Yale New Haven Hospital (YNHH)
Inpatient Consultation Service
The faculty consists of 4 full time attending psychiatrists and 3 part-time attending psychiatrists whose clinical specialty includes psychosomatic medicine, as well as 1 -2 part-time clinical faculty who supervise/lecture 1 to 4 times per month. Fellows will see patients for consultations in the hospital. Virtually all consultations are also seen by an attending psychiatrist. Consultations seen by the service are reviewed each morning on rounds, permitting team discussion of the fellows’ consultations and also permitting each trainee exposure to all consultations seen by the service. Fellows will also participate in education and supervision of more junior psychiatry fellow s and medical students. The Psychiatric Consultation Service is well-integrated into the hospital. Fellows and other members of the consult service often are invited to participate in case conferences and rounds on other services in the hospital, allowing the fellows experience in the liaison and educational aspects of the consultant role.
The hospital is a large urban tertiary referral academic center, providing exposure to a diverse group of patients spanning all socioeconomic strata. Approximately 51% of patients seen are female. In a recent series of patients, 71% were non-Hispanic Caucasian, 19% black, 8% Hispanic and 2% other. Approximately 28% are in the age range <40, 44% 40 – 64, and 27% 65 or older. The chief consultant issues in a recent sampling were: 25% depression and anxiety; 22% delirium/dementia; 11% substance abuse; 11% suicide attempts; 11% suicidal ideation; 9% medical decision making; 5% possible psychogenic etiology of illness. The service sees about 2,000 initial consults per year. Treatment interventions include pharmacological therapy, individual and family psychotherapy, patient and family education, behavioral management planning with consulting service, and legal assessments regarding psychiatric commitment or conservatorship.
- Fellows will perform approximately 120 initial consultations per 3 month block, and will provide follow up subsequent hospital visits as required for their patients. Fellows will assist in seeing consultations and supervision of more junior trainees.
- All patients seen by the service are reviewed in daily rounds. At least 1 staff attending psychiatrist is present on the service throughout the week and involved in review and supervision of initial and follow up clinical care. As noted, all consultations are to be seen by staff attending psychiatrists. Fellows rotating on the service at YNHH will participate in specific clinical and didactic supervision with 1 staff attending for 1 hour per week. This supervision will discuss clinical cases seen by the team that week, as well as the educational and administrative function of the fellows for the service. One or 2 general psychiatry PGY-II fellow s, 1 to 3 medical students, and occasionally fellow s from other services also participate in providing consultations.
- During the course of the year fellows will assume increasing responsibility in patient management.
*As noted in Rotation Schedule. Design of Program, in some cases the rotation at YNHH may be adjusted to 6 to 9 months.
- The faculty consists of 1 staff attending psychiatrist (Dr. Gabriela Balf, who is boarded in both psychiatry and medicine). In addition, a psychiatric social worker is on staff for 20 hours a week. Fellows will see outpatients of the Primary Care Clinic for initial evaluation and continuing psychiatric care. The clinic is particularly oriented towards the interaction of psychiatric and medical factors, both psychiatric conditions affecting medical care and medical conditions or treatments with psychiatric effects. Fellow participate in team rounds and collaborate closely with primary care staff. The service is also integrated with the social work service and case management system of the clinic.
- The fellow will evaluate approximately 4 to 8 new patients per week and follow 4 to 8 patients per week, under supervision by staff attending in clinic. Much of the medical care of the patients in this clinic is provided by house staff in the Internal Medicine program, as well as Internal Medicine faculty. Fellows contribute to education and liaison activities with resident and attending physicians, social work and nursing staff. This clinic is a site of the research efforts of Dr. W. Sledge, who is studying the concentration of medical service utilization and costs among a small number of patients.
- This is a multidisciplinary HIV and AIDS infectious disease clinic under the auspices of Yale-New Hospital. The faculty includes approximately six Internal Medicine faculty and one staff attending psychiatrist (Dr. Maya Prabhu), as well as one Spanish-speaking attending psychiatrist (Dr. Jorge Aguilar-Zonata). Fellows will see outpatients of the clinic for initial evaluation and continuing psychiatric care. Fellows work with multidisciplinary care teams of the clinic which include social work and case management. The hospital has a dedicated HIV inpatient unit, which is in this unit, and fellows have the opportunity to coordinate inpatient and outpatient care.
- This is an inner-city, specialty infectious disease clinic and includes patients from 18 to early 70’s years of age. The average age is roughly 36 years with 65% female and with 20% Hispanic, 40% African-American, and 40% Caucasian. The types of treatment provided are psychiatric evaluation/assessment, medication administration, and engagement in motivational enhancement for substance abusing, as well as mentally ill, patients. Active clinic caseload is about 600 individuals.
- Average caseloads are 4 to 8 patients, depending on acuity, and the amount of time in the elective, seen collaboratively with a staff attending. Fellows will participate in teaching and training of multidisciplinary care teams.
- The faculty consists of 1 staff attending psychiatrist (Dr. Paula Zimbrean) with particular experience in transplantation psychiatry, in addiction psychiatry (with board certification in this qualification), and in outpatient primary care consultation/liaison. The transplantation services include social work and nursing resources which are an integral part of the care team. Fellows will see both outpatients and inpatients for evaluation as transplantation candidates, for psychiatric care before and after transplantation, and for consultation regarding adjustment to the transplant process, psychiatric effects of medications, and other issues specific to the transplantation patient. YNHH has heart, kidney and liver transplantation programs. Chief interventions are psychiatric assessment, counseling and psychotherapy, medication management, and evaluation for appropriate referral to mental health, social work and substance abuse resources.
- Fellows would be expected to participate in approximately 1 initial evaluation and 1 -2 subsequent visits per week. Fellows will work closely with the staff attending psychiatrist.
- Fellows will also participate in guided reading and discussion of recent research literature in transplantation psychiatry with the staff attending psychiatrist. Fellows will participate in rounds and team meetings with the transplantation services.
- Faculty includes 1 staff attending psychiatrist (Dr. Paul Desan), as well as 1 attending neurologist (Dr. Brad Duckrow) and 1 attending neurosurgeon (Dr. Dennis Spencer). Fellows will round with the Epilepsy Service approximately 3 times per week, and attend Epilepsy Neurosurgery rounds once per week. Fellows will provide evaluation and continuing psychiatric care for outpatients with epilepsy, as well as for patients with non-epileptic seizures (“pseudoseizures”). Psychotherapy with non-epileptic seizures is a unique opportunity for training in the approach to conversion disorders. Level of responsibility will vary with trainee experience and clinical context.
- Fellows will be directly supervised by on-site attending staff. Fellows will perform an educational and liaison role for the epilepsy services.
- Faculty includes 1 staff attending psychiatrist with added qualification in geriatric psychiatry (Dr. Raj Tampi), as well as the regular staff of the clinic, including physician, psychologist and social work geriatric specialists. Fellows will participate in team care for geriatric patients. Fellows will become familiar with application of diagnostic criteria for dementia subtypes, formal mental status testing procedures and work up for dementia, and neuroimaging in the elderly. Fellows will participate in the treatment of dementia with cognitive enhancers, the treatment of agitation and psychosis in dementia, and in the treatment of geriatric depression. Fellows are also involved in the education and counseling of families.
- Fellows would be expected to participate in approximately 1 -2 initial evaluations and 3 – 4 subsequent visits per week, in addition to their participation patient care rounds. Fellows will participate with and be directly supervised by on-site multi-disciplinary team.
- This elective is under the direction of Dr. Paul Desan; depending on the medical service, other program faculty will be involved. Multiple medical services in the hospital offer the option of a liaison position for a fellow. Services with which such arrangements have been made in recent years include internal medicine, hospitalist (a non-resident physician/physician assistant team which sees some hospital inpatients without a community attending), medical intensive care, neurology, obstetrics, transplantation, HIV infectious disease, and oncology. Depending on the service, fellows will (1) participate in regular hospital care rounds, (2) participate in case conferences regarding patients with behavioral medicine issues, (3 ) attend or lead didactic presentations relevant to a particular service, (4) participate in or lead debriefing or discussion meetings regarding care provider experiences on the service, (5) perform consultations regarding inpatient or outpatient care, engage in treatment planning and coordination, and provide psychotherapeutic or pharmacological therapy.
- The proportion of liaison provision compared to direct clinical care will vary between different services. Level of supervision and level of responsibility will correspondingly vary, and also depend on the clinical setting, as well as the experience and background of the fellow. In all of these settings, fellow s will work in conjunction with a faculty psychiatrist whose primary clinical responsibilities are to provide care to these specialized, persistently ill patients.
- The CIU is the psychiatric section of the hospital emergency department. The elective is under the direction of Dr. Seth Powsner, who is the director of the CIU and who is board-certified in Psychosomatic Medicine as well as Geriatric Psychiatry. Fellows will also be supervised by staff attending psychiatrists in the unit. Fellows will see patients admitted to the psychiatric emergency department at YNHH for the evaluation and management of acute psychiatric illness.
- Fellows would be expected to perform approximately 4 evaluations per week. An attending psychiatrist is present in the CIU. Fellows will work with and be supervised by CIU attending staff. The CIU also trains medical students, and residents from the general psychiatry program and from the emergency medicine program. Fellows will contribute to the education and supervision of medical students and residents.
- The elective will be supervised by Drs. Paul Desan and Kimberly Yonkers. Fellows will have the opportunity to collaborate with a variety of research investigators from the Department of Psychiatry. Research areas may include inpatient and outpatient consultation psychiatry, other clinical areas of psychiatry, and pre-clinical or basic research. Research training must be in areas consistent with career development in psychosomatic medicine.
- Fellows will meet regularly with the supervising attending for review of research activities. Assessment of fellow performance will be made by the elective supervisors and by the specific research supervisor on a continuing basis.
- Faculty includes 2 staff attending psychiatrist (Dr. Robert Ostroff and Karen Kerfoot) with extensive experience in ECT. Fellows will participate in the evaluation of patients for ECT, administration of ECT, and management of patients after treatment.
- Fellows would be expected to participate in approximately 7 – 9 treatments per week. Fellows will be directly supervised by on-site attending staff. At least 6 months duration is recommended for fellows intending to practice in this area.
- An elective in other specialty clinics could be considered when such an experience would be appropriate for the educational goals of a particular fellow. Such an elective would require the availability of suitable supervision and selection of specific training objective.
The Veterans Administration Connecticut Healthcare System (VACHS)
VACHS is a tertiary care facility associated with the Yale University School of Medicine. It is approximately 4 miles from YNHH. A shuttle runs continuously between the VACHS and YNHH during the day. The VACHS offers a full range of inpatient, outpatient and rehabilitation care, in medicine, surgery, psychiatry, and neurology. It also offers the Comprehensive Cancer Center, the National Center for PTSD, the Eastern Regional Blind Rehabilitation Center (ERBC), the Northeast Program Evaluation Center (health services delivery research), and the Women’s Health Center. The VACHS is recognized nationally as a psychiatry research center, including research in the areas of Addiction Psychiatry and PTSD.
The Psychiatry Consultation-Liaison Service at the VACHS is an active training site of the Yale University School of Medicine for third and fourth year medical students, PGY 2 and 4 psychiatry fellows, and PGY 5 fellows in addiction, and geriatric psychiatry. The C-L Service is a required training site for Fellows in Psychosomatic Medicine, 3-6 months per year, for 80-90% time. Fellows provide psychiatric consultation to inpatient and rehabilitation settings, totaling 150 beds; this includes consultation to intensive care units, acute inpatient medicine and surgery services, and outpatient rehabilitation settings (Eastern Regional Blind Rehabilitation Center, Geriatric Rehabilitation Service), all on site. Fellows also provide liaison to the National Center for PTSD, Addiction and Geriatric Psychiatry Services, and Inpatient Psychiatry Service, all at the VACHS.
Psychosomatic Medicine Fellows have major responsibilities in 1) the education and supervision of colleagues in training, and 2) the administration of the clinical mission. Psychosomatic Medicine Fellows teach service colleagues (fellows, residents and medical students) at the bedside, and in weekly didactic rounds, and administer the triage of consultations on the service. Fellows collaborate with inpatient Medicine Chief Residents for joint, medicine-psychiatry conferences, on a monthly basis, 10 hours per year.
Fellows participate in electives, 10% time, concentrating in areas of special interest; these include outpatient settings: PTSD Clinic, Geriatric Psychiatry Clinic, CBT Seminar/Long-term Supervision, Substance Abuse Clinic, and Women’s Health Center Clinic.
Fellows may also elect to conduct research in C-L psychiatry, by joining service attending psychiatrists in current national research projects in health services research, the medicine/psychiatry interface, or by developing new projects.
Fellows may attend weekly Departmental Grand Rounds at Yale. Travel to Yale is 15 minutes by daily shuttle bus service, for the 4 miles between Yale School of Medicine and VACHS.
Fellows are directly supervised by the service director Dr. Catherine Chiles, service attending Dr. Zinaida Boutaeva, and elective site supervisors: Dr. Dolores Vojvoda, Dr. Paul Kirwin, Dr. Bob Kerns, Dr. Shannon Drew and Dr. Joseph Erdos. All attending psychiatrists are privileged at the VACHS, and appointed at the Yale University School of Medicine.
Inpatient Consultation Service
The faculty includes 1 director, who is a staff psychiatrist with added qualifications in Psychosomatic Medicine, part-time to the consult service, and 1 staff psychiatrist with added qualifications in Addiction Psychiatry, part-time to the consult service. Elective site supervisors, all based at the VACHS, include 4 staff psychiatrists (1 with added qualification in Geriatric Psychiatry, and 1 with added qualification in Addiction Psychiatry), as well as 1 staff psychologist. Fellows are educated at the bedside by the attending psychiatrist, through the year. Fellows attend and may lead service didactic rounds, one hour weekly, in which trainees (including Fellows) on the service, in rotation, lead a case presentation, combined with pertinent literature review, on topics of interest in Psychosomatic Medicine. Fellows also lead/teach monthly Medicine-Psychiatry Joint Case Conference, coordinating the selection of cases and didactics, and collaborating with the medicine chief resident, for junior trainees in medicine and psychiatry. Fellows in Psychosomatic Medicine are supplied with textbooks, APA Practice Guidelines, and computers and given access to libraries at the VACHS and YSM; they have their own dedicated work station. Fellows also attend the Fellowship Program didactics for 2 hours, weekly.
The VACHS is a tertiary care hospital providing care to the 270,000 Veterans in the Connecticut area. Patients span the generations of Veterans from World War II to the current conflict in Iraq, men and women. The VACHS has a mission to serve the underserved, for example, through homeless programs, outreach services and compensated work therapy. The Psychiatry Consultation-Liaison Service performs approximately 700 initial consultations, and 2500 follow-up evaluations per year. Diagnoses of consult patients in a recent sample of 100 inpatients were: Mood 41%, Delirium 34%; Addiction 31%; Anxiety/PTSD 14%; Dementia 13%; Psychosis 8% with a ratio of women to men 1:20. In this sample, Decision-Making Capacity accounted for 30% of consultation requests. The age ranges were 18-45yr: 2%; 46-70yr: 59%; over 71yr: 39%. In an elective experience, in the women’s Health Center, a significant percentage of women patients were seen for a history of Military Sexual Trauma. Treatment modalities offered by the service include biological treatments (pharmacological therapies, ECT referrals) psychotherapies (brief, individual, CBT, supportive), behavior management/training, and safety assessments (suicidality, homicidality, grave disability). Interventions include collaboration with social workers (family meetings), legal counsel/Probate Court (decision-making capacity, guardians), the Ethics Committee (right-to-die, right to refuse treatments), and the VACHS Hospice (end-of-life, palliative care).
- The Fellow performs approximately 40 initial consults and 120 follow-up visits per 4 month block. In this time period the fellow also supervises another 150 initial consults by other trainees, often conducting the interview as a teaching example for medical students and residents, or assisting in the mastery of core interviewing skills in the consultation. The Fellow also supervises follow-up evaluations by service colleagues, either at the bedside or in daily rounds.
- Fellows conduct consultations in the acute hospital and rehabilitation settings, directly supervised by service attending psychiatrists, and conduct follow-up evaluations. Fellows are supervised in their ability to adequately review the electronic chart, glean data from additional sources, and conduct a thorough, focused consultation examination. They are supervised on their ability to interact with multidisciplinary staffs (primary team, social work service, nurses) to liaison to outpatient or inpatient care providers, to synthesize the data, and formulate a treatment plan. Thorough, yet concise documentation of consultation data and treatment plan is reviewed daily, and countersigned by the attending. Fellows may conduct family meetings, and participate in related Ethics Committee reviews, when indicated, all supervised by the attending psychiatrist. Fellows meet individually with the service attending daily during weekdays. All patients seen in consultation by the Fellow are seen by the service attending.
*As noted in Rotation Schedule, Design of Program, in some cases the rotation at VACHS may be adjusted between 3 – 6 months.
- The elective is supervised by Dr. Marc Rosen (Director, Substance Abuse Treatment Program) and Dr. Shannon Drew (Medical Director, Outpatient Detoxification Services), Dr. Kishorchandra Gonsai (Director, Methadone Maintenance Program, and their staff. Fellows will see patients in 3 settings: (1) the outpatient detoxification clinic; (2) the methadone program; and (3) the intensive outpatient care program.
- Fellows will participate with program staff in patient assessment and treatment planning, both in initial and continuing visits. The most predominant substance use disorders are related to alcohol, cocaine and opiates. Modalities include detoxification, medication management including maintenance therapy, and individual and group substance abuse counseling. The detoxification clinic sees approximately 8 patients per day, which are seen by a multidisciplinary team and reviewed on daily rounds. The fellow would be expected to participate in about 1 initial evaluation for the methadone program or intensive outpatient program each week. The Substance Abuse Treatment Program uses a multidisciplinary team approach to care including psychologists and social workers. Fellows will contribute to the education and supervision of medical students and residents as possible.
- Faculty includes 2 full time psychiatrists, 3 full time internists, 1 part-time geropharmacist, 2 full time social workers and 4 full time clinical nurse specialists (1 in geropsychiatry, 3 in geriatric medicine). Fellows participate in providing initial and continuing psychiatric care to geriatric patients, in collaboration with the clinic multidisciplinary team. The clinic population is 70% male and 30% female, 90% white, 5% black and 5% Hispanic. 50-60% of patients have depression, 40-50% of patients have dementia, 10% of patients are psychotic, 30% of patients have personality disorders, 30% of patients have an anxiety disorder, and 20-30% abuse substances, chiefly alcohol or polysubstances.
- Fellows spend the majority of their time doing comprehensive neuropsychiatric evaluations with ongoing follow up and medication maintenance, with individual and group psychotherapy available. Couples, caregiver and family work are an additional although subordinate emphasis. An average caseload includes 2 - 4 new evaluations and 4 – 5 follow up patients per week, seen in team care. Each fellow receives one hour of supervision per week, and is supervised in the performance of each consultation.
- The elective is supervised by Dr. Dolores Vojvoda and her staff. Fellows will participate in (1) initial multidisciplinary evaluations for new patients; (2) brief psychotherapeutic interventions, which will include cognitive-behavioral approaches; and (3) continuing pharmacological management. Fellows who have elected to complete more than 1 4-month block will be able to undertake longer, supervised individual psychotherapeutic treatment. The PTSD Clinic conducts training in cognitive-behavioral psychotherapy several times per year. Such training includes lectures, directed reading, and group supervision.
- Fellows would be expected to participate in at least one initial evaluation in alternate weeks, and to participate in ongoing care of at least 16 patients. The PTSD clinic is multidisciplinary: fellows will participate under the direction of attending staff, psychologists and social workers. Trainees from the adult psychiatry residency program, fellows from other Yale advanced psychiatry residency programs, and psychology interns also complete rotations in these settings. Fellows will contribute to the education and supervision of medical students and residents as possible.
- The elective is under the direction of Dr. Joseph Erdos. Fellows will see patients for psychiatric consultation in this outpatient primary care clinic for veterans who are women. Typical evaluations are for outpatient management of psychiatric conditions such as depression or panic disorder, evaluation of psychological factors affecting health behaviors or treatment adherence, appropriate use of prescription medications, diagnosis and treatment of somatoform disorders, and management of medical effects of psychiatric medications.
- Fellows will see approximately 2 – 4 outpatients per day, under the close supervision of staff psychiatrists. Faculty supervisors are present in the clinic for ongoing case discussion and supervision.
- The elective is supervised by Dr. John Sellinger and staff. Fellows will be assigned a supervisor for psychotherapy cases. Fellows will participate in a series of seminars about cognitive behavioral therapy in September through December, and will see patients for continuing outpatient psychotherapy. The demographics of the patient population are similar to those described for the VACHS above. Typical issues addressed in CBT interventions include panic and other anxiety disorders, depression, adaptation to illness and chronic pain syndromes.
- Fellows would be expected to see approximately 5 patients for continuing treatment. Fellows will participate in didactics as noted, and are expected to meet with psychotherapy supervisors approximately weekly regarding supervision of their ongoing cases. Fellows will contribute to the education and supervision of medical students and residents as possible, directly and through participation in group supervision.
Electives YNHH 2, 3, 4, 5, 6 and 7 and VACHS 3, 4 5 and 6 offer opportunities for continuing post hospital outpatient care. Diagnostic categories will reflect the nature of the clinic: in YNHH 2 (Primary Care Clinic), 3 (HIV Clinic) 4 (Transplantation Psychiatry Clinic), 7 (Medical Service Liaison), and in VACHS 5 (Women’s Clinic) and VACHS 6 (Cognitive Behavioral therapy), the chief diagnoses are typical of psychiatric primary care practice, including depressive and bipolar disorder, panic disorder, obsessive-compulsive disorder substance use disorders, somatization disorders, chronic psychoses and issues related to adjustment to medical illness. In YNHH 5 (Epilepsy Clinic), the chief diagnoses seen are conversion disorder (non-epileptic seizures or “pseudoseizures”). In YNHH 6 (Geropsychiatry Clinic) and VACHS 3 (Geropsychiatry Clinic), chief diagnosis seen is PTSD. Because fellows participate in 1, 2 or 3 blocks of 4 months, patients may be followed for up to 4, 8 or 12 months. In YNHH 5 (Epilepsy Clinic) and VACHS 6 (Cognitive Behavioral Therapy), some patients may be seen in longer term therapy that will continue beyond the 4 month duration of the elective. In general, in these outpatient clinic settings fellows would be expected to see 1 – 2 initial evaluation and 3 – 6 follow up contacts per week.