PGY2 Consultation-Liaison Psychiatry

Rotation Director: Dustin Sanchez, M.D.

Location: Santa Barbara Cottage Hospital

Clinical and Educational Work Hours:

7:00 a.m.-7:00 p.m. daily except Wednesdays, Rotating Weeks

Monthly work hours will be submitted in the New Innovations software program. Total hours
worked for that month will be compiled and the weekly average must not exceed eighty hours
per week averaged over a 4-week period, inclusive of in-house night call. Clinical and
educational work hour violations will be closely reviewed and addressed by the Program
Director.

Residents shall not work in excess of 24 consecutive hours. Allowances for already initiated
care, transfer of care, educational debriefing and formal didactic activities may occur, but shall
not exceed 4 additional hours and must be reported by the resident in writing with rationale to
the Program Director and reviewed by the GMEC for monitoring individual residents and
programs.

Residents will have 48-hour periods off on alternate weeks, or at least one 24-hour period off
each week, and shall have no call responsibility during that time. Wednesday is reserved for didactics and local psychiatry clinic.

Educational Purpose:

To learn about the presentation and disposition of a variety of psychiatric patients seen in a
medical setting. To learn how to evaluate the patient in a consultative role and ensure that
appropriate care, recommendations, and disposition is achieved.

Teaching Methods:

For each interaction, the resident will spend sufficient time with the patient to carry out
an appropriate psychiatric evaluation and then discuss the case with the faculty. The
learning experience surrounding a patient interaction evolves from review of history,
physical examination and laboratory results with faculty. Faculty will provide guidance
and direction to the resident as well as references or other learning materials to facilitate
the resident’s learning experience. The resident will also learn, under supervision, how to
interact with patients, families, and other members of the care team and how to
collaborate to provide an appropriate disposition for the patient.

Disease Mix and Patient Characteristics:

The majority of patients are over age 18 years and many are without health insurance.
Caring for this patient population provides residents with a unique experience in dealing
with the challenges of patients with few resources.

Responsibilities and Procedures:

Residents will perform psychiatric consultations on patients hospitalized at Santa Barbara
Cottage Hospital. Individuals may be hospitalized for different reasons, including for a primary
medical reason after a suicide attempt. Residents, under the guidance and direction of the
psychiatry attending, will coordinate the evaluation and disposition of the patient. Residents are
expected to communicate with the referring physician and case management to ensure optimal
patient care.

Resident consultations include the performance and documentation of a complete psychiatric
evaluation and must include obtaining all pertinent collateral information from external sources
(emergency responders, friends, family, etc.).

Residents are required to carry a cell phone with a HIPAA-compliant texting program, in
addition to being available at their assigned work station for staff communication. Residents will
be required to be in hospital from 7:00 am to 7:00 pm so that they may address all consultations
and clinical situations as they appear. Faculty expect residents to return calls in a timely manner
to address concerns regarding patients.

Residents will attend the formal weekly didactic sessions, Grand Rounds, Journal Clubs, and
Morbidity and Mortality sessions.

Overall Goals and Objectives:

To develop a basic understanding of the skills needed to evaluate and manage the psychiatric
consultation of a medical patient.

Core Competencies:

Patient Care:

Fully gather data from all available sources, including the patient, paper and electronic chart (including physician’s notes, nursing staff notes, social work notes, other staff member notes, medication administration records), hospital staff, and family or friends of the patient.
Adapt interview style to suit the clinical setting and medical and/or psychiatric condition of the patient (i.e. communicate effectively with patients on ventilators, recognize stress and fatigue in patients, communicate effectively with difficult or agitated patients, prioritize questions and perform multiple, brief interviews if necessary).
Ascertain all required information related to patient’s family history, personal history, substance history, premorbid personality, allergies, past medical history, current medications, review of systems, detailed past psychiatric history, detailed history of present illness (including history of present medical illness), and mental status examination, including cognitive examination.
Thoroughly formulate a patient’s case based upon the above information, with particular consideration to perspectives of disease, temperament, behaviors, and life story.
Comprehensively assess self-injury risk, risk of injury to others, dangerousness and appropriate use of constant observation.
Accurately assess medically ill patients for capacity to make medical decisions (competency).
Perform routine follow up of already evaluated patients, monitor the patient’s course during hospitalization and provide continuing input (both pharmacologic and psychotherapeutic) as needed to the patient and treating team.
Accurately and fully document all elements described above on the resident physician consultation form as well as in the patient’s chart, including medical and legal facets, when necessary.
Remain aware of the overall medical status of the patient and general disposition plans as the patient’s hospital course proceeds.

Medical Knowledge:

Learn about the indications for a variety of somatic therapies in medical and surgical patients.
Learn about the use of psychotropic medications in medical and surgical patients and appreciate physiologic effects, contraindications, drug interactions, and dosing concerns.
Gain understanding about the use of psychosocial treatments, including supportive psychotherapy, behavioral management techniques, family therapy, and psychoeducation as they apply to the medical patient.
Gain understanding about the risk factors, recent precipitants, classical and atypical presentations, screening tests, etiologies, appropriate medical evaluation, and comprehensive treatment strategies of delirium.
Learn how to effectively advise medical and surgical teams on appropriate use of antipsychotics and benzodiazepines in agitated patients.
Gain experience in how to perform a comprehensive evaluation for organic causes of psychiatric symptoms or syndromes.
Learn about which medications have psychiatric symptoms as side effects.
Learn about classes of, or specific drug interactions between, psychotropic medications and non-psychotropic medications.
Gain experience in the appropriate indications and dosing strategies for psychostimulants in the medically ill.
Gain understanding in clinical settings which further justify continued medical or surgical inpatient admission while a patient’s disposition is coordinated.
Gain understanding in the appropriate use, risks and benefits, and dosing strategies of psychotropic medications in pregnancy.
Gain understanding of the clinical syndrome of serotonin syndrome and appreciate its evaluation and management.
Gain understanding of the clinical syndrome of NMS and appreciate its evaluation and management.
Understand the differences between somatization disorder, conversion disorder, factitious disorder, and malingering.
Gain understanding of core concepts of decisional capacity and the legal process that may be invoked once a patient has been deemed incompetent.
Be fully trained in treatment and infection control protocols and procedures (e.g. personal protective equipment [PPE]) and trained clinically to properly recognize and care for COVID-19 patients.

Systems Based Practice:

Gain an understanding of the role of the Consult Liaison Team in providing care versus providing consultation to the medical/surgical services, and work effectively and collaboratively with consulting teams.
Gain an understanding of outpatient resources to effectively continue psychiatric management after discharge.
Gain an understanding of the legal system as it applies to the commitment of the medical patient.

Practice Based Learning:

The resident will participate in all conferences and complete all required reading to better understand and frame patients’ issues in a scientific evidenced based manner.
The resident will perform a literature search, when appropriate, to better understand the most current treatment options.

Professionalism:

Dress in professional business attire at all times.
Arrive on time and stay until all work is completed or appropriately transitioned to another provider.
Behave collegially and demonstrate willingness to help other members of the team and other departments.
Assist with, and ask for, assistance in the case of emergencies or clinical uncertainty.
Maintain a thorough list of current patients being followed on the consultation service and address current medications and other pertinent issues for patients and the treating team.
Demonstrate a commitment to ethical principles when dealing with patients, families, and colleagues.

Interpersonal and Communication Skills:

Facilitate the consulting service’s ability to formulate a clinical question relevant to our skillset to aid in the care of the patient.
Directly and promptly reply verbally to the consulting service the clinical impression of the patient as well as specific treatment recommendations and guidelines.
Document in the medical chart all follow up evaluations of patients remaining on the service, including subjective matters, mental status exam, and cognitive examination (if needed in follow up), as well as continued assessment and ongoing recommendations.
Advise and guide consulting services about the role of medical disease in a patient’s presentation, further diagnostic testing required to clarify the clinical picture, and recommended medications.
Advise and educate consulting services about the current diagnostic assessment of the patient and, if applicable, how it may be distinguished from the working diagnosis prior to psychiatric consultation.
Work as a valued member of a multidisciplinary staff to optimize care of complex medically ill patients.
Provide appropriate direction to consulting services regarding management of dangerous, agitated, and/or psychotic patients who are treated on the general medical floor.
Develop a therapeutic alliance with the patient, while respecting their privacy.

Transitions of Care:

All consults are required to be discussed with the referring resident or attending by the end of the
day. End of rotation handoffs require I-PASS.

Evaluation Methods:

The supervising attending will provide verbal feedback to the resident midway through the
rotation and formally evaluate the resident at the completion of the rotation using the Consult
Liaison New Innovations evaluation form. Attendings will assesses the resident’s mastery of
psychiatry core competencies and are encouraged to comment more specifically on the resident’s
performance.

The supervising attending will receive the evaluation the last week of the rotation. They must
complete the evaluation and discuss it with the resident prior to the completion of the rotation.
If a resident receives an unsatisfactory score, the information is communicated to the psychiatry
program director to ensure additional resident education and informal or formal remediation if
indicated.

Residents are also required to evaluate both their rotation and their preceptor at the completion of
the month.

Duration:

The resident will be assigned to the Consult Liaison service for 2-3 months in their PGY2 year.
Residents will be assigned to one of the following Faculty Members or other designated
physicians:

Dustin Sanchez, M.D. (Primary)

Paul Erickson, M.D (Coverage)

Educational Materials/References:

Comprehensive Textbook of Psychiatry—Kaplan and Sadock (various chapters as assigned by
attendings)

Resident Resources:

The resident has access to VCMC resident workrooms that have a desk and computer in the
Inpatient Psychiatric Unit adjacent to the main hospital building.