Psychiatry Clinical Rotations

Rotations

YEAR 1
4 months:  Acute Child & Adolescent Psychiatry- Psychiatric Residential Treatment Facility (LCCA) 
4 months:  Consultation/Liaison Psychiatry (CHOG) 

The above experiences are longitudinal.  Remaining time is devoted to didactics, research, outpatient continuity clinic, group therapy modalities (DBT, autism social skills group), and experiences in pediatric neurology, sexual abuse evaluations, gender clinic, palliative care, and HemeOnc. 

YEAR 2
The majority of the second year consists of outpatient clinic with exposure to various settings, typically for three month blocks a half-day a week including: 

• Community Psychiatry (Transitional Family Services) 
• Forensic psychiatry (Augusta RYDC) 
• Pediatrics Enhanced Primary Care Clinic 
• School Consultation (McDuffie & Richmond Counties) 
• Student Health (Augusta University) 

Additional elective time for research, QI projects, or other treatment modalities is available 

Goals and Objectives

The clinical rotations for the child and adolescent psychiatry training program at the MCG are organized to provide the resident intense and focused experiences to develop the comprehensive skills necessary for the diagnosis and treatment of the full scope of child, adolescent and family psychopathology. Experiences are tailored to train the resident to function as a leader of and collaborator with multidisciplinary teams in a variety of settings (inpatient, outpatient, pediatric hospital, schools, juvenile justice center, community systems of care, etc.). While goals and objectives for each rotation have been developed, it is recognized that clinical learning takes place in every encounter and cannot be totally qualified or quantified by specific goals within the core rotations.

• Clinical Rotation 01: MCG Hospital Child and Adolescent Inpatient Service
• Clinical Rotation 02: MCG Hospital Outpatient Child and Adolescent Mental Health Clinic
• Clinical Rotation 03: Pediatric Neurology
• Clinical Rotation 04: MCG Pediatric Consultation/Liaison Service
• Clinical Rotation 05: Residential Treatment Rotation - Lighthouse
• Clinical Rotation 06: School Consultation
• Clinical Rotation 07: Forensic Consultation/Juvenile Justice Rotation
• Clinical Rotation 08: Community Rotation Experience - Transitional Family Services
• Clinical Rotation 09: Elective Rotation

Clinical Rotation 01: MCG Hospital Child and Adolescent Inpatient Service

The goal of this rotation is to provide the resident with an opportunity to evaluate and treat a wide range of child and adolescent inpatients and their families in a multidisciplinary setting under the close supervision of a child and adolescent psychiatrist.

A. Knowledge - At the end of this rotation the resident should be able to:

1. Recognize the components of a comprehensive inpatient assessment and treatment plan as well as the criteria for inpatient admission.
2. Understand the role of a child and adolescent psychiatrist as an inpatient treatment team member and case manager.
3. Understand the roles of the nurse, psychologist, social worker, occupational therapy, and education members of the inpatient team and how they complement the total treatment approach to the patient and family.
4. Recognize the value of consultants in the hospital setting.
5. Discuss the range of diagnoses for children and adolescents in the inpatient setting.
6. Recognize the teaching role of the child and adolescent psychiatrist in an inpatient milieu.
7. Learn about a number of specific areas such as child protective services, juvenile court and probation issues, parent training and family therapy, group therapies, individual and play interventions, approach to reactive attachment disorder issues, criteria for commitment or hold proceedings, etc.
8. Learn about managed care reviews, quality assurance, performance improvement strategies.

B. Skills - The resident should be able to:

1. Admit, write orders, conduct an assessment, develop a treatment and discharge plan for patients across the developmental spectrum from preschool to adolescence.
2. Implement the psychiatric components of the assessment and treatment plans in a comprehensive and efficient manner.
3. Utilize the milieu staff and available consultants appropriately in the management of patients and families.
4. Work with children/adolescents in groups and individually in a therapeutic manner.
5. Set up behavior management plans for patients with the milieu staff.
6. Communicate findings and treatment plans to referring physicians and mental health providers.
7. Communicate effectively within the utilization review process.
8. Serve as an advocate for children and adolescents with mental illnesses.

C. Attitudes - The resident should demonstrate:

1. An interest in learning about the inpatient treatment of children and adolescents.
2. A non-prejudicial approach to patients and staff.
3. Active participation, regular attendance and preparation.
4. Motivation to work with as many different patients and families as possible.
5. Responsible approach to all aspects of the experience.
6. Professional and ethical approach to all aspects of the experience.

D. Strategies

1. The resident will be the case manager for 4-7 patients at any one time, integrating and orchestrating all ongoing evaluation and therapeutic interventions and directing the team meetings on his/her patients.
2. The resident will also have some cases where he/she is the solo manager of the case, participating in both the child and family evaluations and treatments.
3. The resident will attend all team meetings, presenting ongoing cases and developing treatment and discharge plans for all cases.
4. The resident will participate in pre-admission evaluations for crisis management and interagency conferences as appropriate.
5. The resident will be expected to participate in family sessions with the social worker as time allows but minimally weekly.
6. The resident will be expected to participate in group therapies as time allows
7. Resident record keeping is monitored daily by the attending psychiatrist and reviewed with the resident as necessary.
8. The resident will have weekly individual supervision with the attending child and adolescent psychiatrist to review all ongoing cases.
9. All experiences are reviewed in the context of the Core Competencies. 

Clinical Rotation 02: MCG Hospital Outpatient Child and Adolescent Mental Health Clinic 

The goal of this rotation is to provide the child and adolescent psychiatry resident with numerous opportunities to evaluate and treat, under close supervision, a variety of children, adolescents and their families in an outpatient setting, both on a scheduled basis and occasionally for crisis or emergency assessment and treatment and with the range of therapeutic modalities available. This rotation runs throughout the residency and provides the opportunity for continuity of care over a two year period.

A. Knowledge - At the end of this rotation, the resident should be able to:

1. Recognize the various approaches to evaluation and treatment in the child and adolescent psychiatry outpatient setting.
2. Discuss the components necessary for formulating a diagnosis, biospychosocial formulation and treatment plan for each case.
3. Recognize the broad spectrum of severity of disorders in children and adolescents.
4. Recognize the developmental influences on the presentation, evaluation and treatment of psychiatric disorders in children from preschool through adolescence.
5. Discuss the collaboration necessary between the child and adolescent psychiatrist in the outpatient clinic and the family, school, and other community agencies to insure the best treatment outcome for the patient.
6. Recognize the influence that culture and religion may have on the presentation of mental health issues as will as the psychological accessibility to various interventions.
7. Recognize the contributions of other mental health providers within the outpatient setting.
8. Discuss interventions, including a variety of psychotherapies as well as psychopharmacological interventions.

B. Skills - At the end of this rotation, the resident should be able to:

1. Evaluate and treat children and adolescents of various developmental levels with the full range of psychiatric disorders to include all of the diagnoses listed in the description of the clinical rotation.
2. Complete an initial evaluation, request appropriate collateral information, use appropriate rating scales, request appropriate consultation, etc., to allow the resident to reach a diagnosis, develop a formulation of the case, and recommend appropriate comprehensive intervention strategies.
3. Demonstrate competency in a variety of therapeutic modalities and at least a knowledge of the indications for those for which competency has not yet been achieved.
4. Evaluate and triage to the appropriate level of care emergencies which may present for intake.
5. Demonstrate the ability to integrate community resources into the comprehensive treatment of children, adolescents and their families.
6. Demonstrate clinical proficiency in the outpatient diagnosis and treatment of children, adolescents and families.
7. Keep up-to-date and complete records.
8. Maintain ethical standards in the outpatient setting.
9. Communicate effectively with families and patients and educate them appropriately about their disorders as well as their treatments.
10. Participate in QA monitoring and performance improvement activities within the outpatient setting.

C. Attitudes - The resident should demonstrate:

1. An interest in learning about the outpatient treatment of children and adolescents.
2. A non-prejudicial approach to patients, families and other mental health providers.
3. Active participation, regular attendance and preparation.
4. Motivation to work with as many different patients and families as possible.
5. Responsible approach to all aspects of the experience.
6. Professional and ethical approach to all aspects of the experience.

D. Strategies

1. Each resident will have an intake appointment time on a regular basis.
2. Each intake will be supervised on-site by a child and adolescent psychiatrist, with the resident presenting the chief complaint, history, a formulation and treatment plan.
3. Intakes will be triaged appropriately and may be followed into therapy with the resident.
4. Residents may follow inpatient cases from their inpatient rotations or from other rotations in the outpatient clinic.
5. The resident case load will be monitored by the supervisor and/or the clinic medical director to assure adequate numbers, diagnostic and age diversity, cultural diversity, and the full range of treatment modalities. When a resident does not have enough diversity in the case load, the supervisor will work with the resident and the intake coordinator to facilitate a broader range of patients.
6. Case loads are monitored by using departmental software that allows for the supervisor and resident to access the resident's case load. Occasionally residents maintain their own case log but this is seldom necessary.
7. Resident charting is monitored regularly by the supervisor at the time of the visit and usually signed by the supervisor after review.
8. In addition to on-site supervision on almost all cases, the resident also participates in at least one hour of individual supervision weekly with a child and adolescent psychiatrist. Specific therapies may also be supervised by other professional disciplines with demonstrated expertise in the therapy being employed.
9. All experiences are couched in the Core Competencies.

Clinical Rotation 03: Pediatric Neurology

The goal of this rotation is to expose child and adolescent psychiatry residents to the outpatient practice of pediatric neurology and to facilitate an understanding of the collaboration between these two specialties.

A. Knowledge - At the end of this rotation, the resident should be able to:

1. Discuss the major disorders seen by the pediatric neurologist.
2. Outline an approach to the diagnosis and treatment of these disorders.
3. Recognize the frequent overlap between neurological and psychiatric disorders.
4. Recognize the benefits of neuropsychological testing for pediatric neurology patients.
5. Understand the use of specialized lab testing, EEG, CT and MRI.

B. Skills - At the end of this rotation, the resident should be able to:

1. Take a neurological history and perform an adequate neurological exam on children and adolescents and present an organized case to the neurology attending.
2. Develop a differential diagnosis for the presenting problem.
3. Identify further assessment methodologies appropriate to the findings in the history and physical.
4. Implement a basic treatment plan for the most common pediatric neurology problems.
5. Communicate findings and recommendations to the patient and family as well as to referral sources.

C. Attitudes - The resident should demonstrate:

1. An interest in learning about the pediatric neurology.
2. A non-prejudicial approach to patients, families and other medical providers.
3. Active participation, regular attendance and preparation.
4. Motivation to work with as many different patients and families as possible.
5. Responsible approach to all aspects of the experience.
6. Professional and ethical approach to all aspects of the experience.

D. Strategies

1. The resident will see 1-5 complicated new or return patients per clinic afternoon and review these cases with the pediatric neurology faculty on-site.
2. The resident will participate in any team discussions of particularly interesting or complicated cases and may present the case if it is their clinic patient.
3. The resident will do neurological examinations under the supervision of the pediatric neurologist or the neurology resident.
4. The resident will be exposed to various treatment modalities such as medication management, patient and family education, and collaborative with clinic team and coordination with community resources.

Clinical Rotation 04: MCG Pediatric Consultation/Liaison Service

The goal of this course is to provide a clinical experience in pediatric consultation and liaison, helping the resident to integrate clinical the didactic material presented in the C/L course. Emphasis is on working with the pediatric team, assuming the role of consultant rather than treating physician, and working with patients and their families with chronic pediatric illnesses, acute catastrophic illness and patients with suicide attempts.

A. Knowledge - At the end of the rotation, the resident should be able to:

1. Discuss the process of pediatric consultation and how it differs from primary psychiatric assessment and treatment.
2. Identify appropriate liaison functions for the child and adolescent psychiatrist in a pediatric setting.
3. Recognize the staff as well as family issues cogent to psychiatric consultation.
4. Discuss common emotional issues relevant to specific medical diagnoses.
5. Discuss the assessment of suicidal behavior in children and adolescents.
6. Recognize issues for patient, family, and staff in palliative care and terminal illness.

B. Skills - At the end of the rotation, the resident should be able to:

1. Undertake a consultation on any patient in the pediatric setting.
2. Undertake the role of a consultant appropriately depending on the consultation questions.
3. Write a concise consultation report with practical recommendations for intervention that can be implemented in the pediatric setting.
4. Work with staff to deal with physician/staff or family/staff issues that may interfere with care.
5. Assess a suicidal patient.
6. Work with a dying child or adolescent and his/her family.

C. Attitudes - The resident should demonstrate:

1. An interest in learning about the pediatric consultation and liaison.
2. A non-prejudicial approach to patients, families and other medical providers.
3. Active participation, regular attendance and preparation.
4. Motivation to work with as many different patients and families as possible.
5. Responsible approach to all aspects of the experience.
6. Professional and ethical approach to all aspects of the experience.

D. Strategies

1. Integrated into the Child Psychiatry Residency Lecture series will be the following core consultation/liaison lectures:
   • Evaluation and Triage of Suicidality
   • Pain Management
   • Physical Trauma/PTSD
   • Somatoform Disorders in Children
   • Dealing with Chronic Illness.
   • Death and Dying
2. Residents will see all pediatric consultations requested in a timely manner.
3. Each case will be presented to and most will actually be seen by the attending consultant (either psychologist or child and adolescent psychiatrist) and discussed in depth prior to final assessment and recommendations are formulated.
4. Residents are monitored closely for competency in consultation issues and evaluated on at least four pediatric disease-related categories as to competence to implement interventions independently.
5. Supervision on each case is intensive and includes case review of resident's initial evaluation, modeling of assessment/treatments by the attending, case formulation discussion and supervision of case follow-ups.
6. Handouts and articles are provided on various topics relevant to the specific consultations.
7. All experiences are assessed in the context of the Core Competencies.

Clinical Rotation 05: Residential Treatment Rotation - Lighthouse

The goal of this rotation is to provide residents with an continuous experience working with in a long-term treatment facility for adolescents. The resident will have opportunities to evaluate adolescents as they enter the program and follow them within the program over several months in the program. The resident will also gain experience in working with the multidisciplinary team and observ ing the various facets of the residential treatment program at work.

A. Knowledge - At the end of this rotation, the resident should be able to:

1. Discuss differentiation between the indications for home based, intensive, acute inpatient and residential care for children and adolescents.
2. Discuss aspects of advocacy for adolescents and families within this setting.
3. Recognize the contributions of the various members of the multidisciplinary treatment team and the psychiatrist's role within this setting.
4. Recognize the myriad of disorders and potential psychiatric and social interventions that may be used within the residential setting including psychopharmacology and psychosocial therapies.

B. Skills - At the end of this rotation, the resident should be able to:

1. Function comfortably in the residential treatment setting.
2. Participate in the admission process that brings adolescents to the residential treatment setting.
3. Provide psychiatric services to the multidisciplinary team through direct assessment and treatment recommendations to the team, and through actual provision of direct psychopharmacology, diagnostic, and group and individual therapies.
4. Work with the treatment team to develop intensive behavioral interventions for youth with serious and complicated behavior problems.
5. Work with the treatment team to develop comprehensive discharge plans for youth with severe mental health problems.

C. Attitudes - The resident should demonstrate:

1. An interest in learning about youth with severe mental illness.
2. A non-prejudicial approach to patients, families and providers within the juvenile justice setting.
3. Active participation, regular attendance and preparation.
4. Motivation to work with as many different patients and families as possible.
5. Responsible approach to all aspects of the experience.
6. Professional and ethical approach to all aspects of the experience.

D. Strategies

1. The resident will work within the setting for 6 months to allow continuity and facilitate membership in and contributions to the treatment team.
2. The resident will carry a caseload of patients with serious and complicated psychiatric morbidity.
3. The resident will observe patients in residential treatment facility milieu and work with staff to develop behavioral, individual and group interventions as well as provide psychopharmacology consultation when appropriate.
4. The resident will provide education regarding the provision of services to youth with severe emotional and behavioral disturbances.
5. The faculty supervisor will supervise the resident in all of these endeavors on an individual basis.
6. The resident will be evaluated in the context of the Core Competencies.

Clinical Rotation 06: School Consultation

The goal of this rotation is to expose residents to the role of the child and adolescent psychiatrist in the regular and psychoeducational school setting through didactics that define the consultant's role and boundaries, school visits where residents work collaboratively with teachers, social workers, school psychologists, and school administration to develop and implement educational strategies that optimize academic performance and decrease problematic classroom behavior, and participation in formal educational meetings to formulate individualized educational treatment plans.

A. Knowledge - At the end of this rotation the resident should be able to:

1. Define the models of school consultation and the role of the child and adolescent psychiatrist under each model of service.
2. Understand the role of the child and adolescent psychiatrist in a non-medical setting.
3. Understand the role of school collaboration in the comprehensive treatment of a child or adolescent.
4. Discuss the components of an individualized educational plan and the process for development of such a plan.
5. Understand the legal issues related to children in schools.
6. Recognize teaching methods effective for children with severe cognitive, emotional and behavioral impairments.
7. Discuss behavioral and social skills interventions effective in working with children in schools.
8. Appreciate that information presented to non-medical professionals differ from presentations to medical professionals.

B. Skills - At the end of this rotation the resident should be able to:

1. Conduct a school consultation, including classroom observations and discussions with teachers and other personnel to communicate behavioral approaches to optimizing the child's function in the academic setting.
2. Collaborate with a parent, school teachers, and school administration to develop an individualized educational plan.
3. Actively participate in a student support team or individualized educational plan meeting.
4. Advocate for the child within the school system based on federal laws governing the child's rights.
5. Present information on mental health topics to social workers and school personnel that is appropriate for non-medical professionals.

C. Attitudes - The resident should demonstrate:

1. An interest in learning about children and adolescents within the school setting.
2. A non-prejudicial approach to patients, families and educators within the school setting.
3. Professionalism by active participation, regular attendance and preparation for didactics and school visits related to school consultation.
4. Motivation to work in as many different educational systems and with patients with as many different educational needs as possible.
5. Responsible and ethical approach to all aspects of the experience.

D. Strategies

1. The resident will receive a minimum of four hours of didactics exploring models of consultation, educational rights of students with disabilities including “other health impaired”, educational strategies effective for specific diagnostic categories (i.e. ADHD, autism, oppositional defiant disorder, psychosis), and obstacles that may impede effective school consultation.
2. The resident will work closely with the psychoeducational school system over a period of time that allows for continuity of care and facilitates a process for becoming a part of the educational team.
3. The resident will spend time observing children in the psychoeducational school, focusing on the challenges that emotionally disturbed children and/or autistic students have in the academic setting.
4. The resident will work with the school staff to develop behavioral and social skills interventions for the children for whom consultation is requested. It is expected that the resident will consult on at least one case or classroom every two weeks.
5. The resident will attend monthly multidisciplinary team meetings where he/she will facilitate the discussion of a clinical case or present a mental health topic to teachers, school administrators, and social workers.
6. The resident will visit and observe at least one child or classroom in a regular education setting.
7. The resident will be assigned a formal review of an individualized treatment plan.
8. The resident will attend at least one student support team or individualized educational plan meeting during the rotation.
9. The faculty supervisor will supervise the resident in all of these endeavors on an individual basis.

Clinical Rotation 07: Forensic Consultation/Juvenile Justice Rotation

The goal of this rotation is to provide residents with an in-depth continuous experience working with a system of care within the juvenile justice system. The resident will have opportunities to observe the juvenile justice system at work, to consult on very complicated cases within the system, and to provide education to and team input into the multidisciplinary team working with these troubled youth.

A. Knowledge - At the end of this rotation, the resident should be able to:

1. Discuss the legal process that brings adolescents to a juvenile justice facility.
2. Discuss aspects of advocacy for adolescents within this system.
3. Understand the milieu within which psychiatric consultation and treatment occurs.
4. Recognize the contributions of the various members of the juvenile justice treatment team.
5. Recognize the myriad of disorders and potential psychiatric and social interventions within the juvenile justice system including psychopharmacology and psychosocial therapies.
6. Differentiate between "corrections" and interventions for treatment.

B. Skills - At the end of this rotation, the resident should be able to:

1. Function comfortably in the juvenile justice setting.
2. Participate in the legal process that brings adolescents to the juvenile justice setting.
3. Work with youth and families regarding transition from YDC back into the community, facilitating improvement around parenting issues and consistent limit setting and identifying community resources to help.
4. Provide psychiatric consultation to the multidisciplinary team in team meetings, through direct assessment and treatment recommendations to the team, and through actual provision of direct psychopharmacology, diagnostic, and group and individual therapies.
5. Work with the treatment team to develop intensive behavioral interventions for youth with serious and complicated behavior problems.

C. Attitudes - The resident should demonstrate:

1. An interest in learning about adolescents within the juvenile justice setting.
2. A non-prejudicial approach to patients, families and providers within the juvenile justice setting.
3. Active participation, regular attendance and preparation.
4. Motivation to work with as many different patients and families as possible.
5. Responsible approach to all aspects of the experience.
6. Professional and ethical approach to all aspects of the experience.

D. Strategies

1. The resident will work within the setting for 6 months to allow continuity and facilitate membership in and contributions to the treatment team
2. The resident will carry a caseload of patients with serious and complicated psychiatric morbidity
3. The resident will observe patients in the incarcerative facility milieu and work with staff to develop behavioral, individual and group interventions as well as provide psychopharmacology consultation when appropriate
4. The resident will attend multidisciplinary team meetings during which the cases with whom he/she is involved are discussed
5. The resident will provide education regarding the provision of services to adjudicated youth with severe emotional and behavioral disturbances
6. The faculty supervisor will supervise the resident in all of these endeavors on an individual basis as well as on-site on a weekly basis

Clinical Rotation 08: Community Rotation Experience - Transitional Family Services

The goal of this rotation is to provide residents with an experience that exposes them to children and families that are being served in the community by intensive in home family based services. On this rotation the resident, working with and child and adolescent psychiatry faculty member will provide psychiatric evaluations and medication management services to children and adolescents who have had intake evaluations by transitional family services staff. Then the resident will have an opportunity to participate in team meetings where the ongoing care and treatment planning for these children, adolescents and their families along with other clients are discussed over a period of time as well as have some opportunities to accompany in home service delivery staff as they provide services for a number of times during the rotation.

A. Knowledge - At the end of this rotation, the resident should be able to:

1. Discuss the indications for referral to home based, intensive outpatient mental health interventions for children, adolescents and their families.
2. Identify the components of intensive in home mental health interventions for children, adolescents and their families.
3. Recognize the contributions of the various members of the multidisciplinary treatment on this team.
4. Recognize how in home interventions can serve as the least restrictive alternative intervention for many seriously mentally ill children and adolescents and prevent unnecessary hospitalizations or out of home care.

B. Skills - At the end of this rotation, the resident should be able to:

1. Refer outpatients and inpatients ready for discharge appropriately to intensive in-home and wrap around services in the community.
2. Serve as a psychiatric consultant to community agencies that provide intensive outpatient and in-home services to families with children and adolescents with serious mental illness problems.
3. Provide psychiatric services to the multidisciplinary team through direct assessment and treatment recommendations to the team, and through actual provision of direct psychopharmacology and diagnostic services.
4. Work with the treatment team to develop intensive behavioral interventions for youth with serious and complicated behavior problems.
5. Work with the treatment team to develop comprehensive discharge plans for youth with severe mental health problems.

C. Attitudes -The resident should demonstrate:

1. An interest in learning about youth with severe mental illness.
2. A non-prejudicial approach to patients, families and providers within community mental health setting.
3. Active participation, regular attendance and preparation.
4. Motivation to work with as many different patients and families as possible.
5. Responsible approach to all aspects of the experience.
6. Professional and ethical approach to all aspects of the experience.

D. Strategies

1. The resident will work within the setting for 4 months to allow continuity and facilitate membership in and contributions to the treatment team.
2. The resident will carry a caseload of patients with serious and complicated psychiatric morbidity.
3. The resident will observe patients in community setting and work with staff as appropriate to facilitate treatment.
4. The resident will provide education regarding the provision of services to youth with severe emotional and behavioral disturbances.
5. The faculty supervisor will supervise the resident in all of these endeavors on an individual basis.
6. The resident will be evaluated in the context of the Core Competencies.

Clinical Rotation 09: Elective Rotation

The goal of this rotation is to provide residents with opportunities to choose some of their educational experiences, either to expand or improve their knowledge and skills in a certain area or to explore a new area not specifically covered in the training program. Electives are planned individually between the resident and the PD and may involve any number of possibilities.