PGY1 Inpatient Psychiatry
Rotation Director: Leslie Horton, M.D., Ph.D
Telephone: 805-652-6729
Location: Ventura County Medical Center, Inpatient Psychiatric Unit (IPU) 200 Hillmont Avenue, Ventura, CA 93003
Clinical and Educational Work
Hours: M-F 7:00 a.m.-5:00 p.m.
Monthly work hours will be submitted in the New Innovations software program. Total hours worked for that month will be compiled and the weekly average must not exceed eighty hours per week averaged over a 4-week period, inclusive of in-house night call. Work hour violations will be closely reviewed and addressed by the Program Director.
Residents shall not work in excess of 24 consecutive hours. Allowances for already initiated care, transfer of care, educational debriefing and formal didactic activities may occur, but shall not exceed 4 additional hours and must be reported by the resident in writing with rationale to the Program Director and reviewed by the GMEC for monitoring individual residents and programs.
Residents will have 48-hour periods off on alternate weeks, or at least one 24-hour period off each week, and shall have no call responsibility during that time.
Educational Purpose:
To learn about the presentation and management of the variety of psychiatric patients seen in the inpatient setting. To develop clinical skills to allow residents to contribute and collaborate as members of the inpatient psychiatric treatment team. To provide complete care for the patient from admission through discharge, including completing appropriate, timely documentation and ensuring appropriate follow-up.
Teaching Methods:
For each interaction, the resident will spend sufficient time with the patient to perform an appropriate psychiatric evaluation and then discuss the case with psychiatry faculty. The learning experience surrounding a patient interaction evolves from review of history, mental status examination, laboratory results and other diagnostic tests with faculty. The resident will take direction from faculty, and faculty will provide the resident with references and/or other learning materials to facilitate their independent study for subsequent review with faculty. The resident will also learn, under supervision, how to interact not only with patients and families but also with other members of the treatment team.
Disease Mix and Patient Characteristics:
Patients range in age from 18 to 65 years. The most common admission diagnoses include: psychotic spectrum illnesses (Unspecified, Schizophrenia, Schizoaffective Disorders), major mood disorders (Bipolar and Major Depressive Disorder), Personality Disorders, especially Borderline Personality Disorder; and some exposure to Antisocial Personality Disorder. An overwhelming majority of patients suffer from co-morbid substance use disorders. A significant portion have co-morbid physical health conditions.
The overwhelming majority of patients are covered by Medi-Cal or do not have insurance coverage. Some patients do have Medicare and/or private insurance coverage.
Responsibilities/Procedures:
Residents will perform new admissions and see patients in follow-up daily in the VCMC IPU. Under the guidance and direction of the psychiatry attending, residents will coordinate the evaluation and initial management of a patient’s psychiatric illness. Residents are expected to communicate with all members of the treatment team involved in the patient’s care.
Admitting a patient includes writing admission orders, updating the problem list and ensuring accurate medication reconciliation. Psychiatric evaluations must be documented within 24 hours of the patient’s admission.
Residents are expected to complete all appropriate paperwork necessary to facilitate the patient’s stay in the hospital. This documentation includes, but is not limited to, admission notes, progress notes, consultation notes, discharge paperwork, and discharge summaries.
Progress notes must be timely and are an integral component of the patient’s care. The resident will be expected to document specific diagnosis and treatment recommendations clearly in the EMR.
Ideally, discharges should be completed so that patients can be discharged early in the morning. This timing improves hospital workflow and patient satisfaction. To facilitate this process, residents should complete discharge paperwork, follow-up appointments, and medication reconciliation the day prior and review it the morning of discharge with the attending. Discharge summaries are to be done on the day of discharge; if the resident cannot complete the summary on the day of discharge, they must notify the attending physician.
Medications must be properly reconciled. Discharge medication lists provided to the patient must match the discharge summary.
The residents are expected to notify the patient’s outpatient psychiatrist prior to discharge to relay information about the patient’s hospital stay. Pending studies or future recommendations should be relayed to the outpatient psychiatrist; these should be included in the discharge summary.
Residents are required to be available by electronic means, in addition to being available at their assigned work station for staff communication. This procedure serves as the primary means of communication for staff in regards to patient care. Residents are expected to return calls within a timely manner to address concerns regarding patients.
Residents are expected to attend all didactic lectures, Morning Reports and Grand Rounds.
Overall Goals and Objectives:
To develop a basic understanding of the skills needed to admit and perform follow up rounds on an inpatient psychiatric patient.
Core Competencies:
Patient Care:
1. Perform comprehensive psychiatric evaluations on new patients and daily progress notes on admitted patients.
2. Obtain collateral data as needed.
3. Perform a directed mental status examination that will provide further information in regards to the patient’s clinical presentation.
4. Communicate the patient’s diagnosis and treatment goals.
Medical Knowledge:
1. Be able to recognize and manage commonly encountered disease processes as it relates to psychiatry.
2. Be familiar with appropriate dosing strategies for commonly used medications.
3. Be familiar with the use of long acting injectable antipsychotics.
4. Be familiar with indications and procedures and risks for seclusion and restraints.
5. Be able to order and interpret diagnostic testing related to the patient’s presenting complaint/diagnosis.
6. Be fully trained in treatment and infection control protocols and procedures (e.g. personal protective equipment [PPE]) and trained clinically to properly recognize and care for COVID-19 patients.
Systems Based Practice:
1. Learn how to avoid unnecessary testing and practice cost conscious medical care.
2. Develop a plan related to the patient’s diagnosis, including addressing other factors, such as social determinants of health, which may influence their care.
3. Become aware of local resources to aid the patient with compliance after discharge.
4. Learn the regulations regarding patient transfers.
Practice Based Learning:
1. Residents will participate in all treatment.
2. Residents will participate in rounds and utilize this time effectively to clarify clinical questions at the bedside.
3. Residents will guide their own reading to ensure that they are following the most current and evidence-based clinical directions.
Professionalism:
1. Arrive on time and stay until all work is completed or appropriately transitioned to another provider.
2. Be respectful of patients and other members of the treatment team.
3. Wear appropriate clothing, including professional business attire.
4. Use appropriate discretion in prescribing practices.
Interpersonal and Communication Skills:
1. Develop skills to adjust the interview technique to match the clinical situation.
2. Be able to effectively convey the diagnosis and plan to members of the treatment team and to family members as appropriate.
Transitions of Care:
A verbal check-out is required utilizing I-PASS. The checkout occurs between the resident and the on-call physician. Handoff occurs daily and at the end of month.
Residents are expected to attend all teaching activities, Grand Rounds and didactic sessions.
Evaluation Methods:
Supervising faculty will provide verbal feedback to the resident midway through the rotation and formally evaluate the resident at the completion of the rotation via New Innovations. Evaluators will assess the resident’s mastery of psychiatry core competencies and are encouraged to comment more specifically on the resident’s performance.
The supervising attending will receive the evaluation the last week of their rotation. They must complete the evaluation and discuss it with the resident prior to the completion of their rotation. If a resident receives an unsatisfactory score, the information is communicated to the Psychiatry Program Director to ensure additional resident education and informal or formal remediation if indicated.
Residents are also required to evaluate both their rotation and their preceptor at the completion of the month.
Duration:
Residents will be assigned to the VCMC service for three months at a time. Residents will be assigned to one of the following faculty members or other designated psychiatrist:
Leslie Horton, M.D., Ph.D.
Heather Lewerenz, M.D.
Jason Cooper, M.D. (coverage)
Joseph Vlaskovits, M.D. (coverage)
Educational Materials/References:
Kaplan and Saddock’s Synopsis of Psychiatry MacKinnon, Michels and Buckley, The Psychiatric Interview in Clinical Practice, Third Edition Centers for Disease Control and Prevention COVID-19
World Health Organization: How to put on and remove personal protective equipment (PPE) https://openwho.org/courses/IPC-PPE-EN
Resident Resources:
Residents are provided with a resident workroom. This room includes adequate space for the residents. Each resident is provided with a desk and computer workstation. This room is locked and only administration and faculty/residents will have access.
