Psychosomatic Fellowship Main Rotations and Electives Detail

Yale New Haven Hospital (YNHH)

Main rotation: Inpatient Consultation Service

The faculty consists of 4 full time attending psychiatrists and 2 part-time attending psychiatrists whose clinical specialty includes psychosomatic medicine. 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 more than 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. During the course of the year fellows will assume increasing responsibility in patient management.

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.

YNHH Outpatient experiences

  • 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 two staff attending psychiatrists (Dr. Mark Oldham and Dr. Teofilo Matos Santana). 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). 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.
  • • The faculty consists of 1 staff attending psychiatrist (Dr. Paul Desan, 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 1 to 3 new patients per week and follow 1 to 3 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 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) 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.
  • Depending on the fellow’s specific interests, elective opportunities in other clinics can be arranged. These might include the Bariatric Clinic, which provides evaluation and initial psychiatric care for patients undergoing bariatric surgical procedures; the Sexuality, Intimacy, and Menopause Clinic, which offers care for reproductive system issues arising from cancer survivorship; the Palliative Care Clinic, which provides end-of-life care for inpatients and outpatients; the Sickle Cell Clinic, which offers integrated medical and psychiatric care with consistent providers across both inpatient and outpatient domains.

VA Connecticut Healthcare System (VACHS)

Main rotation: Inpatient Consultation Service

The faculty includes 1 director, who is a staff psychiatrist with added qualifications in Psychosomatic Medicine, and 1 staff psychiatrist with added qualifications in Addiction Psychiatry. 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 in Psychosomatic Medicine will have access to 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 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 600 initial consultations, and 1500 follow-up evaluations per year. Diagnoses of consult patients in a recent sample of 100 inpatients were: substance use disorders 38%; mood disorders 25%; delirium 14%; neurocognitive disorder 11%; anxiety/PTSD 6%; psychosis 5% with a ratio of women to men 1:20. In this sample, Decision-making capacity accounted for 20% of consultation requests. The age ranges were: 18-50yr: 9%; 51-70yr: 65%; over 71yr: 26%. The age ranges were 18-45yr: 2%; 46-70yr: 59%; over 71yr: 39%. 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.

The Psychiatry Consultation-Liaison Service at the VACHS is an active training site of the Yale University School of Medicine medical students, PGY 2 and 4 psychiatry residents, Psychosomatic Medicine fellows and PGY 5 fellows in addiction. The inpatient C-L Service is a required training site for Fellows in Psychosomatic Medicine, 3-4 months per year, for 30% time. Fellows provide psychiatric consultation to inpatient and rehabilitation settings, totaling 200 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 are directly supervised by the service director Dr. Pochu Ho, service attending Dr. Zinaida Boutaeva.

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.

VACHS Electives Detail

  • This outpatient experience is under the direction of Dr. Margaret Altemus. Fellows will see patients for psychiatric consultation in this outpatient primary care clinic for female veterans. 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. In addition to traditional consults, there will be opportunities to see patients with “warm-handoffs” from internal medicine and gynecology attending staff. In the women’s Health Center, a significant percentage of women patients were seen for a history of Military Sexual Trauma. In addition the clinic will provide consults for female veterans with issues related to reproductive psychiatry. Consultations for female veterans may be performed in person or via Telepsychiatry.
  • Fellows will see approximately 4-5 outpatients per day, under the close supervision of staff psychiatrists. Faculty supervisors are present in the clinic for ongoing case discussion and supervision.
  • Dr. David Moore will be the supervisor for the telepsychiatry experience. Fellows will be trained to provide care for patients via telepsychiatry. Typical evaluations are for outpatient management of psychiatric conditions such as depression, anxiety, and PTSD for veterans in rural Connecticut. The VA is a leader in providing mental health to veterans in the rural communities via telepsychiatry.
  • Fellows will see approximately 4-5 outpatients per day, under the close supervision of staff psychiatrists. Faculty supervisors are present in the clinic for ongoing case discussion and supervision.

Outpatient Requirement

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.