PGY3 Outpatient Psychiatry CMH

Site Director/Rotation Director: Ronald Pollack, M.D.

Location: Community Memorial Health Center
Midtown Medical Behavioral Health Clinic

Clinical and Educational Work
Hours: M-F
8:00 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:

The Outpatient Psychiatry rotation provides an opportunity for residents to evaluate and treat outpatients from a wide variety of backgrounds with a range of psychiatric diagnoses. The residents will learn to employ the full spectrum of outpatient treatment psychiatric modalities, including pharmacotherapy and psychotherapy.

Teaching Methods:

The principal teaching and learning activity is centered on direct patient care and interaction. For each encounter, the resident will spend sufficient time with the attending to optimize the learning experience, with supervision appropriate to the resident’s level of training. The learning experience surrounding a patient interaction evolves from review of history, mental status examination, laboratory results and other diagnostic tests with the faculty. Faculty will provide guidance and direction to the resident as well as references or other learning materials to facilitate the resident’s learning experience. The resident will also learn, under supervision, how to interact with patients, families, and other members of the care team.

Psychotherapy Supervision:

Starting in their third year, all residents are assigned a psychotherapy supervisor. Residents will meet with their supervisor for no less than one-hour weekly. The supervisor assignment is for six months and will rotate between psychodynamic, cognitive-behavioral and general psychotherapeutic supervisors. During supervision, learning and teaching occurs through discussions about specific psychotherapeutic modalities, issues surrounding physician-patient relationships, clinical interviewing, and professionalism. In the fourth year, the resident will have the opportunity to have a second round of supervision by a previous or new supervisor, including the opportunity to review other psychotherapeutic modalities.

Psychotherapy:

Residents are required to identify candidates for Cognitive Behavioral Therapy and Psychodynamic Psychotherapy promptly at the start of their clinic year. Residents are required to have at least three (and preferably more) patients receiving each type therapy during their clinic year. Residents will discuss their therapy patients with their supervisor weekly. Residents will have real-time supervision by a supervisor every 4th therapy session. Supervisors will provide residents with immediate feedback after the session. Residents can discuss performing other modalities with their attending.

Disease Mix and Patient Characteristics:

At Midtown Medical Group Specialty Clinic patients have mild to moderate mental disorders, largely in the affective, anxiety, and trauma spectrums; personality disorders; and often concomitant substance use disorders and physical health problems. Insurance coverage varies, with a significant portion insured by Medi-Cal. Patients are all adults.

Responsibilities and Procedures:

Residents will perform initial psychiatric evaluations on new patients, annual evaluations on continuity patients, and follow-up assessments on established patients. Residents will provide pharmacologic treatment and management, under the guidance and direction of the attending. Residents are expected to communicate with all members of the patient’s treatment team, including therapist and primary care provider.

The residents are expected to complete all appropriate paperwork necessary to facilitate the patient’s appointment. This documentation includes, but is not limited to psychiatric evaluations, progress notes and appropriate correspondence/appendix notes.

Documentation must be completed in a timely manner (within 24 hours of office visit). Failure to maintain proper clinic documentation may result in an Academic Learning Agreement.

Medications must be properly reconciled. Residents should review medications with the patient at each visit. Residents must document informed consent for all psychotropic medications that they prescribe. Residents are required to obtain a CURES/PMDP report at each visit when prescribing a controlled substance.

Residents are required to be available to clinic staff during the day to answer questions or phone calls related to their patients. Residents will be assigned a call week in rotation with other third year residents. During their call week, the residents will be responsible for all phone calls in which the patient’s regular psychiatrist (resident or attending) is not available. While on call, the resident will be responsible for all after hours calls from established clinic patients. If the resident receives a call from a non-established patient, they should counsel them to call 911 if they are experiencing an emergency or to call during regular business hours if they wish to establish care. Residents should not provide medical recommendations to non-established patients. Residents are expected to document all phone calls that they receive within 24 hours.

The resident will participate in the formal weekly didactic sessions, as well as all Grand Rounds, Journal Club, and Morbidity and Mortality.

Overall Education Goals and Objectives:

To learn how to diagnose and manage a psychiatric patient in the outpatient setting.

Core Competencies:

Patient Care:

1. Be able to complete a thorough general psychiatric diagnostic assessment.

2. Learn to formulate a case, integrating biological, psychological, and social issues.

3. Be able to generate and carry out a plan of care, including pharmacological, psychological and social interventions.

4. Be able to identify issues and patterns better approached by psychotherapy than by medication.

Medical Knowledge:

1. Understand the various presentations of depression, bipolar disorder, anxiety disorders, adjustment disorders, and other disorders mentioned above, and how to differentiate between them.

2. Understand the pharmacologic management of these disorders, and the complications attendant to the use of SSRIs, TCAs, MAOIs, mood stabilizers, stimulants, typical and atypical antipsychotics.

3. Understand the treatment of refractory disorders, the types of psychotherapy, and their indications, and which are effective in managing problems seen in a general psychiatry clinic.

Systems Based Practice:

1. When appropriate and only with written consent from the patient, the resident will communicate with ancillary medical providers, mental health providers, and other relevant sources of information or providers of education, structure and/or care to the patient, to establish and maintain an optimal treatment plan.

Practice Based Learning:

1. The resident will be conversant with standards for metabolic screenings, assessment of movement disorders, Depression and Anxiety written inventories, and other standards of care, and will incorporate these measurements into patients’ medical records.

2. The resident will be observed in many patient interactions by the attending, and will receive feedback on those interactions, including issues of rapport, adherence, patient education and formulation of a shared treatment plan.

Professionalism:

1. Demonstrate respect for patient autonomy and choice.

2. Demonstrate willingness to seek supervision for psychotherapeutic and pharmacologic assessments and interventions.

Interpersonal and Communication Skills:

1. Be able to create a collaborative relationship with a wide variety of patients, some difficult to engage, to gain essential information and build and implement a therapeutic plan.

2. Be able to educate patients and their families.

3. Demonstrate an understanding of the stresses involved in having a chronic psychiatric illness.

4. Be able to supervise and educate medical students about psychiatric illnesses, interviewing techniques, and presentation skills.

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 the rotation. They must complete the evaluation and discuss it with the resident prior to the completion of the 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.

Transitions of Care:

A verbal checkout is required utilizing I-PASS for patients that require acute management or are having acute issues. The checkout occurs between the resident and the on-call resident. Handoffs utilizing the I-PASS system must occur when handing patients to the incoming yearly resident.

Duration:

Residents will be assigned to the Midtown Medical Group Specialty Clinic for 12 continuous months, starting in July of PGY3 year. Residents will be supervised by one of the following faculty members, or other designated psychiatrist:

Ronald Pollack, M.D.

Danielle Shaw, M.D. (coverage)
Joseph Vlaskovits, M.D. (coverage)

Educational Materials/References:

Kaplan and Saddock’s Synopsis of Psychiatry

Psychiatry Diagnostic and Statistical Manual, 5th Edition

Resources:

Residents will have access to interview rooms and workstations to complete their work.