The Fourth Post-Graduate Year

The Fourth Post-Graduate Year

The PGY-4 year is conceptualized as a time to consolidate the resident's sense of professional identity and to provide experiences that emulate post-graduate practice activities. Residents are expected to rotate through both child psychiatry and administrative psychiatry, with ample time provided for elective experiences.

The child psychiatry rotation occurs in local school and community environments, which offer the resident opportunities to learn the intricacies of consultations in these busy settings. The resident gains experience in providing psychotherapy and psychopharmacologic treatment to children and adolescents.

The administrative rotation allows the PGY-resident to gain experience in the organizational aspects of psychiatry. The resident works with administrative psychiatrists at the Arizona Division of Behavioral Health Services (DBHS) to witness the operation of state-wide mental health services.

The Program supports the resident in selecting electives and maintains lists of electives that have been approved in the past. Elective rotations can be developed to meet a resident’s specific educational needs and professional interests.

PGY-4 residents continue to manage outpatients as part of their longitudinal psychotherapy experience. Supervision is provided for ongoing outpatients. Didactic experiences for PGY-4 residents include seminars and Case Conference/Journal Club.

CHILD PSYCHIATRY ROTATION -- PHOENIX JOB CORPS

This rotation can be used to fulfill part of the PGY-4 child and adolescent psychiatry requirement. Residents rotate 0.5 day/week for six months.

Supervision for psychiatric evaluations and medication management is provided by a full-time child psychiatrist of the Division of Psychiatry. A part-time psychologist employed by Job Corps provides on-site supervision of psychotherapy, and other Job Corps program-oriented issues. Job Corps also has a staff composed of a nurse practitioner and Masters-level counselors, including student interns.

Residents participate in multidisciplinary team meetings in which patients are discussed in terms of their medical and mental health needs. Residents provide information regarding psychiatric aspects of care and learn about other psycho-educational interventions with specific populations (e.g., students with a history of physical abuse). Residents provide psychiatric evaluations for students who are self-referred or, more commonly, referred by teachers and/or Infirmary staff (e.g., a student being treated by a counselor who requests psychiatric evaluation). Residents provide medication management and supportive, short-term psychotherapy.

Residents see a student population, residing on and off the Job Corps campus, that ranges in age from 16 to 22 years. Individuals referred to Job Corps are often students who are having difficulty in a traditional school setting and/or have faced other significant social stressors. Residents, therefore, are exposed to working with adolescents with histories of sexual and/or physical abuse, gang involvement, drug and alcohol abuse, unsafe sexual practices, HIV exposure, and/or unplanned pregnancies. Diagnostically, students present with disruptive behavior disorders (predominately conduct disorder), affective and anxiety disorders (including PTSD), substance abuse disorders, schizophrenia, and other psychotic disorders. Patients often have problems with self-esteem, grief/loss, and chaotic or neglectful/abusive family situations. Residents have an opportunity to treat these students in conjunction with Infirmary staff with both medication and/or crisis-oriented or short-term psychotherapy. In interfacing with school staff, residents have the opportunity to observe how such interventions affect students’ social and academic behavior.

Residents receive one hour/week of individual supervision with a faculty child/adolescent psychiatrist. In addition, they meet with the Center Mental Health Consultant on a weekly basis regarding progress of students and/or psychotherapy issues.

CHILD PSYCHIATRY ROTATIONS--SCOPES (School-Based Community Oriented Psychiatric and Educational Services Project)/OSBORN SCHOOL DISTRICT

This rotation can be used to fulfill part of the PGY-4 child/ adolescent psychiatry requirement. Residents rotate for 0.5 day/week for five months.

Faculty consists of one part-time child/adolescent psychiatrist, one ¾-time social worker who coordinates the research and psycho-educational components, and one full-time social worker who coordinates evaluations and consultations. The child/adolescent psychiatrist is an internal faculty member of the training program. In addition, residents interface with administrators, teachers, and special education experts employed by the Osborn School District. Additional research consultation is provided by the Prevention Research Center at Arizona State University, an NIMH-funded endeavor.

Residents receive an orientation providing background in early intervention and an overview of the treatment protocol for the SCOPES Project. Lectures on school-based consultation are provided at the primary teaching site, Desert Vista Behavioral Health. Residents have the opportunity to learn about behavior management principles and interventions that can be taught to parents and teachers, for use with children, to increase positive social skills and decrease undesired behaviors. Residents observe the intervention program (“Dinosaur School”) in action. Residents also learn to evaluate young children for disruptive behavior and other disorders by providing psychiatric evaluations in conjunction with or under the supervision of a child/adolescent psychiatrist.

Residents work with children who are primarily of lower socio-economic status. These children display a variety of disorders including but not limited to depressive disorders, attention-deficit/hyperactivity disorder, psychotic disorders, bipolar disorders, obsessive-compulsive disorder, and anxiety disorders. In addition, residents work with parents, assess family dynamics, and intervene briefly in areas of family stress. The school-based clinic offers residents the opportunity to evaluate and treat children from the ages of four to 14 years, with the majority falling between the ages of four and eight. These children suffer from disruptive behaviors; their evaluations are comprehensive and involve family interviews and observation of family dynamics. Residents observe the child in the classroom setting, conduct psychiatric evaluations, consult with school staff, provide parent feedback and family interventions, provide social skills training to children, and conduct parent training. Residents learn to provide treatment that is protocol-based and has an extensive research base. In addition, SCOPES participates in one of the first national trials of this kind of intervention within a school-based setting. Residents learn about utilization of research components to study the effects of the intervention within a specific setting. Residents also observe normally developing children in the school setting.

Residents on this rotation receive one hour/week of scheduled supervision time with the faculty child psychiatrist, either individually or with another resident on rotation. They receive other supervision regarding the clinical and research aspects of the project with the CISW and Ph.D. faculty per project needs.

The SCOPES project is jointly funded by a federal grant under the Substance Abuse and Mental Health Services Administration (SAMHSA). The research component continues with the collaboration of the Prevention Resource Center of Arizona State University through Dr. Mark Roosa. Outcome measures and other pre- and post-intervention methods are used to assist investigation of short-term and longitudinal outcomes with this treatment intervention.

CHILD PSYCHIATRY ROTATIONS - DESERT HORIZON CHILD PSYCHIATRY CLINIC

Medical Professional Associates of Arizona (Medpro) is a private group practice organization that provides medical services to Maricopa Integrated Health System (MIHS). It operates an outpatient private practice clinic (Desert Horizon Psychiatry Services) located adjacent to Desert Vista Behavioral Health (primary training site). PGY-4 residents rotate at the Clinic 0.5 day/week for five months or one full day for three months in partial fulfillment of the 2-month FTE Child/Adolescent Psychiatry requirement. The Clinic treats approximately 100-125 children and adolescents, providing evaluation and medication management. The Clinic is closer to a private practice setting than are other Child/Adolescent rotations. Residents learn to work within the limitations of insurance coverage. Patients generally are from more advantaged socio-economic groups than those seen in other Child/Adolescent rotations, with 90% or more of the families having insurance and approximately 5% paying out-of-pocket. While a great number of the patients have ADHD and disruptive behavior disorder diagnoses, the Clinic also serves individuals with mood disorders, anxiety disorders, pervasive developmental disorders, mental retardation, and thought disorders. Residents are involved in psychiatric evaluations and pharmacologic treatment of children under the direct supervision of a child/adolescent psychiatrist. The supervising child/adolescent psychiatrist is a faculty member in the affiliated MIHS Child and Adolescent Fellowship.

CHILD PSYCHIATRY ROTATIONS – DEVEREAUX ARIZONA RESIDENTIAL TREATMENT CENTER

This PGY-4 rotation may be chosen to partially fulfill the requirement for Child/Adolescent Psychiatry or as an elective (one-half to two days per week for four to six months). The Devereaux Foundation operates a 48 bed Residential Treatment Center (RTC) for male and female children ages eight to 18 years experiencing moderate to severe emotional, behavioral, and/or substance abuse difficulties.. The facility provides a 24-hour supportive treatment environment that provides youth with consistency and structure. The treatment program is based on a positive peer culture model and uses a behavioral level system and token economy. Individual, group, family, and psychopharmacologic interventions are available. An accredited school for on-site youth as well as children living elsewhere is present on campus. An MIHS faculty psychiatrist provides evaluations, treatment planning, and psychopharmacologic interventions.

ADMINISTRATIVE PSYCHIATRY/ARIZONA DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)

This rotation can be used to satisfy the PGY-4 requirement for an experience in administrative psychiatry. The rotation is one to three half-days per week for four months (.5 – 1.5 mo. FTE).

Residents receive a seminar on administrative psychiatry in their PGY-3 year. The resident on this rotation will accompany, and, to the extent possible, aid the Medical Director and Associate Medical Director of the DBHS as they go about their administrative duties. The resident will develop an appreciation of the psychiatrist as an administrator in a public mental health system. The resident will learn the operational, financial, and political issues facing the public mental health system and making clinical policy. The resident may be assigned a project to complete during the rotation. There is no patient contact during this rotation. The resident accompanies the Medical Director or Associate Medical Director most of the time and is exposed to selected experiences for which at least one hour/week of supervision is provided. Supervision of assigned tasks and for any project also occur in this context.

ELECTIVES

MIHS McDOWELL CLINIC/ MARICOPA MEDICAL CENTER

This elective PGY-4 rotation runs for six to 12 months, one-half day per week.

Resident education is provided through case-based teaching in weekly individualized supervision and didactic classes.

The outpatient population in the McDowell Clinic is comprised mostly of men with HIV/AIDS. Psychiatric treatment follows careful assessment and includes the provision of psychotropic medications, supportive therapy, crisis intervention, and involvement of families or significant others if indicated. Residents learn to manage medications in this medically at-risk population.

Residents see all cases with the attending psychiatrist and receive case-based, on-site supervision, as well as instruction in issues related to providing care for persons with HIV/AIDS.

A board certified psychiatrist provides one hour per week of individual supervision.

PARADISE VALLEY PSYCHIATRIC ASSOCIATES

This is an elective rotation for PGY-4 residents that occurs 0.5 to one day per week for four to six months.

This site is a multi-physician private psychiatric practice. Patients pay for services with insurance or with cash. As such, they comprise a more socio-economically advantaged group than patients seen in many other rotations. Patients present with an array of conditions typical of a private practice, including mood disorders, anxiety, OCD, and adjustment disorders. Under supervision, residents will conduct a careful assessment and treat patients as appropriate with medications and/or psychotherapy. In the course of practicing, residents will develop an understanding of how a private psychiatric practice operates and what it is like to practice in one.

The average resident caseload consists of four to five patients in a half-day session, seen for evaluation, medication management, and/or psychotherapy.

The resident receives supervision on all cases as they present, from a board certified psychiatrist and receives at least one hour of supervision per week. The supervising psychiatrist is a psychoanalyst and also supervises psychotherapy sessions.

CARL T. HAYDEN VA MEDICAL CENTER, PTSD CLINIC

This is an elective rotation during the PGY-4 year that runs. 0.5 day/week for four to six months.

The PTSD Clinic is located in a large VA medical center and is intended to treat veterans with significant combat-related posttraumatic stress disorder (PTSD). In addition to suffering from PTSD, patients comprise a typical VA population with depressive disorders, substance use disorders, and some psychotic disorders. Forty percent of patients are between 20 and 59 years of age, with 60% over 60 years of age and 0.3% of patients younger than age 20. Treatment follows careful assessment and includes the provision of psychotropic medications, crisis intervention, and psychotherapy. Residents also learn the structure and resources of the VA system.

The average resident caseload consists of four to five patients per day receiving psychiatric medications and/or psychotherapy.

A full-time board certified psychiatrist provides supervision on site. The resident staffs his/her cases with this psychiatrist, who is experienced in treating PTSD. The resident receives at least one hour of supervision per week.

CARL T. HAYDEN VA MEDICAL CENTER -- CHEMICAL DEPENDENCY ROTATION

This elective during the PGY-4 years runs one to two days per week for two to six months .

The Carl T. Hayden VA Medical Center provides a range of chemical dependency services to veterans. The Substance Abuse Clinic (SAC) provides evaluations, individual and group therapy, and four levels of intensive outpatient treatment. Outpatient treatment is provided for continuing care patients, patients with co-occurring disorders including PTSD, and patients on Suboxone maintenance. In addition, the hospital runs a 90-day residential treatment program in partnership with Crossroads as well as a halfway house program for homeless patients. Residents evaluate patients, plan treatment, and take part in components of the VAMC chemical dependency program. Supervision is provided by a board certified psychiatrist.

OUTPATIENT CONSULTATION LIAISON -- MAYO CLINIC

This elective rotation during the PGY-4 year is available 0.5 to one day up to two days per week for two to four months.

This rotation occurs at the Mayo Clinic Hospital in Scottsdale. Patients are generally more economically advantaged than those seen in the public sector. Patients may come from various parts of the world to receive care at this facility. Working with a board certified consultation/liaison psychiatrist, residents will gain experience in providing psychiatric consultation for patients preparing for bariatric surgery, oncology patients, and other patients with medical/surgical problems and accompanying psychiatric issues. Residents will learn how psychiatric patients are managed in a quaternary care outpatient setting and learn to communicate effectively with physicians and staff in other speciality areas to provide optimal care.

ARIZONA STATE HOSPITAL FORENSIC PSYCHIATRY

This is an elective rotation for one or two residents at the PGY-4 level, 0.5 to two days per week for four to six months.

Arizona has a 335-bed State Hospital that houses civilly and forensically committed patients. The forensic hospital has a Restoration to Competency Program that treats and educates patients found incompetent to stand trial due to a mental disorder (60 beds). The hospital also treats patients committed as “Guilty Except Insane” (GEI) and “Not Guilty by Reason of Insanity/Mental Illness” (NGRI) (120 beds). Hospital clinicians evaluate competency to stand trial, diagnose and treat illnesses that may interfere with competency, treat patients with long-term serious mental illness, and work with the Psychiatric Security Review Board (PSRB) to determine if GEI/NGRI patients are well enough to be discharged. The Arizona Community Protection and Treatment Center (ACPTC), a facility created by the Legislature to treat Sexually Violent Persons (SVP) (A.R.S. § 36-3701, et. seq.) is also located on the grounds of the State Hospital. Patients who are committed to this facility have either a paraphilia or a personality disorder that predisposes them to commit sexual acts to such a degree as to render them a danger to the health and safety of others. The mission of the center is to provide therapy to those individuals who have been civilly committed. The ultimate goal is to reintegrate into the community those individuals who have successfully completed the treatment program and who have been determined to function at a level where their presence in the community does not present a risk to public safety.

Residents will complete clinical evaluation of patients referred for restoration of competency, including developing the ability to assess the validity of symptoms on the basis of observation of the patient and from collateral sources (rather than relying exclusively on patient report) . Residents will learn to evaluate patients for competency to stand trial, devise a plan for restoration of competency, and prepare a report for the court. Residents will learn Arizona law with respect to competency to stand trial, pleas of GEI and NGRI, determination of sexual dangerousness, and commitment laws with respect to all forensic patients. Residents will understand the operation and importance of the PSRB.

Residents on this rotation receive supervision from a board certified forensic psychiatrist.

RURAL COMMUNITY PSYCHIATRY AND TELEMEDICINE

This elective is available for PGY-4 residents one to two days per week for four to six months.

The Northern Arizona Regional Behavioral Health Authority (NARBHA) is a non-profit managed care organization that contracts with the Arizona Department of Health Services to monitor/oversee behavioral health services in community-based agencies in rural Northern Arizona. This PGY-4 rotation provides residents with education in the full spectrum of community-based rural psychiatric care and engagement in team treatment models. In addition, residents will develop competency in the provision of telepsychiatry. An option is available to participate in administrative systems of care, including morbidity and mortality reviews, quality management systems, privileging, and medical practitioner meetings.

Residents receive supervision from a board certified psychiatrist who is a national authority on telepsychiatry.

 

 

 

 

 

Last updated on December 16, 2009