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Curriculum: Clinical Rotations II
Rotations PGY II INPATIENT PSYCHIATRYLocation: Educational ObjectivesThe inpatient psychiatry rotation is intended to teach the resident to conduct a thorough biopsychosocial psychiatric assessment including a complete psychiatric history, mental status examination, and physical examination. The resident is expected to, under attending supervision, initiate appropriate work-up, consultations, and ancillary procedures. The resident will be able to make a biopsychosocial formulation of each case and formulate and implement a treatment plan. The resident will also learn to recognize, analyze, and manage the dynamics in an inpatient setting and learn how to work with an interdisciplinary team. The resident will learn how to provide individual and group psychotherapy and to set appropriate boundaries in a therapeutic relationship. The resident will develop skills in timely, concise, and accurate document, including progress notes, treatment plans, and discharge summaries. Description of RotationPGY-II residents complete a required 2-month, full-time rotation on the Inpatient Psychiatry Teaching Units in their PGY-II year. This rotation could be split between the two Acute Inpatient Psychiatry Wards. Ward 2-3-C has a total of 28 beds, including 8 beds which are dedicated for use by female inpatients in a separate wing of the inpatient unit, and can accept up to 12 female inpatients. The resident evaluates, treats, and follows acute admissions to the inpatient unit. Additional inpatient psychotherapy supervision for the inpatient psychiatry residents on this rotation is provided by several senior psychotherapy-oriented psychiatrists and psychologists. The 2 teaching units are staffed by a total of 6 psychiatrists, 3 nurse practitioners, one full-time psychologist, two social workers, an occupational therapist, and designated nurses and nursing assistants. Since these wards are teaching units, the trainees can include a PGY-IV level Psychiatry Senior Teaching Resident, up to five PGY-II or PGY-I level Psychiatry Residents, one or two Psychology Interns, a Social Work Intern, and 1-2 Occupational Therapy students. Nursing students from nearby affiliated programs also receive part of their clinical experience on the unit. The resident will evaluate, diagnose, and manage all aspects of the patient's inpatient stay. The resident will interact with the treatment team in the management of patients. This will involve performing initial evaluations, daily follow-up, team participation, treatment planning, and discharge planning. The resident may also conduct community meetings on a weekly basis and may co-lead medication groups. The resident will complete all necessary evaluations, paperwork, progress notes, medication adjustments, evaluation of privileges, and discharge summaries. The autonomy and independence of the resident's decision-making will be consistent with his/her abilities, teaching needs, and personal comfort in management. The inpatient attending psychiatrists are ultimately responsible for the clinical decisions jointly made. Expected CaseloadThe PGY-II resident's case load is about 6 patients. In the PGY-II year the resident also has the opportunity to assist with electroconvulsive therapy (ECT). ELECTROCONVULSIVE THERAPY (ECT)Location: Educational ObjectivesThe ECT rotation is intended to teach the resident this form of somatic therapy, including the indications for and the evaluation and administration of ECT. The resident is expected to learn how to administer ECT and to monitor and treat side effects and post-treatment complications. Description of RotationPGY-II residents may complement their inpatient experience at the VABHS with an ECT (electroconvulsive therapy) experience in their PGY-II year. The residents spend one or two mornings a week observing and administering ECT under the direct attending supervision. The PGY-II resident will perform comprehensive evaluations of all patients referred for ECT. Referrals can come from the psychiatry inpatient service at Brockton, or from outpatient services at any VABHS site, and are usually initiated by an ECT Consultation Request. The resident will review the indications for ECT, and discuss the case with the attending. During this discussion, a decision will be made regarding the use of ECT. If ECT is indicated, the resident will participate in ECT treatments, which take place on the Jamaica Plain Campus. One ECT course may take up to 14 treatments, and the resident will follow the course of the patient in between treatments. Residents at the PGY-III or PGY-IV level may elect to do additional training in ECT. This will be arranged individually, with the duties and supervision as specified below. Residents at the PGY-I level assigned to an Inpatient Unit may elect to observe ECT being performed on their assigned inpatient. This also will be arranged individually. ECT certification is available. Expected CaseloadVariable. SHORT-TERM INPATIENT UNITLocation: Educational ObjectivesThe PGY-II inpatient psychiatry rotation at the Short Term Unit at McLean Hospital is intended to teach the resident how to make a comprehensive psychiatric assessment, enhance interviewing skills with clear and accurate history taking, formulate a differential diagnosis and treatment plan, and provide major types of therapy including short-term individual psychotherapy, pharmacological therapy, and other somatic therapies under managed care conditions. The CEC rotation is intended to teach residents how to assess, diagnose, and make decisions regarding admissions and will afford them the opportunity to present cases to third-party payers in order to gain approval for admissions. Description of RotationThis required 1-month, full-time PGY-II rotation is sited at the Short Term Unit, a 24-bed unit staffed by psychiatrists and a multidisciplinary staff. The resident will evaluate, diagnose, and manage all aspects of the patient's inpatient stay. Residents will interact with the treatment team in the management of the patients. This will involve the performance of initial evaluations, daily follow-up, team participation, treatment planning, and discharge planning. The resident will complete all necessary evaluations, paperwork, progress notes, medication adjustments, evaluation of privileges, and discharge summaries. The autonomy and independence of the resident's decision-making will be consistent with his/her abilities, teaching needs, and personal comfort in management. Expected CaseloadThe PGY-II resident's case load will not exceed 6 patients during the Short Term Unit rotation. COMMUNITY-BASED ACUTE INPATIENT PSYCHIATRYLocation: Educational ObjectivesResidents develop skills in acute care and integrated inpatient-outpatient treatment in a community-based setting. The inpatient rotation at Corrigan provides residents with experience in managing acute episodes of a wide range of psychiatric illness within a public system of care, enabling them to interact with hospital diversion and follow-up services and other clinical disciplines. The rotation emphasizes the biopsychosocial assessment and treatment of psychotic disorders and also offers some experience with assessing the appropriateness of civil commitment in the community setting. Elective rotations in these services and in research are available for advanced residents. Description of RotationsPGY-II residents spend a required, full-time 1-month rotation at the Corrigan Mental Health Center during their PGY-II year The Dr. John C. Corrigan Mental Health Center in Fall River, MA is a DMH-funded facility serving a catchment area that includes Fall River, New Bedford, and surrounding towns. The Center is a fully accredited, JCAHO facility that provides a variety of training experiences. The Center has, among its multiple facilities, a busy Crisis Unit which operates on a 24-hour basis; a locked Inpatient Unit with 16 beds; and a Day Treatment Rehabilitation Unit which has a capacity of 20 beds. In addition, the Center provides acute inpatient care and follow-up outpatient care including case management and residential programs, and oversees a number of contracted services for other day treatment and residential needs. The Inpatient Unit is composed of two treatment teams, both of which are staffed by a Team Leader, a social worker, a psychiatrist, and designated nurses and mental health workers. The Medical Director for Inpatient Services leads one team and provides overall supervision of the resident's clinical work during the rotation, while the second team is under the psychiatric leadership of another faculty attending. The resident evaluates, treats, and manages acute admissions to the inpatient unit under the supervision of the Unit attending. Preceptor teaching is provided by senior attending psychiatrists. Each resident has the opportunity to evaluate and work with a variety of inpatients and to present cases at one or more conferences during the rotation. Psychopharmacology and general psychiatry case conferences complement the clinical bedside teaching. The rotation may involve experience with closely affiliated Day Treatment Program, permitting residents to follow their own inpatients as they re-enter the community and to better appreciate the course of these disorders through time and phases of illness. The resident is also assigned off-Unit supervision two hours per week with which to explore issues, reactions, or specific interests generated by the rotation. A monthly journal club involving the psychiatry resident and on-site psychology interns and graduate students is also available. The resident presents cases regularly during the rotation at a clinical case conference held bi-weekly. The resident also presents a single in-depth case with an attending psychiatrist as discussant during the second month of the rotation; the focus in the latter activity will be on the diagnosis, differential diagnosis, and treatment of the patient. Guided reading and consultation are offered to assist in preparation of the case. Expected Case LoadThe resident's caseload will not exceed eight patients. CONSULTATION-LIAISON PSYCHIATRYLocation: This rotation in the PGY-II year provides the core educational experience in consultation-liaison psychiatry. The resident will learn both principles of psychopharmacology in the medical setting and the application of time limited psychotherapy, supportive therapy, couples therapy and cognitive behavioral therapy including hypnosis. Description of RotationPGY-II residents spend a required, 2-month rotation training in medical psychiatry. The West Roxbury Campus is a tertiary care medical center that serves veterans from throughout New England. The medical psychiatry service is staffed by two attending psychiatrists. The resident receives training in managing medical patients and surgical patients with psychiatric needs. The patient population includes patients with neurologic, renal, oncologic, respiratory, orthopedic, and cardiac disorders, with a heavy representation of complex patients in the geriatric age range. Specialty foci include sleep disorders, pain disorders, and spinal cord injury. There is an active academic program including training in forensic psychiatry and systems-administrative psychiatry. There are ongoing didactics for Psychosomatic Fellowship Program fellows, and residents can attend while they are on service; including an ongoing course in advanced psychopathology. There is intensive supervision, daily teaching rounds and allied meetings with social work and nursing staff. Residents are expected to review and present a formal academic topic during the rotation. They are encouraged to attend Schwartz Rounds Harvard-sponsored multidisciplinary conferences that focus on compassionate humanistic care; topics have included the care of the difficult patient, the homeless patient, the returning Iraqi veteran, and staff conflict around specific patient care issues and Ethics Committee meetings. Residents also have an opportunity to teach Boston University and Harvard medical students.
Expected CaseloadExpected workload for the PGY-II resident is to evaluate 1-3 new consults per day under supervision and conduct follow ups on all patients that remain on service. The PGY-II resident will carry the emergency beeper 2-3 days per week and see emergency room cases under supervision. The resident will also present an academic review of a selected topic during the rotation. CLINICAL EVALUATION CENTERLocation: Educational ObjectivesThe PGY-II resident on the Clinical Evaluation Center (CEC) develops skills in psychiatric evaluation, triage and stabilization. S/he further serves as liaison with inpatient and community resources and negotiates care provision with insurance companies. While the majority of patients seen are admitted to locked inpatient units, a percentage of them are able to return to outpatient care after receiving crisis intervention and/or other outpatient supports. Description of RotationResidents spend a required 1-month full-time rotating on the CEC. Patients are referred from a variety of sources. These include real emergency rooms, crisis teams, other McLean Hospital programs, outpatient psychiatric clinicians, primary care physicians, family members or friends, or via self-referral. The resident and CEC staff conduct a thorough evaluation to identify potentially unstable medical and psychiatric conditions. Subsequently, they arrange for the initiation of appropriate care. Major goals of the rotation is to learn how to complete acute psychiatric evaluations, develop brief focused inpatient treatment plans and negotiate with managed care organizations around these issues. CEC staff consists of attending psychiatrists, clinical nurse specialists (advanced practice nurses), nurses, mental health workers, and triage specialists. We serve as a training site for psychiatric residents, medical students, advanced practice nursing students, and pharmacy students. CEC staff works closely with the McLean internal medicine department and all inpatient and outpatient services at the hospital. While on rotation, residents also benefit from attending teaching rounds at the start of their shift. Expected CaseloadAt the CEC, the PGY-II is expected to conduct comprehensive evaluations with approximately 2 -3 cases per day. CHILD & ADOLESCENT PSYCHIATRYLocation: The inpatient child and adolescent rotation at Cambridge/Somerville is intended to teach the resident to evaluate, diagnose, and treat children and adolescents with psychiatric disorders. The resident is expected to collaborate with the interdisciplinary treatment team in the assessment, management and aftercare planning for patients and families. Description of RotationPGY-II residents spend a required, full-time, 1-month rotation at the Child Assessment Unit (CAU) in Cambridge Hospital and another required full-time, 1-month rotation is spent at the Somerville Hospital Adolescent Assessment Unit (AAU) at Somerville Hospital. The Child Assessment Unit and the Adolescent Assessment Unit both have treatment teams comprised of attending Child and Adolescent psychiatrists, a child and adolescent psychiatry fellow, a psychologist, social workers, nurses and milieu counselors. On both units, the resident is assigned to cases and is expected to collaborate with the other clinicians working with the patient and family. The initial evaluation is usually done with a senior child clinician, a child psychiatry fellow and an attending child psychiatrist. The PGY-II resident evaluates, treats, follows, and manages all aspects of the child's inpatient stay. Changes in medication, status, etc. are made in consultation with the child fellow or the attending psychiatrist. The resident also participates in communicating with the outpatient psychiatrist, the pediatrician, the school, the families, etc. and in discharge planning. The resident participates in groups and activities on the unit, learning about the elements of a restraint-free, child and family-centered therapeutic milieu. Expected CaseloadThe resident's caseload is approximately 3-4 patients. PARTIAL HOSPITAL PROGRAMLocation: Educational ObjectivesIn this partial hospitalization treatment setting, the resident will further develop skills in comprehensive biopsychosocial assessment and treatment of individuals with serious mental illnesses who are too impaired for outpatient treatment. They will also gain experience in intensive group therapy with the goal of developing greater understanding of the potential benefits and challenges of group treatments. The resident will also learn the relative indications and contraindications for group treatment. Residents will be able to define strategies for group formation and will be able to describe theories of group process and how this process may be employed therapeutically. Description of RotationPGY-II residents will spend a required full-time, 1-month rotation at the McLean SouthEast Partial Hospital Program, a component of the satellite inpatient/outpatient site of McLean Hospital located on the grounds of the Brockton campus of VABHS. The program provides comprehensive diagnosis of and treatment for individuals experiencing psychiatric illness. It offers a continuum of care that includes an inpatient service for acute hospitalizations and a partial hospital program. The Partial Hospital Program offers a highly structured intervention for individuals who are in crisis but can safely reside in the community. The program is available as either a step-down level of treatment from an inpatient unit or as a direct admission to avoid hospitalization. The partial hospital level of care offers a more intensive psychiatric supervision and treatment than the traditional outpatient setting. McLean SouthEast utilizes a multidisciplinary approach with case management, rehabilitation therapy, structured group programming and psychiatry. The resident will be a full participant in the partial hospitalization program, including involvement in several group therapy sessions during the day. Patients involved with groups may be recent discharges from a psychiatric inpatient unit or they may be community referrals. Caseload is varied, including bipolar, MDD, anxiety disorders, eating disorders, Axis II disorders, partially compensated schizophrenia, and post-partum depression. Treatment modalities include cognitive behavioral groups, supportive psychotherapy groups, and medication management groups etc. The resident is involved in all groups and leads the medication management group under attending supervision. The resident will also collect information from outpatient clinicians, monitor patient improvement daily and adjust medications accordingly. The resident takes part in individual psychotherapy sessions wherein a member of the group is taken aside to focus on a particular issue that may not have been totally explored or discussed in group. Family meetings are also an integral part of partial hospitalization treatment, and the resident is involved in these interventions as well. Expected Case LoadVariable. (Program Admissions and group therapy patients)
FORENSIC PSYCHIATRYLocation: The inpatient forensic rotation at Taunton State Hospital is intended to familiarize PGY-II residents with the interface between psychiatry and the law. The goals of the rotation are to give each resident a solid experience in recognizing and evaluating patients committed under the various subsections of the Massachusetts General Law and to assess and manage the clinical needs of such patients. Residents will learn how to undertake forensic evaluations in order to determine the patient's criminal responsibility and ability to stand trials. Description of RotationThe PGY-II resident spends a required full-time, 1-month rotation at Taunton State Hospital, a fully JCAHO-accredited hospital. The Forensic Unit is staffed by a psychiatrist, a prescribing nurse-clinician, a forensic psychologist, a social worker, and designated nurses and mental health workers. The resident will participate in the evaluation, diagnosis, and management of all aspects of the patient's inpatient stay. Residents will interact with the treatment team and the forensic evaluators in the management of the patients. This will involve performing initial evaluations, daily follow-up, team participation, treatment planning, and discharge planning. Residents also get to attend court hearings of committed patients to observe the proceedings during commitment or Roger's hearings. There will be an additional one hour of weekly supervision by another staff psychiatrist. Residents will attend and contribute to the weekly case conference program and the weekly academic conference which focuses on literature reviews. Expected CaseloadThe resident's caseload will be approximately four patients, and will include at least one comprehensive forensic assessment and presentation. CONTINUITY CLINICLocation: Educational ObjectivesThe Continuity Clinic at the VA Brockton provides an opportunity for residents to follow patients over 2-3 years emphasizing psychotherapeutic and especially psychodynamic modalities. Description of RotationIn this required 24-month part-time rotation, the resident will have the opportunity to initiate, conduct, and to terminate long-term psychotherapy. This allows the resident to learn the vicissitudes of chronic psychiatric illness by following the patients whom they have known l over a longer course of illness and to emphasize developing and managing a long-term psychotherapeutic relationship. The resident will have the ability to improve skills and competencies in all core competencies during the rotation, with special emphasis on improvement in interpersonal communication managing transference, and psychodynamic assessment, interpretation, and intervention. Residents begin the Continuity Clinic in their PGY-II year in order to have long-term follow-up of outpatients for pharmacotherapy and psychotherapy, and continue to follow patients through their PGY-III year and if desire, their PGY-IV year. Each resident evaluates, diagnoses, and treats outpatients needing psychiatric treatment. Residents also participate in the weekly intake Case Conference in which a new patient is interviewed by a senior attending psychiatrist. Expected CaseloadEach resident will follow 3 long-term psychotherapy cases, in the PGY-II year with increase to up to 6-8 patients in the PGY-III year. |
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