Rotations and Call

Overview

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 PGY-1 residents work closely with eight PGY-1 Primary Care medicine residents 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.

PGY-1 residents 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, creation of an Intern’s Oath and discussions of 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 first year, PGY-1 residents develop their identity as a physicians and gain familiarity with Cambridge Health Alliance and the communities it serves. Interns are given considerable responsibility for patient care to foster competence in general medicine. Residents rotate on the general medical teaching service, with a protected four-hour didactic block on Tuesday afternoons. This creative didactic seminar helps prepare interns for step three of the USMLE.

Rotations

Half of the PGY-1 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, addiction medicine, child psychiatry, geriatric psychiatry, and rehabilitation / community psychiatry.

On neurology rotations, PGY-1 residents provide inpatient and outpatient assessment and treatment under the supervision of attending neurologists and behavioral neurologists. General neurology training at the Cambridge Health Alliance can be enhanced with a focus in one of the specialty neurology services, such as the headache, seizure or cognitive disorders clinics. The behavioral neurology month at the McLean Hospital provides residents an experience learning about neuro-imaging, and assessment of psychiatric patients with neuro-behavioral symptoms.

On the community rotation residents contribute to the intensive care of chronically and severely mentally ill patients on our Ambulatory Care Service and see patients needing psychiatric emergency services. PGY-1 residents work with senior residents, nurse clinicians, social workers and faculty to care for psychotic patients living in the community who access shelters and drop-in centers.

Med Psych Integration: On this two-week rotation, residents spend time on services at the interface between the medical and psychiatric care of patients. One week will be spent in the Medical ED, as a medical ED provider, to learn about care of patients in this environment prior to serving as a psychiatric consultant to the Medical ED in the later years of residency. Interns will also spend time with the Behavioral Health Communications Center, to gain an increased systems-level appreciation of the process of finding appropriate placements for acutely ill psychiatric patients.

The second week will be spent at the Beth Israel Deaconess Medical Center (BIDMC), where interns will have a one-week immersion in TMS and ECT, under the guidance of BIDMC faculty.

On the child rotation, residents can choose to work either on the Child Assessment Unit (CAU), or the Adolescent Assessment Unit (AAU). During this rotation they learn about child psychopathology, family structures and pediatric psychopharmacology. Residents observe intakes and groups, child play therapy, and have a designated child psychiatrist as an additional supervisor. Residents also have an experience on the outpatient child psychiatry teams, observing intakes and assessments of children and adolescents.

On the geriatric psychiatry rotation, residents care for patients with delirium, dementia, intractable depression and chronic psychosis. Supervision by a geriatric psychiatrist includes learning about psychopharmacological issues in the medically ill, and older population with psychiatric issues.

The addiction rotation introduces residents to outpatient care of patients with chronic, acute and intermittent substance use disorders. They participate in intakes, group therapy and learn about Motivational Interviewing and psychopharmacological treatments as well as the underlying neuropathology of addiction. Residents have an opportunity to learn about methadone treatment in the Associated Methadone Maintenance Treatment Program, and about the outpatient use of buprenorphine for opioid addiction.

Electives

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 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. Examples of resident initiated electives include Palliative Care, Eating Disorders, and school based mental health.

Psychiatric Call

In the second half of the PGY-1 year, residents in psychiatry begin "buddy call" in psychiatric emergency services. This allows for the learning of basic emergency psychiatry skills for after hours care in an extremely busy 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 on Wednesdays from April through June that provide an introduction to the topics below:

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.

The psychiatric inpatient experience includes two three-month rotations, with three months on an inpatient unit at the Cambridge campus, and three months at CHA Everett Hospital. 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. Teams also include 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 are supervised by a forensic psychiatrist.

Residents work with attendings to assess and treat patients with a range of psychopharmacologic and behavior treatments. While on the inpatient services, Residents co-lead groups, assess medical risk factors and monitor patients with co-morbid medical problems including obesity, diabetes, metabolic syndrome, and cardiovascular disease. 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 years as well.

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 in psychiatric emergency services within the Cambridge Hospital Emergency Department [ED]. With over 5,000 mental/behavioral health 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. Emergency Psychiatric Services are provided by attendings, social workers, residents and ED physicians, nurses, and staff.

Three months are spent working with patients in a partial hospital program at the Massachusetts Mental Health Center. Cambridge residents work alongside residents from the Harvard/Longwood Residency program where they focus on CBT and DBT training with the most severely impaired patients with psychosis, mood disorders and psychosocial dysfunction. During this rotation residents return to Cambridge Health Alliance for Wednesday didactics, outpatient continuity care, and supervision.

Weekly individual psychotherapy supervision begins at the start of the PGY-2 year. Residents begin to treat up to four patients in individual therapy who they may follow for as long as three years when appropriate. Residents meet as a group with the director of outpatient services to learn about the transition from intensive services to outpatient care. Residents also get an introduction in this forum to managed mental health care and the interface with public sector funding. One of the PGY-4 chief residents meets regularly with PGY-2 residents to oversee the administrative aspects of outpatient care, and to provide practical supervision about patient management and documentation.

Psychiatry Call

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-fourteen days. Residents begin their teaching and supervision of other residents and medical students in psychiatric emergency services. Residents in good standing have the option of joining the back-up coverage pool at the Cambridge Hospital campus.

Cambridge Health Alliance is moving towards a completely integrated, collaborative care model of primary care and mental health. Each of the primary care centers provides an opportunity for residents to train in the model of care that is mission driven and focused on access to excellent evidence based care. At the same time, residents will continue to learn the fundamentals of outpatient care in an interdisciplinary training model with a broad based population.

The emphasis in PGY3 is on providing an extensive 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.

Outpatient Psychiatry

The primary PGY3 rotations take place in the psychiatric outpatient department. 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 Department also provides services throughout the Cambridge Health Alliance 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. Residents may choose to focus some of their outpatient time in the Victims of Violence Clinic (Trauma), or the Ambulatory Community Care Clinic with an emphasis on more severe and chronic psychotic, mood, and character disorders.

The outpatient experience has been organized to provide structure, precepting and supervision of residents and other mental health trainees. Residents carry a defined number of psychotherapy cases. Preceptors monitor caseloads to insure a broad spectrum of patients diagnostically, culturally, and functionally. Residents often share cases with psychology interns and social work students.

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.

Integrated Primary-Behavioral health: Psychosomatic and Consultation Liaison Medicine

In addition to the psychiatric ambulatory rotation, PGY3 Residents have a six-month outpatient experience in Integrated Care at a primary care or specialty clinic. . Residents learn a Stepped Care Model of Collaborative Care, providing direct psychiatric consultation to Primary care Providers, evaluating patients with mental health symptoms and recommending treatment to primary care providers, and/or providing short term treatment or referral to an appropriate outpatient clinic. Opportunities also exist to provide psychiatric consultation to patients on the palliative care service, or in one of the specialty clinics within the Cambridge Health Alliance such as the multidisciplinary HIV clinic and the women’s health clinic. Residents can elect the Psycho-oncology clinic of the Dana Farber Cancer Center.

Child and Adolescent Psychiatry

PGY3 residents meet weekly with a senior child psychiatrist to discuss two child/ adolescent cases. They may also be involved in evaluating parental function in adults referred by the Department of Social Services.

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.

Psychiatry Call

On-call hospital and emergency room coverage for [nighttime and weekends] continues on average once every two weeks.

Up to 70% of the PGY-4 year is elective.

The PGY-4 year consolidates previous learning and training and provides opportunities for residents to pursue individual interests and develop further professional competence through teaching, clinical work, administration, or research. Residents 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.

Psychodynamic Research Clinic

PGY-4 residents, psychology interns, and two advanced social work interns work together as part of the Psychodynamic Psychotherapy Research Clinic. Trainees each see two patients up to 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.

Chief Residency Positions

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.

Electives

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, , 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.

Health Care for the Homeless: PGY-4 residents may elect a 6-12 month elective in the collocated, integrated Health Care for the Homeless Clinic that is part of the Cambridge Health Alliance. Residents are supervised by primary care physicians and nurse clinicians providing basic health care, and by psychiatric nurses and psychiatrists providing mental health assessment and treatment.

PGY-4 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.

Supervision Training

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 in preparation for an academic career. PGY-4 residents each meet in the Psychiatry transition service one morning a week for 6 months with a PGY-3 resident who is seeing patients. The PGY-4 resident has primary supervisory experience for the PGY-3, and there is always an attending present in the clinic for back up. PGY-4 residents meet with the Training Director weekly throughout the summer and intermittently during the year as a group to present their supervision experience and get feedback from the other PGY-4’s. Audio-taping of the supervision sessions are brought into the group seminar for in depth discussion about supervision in a variety of clinical settings.

Psychiatry Call

There is no overnight call in the PGY4 year. However, 4th year residents serve as the senior on call (SOC) to provide back-up support and supervision for the Psychiatry resident on call (DOC) two non-consecutive weeks out of the year.

The above rotations are not in any particular order for all. Medicine ward time is broken up into three 1-month blocks and not one continuous block.

The above rotations are not in any particular order. Psych Emergency Svc. and CL are done as contiguous blocks.

The above rotations are not in any particular order and may overlap each other. Some may be deferred to PGY4 year.

The above experiences may be scheduled throughout the year and may overlap each other.

PGY1
In the second half of the PGY1 year, residents in psychiatry begin "buddy call" for psychiatric emergency services. This allows for the learning of basic emergency psychiatry skills for after hours care in an extremely busy psychiatric emergency service. PGY2 and 3 residents work side by side with the PGY1's, teaching and monitoring the work to prepare residents to begin solo call at the beginning of the PGY2 year.

PGY2
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 psychiatric emergency services. Residents in good standing have the option of joining the back-up coverage pool at Cambridge Hospital.

PGY3
Call continues throughout the PGY3 year.

PGY4
There is no overnight call in the PGY4 year. However, 4th year residents serve as the senior on call (SOC) to provide back-up support and supervision for the Psychiatry resident on call (DOC) two non-consecutive weeks out of the year. PGY-4’s always have an attending backing them up.