronous learning as well as the synchronous workshop, and the asynchronous part of this curriculum uses the ADMSEP, which is the Association of Directors of Medical Student Education in Psychiatry. They have a lot of really great online modules geared towards medical student learning in psychiatry, and so we're utilizing their capacity module as the asynchronous learning component of this workshop. So students in our program are expected to have watched this, which if you watch it all the way through, just clicking through the module and listening, it takes less than 30 minutes, but there are some interactive and engaging components, so it could take a little bit more than that. The purpose of this part, the asynchronous learning in our mind, thinking of Miller's Pyramid of Medical Education model, is getting that foundational knowledge base. So this is teaching students to know what is decision-making capacity, and that then we can build on in our synchronous learning component of this curriculum, which is the workshop that we'll be doing together today, and that is to try to get to that next level in Miller's period, working on knowing how. So starting to practice the skills, and ideally moving them up on that pyramid model towards becoming more expertise at this particular skill set. So our workshop, which is in person with students, is focused more so on how do we assess decision-making capacity, and we do that by very briefly reviewing what they should have learned in the Adam Set video, in the asynchronous learning component. Then we learn the how, which will go through the item checklists that we've created for this communication skill. Then we actually practice in small groups, where they get to practice the skill, and then we come back together and debrief and discuss as a big group. So we're going to work together just like we do it when we're working with our students, and at the end, we'll be able to take a step back to talk about how you might apply it in different settings, not just to medical students. But given the audience, a lot of you, I'm sure, are coming in with information on your own capacity assessments and how you do so, this will be a little bit more editorialized of explaining how we present it to trainees when we're giving this curriculum, but it is more or less the exact same curriculum that we use in our program. So we start out with that review of what they now know, which is defining decision-making capacity. So as you all know, it's the ability to make an informed decision about medical care, and I take the opportunity with students to highlight that no matter what type of physician they are going to graduate and become, based on what state they're practicing on in, they probably are all going to be expected to legally, at the end of the day, be able to determine their patient's decision-making capacity. And depending on what state, of course, it will depend on how specific those statutes are in terms of you have the broader and more vague end of the spectrum, the New York laws just say an attending practitioner, it doesn't even specify that that practitioner is a physician. Illinois, where we're practicing, for instance, is somewhere in the middle, it's an attending physician, but it could be any type of attending. And then on the more restrictive end, California actually specifies it's the primary physician who ultimately has to make that determination. And so this is to highlight the importance of you don't have to be going into psychiatry as a medical student, all of you will need to be expected as future physicians to be able to do this skill. So then we'll review with the students the four functional abilities that a patient needs to demonstrate to show that they have decision-making capacity for a specific decision. And as you all know, that's going to include the patient's ability to communicate a choice, and we like to highlight that. Communicate is specifically a broad word because that doesn't mean that it has to be through speech, it just has to be consistent and reliable. And so we give students examples, it could be written, it could be through gestures, as long as you're able to test that it is reliable communication and that it's a consistent choice. Understanding the situation, and we get into how that includes both what is going on with the patient medically that they have to understand, as well as do they understand all of the choices and the risks and benefits to those choices. And then being able to appreciate how that situation and consequences of their choices actually apply to them as a person. And that oftentimes is one of the more trickier components to teach trainees, that this is actually manipulating that second point of regurgitating information, how does the patient then manipulate it to their own personal values, beliefs, experiences, and goals of care. And then reasoning, we like to highlight that it doesn't have to be the same reasoning that you as a medical student or a doctor is going to use, but it just has to be based in logic and informed by reality. So then we move on to learning the how of capacity assessment. So we developed a capacity assessment checklist with a group of about 17 experts from across the country in multiple disciplines, so consult psychiatry, forensic psychiatry, general psychiatry, but also internal medicine, emergency medicine, and surgery, and forensic psychology as well to really think through how do physicians think about this in making these decisions and what are the components of the types of questions that somebody assessing for capacity needs to be asking of patients. So the first four components of the checklist are that really you need to establish rapport with the patient, you need to explain technical terms in jargon-free language, you need to introduce yourself to the patient and explain the purpose of the conversation. Learning is where we, the expert group, decided that there really needs to be the most questions. So does the patient understand their current health, their current problem with their health? Do they, you ask the patient, especially if you're coming in as a consultant, did the healthcare team talk to you about what your options are, explain the treatment options, ask the patient to describe the recommended treatment, review the name and details of that treatment, explain the purpose of the treatment, the potential benefits, risks, and the treatment alternatives. And then ask the patient about their understandings of the risks of no treatment and their patient's perspective on the potential benefits of not getting treatment. For appreciation, the two items we look for are ask the patient to explain their belief or perspective about the treatment recommendation and ask the patient what will happen if they're not treated. And then asking the patient to indicate a treatment choice. And then in terms of reasoning, we ask the patient how they made their choice and ask the patient to compare treatment options. And then we have a conclusion item on the checklist asking the trainee to just inform the patient of the next steps. So in our medical student curriculum, that's saying something like, okay, I'm going to go talk with the attending and the resident team about what we've discussed and we'll come back with you, come back and talk to you more. Okay, so then in this curriculum, we would move on to actually practicing this skill. And so we're going to do that here today together. And the way that we do it is we break up the, we'll break up students into groups of three, depending on how many people there are, sometimes groups of four, and we do a role play. And in our curriculum, we've been doing three cases for time's sake. We've included two cases for us to do together today. That being said, if you look on the app, the PDF materials does have the third case in case you're interested in seeing what it is that we use for the third case. So we're going to break up into groups of three. There might be one or two groups of four. And when you get the packet, each group will have two cases. So for each case, there's going to be three roles. The role number one labeled is the physician role. And this is where we want students to really get into the mindset that this is, I'm ultimately the person in charge of determining whether this patient does or does not have capacity. So you'll see in the prompts, we ask students that they're pretending that they're an intern resident on call. So it doesn't necessarily mean that they're in a consultant role, like CL psych rotation, but it does mean that they might not be the primary daytime team, so they have to gather all of this information from scratch in this role play. We also inform students that the goal of this isn't to come up with a diagnosis. There's no physical exam. And really, we're focusing on the how, not actually their ability to then not yet at least synthesize what their determination of capacity is. So really, it's just getting practice doing this interview and not worrying about the final decision, which we come back together at the end to do as a big group. Then role two is going to be the patient role. So the person acting as the patient will read the prompt as to what information the patient does or does not know and what the patient's values and belief systems are, and use that to guide their responses to the person playing the role of the physician. And then role three, plus or minus role four, are going to be in charge of holding on to that checklist that we had just read through all together and providing feedback at the end. So they have a checklist of what things were and were not completed. They can write notes on what was effective, what they might have done differently or tried differently. And then at the end, part of the recorder's role, and if there's a fourth person, we'll make the fourth person be the timekeeper, is to make sure that they finish each case within 15 minutes, allotting the last three to five minutes or so for feedback. So if the interview is continuing to go on close to that 15-minute mark, the recorder is just in charge of letting them know to wrap it up so there's time for feedback at the end. It is totally guided time. The time is guided by the small group. So we will do case one. Once you're done with case one, move directly on to case two. And then after the 30 minutes for each case, so 15 minutes per case, we'll come back together and discuss what your thoughts were, what determinations you think based on your patient. And so we're actually going to practice this together today. So Kara will pass out packets to groups of three. And when you get your packet, you can open it up, introduce yourself to your group of three. Decide who wants to do which role for each case. And then just a reminder to read the prompts to yourself before you begin. So thank you all for participating. We will continue going through the curriculum, again, as we've been giving it. And the next component would be for us to debrief. And just to give you a sense of how this has been going for us, so I've now completed one full academic year of giving this curriculum to our third-year medical students who are going through the psychiatry clerkship rotation. So that's nearing about 200 students who have completed this. And we'll go through on this slide where I usually would put it to the students to tell me what they observe more generally, not specific to any one case in particular, but just what went well, what was surprising or challenging, what was it like to be a patient, what was it like to be interviewing for capacity. And what I want to share with this group today is what some of the themes that tend to come up and thinking about how you might respond to them. So a really common one is the experience that students have that they feel their role is to persuade the patient in that moment. And trying to handle that challenge of, is my role to actually get the patient to agree with me versus am I just gathering information? Now the way that we wrote these cases for students is to be an on-call intern year resident. So it would really be more about the gathering the information that then the primary team would have to make decisions on the following day. And so we often will talk through when is it your role to try to do the next steps of maybe you need to provide more information and more education to the patient versus when is it just gathering these four components do they or do they not demonstrate them for capacity and then bringing that information to the attending to decide whether the patient can make that decision in that moment in time. Another theme that often comes up which and if it doesn't come up usually I'll bring it up as a point of discussion which is important is what are the next steps? So if they determine that the patient doesn't have capacity what do we do with that information? And so that's where we'll spend time talking about we have to find out now why don't they have capacity? Is it for a reason that could be reversible? Is it because the patient is confused and they're confused because they have delirium? Then why do they have delirium and can we treat that underlying cause and regain their capacity? Is it because they have psychosis that's informing their version of reality that goes into a decision that might not be a decision they would be making otherwise in which case then we would have to come up with a plan to treat the psychosis again trying to restore capacity. And bringing up that sometimes it's a really easy solution it's just providing more education to the patient and that's something that anyone on a primary team during the daytime can do and hopefully then reassess for capacity and maybe have regained it in a short period of time. One other theme that often comes up is that especially for in today's cases the second case wanting to highlight that just because a patient that you're assessing has a known psychiatric illness doesn't off the bat negate the fact that they might have capacity for one very specific decision in one specific moment in time. And so making sure that we find the balance with students that yes you should probably be assessing still to make sure that is the case. So if someone has a known psychotic disorder are they currently having hallucinations that are informing their decision or delusions that are informing their decisions. However you shouldn't walk in the room assuming that that's the case. And so those are some common themes that are often brought up by the students themselves or that I try to point out along the way. So the next thing that we would do in the curriculum is then go through the actual cases to discuss what students felt their patients demonstrated in terms of capacity. And the one tricky part about this is obviously every person is going to portray their patient based on the prompt a little bit differently. And so we have to give that caveat knowing that some people might have come to different determinations just based on the fact that their patient portrayed their role differently. That being said when we come together as a group I'll explain what was at least meant to be the case based on how the prompt was written. So out of curiosity based on case one which was a patient on the medical floor wanting to leave against medical advice by raise of hands anyone here feel that the patient did have capacity to leave AMA? And then how many people said no they could not leave AMA? Okay. So oftentimes this particular case is actually can be a pretty even split. I think this one highlights the example of students saying they feel like they had to persuade the patient and keep going until the patient agreed with the doctor's role. And so here we get to focus on the appreciation and reasoning. So this patient actually had a pretty impressive understanding of the medical situation, the medications they were on, why they were in the hospital and were very clearly communicating their choice consistently that they wanted to go home. But in terms of I usually start with the appreciation being unclear that they consistently understand that something could really happen to them if the patient were to go home. It seems like the patient have this belief that as long as I'm not here in this hospital room everything is gonna be okay. And so the appreciation's wavered somewhat from that argument. And then really the take home point was the reasoning. The patient in this, the way the prompt was written was saying something about the room just wasn't right and something about the members of the team just wasn't right. And no matter how much information you can give about the machines in the room, why they're there, why they may or may not be relevant but aren't dangerous as well as no matter how many times you tell someone that yes in fact you do have a physician guiding your care, for whatever reason that we don't know this patient had a problem believing that that was the case. And so that also will then bring in that conversation of we really need to at the next step understand why it is that they don't have capacity but that could be so many different reasons in this case. Is this patient paranoid? Do they have dementia or delirium that's just making them confused? So the next steps being assessing what is going on that this patient really fears the room and then can we do something about that to help them regain capacity. So then case two we'll discuss. Same thing, this was capacity to refuse disposition to a subacute rehab center. So by show of hands how many people felt that their patient did have capacity to refuse? Most people. Anyone who felt the patient did not have capacity? Okay, so that's pretty consistent. Sometimes there's a little bit of a more mixed bag with the students. So again just rehashing with students that yes this patient very clearly and consistently communicated their choice. They had a very good understanding of what was going on with them medically. The fact that PT and OT were indicated but that there were other ways in which they can get PT and OT other than going to a SAR. The most elegant part of this prompt which hopefully comes out when you're portraying the role of the patient is how much they're able to use their own values, systems and beliefs to appreciate how for them family is so important that it would be more important to be with family than to be at perhaps the best place possible to get that rehab. And then the reasoning also very descriptive in that it was based off of things that are truly realistic. They made arguments such as you can get healthcare acquired infections at a SAR which isn't wrong. So again while they're able to manipulate that information but at the end of the day are still able to make a decision that's different than what the physician is recommending. So now we're gonna take a step back get a little bit meta with the teaching about teaching and talk about how you might be able to replicate this. So to review the curriculum the first part's an asynchronous model where the students are given information they need to review before they come to the workshop and then we do the synchronous workshop where they review the capacity definition, learn the checklist, practice in small groups and in our small groups we do three cases so that everybody tries each role and then we debrief and discuss capacity determinations together. So we're hoping this is moving them along from knowing to knowing how and some practice showing. In terms of ways this curriculum could be developed further in a student setting practicing with standardized patients or doing it in an OSCE setting as part of a testing to really demonstrate the knowledge of the learning or observing it then on the consult service in the hospital or other settings where the student then demonstrates to their attending physician that they're able to do it are some examples of ways that this could be moved further along. We also talk about like how we've adapted this curriculum. So Brittany's done this with about 200 medical students and it's been well received in our third year curriculum and much preferred to what we were doing before which was just a straight lecture about this is capacity, this is what capacity means. On the students engagement and being sort of like oh this is something I really might have to do when I start intern year has been interesting to see too. The sort of realizing they might be at a hospital that is not a big academic hospital where there's a psychiatrist available 24-7 to help with these kinds of issues has been interesting and fun to observe that they're more engaged in learning this aspect of psychiatry as a key skill. We are now adapting it to do with our incoming PGY-1 interns as part of their boot camp introduction to psychiatry so they have some more practice before they hit the wards on our consult service and then Brittany's also been asked to adapt it for other learners and other residency programs. For example, our PM&R fellowship, their program director, or PM&R residency, the physiatry residency, their residents get asked to do a lot of capacity type, they get a lot of capacity type questions in some of the settings where they rotate, right? Like at nursing homes and things like that where psychiatry's not available. So we think it has applications in a lot of settings. In terms of, we would love to get your feedback about how you think this would potentially apply in your setting, what you thought of the strengths and limitations of the cases, the workshop, the checklist, and any thoughts you have for us as we continue to iterate this curriculum. So I'll let Brittany take questions. So, you know, we were talking about ideal situation that patient cooperate with you and answering all questions. My, you know, all of you, when we do CL consultation from time to time, actually pretty frequent in my case when I work, I have patients who would refuse or partially refuse. They provide some information, but then they would refuse to cooperate with the full assessment. And what would you recommend in this situation? So practically, we're talking about someone who wants to sign AMA and is refusing completely or partially refusing full assessment. Do you assume patient doesn't have capacity? Do you let them leave AMA? You know, this is like happens. Yes, and that actually ties into another thing that sometimes comes up with case one. So thank you for that question. So in terms of what, I'm going to tie it in first to how it has come up in my experience teaching the students and then answer your question more directly. A lot of times when the students say that they actually thought the patient in the first case had capacity, when I ask them to tell me what the patient's reasoning was that they want to go home, they start getting very vague and, well, he didn't like the room and, but, you know, he said all the other things and he was willing to take on the risk to go home. And so I remind them in that setting that if they've gotten this far and they're a third year medical student and they're confused, probably they haven't gathered enough logical linear based in reality reasoning to say that the patient does in fact demonstrate capacity. And so more directly to your question then, the way we usually practice at least at our hospital in the CL service is if a patient isn't able or willing to cooperate enough in terms of communicating all of the information that we would need to demonstrate all four points, then they really don't meet the criteria of communicating and they might not even give us enough information to meet all of the other four criteria, in which case at that point in time we say that they don't demonstrate capacity and that's an opportunity to teach students or trainees of any level that that is why capacity is something for a given time and situation and question. So they can come again tomorrow, maybe the patient was irritable at the moment and has had time to calm down, maybe they've gotten medications for other things like uncontrolled pain and are more able to engage or maybe they need to do more of a psychosocial assessment to figure out why it is that the patient can't communicate fully in the assessment and then address that to help restore capacity. Does that answer your question? Thanks a lot for this talk. On our consult service in Massachusetts we primarily have attending psychiatrists and nurse practitioners, so just kind of curious how you might sort of adapt or think about these training modules when it comes to other professionals such as nurse practitioners, that's one question. And then the other is how you sort of think about this curriculum in terms of also teaching ethics, particularly as most of these capacity consults are sort of conflicts of various ethical principles, autonomy versus whatever. The example that often comes up for us is capacity to refuse a cardiac catheterization where ethical principles may inform the current issue of they might not have capacity to refuse a cardiac catheterization, but what about the stents you're going to place and the six months of anticoagulants that they need to be adherent to and should we do this? So curious about both of those questions. Yes, so first question being how might we adjust the curriculum when we're talking more about people who are already in the profession and not necessarily students or resident trainees? And so that's one of the questions that we're working on too in terms of seeing how far we can use this in our own programs at Northwestern, and so I appreciate that question very much. And the things that we've thought of thus far is in terms of, again, thinking of Miller's pyramid of medical education, everyone still needs to know and sometimes review those first two foundational steps. So knowing the information, which we find that the Adam Supp video is excellent and very easily attainable, free to everyone, online module, and then using a checklist item might not necessarily be something that is realistic or feasible at that level of professional development, depending on the time that you have to dedicate to this training. That being said, having it available as a tool could be useful for people to review. And then also, I think what's even more important at that step is once you get those first two, the knowledge and the know-how with the skill, moving beyond that towards what are the next steps that I do as a provider, when someone in this example doesn't have capacity, that brings in ethics and brings in other team members, like the primary team. So how can we work together to diagnose why this patient doesn't have capacity in this moment? If it's something that either will take a long time to recapacitate them, or it's something that probably we won't be able to recapacitate them, that's causing them to not have capacity in that moment, then who do I call to make that decision at that point? So also reviewing your state laws in terms of surrogacy, like who is the, and in what order do you have to go through in terms of surrogate decision makers, as well as what is the process to get a legal guardian? And when, at what point does your team feel that you initiate that process, knowing that, at least I know in the state of Illinois, sometimes that could take weeks, several weeks, if not a month. And so it might be something that you want to, amongst your team and your setting, hospital setting, say, this is something where if we feel that it might even be possible, we're gonna do earlier rather than later, initiate that process. And so I think at that level, those next step questions are really important. And to your second question, which was about considering the ethics involved, especially when someone doesn't demonstrate capacity, that also brings in something that we didn't discuss today because we didn't do the third case that I usually would do with students. However, you can look at the details of the case on the PDF if you look in the app. Briefly, though, it's a case where a patient doesn't demonstrate capacity to refuse surgical intervention. So very similar to your example with the catheterization. And talking through the fact that, okay, so what do we, do we drag a patient, kicking and screaming, into the OR in that situation? And talking through the ethics that get involved when you do involve a guardian or a surrogate decision maker and the fact that those people are supposed to be making those decisions on behalf of the patient to the best of their knowledge. So they aren't just deferring to the physician and what the physician says is best, but really trying to learn as much as they can about the patient's prior wishes, beliefs, value systems, and make the decision with that in mind. Those are great questions. One of our hopes, too, is that people would feel free to use this curriculum to adapt it to the people they're working with. So if you supervise nurse practitioners or physician's assistants on your team, you could do this as a workshop with them in a briefer way or use the checklist to help provide some extra training to help make sure everybody's on the same page. I think in addition to the ethics that you brought up, which is such a good point, is also a lot of the practicality of these decisions is the other piece of it. And that's where that liaison part of what consult and liaison psychiatrists do, of talking to the team about, look, he might not have the capacity to refuse this, but what are the risks if he's not gonna take the anticoagulant for the next six months, and do you really wanna do the procedure given that? And so adding that piece of it, too, is often really important for trainees to learn. It's not just so concrete as what, what is it capacity or not capacity, but what are the implications practically of that? I wanted to congratulate you for this type of setting. It's a very good practice for particularly residents or persons that enter, there is two fellows in forensic psychiatry here, so, and who does this on a daily basis? I just wanted to mention that one of the aspects that is more important, most important, and many of us that do this job is the report and the putting yourself in the patient's situation. This must be addressed very seriously, in fact, and I think that in your three modules, the reasoning difficulties that you mentioned are because we don't have possibly a very good introduction to the patient, what is our purpose? We're not here to convince you. We want to talk about what you feel about doing and how you like to live and what are your options, and this is the most difficult aspect because you will find many, many patients always refusing to even talk to you if you don't present the situation clearly. Thank you very much. Yes, thank you for that point, and obviously, with the medical school trainees, all of that is really important to be instilling at such a young part of their training. Thank you. Two questions. One is a follow-up from Dr. Van Norsen's question. Is there literature or have you tried to expand the training to colleagues who are in the surgical or medical teams to expand a little bit the capacity to do this capacity elevations in the medical teams? That's what I'm asking. The other one is I appreciated the second case, the woman with schizophrenia. However, that was a very super clear-cut case in some ways, right? Somebody with a serious mental illness, but it doesn't interfere, blah, blah, blah, right? In many situations, it's more difficult to tease out, so I'm thinking of a woman I saw with severe major depression with, I'm not sure in that moment, but history of suicidal thoughts, et cetera, who was refusing care, right? And it becomes really hairy, right? So it's more like a question, can you add anything to that intersection when somebody has a psychiatric illness that cognitively, they can understand, they can tell you the pros and the cons of everything, right? But you're still not sure if it's interfering in how they are designed. Thank you. Yes, thank you. And can I actually ask, I definitely understood the second question. Can you repeat the first question once more? So one of the things we deal with is the idea, so you don't need to be a psychiatric or a mental health professional, right, to assess someone's capacity. However, as you know, the medical team tends to be reluctant to call it one way or the other. So if there is any literature or you have experience of trying to expand their knowledge and their know-how, so this is their skills and acceptance of doing the capacity, the evaluation. Gotcha, thank you so much for both those questions. So in terms of what's in the literature about addressing this at the professional level, what I have seen thus far is one, confirmation that somehow we get to become physicians and yet most people are still very uncomfortable with assessing decision-making capacity. And the way that it's been addressed for the most part in the literature is very much system-based in terms of hospital systems trying to come up with a strategy or a structure of what to do and how to do it when someone is questioning a patient's decision-making capacity abilities. I have not seen in the literature really much anything of substance in terms of how do we actually just take a step back and start retraining people at that level. And so that's why, one of the reasons why we think it's so important to have such an in-depth type of workshop model where we're working through those levels of the Miller Pyramid as early as possible in medical training and why we're addressing it right now at the psychiatry clerkship for third-year medical students. That being said, there are many physicians who are already out in the world practicing and so how do we apply this then in those situations? Kind of similar to what we were just talking about before in that it might be that it's a briefer version of this, it might be sending out the online module and asking everyone to review it on their own and then sending out the checklist to have as a tool. But really as much as we can do these workshops where we're practicing the skill and actually doing real live practice is what we believe at least is going to be the best way to make sure that everyone feels like they have the competency and comfort level to be doing this because truly every physician should theoretically be able to do that even though we know that's not the case. And then to your second question. So yes, that is actually something that we were thinking about when we were first rolling out the cases that we chose. And part of the reason why it is a little bit more of a slam dunk is we did want to emphasize the fact that just because someone has that history of schizophrenia you shouldn't walk in the door saying, okay, I know they don't have capacity because they have psychosis. That being said, I think that is best, how nuanced you get is best addressed by thinking about who you're giving this training to. So at the medical student level, that may be where we get started. But as we move on to the residency level, I actually really appreciate that example. I think that's a wonderful example where it's suicidal ideation, not how you're thinking about the world in reality that's affecting your decision. And so I think as you utilize this type of curriculum for different levels of training or professional development, that is where you want to get more complex cases for sure. And so I really appreciate that idea. Now sometimes it does come up in conversation with the medical students, patients who have to, usually in the case three example when we're talking about the determination. Sorry, that's confusing. In our case three, which is the case that you all did not see today where it was, or yeah, someone with, sorry, schizophrenia. So your case two, you did see it today. Someone with schizophrenia, it's the medical student's case three. And so I will bring up as an example that yes, just because they have schizophrenia, just because they have depression, just because they have bipolar disorder, and that might bring up the example of, so someone with depression and SI, that's something we consider. But I certainly think that should be a foundational case example if you are training a higher level of trainees like residents or people who are already working in the profession. So thank you for those. Ruben. Hi, great talk. I have a question. I feel like the three cases you've talked about all involve a medical provider who has an idea of what they think would probably be best for the patient or the patient from their perspective. And I'm wondering if at a level of training, do you think about cases where the medical provider and the patient both have the same prior for treatment, and there's a question of whether the patient really has capacity to agree to that treatment? I imagine surgery. Yes, thank you. That's a good question. So what we often find, and I think this is what students then learn because in practice this is what's happening, is that the decision-making capacity consults on the CL service usually are only coming when the patient disagrees with the team. So that is often the time that our trainees and students are learning how to assess decision-making capacity. And I think that's a wonderful point that every patient decision technically is supposed to involve us knowing that they are making an informed decision and therefore have decision-making capacity. In reality, if someone with a UTI agrees to take the antibiotics, we don't usually question it, but it should be in the back of our minds. And so I do think part of, in terms of how we're using this curriculum with the medical students right now, part of that training should definitely include that, again, not just as potential future psychiatrists, but any physician, every decision you make with your patient is gonna involve you having a sense for if they have capacity to make that decision. And also pointing out that, and it doesn't necessarily mean only the decisions that they disagree with you on. Coming up with a case example, I think would be really important. Maybe though, depending on resources and time for more of the higher level trainees, and you might wanna be focusing on that. Again, as the example we talked about earlier, one of those more nuanced and complex cases that we do need to also sout as we progress through our professional career. So I think I have great colleagues to work with, and it's so good to know the different systems they work with. So I found that very helpful. I think you guys did a great job, and as a program director myself, you trained very well. She made it easy. So questions I had was, we talk about CL, and the L is sometimes, if not more the time, more important than the C. And I think this is extremely helpful. My question is, have we given thought, and I think the folks that asked questions may have already mentioned it, but what kind of pre-capacity work? So for example, if you don't know this, you get the capacity consult, and they don't know what the question is. So the students who benefit in learning how do we liaison so that, so they don't escalate. I'll get a call from the attending who'll say, you know what, they didn't answer the question. Can you just do it? But that's not what the purpose was. So probably some sort of, I think it might be helpful if you agree, how do the liaison, how do they, have they, and you know, they make all this invention capacity too quickly. And we don't want them not to call a consult, but has the due diligence been done calling the family, so forth and so on. That might be a good checklist. And then of course, you also mentioned what do you do after, so that the question came up, what if they don't have capacity? What if the team doesn't agree with their capacity? What if they had capacity two days ago and they didn't resolve it? Right, that could be a good checklist that the students, you know a good student who's done, not just checklist, but has come up and really done due diligence. Those are just my thoughts, but incredibly helpful. I appreciate those, those are excellent points, thank you. Thank you all for coming, we really appreciate it, and thanks for the feedback.

decision-making capacity

psychiatry residents

medical education

curriculum development

role-playing exercises

ethical considerations

capacity assessment

interdisciplinary training