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Postgraduate Year-1 Residency Training in Emergency Psychiatry: An Acute Care Psychiatric Clinic at a Community Mental Health Center

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Postgraduate Year-1 Residency Training in Emergency Psychiatry: An Acute Care Psychiatric Clinic at a Community Mental Health Center
  See discussions, stats, and author profiles for this publication at: Postgraduate Year-1 Residency Training inEmergency Psychiatry: An Acute CarePsychiatric Clinic at a Community...  Article  · September 2010 DOI: 10.4300/JGME-D-10-00027.1 · Source: PubMed CITATION 1 READS 14 7 authors , including:Jeffrey Ivan BennettSouthern Illinois University School of Medicine 7   PUBLICATIONS   37   CITATIONS   SEE PROFILE Mir Nadeem MazharQueen's University 14   PUBLICATIONS   27   CITATIONS   SEE PROFILE All content following this page was uploaded by Jeffrey Ivan Bennett on 16 April 2014. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the srcinal documentand are linked to publications on ResearchGate, letting you access and read them immediately.  Postgraduate Year-1 Residency Trainingin Emergency Psychiatry: An Acute CarePsychiatric Clinic at a CommunityMental Health Center Jeffrey I. Bennett, MDGeorge Costin, MDMehnaz Khan, MDMir Nadeem Mazhar, MDKristina Dzara, PhDMary Conklen, APN, CNS, BCJo Ann Hannig, RN Background Residency programs should provide training thatincorporates recent developments in the field, and helpsresidents meet the changing needs of their patients. With thedevelopment of emergency psychiatry and the increase of acute psychiatric interventions, academic psychiatry hasstruggled to adequately incorporate emergency psychiatriceducation into the curriculum. 1–3 In response, recentrevisions to the Accreditation Council for Graduate MedicalEducation program requirements for psychiatry have movedtoward more intensive training in emergency psychiatry, inaddition to on-call duties This experience must be conducted in an organized, 24-hourpsychiatric emergency service, a portion of which may occur inambulatory urgent-care settings, but not as part of the 12-month outpatient requirement. Residents must be providedexperiences in evaluation, crisis evaluation and management,and triage of psychiatric patients. On-call experiences may be apart of this experience, but no more than 50%. 4 Many programs have developed model acute carepsychiatric clinics as an alternative to emergencydepartment on-site training. These clinics can provide anemergency psychiatry training experience as well as betteraccess for patient evaluation and intervention. 5 Acute care clinics require residency programs to beflexible and innovative to provide requisite training andservice that realistically address the community’s health careneeds. Public sector mental health clinics often service amore vulnerable and chronically ill patient population.Trainees in such settings therefore may be exposed to more At the time of the study, Dr Mazhar was Resident Physician in the PsychiatryTraining Program, Department of Psychiatry, at Southern Illinois UniversitySchool of Medicine.The authors declare that they have no competing interests. Jeffrey I. Bennett, MD,  is Assistant Professor of Clinical Psychiatry at SouthernIllinois University School of Medicine;  George Costin, MD,  is Resident Physicianin the Combined Medicine-Psychiatry Training Program, Department of Internal Medicine, Southern Illinois University School of Medicine;  MehnazKhan, MD,  is a Fellow in the Child and Adolescent Psychiatry FellowshipTraining Program, Department of Psychiatry, Southern Illinois UniversitySchool of Medicine;  Mir Nadeem Mazhar, MD,  is Assistant Professor inPsychiatry, Queen’s University, Kingston, Ontario, Canada;  Kristina Dzara, PhD, is Researcher III, Clinical Assistant Professor in Psychiatry, Southern IllinoisUniversity School of Medicine;  Mary Conklen, APN, CNS, BC,  is AdministratorMedical Services, Mental Health Centers of Central Illinois, a Memorial HealthSystem Affiliate;  Jo Ann Hannig, RN,  is Nurse Manager, Mental Health Centersof Central Illinois, a Memorial Health System Affiliate.Corresponding author: Jeffrey I. Bennett, MD, Assistant Professor of ClinicalPsychiatry, Southern Illinois University School of Medicine, 901 West JeffersonStreet, PO Box 19642, Springfield, IL 62794-9642, 217.545.7662, jbennett@siumed.eduReceived February 16, 2010; revision received May 7, 2010, June 7, 2010;accepted July 21, 2010. DOI: 10.4300/JGME-D-10-00027.1  Abstract Objective  The purpose of this study was to determineresident satisfaction with an acute care psychiatric clinicdesigned in collaboration with a nearby communitymental health center. We also sought to demonstratethat this rotation helps meet program requirements foremergency psychiatry training, provides directassessments of resident interviewing skills and clinicalknowledge in the postgraduate year-1, and providesexposure to public sector systems of care. Methods  We developed a resident satisfactionquestionnaire and fielded it to each of the residents whoparticipated in the clinic over the first 3 years. Data werecollected, organized, and analyzed. Results  Of the 15 residents in the acute care psychiatricclinic, 12 completed and returned the satisfactionquestionnaires. Educational aspects of the clinicexperience were rated favorably. Conclusions  This postgraduate year-1 acute carepsychiatric clinic provides a mechanism for thefulfillment of emergency psychiatry training as well asdirect supervision of clinical encounters, which is asatisfactory and useful educational experience fortrainees. PRACTICAL ARTICLE 462  Journal of Graduate Medical Education, September 2010  severe psychiatric acuity. In addition, exposure to the publicsector mental health system provides trainees withexperiences increasingly more important to newer residencyprogram graduates as this is becoming the most commoncare setting. 6 Community mental health services have alsotended to become a casualty to state or local budgetlimitations, and services rendered by trainees are oftenhighly valued.In conjunction with newer emergency psychiatrytraining requirements, there has been a demand fordocumented ‘‘direct supervision’’ in psychiatric residencytraining. During direct supervision, faculty supervisorsmonitor real-time resident-patient interactions and provideimmediate feedback regarding interviewing andexamination technique, clinical knowledge base, diagnosticskills, and treatment planning. 4 Early direct observation andevaluation of residents can help to tailor individual trainingplans, but coordinating direct supervision in the busypostgraduate year-1 (PGY-1) can be elusive. The purpose of this article is to provide the description of an acute carepsychiatric clinic that was designed to provide directsupervision and train residents in emergency psychiatryduring their first year, simultaneously exposing them tocommunity mental health center systems of care. Thisdescription is supplemented by resident satisfaction ratings. Methods Need for an Acute Care Psychiatric Clinic The development of this clinical experience was expeditedby the general need of the community mental health centerfor psychiatric services. There was a need for more urgentcare to many of the clients who received services throughthe center’s various programs, which included routinepsychiatric appointments, an 8-bed crisis center, a homelessoutreach case management program, a long-stay residentialpsychosocial rehabilitation program, and a linkage programfrom local area psychiatric inpatient services. The additionof an acute care psychiatric clinic in which waiting timescould be reduced to only a few days or less was seen as apotential asset in avoiding referrals to the emergencydepartments, hospitalizations, and providing rapidevaluation and management of patients in crisis. Development of an Acute Care Psychiatric Clinic The Department of Psychiatry at Southern IllinoisUniversity’s community-based residency training programdeveloped a community mental health center acute carepsychiatric clinic. The clinic was staffed for 2 hours twiceeach week during late afternoons. Postgraduate year-1residents were excused from other clinical commitmentsduring each of their month-long psychiatry rotations toattend the clinic singly or in pairs. For residents in thecategorical psychiatry program, this constituted 4 monthsdistributed throughout the year (3 months of inpatient adultpsychiatry and 1 month of substance abuse evaluation andmanagement). Residents in an affiliated combined medicineand psychiatry training program spent 2 months at the clinic(1 month of inpatient adult psychiatry and 1 month of substance abuse evaluation and management). Facultysupervised no more than 2 residents at any given time.Patient appointments were staggered to enable directsupervision of each resident. At their first mental healthcenter visit, residents were given a 45-minute orientationsession by the mental health center staff on the variousservices and populations served by the center, the clinicstructure, patient flow, and medical documentationmethods.Clinic costs were the contractual hourly rate for theattending faculty clinic director and were similar to theamounts paid to the other psychiatrists who worked at thefacility. Resident stipend costs were borne by 2 of theparticipating teaching hospitals, one of which was affiliatedwith the community mental health center. Both hospitalswere supportive of the added aspects of the clinic service.Travel time for residents was approximately 5 minutes toand from the clinic site. Nursing and other staff resourcesand materials were provided through the community mentalhealth center. Curriculum This clinic experience differs from the usual emergencypsychiatry experience provided to residents, which tookplace predominantly during on-call periods. Residentsevaluated patients presenting to the emergency departmentsof 2 busy university-affiliated general city hospitals. Thesepatients were first seen and evaluated by the emergencydepartment physicians and then referred to mental healthstaff, who provided assessments and then discussed thesecases with the resident on call. The resident would theninterview and examine the patient and discuss the case withthe attending faculty supervisor via telephone to determinethe disposition and treatment plan. Residents from thePGY-1, -2, and -3 levels were expected to perform on-callduties, taking call approximately 5 to 6 times each month.Residents conducted 60-minute evaluations of newpatients and, where necessary, 30-minute follow-upappointments. Each 60-minute session was directlysupervised by the clinic director, a faculty psychiatrist. Theclinic director was present in the room with the resident andpatient for the first 15 minutes of each session. For newpatients, the clinic director also attended for at least the last15 minutes in order to guide the treatment discussion anddisposition. Residents were given immediate verbalfeedback regarding their interview (conduct, rapport,controlling flow, and content covered), examinationapproach, focused psychiatric interviewing, and  Diagnosticand Statistical Manual  , Fourth Edition, Text Revision-baseddiagnosis and treatment. Interventions included the use of acutely acting anxiolytic and antipsychotic agents, initiating PRACTICAL ARTICLE Journal of Graduate Medical Education, September 2010  463  or continuing longer-acting psychotropic medications, theuse of the locally available diagnostic laboratories,psychotherapy, case management, or transfer to a hospital. 5 Survey A 25-item resident acute care psychiatric clinic satisfactionquestionnaire, modeled after a previously published andvalidated instrument, 7 was developed. Answers were ratedon a 5-point Likert scale (1 5  ‘‘Very dissatisfied’’; 2  5 ‘‘Dissatisfied’’; 3 5 ‘‘Neither satisfied nor dissatisfied’’; 4 5 ‘‘Satisfied’’; or 5 5 ‘‘Very satisfied’’). The questionnaire wasintended to measure resident satisfaction with educationalaspects of the clinic experience, including diversity of thepatient population and presenting psychopathology,exposure to public sector systems of care, biological andpsychosocial interventions, medical knowledge, andimprovement in psychiatric interviewing skills. Respondentswere also asked to make comments about any aspect of theclinical rotation experience at the end of the questionnaire.Questionnaires were distributed to each of the 15 residentswho participated in the clinic, and were anonymouslycompleted. Data were analyzed using SPSS 14.0 software(SPSS Inc, Chicago, IL). A retrospective chart reviewprovided patient demographics. Patient demographic datawere analyzed in SPSS 14.0, and standard descriptivestatistics were calculated. 8 The institutional review boardgranted this project exempt status prior to data collection. Results A total of 158 patients (70 women) attended the clinic overthe first year. The mean age of the patients was 36.4 years(range, 19–69); ethnicity was 70.5% white, 23.9% AfricanAmerican, and 5.6% other. Reasons for referral weredecompensating, 41.1%; no access to psychiatrist, 29.8%;acutely suicidal, 6.3%; acutely psychotic, 5.1%; andunspecified, 17.7%. Axis I pathology included mooddisorders, 59.8%; psychotic disorders, 28.3%; anxietydisorders, 5.1%; and other diagnoses, 6.8%. Comorbidmedical conditions were present in 70.4% of the patients.The mean Global Assessment of Functioning score forpatients on presentation was 48.5 (range, 29–75).The 25 questionnaire items and summary statisticsrelated to the quality of the educational experience arepresented in the  TABLE . The residents rated the educationalquality and diversity of the clinical experience favorably,and rated highly the training in emergent interviewing,psychosocial aspects, and biomedical aspects. The highestrated items were those measuring quality of supervision aswell as access to direct supervision and feedback as beinghelpful for the mock board examination. Compared withthe other items, residents rated less favorably theirperception that the clinic experience improved PsychiatryResident In-Training Examination (PRITE) scores. Overall,residents regarded the clinical experience as satisfactory. Discussion With the initiation and maintenance of this acute carepsychiatric clinic, the community mental health centerfound improvement in client retention, a reduction inemergency referral, and quicker availability of psychiatricservices. The clinic was featured in the annual reports of both the affiliated hospital system 9 and the communitymental health center, 10 which subsequently applied for andwas awarded an innovative community service grant thatenhanced the clinic continuity. 11 The broad emphasis on diversity of both patients andpsychopathology in a directly supervised setting likelycontributed to a higher sense of confidence in approachingboth the program’s mock board examination and thePRITE. The varied and integrated aspects of the rotationwere likely contributors to the overall positive evaluation of the acute care psychiatry clinic rotation by residents. Asmall number of respondents chose to provide qualitativecomments at the end of the resident satisfactionquestionnaire. These comments were positive, providingadditional support to our findings that the acute carepsychiatry clinic is a beneficial resident educationalexperience.Limitations in this study include the single-site location,which limits the generalizability of application, lownumbers of residents in the clinic rotation, and use of aquestionnaire that was not formally validated elsewhere,despite our use of several items from a previously validatedpsychiatry resident satisfaction questionnaire. In addition,only one faculty supervisor participated. That facultymember also served as author, but did not participate indistribution of the satisfaction questionnaire in efforts toreduce potential response bias. Some PGY-1 residentsexperienced this clinic before taking their first PRITE, sofurther study is needed to determine whether this clinicalexposure can help residents improve either global psychiatryor subscale scores in tests of emergency psychiatry. Thereare no comparable survey statistics to compare with the on-call or traditional hospital emergency department trainingexperience. Conclusions Overall, this acute care psychiatric clinic rotation issuccessful as a collaborative residency training model inpublic sector-based emergency psychiatry. First-yearpsychiatric residents indicated an overall satisfaction withthe experience. They were exposed to a wide range of acutepsychopathology in a public sector system of care. Thepatient population differed from that seen by residents intheir other outpatient rotations. Direct faculty supervisionin the setting of acute care psychiatric interviewing providedthe trainees with immediate feedback, which they founduseful in their emergency psychiatry education. Theopportunity to observe PGY-1 residents directly also PRACTICAL ARTICLE 464  Journal of Graduate Medical Education, September 2010  provided formative information on their clinical knowledgeand skills needs early in their training.The acute care psychiatry clinic offers analternative to the hospital emergency departmentexperience for meeting psychiatry residency trainingrequirements in emergency psychiatry. It is likely that thecombination of respect, diversity, emphasis on education, afair and responsive faculty, and positive morale led to theoverall positive evaluation of this rotation. We suggest thatiterations of this training clinic be implemented elsewhereand assessed to determine validity and generalizability,using larger samples of trainees as well as more concreteeducational outcome variables, including effects on mockboard, PRITE subscale scores, and the newly implementedclinical skills verification requirement. 12 This cliniccurrently provides a successful model experience forpsychiatry residency training in emergency psychiatry and isa positive step in academic-public sector collaborativemodels. References1  Larkin GL, Claassen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in U.S.emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv  . 2005;56(6):671–677. T A B L E  Descriptive Statistics by Questionnaire Item Questionnaire Item Mean MedianStandardDeviation Exposure to nonpsychiatric aspects of medical care (medicine, neurology or others).  3.25 3.00 .622 Responsibility given for patients care.  4.00 4.00 .894 Improvement of PRITE scores.  3.27 3.00 .467 Education prioritized over service.  4.36 4.00 .674 Did access to direct supervision and direct feedback help you for mock board examination?  4.36 5.00 .809 Quality of supervision.  4.50 5.00 .674 Diversity in patient’s population (age, gender, ethnicity, socioeconomic status).  3.91 4.00 .539 Exposure to public sector systems of care.  4.08 4.00 .669 Exposure to diverse psychopathology.  4.33 4.00 .651 ACPC’s ability to offer a different emergency psychiatry experience compared to working in thehospitals. 4.33 4.00 .492 Support from staff.  4.36 5.00 .809 Support from peers.  3.91 4.00 .831 Respect of supervisor/staff for residents.  4.33 4.50 .778 Responsiveness for feedback from residents.  3.55 3.00 .934 Morale in the ACPC and Mental Health Center.  4.45 5.00 .688 Traveling to another site.  3.17 3.00 .937 Training in emergent interviewing—did it help your skills for evaluating patients in ER?  4.36 5.00 .809 Training in psychosocial aspects of psychiatry.  4.27 4.00 .647 Training in biomedical aspects of psychiatry.  4.18 4.00 .751 Balance between psychosocial and biomedical aspects of psychiatry.  4.09 4.00 .701 Balance between exposure to emergency psychiatry and continuity of care.  3.50 3.00 .905 Experience in disposition of acutely ill patients (apart from hospital admission).  3.92 4.00 .900 Ability to manage overlapping inpatient commitments.  3.64 4.00 .674 Adequacy of medical records.  3.64 3.00 .809 Overall satisfaction  4.18 4.00 .751 Abbreviations: ACPC, acute care psychiatric clinic; ER, emergency room; PRITE, Psychiatry Resident In-Training Examination. PRACTICAL ARTICLE Journal of Graduate Medical Education, September 2010  465
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