Learning Objectives for Addictions Rotations

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1 Learning Objectives for Addictions Rotations Educational Rationale: The addictions rotations provides an opportunity for residents to evaluate and treat inpatients and outpatients with the major types of drug and alcohol addictions, from a wide variety of diagnoses and backgrounds, and learn to employ the full range of addiction treatment modalities. Patient Mix: The patient population in the inpatient unit at the VA Hospital is 95% male, almost entirely voluntarily admitted, and comes from the surrounding community. There is a high prevalence of dually diagnosed patients (approx 80-85%), including substance abuse and dependence that involves alcohol, cocaine, heroin, sedatives, marijuana, nicotine, and occasionally other intoxicants. Axis I comorbidity includes schizophrenia, schizoaffective and bipolar disorders, PTSD, acute and chronic depression, other anxiety disorders, sleep and sexual disorders, ADHD, and cognitive disorders. Axis II comorbidity is also common, including mostly borderline, narcissistic, paranoid, antisocial, and dependent disorders. Medical comorbidy is also very prevalent. At Pennsylvania Hospital and HUP, the patients are also drawn from the local community but include a higher proportion of tertiary referrals from the surrounding suburbs and contiguous states. Male/female ratio is closer to 50/50% and the prevalence of substance-related disorders is lower, but the prevalence of involuntary patients is higher than at the VA hospital. Procedures: Residents perform initial assessments to determine the appropriate addiction treatments. They perform detoxification procedures in both inpatient and outpatient settings, and use group, 12 step, and IOP modalities, as well as specialized psychopharmacology, to treat addictions. Principal Teaching Methods/Learning Venues: The curriculum in addiction psychiatry includes didactic, supervisory, and clinical care components. The principal teaching/learning activity is through direct patient care. Didactics and supervision are designed to complement and augment the learning through direct patient care. a) Didactics There are four main didactic experiences in addiction psychiatry. The PGY1 Crash Course introduces residents to the basics of addictions diagnosis and inpatient management, including detoxification. In the PGY2 year, Introduction to Psychiatric Diagnosis and Treatment covers the neurobiology,

2 course and psychopharmacology of addictions in more detail. Residents participate in monthly case conferences while on rotations at the VA with discussion of addictions cases by a senior faculty member. During the PGY3 year outpatient addictions rotation, residents attend the Monday Addictions Fellows Seminar at the Treatment Research Center. Finally, during the PGY3 year, residents attend the monthly didactic lunch seminar on Addiction Psychiatry lead by Alex McLean, MD. b) Supervision Each PGY1 and 2 resident on the 7 South Addictions rotation at the VA is supervised by Dr. Dhopesh on a weekly basis, and also receives supervision from either Charles O Brien, MD or Kyle Kampman, MD, both national addictions experts, on a weekly basis. PGY 1 and 2 residents rotating on 7 East (the general psychiatric unit at the VA) are usually supervised by Dr. Gregg Gorton, who is board-certified in Addiction Psychiatry. Each PGY3 resident on the outpatient rotation has weekly supervision by John Listerud, MD while at the Treatment Research Center. The supervision focuses primarily on addictions patient care, but addresses the more general issues in residency training, such as medical knowledge base, professionalism and systems-based practice. c) Clinical Inpatient residents rotate in one-month blocks on 4 separate inpatients at three hospitals, including: 7E (general psychiatry) and 7S (Dual Diagnosis and Addiction psychiatry) at the VA Hospital; 4 Spruce (general psychiatry) at Pennsylvania Hospital; and, Founders 11 (general psychiatry) at HUP. They are assigned a variety of patients, all with an acute reason for admission, and many with comorbid substance-related disorders. At the VA Hospital roughly 20% of patients are admitted for stabilization and detoxification, and these patients are quickly moved from the admitting ward (7E) to the Intermediate Care Dual Diagnosis and Addiction Unit (7S). Treatment consists of: comprehensive assessment; stabilization with medication and psychosocial interventions, including brief therapy, group therapy, family sessions, psychoeducation (videos and presentation/discussion groups), and self-help groups; coordinated multi-disciplinary team treatment that addresses medical needs (with medical consultants), psychiatric and addiction issues, and social issues (housing, financial & legal issues, short- and long-term rehabilitation placement). At any given time, residents on 7E may carry 4-6 patients with some form of substance-related disorder, whether active or in remission; residents on 7S may carry 6-8 patients all of whom have some form of substance-related disorder, and at least 50% of which have a comorbid Axis I and/or II disorder. Length of stay at the VA Hospital averages days; at HUP and Pennsylvania Hospitals, the stay is shorter, averaging about 6 days.

3 Principal Educational Goals by Relevant Competency In the sections below, the principal educational goals for addictions psychiatry rotations are listed for each of the six ACGME competencies. The second column of the sections indicates the most relevant principal teaching/learning activity for each goal, using the legend below: VAI VA 7 South Inpatient Unit Dual Diagnosis Intermediate Care unit; VA 7 East Acute General Psychiatric unit with high prevalence of Dually Diagnosed patients IP Other inpatient psychiatry units: Founders 11 and 4 Spruce VAO VA Outpatient Clinics, including Methadone Clinic, Addiction Recovery Unit GAP- General Ambulatory Practice (medication management clinic) GR- Grand Rounds HH/HM -- Horizon House community psychiatry rotation and Hall-Mercer Community Mental Health Center SUP Supervision DID- Didactics 1) Patient Care Develop effective working alliance based on empathic doctor-patient interaction, SUP Conduct a comprehensive diagnostic assessment and treatment formulation., SUP Provide competent clinical management, Psychopharmacological treatment, stages-of change Assessment, motivational interviewing, and brief or more extended psychotherapy, as indicated by clinical setting and patient needs, SUP 2) Medical Knowledge Demonstrate knowledge of the gamut of DID, substance-related disorders, including intoxication states, withdrawal states, use-abuse-dependence conditions, and substance-induced conditions such as mood disorders, delirium, dementia, psychoses, amnestic states, sleep and sexual disorders., SUP, GR, DID

4 Demonstrate knowledge of addiction, including: DID, theories of etiology, natural history, epidemiology, neurobiology, brain imaging findings, psychodynamic aspects, socio-cultural and spiritual aspects, and medical complications (including TBI, HIV, Hepatitis C, major organ system dysfunction, nutritional deficiencies)., SUP, GR, DID Demonstrate knowledge about the variety of psychopharmacological, psychotherapeutic, group, religious, and residential treatments., SUP, GR, DID Demonstrate knowledge about routine detoxification protocols, both inpatient and outpatient, and smoking cessation approaches., SUP, GR, DID Demonstrate knowledge of maintenance drug therapies, including naltrexone, buprenorphine, methadone, disulfiram, acamprosate, and nicotine replacements., SUP, GR, DID 3) Practice-based Learning and Improvement Use supervision and feedback to improve clinical skills., SUP, GR, DID Consult medical literature regularly to enhance knowledge base and explore research findings relevant to patient care so as to provide optimal evidence-based treatment., SUP, GR, DID Participate in quality improvement activities 4) Interpersonal and Communication Skills Demonstrate effective communicative and interactive skills with patients, families and other professionals. Demonstrate effective skills in interviewing and data-gathering, empathic attunement, boundary establishment and maintenance, and psychotherapy of various kinds.

5 Demonstrate effective communication and interaction with patients and families with a broad range of demographic, socioeconomic, ethnic, cultural, and religious backgrounds 5) Professionalism Maintain appropriate professional demeanor, attire, and time management in relationships with both patients and fellow professionals, including teachers and supervisors Demonstrate conduct with patients, families, that meets ethical standards, including establishing and maintaining appropriate boundaries, diligently meeting fiduciary responsibility, and seeking consultation 6) Systems-based Practice Demonstrate ability to implement preventive interventions HM, GAP with families and patients. Demonstrate ability to document clinical work, including basic historical data, differential diagnosis, treatment plan, clinical reasoning, ethical decision-making, and informed consent. Demonstrate ability to manage time appropriately, schedule and triage patients, and allocate other scarce resources appropriately. Principal Education Goals by PGY level PGY-1 Develop skills in evaluation and management of a diverse population of inpatients using a biopsychosocial framework.

6 Develop the ability to assess families and other system's involvement in inpatient's care, and provide basic family psychoeducation, as well as coordination of care with outpatient providers and agencies. Develop skills in treatment planning with a multi-disciplinary treatment team. Develop skills in collaborative team-treatment of inpatients. Develop basic skills in brief psychotherapy on the inpatient unit, including supportive, cognitive-behavioral, insight-oriented, and relaxational approaches. Provide continuous primary psychiatric care of a panel of acute dual diagnosis or addicted inpatients during their length-of-stay in the hospital. Develop skills in documentation of all aspects of clinical care. Develop ward-based time management skills. Competently present cases to supervisors, consultants and case conference discussants. PGY-2 Manage a panel of dually-diagnosed or addicted inpatients, with supervision by a faculty attending. Co-lead a group of dually-diagnosed, addicted, and general psychiatric inpatients along with a faculty co-leader. Collaborate in presenting cases to an off-unit supervisor who is an expert in addiction treatment. Demonstrate advanced skills in detoxification and stabilization of addicted patients. Demonstrate advanced skills in brief therapy of addiction, including motivational interviewing, empathic confrontation of denial, and ego-supportive, cogntiviebehavioral and insight-oriented techniques. PGY 3/4 Learn to evaluate for addiction during outpatient psychiatric initial evaluations and ongoing treatment. Learn to integrate addiction treatment into the treatment plan of patients being treated for other psychiatric illnesses.

7 Gain knowledge of and skills in implementing outpatient management of alcohol and benzodiazepine withdrawal including the use of benzodiazepines in treatment of withdrawal syndromes. Gain knowledge of and skills in implementing opiate withdrawal including the use of opiate agonists/partial agonists in the treatment of opiate withdrawal syndromes and the use of alpha-2 agonists Gain knowledge of and skills in implementing nicotine replacement strategies for nicotine withdrawal syndromes and medications for smoking cessation. Gain knowledge of and skills in implementing the use of a protocol withdrawal with phenobarbital for complex withdrawal syndromes. Gain knowledge of and skills in implementing maintenance of treatment, including use of pharmacology, individual psychotherapy, group psychotherapy/supports. Alcohol maintenance treatments include opiate antagonists, including short and long acting naltrexone, acamprosate, and disulfiram. Opiate maintenance treatments include methadone maintenance, buprenorphine/naloxone Gain knowledge of and skills in implementing non-pharmacological interventions in the outpatient setting including individual psychotherapty, motivational interviewing, assessing for readiness of change, group interventions such as Group psychotherapy, AA/NA/12-step process, and family interventions/ general techniques for involving family in the process of care.

8 Evaluation Methods The evaluation methods that apply to these rotations include: Web-access competency-based supervisor evaluation forms that are completed by faculty, peers and students when applicable. PRITE examination scores Mock Boards Patient Logs Supervisor Evaluations PRITE Exam Mock Boards Patient Logs Patient Care XXX XX XX Medical XXX XXX XXX Knowledge Interpersonal & XX XXX Communication Professionalism XX XXX Practice-based XXX X X X Learning Systems-based Practice XXX X XX

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