Author's Accepted Manuscript
Recommendations for Training Psychiatry Residents in Psychosomatic Medicine Thomas W. Heinrich MD, Ann C. Schwartz MD, Paula C. Zimbrean MD, Sermsak Lolak MD, Mark T. Wright MD, Kristen B. Brooks MD, Carrie L. Ernst MD, David F. Gitlin MD
PII: DOI: Reference:
S0033-3182(13)00248-X http://dx.doi.org/10.1016/j.psym.2013.12.016 PSYM425
To appear in:
Psychosomatics
Cite this article as: Thomas W. Heinrich MD, Ann C. Schwartz MD, Paula C. Zimbrean MD, Sermsak Lolak MD, Mark T. Wright MD, Kristen B. Brooks MD, Carrie L. Ernst MD, David F. Gitlin MD, Recommendations for Training Psychiatry Residents in Psychosomatic Medicine, Psychosomatics, http://dx.doi.org/ 10.1016/j.psym.2013.12.016 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Recommendations for Training Psychiatry Residents in Psychosomatic Medicine Guidelines from the Academy of Psychosomatic Medicine’s Residency Education Subcommittee Authors Thomas W. Heinrich, MD Department of Psychiatry and Behavioral Medicine Medical College of Wisconsin 8701 Watertown Plank Road Milwaukee, Wisconsin 53227 414.955.8958
[email protected] Ann C. Schwartz, MD Emory University School of Medicine
Paula C. Zimbrean, MD Yale School of Medicine Sermsak Lolak, MD Stanford University School of Medicine
Mark T. Wright, MD Medical College of Wisconsin
Kristen B. Brooks, MD Kaiser Permanente
Carrie L. Ernst, MD Icahn School of Medicine at Mount Sinai
David F. Gitlin, MD Brigham and Women's Hospital
Abstract The Accreditation Council of Graduate Medical Education (ACGME) mandates that residents in psychiatry training programs learn to provide psychiatric consultation to other 1
medical and surgical services. The ACGME, however, offers little information to instruct academic faculty and institutions to what constitutes a quality educational experience in psychosomatic medicine/consultation‐liaison psychiatry for the resident trainee. A consultation‐liaison rotation that is viewed positively by residents is important as it likely provides a foundation for a growing interest in Psychosomatic Medicine and the development of future fellows and subspecialty trained physicians. It is with the goal of providing a broad framework for what constitutes a well‐rounded clinical and academic resident rotation in psychiatric consultation‐liaison services that the Academy of Psychosomatic Medicine’s Residency Education Subcommittee established the following guidelines for training residents in psychosomatic medicine.
Key Words Core competencies, residency training, psychosomatic medicine, trainee, consultation‐ liaison psychiatry, supervision
Introduction The training of psychiatry residents in the field of Psychosomatic Medicine is vital if we are to develop future generations of physicians who are competent to care for patients suffering from co‐morbid medical and psychiatric conditions. A quality rotation in Consultation‐Liaison (C‐L) Psychiatry during residency training will likely strengthen the practice of Psychosomatic Medicine by both improving the care of patients by general psychiatrists and increasing the flow of residents into psychosomatic medicine fellowship programs. Residents in psychiatry often discover their interest in the field of psychosomatic medicine during a superior consultation‐liaison rotation. This interest usually starts with exposure to remarkable cases, quality clinical supervision, and skilled professional mentorship. An awareness of the importance of providing excellent care at the interface of medicine and psychiatry can be further nurtured by attention to fundamental structural aspects of the rotation such as assuring exposure to a wide variety of clinical experiences, continuity of care, and a comprehensive curriculum.
History Historically, there have been several surveys to assess C‐L training practices. The first national survey of training in psychiatric consultation in non‐psychiatric medical settings was published in 1966.1 In this survey, Mendel found that 75% of 202 residency education centers did offer some training in consultation techniques, but most of the training was conducted in an informal manner through supervised experience. The questionnaire responses indicated that the majority of psychiatry physicians in training were receiving inadequate preparation in consultation psychiatry. Brook2 surveyed the 2
training of a highly selected group of psychiatrists in England, who had finished their training through 1963‐1969. This survey found that many programs failed to provide adequate supervision in ward consultation in a general hospital compared with other psychiatric training experiences. A follow‐up to the Mendel survey conducted by Schubert and McKegney3 was designed to identify any shifts in residency training over the prior decade, considering the increased emphasis on the psychosomatic training of non‐psychiatrist physicians as well as an increased emphasis on training psychiatrists to function within a general medical health care setting. Ninety two medical schools (81% of those surveyed) responded to a one‐page questionnaire on the teaching of C‐L psychiatry to psychiatric residents, medical students, and other trainees. Psychiatric residency programs reported devoting approximately 10% of their time to C‐L training, a slight but definite increase in the amount of C‐L training as compared to the 7% ten years ago.1,3 However, the total residency training time spent in C‐L still represented a smaller percentage of time compared to that devoted to other experiences in training programs. A recent survey of directors of general psychiatry residencies revealed a wide variety in the structure and educational content of C‐L rotations during post‐graduate psychiatry training.4 Although the resident’s exposure to the practice of consultation‐ liaison psychiatry met the Accreditation Council for Graduate Medical Education’s (ACGME) basic requirement, the educational experience was often suboptimal because C‐L rotations were commonly part‐time and fragmented throughout multiple years of residency training. In addition, resident supervision was often not performed by a faculty psychiatrist with sub‐specialty training and/or board‐certification in psychosomatic medicine.
Current Requirements and Previous Professional Organizations’ Recommendations In the United States the components of residency and fellowship training are overseen by the Accreditation Council for Graduate Medical Education. The ACGME Program Requirements for Graduate Medical Education in Psychiatry include the six core competencies (Figure A).5 The core skills required for a general psychiatric resident in psychosomatic medicine are alluded to throughout psychiatry’s program requirements, but psychosomatic medicine is only explicitly mentioned under Medical Knowledge, in which there is a required two month full‐time equivalent period to be spent consulting to other medical and surgical specialties.6 The Academy of Psychosomatic Medicine (APM) last published recommendations for training residents in consultation‐liaison psychiatry in 1996.7 This report clearly delineated goals and objectives for residents rotating on a consultation liaison psychiatry 3
service. The report also provided recommendations for topics to be included in a consultation‐liaison curriculum. The recommended curriculum content was categorized into three levels based on educational importance: Essential, Valuable, and Advanced. APM Task Force of Residency Education, which was first convened in 1992, outlined that the overall goal of a resident’s rotation in C‐L psychiatry was the development of a basic competence in working with patients who have a psychiatric presentation in a medical setting. It was suggested that upon completion of the rotation, the resident should display the capacity to engage effectively in the clinical consultation and liaison process, perform an appropriate psychiatric examination of medically ill patients, and develop a suitable therapeutic intervention. Structurally the rotation should consist of discrete blocks of time. These block rotations should consist of no less than a 3‐month full‐time equivalent (FTE) with the resident present on service greater than 50% of the time during the rotation. The resident should perform no fewer than 50 consultations during the course of the C‐L rotation. Given the complexity of the patients seen on the C‐L Service it was recommended that residents rotate on C‐L during their PGY‐III or IV years, when they are more experienced. The Task Force also recommended that residents be supervised by faculty with C‐L expertise who are on‐service and providing supervision daily. They further recommend a ratio of 1 FTE faculty to 1.5‐2 FTE residents. The European Association of Consultation‐Liaison Psychiatry and Psychosomatics (EACLPP) published guidelines for training in consultation‐liaison psychiatry for European psychiatric and psychosomatic residents in 2007.8 These recommendations were developed by a workgroup of twenty C‐L specialists representing 14 European countries. The report detailed recommendations for both psychiatry resident level training and advanced fellowship training in C‐L psychiatry and psychosomatics. The key consensus recommendations for residency training included comments on duration, location, and timing of the C‐L rotation along with acceptable staffing models. Similar to the 1996 APM report,7 the EACLLP also outlined certain areas of specialty‐related knowledge, skills, and attitudes in which a resident in psychiatry should display competence.
Structural Issues Length of Rotation As previously mentioned, the Psychiatry Residency Review Committee (RRC) of the ACGME requires that psychiatry residents spend a minimum of two months (or its part time equivalent) in psychosomatic medicine training.6 This is in contrast to historically published guidelines that have recommended C‐L rotations lasting up to six months or longer.7 Based on clinical and educational experience coupled with prior recommendations, the authors believe that the length of C‐L exposure should be no less than a 3‐month full‐time equivalent rotation. In addition, the resident rotating on the inpatient C‐L service should be present on service no 4
less than 30 hours/week. If an outpatient rotation is the trainee’s primary exposure to C‐L psychiatry, it should be a minimum of 6 months in duration to maximize the possibility of continuity of care. However, it should be stated that currently there is no objective evidence showing that exposure to psychosomatic medicine beyond the RRC mandated two months improves performance on standardized examinations, professional performance, or increases the percentage of residents choosing to pursue fellowship training in psychosomatic medicine. It is likely that the appropriate length of residents’ psychosomatic medicine rotations will need to be determined by each residency program individually, based on factors such as service demands, feedback from faculty and graduates of the program, and residents’ performance on the psychosomatic medicine portion of the PRITE exam. Ideally, residents who wish to receive more training in psychosomatic medicine than that required by the RRC and their residency program will be able to pursue this extra training during their elective time. If possible, the resident’s C‐L experience should be in consecutive months. This “block schedule” allows for optimal continuity of care and consolidation of the required skills and knowledge during the rotation. Programs that utilize the more part‐time “longitudinal” rotation schedule must take care to ensure that the resident’s clinical and educational experience is not further fragmented by other trainee responsibilities. In addition, the numerous transitions of care inherent in this part‐time model places additional significance on appropriate “hand‐offs” of clinical responsibility between rotating residents to ensure adequate clinical care of the patients.
Year of Rotation The effective provision of psychiatric services in the general medical setting requires expertise gained through experience in the physician’s role as well as training and experience in both general psychiatry and medicine. Previous residency training guidelines have suggested that residents should be in the later stages of their training and have completed some training in neurology, inpatient psychiatry, emergency psychiatry, chemical dependence, and general medicine prior to training in psychosomatic medicine.7,8 In addition, the impact of duty hours restrictions on clinical rotations is often less for senior residents as in‐house call frequency decreases. Therefore it seems prudent to continue to recommend that psychosomatic medicine rotations occur at the later stages of training. It is, however, important to allow residents to have at least an overview of the subspecialty before they must make career decisions on whether or not to pursue fellowship training. If a second‐year rotation is required due to competing residency requirements, consideration should be given to the resident spending additional time on a Psychosomatic Medicine Service during the PGY‐III or IV year. This additional exposure to psychosomatic medicine as a senior resident may allow the resident to better solidify his or her C‐L knowledge 5
and maximize his or her appreciation of the field of psychosomatic medicine. In addition, adequate mechanisms must be in place to guarantee that junior residents rotating on a C‐L receive full supervision by faculty for all cases due to the inherent complexity of the patients seen on these services.
Clinical Volume of Cases While there is likely a minimum number of consultations required for a psychiatry resident to achieve competency in psychosomatic medicine, the actual number may vary depending on the nature of the service, the patient population, the complexity of cases, and the individual resident. Previous guidelines recommended that each resident perform 50‐100 new consultations during the rotation period to ensure adequate exposure.7,8 Although exposure to a good number of cases is important for a resident to truly experience the subspecialty of Psychosomatic Medicine, it will not be the total number of consults performed that determines the trainee’s clinical competence. It will most likely be determined by multiple interdependent aspects of the rotation, including but not limited to quality of supervision, variety of cases, and clinical setting. As a result, we feel that the program should aim to provide the residents with adequate supervision and a diverse patient population that they may utilize to develop the necessary competencies in C‐L psychiatry. Programs that require residents to see too many consults may adversely affect the quality of their learning and impair their acquisition of the necessary skills to obtain residency‐ level competence in psychosomatic medicine. Supervisors must be aware of the trainee’s clinical workload and determine how it is impacting learning, but given the number of factors that influence workload (volume, complexity, liaison, etc.) it is felt to be overly simplistic to merely limit the number of consults performed by the trainee. There must be a healthy balance between education and clinical service.
Rotation Site(s) The principal training site should be a general medical hospital that treats a broad range of patients. The patient population ought to be culturally and socioeconomically diverse and present with a wide variety of medical and psychiatric problems. These types of clinical settings often provide the optimal exposure to a wide variety of clinical and educational experiences for residents. An ambulatory C‐L experience provides exposure to different patient populations and models of care and strong consideration should be given to including such experiences as part residency training. Models of outpatient C‐L psychiatry include a free‐standing psychosomatic medicine clinic, a psychiatric liaison clinic embedded in a medical home or primary care clinic, or medical/surgical subspecialty clinic. These models of integrated clinical care may 6
complement the inpatient C‐L experience and provide the resident with a unique perspective on service delivery. This outpatient model of clinical practice more closely reflects the future practice of a majority of psychiatry residents and, therefore, a thoughtful approach may be to include such clinical rotations within the trainee’s 12 month outpatient residency requirement and not limit these worthwhile clinical experiences to only the C‐L rotation. In addition, liaison experiences whether in a hospital setting (e.g., rounding with oncology team or ICU team) or outpatient setting (e.g., multidisciplinary team meeting for organ transplant program) can provide valuable collaborative learning opportunities for the residents. The ability of the resident to experience psychiatric liaison activities will enhance the overall C‐L rotation and improve the resident’s understanding of the C‐L process. However, this benefit is highly dependent on the culture of the institution and availability of experienced faculty supervision. Liaison experiences should be offered only if there is adequate faculty involvement to provide supervision and should not entirely replace a quality inpatient C‐L rotation. Broad exposure to a variety of patients and illnesses is particularly important and may be challenging for programs utilizing only specialty hospitals as their primary C‐L training site. Clinical settings, such as Veterans Administration hospitals or oncology centers, may by their very nature limit the types of patients evaluated and treated by the C‐L Service. This potential educational liability may be partially addressed by additional educational experiences in the areas in which the residents may be underexposed in these unique clinical settings. Programs that combine the C‐L and emergency psychiatry services into a single rotation should ensure adequate exposure to the C‐L experience. These combined rotations should only occur at sites in which the medical and psychiatric emergency departments are co‐located, ideally within the setting of a general medical hospital. While there may be a situation where seeing patients in the Emergency Departments can count as a C‐L experience, we agree with prior recommendations that the time spent consulting on patients in the Emergency Department not be counted towards the resident’s C‐L requirements.
Faculty Supervision Ideally, faculty on the C‐L service should have completed a C‐L fellowship or a combined residency in internal medicine‐psychiatry, family medicine‐psychiatry, neurology‐psychiatry, or pediatrics‐child psychiatry‐psychiatry and /or be board certified in Psychosomatic Medicine, but extensive clinical experience and expertise in C‐L psychiatry is acceptable. This standard is particularly important for the chief of the service. If the size of the program allows, it is preferable that residents are supervised by more than one C‐L faculty member. The residents’ experience working with multiple supervisors likely enhances their exposure to a diverse knowledge‐base, different expertise (clinical, research, and administrative), and various
7
approaches to the practice of C‐L psychiatry. It also improves the likelihood of an interested resident finding a potential mentor in the field of Psychosomatic Medicine. Similar to prior recommendations,7 faculty should be "on service" for a block of time and responsible for all educational and clinical aspects of their service. For an inpatient C‐L service this is similar to an inpatient hospitalist model of service coverage, but is also applicable to the outpatient setting in which a faculty supervisor has a longitudinal clinical liaison presence within the medical/surgical clinic. The service that has faculty alternating coverage depending on the day of the week offers less supervisory continuity. This can be an acceptable alternative only under the leadership of a clinical director who coordinates the various missions of the service in a cohesive fashion. The number of faculty will vary by service requirements but must be sufficient to provide for both adequate supervision and teaching of residents along with the provision of quality subspecialty clinical care. Typically, this should be a minimum of one full‐ time equivalent faculty member for 1.5‐2 full‐time equivalent trainees and/or mid‐levels professionals (e.g., psychiatric nurse practitioners). The addition of other trainees such as medical students, psychology interns, residents from other specialties, or psychosomatic medicine fellows will further increase the recommended level of faculty staffing. The presence of a psychosomatic medicine fellow on a C‐L Service must not detract from the resident’s educational experience. The fellow may supplement the faculties’ teaching and supervision of the residents rotating on the Service, but it is not acceptable for the residents to be solely supervised by the fellow.
Education Guidelines for Residents on C‐L Service The following suggested education and clinical supervision guidelines are updated from the 1996 APM guidelines7 and revised to incorporate the ACGME core competencies.5 (Table A) 1. All cases seen in consultation by the resident should be “staffed” by an attending physician in a timely manner, typically the same day or within 24 hours of the consult request. 2. Ideally, the attending psychiatrist should conduct bedside team rounds on a daily basis. “Table rounds” may compliment bedside rounds but are not an acceptable sole alternative to the clinical teaching that occurs at the patient’s bedside. 3. During the early part of each resident's rotation, the attending psychiatrist should find an opportunity to model the process of performing a psychiatric consultation. This ideally should include a discussion with the consultee, patient evaluation, formulation of a differential diagnosis, development of appropriate recommendations, and speaking with family members and/or clinical staff. 4. The supervising psychiatrist should find an opportunity to observe the resident complete an entire initial evaluation and observe the resident’s interaction with the consultee. 8
5. When possible, the attending psychiatrist should demonstrate leadership of a multidisciplinary team, facilitation of family and multidisciplinary team meetings, and provide interdisciplinary education on psychiatric issues. 6. The attending psychiatrist should read, edit, and co‐sign the resident’s initial consultation note and subsequent progress notes typically the same day or within 24 hours of the resident’s documentation. 7. Feedback on the trainee’s progress in developing the proposed competencies should be given on a regular basis. Supervision and feedback should occur face‐to‐face with the resident on a regular basis. Ideally this process should be formalized and allow for an ongoing dialogue with the resident on his or her performance and, if necessary, facilitate the development of a plan to address identified areas in need of improvement or remediation.
8. Didactic time during the C‐L rotation should be reserved for teaching C‐L topics and should complement the ongoing residency didactic program. Consideration should be given to including case conferences, journal clubs, quality assurance topics, and discussion of relevant issues in evidence‐based medicine to the educational curriculum of the C‐L rotation.
Core Competencies in Psychosomatic Medicine Although some of the following core competencies may be experienced and demonstrated outside of the of required C‐L rotation, they are felt to be fundamental to development of general psychiatry residents’ competence in psychosomatic medicine. Patient Care A. Perform an appropriate diagnostic assessment of patients in the general medical hospital or medical/surgical clinic • General diagnostic interview in diverse clinical settings • Focused physical and neurological examination • Neuropsychiatric evaluation including psychological/neuropsychological testing • Diagnostic studies (imaging, laboratory, EEG) B. Document a complete, concise, and useful consultation note • Data should be gathered from the appropriate sources. These sources may include, but are not limited to: medical records, hospital staff, clinic staff, family, outside mental health providers, and other relevant individuals. C. Monitor the patient’s course throughout the episode of care, whether a hospitalization or outpatient treatment, providing further guidance as appropriate D. Develop an appropriate differential diagnosis along with detailed treatment plan
9
•
Specific areas of attention include neuropsychiatric complications of medical/surgical illnesses and psychologic factors that affect medical/surgical conditions • Case formulation and treatment plan should utilize a biopsychosocial approach to the patient E. Assess and document the medically ill patient’s potential for dangerousness towards self or others Medical Knowledge Categories A‐F below are considered important for the education of general psychiatry residents and should be covered during the C‐L rotation, in both clinical experiences and didactics. Topics G‐I are considered advanced and/or of possible interest for residents. Programs should make every effort to offer exposure to the topics covered in these later categories: A. General psychiatric illnesses in the medical setting (i.e., depression, anxiety, personality disorders, etc.) • The resident shall demonstrate knowledge regarding: epidemiology of the disorder, etiology of the disorder (genetic, medical, sociocultural factors), phenomenology of the disorder, DSM diagnostic criteria, treatment, prognosis, experience of the illness, and explanation of the illness to the patients, family and other medical providers B. Psychiatric illnesses that manifest primarily in the medical setting (i.e., factitious disorder, malingering, somatic symptom disorder, etc.) • The resident shall demonstrate knowledge regarding: epidemiology of the disorder, etiology of the disorder (genetic, medical, sociocultural factors), phenomenology of the disorder, DSM diagnostic criteria, treatment, prognosis, experience of the illness, and explanation of the illness to the patients, family and other medical providers C. Psychiatric manifestations of medical/surgical illness (i.e., delirium, disorders secondary to general medical conditions, neuropsychiatric side effects of medical treatments, etc.) • Residents shall demonstrate knowledge regarding: epidemiology of the disorder, etiology of the disorder (genetic, medical, sociocultural factors), phenomenology of the disorder, DSM diagnostic criteria, treatment, prognosis, experience of the illness, and explanation of the illness to the patients, family and other medical providers • Residents shall demonstrate knowledge of the neuropsychiatric side effects of the most commonly prescribed medical treatments 10
D. Psychiatric co‐morbidities associated with specific medical/surgical illness (i.e., HIV, end stage renal disease, cancer, etc.) • Residents shall demonstrate knowledge in the epidemiology of psychiatric co‐morbidities of specific medical illness, phenomenology of the disorder, effective treatment strategies, impact of the psychiatric problems upon medical illness, course and prognosis E. Psychiatric treatment modalities in the medical setting (ECT, psychopharmacology, psychotherapy) • Residents shall demonstrate knowledge of clinical indications and appropriate prescribing/delivering practices related to age, gender and ethnocultural variations. • Residents shall demonstrate knowledge of the pharmacological action (pharmacodynamic properties), potential side effects, appropriate dosing in patients with medical illness, and drug‐drug interactions (pharmacokinetic properties) of psychiatric medications commonly prescribed in the medical setting • Residents shall demonstrate knowledge in psychotherapies appropriate for the medical setting (motivational interviewing, brief cognitive‐behavioral therapy, supportive therapy) • Residents shall understand the appropriate roles of rapid tranquilization, 1:1 sitters, and physical restraints in the management and treatment of the agitated or dangerous patients in the medical setting • Residents shall demonstrate an appreciation of potential indications for electroconvulsive therapy in the medical setting F. Legal aspects of Consultation Liaison Psychiatry • Residents shall demonstrate knowledge in assessing the capacity to make decisions about medical treatment, interact appropriately with other hospital services involved in these matters (legal office, risk management, ethics committee). G. Psychiatric practice in specific medical or surgical settings (i.e., burn units, ICUs, transplantation service, OBGYN, etc.) • The resident shall demonstrate knowledge regarding: epidemiology, etiology (genetic, medical, sociocultural factors), and phenomenology of disorders along with treatments and prognosis specific to these subspecialty patient populations H. Psychiatric consultation and or liaison in the outpatient medical or surgical setting • The resident shall demonstrate knowledge regarding: epidemiology, etiology (genetic, medical, sociocultural factors), and phenomenology of the 11
disorders along with treatments and prognosis in patients evaluated and treated in an ambulatory medical or surgical setting I. Pediatric C‐L psychiatry • The resident shall demonstrate knowledge regarding: epidemiology of common childhood disorders along with the etiology (genetic, medical, sociocultural factors) and phenomenology of the disorder, DSM diagnostic criteria, treatment, prognosis, experience of the illness, and explanation of the illness to the patients, family and other medical providers • Residents shall be able to assess the developmental impact of medical care and hospitalization in pediatric patients with co‐morbid medical illness and interact appropriately with available resources Interpersonal and Communication Skills The C‐L rotation presents the opportunity to demonstrate interpersonal and communication skills at several levels: A. Communication with patient and families. The residents shall demonstrate the ability to communicate effectively with patients and family as demonstrated by: • Creating and sustaining a therapeutic alliance with patients and families • Respecting the patient’s cultural, ethnic and economic background along with their potential impact on the experience of the illness B. Serve as effective consultant to other medical specialists • Communicate effectively with the consultee to clarify the consultation question and degree of urgency of the request • Maintain the role of consultant • Communicate relevant findings and clear and specific recommendations (including discharge plans) • Respect the knowledge and expertise of the consultee C. Communicate and work effectively with nursing and other allied healthcare professionals D. Develop the ability to prepare clear verbal and written sign out instructions to their colleagues or other covering practitioners for periods when they are off the service Practice‐Based Learning and Improvement Residents must demonstrate an ongoing effort to investigate and evaluate their patient care practices, maintain and expand their knowledge and skills, appraise and assimilate scientific evidence, and improve their patient care practices through the following: A. Identify both strengths and deficiencies in one’s knowledge and expertise 12
B. Incorporate evaluation feedback into improvement and set learning and improvement C.
D. E. F.
goals Use information technology to obtain current information from the scientific literature, with the goal of ensuring ongoing practice improvement and optimizing the psychiatric assessment and care of medical, surgical, and obstetrical patients Facilitate the learning of other healthcare professionals and trainees through active participation in conferences, seminars, grand rounds, and in‐services Facilitate the learning of patients and their families through ongoing efforts at psychoeducation Demonstrate an ability to utilize clinical and scientific literature • Locate appropriate references utilizing a wide variety of sources (library, electronic databases, etc.) • Critically evaluate literature • Apply scientific and evidence based literature to the practice of psychosomatic medicine
Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles by demonstrating: A. Sensitivity and responsiveness to a diverse patient population, including diversity in gender, age, culture, language fluency, race, religion, disabilities, and sexual orientation B. Compassion, integrity and respect for medical, surgical, and obstetrical patients, their families, and other healthcare professionals C. Commitment to self‐evaluation and acknowledgment of errors D. Respect for patient privacy/confidentiality and autonomy E. Responsible behavior, including responding to communications from patients and healthcare teams in a timely manner F. Utilization of appropriate clinical hand‐offs to help ensure a safe transition of care G. Sensitivity to issues that uniquely arise in medical, surgical, and obstetrical settings, such as those pertaining to end‐of life care, involuntary medical or psychiatric treatment, and disagreements with other healthcare professionals about diagnostic assessment and treatment planning H. Understanding of palliative medicine and sensitivity to the issues of end of life care I. Respect for patients, patient’s families, and consultees J. Demonstration of ethical behavior • Informed consent • Confidentiality • Honesty 13
• Avoidance of conflict of interest • Maintenance of professional boundaries K. Responsible work habits • Timely and appropriate consultation and follow‐up • Appropriate documentation in medical records • Providing for coverage when unavailable • Coordinating care with other consultation team members and the medical/surgical team L. Accountability • Accepting of supervisory feedback • Recognition of knowledge deficits and attempting to actively correct these limitations • Commitment to excellence and ongoing professional development Systems‐Based Practice Residents must demonstrate an appreciation of systemic issues in the delivery of health care along with the ability to effectively call on system resources to provide optimal patient care through the following skills: A. Collaborate in a multidisciplinary treatment planning process to address patient‐related problems within a biopsychosocial framework B. Provide consultation in the settings of: general medical and surgical units; medical, cardiac, surgical, neurological ICU’s; hematology and oncology units; rehabilitation medicine C. Develop skills to work with organizational and administrative units of the general hospital, recognizing financial and political realities D. Understand the roles of different medical specialties and various levels of care professionals that provide patient care and how they interact in order to provide optimal care in the medical setting E. Understand the mental health resources available in the area and their role in the care of patients admitted to the general hospital F. Detect and correct the problems with communications between patients, mental health providers, and other medical providers G. Advocate for quality patient care and help patients through the complexities of the medical system H. Participate in educational events aimed at increasing the awareness of mental health issues among health professionals I. Work as a member of a multidisciplinary team to maximize care of complex medical and surgical patients 14
Practice cost effective health care K. Understand the various models of consultation and liaison psychiatry
J.
Assessment methods Residency programs must develop curricula and provide educational experiences to develop the six competencies, and programs must have reliable evaluation tools to assess the competencies.9 These assessments must occur in a timely manner and provide an objective assessment of the resident’s competence in these core competencies. At present, each residency program determines which assessment tools will provide the most accurate, constructive, and reliable data for resident evaluations. Ideally, the assessment results will guide further improvements in the development of individual residents as well as the educational programs.10 Several assessment tools are currently utilized, however there are no perfectly accurate and reliable evaluation instruments for evaluating the competencies in psychiatric training.10 In addition, one single evaluation tool or instrument many not be equally reliable or valid across all of the competencies.9 Assessment tools used on the C‐L service may include global ratings, 360‐degree assessments, direct observation, standardized written examinations (PRITE), and standardized clinical examinations.11 These tools all have their strengths and weaknesses. Global ratings are widely used in residency training, including the C‐L setting, and require evaluators to make global conclusions about the skills, knowledge, and behaviors of trainees. These evaluations are typically completed at the end of each rotation. While these are the most widely used evaluation tools, there tends to be much variation in the items on the evaluation forms as well as how different evaluators rate the trainees.10,12 Assessment by direct observation involves the faculty shadowing and directly observing residents performing clinical duties, followed by evaluating the competencies with checklists or with global ratings.10,13 The use of direct observation can be used in C‐L rotations and reasonable reliability can be achieved with adequate checklists. The limitations of this type of assessment include poor inter‐rater reliability, sampling bias, and the “Hawthorne effect” wherein residents are on their best behavior because they know they are being observed.10 Standardized written or oral examinations, such as the Psychiatry Residency In‐ Training Examination (PRITE), have limited validity but are most valid for evaluating the competencies of patient care, medical knowledge, and interpersonal communication.10,14 Individual performance on the consultation‐liaison questions can be examined in addition to the residents’ overall performance. The usefulness of the PRITE in this regard is often tempered by the fact that less than 10% of the examination is devoted to psychosomatic
15
medicine. Comparisons with other institutions, however, may help guide improvements in the training program, including the C‐L training experience. Standardized clinical examinations, such as standardized patient examinations and objective structured clinical examinations (OSCEs) can be useful in evaluating the competency of psychiatry residents. In these examinations, trained faculty observe and rate the residents’ performance with a detailed checklist. In particular, standardized clinical examinations can be valuable in evaluating professionalism and interpersonal skills, however are costly and time‐consuming which limit their use. 360‐degree instruments are a valuable assessment tool and lend themselves well to the assessment of patient care, interpersonal and communication skills, practice‐based learning, professionalism, and systems‐based practice.10 Ideally these assessments should be completed by multiple evaluators representing different aspects of the resident’s rotation and clinical work and could include input from staff, attendings, fellow residents, and occasionally patients.9 Detailed information from a variety of sources can be a powerful tool in identifying patterns of strengths and weaknesses as well as promoting resident self‐awareness.10 The clinical supervisor should directly discuss these evaluations with the resident and this conversation and resulting feedback carefully documented. For example, the social workers and nurses on the medical floors may have valuable insights into how the resident manages stressful situations and interacts with staff on a C‐L service (professionalism and interpersonal and communication skills) when not being directly observed by an attending.11 It should be noted that the ACGME has recently introduced the Next Accreditation System (NAS), an outcomes‐based accreditation process through which doctors are measured for competency.15 The NAS was implemented in July 2013 by 7 of the 26 ACGME‐accredited core specialties. Psychiatry is in Phase II of the NAS, and the milestones for graduate medical education in Psychiatry were released by the ACGME in November 2013 with implementation in July 2014. The educational milestones document the trainee’s progression through the six domains of clinical competence and are organized as a developmental progression, from Level 1 to Level 5. They begin with skills that a resident might exhibit in the initial days of the residency and progress to milestones expected of graduates, and end with milestones that might be demonstrated by an exceptional resident. 16 Principles of psychosomatic medicine are included throughout the milestones and there is a continuum of skills that need to be acquired over the course of training. One milestone is specific to the development of consultation skills. The Milestone SBP4 (Systems‐Based Practice) is titled “Consultation to non‐psychiatric medical providers and non‐medical systems and assesses trainees on skills.” This milestone assesses trainees in their knowledge of provider 16
roles related to consultation, care provided as a consultant and collaborator, and specific consultative activities such as the management of complicated and challenging consultation requests. Psychosomatic principles are also distributed throughout other milestones. For example, ICS1 (Relationship development and conflict management with patients, families, colleagues, and members of the health care team) might be a skill developed on a C‐L service.16 A more comprehensive review of the milestones as they relate to the training of residents in C‐L psychiatry is beyond the scope of this manuscript and should be addressed in future manuscripts.
Conclusions The resident who has the unique opportunity to witness the true breadth and depth of the art and science of psychosomatic medicine will be most likely to choose to pursue further training in this medical subspecialty. The C‐L rotation provides an unparalleled opportunity to teach trainees about the practice of psychosomatic medicine.17 However, residents must be prepared academically to appreciate C‐L psychiatry and the service must be structured in such a way as to maximize the educational experience. The resident must be senior enough in his or her psychiatric training to exhibit the clinical sophistication required care for these often complex patients. Supervision must be adequate for the acuity of the patients treated and should be provided by staff with appropriate training and/or certification in Psychosomatic Medicine. In addition, the resident’s rotation must be structured in such a way that there is sufficient time on service to see an adequate number of diverse cases and monitor the patients’ conditions longitudinally. We need to encourage this type of training in psychiatry residency. A comprehensive clinical and educational experience on a well‐staffed and managed academic consultation‐liaison psychiatry service will ensure the future of psychosomatic medicine. It is only through such measures that we, as a subspecialty, can effectively arm the next generation of psychiatrists with the knowledge, skills, and attributes to improve the care of patients at the interface of medicine and psychiatry. APM needs to be actively involved in residency education on multiple levels: institutional, professional societies (clinical and educational), and regulatory organizations. Training in C‐L psychiatry must be well represented in the six domains of clinical competencies that each trainee must master before graduation from residency. Active involvement in residency education will only enhance the subspecialty field of psychosomatic medicine. Disclosure Statement
17
The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. Acknowledgements We thank the following colleagues whose feedback contributed to the development of these guidelines: Philip Bialer MD, FAPM (Memorial Sloan‐Kettering Cancer Center) along with the members of the Academy of Psychosomatic Medicine’s Residency Education Subcommittee and Education Committee, past and present.
18
1
Accreddition Council for Graduate Medical Education (ACGME) Common Program Requirements. July 2013. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf: Last accessed 12/10/2013.
Figure A: The ACGME’s Six Core Competencies18 • • • • • •
Patient Care Medical Knowledge Practice‐based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems‐based Practice
Table A: Comparison of Training Guidelines
Sponsoring Organization
Process
Length of Training
Year of Training
Number of Consults
Prerequisite
Liaison
Gitlin et al, 199619
Sӧllner and Creed, 200720
Heinrich et al, 201421
APM
EACLPP
APM
1992: Survey of CL training 2001: Survey of CL directors of 196 psychiatry experts of 16 European countries; residency training programs; Expert consensus representing 14 APM task force then European countries developed guidelines
2010: Survey of 206 general psychiatry residency program directors; APM residency training subcommittee workgroup
Minimum is 3 months of FTE; Minimum 20 hours/week Ideal is 4-6 months of full time “block rotation”
Minimum of 6 months FTE
Minimum 3 months of FTE; Minimum 30 hours/week if part time; Minimum of 6 months, if outpatient CL is resident’s primary exposure
Most experienced residents available
Second half of residency
Later stage of training; If PGY2 rotation is required then consider additional time during later years
50 minimum; 100 ideal
100 referrals
Determined by core competencies
Rotations in neurology, inpatient psychiatry, emergency psychiatry, and chemical dependence
Expertise in general medicine (may obtain it as part of CL training)
Experience in both general psychiatry and medicine
Optional, but only if
Residents ideally
Outpatient liaison
19
Experience
Faculty Supervision
adequate supervision is available; Inpatient liaison time should be spent with one service
should be assigned to units with liaison service
rotation(s) complement inpatient consultation work and reflect changes in the practice of psychiatry
Full time faculty recommended; Minimum faculty/resident ratio is 1:1.5-2
Clearly designated supervisor; Clear duration and frequency of supervision
Exposure to multiple faculty members preferred; Minimum faculty/resident ratio is 1:1.5-2
Recommendations for advanced training (fellowship) in psychosomatic medicine
Residency level core competencies in psychosomatic medicine, assessment methods
Historical review of Additional guidelines on residency Information training in CL psychiatry Provided in the Article 1
Gitlin DF, Schindler BA, Stern TA, Epstein SA, Lamdan RM, McCarty TA, et al: Recommended guidelines for consultation-liaison psychiatric training in psychiatry residency programs. A report from the Academy of Psychosomatic Medicine Task Force on Psychiatric Resident Training in ConsultationLiaison Psychiatry. Psychosomatics 1996;37(1):3-11. 1 Söllner W, Creed F; European Association of Consultation-Liaison Psychiatry and Psychosomatics Workgroup on Training in Consultation-Liaison: European guidelines for training in consultation-liaison psychiatry and psychosomatics: report of the EACLPP Workgroup on Training in Consultation-Liaison Psychiatry and Psychosomatics. J Psychosom Res 2007;62(4):501-9. 1 Heinrich TW, Schwartz AC, Zimbrean PC, Lolak S, Wright MT, Brooks KB, et al: Recommendations for training psychiatry residents in psychosomatic medicine: Guidelines from the academy of psychosomatic medicine’s residency education subcommittee. Psychosomatics (hopefully)
20
1
Mendel WM: Psychiatric consultation education – 1966. Am J Psychiatry 1966;123:150-155. Brook P: The post-graduate education and training of consultant psychiatrists. Br J Psychiatry 1974;124:109-124. 3 Schubert DSP, McKegney FP: Psychiatric Consultation Education – 1976. Arch Gen Psychiatry 1976;33:1271-1273. 4 Heinrich TW, Schwartz AC, Zimbrean PC, Wright MT, Academy of Psychosomatic Medicine's Residency Education Subcommittee: The state of the service: a survey of psychiatry resident education in psychosomatic medicine. Psychosomatics 2013;54(6):560-6. 5 Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements. July 2013. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf: Last accessed 12/10/2013. 6 Accreditation Council for Graduate Medical Education (ACGME) ACGME Program Requirements for Graduate Medical Education in Psychiatry. July 2007. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/400_psychiatry_07012007_ u04122008.pdf: Last accessed 12/10/2013 http://www.acgme.org/acgmeweb/Portals/0/PFAssets/PIFs/400_PsychiatryNew_112007_u02292008.doc 7 Gitlin DF, Schindler BA, Stern TA, Epstein SA, Lamdan RM, McCarty TA, et al: Recommended guidelines for consultation-liaison psychiatric training in psychiatry residency programs. A report from the Academy of Psychosomatic Medicine Task Force on Psychiatric Resident Training in ConsultationLiaison Psychiatry. Psychosomatics 1996;37(1):3-11. 8 Söllner W, Creed F; European Association of Consultation-Liaison Psychiatry and Psychosomatics Workgroup on Training in Consultation-Liaison: European guidelines for training in consultation-liaison psychiatry and psychosomatics: report of the EACLPP Workgroup on Training in Consultation-Liaison Psychiatry and Psychosomatics. J Psychosom Res 2007;62(4):501-9. 9 Joshi R, Ling FW, Jaeger J: Assessment of a 360-degree instrument to evaluate residents’ competency in interpersonal and communications skills. Academic Medicine 2004;79:458-463. 10 Swick S, Hall S, Beresin E: Assessing the ACGME competencies in psychiatry training programs. Academic Psychiatry 2006;30:330-351. 11 Schwartz AC, Kotwicki RJ, McDonald WM: Developing a modern standard to define and assess professionalism in trainees. Academic Psychiatry 2009;33:442-450. 12 Swing S: Assessing the ACGME general competencies: general considerations and assessment methods. Acad Emerg Med 2002;9:1278-1288. 13 Shayne P, Heilpern K, Ander D, Palmer-Smith V; Emory University Department of Emergency Medicine Education Committee: Protected clinical teaching time and a bedside clinical evaluation instrument in an emergency medicine training program. Acad Emerg Med 2002;9:1342-1349. 14 Beresin E, Mellman L: Competencies in psychiatry: the new outcomes-based approach to medical training and education. Harvard Rev Psych 2002;10:185-191. 15 Nasca TJ, Philibert I, Brigham T, Flynn TC: The next GME accreditation system--rationale and benefits. N Engl J Med 2012;366(11):1051-6. 2
16
The Psychiatry Milestone Project, A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. November 2013. http://www.acgme-nas.org/assets/pdf/Milestones/PsychiatryMilestones.pdf: Last accessed 12/10/13. 17 Wei, MH, Querques J, Stern TA: Teaching trainees about the practice of consultation-liaison psychiatry in the general hospital. Psychiatr Clin N Am 2011;34:689-707. 18 Accreddition Council for Graduate Medical Education (ACGME) Common Program Requirements. July 2013. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf: Last accessed 12/10/2013. 19 Gitlin DF, Schindler BA, Stern TA, Epstein SA, Lamdan RM, McCarty TA, et al: Recommended guidelines for consultation-liaison psychiatric training in psychiatry residency programs. A report from the Academy of Psychosomatic Medicine Task Force on Psychiatric Resident Training in ConsultationLiaison Psychiatry. Psychosomatics 1996;37(1):3-11.
21
20
Söllner W, Creed F; European Association of Consultation-Liaison Psychiatry and Psychosomatics Workgroup on Training in Consultation-Liaison: European guidelines for training in consultation-liaison psychiatry and psychosomatics: report of the EACLPP Workgroup on Training in Consultation-Liaison Psychiatry and Psychosomatics. J Psychosom Res 2007;62(4):501-9. 21 Heinrich TW, Schwartz AC, Zimbrean PC, Lolak S, Wright MT, Brooks KB, et al: Recommendations for training psychiatry residents in psychosomatic medicine: Guidelines from the academy of psychosomatic medicine’s residency education subcommittee. Psychosomatics (hopefully)
22