Orientation to the 2004-05 PGY-III Residency Year

The PGY-III year in the GWU psychiatry residency is a tightly-integrated year of training designed to help residents acquire the broad range of outpatient and consultation-liaison competencies that have long been the hallmark of our residency. This memorandum provides an overview of the PGY-III year in terms of its conceptualization, educational objectives, and clinical training that embodies these objectives.

How the PGY-III Year Has Been Conceptualized

The design of the PGY-III year facilitates achievement of the professionalism, knowledge, and competencies for conducting biopsychosocial treatment in a manner that is sensitive to patients’ family, community, and cultural contexts. By the end of the PGY-III year, a GWU psychiatry resident should be able to create a collaborative relationship with a patient or family, discern a priority of concerns, and creatively tailor appropriate therapies that respond to those concerns. A resident should be able to draw from multiple perspectives and a broad repertoire of skills to compose a rational, integrated program of treatment that responds to the patient’s uniqueness. Such a program typically should include psychoeducation, psychopharmacological treatment, individual psychotherapy, and psychosocial interventions with families and communities that build resilience against illness. The PGY-III residency year is the critical year in which residents build upon inpatient and emergency psychiatry skills acquired during the PGY-I and PGY-II years to become psychiatrists who implement such complex programs of biopsychosocial treatment in outpatient and consultation-liaison settings.

Our residency has selected domains of excellence in which we are committed to developing the leading educational programs among the psychiatry residencies of our region, based upon our academic resources, patient populations, and teaching faculty. Throughout the residency, these six areas are prominently featured in seminars, supervisions, and organization of clinical training, but are represented particularly strongly in the PGY-III year:

• Cross-Cultural and International Psychiatry
• Child, Adolescent, and Family Psychiatry
• Mental Health Advocacy and Public Policy
• Broad Training in the Psychotherapies
• Consultation-Liaison Psychiatry and Neuropsychiatry
• Integration of Pharmacological and Psychosocial Therapies

In addition to commitments that reflect our specific values and educational philosophy, the structure of the PGY-III year is also shaped by:

• National mandates from the American Council on Graduate Medical Education, particularly those regarding assessment of the six core competencies;
• Policies set by our departmental leadership and the GWU Residency Training Committee;
• Feedback from our 2003-2004 PGY-III residency class regarding their training experiences from the previous year;
• Ongoing feedback over the course of the year from the current PGY-III class.

When reviewed at the end of the 2003-2004 academic year, the current PGY-III year required an estimated 40 - 42 hours of work per week, with an additional 8 hours likely needed to complete administrative and paper work. For each residency year, the general expectation for academic work load is 50 hours per week, plus night and weekend call. Work schedules are periodically reviewed and revised if found to exceed this level consistently over time.

Educational Objectives for the PGY-III Year

The following broad educational objectives are further detailed within the learning objectives of specific seminars and supervisions. By the end of the PGY-III year, a resident should be able to:

• Evaluate patients in outpatient and consultation-liaison settings, including presentation of:

1. An appropriate listing of DSM-IV differential diagnoses;
2. An accurate biopsychosocial formulation of the clinical problem;
3. A program of biopsychosocial treatment that includes appropriate psychoeducation, psychopharmacological treatment, individual psychotherapy, and family and community psychosocial interventions for building resilience to illness.

• Conduct psychodynamic psychotherapies with competence;
• Conduct focused brief and supportive individual psychotherapies competently, utilizing at least two different clinical approaches for brief psychotherapy;
• Conduct group therapy with competence;
• Conduct with competence couple therapy, family therapy, and family-centered care for the psychosocial sequelae of medical illnesses;
• Conduct psychopharmacological treatments with a level of competence required to treat patients who failed to respond to first-line treatments or who present atypical patterns of symptoms;
• Work competently as a psychiatrist on an interdisciplinary treatment team providing community mental health services;
• Conduct competently the psychiatric evaluation for an immigrant seeing political asylum in the United States;
• Complete a minimum of 75 new consultations on medically or surgically-ill inpatients;
• Demonstrate the acquisition of cognitive knowledge and clinical competencies in consultation-liaison psychiatry, as stipulated in the Guidelines for Consultation-Liaison Psychiatry Residency Training by the American Academy of Psychosomatic Medicine (detailed in a separate memorandum);
• Demonstrate competency in the role of liaison psychiatrist with the GWU Epilepsy program through the diagnostic assessment of patients with non-epileptic seizures and the implementation of specific psychotherapy focused upon somatoform dissociative symptoms;
• Demonstrate competency in the role of liaison psychiatrist for the GWU Sleep Disorders Program through the diagnostic assessment of patients with sleep complaints and the implementation of appropriate psychoeducational, psychotherapeutic, behavioral, and pharmacological interventions;
• Demonstrate a cognitive knowledgebase in general psychiatry by a score of 50^th percentile or higher for both the Global Psychiatry and Global Neurology scores on the national PRITE inservice examination;
• Demonstrate in the course of clinical work and training the six core competencies in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice, according to residency criteria for each.

PGY-III Clinical Training and Supervisions

Clinical training during the PGY-III year is highly-supervised and constituted by multiple integrated components. Clinical training is divided between a range of outpatient training experiences and the GWU consultation-liaison psychiatry service, with a division of clinical time that is 80% outpatient and 20% consultation-liaison psychiatry. However, these two clinical domains are also linked, in that inpatient consultations are a primary source of cases for the range of residents’ outpatient therapies. Residents’ initial evaluations of outpatient cases often thus consist of the inpatient C-L Service evaluation. In particular, C-L Service evaluations of patients for non-epileptic seizures are an important source of referrals for residents’ outpatient brief psychotherapies for dissociative symptoms. Competency in outpatient treatment of medically-ill patients with individual, family, and psychopharmacological therapies is itself a training objective for the PGY-III year.

Outpatient cases are predominantly drawn from: (1) community referrals as resident clinic sliding-scale cases, many of whom are referred by our clinical faculty members; (2) the GWU Hospital psychiatric consultation-liaison service; (3) the GWU Hospital inpatient psychiatry service.

A primary responsibility of the chief resident is oversight of PGY-III residents’ outpatient caseloads, so new cases can be assigned as soon as openings appear. These managed caseloads consist of brief individual psychotherapies (cognitive-behavioral, future-focused, motivational enhancement), long-term psychodynamic psychotherapy, group therapy, couple and family therapy, and psychopharmacology. Future-focused psychotherapy is designed to serve roles both as a brief psychotherapy and as a framework for supportive psychotherapy with major psychiatric disorders. Each therapeutic modality has its weekly supervisions that are coordinated with didactic seminars.

Outpatient caseloads can be tailored by residents to best fit their career aspirations, within the parameters listed below. The Chief Resident monitors these case loads, assigning new cases as needed and reporting to the Residency Director on a monthly basis regarding each resident’s profile of cases. Residents typically average 20 hours per week of outpatient therapies.

Approximate Hours Per Week of Outpatient Therapies

* Lower number for outpatient therapies is minimum training expectation; larger number is for residents with special interests in a particular therapeutic approach.

Outpatient Psychiatry Supervisions:

Didactic Seminars and Teaching Conferences

Over the course of the academic year, 7 to 8 hours of didactic seminars are scheduled weekly in the PGY-III curriculum. 70% minimum attendance is required by the American Council on Graduate Medical Education in order for a resident to receive credit for completing a seminar.

In addition to didactic seminars, attendance is required for Psychiatry Grand Rounds, the Goodwin Psychopharmacology Conference, the Psychotherapy Case Conferences, and other special conferences as scheduled. Attendance at the weekly Epilepsy Conference and Sleep Disorders Medicine Conference is required for assigned residents.

Assessment of Clinical Competencies

The systematic assessment of clinical competencies is a nationally-mandated initiative that is being implemented through each residency year. The primary new method of assessment that is introduced during the PGY-III year is the use of psychotherapy portfolios to assessment competencies in brief psychotherapies and long-term psychodynamic psychotherapy. With a psychotherapy portfolio, a resident prepares illustrative vignettes from a psychotherapy and accompanying explanatory text that show how he or she has implemented a particular skill. This assessment method is utilized in long-term psychodynamic psychotherapy with the resident case conferences scheduled in the last half of the academic year. It is also used for future-focused psychotherapy and for clinical work associated with the "Conducting Psychotherapy with Spiritually, Religiously, or Ideologically-Committed People." Portfolio examples from residents’ work during the 2003-2004 year can be examined to illustrate their use last year. Each resident’s psychotherapy portfolios are entered as a part of his or her residency file as documentation of competency in the psychotherapies.

Cognitive knowledge is assessed with the annual PRITE examination for each of the PGY-II through PGY-IV classes. It is expected that GWU residents score in the upper 50^th percentiles on global scores for both psychiatry and neurology, compared to residents nationally in comparable years of training. In addition, specific seminars will assess residents’ cognitive knowledge through end-of-seminar examinations. Remedial work may be required when assessments of residents’ cognitive knowledge fall short of expected standards.

Each clinical supervisor completes an evaluation every six months, assessing the development of clinical competency for that clinical activity. Over the course of the PGY-III year, residents are expected to complete two Mock Board examinations, in which skills are examined for diagnostic interviewing, biopsychosocial formulation, differential diagnosis, and treatment planning. Mock Board examinations are modeled after the Part II American Board of Psychiatry and Neurology oral examination.

During the second semester, the Chairman, Residency Director, Associate Residency Director, and Chief Resident meet to draw together all available feedback regarding residents’ performances. This administrative group then provides specific feedback to each resident regarding both strengths in his or her performance, as well as guidance for needed improvements.

Finally, each resident should meet with Dr. Griffith at least every six months to review evaluations, to discuss how the academic year is proceeding, and to discuss longer term issues of professional development.

Medical Student Teaching

PGY-III residents teach and supervise medical students during their M-3 consultation-liaison psychiatry clerkships. They teach basic principles for conducting consultations, including biopsychosocial formulation, psychiatric diagnosis, and making recommendations. Students are instructed how to write an appropriate consultation. Students are observed and critiqued in their performance of bedside interviews and mental status examinations, including the cognitive mental status examination. Specific learning objectives for students include assessment for risk of suicide or violence, assessment of medical decision-making capacity, evaluation of depression in a medically ill patient, and the diagnosis of delirium. Residents provide feedback about each student to Dr. Lynne Gaby at the end of the month to be incorporated into the student’s grade for the rotation.

Research

PGY-III training in psychiatric research is centered in Dr. David Reiss’s twelve-week seminar on "Research and Clinical Projects Seminar" during the spring of the year. Research projects designed through the course of this seminar can easily serve as the focus of a PGY-IV project that results in a presentation at a scientific meeting and research publication.

A T32 Post-Doctoral Research Fellowship Program is sponsored by our department through the National Institutes of Health. This program can provide full-time support for a PGY-IV elective research project. PGY-III residents considering this program should express their interests to Drs. Reiss and Griffith during the current year so that necessary planning can be initiated for the upcoming year.

Our faculty encourage the writing of case reports and brief clinical reports that can be generated in the course of clinical work on the consultation-liaison psychiatry service or in outpatient treatments.

How the Six Domains of Excellence Are Implemented in the PGY-III Year

Cross-Cultural and International Psychiatry

Cross-cultural seminars during the PGY-III year include "Cross-Cultural and International Psychiatry Seminar," "Trauma-Focused Brief Psychotherapy," and "Conducting Psychotherapy with Spiritually, Religiously, and Ideologically-Committed People" seminars. Our multi-year curriculum in the assessment and treatment of traumatic stress disorders is regarded as a component of Cross-Cultural and International Psychiatry due to prevalence of traumatic stress disorders in our patient populations from global trauma due to war, famine, or political oppression.

Clinical training and supervisions emphasize skills for conducting clinical work across differences in ethnicity, religion, socioeconomic status, gender or sexual identity, or political commitments. These methods emphasize a collaborative therapeutic relationship and interview skills that prioritize identification of strengths and building resilience. These training sites and supervisions include:

• A half-day clinic at the Center for Multicultural Human Services (CMHS) with immigrants and refugees from a broad range of countries;
• Weekly clinical supervision at CMHS with Drs. Gaby and Griffith;
• The psychiatric evaluation of a refugee seeking political asylum in the United States, including participation in court hearings when needed;

Child, Adolescent, and Family Psychiatry

Residents entering the PGY-III year have already completed their PGY-II core rotations in Child and Adolescent Psychiatry.

The PGY-III year emphasizes training in family psychiatry. The didactic component consists of Dr. Stephen Wolin’s seminar on "Issues in Family Therapy" that brings together leading clinicians and teachers to address specific family therapy topics. Clinical supervision in couple and family therapy is conducted by Jim Lieberman, M.D. and Jane Jacobs, Ph.D. who provide weekly live supervision as consultations to residents outpatient therapies. One supervisor conducts a consultation with the couple or family, while the other supervisor and other residents observe the session over closed circuit television. After the interview, the case is discussed among the group.

Broad Training in the Psychotherapies

The amount and quality of supervised training in psychotherapy is a primary reason why many residents have sought to train at GWU. The longstanding strengths of our residency in psychodynamic psychotherapy have been broadened by the formal partnership between our residency and the Washington Psychoanalytic Institute. In addition to psychodynamic psychotherapy, our department historically has made important contributions to the development of the brief psychotherapies and family therapy.

The PGY-II psychodynamic psychotherapy seminars and supervisions prepare residents for a rapid start at the beginning of the PGY-III year. PGY-III residents conduct 3 - 6 hours weekly of psychodynamic psychotherapies. These consist of once- or twice-weekly psychotherapies. Residents electing not to emphasize psychotherapy training can choose to see no more than 3 hours weekly, while those aiming to acquire a greater level of competence can choose to treat as many as 6 hours weekly. Residents are each assigned two psychodynamic supervisors for weekly supervisions.

Due to the complexity of the PGY-III year schedule, it is expected that supervisors will come to Foggy Bottom to meet for supervision in the department, unless the supervisor’s office is within a 5-minute walk (i.e., immediate Washington Circle and K Street area). The "5-minute rule" applies to all clinical supervisions during the PGY-III year, with the exception of the private office family therapy experience for which working in a clinical faculty private practice setting is one of the training objectives.

Residents seeking intensive training in psychodynamic psychotherapy can add a third supervisor and conduct additional psychotherapies that exceed 6 hours per week. However, these additional hours are elective time that cannot substitute for program requirements stipulated for other psychotherapies or other components of the PGY-III year.

PGY-III didactic seminars in psychodynamic psychotherapy include "Object Relations and Ego Psychology," "Psychotherapy for Borderline and Narcissistic Personality Disorders," and "Adult Development and Psychotherapy."

Competency assessment in psychodynamic psychotherapy is conducted through semi-annual evaluations by each psychodynamic supervisor and through preparation of a psychotherapy case conference to be presented to the department in the spring. The latter includes a written case presentation that illustrates the residents’ competencies. The written case presentation is included in the resident’s educational record.

Each PGY-III resident conducts a group therapy and meets weekly in group supervision. A didactic "Group Therapy Seminar" is conducted during the summer and fall of the year.

Each PGY-III resident also conducts 2 - 4 hours weekly of brief psychotherapies. These psychotherapies are divided between cognitive-behavioral psychotherapies supervised by Andy Molchon, M.D. or other clinical faculty, and future-focused brief psychotherapy supervised weekly by Dr. James Griffith. Future-focused brief psychotherapy is constituted by theoretical frameworks and clinical interventions drawn from narrative, solution-focused, resilience-building, and cognitive-behavioral psychotherapies, packaged to serve a dual role as a time-limited focal psychotherapy or as supportive psychotherapy for chronic psychiatric disorders that need long-term psychosocial care. Competency assessment in the brief psychotherapies consists of composition of a psychotherapy portfolio in which case vignettes illustrate competencies in various skills of brief psychotherapy, including assessment, formulation, treatment interventions, and termination.

Brief psychotherapies for specific clinical problems are emphasized during the PGY-III year. These include somatic psychotherapy for dissociative and post-traumatic stress disorders; cognitive-behavioral psychotherapy for depression, anxiety, and sleep disorders; and motivational enhancement psychotherapy for alcohol and substance abuse. Residents typically have two hours weekly with different brief psychotherapy supervisors. The brief psychotherapy didactic curriculum includes seminars in "Cognitive-Behavioral Psychotherapy," "Future-Focused Brief Psychotherapy," "Somatic Psychotherapy for Traumatic Stress Disorders," "Motivational Enhancement Therapy," and "Conducting Psychotherapy with Spiritually, Religiously, and Ideologically-Committed People."

The PGY-III couple and family therapy curriculum has been outlined above.

Consultation-Liaison Psychiatry and Neuropsychiatry

The PGY-III Consultation-Liaison Psychiatry curriculum includes didactic seminars, hospital consultations, liaison patient assessments in the Epilepsy Program and Sleep Disorders Medicine program, and outpatient treatment of psychosocial sequelae of medical illnesses in brief and family psychotherapies.

The consultation-liaison psychiatry didactic curriculum includes seminars on "Introduction to Consultation-Liaison Psychiatry," "Topics in Consultation-Liaison Psychiatry," "Family-Centered Treatment of the Psychosocial Sequelae of Medical Illnesses," and "Sleep Disorders and Neuropsychiatry."

PGY-III residents conduct consultations on medically ill patients in GWU Hospital on a part-time basis. Between 80 and 120 new consults are typically evaluated over the course of the year, with appropriate follow-up during hospitalization as indicated for the clinical problem. All PGY-III residents attend daily attending rounds conducted by Drs. James Griffith and Lynne Gaby, unless specifically assigned on certain days to a different clinical activity.

This Consultation-Liaison Psychiatry Service serves a liaison role in the Epilepsy Program and Sleep Disorders Program. Comprehensive diagnostic assessments are conducted for patients with non-epileptic seizures (pseudoseizures). Patients with non-epileptic seizures, as a conversion disorder, are then treated with specific outpatient psychotherapy for somatic dissociation. Patients with a range of sleep-related complaints are assessed and treated as outpatients. Outpatient training in consultation-liaison psychiatry occurs as residents continue brief, family, and psychopharmacological therapies with other medically ill patients whom they first evaluated in GWU Hospital.

Mental Health Advocacy and Public Policy

A joint program in psychiatry residency training and a Masters in Public Health in mental health policy in the School for Public Health and Health Services was initiated in 2003. Residents can jointly pursue an M.P.H. and psychiatry residency upon admission to this dual track.

Integration of Pharmacological and Psychosocial Therapies

The PGY-III curriculum emphasizes the design of multi-modality programs of treatment, rather than singular treatments for psychiatric disorders. Residents are expected to learn how to integrate psychoeducation, pharmacotherapeutics, individual psychotherapy, psychosocial interventions with couples, families, and social networks, and mobilization of community resources within a coherent treatment program. This is the didactic focus of the "Psychiatric Services Seminar," and residents implement such multi-modality treatment programs in their brief psychotherapies. Dr. Fred Goodwin’s monthly case conference models this programmatic approach to psychiatric treatment through consultations to residents’ therapies that emphasize the integration of psychopharmacology, psychosocial therapies, and psychoeducation.

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