key: cord-1012355-fjjp5smg
authors: Beach, Scott R.; Shalev, Daniel; Fischel, Steven V.; Boland, Robert J.; Ernst, Carrie L.
title: Optimizing Fit: Targeting a Residency Psychiatry Consultation-Liaison Rotation to Various Levels of Training
date: 2020-07-17
journal: Psychosomatics
DOI: 10.1016/j.psym.2020.07.002
sha: 008f12871ed535e8b890ce07b2fd28941820fa7b
doc_id: 1012355
cord_uid: fjjp5smg

INTRODUCTION: Determining the optimal timing and structure for a core residency rotation in consultation-liaison psychiatry (CLP) remains a key challenge for program directors and rotation leaders. Previous surveys have been conducted regarding these questions and guidelines from national organizations have been issued, but practices remain varied among institutions. METHODS: We conducted a narrative review of the literature related to the timing of CLP rotations and generated consensus recommendations based on our experience as program directors, rotation leaders, and residents. RESULTS: Explicit goals of CLP training in residency include identifying and treating psychiatric manifestation of medical illness and communicating effectively with primary teams. Implicit goals of training may include conflict management, limit setting and “thinking dirty.” DISCUSSION: Though CLP rotations earlier in residency often create a better fit within the overarching curriculum and allow for generating early interest in the field, significant amounts of supervision are required and consultees may look to attendings as the primary consultant. Conversely, while later rotations are sometimes challenging to structure with other outpatient responsibilities, they allow for greater autonomy and may map better onto the informal curriculum. A hybrid model, with training spread across multiple years, is another approach that may mitigate some of the disadvantages of confining CL training to a single year. CONCLUSIONS: Compelling arguments can be made for placing the core CLP rotation in PGY-2 or -3 or using a hybrid model. Regardless of placement, program directors and rotation leaders should be mindful of tailoring the rotation to the trainees’ developmental stage.

When and how to expose residents to consultation-liaison (CL) psychiatry experiences remains a key issue in residency training. Training programs continue to grapple with questions regarding the optimal year of training for CL rotations, the duration, the types of patients seen, Despite these guidelines, national practices remain highly variable. A 2013 national survey of residencies found that 54% of programs had residents spending 3-6 months on CL rotations, whereas 42% of programs had less than 3 months, and only 4% of programs had more than 6 months (4). Furthermore, 54% of programs included CL training in multiple years, while 34% had CL exclusively in post-graduate-year-2 (PGY-2), and 11% exclusively in PGY3. When residents were on service, 42% of programs had them performing CL-related duties less than full time. At the time, 30% of programs included an ambulatory component to the CL experience.

The varied training experiences throughout the country likely speak to the challenges of structuring a rotation in the context of the competing demands of the overall residency experience. Accordingly, we aimed to outline recommendations for approaches to structuring a CL experience in various years based on the literature and our collective experience training in psychiatry, supervising residents on rotations, directing consultation-liaison services, and running residency programs. We reviewed the small literature base, discussed as a group and also utilized feedback and discussion generated by our presentation of a workshop on this topic at the ACLP 2019 Annual Meeting. In doing this, we focused on better understanding the explicit and implicit goals of CL training in residency. We also hoped to provide an analysis of the relative advantages and disadvantages to certain approaches, in an effort to help program directors determine which strategy might best fit in their own curriculum. While we used the 2014 ACLP training recommendations and other prior surveys as a point of departure, our efforts are focused primarily on providing more granular, practical advice for structuring rotations than is present in those manuscripts.

The specific content of the CL rotation curriculum is left broad in the Accreditation Council for Graduate Medical Education (ACGME) program requirements. The requirements are listed under Section IV.a: Patient Care and Procedural Skills and Section IV.A.5.d: Interpersonal and Communication Skills. The ACGME requires that residents must demonstrate competence in providing consultation to a variety of medical and surgical settings. Also, they are expected to "act in a consultative role" to other physicians and health professionals and to communicate effectively with those and other professionals. The ACGME is currently going through a process of focused revisions of the common program requirements, with a plan for the adoption of the new requirements this year. Although some substantial changes will affect psychiatric training, the curriculum for the CL training remains largely unchanged in the current draft of the new requirements.

In addition to program requirements, the ACGME also defines "milestones," which are intended to be used as part of the semiannual evaluation of resident progress through training (5) .

The intention is to move from a binary process of evaluation to a developmental approach in which residents progress at different rates throughout their years of training. The ACGME milestones for residency training in psychiatry include several competencies specific to CL psychiatry. Residents are expected to demonstrate "sufficient knowledge to identify and treat common psychiatric manifestations of medical illness [KM2 3.3/C]" and should aspire to identify and treat "uncommon psychiatric conditions in medical illness [MK2 5.2/C]" (6 In the revised version of the milestones (Milestones 2.0) which are being planned for use in 2021, the milestones for providing consultation range from the task of respectfully receiving a consult and clearly and concisely responding, to more complex tasks such as helping the consulting team identify unrecognized clinical issues and managing challenging requests (7) . At the highest level, the resident leads a team, although it is understood that not all residents may obtain this level of expertise.

The 1996 ACLP recommendations suggest that the core goal of a resident rotation in CL should be to develop competence in working with patients who have a psychiatric presentation in a medical setting (1) . Specific skills for residents to master include engaging effectively in consultation and liaison processes, performing appropriate psychiatric evaluations of medicallyill patients, and developing suitable therapeutic interventions. In the 2014 update of this recommendation, the ACLP reorganized the goals according to the ACGME core competencies

(2). The goals are greatly broadened and include patient care issues such as performing an appropriate assessment in the medical hospital setting and monitoring their course throughout hospitalization. The medical knowledge goals have been broadened as well, and include understanding both general psychiatric illness in the medical setting (e.g., depression and anxiety), psychiatric illnesses that manifest primarily in medical settings (e.g., somatic symptom disorder), and psychiatric manifestations of medical or surgical disorders (e.g., delirium).

Finally, rotation goals for a CL experience often focus on practical skills that residents may learn during that experience. Residents are expected to develop examination skills that allow them to interview patients in medical settings, develop an alliance with patients relatively quickly, and evaluate medically-ill patients for psychiatric symptoms and cognitive ability.

Communication skills, such as learning to determine the consultee's question and communicating effectively with primary teams, are often highlighted. Documentation is another commonly emphasized area, as residents are expected to learn how to create a consultation note that is comprehensive enough to delineate the patient's medical and psychiatric histories, but concise and clear enough to be useful to the consultee in terms of conveying diagnostic impressions and treatment recommendations. Residents are also often expected to develop important leadership skills by helping to direct the hospital course of patients under their care.

Psychiatrist Ed Hundert and medical sociologist Frederic Hafferty were some of the early authors to apply the terms "hidden curriculum" and "informal curriculum" to medical education.

In contrast to the formal curriculum, which refers to the stated curriculum which is formally offered and endorsed at an institution, the term informal curriculum has been used to describe the ad hoc learning that happens outside of the classroom, during interpersonal interactions between faculty and students. The broader term, hidden curriculum, has been used to describe the attitudes and values conveyed implicitly via an institution's culture, practices and structure (8) (9) (10) (11) . While Hundert and Hafferty were primarily interested in use of these terms are pertaining to bioethics education and the moral and professional development of medical students, they can easily be applied to other aspects of training.

We use the term hidden curriculum here to refer to skills and attitudes acquired by residents during a rotation that are not explicitly stated as goals or objectives of the experience but often end up being more formative and important to one's identity as a physician than do the more traditional goals outlined above. On the C-L Psychiatry service, these values and attitudes are often inferred from the behavior of individual faculty or senior trainee role models as well as from observing group processes during team rounds or consultant/consultee interactions, chart notes (inclusions vs omissions, tone), how and which expectations are set by supervisors at the start of the rotation, and the degree of adherence to consultant recommendations. The argument can be made that the hidden curriculum strongly influences professional identify development of trainees and thus has a more powerful influence that the formal curriculum.

One of the most important skills developed by residents on the CL Psychiatry service is conflict management. Many residents learn quickly that people are not always happy with the psychiatric consultant. Patients may be upset because psychiatry is involved in the first place or may feel that the consultant is setting unfair boundaries and limits. Primary teams may be frustrated that the consultant cannot cure the patient or that the patient remains on their service despite the involvement of the consultant. Other teams may feel as though the consultant is stepping on their toes or disputing their recommendations. To be successful consultants, residents on CL must learn to tolerate conflict and to move beyond their own countertransference towards patients and potential negative affect towards others involved in the care. They must monitor their own affect while also validating the emotional response of the consultee. They learn to set expectations proactively with primary teams at the time of the consult so that recommendations do not ultimately feel anticlimactic. For example, in the case of the patient with functional neurologic symptoms, the resident learns to prime the consultee to not expect a bedside cure, and therefore mitigates a negative reaction when the ultimate recommendation is to pursue outpatient psychotherapy. Learning to manage conflicts and set expectations are useful skills residents can utilize in future work with patients in various settings.

Related to conflict management are the important skills of limit setting and negotiation of ownership. Issues of ownership are a frequent source of conflict on the service, such as the case of the patient with active psychiatric illness whose medical needs cannot be managed on the inpatient psychiatric service or the delirious patient with behavioral dysregulation. Trainees learn to share responsibility for the care of such complex patients while at the same time setting limits to channel ownership back to the consultee. The CL psychiatry trainee also learns quickly the importance of flexibly defining one's limits and usefulness for each unique case, either expanding one's role to ensure quality care when asked an overly narrow question or restricting one's focus or activities if a consultee's expectations are excessive or unreasonable (12) . This process could involve compromise and creative thinking, but should not involve acquiescence to inappropriate treatment or requests (13) . One of the major challenges for many residents on the consult service around defining limits is learning when and how to sign off on patients. Such situations are often highly laden with affect, and residents must ensure that the decision to sign off is not driven by anger at the patient or consultee. At the same time, residents must be taught to maintain awareness of situations where continuing to remain involved may be detrimental to the patient's care.

Through observation of faculty as they interview patients and attentiveness to group discussion during rounds, residents learn to "think dirty," -that is, to recognize hidden motivations for symptoms or behaviors and to better regulate their own emotional responses to patients who engage in such behaviors (14) . Attendings often model curiosity for an individual patient's motives for deception and a skillful interview style which includes strategies for confrontation of the patient if appropriate. CL psychiatry trainees learn that shame and fear are powerful non-pathologic reasons why a patient might deceive the provider and that finding empathy for the patient and seeking truth without embarrassing the patient are important clinical goals. If a therapeutic discharge of the deceptive patient is needed, the resident may be able to observe the attending facilitate this discharge or may have the opportunity to take the lead under direct attending supervision.

Outside of conflict management and negotiation skills, the CL psychiatry service can provide trainees with the opportunity to learn important and timely lessons about resource allocation, healthcare disparities, cultural competency, and unconscious bias. Trainees may be called upon to assess psychosocial clearance for transplant or bariatric surgery or to comment upon candidacy for cardiac valve replacement surgery in a patient with psychosocial risk factors, such as active substance use or prior psychiatric treatment. CL Psychiatrists may also be part of discussions about allocation of hospital resources such as intensive care unit beds or ventilators, as occurred in some hospitals during the coronavirus disease 2019 (COVID-19) pandemic. In such cases of limited resources and concern for poor outcomes, trainees will learn to weigh the ethical principle of social justice with the need to treat all patients equitably, while at the same time avoiding imposing personal or consultee moral values. In the process, trainees may observe overt or unconscious biases against vulnerable patients with chronic psychiatric and substance use disorders or suboptimal socio-economic situations. Such biases risk contributing to healthcare disparities in the provision of care for such individuals, such as lack of access to routine cancer screening, misattribution of symptoms to mental illness, inadequate pain control, and delays to surgical interventions such as cardiac stenting and bypass grafting (15, 16) . The PGY-2 PGY-2 is the most common year for residents to complete their CL rotation (Heinrich 2013 ). By placing CL early in training alongside rotations in inpatient psychiatry and other subspecialty areas such as emergency psychiatry, addictions, geriatrics and child and adolescent psychiatry, residents are more likely to view CL as a core psychiatry rotation, equating it with other subspecialties. Furthermore, the PGY-2 year is still early enough in training to have a profound effect on the residents' appreciation for working at the interface of psychiatry and medicine, to develop formative mentorship relationships, become involved in academic projects or cases that can be presented at national meetings, and promote interest CL psychiatry as a career choice. Despite these advantages and despite being able to appreciate more detailed knowledge than interns, PGY-2 residents still require a significant amount of supervision and teaching. For example, PGY-2 residents have typically not yet developed an understanding of psychodynamic and group therapy principles which can be vital to formulating assessments and managing complex team dynamics as a consultant. Supervisors need to incorporate this teaching into the CL rotation curriculum in addition to other topics. Consultees (and the resident) may still look to the supervising psychiatrist as the primary consultant, especially in complicated cases, but PGY-2 residents are developmentally ready to successfully take on this role with the support of their supervisor.

PGY-3 PGY-3 was previously a common time for CL rotations, though there has been a trend towards earlier experiences in the last two decades (4) . CL in PGY-3 allows residents to serve as ambassadors for psychiatry in the hospital. The CL rotation can serve as a capstone experience, pulling together various skills acquired during training. Because PGY3 is often primarily an outpatient year, however, logistical challenges can arise in trying to balance a clinically intense CL rotation with an ongoing outpatient continuity clinic. Though a longitudinal CL rotation could fit well into the structure of PGY-3, this makes it difficult to maintain continuity of care on an inpatient CL service, and issues of ownership arise. Adding a block CL experience creates competing demands for residents, even when efforts are made to protect certain days for outpatient work or for didactics. While such a structure may very well teach residents important time management skills and help them learn to effectively juggle multiple roles, specific issues may arise surrounding the scheduling of psychotherapy patients and outpatient supervision.

Residents wanting to present at conferences or interviewing to fast-track into child fellowship may also have less flexibility given the clinical demands. Finally, residents who complete CL late in the PGY-3 year may have already committed to a different career trajectory, and the additional requirement may be perceived as burdensome.

Many programs offer CL experiences in the PGY-4 year, and there are several different models for this approach. Some programs offer a chief residency in CL, a role that tends to be largely focused on teaching and administration, in which the chief helps to oversee the rotation for junior residents and may take an active role in running rounds or staffing cases with backup attending supervision. Other programs may offer elective experiences, which could be inpatient, as in the case of a liaison rotation to a specific service, or outpatient, with collaborative care or co-located models. A very small number of programs have CL as a core experience in PGY-4, either analogous to the PGY-3 rotation or as an addition to an earlier rotation, in which all residents return to the service for a shorter period of time as PGY-4's.

Another model is a hybrid approach spanning multiple years which spreads out CL experiences. National survey data from psychiatry residency programs suggests that a slight majority (54%) of programs actually divide CL training over several training years in some form (4) . While the years in which residents complete their CL training vary, the most frequent multiyear configuration is a 2-year PGY-2/PGY-4 split, occurring in 33% of programs (4) . It should be noted, however, that it is not clear from the data how many of these programs include only nominal CL experiences, such as occasional weekend call, in the PGY-4 year. Programs with formal didactic curricula in CL psychiatry similarly tend to split these up over years of training.

The authors are aware of a number of models used to divide CL training across residency years. A classic model is the "junior/senior" model, in which senior residents provide teaching and administrative support to junior residents on the service. While this is a familiar model in medical training across specialties, its success is contingent on having a number of residents assigned to CL services concurrently. Survey data suggest that very few residencies have more than two residents assigned to the CL service simultaneously, however. An alternative "inpatient/outpatient" model consists of having discrete inpatient and outpatient experiences across different training years -for example, completing inpatient CL during the PGY-2 year and outpatient collaborative care during the PGY-3 year. A sizable minority of programs have an outpatient component to residency training in CL, and these rotations tend to occur later in residency. Finally, the "general/sub-specialty" model consists of junior residents completing training in general CL before later rotating in sub-specialty CL experiences, such as solid organ transplant or HIV psychiatry as senior residents.

There are a number of benefits to splitting CL training across training years. Split training allows trainees to develop foundational skills earlier in training and consolidate them towards the end of training. Split training also mitigates many of the negative aspects of condensing all training either early or late in residency; for example, it allows trainees to explore careers in CL early on, but also allows them to integrate CL experiences into their professional identity later in training. Furthermore, it creates opportunities for practicing CL across roles and settings: inpatient vs. outpatient, embedded liaison vs. consultant, supervisor vs. front line clinician, and so forth. However, there are costs to splitting CL training across years. Successful CL training in multiple years likely requires more overall time than do single-year training paradigms. Split training models may also afford trainees less time to acclimate to the rotation and their roles in any of its iterations. Faculty need to be more thoughtful about adjusting their teaching points to multiple levels of learners. Finally, having residents from multiple years on service may lead to an increase in the overall number of learners on the service. While it can be advantageous to have senior residents available to help teach junior residents, it also leads to a smaller faculty to resident ratio. Regardless of model, the ACLP recommends adhering to a minimum ratio of 1 attending per 2 residents (2).

Debate also remains regarding the total length and scheduling of the CL rotation.

Historically, many CL rotations were 6 months or longer. The ACGME currently requires a minimum 2 month experience (19). Residents must also have exposure to emergency psychiatry according to the ACGME, though this is considered separate from CL psychiatry. The 2014 ACLP guidelines recommend a minimum of 3 months, with residents spending at least 50% of their time and at least 30 hours per week on service during that time (2). Residents are encouraged to see at least 50 consultations during their CL experience. Notably, however, there is no data showing that a longer time on service leads to increased knowledge base or an increase in the number of residents who pursue CL as a specialty.

In terms of the structure of the rotation, as alluded to above, most programs employ a block model, either contiguously or in 1-month blocks. Some programs alternatively use a longitudinal model, whereby residents are on-service for 1 or 2 days a week for an entire year. A 2015 study from Dartmouth found that when the program moved from a longitudinal model to a block model, the block model was associated with better education, improved clinical care, and higher satisfaction from consultees (20) . In line with these findings, the ACLP recommends a contiguous block model.

Though prior guidelines have recommended placement of the core CL experience in PGY-3, it appears that most programs have moved towards having CL in PGY-2. Based on the factors outlined above, there does not appear to be a clear, compelling argument to prioritize placement in PGY-3 over PGY-2 from an educational perspective. We therefore recommend that if possible, programs place CL in PGY-2 or PGY-3, with attention paid to the relative advantages and disadvantages of each approach. We also recognize that there may be individual circumstances that lead a program to place the rotation elsewhere during residency training.

Programs are also strongly encouraged to consider a hybrid model, which may allow for better consolidation of knowledge and skills over time.

Placing the sole CL experience in the PGY-1 year may not allow residents to function autonomously on the team, and interns are likely unable to grasp much of the hidden curriculum.

"Thinking dirty," for example, requires experience; the roles of conflict manager, advocate and teacher are generally advanced skills; and consolidation of these skills occurs best over a longer time period with higher engagement in the work. Conversely, having the sole CL experience in PGY-4 impinges on what otherwise may be a largely elective year, and is unlikely to stimulate early interest in the field, leading to pursuit of fellowship. Nonetheless, program directors may not have the ability to shift historical timing of the rotation, as such major changes to curriculum often require enormous upheaval of other rotations and significant adjustments to the culture of the program. For that reason, and recognizing the challenges faced by program directors and rotation leaders in trying to optimally tailor a CL rotation to fit a particular year of training, we have created a set of recommendations for each year of training. These can be found in Table 2 .

Though some guidance is available from professional subspecialty organizations and ACGME regarding the timing and structure of CL experiences, residency program directors and rotation leaders are often tasked with tailoring a rotation to a specific year of training based on external factors such as pre-existing curriculum structure, other program requirements, and the culture of the program. While placing a CL rotation into any year of training has advantages and disadvantages, the most compelling arguments can be made for placement in PGY-2 or -3, or use of a hybrid model. Furthermore, there are steps that can be taken to optimize the educational experience for trainees and to maximize consultee and patient satisfaction, regardless of rotation placement. If program resources are available, hybrid models may benefit from allowing returning residents to customize experiences to their interest (e.g. designing a customized liaison rotation to a service of interest) *These recommendations assume a typical residency curriculum structure, including the longitudinal outpatient year in PGY-3

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