INPATIENT PSYCHIATRY (ADULT)
Our inpatient services treat patients with a broad diagnostic range of acute and chronic psychiatric disorders. There are 3 adult inpatient units, one of which has med-psych beds.
Residents spend 10-12 hours weekly in seminars, rounds, and clinical case conferences; case loads are carefully monitored (by the attending and resident logs) and controlled for both breadth and variety of experience. Rounds take place daily and residents interview patients in front of the team, as well as participating in treatment planning. Residents also have a clinical skills examination during the rotation. Learning the biopsychosocial evaluation is emphasized. The clinical population on the inpatient service is extremely heterogeneous, with ages from 18 and older. The unit with the med-psych beds had more geriatric patients and more patients with significant medical illnesses. Diagnostically, the patient population spans the spectrum from psychotic/schizophrenic disorders to affective disorders, personality disorders, neurocognitive and somatoform disorders, frequently co-morbid with substance abuse. Residents see patients individually and work with the social workers on family therapy meetings and discharge planning. Residents spend their time learning psychopharmacology, psychotherapy (individual/group/family) and the medical management of the patient, and also work with medical students assigned to their unit.
PSYCHIATRIC EVALUATION AND REFERRAL CENTER (PERC)
PERC serves patients of all ages and is available 24 hours a day. Patients undergo evaluation for admission or referral to the outpatient department for short or long-term treatment. Emphasis is on the diagnosis and evaluation of medical and neurological problems presenting with psychiatric symptoms as well as psychiatric disorders. These patients commonly have acute symptomatology and often require acute hospitalization. Residents do the initial evaluation, give emergency medications when indicated, and collaborate with the E & R attendings regarding final disposition, i.e., admission or discharge. Emphasis is placed on comprehensive, efficiently done evaluations and treatment of emergency patients. Residents are directly observed while doing all clinical evaluations of patients until such time as resident is competent to do these on their own. All cases are presented to attendings after the initial interview, and all cases are presented and reviewed by an attending during daily morning rounds the following morning when a resident has worked a night shift. Residents learn about the legal papers required for involuntary admission to the hospital, and dealing with patients in acute crisis. Other clinical staff members, such as psychologists and mental health workers, also evaluate patients in the PERC. They are responsible for most non-complicated initial evaluations of patients referred to the OPD.
There are between 400-500 patients seen each month in the emergency room. These patients come from a wide range of ethnic and socioeconomic groups and range from children to the elderly. The most common diagnostic groups seen are psychosis and suicide attempt secondary to schizophrenia, mood disorder, personality disorders and drug related problems.
ADULT PSYCHIATRIC OUTPATIENT SERVICE
Behavioral Health Center at Westchester Medical Center
Our outpatient service offers a full range of psychiatric treatment options. The adult OPD averages about 11,000-12,000 visits per year, and is staffed by social workers, psychologists, mental health workers, a nurse practitioner, psychiatry attendings, residents and other trainees. Residents may spend three to four hours per week evaluating new patients. Once they have seen the patient, they present the case to a supervisor who then joins the resident in seeing the patient. Interviewing technique, differential diagnosis and treatment planning are discussed. Residents treat adult patients in individual, group and family modalities. Treatment approaches utilized include: supportive psychotherapy, crisis intervention, brief and long-term psychodynamic therapies, combined psychotherapy and medication, cognitive behavioral therapy, group and family therapy, and psychopharmacological treatment. Each resident sees individual patients, co-leads one or two weekly groups, and does one or two weekly intake evaluations. Residents participate in a weekly meeting of all OPD staff to discuss patient evaluations and treatment planning.
The OPD has a broad ethnic mix, reflecting the surrounding community. The predominant patient populations are middle-class, working class, and poor socio-economic groups. Patients have the full-spectrum of psychiatric diagnoses, including adjustment disorders, major depression, anxiety disorders, personality disorders, and some cases of dementia. The OPD also treat patients with severe and chronic mental illness including patients with schizophrenia, and bipolar disorder. Many of the patients have co-morbid medical problems including hepatitis C, multiple sclerosis, chronic pain, and HIV. There are specific programs that residents participate in for specific patient populations, ITOP for fragile, chronically mentally ill patients, Gateway for gay, lesbian, bisexual and transgender patients, and Step-Up for patients with severe personality disorders. Residents have the option of seeing an adolescent patient, and there are a significant number of geriatric patients as well.
50% of the residents’ time is spent on the outpatient day treatment substance abuse service and 50% on the inpatient detoxification unit at St. Vincent’s Hospital in Harrison, NY. Working closely with the faculty, residents learn to perform comprehensive substance abuse assessments and refine their interviewing techniques. There are extensive daily rounds with the attending psychiatrist. The resident learns inpatient and outpatient detoxification protocols, sees individual patients as well as some families of patients who have substance abuse problems. The resident does 3 comprehensive substance abuse evaluations per week and is also assigned 5 patients who are each seen individually 1 to 3 times per week. The resident attends 3 to 5 outpatient substance treatment groups per week and 3 outpatient team meeting per week, and does 1 inpatient unit presentation per rotation.
CONSULTATION LIAISON PSYCHIATRY
The Division of Psychosomatic Medicine provides psychiatric consultation and liaison activities to all the clinical services of the university hospital, a 600 bed general and tertiary care hospital with many extremely ill patients. Consultations are provided for patients with a wide variety of disorders connected to their physical illness. Liaison services may also be offered to specialty clinical services such as our dialysis, burn, stroke, trauma, cancer, and various transplant services. Residents attend four hours of weekly C-L Journal Club, rounds, chart rounds and case discussions. In addition, all of their clinical cases are supervised at the bedside by an attending. Residents spend about 35% of their time seeing new patients, 35% of their time seeing follow-up patients and 30% of their time in supervisory and other teaching activities.
Consultation liaison psychiatry is also available at Lenox Hill Hospital with 650 beds. The hospital is particularly well known for excellence in internal medicine, cardiovascular disease, orthopedics, sports medicine, otolaryngology/head and neck surgery, and maternal/child health. It has an active C/L service where residents can rotate in conjunction with a junior attending selective on the inpatient unit.
C/L is also a very popular elective, providing the opportunity for more experience is a specialized setting such as transplant, burn, HIV Clinic, trauma or pregnancy, labor and delivery.
CHILD AND ADOLESCENT PSYCHIATRY
WMC has both an inpatient adolescent unit as well as a children’s unit. Residents on the inpatient units are directly supervised on new admissions. The resident is responsible for diagnostic work-ups, individual and group psychotherapy, and psychopharmacotherapy, as well as treatment planning. They attend daily rounds, weekly multi-disciplinary team meetings, teaching rounds by voluntary faculty, and participate and receive supervision in patient groups and family meetings. Each resident has at least 2 hours of individual supervision per week. Most patients are from foster or single-parent families with multiple psychosocial problems, i.e. physical and sexual abuse, domestic violence, parental incarceration, parental alcohol and substance abuse. Diagnoses include ADHD, disruptive behavior disorder, depression, PTSD & anxiety disorders, psychotic disorders, mental retardation and pervasive developmental disorders. A multimodal treatment approach is used with milieu, individual, group and family therapy, as well as pharmacological treatment.
In addition, we provide evaluation and treatment of children and adolescents on pediatric consultation/liaison, outpatient, and forensic services.
We offer evaluation and treatment of geriatric patients in an inpatient medical setting. Residents usually rotate on the med-psych unit at WMC and gain experience in the treatment of elderly patients, with and without co-morbid medical illnesses. They may also rotate on the geriatric inpatient unit at St. Vincent’s Hospital in Westchester for experience with ECT.
SCHOLARLY PROJECT REQUIREMENT
A scholarly project is required of all residents. The resident may begin a project during the PGY 2 year and must complete this requirement in order to graduate from our program. The scholarly product may be an original clinical research report, a case report, a comprehensive literature review, or a research project. Under the supervision of an attending psychiatrist or research psychologist, residents can participate in either clinical or basic science research in the department, medical school, or pursue their own original research. A research psychologist is available to match residents with projects and assist in data analysis. The scholarly project must be written up, and be of sufficient quality to be either submitted for publication or presented. If not submitted for publication, the project must be presented in Grand Rounds or another appropriate format. All residents present their projects at a Resident Research Forum in June.
Discussions are underway to provide research electives for residents at the Nathan Kline Institute, one of two psychiatry research institutes in New York State. NKI is located on the grounds of Rockland Psychiatric Center and is staffed by world- renowned researchers. This should afford an opportunity for residents with an interest in research to gain more experience and have additional mentors. Residents also have the opportunity to work with faculty from other departments including internal medicine and neuroradiology on research projects.
THE PSYCHOANALYTIC INSTITUTE
The Psychoanalytic Institute of the Department of Psychiatry at New York Medical College offers comprehensive instruction in psychodynamic psychotherapy. The faculty of the Psychoanalytic Institute provides senior teachers and supervisors to the psychiatric residency training program. Residents can take a two-year course starting in their third year of residency, which leads to Certification in Psychodynamic Psychotherapy. Credit for the first year of training in the Psychoanalytic Institute can be given to residents who complete this course. In addition, an elective in psychodynamic psychotherapy is offered to residents as part of the curriculum.