PGY4 Atascadero State Hospital Forensic Psychiatry Rotation

Educational Purpose:

To provide residents with a comprehensive understanding and skill set in the field of forensic psychiatry, which may include the following subcategories; broad understanding of the legal system and its interactions with mental health, specialized assessments, deeper understanding of psychiatric and psychological issues encountered in forensic cases, and learning to collaborate with other professionals within the legal and criminal justice systems.

Teaching Methods:

For each interaction, the resident will spend sufficient time with the patient/evaluee 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, psychiatric examination and when indicated, imaging 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. Under supervision, the resident will also learn 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:

Patients are male over age 18 years, remanded for treatment by County Superior Courts or by the Department of Corrections and Rehabilitation. The commitment categories of patients treated are Incompetent to Stand Trial, Not Guilty by Reason of Insanity, Various Lanterman-Petris-Short Act Commitments, Offenders with Mental Health Disorders, and Mentally Ill Prisoners paroled from CDCR.

Responsibilities and Procedures:

Residents will perform psychiatric assessments on hospitalized patients. 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 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 (legal records, medical records, etc.).

Residents will be required to be in hospital from 8:00 am to 5:00 pm so that they may address all consultations and clinical situations as they appear. Faculty expect residents to return pages in a timely manner to address concerns regarding patients.

Residents will attend the formal weekly didactic sessions, Grand Rounds remotely and assigned conferences at the Host Institution as appropriate.

Overall Goals and Objectives:

To develop a basic understanding of the skills needed to evaluate and manage the psychiatric assessment/evaluation of those remanded for treatment by county superior courts or by the Department of Corrections and Rehabilitation (CDCR).

Core Competencies

Patient Care:

Psychiatry Residency Patient Care

1. Residents must demonstrate competence in the psychiatric evaluation of individuals with a history of the following; criminal behavior, criminal responsibility and competency to stand trial, dangerousness, sexual misconduct.
2. Residents must demonstrate competence in applying civil law and regulation of psychiatry issues when conducting a psychiatric evaluation of individuals with a history of the above
3. Residents must demonstrate competence in the treatment of justice-involved patients of different ages from diverse backgrounds, and from a variety of ethnic, racial, sociocultural, and economic backgrounds;
4. Be able to forge a therapeutic alliance with patients of different ages, from diverse backgrounds, and from a variety of ethnic, racial, sociocultural, and economic backgrounds;
5. Formulating a clinical diagnosis for patients by conducting patient interviews
6. Eliciting a clear and accurate history.
7. Performing a physical, neurological, and mental status examination, including use of appropriate diagnostic studies.
8. Completing a systematic recording of findings in the medical record
9. Formulating an understanding of a patient’s biological, psychological, behavioral, and sociocultural issues associated with etiology and treatment
10. Developing a differential diagnosis and treatment plan for patients with psychiatric disorders
11. Managing and treating patients using pharmacological regimens, including concurrent use of medications and psychotherapy
12. Managing and treating patients using both brief and long-term supportive, psychodynamic, and cognitive - behavioral psychotherapies.
13. Providing psychiatric consultation in a variety of medical settings.
14. Managing and treating chronically-mentally ill patients with appropriate psychopharmacologic, psychotherapeutic, and social rehabilitative interventions.

Medical Knowledge:

Psychiatry Residency Patient Care

1. Residents must demonstrate knowledge of forensic psychiatry, including: assessment of competency to stand trial, criminal responsibility, and civil competency; ethical, administrative, and legal issues in forensic psychiatry; evaluation and treatment of incarcerated individuals.
2. Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care
3. major theoretical approaches to understanding the patient-doctor relationship
4. biological, genetic, psychological, sociocultural, economic, ethnic, gender, religious/spiritual, sexual orientation, and family factors that significantly influence physical and psychological development throughout the life cycle
5. Fundamental principles of the epidemiology, etiologies, diagnosis, treatment, and prevention of all major psychiatric disorders in the current standard diagnostic statistical manual, including the biological, psychological, family, sociocultural, and iatrogenic factors that affect the prevention, incidence, prevalence, and long-term course and treatment of psychiatric disorders and conditions
6. diagnosis and treatment of neurologic disorders commonly encountered in psychiatric practice, including neoplasm, dementia, headaches, traumatic brain injury, infectious diseases, movement disorders, neurocognitive disorders, seizure disorders, stroke, intractable pain, and other related disorders
7. reliability and validity of the generally-accepted diagnostic techniques, including physical examination of the patient, laboratory testing, imaging, neurophysiologic and neuropsychological testing, and psychological testing
8. indications for and uses of electroconvulsive and neuromodulation therapies
9. history of psychiatry and its relationship to the evolution of medicine
10. legal aspects of psychiatric practice
11. aspects of American culture and subcultures, including immigrant populations, particularly those found in the patient community associated with the educational program, with specific focus on the cultural elements of the relationship between the resident and the patient, including the dynamics of differences in cultural identity, values and preferences, and power;
12. medical conditions that can affect evaluation and care of patients

Systems Based Practice:

Psychiatry Residency SBP

1. Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, including the social determinants of health, as well as the ability to call effectively on other resources to provide optimal health care..

Practice Based Learning:

Psychiatry Residency PBL

1. Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.
2. Residents must demonstrate competence in: identifying strengths, deficiencies, and limits in one’s knowledge and expertise; setting learning and improvement goals; identifying and performing appropriate learning activities; systematically analyzing practice using quality improvement methods, and implementing changes with the goal of practice improvement; incorporating feedback and formative evaluation into daily practice; locating, appraising, and assimilating evidence from scientific studies related to their patients’ health problems; and, using information technology to optimize learning.

Professionalism:

1. Residents must demonstrate a commitment to professionalism and an adherence to ethical principles.
2. Residents must demonstrate competence in: compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society, and the profession; respect and responsiveness to diverse patient populations, including but not limited to diversity in gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation; ability to recognize and develop a plan for one’s own personal and professional well-being; and, appropriately disclosing and addressing conflict or duality of interest.

Interpersonal and Communication Skills:

Psychiatry Residency ICS

1. Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.
2. Residents must demonstrate competence in: communicating effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds; communicating effectively with physicians, other health professionals, and health-related agencies; working effectively as a member or leader of a health care team or other professional group; educating patients, families, students, residents, and other health professionals; acting in a consultative role to other physicians and health professionals; and, maintaining comprehensive, timely, and legible medical records, if applicable.

Transitions of Care:

All consults are required to be discussed with the referring resident or attending physician 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 Forensic Psychiatry New Innovations evaluation form. Attending physicians 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.

Educational Materials/References:

The American Psychiatric Association Publishing Textbook of Forensic Psychiatry