The Geezer’s Take On Teaching C-L Psychiatry in Iowa

Iowans got encouraging news recently about the new Psychiatry Residency programs launching in July 2018 at Mercy Medical Center and Broadlawns Medical Center, both located in Des Moines. I hope this will reduce the shortage of psychiatrists in Iowa. The University of Iowa Hospitals and Clinics historically has been the only place where psychiatry residencies and fellowships were offered.

I wonder what kind of educational program Mercy and Broadlawns will provide residents in order to meet the Accreditation Council for Graduate Medical Education (ACGME) requirement in Consultation-Liaison (C-L) Psychiatry.

I took a casual look at the literature about recommended reading lists and curriculum structure.  This is by no means an exhaustive review.

Reading Lists

The most recent article I could find about recommended reading lists was by M. Nisavec et al. If you’re looking for a recommendation on the best textbook or articles, you’ll be disappointed. The reason is that there was great variability in the references cited amongst the books and papers. The authors recommend practical topical reviews and selected readings.

I have many of the books. I confess I don’t crack the textbooks, although they are exemplary references. I prefer small practical guides, preferably those you can carry around in the pocket of a white coat. An interesting side note on one of them, Consultation-Liaison Psychiatry by Blumenfield and Tiamson, published in 2003, is that it drew high praise from Don R. Lipsitt, a giant in C-L Psychiatry. It was very popular and got excellent reader reviews.

That little book was published in the year the American Board of Psychiatry and Neurology (ABPN) and the American Board of Medical Specialties (ABMS) approved specialty status for C-L Psychiatry, but unfortunately decided to call it Psychosomatic Medicine. Several years later, by an ironic contrast, the same authors retitled their book Psychosomatic Medicine. As we know, the boards and the flagship organization of the specialty (the Academy of Psychosomatic Medicine, which will become the Academy of C-L Psychiatry in April 2018) have decided to rename the specialty C-L Psychiatry—which most of us, including Don Lipsitt, preferred in the first place.

Although it’s not a textbook, Lipsitt’s history of C-L Psychiatry, Foundations of Consultation-Liaison Psychiatry: The Bumpy Road to Specialization, would be an essential part of any resident’s reading list, in my opinion. An alternative could be the abbreviated version by Ali et al (see reference list below).

I guess I should say that Lipsitt has also mentioned a few other sources of worthwhile reading on the C-L Psychiatry practice itself, including the chapter on consultation process in the book Bob Robinson and I co-edited, Psychosomatic Medicine: An Intro to C-L Psychiatry. It was written by Dr. Jeanne Lackamp, who did her residency at Iowa. The other two are Manual of Psychiatric Consultation by Nada Stotland MD and Thomas Garrick, MD (published 1990) and Sigmundoscopy: Medical-Psychiatric Consultation-Liaison: The Bases by David Robinson, MD (published 1999).

By the way, look for a new edition of Psychosomatic Medicine: An Intro to C-L Psychiatry in the future, under brand new editorship. I think it will be outstanding.

The Academy of C-L Psychiatry, of course, has reading lists, PowerPoint lectures and much more for psychiatry residents, available to members only, which is still very affordable.

Curriculum

There are a couple of very nice reviews of what exactly we should be teaching residents about C-L Psychiatry. One of them is by Heinrich et al. It was recently published and comprehensive. The authors noted that there is still wide variation in the structure and educational content of C-L rotations, which echoes the variation in recommended readings. Among the recommendations is that the rotation be a minimum of 3 months, should be in the later years of post-graduate training, and should have adequate faculty supervision (one faculty per 1-2 FTE residents with more faculty members if medical students or other trainees are involved, which is almost always in an academic medical setting). There’s a nice table of training guidelines, past and present (Heinrich, T. W., et al. (2014). “Recommendations for training psychiatry residents in psychosomatic medicine.” Psychosomatics 55(5): 438-449.):

They key them to the 6 core competencies, which I like.

Core Competency Pizza

Another review with excellent recommendations is by Wei et al and I especially like the relaxed tone of it, which I think is characteristic of Theodore Stern and the Massachusetts General Hospital style. The authors begin by acknowledging the specific features of adult learning:

  • “Adult learners need to understand why learning something is important before they learn it
  • Adults prefer being responsible for their decisions and they want their education to be self-directed
  • Adults have more experience to draw on and, therefore, want individualized approaches and learning strategies
  • Adults learn when they realize how specific knowledge can be integrated into real-life situations
  • Adults are more interested in problem-oriented and task-centered approaches than in subject-centered ones
  • Adults are more responsive to internal rather than external motivation”

The authors describe the Socratic style of conducting teaching rounds, which fosters independent thinking rather than rote memory. They also emphasize the importance of humor. They stress the importance of recognizing that C-L Psychiatry is an art in which it’s important to cultivate communication and interpersonal skills that manage the interaction between consultants and consultees. We don’t always agree.

On that note, I have a couple of articles from 1981 about teaching residents that I’ve thought might be helpful as well. They’re a little dated, and the point the authors make about “manipulation” might sound a bit crass these days if you don’t account for the psychodynamic definition of it. On the other hand, a good deal of what Perry and Viederman say about helping residents adapt to communicating with the physically ill and with non-psychiatric medical staff is still valid.

Finally, how about “Sharpening the Saw,” a term coined by Stephen Covey which would apply to the Practice-Based Learning and Improvement core competency? Wei and colleagues also mentioned that a weekly case conference format would make good sense. It’s what we try to do here when we can make time for it. It’s based on Dr. William R. Yates’ problem-based learning exercise which became the Clinical Problems in Consultation Psychiatry (CPCP). It’s relevant to a C-L Psychiatrist’s practice, much more so than Maintenance of Certification (MOC), although a resident and I did contribute a Performance in Practice (PIP) clinical module about delirium on the ABPN website.

Anyway, that’s my take. What suggestions do you have? I wish the best of luck to both of the new psychiatry residencies in Des Moines.

References:

Nisavic, M., et al. (2015). “Readings on psychosomatic medicine: survey of resources for trainees.” Psychosomatics 56(4): 319-328.

BACKGROUND: As systems of care become more complex and comorbid medical and psychiatric illness becomes more evident, it is essential to prepare psychiatric trainees for practice in more integrated models of care. OBJECTIVE: We sought to identify readings available for residency training in consultation-liaison (C-L) psychiatry/psychosomatic medicine with the intent to help educators and trainees identify appropriate and essential learning resources within the field. METHODS: We reviewed readings available to the residents (including commonly used textbooks in C-L psychiatry and C-L training programs’ required reading lists) and identified areas of consensus regarding the topics germane to the care of patients with comorbid medical and psychiatric illness (namely depression, dementia, and delirium) and the education of trainees. RESULTS: There was considerable variation in the references cited by well-regarded textbooks and by reading lists created for trainees in C-L psychiatry. In the 4 textbooks reviewed, there were 83 shared citations on delirium (including 10 citations that were common to all 4 textbooks and 17 citations shared by 3 textbooks). Markedly less overlap was noted in the chapters on depression (only 2 references cited in all of the textbooks with relevant content) and dementia (only 7 shared references). CONCLUSION: Given the paucity of overlap of citations in commonly used textbooks, we recommend that practical topical reviews or textbook chapters be used as core (required) or recommended readings for residents on C-L psychiatry rotations, supplemented by a small number of studies or case series that illustrate key teaching points on each essential topic.

 

DON R. LIPSITT (2004). “Consultation-Liaison Psychiatry.” American Journal of Psychiatry 161(4): 769-769. https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.161.4.769

 

Ali, S., et al. (2006). “Consultation-liaison psychiatry: how far have we come?” Curr Psychiatry Rep 8(3): 215-222.

This article takes stock of how far the field of consultation-liaison psychiatry has come since its inception in the 20th century. In order to do this, we review its past in terms of its knowledge base in psychosomatic medicine and in terms of its practice at the bedside in the general hospital setting. We also offer a contemporary account of the field and finish with a subjective view of the opportunities and pitfalls faced during the next phase of consultation-liaison psychiatry in the 21st century.

 

Heinrich, T. W., et al. (2014). “Recommendations for training psychiatry residents in psychosomatic medicine.” Psychosomatics 55(5): 438-449.

BACKGROUND: The Accreditation Council of Graduate Medical Education (ACGME) mandates that residents in psychiatry training programs learn to provide psychiatric consultation to other medical and surgical services. The ACGME, however, offers little information to instruct academic faculty and institutions to what constitutes a quality educational experience in psychosomatic medicine/consultation-liaison psychiatry for the resident trainee. METHODS: These recommendations were developed through a collaborative process between educators in C-L psychiatry and members of the Academy of Psychosomatic Medicine’s Residency Education Subcommittee. RESULTS: This manuscript provides a broad framework for what constitutes a well-rounded clinical and academic resident rotation on psychiatric consultation-liaison services. A rotation that is viewed positively by residents is important as it likely provides a foundation for a growing interest in Psychosomatic Medicine and the development of future fellows and subspecialty trained physicians.

 

Wei, M. H., et al. (2011). “Teaching trainees about the practice of consultation-liaison psychiatry in the general hospital.” Psychiatr Clin North Am 34(3): 689-707.

 

Perry, S. and M. Viederman (1981). “Adaptation of residents to consultation-liaison psychiatry. II. Working with the nonpsychiatric staff.” Gen Hosp Psychiatry 3(2): 149-156.

When working with the staff in a general hospital, psychiatry residents may be overly competitive, solicitous, or detached. These defensive reactions often arise because of the special challenges of performing a consultation, including the skepticism about the value of psychiatry and the demeaning or unrealistic expectations about what the psychiatrist can do. Furthermore, the psychiatry resident feels even more challenged if the attitudes and behavior of the staff must be changed for the patient’s benefit. To affect this influence on the staff the psychiatry resident may need to assume a “liaison stance.” This stance involves not only establishing a collegial alliance but also using modified therapeutic maneuvers to alter staff behavior. By applying psychodynamic knowledge to understand and potentially to influence the staff, psychiatry residents, as participant observers, can feel less helpless and frustrated by difficult liaison situations.

 

Perry, S. and M. Viederman (1981). “Adaptation of residents to consultation-liaison psychiatry. I. Working with the physically ill.” Gen Hosp Psychiatry 3(2): 141-147.

When working with hospitalized physically ill patients, psychiatry residents may impose a pseudoanalytic, rigidly biological, or overly sympathetic approach. These approaches often fail to address the special requirements and altered psychological state of the physically ill. To have a therapeutic impact on such patients, the psychiatrist needs to assume an engaging, more spontaneous “therapeutic stance” and deviate from anonymity, abstinence, and neutrality. In learning how these deviations are dictated by the therapeutic intent by the patient’s character style and psychodynamics, the resident acquires a model of influence useful in other areas of psychiatry.

 

Covey, S. R. (1990). The seven habits of highly effective people: restoring the character ethic. New York, Simon and Schuster.

 

Yates, W. R. and T. T. Gerdes (1996). “Problem-based learning in consultation psychiatry.” Gen Hosp Psychiatry 18(3): 139-144.

Problem-based learning (PBL) is a method of instruction gaining increased attention and implementation in medical education. In PBL there is increased emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education. A weekly PBL conference was started by a university consultation psychiatry team. One active consultation service problem was identified each week for study. Multiple computerized and library resources provided access to additional information for problem solving. After 1 year of the PBL conference, an evaluation was performed to determine the effectiveness of this approach. We reviewed the content of problems identified, and conducted a survey of conference participants. The most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%). Computerized literature searches provided significant assistance for some problems and less for other problems. The PBL conference was ranked the highest of all the psychiatry resident educational formats. PBL appears to be a successful method for assisting in patient management and in resident and medical student psychiatry education.