|
|||
 |
|||
 |
|
THE CORE TRAINING EXPERIENCE PGY I
POSTGRADUATE YEAR I - 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. Cambridge Health Alliance is also home to a Family Practice Residency affiliated with Tufts Medical School, providing opportunities for psychiatry trainees to work in consultation with the community family practice program. Interns start orientation week with a team building day followed by ACLS and other preparatory sessions before starting clinical duties. Sessions on resident health and safety, work hours, sleep, and well being set a tone for the residents from all departments who share in the care of Cambridge Health Alliance patients. Psychiatry residents are fully integrated with primary care, family practice, transitional and podiatric interns in the first year of training. During the PGY1, the Intern develops his/her identity as a physician and gains familiarity with Cambridge Health Alliance and the communities it serves. Interns are given considerable responsibility for patient care to foster competence in general medicine. Interns rotate on the general medical teaching service, with a newly protected four hour didactic block on Tuesday afternoons. This creative didactic seminar helps prepare interns for step three of the USMLE. 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 two 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 consult to medicine for acute detoxification, 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 see patients in the Transition program designed to hold patients recently discharged from inpatient care for acute stabilization. Interns work with senior residents and faculty to care for psychotic patients living in the community who access shelters and drop in centers. 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.
PGY1 Didactic Curriculum/ Seminar Faculty Introduction to Psychiatry: Stuart Beck, MD Introduction to Emergency Psychiatry: Suzanne Bird, MD Intro to Psychopharmacology: Matthew Ruble, MD Intro to Addiction Psychiatry: Jan Kaufman, MPH Ethical Interactions with the Pharmaceutical Industry: Matthew Ruble, MD Meet the Experts: Resident as Teacher, Matthew 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…": Robert
Levin, MD and Marshall Forstein, MD Preparation Seminar for the PGY-2 year: Elisa Cheng, MD (PGY-5)
, Dan Reilly, MD, (PGY-4 Chief Inpatient Resident), Suzanne Bird,
Stuart Beck, MD.
POSTGRADUATE YEAR II - 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 Chief Resident meets regularly with PGY-2 residents to oversee the administrative aspects of outpatient care. The psychiatric inpatient experience includes a six-month rotation, with three months on an inpatient unit at the Cambridge campus, and three months at the Whidden Hospital. 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. Forensic cases at the Whidden Campus are supervised by the Medical Director who is a forensic psychiatrist. Three months are spent working in the ACS (Ambulatory Care Service) that is dedicated to the most severely impaired patients with psychosis, mood disorders and psychosocial dysfunction. Residents work with attendings to assess and treat patients with a range of psychopharmacologic and behavior treatments. PGY-2 residents can choose to pick up to two patients with chronic psychosis or bipolar disorder as part of their continuity care for the PGY-3 and 4 year as well. Residents co-lead groups, assess medical risk factors and monitor patients with co-morbid medical problems including obesity, diabetes, metabolic syndrome, and cardiovascular disease. Supervision occurs with attendings, an experienced psychiatric
nurse clinician, and social workers. Residents visit patients in
supervised living situations, consult to drop in centers and other
community based agencies for people with chronic mental illness.
Pgy-2 residents work with PGY-1 residents on their Community rotation
during this time as well. There is an opportunity for residents
to also develop relationships with Health Care for the Homeless
to provide a conduit for patients in need of mental health services. The Consultation-Liaison 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 over 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 adult and child 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. Residents have an opportunity to provide ongoing therapy with these patients for the full duration of the residency. During PGY2, Residents also 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. Residents have the option
of joining the moonlighting pool at the Cambridge Hospital Campus. PGY2 Curriculum/ Seminar Faculty Introduction to Psychotherapy: Cathy Schen, MD Integrated Psychopathology, Diagnostic Formulation, and Psychopharmacology. Matthew Ehrlich, MD, Catherine Fullerton, MD, Stuart Beck, MD and Matthew Ruble, MD Consultation-Liaison Seminar: Robert Joseph, MD; Chief Resident Forensic Seminar: James Beck, MD Emergency Psychiatry: Suzanne Bird, MD Group Therapy Module: Stephanie Bukema, EdD Rehabilitation Psychiatry: Raymond Flannery, PhD Journal Club: Lior Givon, MD; Ed Trejo, MD Annual Observed Clinical Exams and ABPN Certification Exams: The Faculty T-Group: Training group. Facilitated by Laurie Raymond, MD
POSTGRADUATE YEAR III - 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 outpatient
department. Residents continue the supervised outpatient treatment
of four patients from their PGY2. 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 Department also includes a Clinic for African Americans, and provides services to the gay, lesbian, bisexual and transgender communities. Residents may choose to do some of their PGY-3 outpatient work in one or more of these services. 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. Each PGY-3 resident and each of eight psychology interns work together as part of the Psychodynamic Psychotherapy Research Clinic. Trainees each see two patients twice a week for dynamic psychotherapy as part of a research clinic that includes systematic assessment and evaluation at the beginning, middle and end of treatment. This clinic includes a year long seminar in assessment, diagnostic formulation and psychodynamic theory. Psychotherapy sessions are audiotaped and utilized in supervision. 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. Residents who choose to fast track into a Child and Adolescent
Fellowship will have met all ACGME requirements for the adult training
program before doing so. PGY3 Curriculum/ Seminar Faculty Human Development & Developmental Psychopathology: Nancy Rappaport, MD Psychotherapy Seminar: - CBT ( Wayne Brunell, MD) Biological Therapies and Neuroscience: Lior Givon, MD Evidence Based Medicine/Research: Steve Leff, PhD Psychopharmacology: Matthew Ruble, MD Journal Club: Lior Givon, MD Geriatrics: Steve Pinals, MD History of Psychiatry: Marla Eby, PhD Writing Seminar: Malkah Notman, MD Psychology and Neuropsychological Testing: Marla Eby, PhD Sexuality and Psychiatry: Marshall Forstein, MD and Malkah Notman, MD Spirituality and Psychotherapy: John Chirban, PhD Annual Observed Clinical Exams and ABPN Certification Exams: The
Faculty
POSTGRADUATE YEAR IV - 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 may 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. Clinical and administrative supervision is an important role of
any faculty member, and yet little is traditionally done in residency
training to prepare graduates for this essential role. To address
this deficit in residency training, we have implemented supervision
training as Part of the PGY-4 experience. During the summer, PGY-4
residents meet to read and discuss the process of becoming a supervisor
for preparation for an academic career. Meeting weekly for 6 weeks
in the summer, and then monthly during the first half of the year,
each PGY-4 will supervise a medical student, junior resident, or
other mental health trainee who agrees to have their supervision
audiotaped and discussed in the seminar. PGY4 Didactic Curriculum Psychotherapy/ Theory: Jack Beinashowitz, PhD Psychotherapy Cases: Alfred Margulies, MD Supervision Seminar; Marshall Forstein, MD Neurobiology and Neuropsychiatry: Lior Givon, MD Advanced Biologic Therapies and Neuroscience: Bruce Price, MD; Matt Ruble, MD; Nassir Ghaemi, MD, MPH Transition to Practice: Donna Moores, MD Advanced CBT Seminar and Supervision: Peter McEntee, PhD Advanced Couples and Family Therapy Seminar and Supervision: Danielle Greene, MSW, Suzanne McCarthy, PsyD History of Psychiatry - Case Studies: Bennett Simon, MD Ethics in Psychiatry: J. Wesley Boyd, MD, PhD Psychiatry and Neurology Boards Review: Marshall Forstein, MD, and faculty Annual Observed Clinical Exams and ABPN Certification Exams: The
Faculty
DIDACTIC THEMATIC STRUCTURE AND VALUES The bio-psycho-social-cultural model of mental illness provides the framework for the entire educational experience. 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 summer seminar, "Cross Cultural Issues in Psychiatry"
is jointly taught by residents and faculty. The seminar is required
of PGY-2 residents and Psychology Interns. 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, Diagnostic Formulation, and psychopharmacology seminar begins with descriptive modules based on DSM diagnostic categories. A two hour seminar, the faculty team teachers coordinate the diagnosis of psychiatric disorders with the pharmacologic and psychotherapeutic treatment of those disorders. 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. Residents prepare and present to their peers and get feedback about the academic work as well as the teaching style and preparation. 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 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.
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. A new summer seminar for PGY-2 through PGY-4 is taught by Lior Givon, MD and Christopher Bullock, MD, entitled: "Neurobiology and Psychotherapy: Desire, Aversion, and Mirroring in the Drama of Self and Other". 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, 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. As part of the PGY-4 experience, residents are required to engage in a Scholarly Project. Projects have included: Review articles, pilot research studies, case reports, development of teaching materials and curriculum, presentations at national meetings, a literature review, participation in an ongoing research project, a teaching experience with written assessment and critique, amongst many others. 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. At the end of the PGY-2 year, the residents make a group decision about whether to continue their training group for the PGY-3 year.
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 adult and three child Harvard Medical School 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.
|
|
