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Behavioral/Mental Health

Behavioral/Mental Health Longitudinal Experience Educational Goals & Objectives

Mental illness is prevalent in the general population and is commonly seen and treated in the office of the primary care provider. Educational experiences in mental health are designed to provide residents with an opportunity to evaluate and treat patients with mental disorders. The goal is for residents to feel comfortable with a wide range of mental disorders, behavioral issues, and stress-related problems that manifest as primary disorders or exacerbate underlying medical conditions. This longitudinal educational experience will take place in the outpatient setting over all 3 years of residency and during a dedicated PGY2 Behavioral/Mental Health rotation. The focus will be on identifying risk factors for early diagnosis, managing chronic common psychiatric illnesses, recognizing warning signs for serious psychiatric morbidity, such as suicide, and understanding indications for referral to a psychiatrist. Residents will be able to identify signs of underlying organic medical disorders, learn an appropriate diagnostic workup, develop basic skills in counseling and behavior modification, understand the initial pharmacologic management of psychiatric disease, and understanding indications for referral to a psychiatrist, psychologist, or other mental health professional.

Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

I. All residents must be able to provide compassionate, culturally-sensitive, and appropriate care for patients with mental disorders.

  • PGY2s should seek directed and appropriate medicine or subspecialty consultation when necessary to further patient care.
  • PGY3s should supervise and ensure seamless transitions of care between primary and consulting teams and between inpatient and outpatient care.

II. Residents will demonstrate the ability to take a pertinent psychiatric history, including substance use and family psychiatric histories, and when appropriate, developmental history. Residents will be able to perform a focused physical exam, with emphasis on the mental status and neurologic exams.

  • PGY1s should be able to do a screening medical exam for patients requiring mental health hospitalization.
  • PGY1s should be able to differentiate between patients with stable and unstable psychiatric symptoms.
  • PGY1s should know the psychiatric review of systems for depression - SIGECAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal thoughts), and for mania – DIGFAST (Distractibility, Indiscretion, Grandiosity, Flight of Ideas, Activity increased, Sleep decreased, Talkativeness)
  • PGY2s should be able to differentiate between neurologic and psychiatric disease.
  • PGY3s should be aware of psychiatric manifestations of systemic organic disease.

III. Residents will demonstrate knowledge of the indications, contraindications, limitations, risks, benefits, and appropriate timing for the following procedures:

  • Electroconvulsive therapy

IV. Residents will demonstrate knowledge of gender dysphoria and be able to counsel patients and/or families, as many people with gender dysphoria also experience mental health conditions.

Medical Knowledge

I. PGY1s will develop an understanding of the basic pathophysiology and approach to the following conditions:

  • Agitation or otherwise altered mental status
  • Alcohol or substance abuse
  • Anxiety
  • Change in personality or performance
  • Chronic pain
  • Cognitive impairment and memory loss
  • Delirium
  • Delusions or bizarre beliefs
  • Elevated or depressed mood
  • Insomnia
  • Mental retardation
  • Paranoia
  • Poor hygiene or self-care
  • Reaction to an acute emotional stressor, such as death in the family
  • Strange speech or behavior
  • Suicide risk
  • Unexplained physical symptoms suggesting somatization

II. PGY2s will also develop an understanding of the pathophysiology, clinical presentation, DSM-5 criteria for diagnosis, and therapy for the following psychiatric conditions:

  • Adjustment disorders
  • Anxiety and Panic disorders
  • Attention Deficit Hyperactivity Disorder in adults
  • Bipolar disorders
  • Dementia
  • Dissociative disorders
  • Eating disorders
  • Impulse control disorders
  • Major depressive disorder and dysthymia
  • Obsessive compulsive disorders
  • Personality disorders and somatization
  • Post-traumatic Stress Disorder
  • Seasonal Affective Disorder
  • Schizophrenia
  • Sexual dysfunctions

III. PGY3s will also demonstrate knowledge of

  • which medical illnesses are associated with an increased risk of depression
  • psychiatric manifestations of systemic diseases, such as HIV, Parkinson’s disease, pernicious anemia, seizure disorder, syphilis, stroke, and thyroid disease
  • substances that may provoke or exacerbate mental disorders, such as alcohol, anticholinergic medications, benzodiazepines, fluoroquinolones, recreational drugs, and steroids
  • appropriate use of psychiatric medications, including drugs of first choice, dosing, side effect profile, contraindications, drug interactions, and patient follow up
  • herbal medications used by patients to treat psychiatric disease

IV. Residents will become familiar with the evaluation and treatment of acute mental health conditions, including:

  • Acute abstinence syndrome or withdrawal
  • Conversion disorder
  • Drug overdose
  • Dystonic reaction
  • Neuroleptic Malignant Syndrome
  • Panic attack
  • Psychosis
  • Serotonin syndrome
  • Suicidal or homicidal ideation
  • Violence or extreme agitation

V. Residents will understand the effective use and interpretation of the following tools:

  • Alcohol Single-Question Screener
  • Brief Patient Health Questionnaire (PHQ-9 and 5-item tool to screen for panic disorder)
  • CAGE questionnaire
  • Depression inventory
  • HIV Dementia Scale
  • Mini Mental State Examination
  • Mood Disorder Questionnaire

VI. Residents will understand the impact of chronic medical illness and mental health disorders on patients’ families.

VII. Residents will learn basic tenets of law specific to patients with mental disorders:

  • PGY1s should understand that there are legal implications involving the care of patients with mental health disorders, and understand the definition of a 5150
  • PGY2s should become familiar with definitions of competence, 5250, and Tarasoff, and with legal obligations with respect to reporting suspected child/elder abuse and/or neglect
  • PGY3s should also understand bioethical concepts such as autonomy, capacity, and surrogate decision-making and their impact on patient care.

VIII. PGY1s will understand the basic indications for ordering and the interpretation of the following laboratory values and procedures:

  • B12 or MMA
  • Drug levels
  • Electroencephalography
  • Folic acid
  • Neuroimaging with CT and/or MRI
  • Neuropsychologic evaluation
  • Screen for toxins, heavy metals
  • Thyroid function tests
  • VDRL, FTA, RPR

PGY2s will order and interpret the above laboratory and diagnostic studies in more complex cases.

PGY3s will independently, appropriately order studies and be able to interpret results within the context of patient comorbidities, pretest probability of disease, and patient values.

Practice-Based Learning and Improvement

I. All residents should be able to access current national guidelines to apply evidence-based strategies to patient care.

II. PGY2s should develop skills in evaluating new studies in published literature, through Journal Club and independent study.

III. All residents should participate in case-based therapeutic decision-making, involving the primary care provider and psychiatrist. Residents should learn to coordinate patient care as part of a larger team, including the nurse, pharmacist, psychologist, crisis team, and social worker to optimize patient care, and PGY3s should take a leadership role.

IV. All residents should respond with positive changes to feedback from members of the health care team.

Interpersonal and Communication Skills

I. PGY1s must demonstrate organized and articulate written (electronic) and verbal communication skills that build rapport with patients and families, convey information to other health care professionals, and provide timely documentation in the chart.

II. PGY2s must also develop interpersonal skills to cope with challenging patients and to be able to discuss sensitive topics with patients and their families.

III. PGY3s should develop effective personal coping strategies for dealing with the stress of caring for challenging patients with mental disorders.

Professionalism

I. All residents must demonstrate strong commitment to carrying out professional responsibilities as reflected in their conduct, ethical behavior, attire, interactions with colleagues and community, and devotion to patient care.

II. PGY1s should be able to set aside preconceived notions regarding mental health patients and educate patients in a manner respectful of gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation on choices regarding their care.

III. PGY2s should be able to use time efficiently in the clinic to see patients and chart information.

IV. PGY2s should be able to counsel patients and families both on diagnostic and treatment decisions.

V. PGY3s should be able to provide constructive criticism and feedback to more junior members of the team.

Systems-Based Practice

I. PGY1s should understand that mental illness contributes to comorbidity in their patients with chronic medical illness, increased use of health care resources, and higher cost of care.

II. PGY2s must be able to identify systemic barriers to care for patients with mental illness and understand the effectiveness, differing costs, and risks of different mental health treatment strategies.

III. PGY2s should understand the impact of insurance status on patient access to mental health services and be aware of the availability of case workers, community resources, dual diagnosis resources, and geropsychiatry resources to maximize care.

IV. PGY3s must demonstrate an awareness of and responsiveness to established quality measures, risk management strategies, and cost of care within our system.

Teaching Methods

I. Supervised patient care, primarily in the outpatient setting.

  • Residents will initially be directly observed with patients, to facilitate the acquisition of excellent history taking and physical exam skills.
  • As residents become more proficient, they will interact independently with patients and present cases to faculty
    • Initial emphasis will be on diagnosis and basic management
    • When residents have mastered these skills, focus will be on medical decision-making, and residents will work with supervising physicians to finalize a care plan.

II. Conferences

  • Specialty-specific didactics

III. Independent study

Evaluation

I. Verbal individual feedback

II. 360 Evaluation

III. Attending written evaluation of resident at the end of each semester based on observation and chart review.

Procedure

I. Residents will spend their time in clinic under the direction of our faculty psychiatrist. Since the spectrum of mental illness is broad, to meet the above educational goals residents will have exposure to the diagnosis and treatment of more acute mental health conditions on the inpatient medicine service.

  • Residents will be involved in discussion of patient presentation, differential diagnosis, and treatment.
  • If the same patient returns to the clinic, the resident should see the follow-up
  • Residents may be asked to do focused literature searches or presentations during the course of the rotation.
  • Residents may be asked to communicate with patients, family members, primary care providers, and consulting providers as is appropriate. Discretion and decorum is always paramount.
  • When doing consults, ensure the resident understands the question asked and provides a concise answer.

II. Residents should attend group therapy sessions and psychological evaluations as appropriate to gain an understanding of their role in treating patients.

III. Call and weekend responsibilities TBD by the attending physician.

  • Hours worked must be consistent with ACGME requirements and are subject to approval by the Program Director.

IV. Residents have specialty-specific didactics and should be excused in a timely fashion to attend.