PGY4 Consultation-Liaison Psychiatry

Rotation Director: Jason Cooper, M.D.

Location: Ventura County Medical Center

Clinical and Educational Work Hours:

M-F
7:00 a.m.-5:00 p.m.
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.

Educational Purpose:

This assignment builds on the knowledge and experience from the PGY2 year. Additional responsibilities such as leading the consult-liaison team, and acting as a teacher to junior residents and medical students are also expected. The goal is to master how to evaluate the patient in a consultative role and ensure that appropriate care, recommendations, and disposition are 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 Ventura County Medical Center. 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 are required to be in hospital from 7:00 am to 5:00 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:

1. 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.

2. 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).

3. 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.

4. Thoroughly formulate a patient’s case based upon the above information, with particular consideration to perspectives of disease, temperament, behaviors, and life story.

5. Comprehensively assess self-injury risk, risk of injury to others, dangerousness and appropriate use of constant observation.

6. Accurately assess medically ill patients for capacity to make medical decisions (competency).

7. 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.

8. 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.

9. Remain aware of the overall medical status of the patient and general disposition plans as the patient’s hospital course proceeds.

Medical Knowledge:

1. Strive for mastery of knowledge of the indications for a variety of somatic therapies in medical and surgical patients.

2. Strive for mastery of the use of psychotropic medications in medical and surgical patients and appreciate physiologic effects, contraindications, drug interactions, and dosing concerns.

3. Strive for mastery of the use of psychosocial treatments, including supportive psychotherapy, behavioral management techniques, family therapy, and psychoeducation as they apply to the medical patient.

4. Strive for mastery of knowledge of risk factors, recent precipitants, classical and atypical presentations, screening tests, etiologies, appropriate medical evaluation, and comprehensive treatment strategies of delirium.

5. Effectively advise medical and surgical teams on appropriate use of antipsychotics and benzodiazepines in agitated patients.

6. Know how to perform a comprehensive evaluation for organic causes of psychiatric symptoms or syndromes.

7. Know which medications have psychiatric symptoms as side effects.

8. Understand classes of or specific drug interactions between psychotropic medications and non-psychotropic medications.

9. Know the appropriate indications and dosing strategies for psychostimulants in the medically ill.

10. Know clinical settings which further justify continued medical or surgical inpatient admission while a patient’s disposition is coordinated.

11. Know the appropriate use, risks and benefits, and dosing strategies of psychotropic medications in pregnancy.

12. Understand Serotonin Syndrome and its evaluation and management.

13. Understand Neuroleptic Malignant Syndrome and its evaluation and management.

14. Understand core concepts of decisional capacity and the legal process that may be invoked once a patient has been deemed incompetent.

Systems Based Practice:

1. The psychiatry resident will demonstrate a thorough understanding of the role of the Consult Liaison Team in providing care versus providing consultation to the medical/surgical services and will work effectively and collaboratively with consulting teams.

2. The psychiatry resident will “run” the Consult Liaison team, supervising students and managing consults and assignment of patients to other residents.

3. The psychiatry resident will demonstrate a thorough understanding of outpatient resources to effectively continue psychiatric management after discharge.

4. The psychiatry resident will demonstrate a thorough understanding of the legal system as it applies to the commitment of the medical patient.

5. The psychiatry resident will educate the non-psychiatric ward staff about psychological issues affecting patients for whom consultation is requested.

Practice Based Learning:

1. 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.

2. The resident will perform a literature search, when appropriate, to better understand the most current treatment options.

Professionalism:

1. Dress in professional business attire at all times.

2. Arrive on time and stay until all work is completed or appropriately transitioned to another provider.

3. Behave collegially and demonstrate willingness to help other members of the team and other departments.

4. Assist with and ask for assistance in the case of emergencies or clinical uncertainty.

5. 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.

6. Demonstrate a commitment to ethical principles when dealing with patients, families, and colleagues.

7. Provide role modeling and supervision for the off-service residents and medical students.

Interpersonal and Communication Skills:

In addition to the Interpersonal and Communication Skills enumerated under the PGY2 CL Rotation, the PGY4 CL resident will accomplish the following:

1. The resident will provide supervision of and teaching to medical students, psychiatry residents and non-psychiatry residents on the CL service.

2. The resident will further interdepartmental alliances by serving as a respected medical colleague in the hospital and attending multidisciplinary task-specific meetings about problematic cases.

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 a half-day throughout their PGY4 year.

Residents will be assigned to one of the following Faculty Members or other designated physicians:

Jason Cooper, M.D. (Primary)

Vanessa Hernandez, 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.