PGY2 Consultation-Liaison Psychiatry
Rotation Director: Dustin Sanchez, M.D.
Location: Santa Barbara Cottage Hospital
Clinical and Educational Work Hours:
7:00 a.m.-7:00 p.m. daily except Wednesdays, Rotating Weeks
Monthly work hours will be submitted in the New Innovations software program.
Total hours worked for that month will be compiled and the weekly average
must not exceed eighty hours per week averaged over a 4-week period, inclusive
of in-house night call. Clinical and educational work hour violations
will be closely reviewed and addressed by the Program Director.
Residents shall not work in excess of 24 consecutive hours. Allowances
for already initiated care, transfer of care, educational debriefing and
formal didactic activities may occur, but shall not exceed 4 additional
hours and must be reported by the resident in writing with rationale to
the Program Director and reviewed by the GMEC for monitoring individual
residents and programs.
Residents will have 48-hour periods off on alternate weeks, or at least
one 24-hour period off each week, and shall have no call responsibility
during that time. Wednesday is reserved for didactics and local psychiatry clinic.
Educational Purpose:
To learn about the presentation and disposition of a variety of psychiatric
patients seen in a medical setting. To learn how to evaluate the patient
in a consultative role and ensure that appropriate care, recommendations,
and disposition is achieved.
Teaching Methods:
For each interaction, the resident will spend sufficient time with the
patient to carry out an appropriate psychiatric evaluation and then discuss
the case with the faculty. The learning experience surrounding a patient
interaction evolves from review of history, physical examination and laboratory
results with faculty. Faculty will provide guidance and direction to the
resident as well as references or other learning materials to facilitate
the resident’s learning experience. The resident will also learn,
under supervision, how to interact with patients, families, and other
members of the care team and how to collaborate to provide an appropriate
disposition for the patient.
Disease Mix and Patient Characteristics:
The majority of patients are over age 18 years and many are without health
insurance. Caring for this patient population provides residents with
a unique experience in dealing with the challenges of patients with few
resources.
Responsibilities and Procedures:
Residents will perform psychiatric consultations on patients hospitalized
at Santa Barbara Cottage Hospital. Individuals may be hospitalized for
different reasons, including for a primary medical reason after a suicide
attempt. Residents, under the guidance and direction of the psychiatry
attending, will coordinate the evaluation and disposition of the patient.
Residents are expected to communicate with the referring physician and
case management to ensure optimal patient care.
Resident consultations include the performance and documentation of a complete
psychiatric evaluation and must include obtaining all pertinent collateral
information from external sources (emergency responders, friends, family, etc.).
Residents are required to carry a cell phone with a HIPAA-compliant texting
program, in addition to being available at their assigned work station
for staff communication. Residents will be required to be in hospital
from 7:00 am to 7:00 pm so that they may address all consultations and
clinical situations as they appear. Faculty expect residents to return
calls in a timely manner to address concerns regarding patients.
Residents will attend the formal weekly didactic sessions, Grand Rounds,
Journal Clubs, and Morbidity and Mortality sessions.
Overall Goals and Objectives:
To develop a basic understanding of the skills needed to evaluate and manage
the psychiatric consultation of a medical patient.
Core Competencies:
Patient Care:
- Fully gather data from all available sources, including the patient, paper
and electronic chart (including physician’s notes, nursing staff
notes, social work notes, other staff member notes, medication administration
records), hospital staff, and family or friends of the patient.
- Adapt interview style to suit the clinical setting and medical and/or psychiatric
condition of the patient (i.e. communicate effectively with patients on
ventilators, recognize stress and fatigue in patients, communicate effectively
with difficult or agitated patients, prioritize questions and perform
multiple, brief interviews if necessary).
- Ascertain all required information related to patient’s family history,
personal history, substance history, premorbid personality, allergies,
past medical history, current medications, review of systems, detailed
past psychiatric history, detailed history of present illness (including
history of present medical illness), and mental status examination, including
cognitive examination.
- Thoroughly formulate a patient’s case based upon the above information,
with particular consideration to perspectives of disease, temperament,
behaviors, and life story.
- Comprehensively assess self-injury risk, risk of injury to others, dangerousness
and appropriate use of constant observation.
- Accurately assess medically ill patients for capacity to make medical decisions
(competency).
- Perform routine follow up of already evaluated patients, monitor the patient’s
course during hospitalization and provide continuing input (both pharmacologic
and psychotherapeutic) as needed to the patient and treating team.
- Accurately and fully document all elements described above on the resident
physician consultation form as well as in the patient’s chart, including
medical and legal facets, when necessary.
- Remain aware of the overall medical status of the patient and general disposition
plans as the patient’s hospital course proceeds.
Medical Knowledge:
- Learn about the indications for a variety of somatic therapies in medical
and surgical patients.
- Learn about the use of psychotropic medications in medical and surgical
patients and appreciate physiologic effects, contraindications, drug interactions,
and dosing concerns.
- Gain understanding about the use of psychosocial treatments, including
supportive psychotherapy, behavioral management techniques, family therapy,
and psychoeducation as they apply to the medical patient.
- Gain understanding about the risk factors, recent precipitants, classical
and atypical presentations, screening tests, etiologies, appropriate medical
evaluation, and comprehensive treatment strategies of delirium.
- Learn how to effectively advise medical and surgical teams on appropriate
use of antipsychotics and benzodiazepines in agitated patients.
- Gain experience in how to perform a comprehensive evaluation for organic
causes of psychiatric symptoms or syndromes.
- Learn about which medications have psychiatric symptoms as side effects.
- Learn about classes of, or specific drug interactions between, psychotropic
medications and non-psychotropic medications.
- Gain experience in the appropriate indications and dosing strategies for
psychostimulants in the medically ill.
- Gain understanding in clinical settings which further justify continued
medical or surgical inpatient admission while a patient’s disposition
is coordinated.
- Gain understanding in the appropriate use, risks and benefits, and dosing
strategies of psychotropic medications in pregnancy.
- Gain understanding of the clinical syndrome of serotonin syndrome and appreciate
its evaluation and management.
- Gain understanding of the clinical syndrome of NMS and appreciate its evaluation
and management.
- Understand the differences between somatization disorder, conversion disorder,
factitious disorder, and malingering.
- Gain understanding of core concepts of decisional capacity and the legal
process that may be invoked once a patient has been deemed incompetent.
- Be fully trained in treatment and infection control protocols and procedures
(e.g. personal protective equipment [PPE]) and trained clinically to properly
recognize and care for COVID-19 patients.
Systems Based Practice:
- Gain an understanding of the role of the Consult Liaison Team in providing
care versus providing consultation to the medical/surgical services, and
work effectively and collaboratively with consulting teams.
- Gain an understanding of outpatient resources to effectively continue psychiatric
management after discharge.
- Gain an understanding of the legal system as it applies to the commitment
of the medical patient.
Practice Based Learning:
- The resident will participate in all conferences and complete all required
reading to better understand and frame patients’ issues in a scientific
evidenced based manner.
- The resident will perform a literature search, when appropriate, to better
understand the most current treatment options.
Professionalism:
- Dress in professional business attire at all times.
- Arrive on time and stay until all work is completed or appropriately transitioned
to another provider.
- Behave collegially and demonstrate willingness to help other members of
the team and other departments.
- Assist with, and ask for, assistance in the case of emergencies or clinical
uncertainty.
- Maintain a thorough list of current patients being followed on the consultation
service and address current medications and other pertinent issues for
patients and the treating team.
- Demonstrate a commitment to ethical principles when dealing with patients,
families, and colleagues.
Interpersonal and Communication Skills:
- Facilitate the consulting service’s ability to formulate a clinical
question relevant to our skillset to aid in the care of the patient.
- Directly and promptly reply verbally to the consulting service the clinical
impression of the patient as well as specific treatment recommendations
and guidelines.
- Document in the medical chart all follow up evaluations of patients remaining
on the service, including subjective matters, mental status exam, and
cognitive examination (if needed in follow up), as well as continued assessment
and ongoing recommendations.
- Advise and guide consulting services about the role of medical disease
in a patient’s presentation, further diagnostic testing required
to clarify the clinical picture, and recommended medications.
- Advise and educate consulting services about the current diagnostic assessment
of the patient and, if applicable, how it may be distinguished from the
working diagnosis prior to psychiatric consultation.
- Work as a valued member of a multidisciplinary staff to optimize care of
complex medically ill patients.
- Provide appropriate direction to consulting services regarding management
of dangerous, agitated, and/or psychotic patients who are treated on the
general medical floor.
- Develop a therapeutic alliance with the patient, while respecting their privacy.
Transitions of Care:
All consults are required to be discussed with the referring resident or
attending by the end of the day. End of rotation handoffs require I-PASS.
Evaluation Methods:
The supervising attending will provide verbal feedback to the resident
midway through the rotation and formally evaluate the resident at the
completion of the rotation using the Consult Liaison New Innovations evaluation
form. Attendings will assesses the resident’s mastery of psychiatry
core competencies and are encouraged to comment more specifically on the
resident’s performance.
The supervising attending will receive the evaluation the last week of
the rotation. They must complete the evaluation and discuss it with the
resident prior to the completion of the rotation. If a resident receives
an unsatisfactory score, the information is communicated to the psychiatry
program director to ensure additional resident education and informal
or formal remediation if indicated.
Residents are also required to evaluate both their rotation and their preceptor
at the completion of the month.
Duration:
The resident will be assigned to the Consult Liaison service for a half-day
throughout their PGY4 year.
Residents will be assigned to one of the following Faculty Members or other
designated physicians:
Jason Cooper, M.D. (Primary)
Vanessa Hernandez, M.D (Coverage)
Educational Materials/References:
Comprehensive Textbook of Psychiatry—Kaplan and Sadock (various chapters
as assigned by attendings)
Resident Resources:
The resident has access to VCMC resident workrooms that have a desk and
computer in the Inpatient Psychiatric Unit adjacent to the main hospital building.