Adult Psychiatric Consultation Service

FOR CLERKSHIP STUDENTS


Orientation for Medical Students for Clinical Clerkship in General Hospital Psychiatry. 2008-2009

                             Prepared by M. Tobin MD

 

Dear Student:

 

Welcome to your medical student experience in General Hospital Psychiatry Consultation (Psychosomatic Medicine)

 

General Hospital Psychiatry Consultation was developed in response to evidence supporting a high prevalence of psychiatric symptoms and disorders in patients with complex medical illnesses. The spectrum ranges from a psychiatric disorder complicating medical treatment to psychiatric symptoms being wholly produced by the medical illness. Changes in health care provision in recent years have resulted in sicker, older hospital patient populations. The result of this has been an increase in the incidence of certain conditions (such as delirium and HIV related disorders) with associated significant increases in psychiatric co-morbidity. Consultation psychiatrists have specialized expertise in assessing the interplay of medical illnesses and psychiatric symptomatology.

 

The goal of the student specialty experience in the General Hospital Psychiatry Consultation Service is to gain a specialized experience in this unique area of expertise in psychiatry. Experience and learning in the field of Psychosomatic Medicine is invaluable to the practice of all other fields of Medicine and exposes one to the unique challenges of managing psychiatric disease in the medically ill. This is achieved by developing clinical skills in the diagnosis of psychiatric issues arising in the medically ill hospitalized patient population, by assuming some administrative responsibility for providing day-to-day psychiatric services to the patients allocated to your care during your rotation, by witnessing the development and working of liaison relationships with other hospital services and by acquiring a sound knowledge base in the field of psychosomatic medicine. More specifically at the end of your six week rotation it will be expected that you will be able to perform the following

 

General Hospital Psychiatry Consultation is the subspecialty concerned with surgically and medically ill patients and provides evaluation and management of these patients.

1.             A clinically appropriate History and Neurological examination (if appropriate) on a medically ill hospitalized patient.

            2.            A Mental State Examination (MSE).

            3.             A basic Cognitive Examination.

4.            A case presentation using the Bio-Psycho-Social and Development model of understanding psychiatric illness.

Additionally it will be expected that you will be familiar with the DSM-IV diagnostic criteria for Mood and Anxiety Disorders, Schizophrenia and other Psychotic Disorders, Substance Use Disorders and have some awareness of the presence of personality disorders and somatoform disorders. Finally, some elemental skill in evaluating safety (patient, staff and environmental) and ethical and legal questions in the medically ill hospitalized patient will be expected.

 

 These Goals for your education will be accomplished primarily by becoming an integral part of the General Hospital Psychiatry Consultation team. This team is led by the Attending Psychiatrist with invaluable assistance from the Chief Resident in C/L psychiatry and by the PGY-II resident who is primarily responsible for the day-to-day running of the service.

The nature of the experience you will have a part of the GHPC team is unique in many ways. Team work is essential! Performing initial consults referred from many different services affords the opportunity to experience a great variety of psychiatric pathology at the Medicine-Psychiatry interface. Performing follow-up work allows one to see the evolution of psychiatric illness in the General Hospital and to gain experience in applying various treatment modalities (psychopharmacological and psychotherapeutic).The experience gained at the bedside is enhanced one hundred fold by expanding your knowledge base by reading in the area of Psychosomatic medicine. A good philosophical approach to consider “everything as potential information”. To this end you are encouraged to be open to educational opportunities and to seek extra experience in an area of special interest to you. It is, additionally, extremely important to pay especial attention to the feelings evoked within your self during your experience with us and to discuss these feelings with the Attending and Residents as you feel comfortable.

 

Consults are performed at the University Of Chicago Mitchell Hospital. Your base location is in the Department of Psychiatry.  You will meet with the C/L resident on the first day of your rotation. The resident will orient you to the day-to-day operation of the service (e.g. allocation of consults, forms used, times of rounds etc.) Also the resident will be responsible for helping you to achieve the educational goals we have set for you and to provide feedback on a regular but informal basis. After your first day you will begin your day by doing follow-up work at the U of C Hospitals before meeting for rounds with the whole team.

During your C/L rotation your schedule will be from 8am -5pm. Your time will be dedicated, primarily, to performing initial consults and follow-up work. You are encouraged to attend all of your didactic teaching while on rotation with us. If there is an anticipated absence it is your responsibility to inform the team no later than the first day of the rotation. On the first day of the rotation, after general orientation you will join the team by contacting the PGY-II resident (pager # 6504)

In performing the initial consultation you will follow the 10 steps outlined in the attached lecture. Consults will be assigned in an even distribution of labor and on a rotating basis by the resident. You are encouraged to do the write up of your psychiatric assessment of the patient on the universal form which will become part of the patient’s permanent medical record. Formulation, diagnostic impression and treatment recommendations should be completed only after full discussion with the Attending and the team. In your daily follow-up note you are encouraged to adhere to the SOAP format.

During rounds you will be expected to do an oral presentation on the patient evaluated by you, to the team using the Bio-Psycho-Social and Development format.  Presentation of cases is encouraged to develop communication skills and a facility in integrating medical and psychiatric data in thinking about cases.

You will be observed while performing a psychiatric evaluation on at least two occasions, initially at towards the beginning of your rotation and thereafter in the second three weeks of your C/L experience.

 

Communication is critical to the performance of excellent GHPC work. As a key team member this is certainly true for you. However, it is critically to understand that as a student all patient information will of necessity be shared with the team and patients need to be made aware of this. Additionally, while it is standard of care to obtain collaborative information from family members and community physicians this must be accomplished with the patient’s permission and this must be documented in the medical record. At all times the standards of patient confidentiality and clear keeping of boundaries must be observed. A good rule of thumb is to discuss and concerns you have with the resident or attending.

 

The educational curriculum to be followed during your six week rotation mirrors that of the residents. (See attached). The learning objectives have been outlined. Your reading requirements are in your primary textbook (Sadock and Sadock: Synopsis of Psychiatry 9th Edition). Additionally, you may receive didactic materials (lectures, articles, and recommended reading) as appropriate to the week of the curriculum (e.g. anxiety and associated disorders, week 1 etc.) Additionally, you will attend a weekly multi-disciplinary case-conference (Fridays at 12 noon). You may be expected to present a case from your patient case load to highlight the topic of the week (e.g. delirium) or at Professor’s rounds at 12 noon on Wednesday. You will have the opportunity to meet weekly with the Chief Resident in C/L to discuss cases, perform observed interviews and trouble shoot as necessary.

You will not take an examination specific to your rotation in C/L but you will be tested in the field of psychosomatic medicine as part of your overall end-of rotation examination.

At the end of the rotation evaluation of your clinical performance will be based on input from the resident and attending.

 

There is an inevitable buildup of evidence which points to the multi-factorial (physical, psychological, social) nature of illness in terms of etiology, diagnosis and treatment.

The experience in  General Hospital Psychiatry Consultation allows you the opportunity to become comfortable in performing diagnostic psychiatric interviews, in eliciting psychiatric symptoms, in becoming familiar with the diagnostic criteria for psychiatric syndromes as outlined in the Diagnostic and Statistical Manuel (DSM-IV) and in beginning to formulate treatment plans. This skill set will prove invaluable in your future as a physician.

 

Welcome and we hope you enjoy you experience as a General Hospital Psychiatry Consultation team member enormously!!!!!

 

FOR RESIDENTS:

 University of Chicago General Hospital Psychiatry Consultation

 

Description of Curriculum for Residents in General Hospital Psychiatry Consultation

 

This curriculum is developed according with the recommendations for Consultation-Liaison Psychiatry Training in Psychiatry Residency programs and developed by the Academy of Psychosomatic Medicine  (APM)(1).

It is also developed to incorporate the General competencies for resident training in psychiatry set for the by the Accreditation Council for General Medical Education (ACGME) (2).

 

What follows is a list of topics to be taught which have been characterized as Category 1 topics in the guidelines developed for residents in C-L psychiatry by the APM. Category 1 topics are classified as topics essential for all general psychiatrists and thereby should be addressed during the C-L rotation. Further topics are classified as Category 2 and Category 3 topics and are considered valuable and more advanced accordingly. A complete list of these topics is contained in the attached guidelines.

 

Category 1 Topics

Topic is considered essential knowledge for all general psychiatrists and should be covered during the C-L rotation in every program.

Acute Stress Disorders
Aggression/Impulsivity
AIDS/HIV Disease
Alcohol and Drug Abuse in the General Medical Setting (including withdrawal states)
Anxiety in the General Medical Setting
Determination of Capacity and other Forensic Issues in C-L Psychiatry
Coping with Illness
Death, Dying, and Bereavement
Delirium/Agitation
Dementia in the General Medical Setting
Depression in the General Medical Setting
Factitious Disorders and Malingering
Pain
Personality Disorders in the General Medical Setting
Psychiatric Manifestations of Medical and Neurological Illness
Psychological Factors Affecting Medical Conditions
Psycho-Oncology
Psychopharmacology of the Medically 111 (including drug interactions)
Psychotherapy of the Medically Ill
Somatoform Disorders
Suicide

 

 

 

It is proposed to address the topics outlined below in several ways.
 

Topics will be covered during the successive 8 weeks of the rotation as follows

 
1: Introduction, Process of doing a consultation, coping with illness
 
2: Anxiety Disorders, Stress Disorders, Somatoform Disorders
 
3: Mood disorders, Death, dying and bereavement,

4: Delirium, Dementia, Agitation

5: Substance use disorders, personality disorders, Impulsivity

6: Psycho-oncology, AIDS/HIV Disease, Pain

7: Determination of Capacity and other Ethical and Legal issues in C-L Psychiatry

8: Psychopharmacology of the medically ill, Psychotherapy of the medically ill.

 

For each topic week a teaching will be provided and residents/trainees will be encouraged to pursue other sources of information (web-based, articles, recommended reading). During the week cases relevant to the topics under consideration will receive special attention at the bedside during rounds. Additionally, trainees will be encouraged to develop case presentations on the week’s topics to be delivered and reviewed at the weekly multi-disciplinary case conference. Feedback on the learning experience will be encouraged to help in the ongoing development of this curriculum.

At the end of the rotation residents will be evaluated very specifically, on the development of their knowledge base in the field in addition to their openness and willingness to acquire knowledge.

It is anticipated that a course in Psychosomatic Medicine will be taught to augment the experience gained during the C-L rotation.

The six competencies identified for resident training in psychiatry by the ACGME are patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems based practice. The curriculum in C-L psychiatry is designed to address the “medical knowledge” competency specifically in the field of General Hospital Consultation Psychiatry. To enhance the achievement of competency in this field in keeping with the ACGME guidelines, residents will be strongly encouraged to apply a questioning and investigatory approach to each topic. Additionally, every effort will be made to incorporate epidemiology, social science, behavioral science and biomedical information with the clinical information being taught.

A useful “cheat sheet” to help focus on what is exactly meant for each of the above competencies is also attached.

 

It is fully appreciated that it is not possible to comprehensively “cover” each of the topics listed as Category 1 topics in the short time span of an 8 week rotation. However, it is hoped that awareness of the importance of each of these topics in the psychiatric care of the medically ill-hospitalized patient in addition to the experience gained on the service will generate the curiosity and form the basis for a lifetime of learning in this enormously exciting and relevant field!

 

 

 



Last Updated on 06/24/03
By Nancy Welsh
Email: nwelsh@yoda.bsd.uchicago.edu