Learning Objectives for Inpatient Psychiatry Ward Rotations

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1 Learning Objectives for Inpatient Psychiatry Ward Rotations Educational Purpose Inpatient training in adult psychiatry is designed to enable house officers to achieve the knowledge, skills and attitudes of competent general adult psychiatrists. In the course of their inpatient rotations at HUP, PAH and the PVAMC, residents are expected to gain proficiency in the diagnosis and management of inpatient psychiatric issues. Learning occurs through hands on, supervised clinical experiences, amplified by bedside teaching. Teaching rounds occur 5 days per week and are designed to reinforce the etiology, pathogenesis, clinical presentation and natural history of mental disorders treated by general psychiatrists; demonstrate appropriate skills in diagnosis, judgment and resourcefulness in therapy; receive instruction and feedback to master interviewing, communication and interpersonal skills that are necessary to elicit and record a thorough and accurate history, establish and maintain a therapeutic physician-patient relationship, and initiate or motivate the patient to implement optimal management; receive instruction and feedback to master mental status exam skills; demonstrate the humanistic treatment and care of patients. The average PGY1 and PGY2 spend 4 and 5 months respectively on the inpatient psychiatry services at HUP, PAH and the VA. Patient Characteristics/Disease Mix: The combination of 3 clinical sites affords a unique opportunity to experience the breadth of psychiatry. HUP is both a community hospital as well as a tertiary and quaternary referral center. The patient population is drawn from surrounding West Philadelphia, a working class population with large number of unemployed and homeless people. A network of community mental health centers, the primary care network and outpatient psychiatry practices of the University of Pennsylvania Health System and the University of Pennsylvania provide a large referral base for both common and uncommon presentations of serious mental disorders. In addition, HUP is a regional and national leader for many types of care from referrals nationwide. There are 3 acute inpatient psychiatry ward services at HUP: mood disorders, geriatric psychiatry and neuropsychiatry. PAH, the oldest hospital in the United States is predominantly a communitybased hospital serving the South and Center City Philadelphia communities. The patient population reflects the upper middle class, working class, indigent and homeless. The PVAMC is a large veteran s hospital that cares for patients with a large number of co-morbidities, psychosocial problems and HIV disease. Procedures: Diagnostic evaluation Residents have the opportunity to acquire skills of comprehensive diagnostic assessment of mental disorders as they present in the inpatient setting. Evaluation skills include gathering accurate, thorough data regarding present symptoms, course of illness, past medical and psychiatric history (including prior treatment), and the impact of the disorder(s) on patient and family functioning. Formulation of the patient s psychopathology into a multiaxial and biopsychosocial framework, and ongoing evaluation of patient symptoms and course of illness are considered to be essential procedures.

2 Psychopharmacologic management Residents have the opportunity to learn how to administer psychotropic medications in a safe and effective manner including selecting appropriate agents, educating patients about the risks and benefits of these medications, monitoring efficacy and side effects, and adjusting or altering medications as indicated. Psychotherapy Residents have the opportunity to learn to implement inpatient psychotherapy techniques including (but not limited to) empathic listening, supportive-expressive therapy, crisis intervention, cognitive behavioral therapy, psychodynamic brief therapy, couples and family intervention. Electroconvulsive Therapy (ECT) - Residents have the opportunity to learn how to administer ECT under the supervision of the faculty of the ECT service. Principal Teaching Methods/Learning Venues: Listed below are the principle educational goals for the Inpatient Psychiatry rotations for all 3 sites. Each goal is listed as a function of the six ACGME competencies. The second column of the table indicates the most relevant principal teaching method/learning venue for each goal, using the legend below. Intern/Resident Pre Rounds (IRPR) mark the arrival of the intern or resident at the hospital between 7:00 AM and 8:00 AM in order to "preround" on their own patients before Morning Report and Attending Rounds. Morning Report (MR) run from 8:00 AM until 9:00 at HUP. These rounds consist of interns and residents along with a designated teaching faculty member reviewing key principles of acute psychiatric care, emergency room patient management, professionalism and teaching of medical students. This is a major educational forum and a time when residents are expected to review mental status exam findings, discuss literature and practice evidence-based psychiatry. Multidisciplinary Care Rounds () occurs between 9:15-9:30 and includes nursing, clinical resource managers and social workers. The goal is discharge planning. Attending rounds (AR) run from 9:00-11:00 am daily. In addition 30 minutes of core didactic material time is also spent reviewing clinical details of patient management and teaching at the bedside. There is a strong emphasis in separating the service/management issues from the more formally structured teaching. Residents are encouraged to define the goals and objectives of teaching rounds each month and use time outside of these rounds for review of clinical details related to the patients on their service. Attending Supervision (AS) occurs two hours weekly at each hospital. One hour is set aside for the attending on service to review the intern or resident s performance and discuss issues of clinical care, team management, and communication skills. Another

3 hour of supervision is provided by a faculty preceptor who reviews issues of professional development. Psychiatry Grand Rounds (GR) occurs each Tuesday at noon. It features national, regional and local experts in all aspects of Psychiatry as well as many other disciplines. The content spans basic science and clinical psychiatry. Professors rounds (PR) occur weekly on 1 service at each hospital. It is typically run by the chief resident and invited teaching faculty and is focused on interviewing and formulation skills. Didactics (DID) occur weekly on Wednesday afternoons at a centralized location. Attendance at these seminars is mandatory. See next section for listing of topics covered. by Relevant Competency In the tables below, the principal educational goals of the floor rotation are highlighted for each of the six ACGME competencies. The second column of the table indicates the most relevant principal teaching/learning activity for each goal, using the legend below. * Legend for Learning Activities (See above for descriptions) DPC - Direct Patient Care AR - Attending Rounds AS-Attending Supervision PR - Professor's Rounds GR - Grand Rounds MR Morning Report IRPR-Intern/Resident Pre-rounds IS Interviewing Seminar DID Didactics -Multidisciplinary Care Rounds 1) Patient Care Evaluation and Assessment Skills Interview patients skillfully Create and sustain doctor patient relationships that maximize the likelihood of the best outcomes for patients and the greatest personal satisfaction for physicians. Define and prioritize patients' psychiatric problems and develop a comprehensive data base Generate and prioritize a full differential diagnoses Make a comprehensive formulation of patient s problems DPC, AR, AS, PR, IS, DID DPC, AR, IS, DID DPC, IRPR, IS DID, DPC, IRPR DPC, IRPR, IS

4 Evaluate suicidal and homicidal potential DPC, AR, PR, IRPR, MR, IS, DID Treatment Skills Develop rational, evidence-based management strategies Convey diagnosis and formulation to patient and family Prescribe medications safely and effectively Evaluate ongoing treatment effectively Respond appropriately to medical and psychiatric emergencies DPC, IRPR, DID DPC, IRPR, DID DPC, IRPR, DID ALL DPC, IRPR, DID, 2) Medical Knowledge Gain knowledge about relevant medical illnesses and medicalpsychiatric differential diagnosis Gain knowledge about the epidemiology, natural history, neurobiology psychology and systems aspects of major psychiatric disorders Gain knowledge about the indications for psychiatric treatment Gain knowledge about psychopharmacologic agents, indications, side effects and interactions IRPR, GR, DID IRPR, GR, DID IRPR, DID IRPR, GR, DID Gain knowledge about psychotherapies, indications and potential pitfalls IRPR, GR, IS, DID 3) Practice-Based Learning and Improvement Use supervision and feedback to improve interaction with patients and family members ALL Develop and implement strategies for filling gaps in medical knowledge, AR, AS, MR, IRPR diagnostic and treatment skills using supervision and feedback

5 Demonstrate the ability to consult the medical literature as needed to Improve knowledge base and care of patients Demonstrate facility in using electronic data bases, literature retrieval services and computer-based diagnostic reasoning programs. Participate in quality improvement activities appropriately AR, AS, MR, IRPR, DID IRPR, DID AR, AS, 4) Interpersonal Skills and Communication Communicate effectively with patients and families Communicate effectively with physician colleagues at all Communicate effectively with all non-physician members of the health care team to assure comprehensive and timely care of hospitalized patients Present patient information concisely and clearly, verbally and in writing Know how to inform patients and obtain voluntary consent for the general plan of psychiatric care and specific diagnostic and therapeutic interventions DPC, AR, AS, PR, MR, IRPR, IS, DID DPC, AR, AS, PR, MR, IRPR, IS, DID DPC, IRPR, IS, IRPR, IS, IRPR, DID, 5) Professionalism Behave professionally and ethically toward towards patients, families, colleagues, and all members of the health care team Understand one's own personal reactions to difficult situations in order to understand potential barriers to professionalism Demonstrate appropriate demeanor, appearance and attire ALL IRPR, IS, DID, ALL

6 6) Systems-Based Practice Document medical observations in a timely and accurate fashion Understand and utilize the multidisciplinary resources necessary to care optimally for hospitalized patients Collaborate with other members of the health care team to assure comprehensive patient care Use evidence-based, cost-conscious strategies in the care of hospitalized patients, including test ordering and scheduling IRPR, DID, IRPR, IRPR, DID, by PGY level In addition to the above goals by competency, each level of training also has specific goals as it relates to each rotation. PGY 1 Provide direct care for 4-6 patients on the inpatient psychiatry wards, including all order writing, test ordering, relevant procedures and timely documentation. Conduct comprehensive evaluations of all new patients and ongoing assessments of currently hospitalized patients. Participate in treatment decisions and monitoring the impact of all interventions. Function as an integral team member and communicate effectively with other members of the health care team. Participate in effective work rounds. Supervision of 1-2 core medical students each month, including modeling and teaching oral presentation and documentation skills as well as history taking and mental status exam skills. Consult current medical literature and apply relevant findings to patient care decisions. Enhance general psychiatric knowledge by attending at least 70% of required departmental conferences, including morning report. PGY2 In addition to PGY 1 skills, Provide leadership viz. the educational content of resident teaching and attending rounds, including the liberal use of literature for the practice of evidence based medicine. Run effective work rounds. Develop feedback skills designed to improve the performance of medical students and interns.

7 Participate in quality assurance activities. Further enhance general psychiatric knowledge by attending at least 70% of required departmental conferences, including morning report, grand rounds and didactics. PGY4: Function as a junior attending for the inpatient team, including assisting the attending in running inpatient service, managing daily patient care activities, teaching residents and medical students, and providing leadership to team multidisciplinary care rounds. Supervision of 1 intern or resident student each month, including modeling and teaching effective skills of patient care including but not limited to time management, medical decision making and clinical problem solving. Enhance feedback and evaluation skills. Enhance teaching skills. Function as role models and mentors for younger trainees. Develop a comprehensive approach to learning based on self assessment of gaps in fund of knowledge Lines of Responsibility for and Supervision of Patient Care All core medical students on this rotation are supervised by PGY 1 and PGY 2 residents. The PGY 1/2 is responsible for verifying patient information collected by and communicated from each medical student. This includes a daily review of any chart documentation. All subintern medical students are by PGY 2 residents. The PGY 2 is responsible for verifying patient information collected by and communicated from the medical student. This includes a daily review of any chart documentation. The PGY 1 and 2 residents on the team reports directly to their assigned attending psychiatrist. The attending psychiatrist has responsibility for all patients under the care of their assigned PGY 1/2 residents. This includes daily review of all aspects on patient care. The attending psychiatrist is responsible for supervising all members of the team in accordance with the institutional policy on Attending supervision. Recommended Educational Resources All residents are expected to read about their patients in an appropriate general psychiatry text. Because it is frequently updated, extensively referenced, and includes abstracts of referenced articles, the program highly recommends UpToDate as a primary resource. UpToDate is available at all 3 sites on the UPHS network. The reference shelf from the Biomedical library is also available online. Additional educational resources include the didactic conference curriculum, primary review of studies, as well as the review of microscopic and gross pathology.

8 Evaluation Methods A competency-based evaluation matrix is available at the end of the curriculum. The evaluation methods that apply to these rotations include: Web enabled competency-based evaluation forms that are completed by faculty, peers and students when applicable. Monthly Observed Clinical Assessment (MOCA) Patient logs In-training examination (PRITE) scores 360º evaluations PQIP

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