Clinical Rotations

Inpatient Psychiatry Consult/Liaison Service (VAMC)

This is the core rotation of the psychosomatic medicine fellowship, and as such is allowed 0.7 full time equivalents (FTE) throughout the year of specialty training.  Fellows will be supervised by Drs. Apple and Press, but will assume progressive responsibility for independent work as their training progresses.  Ultimately, fellows will function as multidisciplinary team leaders, coordinating the efforts of primary physicians, psychologists, social workers, and nurses to optimize the psychiatric care of patients with complex medical illnesses.  Fellows will also supervise and teach third and fourth year medical students, general psychiatry residents, and residents from other training programs such as neurology, PM&R, and internal medicine.

The goals of the rotation are for fellows to obtain and demonstrate competence in the following areas:

• Psychiatric complications of medical illnesses
• Psychiatric complications of medical treatments, especially medications, new medical and surgical procedures, and experimental therapies
• Typical and atypical presentations of psychiatric disorders that are due to medical, neurological, and surgical illnesses
• Evaluation and management of delirium, dementia, and secondary (“organic”) psychiatric disorders
• Assessment of capacity to give informed consent for medical and surgical procedures in the presence of cognitive impairment
• Indications for, and use of psychotropics in specific medical, neurological and surgical conditions
• Interactions between psychotropic medications and the full-range of medications used for a variety of medical and surgical condition
• Collaboration with other physicians, and other members of the multidisciplinary treatment team
• Teaching other physicians and other members of the multidisciplinary team how to recognize and respond to various psychiatric disorders
• Leading an integrated psychosocial health care team in the medical setting

The inpatient psychiatry C/L service receives about 1000 requests for psychiatric consultation a year; about 20% of these are for delirium.  The other 80% include depression, anxiety, capacity, psychosis, dementia, substance use disorders, traumatic brain injury and polytrauma.

Fellows are expected to see at least ten new and follow-up consultation patients each week.

Psychosomatic Medicine Outpatient Clinic (VAMC)

The dual goals of the psychosomatic medicine outpatient clinic at the VA are for fellows to (1) provide continuity of care for patients initially seen on the inpatient consult service, and (2) learn and provide non-pharmacologic interventions including cognitive therapy, interpersonal psychotherapy, and short-term supportive psychotherapy to patients suffering the effects of complex medical disorders or their treatments. 

This .1 FTE clinical experience will be supervised by Dr. Mylan PhD and Dr. Arbisi PhD.  Appropriate patients with somatoform disorders and chronic pain will be recruited from the women’s health clinic, mental health intake, and behavioral health service.  Fellows are expected to see at least four patients each week in this clinic.

Psychosomatic Medicine Outpatient Clinic (University of Minnesota)

In this specialty outpatient clinic, fellows will see patients for psychosomatic medicine consultation and management of such issues as peri-partum mood and psychotic disorders, psychiatric complications of transplantation, and psychiatric sequelae of experimental therapies, including assessment of capacity to consent for participation in research.  This .1 FTE clinical experience will be supervised by Drs. Randy Ward, M.D. and Lisa Capell M.D.  Fellows are expected to see at least four patients each week in this clinic.

Clinical Research

Psychosomatic medicine fellows will have .1 FTE each week to pursue clinical research under the mentorship of a staff psychiatrist.  At a minimum, fellows will present their research findings at Psychiatry Grand Rounds sponsored by the VA.  Ideally, fellows will be published first authors in a peer reviewed journal, and present at least a poster at a conference.

Duty Hours

A full-time equivalent for psychosomatic medicine fellows is 50 hours per week.  Psychosomatic medicine fellows will not have in-house call responsibilities, but may moonlight as the VA POD, as long as the moonlighting does not interfere with fellowship responsibilities and does not cause the fellow to have either more than 80 hours per week in the hospital or to be on duty more than 24 consecutive hours.  The psychosomatic medicine training director must approve requests for moonlighting and will monitor duty hours for compliance with ACGME requirements.

Patient Logs

Psychosomatic medicine fellows must keep a log of all patients seen for review by the training director.  Logs will be used to ensure a sufficient number and proper variety of patients are being seen by the fellow for training purposes.

Supervision and Oversight

Psychosomatic medicine fellows will receive both directly observed supervision and indirect supervision in which the fellow reports the case to a staff psychiatrist, as appropriate.  Fellows will have at least two hours each week of individual supervision.  Staff psychiatrists will always be available to communicate with fellows rapidly and to provide back-up support when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances created resident fatigue sufficient to jeopardize patient care.

Evaluation of Clinical Rotations

Formative evaluation of fellow performance will be provided by the supervising staff psychiatrist at each encounter.  Although this may be only verbal feed-back, supervising staff are encouraged to make notes of supervision and evaluation for inclusion in the fellows’ file.  The psychosomatic medicine training director will provide official formative evaluation at least once during the first six months of the fellowship (semi-annual evaluation). 

The semi-annual evaluation will address:

• Patient care
• Medical knowledge
• Practice based learning
• Interpersonal and communication skills
• Professionalism
• Systems based practice

as outlined in the core competencies.

The training director will make use of direct supervision, comments of other supervising faculty and staff, reports from patients, and/or results of cognitive examinations (quizzes) in assessing the fellows’ competence.

A final summative evaluation of fellows’ competence will address:

• Knowledge of abnormal behavior and psychiatric illness that occur among medical, neurological, obstetrics-gynecology, and surgical patients
• Knowledge of biological, psychological and social factors that influence the development, course and outcome of medical/surgical diseases
• Ability to diagnose and treat psychiatric disturbances that occur among the physically ill, including the administration of psychotropic medications to seriously ill patients
• Understanding of pharmacology, including the psychopharmacology of the medically ill, with emphasis on, and psychiatric side effects of, non-psychotropic medications and the interactions of psychotropic medications with other medications on the central nervous system
• Ability to provide consultation in medical and surgical settings
• Facilitative skills necessary to enhance the care of psychiatric disturbances among the physically ill through cooperative interaction with other physicians and allied health professionals
• Ability to effectively supervise medical students and residents performing consultations and to teach medical and surgical colleagues about psychiatric  complications of physical illness
• Participation in the development of new knowledge, evaluation of research findings, and the continuing acquisition of new knowledge, through the development of good habits of inquiry
• Knowledge of the organizational and administrative skills needed to finance, staff, and manage a psychosomatic medicine service.