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Papers by Heidi Combs

Introduction: Mistreatment in medical school is an enduring problem in medical education. Little ... more Introduction: Mistreatment in medical school is an enduring problem in medical education. Little is known about the concept of ‘public humiliation,’ one of the most common forms of mistreatment as identified on the AAMC Graduation Questionnaire. The objective of this study was to further investigate ‘public humiliation’ and to understand the underpinnings and realities of ‘public humiliation’ in medical education. Method: Focus groups of medical students on clinical rotation at the University of Washington School of Medicine were conducted over one and a half years. Qualitative analysis of responses identified emergent themes. Results: Study results included responses from 28 third year and one fourth-year medical student obtained over five different focus groups. Participants defined the term ‘public humiliation’ as negatively, purposefully induced embarrassment. Risk factors for the experience of public humiliation in educational settings were found to include the perceived intent...

Dermatology Online Journal, 2008

The Clinical Interview, 2019

Current psychiatry, 2017

Ms. B, age 60, has schizophrenia, which has been stable on clozapine for 2 decades when she is di... more Ms. B, age 60, has schizophrenia, which has been stable on clozapine for 2 decades when she is diagnosed with cancer. How do you manage her psychiatric illness during chemotherapy? CASE Stable with a new diagnosis Ms. B, age 60, has a history of schizophrenia, which has been stable on clozapine, 500 mg/d, for more than 2 decades. After a series of hospitalizations in her 20s and 30s, clozapine was initiated and she has not required additional inpatient psychiatric care. She has been managed in the outpatient setting with standard biweekly absolute neutrophil count (ANC) monitoring. She lives independently and is an active member in her church. After experiencing rectal bleeding, Ms. B is diagnosed with rectal carcinoma and is scheduled to undergo chemotherapy and radiation treatment. How would you manage Ms. B's psychiatric illness at this time? a) continue clozapine and the current monitoring schedule b) continue clozapine and increase ANC monitoring to weekly c) discontinue cl...

Academic Psychiatry, 2021

Objective One possible factor associated with choosing psychiatry as a career is students rating ... more Objective One possible factor associated with choosing psychiatry as a career is students rating their psychiatry clerkship as excellent. Although this suggests that an excellent clerkship may improve recruitment into psychiatry, to our knowledge there has never been a multi-site survey study of graduating medical students that identify what factors lead to an excellent clerkship rating. The purpose of this study was to determine factors that medical student find important for an excellent psychiatry clerkship experience. Methods A total of 1457 graduating medical students at eight institutions were sent a 22-item Likert-type survey about what clinical and administrative factors they considered when rating their psychiatry clerkship via email in the fall of their last year. 357 (24.5%) responded and Z-test, t-tests, and multiple regression analyses were carried out. Results The factors which students rated higher than the mean included planned application to psychiatry residency, clear expectations, a transparent grading process, feeling part of a team, timely feedback by faculty, and a competent clerkship coordinator and director. Lectures, active learning, and self-study were rated as less pertinent, and the overall clerkship rating did differ between students going into psychiatry versus other specialties. Conclusions Although the low response undermines the validity of findings, by improving the administration of the clerkship with clear expectations, grading, feedback, and by encouraging clinical teams to fully integrate students clerkship ratings might improve which could potentially improve recruitment. Future research could further quantify and qualify these parameters and compare psychiatric clerkships to other clerkships.

Medical Education Online, 2019

Introduction: Mistreatment in medical school is an enduring problem in medical education. Little ... more Introduction: Mistreatment in medical school is an enduring problem in medical education. Little is known about the concept of 'public humiliation,' one of the most common forms of mistreatment as identified on the AAMC Graduation Questionnaire. The objective of this study was to further investigate 'public humiliation' and to understand the underpinnings and realities of 'public humiliation' in medical education. Method: Focus groups of medical students on clinical rotation at the University of Washington School of Medicine were conducted over one and a half years. Qualitative analysis of responses identified emergent themes. Results: Study results included responses from 28 third year and one fourth-year medical student obtained over five different focus groups. Participants defined the term 'public humiliation' as negatively, purposefully induced embarrassment. Risk factors for the experience of public humiliation in educational settings were found to include the perceived intent and tone of the teacher, as well as situations being 'public' to patients and taking place during a medical or surgical procedure. Socratic teaching or 'pimping' was not found to be a risk factor as long as learners were properly oriented to the teaching practice. Discussion: This study investigated and defined 'public humiliation' in the setting of medical student mistreatment. More subtle forms of mistreatment, like public humiliation, may be amenable to interventions focused on teaching educators about the importance of orientation and clear communication of intent during the teaching process.

Journal of Hospice & Palliative Nursing, 2009

A s psychiatrists caring for patients on a psychiatric intensive care unit, we occasionally encou... more A s psychiatrists caring for patients on a psychiatric intensive care unit, we occasionally encounter a profoundly mentally ill patient whose condition is complicated by terminal medical illness. As with dying patients not burdened by severe mental illness, the distinction between somatic distress, psychological pain, and spiritual angst can be blurred. 1 Even as we strive to provide care for patients, advocate for their interests, and respect their wishes, it can be difficult or impossible to elicit their concerns and preferences when decisions have to be made. We have found that consultation among services is the best way to care for the patient and address these dilemmas and that collaboration with a palliative care service, in particular, can offer unexpected benefits. We may unexpectedly gain a glimpse of feelings and moments of coherence. For example, we wanted to learn the wishes about resuscitation of a patient whose delusional ramblings revealed nothing but antagonism. He experienced severe cardiac compromise, as well as schizophrenia, extensive alcohol abuse,

Teaching and Learning in Medicine, 2019

Phenomenon: Feedback given by medical students to their teachers during a clerkship has the poten... more Phenomenon: Feedback given by medical students to their teachers during a clerkship has the potential to improve learning by communicating students' needs and providing faculty with information on how to adjust their teaching. Aligning student learning needs and faculty teaching approach could result in increased student understanding and skill development before a clerkship's end. However, little is known about faculty perceptions of formative feedback from medical students and how faculty might respond to such feedback. Approach: In this qualitative study, semistructured interviews of 24 third-year clerkship faculty were conducted to explore faculty opinions about receiving formative feedback from students. Transcripts of these interviews were reviewed, and content analysis was performed. Findings: Faculty endorsed the idea of obtaining formative feedback from medical students. However, probing revealed factors that would significantly influence their receptivity and response to the feedback provided, including (a) who would be giving the feedback, (b) what content was included in the feedback, (c) how the feedback was framed, and (d) why the feedback was given. Although participants endorsed the concept of receiving formative feedback from medical students, their accounts of how they might respond to it presented a mixed picture of receptivity, acceptance, and response. Insights: These findings have practical implications. If formative feedback from medical students to faculty is to be encouraged, institutions need to find ways of creating a feedback culture in which more dialogic models become "the norm" and work with faculty to increase their receptivity to and acceptance of student feedback. This is essential for students to feel safe and be safe from retribution when providing insights into how faculty can better meet their learning needs.

Handbook of Clinical Teaching, 2016

Medical Clinics of North America, 2014

Teaching and Learning in Medicine, 2015

WGEA 2015 CONFERENCE ABSTRACT (EDITED)Faculty Perceptions of Receiving Feedback From Third-Year C... more WGEA 2015 CONFERENCE ABSTRACT (EDITED)Faculty Perceptions of Receiving Feedback From Third-Year Clerkship Students Amanda Kost, Heidi Combs, Sherilyn Smith, Eileen Klein, Patricia Kritek, and Lynne Robins Phenomenon: In addition to giving feedback to 3rd-year clerkship students, some clerkship instructors receive feedback, requested or spontaneous, from students prior to the clerkship's end. The concept of bidirectional feedback is appealing as a means of fostering a culture of respectful communication and improvement. However, little is known about how teachers perceive this feedback in practice or how it impacts the learning environment. We performed 24 semistructured 30-minute interviews with 3 to 7 attending physician faculty members each in Pediatrics, Internal Medicine, Family Medicine, Surgery, Psychiatry, and Obstetrics and Gynecology who taught in 3rd-year required clerkships during the 2012-2013 academic year. Questions probed teachers' experience with and attitudes toward receiving student feedback. Prompts were used to elicit stories and obtain participant demographics. Interviews were audio-recorded, transcribed, and entered into Dedoose for qualitative analysis. Researchers read transcripts holistically for meaning, designed a coding template, and then independently coded each transcript. A constant comparative approach and regular meetings were used to ensure consistent coding between research team members. Participants ranged in age from 37 to 74, with 5 to 35 years of teaching experience. Seventy-one percent were male, and 83% identified as White. In our preliminary analysis, our informants reported a range of experience in receiving student feedback prior to the end of a clerkship, varying from no experience to having developed mechanisms to regularly request specific feedback about their programs. Most expressed openness to actively soliciting and receiving student feedback on their teaching during the clerkship although many questioned whether this process was feasible. Actual responses to receiving student feedback were mixed. Some reported having received feedback that motivated change, and others rejected the feedback they received on the grounds that it lacked validity or was inappropriate. Others expressed uncertainty about how they would react to student feedback. Faculty expressed a preference for receiving feedback about behaviors and items that were within their control. Insights: These findings suggest there is opportunity to pilot implementation of a structured student feedback mechanism, separate from teacher evaluations, in selected 3rd-year clerkships. Materials should developed to help faculty solicit, understand, and respond to student feedback and to help students frame and provide the kinds of feedback to teachers that will lead to suggested improvements. Both these endeavors have the potential to improve the clinical learning environment during 3rd-year clerkships through the cultivation of respectful communication and the encouragement of improvement in teaching efforts.

Dermatology online journal, Jan 15, 2008

There are several unique psychiatric disorders that are likely to present to a dermatologist beca... more There are several unique psychiatric disorders that are likely to present to a dermatologist because of their accompanying skin complaints. Delusions of parasitosis (DP) is a fixed, false belief of parasitic infestation that may lead patients to compulsively self-mutilate while attempting to remove the non-existent parasites. Morgellons disease is a controversial condition characterized by a fixed belief that fibers that are imbedded or extruding from the skin; this condition is likely in the spectrum of DP. Body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in appearance that causes significant distress and is associated with time consuming rituals, isolation, depression, and increased risk of suicide. Olfactory reference syndrome (ORS) is a preoccupation with body odor leading to the stigmata of shame, embarrassment, and social isolation. This brief review examines each of these conditions and their management because any one of them may present to a dermato...

Psychosomatics, 2012

reviewed the literature on significant psychiatric side effects of corticosteroids, noting presen... more reviewed the literature on significant psychiatric side effects of corticosteroids, noting presentations of depression, mania, psychosis, and memory deficits. 1 Naber et al. followed a prospective, uncontrolled cohort of 50 patients on methylprednisolone or fluocortolone, at initial doses of 119 Ϯ 41 mg/d, and tapered to 75 Ϯ 22 mg/d over 8 days. They found that "manic-type" symptoms were reported by 26% of the participants, most of which began in the first 3 days of treatment and continued, despite the taper, over the 8 days of the study. If possible, removing the offending steroid is desirable when patients present with psychiatric side effects. However, if the steroid-induced behavior puts the patient at significant risk of morbidity and mortality, adjunctive use of an anti-manic medication may also be warranted. The data for pharmacologic intervention in steroid-induced mania is limited in scope and study design. Among the classic mood stabilizers, lithium has the most evidence in steroid-induced mania, with a 71-patient, retrospective report. 3 There is a positive case report regarding the use of valproic acid. 4 Amongst the antipsychotics, the use of phenothiazines is supported by a 14-patient case series. 5 Haloperidol 6 and quetiapine 7 have positive case reports. Olanzapine use is supported by an open-label trial in 12 patients. 8 Risperidone has recent pediatric case reports. 9

Kidney International, 1998

Journal of Burn Care & Research, 2008

Accounts of self-inflicted death by fire are numerous and are found from antiquity to present tim... more Accounts of self-inflicted death by fire are numerous and are found from antiquity to present times. We review selected examples of self-immolation from historical record, in mythology and as part of religious and cultural tradition. We discuss the use of self-immolation as a literary device in the arts including fiction, opera, movies, and song. We offer motives for this horrifying act and discuss how it has been used as a form of protest for political reasons or for individual maltreatment or as a means to end intense personal suffering. Finally, we explore what setting oneself alight may represent from a psychodynamic perspective.

Introduction: Mistreatment in medical school is an enduring problem in medical education. Little ... more Introduction: Mistreatment in medical school is an enduring problem in medical education. Little is known about the concept of ‘public humiliation,’ one of the most common forms of mistreatment as identified on the AAMC Graduation Questionnaire. The objective of this study was to further investigate ‘public humiliation’ and to understand the underpinnings and realities of ‘public humiliation’ in medical education. Method: Focus groups of medical students on clinical rotation at the University of Washington School of Medicine were conducted over one and a half years. Qualitative analysis of responses identified emergent themes. Results: Study results included responses from 28 third year and one fourth-year medical student obtained over five different focus groups. Participants defined the term ‘public humiliation’ as negatively, purposefully induced embarrassment. Risk factors for the experience of public humiliation in educational settings were found to include the perceived intent...

Dermatology Online Journal, 2008

The Clinical Interview, 2019

Current psychiatry, 2017

Ms. B, age 60, has schizophrenia, which has been stable on clozapine for 2 decades when she is di... more Ms. B, age 60, has schizophrenia, which has been stable on clozapine for 2 decades when she is diagnosed with cancer. How do you manage her psychiatric illness during chemotherapy? CASE Stable with a new diagnosis Ms. B, age 60, has a history of schizophrenia, which has been stable on clozapine, 500 mg/d, for more than 2 decades. After a series of hospitalizations in her 20s and 30s, clozapine was initiated and she has not required additional inpatient psychiatric care. She has been managed in the outpatient setting with standard biweekly absolute neutrophil count (ANC) monitoring. She lives independently and is an active member in her church. After experiencing rectal bleeding, Ms. B is diagnosed with rectal carcinoma and is scheduled to undergo chemotherapy and radiation treatment. How would you manage Ms. B's psychiatric illness at this time? a) continue clozapine and the current monitoring schedule b) continue clozapine and increase ANC monitoring to weekly c) discontinue cl...

Academic Psychiatry, 2021

Objective One possible factor associated with choosing psychiatry as a career is students rating ... more Objective One possible factor associated with choosing psychiatry as a career is students rating their psychiatry clerkship as excellent. Although this suggests that an excellent clerkship may improve recruitment into psychiatry, to our knowledge there has never been a multi-site survey study of graduating medical students that identify what factors lead to an excellent clerkship rating. The purpose of this study was to determine factors that medical student find important for an excellent psychiatry clerkship experience. Methods A total of 1457 graduating medical students at eight institutions were sent a 22-item Likert-type survey about what clinical and administrative factors they considered when rating their psychiatry clerkship via email in the fall of their last year. 357 (24.5%) responded and Z-test, t-tests, and multiple regression analyses were carried out. Results The factors which students rated higher than the mean included planned application to psychiatry residency, clear expectations, a transparent grading process, feeling part of a team, timely feedback by faculty, and a competent clerkship coordinator and director. Lectures, active learning, and self-study were rated as less pertinent, and the overall clerkship rating did differ between students going into psychiatry versus other specialties. Conclusions Although the low response undermines the validity of findings, by improving the administration of the clerkship with clear expectations, grading, feedback, and by encouraging clinical teams to fully integrate students clerkship ratings might improve which could potentially improve recruitment. Future research could further quantify and qualify these parameters and compare psychiatric clerkships to other clerkships.

Medical Education Online, 2019

Introduction: Mistreatment in medical school is an enduring problem in medical education. Little ... more Introduction: Mistreatment in medical school is an enduring problem in medical education. Little is known about the concept of 'public humiliation,' one of the most common forms of mistreatment as identified on the AAMC Graduation Questionnaire. The objective of this study was to further investigate 'public humiliation' and to understand the underpinnings and realities of 'public humiliation' in medical education. Method: Focus groups of medical students on clinical rotation at the University of Washington School of Medicine were conducted over one and a half years. Qualitative analysis of responses identified emergent themes. Results: Study results included responses from 28 third year and one fourth-year medical student obtained over five different focus groups. Participants defined the term 'public humiliation' as negatively, purposefully induced embarrassment. Risk factors for the experience of public humiliation in educational settings were found to include the perceived intent and tone of the teacher, as well as situations being 'public' to patients and taking place during a medical or surgical procedure. Socratic teaching or 'pimping' was not found to be a risk factor as long as learners were properly oriented to the teaching practice. Discussion: This study investigated and defined 'public humiliation' in the setting of medical student mistreatment. More subtle forms of mistreatment, like public humiliation, may be amenable to interventions focused on teaching educators about the importance of orientation and clear communication of intent during the teaching process.

Journal of Hospice & Palliative Nursing, 2009

A s psychiatrists caring for patients on a psychiatric intensive care unit, we occasionally encou... more A s psychiatrists caring for patients on a psychiatric intensive care unit, we occasionally encounter a profoundly mentally ill patient whose condition is complicated by terminal medical illness. As with dying patients not burdened by severe mental illness, the distinction between somatic distress, psychological pain, and spiritual angst can be blurred. 1 Even as we strive to provide care for patients, advocate for their interests, and respect their wishes, it can be difficult or impossible to elicit their concerns and preferences when decisions have to be made. We have found that consultation among services is the best way to care for the patient and address these dilemmas and that collaboration with a palliative care service, in particular, can offer unexpected benefits. We may unexpectedly gain a glimpse of feelings and moments of coherence. For example, we wanted to learn the wishes about resuscitation of a patient whose delusional ramblings revealed nothing but antagonism. He experienced severe cardiac compromise, as well as schizophrenia, extensive alcohol abuse,

Teaching and Learning in Medicine, 2019

Phenomenon: Feedback given by medical students to their teachers during a clerkship has the poten... more Phenomenon: Feedback given by medical students to their teachers during a clerkship has the potential to improve learning by communicating students' needs and providing faculty with information on how to adjust their teaching. Aligning student learning needs and faculty teaching approach could result in increased student understanding and skill development before a clerkship's end. However, little is known about faculty perceptions of formative feedback from medical students and how faculty might respond to such feedback. Approach: In this qualitative study, semistructured interviews of 24 third-year clerkship faculty were conducted to explore faculty opinions about receiving formative feedback from students. Transcripts of these interviews were reviewed, and content analysis was performed. Findings: Faculty endorsed the idea of obtaining formative feedback from medical students. However, probing revealed factors that would significantly influence their receptivity and response to the feedback provided, including (a) who would be giving the feedback, (b) what content was included in the feedback, (c) how the feedback was framed, and (d) why the feedback was given. Although participants endorsed the concept of receiving formative feedback from medical students, their accounts of how they might respond to it presented a mixed picture of receptivity, acceptance, and response. Insights: These findings have practical implications. If formative feedback from medical students to faculty is to be encouraged, institutions need to find ways of creating a feedback culture in which more dialogic models become "the norm" and work with faculty to increase their receptivity to and acceptance of student feedback. This is essential for students to feel safe and be safe from retribution when providing insights into how faculty can better meet their learning needs.

Handbook of Clinical Teaching, 2016

Medical Clinics of North America, 2014

Teaching and Learning in Medicine, 2015

WGEA 2015 CONFERENCE ABSTRACT (EDITED)Faculty Perceptions of Receiving Feedback From Third-Year C... more WGEA 2015 CONFERENCE ABSTRACT (EDITED)Faculty Perceptions of Receiving Feedback From Third-Year Clerkship Students Amanda Kost, Heidi Combs, Sherilyn Smith, Eileen Klein, Patricia Kritek, and Lynne Robins Phenomenon: In addition to giving feedback to 3rd-year clerkship students, some clerkship instructors receive feedback, requested or spontaneous, from students prior to the clerkship's end. The concept of bidirectional feedback is appealing as a means of fostering a culture of respectful communication and improvement. However, little is known about how teachers perceive this feedback in practice or how it impacts the learning environment. We performed 24 semistructured 30-minute interviews with 3 to 7 attending physician faculty members each in Pediatrics, Internal Medicine, Family Medicine, Surgery, Psychiatry, and Obstetrics and Gynecology who taught in 3rd-year required clerkships during the 2012-2013 academic year. Questions probed teachers' experience with and attitudes toward receiving student feedback. Prompts were used to elicit stories and obtain participant demographics. Interviews were audio-recorded, transcribed, and entered into Dedoose for qualitative analysis. Researchers read transcripts holistically for meaning, designed a coding template, and then independently coded each transcript. A constant comparative approach and regular meetings were used to ensure consistent coding between research team members. Participants ranged in age from 37 to 74, with 5 to 35 years of teaching experience. Seventy-one percent were male, and 83% identified as White. In our preliminary analysis, our informants reported a range of experience in receiving student feedback prior to the end of a clerkship, varying from no experience to having developed mechanisms to regularly request specific feedback about their programs. Most expressed openness to actively soliciting and receiving student feedback on their teaching during the clerkship although many questioned whether this process was feasible. Actual responses to receiving student feedback were mixed. Some reported having received feedback that motivated change, and others rejected the feedback they received on the grounds that it lacked validity or was inappropriate. Others expressed uncertainty about how they would react to student feedback. Faculty expressed a preference for receiving feedback about behaviors and items that were within their control. Insights: These findings suggest there is opportunity to pilot implementation of a structured student feedback mechanism, separate from teacher evaluations, in selected 3rd-year clerkships. Materials should developed to help faculty solicit, understand, and respond to student feedback and to help students frame and provide the kinds of feedback to teachers that will lead to suggested improvements. Both these endeavors have the potential to improve the clinical learning environment during 3rd-year clerkships through the cultivation of respectful communication and the encouragement of improvement in teaching efforts.

Dermatology online journal, Jan 15, 2008

There are several unique psychiatric disorders that are likely to present to a dermatologist beca... more There are several unique psychiatric disorders that are likely to present to a dermatologist because of their accompanying skin complaints. Delusions of parasitosis (DP) is a fixed, false belief of parasitic infestation that may lead patients to compulsively self-mutilate while attempting to remove the non-existent parasites. Morgellons disease is a controversial condition characterized by a fixed belief that fibers that are imbedded or extruding from the skin; this condition is likely in the spectrum of DP. Body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in appearance that causes significant distress and is associated with time consuming rituals, isolation, depression, and increased risk of suicide. Olfactory reference syndrome (ORS) is a preoccupation with body odor leading to the stigmata of shame, embarrassment, and social isolation. This brief review examines each of these conditions and their management because any one of them may present to a dermato...

Psychosomatics, 2012

reviewed the literature on significant psychiatric side effects of corticosteroids, noting presen... more reviewed the literature on significant psychiatric side effects of corticosteroids, noting presentations of depression, mania, psychosis, and memory deficits. 1 Naber et al. followed a prospective, uncontrolled cohort of 50 patients on methylprednisolone or fluocortolone, at initial doses of 119 Ϯ 41 mg/d, and tapered to 75 Ϯ 22 mg/d over 8 days. They found that "manic-type" symptoms were reported by 26% of the participants, most of which began in the first 3 days of treatment and continued, despite the taper, over the 8 days of the study. If possible, removing the offending steroid is desirable when patients present with psychiatric side effects. However, if the steroid-induced behavior puts the patient at significant risk of morbidity and mortality, adjunctive use of an anti-manic medication may also be warranted. The data for pharmacologic intervention in steroid-induced mania is limited in scope and study design. Among the classic mood stabilizers, lithium has the most evidence in steroid-induced mania, with a 71-patient, retrospective report. 3 There is a positive case report regarding the use of valproic acid. 4 Amongst the antipsychotics, the use of phenothiazines is supported by a 14-patient case series. 5 Haloperidol 6 and quetiapine 7 have positive case reports. Olanzapine use is supported by an open-label trial in 12 patients. 8 Risperidone has recent pediatric case reports. 9

Kidney International, 1998

Journal of Burn Care & Research, 2008

Accounts of self-inflicted death by fire are numerous and are found from antiquity to present tim... more Accounts of self-inflicted death by fire are numerous and are found from antiquity to present times. We review selected examples of self-immolation from historical record, in mythology and as part of religious and cultural tradition. We discuss the use of self-immolation as a literary device in the arts including fiction, opera, movies, and song. We offer motives for this horrifying act and discuss how it has been used as a form of protest for political reasons or for individual maltreatment or as a means to end intense personal suffering. Finally, we explore what setting oneself alight may represent from a psychodynamic perspective.