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THE CORE TRAINING EXPERIENCE
PGY I
PGY II
PGY III
PGY IV
Seminars/ Didactics
Didactic Structure and Values
The core educational experience is comprised of three coordinated
activities: (1) clinical experience, (2) the didactic curriculum,
and (3) supervision. These are described by training year in greater
detail.
POSTGRADUATE YEAR I -
The First Year of Residency
The first year of the four-year training program consists of a
categorical psychiatry internship (PGY1 residency) at Cambridge
Health Alliance. Eight Intern positions are available. These Interns
work closely with eight Primary Care medicine interns and seven
Transitional Year Interns. The Department of Psychiatry is responsible
for curriculum, oversight, and support for the psychiatry Interns.
Since a number of the rotations take place within the Department
of Medicine, the Adult Residency Training program directors collaborate
closely with the Internal Medicine and Transitional Year program
directors to design and implement a well-integrated experience.
During the PGY1, the Intern develops his/her identity as a physician
and gains familiarity with Cambridge Health Alliance and the community
it serves. Interns are given considerable responsibility for patient
care to foster competence in general medicine.
Half of the internship year focuses on primary care in a community
hospital setting. Rotations include medical wards, the ICU, ambulatory
care, and/or Pediatrics. The remainder is devoted to psychiatric
rotations. These include one month each of general neurology, behavioral
neurology, addictions medicine, child psychiatry, geriatric psychiatry,
and rehabilitation community psychiatry. In child psychiatry, Interns
work alongside a child fellow on an inpatient unit and have the
opportunity to serve in a variety of roles. In their geriatric rotation,
Interns work at our Geriatric Specialty Unit with three psychiatrists
in an inpatient setting and with our multidisciplinary geriatric
team making rounds in nursing homes and private residences. In neurology
rotations, Interns provide inpatient and outpatient assessment and
treatment under the supervision of attending neurologists and behavioral
neurologists. In their addiction rotation, PGY1 Interns work on
an inpatient detoxification unit, and observe and participate in
outpatient group therapy and residential treatment. Residents contribute
to the intensive care of chronically and severely mentally ill patients
on our Assertive Community Treatment team and will rotate through
our Partial Hospital Program during the rehabilitation community
psychiatry month.
Each PGY-1 psychiatry resident has a two-week and a four-week block
of elective time. Residents design a learning experience with the
Training Directors that range from academic projects, clinical experiences
locally or at other institutions or community agencies. Residents
have created exciting opportunities to work on issues of international
mental health, community advocacy programs, academic research, scientific
writing, and intensive clinical rotations in areas of interest.
In the second half of the PGY-1 year, residents in psychiatry begin
"buddy call" for the Psychiatric Emergency Service. This
allows for the learning of basic emergency psychiatry skills for
after hours care in an extremely busy psychiatric emergency service.
PGY-2 and 3 residents work side by side with the PGY-1's teaching
and monitoring the work to prepare residents to begin solo call
at the beginning of the PGY-2 year.
As a transition to PGY2, Interns begin didactic seminars that provide
an introduction to the topics below:
PGY1 Didactic Curriculum/ Seminar Faculty
Introduction to Psychiatry: Stuart Beck, MD
Introduction to Emergency Psychiatry: Suzanne Bird, MD
Culture and Psychiatry: Xenia Johnson, MD
Intro to Psychopharmacology: Mathew Ruble, MD
Talking to Patients: Alfred Margulies, MD
EBM/Medical Library Introduction: Jenny Lee-Olsen, Medical Library
Staff
Professional Identity Development: Transitioning from Physician
to Physician/Psychiatrist:
Marshall Forstein, MD
Psychodynamic Formulation: "what lies beneath…": Marshall
Forstein, MD
POSTGRADUATE YEAR II -
The Second Year of Residency
PGY2 training includes six months of clinical experience caring
for psychiatric inpatients, three months working in partial hospitalization,
six weeks working in Consultation-Liaison Psychiatry, and six weeks
in the Psychiatric Emergency Service. PGY2 Residents also begin
their work in long-term outpatient psychotherapy. Didactics support
and complement the clinical curriculum.
Individual psychotherapy supervision begins at the start of the
PGY-2 year and residents meet with the director of outpatient services
as a group to learn about the transition from intensive services
to outpatient care, including how to use the electronic medical
record to insure the highest quality of integrated medical care
for psychiatric patients seen elsewhere in the Cambridge Health
Alliance. Residents also get an introduction in this forum to managed
mental health care and the interface with public sector funding.
The psychiatric inpatient experience includes a six-month rotation
on an inpatient unit at the Cambridge
campus.
Here, Residents develop basic skills in interviewing, evaluating,
and treating patients with a range of diagnostic and therapeutic
problems. On the inpatient units, the Resident works in collaboration
with a multidisciplinary team under the supervision of an attending
psychiatrist. At the Cambridge campus the team also includes Harvard
Medical students and trainees in other mental health professions.
In addition to carrying their own patients, each Resident is responsible
for the medical student assigned to the team, beginning a three
year experience in learning how to supervise and teach. During the
inpatient rotations, Residents present cases attended by faculty,
staff, and trainees of all disciplines. A rotation based didactic
seminar provides an academic component to the clinical training
in intensive services.
Three months are spent working on the partial hospitalization program
alongside residents from the Harvard Longwood Program through the
Massachusetts Mental Health Center Partial Hospitalization Program
at the Lemuel Shattuck Hospital, a Department of Mental Health facility
within a Department of Public Health Hospital. Here, Residents manage
a caseload of patients needing slightly less acute services than
the inpatient setting, assessing and treating people with persistent
mental illness. Didactics during this rotation include training
in in DBT (Dialectic Behavior Therapy), CBT (Cognitive Behavior
Therapy), forensics, and psychopharmacology.
The C-L experience is a six-week full-time rotation on the inpatient
consultation psychiatry service. This rotation teaches Residents
the fundamentals of psychiatric consultation in a primary care hospital
setting. Residents learn to work as a consultant to medical/surgical
staff to evaluate psychiatric symptoms in medically ill patients
and to offer appropriate psychotherapeutic and psychopharmacologic
interventions. The Emergency experience is a six-week rotation at
The Cambridge Hospital Psychiatric Emergency Service. With nearly
5,000 visits per year, this service is one of the busiest in Massachusetts.
Here, the PGY2 Resident focuses on rapid diagnostic and dispositional
assessments of patients with acute mental health issues.
In addition to the inpatient rotations, the PGY2 Resident begins
treating four outpatients under the guidance of two faculty supervisors.
We strongly support ongoing therapy with these patients for the
full duration of the residency.
During PGY2, Residents begin after-hour coverage in psychiatry.
On-call hospital and emergency room coverage for nights and weekends
occurs on average once every eleven days. Residents begin their
teaching and supervision of other residents and medical students
in the Psychiatric Emergency Service.
PGY2 Curriculum/ Seminar Faculty
Intensive Summer Seminar: Stuart Beck, MD; Chief Resident
Introduction to Psychotherapy: Cathy Schen, MD
Psychopathology and Diagnostic Formulation: Stuart Beck, MD
Principles and Practice of Psychopharmacology: Mathew Ruble, MD
Consultation-Liaison Seminar: Nick Kontos, MD; Chief Resident
Forensic Seminar: Barry Mills, MD
Emergency Psychiatry: Suzanne Bird, MD
Group Therapy Module: Karsten Kueppenbender, MD
Rehabilitation Psychiatry: Raymond Flannery, PhD
Journal Club: Lior Givon, MD; Ed Trejo, MD
POSTGRADUATE YEAR III -
The Third Year of Residency
The emphasis in PGY3 is on providing a broad experience in the
evaluation and treatment of adult outpatients. Other objectives
include developing skills in child and adolescent outpatient psychiatry,
working with adult and geriatric patients with both addictions and
psychiatric diagnoses, and learning to provide outpatient consultation
to primary care physicians.
The primary PGY3 rotations take place in the psychiatric ambulatory
services. Residents continue the supervised outpatient treatment
of four patients from their PGY2.
Approximately fourteen clinical hours per week are designated for
working with additional adult outpatients, including individual
and group psychotherapy cases and psychopharmacology patients. Individual
clinical supervision is assigned for each therapeutic modality:
psychodynamic treatment, cognitive-behavioral treatment, short-term
treatment, group treatment, and psychopharmacology.
At ambulatory sites, the Resident is a member of a multidisciplinary
team. PGY3 Residents learn the skills and value of teamwork while
treating patients who have limited resources and multiple psychosocial
problems. Residents may also choose to treat patients in one of
the linguistic clinics (Haitian, Latino, Portuguese, Asian).
The outpatient experience has been reorganized to provide increased
structure, precepting and supervision of residents and other trainees.
Residents carry a defined number of psychotherapy cases. Preceptors
monitor caseloads to insure a broad spectrum of patients diagnostically,
culturally, and functionally.
Residents also work in the psychopharmacology clinics twice a week.
Each session includes evaluations and ongoing medication management,
and is closely supervised by both an attending psychiatrist and
a Clinical Nurse Specialist. Each psychopharmacology clinic ends
with an overall discussion about patients with attention to specific
learning objectives for the residents.
In addition to the psychiatric ambulatory rotation, PGY3 Residents
participate in a six-month outpatient consultation psychiatry rotation.
This allows Residents to further develop consultative skills. In
keeping with the trend towards a primary care approach, Residents
work as psychiatric consultants in the hospital's outpatient medical
clinics.
Opportunities exist to provide psychiatric consultation to patients
in the multidisciplinary HIV clinic, the Psycho-oncology clinic
of the Dana Farber Cancer Center, and to palliative medicine.
During their Child and Adolescent rotation PGY3 Residents meet
weekly with a senior child psychiatrist to observe evaluations and
to discuss cases. Each Resident also treats two children under the
supervision of our faculty. They may also be involved in evaluating
parental function in adults referred by the Department of Social
Services.
Residents evaluate patients through our Outpatient Addiction Service
where they co-lead groups and provide psychopharmacologic treatment
to dual diagnosis patients. On-call hospital and emergency room
coverage for nighttime and weekends continues on average once every
two weeks.
PGY3 Curriculum/ Seminar Faculty
Human Development & Developmental Psychopathology: Nancy Rappaport,
MD
Psychotherapy Seminar - CBT, Short Term, and Long Term Dynamic
Therapy: Wayne Brunell, MD; Alan Siegel, EdD; Jim Harburger, MD;
Marshall Forstein, MD
Biological Therapies and Neuroscience: Nick Kontos, MD
Evidence Based Medicine/Research: Steve Leff, PhD
Psychopharmacology: Laurie Beizer, MD
Journal Club: Lior Givon, MD; Ed Trejo, MD
Geriatrics: Steve Pinals, MD
History of Psychiatry: Marla Eby, PhD
Writing Seminar: Malkah Notman, MD
Psychology and Neuropsychological Testing: Marla Eby, PhD
Spirituality and Psychotherapy: John Chirban, PhD
Child Psychiatry Seminar/Practicum: Robert Ziegler,
MD
POSTGRADUATE YEAR IV -
The Fourth Year of Residency
In the PGY4, Residents pursue individual interests and develop
further professional competence through teaching, clinical work,
administration, or research. They also continue with fifteen hours
per week of outpatient work. In addition, Residents treat a couple
or family under the supervision of staff from our Couples and Family
Clinic.
PGY4 Residents choose a chief residency position within the Department
of Psychiatry. We have several positions, including one with the
Department of Mental Health that offers an advanced Resident a unique
opportunity to teach, supervise, and gain administrative experience
as a clinician working between state and local mental health systems
with patients who have severe and persistent mental illness. Other
chief residencies include positions in the intensive services, the
outpatient services, the consultation-liaison service, the emergency
service, the psychopharmacology service, and the addictions service.
As a chief resident, a PGY4 exercises leadership, and deepens his
or her intellectual and clinical skills in a specialized treatment
setting. Learning how to teach medical students and residents, and
how to supervise are expectations of the chief residency.
Some Residents have used the flexibility in the fourth year to
work in elective settings or to pursue special interests that have
developed during the first three years of residency. Residents have
worked at the university health services at MIT, Tufts, or Harvard,
begun a Fellowship in Child and Adolescent Psychiatry, pursued academic
and clinical experience in advanced training programs within the
Alliance, or participated in research. Advanced training programs
are offered in Behavioral Medicine, the Victims of Violence Program,
the Couples and Family Clinic, and the Program for Psychotherapy.
Residents have opportunities to take courses in any of the Harvard
Graduate programs: School of Education, School of Public Health,
Business School, Law School, and/or Kennedy School of Government.
PGY4 Didactic Curriculum
Psychotherapy/ Theory: Jack Beinashowitz, PhD
Psychotherapy Cases: Alfred Margulies, MD
Neurobiology and Neuropsychiatry: Nick Kontos, MD
Advanced Biologic Therapies and Neuroscience: Bruce Price, MD;
Matt Ruble, MD
Chair's Seminar: Jack D. Burke, MD, MPH
Transition to Practice: Donna Moores, MD
History of Psychiatry: Case Studies: Bennett Simon, MD
Ethics in Psychiatry: J. Wesley Boyd, MD, PhD
Psychiatry and Neurology Boards Review: Marshall Forstein, MD
Mock Boards: The Faculty
DIDACTIC THEMATIC STRUCTURE AND VALUES
The biopsychosocial model of mental illness provides the framework
for the entire educational experience. Seminars are organized on
the basis of these three perspectives. The principles and application
of evidence-based medicine are incorporated throughout the didactic
and rotation based seminars.
Psychotherapy, psychopharmacology, neurobiology/ neuropsychiatry,
and Evidence Based Medicine and Critical Thinking are major themes
throughout the four years of didactics and clinical rotations. All
seminars are intended to supplement the clinical training with theory
and the research findings to support the best clinical outcomes
possible. Some examples of these seminars follow:
A newly developed summer seminar, "Cross Cultural Issues
in Psychiatry" is jointly taught by residents and faculty.
The seminar is open to all trainees in psychiatry, psychology, social
work and nursing, and well attended. In this 8 week didactic/experiential
seminar, trainees explore the impact of culture, class, sexual orientation,
ethnicity and race on psychiatric disorders and their treatment.
The seminar brings together a multidisciplinary group of diverse
trainees for mutual learning and focuses on the specific issues
reflected in the multicultural populations of Cambridge Health Alliance.
In the PGY2, the Psychopathology and Diagnostic Formulation
seminar begins with descriptive modules based on DSM diagnostic
categories. Lecturers present an overview of epidemiology, diagnostic
criteria, hypotheses regarding etiology, course/prognosis, and treatment.
This descriptive material is interspersed with lectures on various
biological and psychological concepts regarding mental disorders,
with an emphasis on the role of culture, class and social structures
on formulation.
A comprehensive seminar on rehabilitation issues for people
with chronic and persistent mental illness introduces the residents
to the possibilities of enhancing strengths and resiliency to improve
the lives of patients.
In the PGY3 year, Residents are introduced to the paradigms that
we have used in psychiatry to understand human development and function.
The Normal and Abnormal Child and Adolescent Development seminar
will provide a basic foundation for understanding the roots of childhood,
adolescent, and adult behavior and psychopathology. The course is
directed by a child and adolescent psychiatrist who invites experts
in the field of separation attachment, moral development, adolescent
sexuality, childhood psychopathology and other critical issues in
child development to enhance the seminar and showcase leaders in
the field. Seminars deepen the experience of psychotherapy, and
broaden the basic science knowledge in neurobiology and biological
therapies.
In the PGY4 year, seminars continue to enhance knowledge and practice
in the areas of psychotherapy, psychopharmacology and neuropsychiatry.
Residents may choose to pursue and deepen their knowledge in a specific
area by enrolling in specialized seminars. A large number of elective
seminars are open to trainees and staff at Cambridge Health Alliance.
Residents may choose to acquire expertise in a specific area by
becoming advanced trainees in specialized programs within our system,
which offer didactics, supervision, and clinical experience. Examples
of such programs are the Victims of Violence Program in which many
kinds of trauma are treated and researched; the Program for Psychotherapy,
in which residents treat patients with intensive psychodynamic psychotherapy.
The focus of the fourth year is integration of the biological,
psychological and social aspects of mental illness into a comprehensive
view of a person within the context of his/ her biology/ family
and community.
BIOLOGIC THERAPIES AND NEUROSCIENCE
This four-year sequence is designed to establish a solid base of
knowledge in the areas of biologic therapy and neuroscience. In
the PGY1, Interns learn about the principles of psychopharmacology.
In the PGY2 seminar, instruction is organized around the major classes
of psychotropic medications. Other topics include drug interactions,
toxicities, ECT, the use of medication in special patient populations,
and psychodynamic issues in the practice of psychopharmacology.
The PGY3 seminar focuses on medication management in the outpatient
population. The major classes of medications are discussed with
an emphasis on the literature supporting their use. The mechanism
of action of these drugs is reviewed and the neurobiology of major
psychiatric disorders presented. In an ongoing Journal Club, Residents
read relevant articles and learn to critically assess their value.
The PGY4 seminar features invited speakers who are recognized experts
in particular areas of biological psychiatry, psychopharmacology,
and behavioral neurology.
The neurobiology and neuropsychiatry seminars provide a basic anatomical
and neurobiological framework on which to place the clinical neuropsychiatric
syndromes encountered by the residents in patients with complex
medical and psychiatric disorders. Opportunities exist for residents
with particular interests in neuropsychiatric disorders like Parkinson's
Disease, Huntington's Chorea, and HIV dementia to obtain clinical
experience in these areas.
At the end of the year, the department sponsors a "brain cutting"
session for an afternoon with a psychiatrist and neuro-anatomist
to bring together clinical syndromes with anatomical dissection
and discussion. Residents bring clinical experience and basic science
knowledge together to consider how brain function and mind function
get integrated.
PSYCHOTHERAPY SEMINAR
Psychotherapy is taught over the course of three years as a series
of seminars that focus on clinical work at each stage of training.
In the PGY2, when Residents are primarily on inpatient units in
an acute care setting, the focus of the seminar is on crisis management,
alliance formation, and underlying dynamic processes in the patient-therapist
relationship. In the first month of the seminar, the discussion
centers on meeting and beginning therapy with outpatients. Subsequently,
Residents are asked to present transcribed material from inpatient
cases or from their outpatient psychotherapy sessions. Adjunctive
readings are assigned. The case-based format encourages Residents
to learn experientially about basic concepts of psychotherapy, such
as transference, countertransference, resistance, and interpretation.
The PGY3 psychotherapy seminar introduces Residents to a variety
of therapeutic modalities while they are working on multidisciplinary
outpatient treatment teams. Residents learn about cognitive behavioral
therapy, supportive, and short-term therapy. They continue to deepen
their understanding of dynamic psychotherapy with guided reading
and case-based discussions. The two PGY4 psychotherapy seminars
are advanced courses that introduce contemporary theoretical perspectives
and techniques. An integrative approach is emphasized in topics
such as process and outcome research, models of brain/mind, and
the interaction between psychopharmacology and psychodynamics. Case-based
discussions with senior staff help the Residents gain insight into
their own therapeutic style.
Over the span of three years, the Resident emerges with a solid
foundation in psychotherapy practice and theory as preparation for
the further study of psychotherapy or for a career as a general
psychiatrist.
EVIDENCE BASED MEDICINE/ RESEARCH SEMINAR
Evidence based medicine, journal club and research seminars are
threaded throughout each of the 4 years of training. During the
PGY1 year, residents learn research skill building and practice
the use of library resources, which include not only the Cambridge
Health Alliance library but direct access to the Harvard Medical
School Countway Library and Electronic Journal system. In the second
year, residents work through individually the basics of Evidence-Based
psychiatry, identifying areas for further study through the critical
reading of published research articles in the Journal Club. Residents
are encouraged to find mentors in the areas of interest to begin
thinking about the scholarly project that is required by the end
of the program.
In the PGY3 year, residents will learn about research design and
review important methodological and statistical concepts. Each resident
will pursue a clinical question and create a research protocol.
In the research seminar, residents are also encouraged to develop
and present on topics of their own choice. Residents will determine
how to conduct the research and what its impact might be, and in
the PGY4 year a subset of residents will elect to implement their
research protocols. While not all residents will choose to pursue
clinical research in the fourth year, or afterwards, every resident
will develop the skills required to be critical evaluators of research
in order to bring the highest quality of care to their patients,
and to develop the skills necessary for lifelong learning.
GROUP THERAPY MODULE / TRAINING GROUP
At the beginning of the PGY2, Residents are introduced to concepts
of group therapy in a didactic module that precedes the beginning
of their own group experience. PGY2 Residents are required to participate
in a weekly training group led by an experienced group therapist.
This module and personal exposure to group dynamics prepares them
to lead psychotherapy groups for patients.
SPECIAL SEMINARS
A series of shorter seminars that compliment specific clinical
rotations or stages of training are offered throughout the residency.
These seminars include cross-cultural psychiatry, ethical principles
in the practice of psychiatry, sexuality and psychiatry, and psychosocial
rehabilitation. Residents also learn about the history of psychiatry
and have an opportunity to think about the role of spirituality
in the treatment of patients with psychiatric disorders. Throughout
the four years of the program a considerable emphasis is given to
learning how to interview patients from various points of views
and schools of thought. An ongoing discussion throughout the academic
year starts with a Summer Grand Rounds Series on Gender and Sexuality
that is open to all trainees and faculty.
Several times a year, residents from the four Harvard Departments
of Psychiatry training programs meet for special educational events.
Each year in November, at All Harvard Day, one of the programs has
responsibility for organizing a full day of didactics on some area
of importance to the field of psychiatry. In the past, topics have
included: sexuality, ethics, spirituality, evidence based practices,
current research, psychotherapies.
Another "All-Harvard Day" is Medical Education Day, where
residents and faculty present posters pertaining to innovations,
or research in training and education in medicine.
In March, the Mysell Research Day brings the departments and training
programs together for a lecture of significance and the presentation
of awards to residents and fellows for poster presentations of research
done by trainees from the four Harvard psychiatry training programs.
This provides an opportunity for Cambridge Health Alliance residents
to present their work and continue building professional relationships
with peers and faculty from the Harvard Departments of Psychiatry.
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