Combined Family Practice – Psychiatry Residency Training Program at UPMC

Program Description

CURRICULUM

The curriculum is combined so that residents spend between 4 and 8 months per year in each discipline with longitudinal outpatient experiences that extend across all 5 years and represent family medicine primary care, psychiatric specialty care, as well as an integrated family medicine/psychiatry experience in a community health center.  Didactics will be provided in each discipline separately.  It is assumed that the combined program will also enhance the residency training experience for those residents going through each individual training program as well.  Clinical rotations are generally in 4-week blocks in Primary Care so there are 13 blocks per year. In Psychiatry, with the exception of longitudinal ambulatory psychiatry, the Clinical Rotations are between 4 and 10 weeks and are integrated with the Primary Care experience.

All Family practice training will take place in either UPMC McKeesport Hospital, (MCK) or UPMC St. Margaret’s Hospital, (STM) systems.

PGY1    PGY2    PGY3    PGY4    PGY5

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PGY-1

The goal of the PGY-1 (internship) year is to learn the basics of family medicine and psychiatry to provide a foundation for subsequent training in both primary care and psychiatry.  The first year is weighted towards family medicine, as 4 months of training in general medicine is also required for psychiatry training.  A total of 6 4-week periods and one 10-week period will be spent in family medicine rotations.  The Family Medicine Teaching Service, Emergency Department, Intensive Care Unit and surgery rotations will all be completed at MCK or STM.  MCK and STM are community-based hospitals that provide basic inpatient medical care as well as intensive medical and surgical care.  The residents on these rotations will encounter adult and geriatric patients with the full spectrum of medical illnesses.   During the 34 weeks of family medicine rotations, the PGY-1 resident will spend ½ day per week in the family health center and begin to develop his or her panel of continuity patients.

Each PGY-1 resident will provide service for ten weeks on the inpatient Family Medicine Teaching Service.  Residents evaluate patients needing admission from the emergency department and participate in their daily management including discharge planning under the supervision of senior residents and attending physicians.  Cases are presented and discussed each morning and educational conferences are held daily.

PGY-1 residents spend 4 weeks in the Emergency Department at MCK or STM.  This rotation provides exposure to the emergency care and initial management of a myriad of medical illnesses. 

PGY-1 residents spend 4 weeks in the Intensive Care Unit of MCK or STM.  While working with this team, PGY-1 residents manage the care of critically ill patients under the supervision of senior internal medicine residents and faculty physicians trained in critical care medicine.  This rotation is an opportunity to learn an interdisciplinary model of care, as pharmacists, nurses and social workers participate in the ICU’s daily teaching rounds.

On-call hours, including 4 weeks of night float as described below, will be undertaken at MCK or STM.  Shifts will be scheduled an average of every six days.  Residents will admit patients to the family practice inpatient teaching service at the hospital and manage the floor problems of family medicine inpatients.  In-house senior family medicine residents and community family physicians taking calls for their patients by telephone will supervise their work.

PGY-1 residents spend four weeks on their inpatient obstetrics rotation at Magee-Women’s Hospital, one of the nation’s foremost women’s health facilities.  Here, residents will have the opportunity to learn family-centered obstetrical care in a high-volume center.  A specific hospital unit and teaching service emphasizing the family-centered obstetric care model has been created and staffed by family medicine and OB/GYN attending physicians as well as doulas and nurse-midwives.    In this unit, they will participate in triage, evaluation of labor progress, delivery and postpartum management of family medicine and low-risk OB/GYN patients.  Additionally, residents will have the opportunity to develop their surgical and procedural skills.  Residents regularly perform circumcisions, participate in Cesarean sections, and manage perineal wounds patients incur during deliveries.  This rotation also features at least 12 hours of case-based small group didactic instruction. 

The PGY-1 year also includes 4 weeks of pediatrics, 2 weeks of which are predominantly outpatient with one of several community preceptors.  There are regular pediatric didactic sessions each day and they see a variety of pediatric cases.  There may be some time seeing inpatient cases as well, but this is not the main emphasis of this rotation.  This rotation provides the opportunity for residents to gain concentrated experience in the ambulatory management of common pediatric medical problems as well as routine well-child care.  Two weeks are also spent in the neonatal unit at Magee Women’s Hospital where the resident cares for sick and well newborns and learns the principles of neonatal resuscitation.

There will be 4 weeks of surgery in the PGY-1 year, which is a combination of outpatient and inpatient work at MCK or STM.  The residents admit and evaluate surgical patients with their attending surgeons and assist in the operating room. The main goals will be to develop expertise in the assessment of surgical illnesses, and to develop skills needed for procedures in the outpatient setting.  They will master skills needed to maintain sterile technique and become comfortable with basic wound cleansing and closure via suture or stapling.  Upon completion, residents will be able to treat minor wounds, remove ingrown toenails and use cryotherapy and excision or punch biopsies to manage skin lesions.

The first night float rotation will occur for 4 weeks during PGY-1.  During this time, residents work overnight on weeknights.  Residents field calls from the family health center’s answering service, manage inpatient floor problems, and triage or complete all admissions to and from the Department of Family and Community Medicine.  Supervision is provided by senior family medicine residents and family medicine attending physicians’ on-call from home for each patient cared for by the night float resident.  The night float resident presents admissions at morning report and is responsible for developing teaching sessions in the morning based on the inpatient service.

Four weeks is spent on the Neurology inpatient service where residents carry a caseload of 6-10 neurologically ill patients.  Residents receive supervision from Neurologists consisting of bedside clinical teaching and didactic teaching.  There is also office time and time spent in neurologic consultation.  This is a complimentary rotation for both Psychiatry and Family Medicine requirements.

Psychiatry

The Psychiatry component of PGY1 takes place at the end of the PGY1 year and comprises 8 weeks of inpatient addictions/dual diagnosis and 6 weeks of ambulatory psychiatry. The focus of these rotations will be on giving the PGY1s the necessary basic skills to assess acute psychiatric patients and formulate management plans under close supervision.

PGY-1 Psychiatry inpatient experiences involve 8 weeks on the Dual Diagnosis unit within the addictions service. The Dual Diagnosis services focuses on an integrated approach to Addiction Psychiatry including motivational interviewing, cognitive-behavioral approaches, pharmacotherapy and detoxification.  Residents take overnight call at WPIC when rotating through the WPIC inpatient units. 

PGY1s will spend 6 weeks learning about the evaluation and management of acute ambulatory patients in the Diagnostic and Evaluation Center (DEC). The DEC is a 24-hour emergency service that serves walk-in patients as well as referrals from other UPMC and non-UPMC facilities. This rotation also provides the residents with experience of Emergency Psychiatry as the DEC is one of the busiest Psychiatry dedicated Emergency Rooms in the country. The DEC’s primary function is to assess patients and make treatment recommendations using appropriate referral resources both internal and external to UPMC.  A complete assessment includes information along biologic, neurologic, psychosocial and clinical psychiatric parameters.  Residents evaluate 1-3 patients during the day shift and 8-14 patients on the night shift (5 nights in a row once a month).  Psychiatry faculty who are on site for direct supervision 24 hours per day except for weekend nights supervise residents.  Nurses, clinicians and safety officers also staff the service.  The didactic educational component consists of a week long orientation focusing on psychiatric evaluation and managing crises, daily morning report, and a weekly 3 hour interviewing experience which involves observing a resident interview a patient behind a 2 way mirror.  Residents also participate in the outpatient detoxification program.

The formal didactic curriculum in family medicine during the family medicine components of each residency year will take place at MCK or STM, and consists of organized lectures, seminars and case conferences specifically focused on topics pertinent to primary care.  An evidence-based approach to medical care is strongly emphasized.  In all, the family medicine residency program devotes at least 20 hours each month to such sessions with a structured curriculum based on program evaluations.  Didactic sessions cover the full scope of family medicine.  There are also 3 hours per week of regular didactic sessions in the hospital for both the internal medicine and family medicine residents to attend.  There is a monthly journal club led by the residents where they learn to critically review the medical literature and apply it to their practice.  Two hours each month are devoted to behavioral science topics as it applies to primary care.  A seasoned, well-trained behaviorist coordinates the behavioral science curriculum.    There is a weekly joint grand rounds addressing topics of interest to internal medicine and family medicine residents. The family medicine didactics are open to all residents regardless of level of training and this description applies to all years of residents.  In general, a resident in the combined program will attend the family medicine didactics when they are on a family medicine rotation.

In psychiatry, it is anticipated that the residents will attend the WPIC Psychiatry Didactics every Thursday afternoon from the mid-point of PGY1 out to the end of PGY4 with the corresponding General Psychiatry Trainees. The formal didactics focus on a fundamental psychiatric knowledge base upon which subsequent training and education will build.  The curriculum includes lectures, seminars, case conferences, grand rounds and workshops.  These programs are directed and taught by faculty, many of whom are renowned experts in their fields.  The following is the list of courses, which are given one afternoon per week and will be required for all combined residents whether they are rotating on Family Medicine or Psychiatry rotations:

            Introduction to Clinical Psychiatry

            Emergency Psychiatry

            Introduction to Psychotherapy

            Neuropsychiatry

            Psychiatric Interviewing

            Psychiatry and Societal Issues

            Substance Related Disorders and Dual Diagnosis

There are also case conferences specific to each clinical rotation.  There are also didactics which are available to all residents including Clinical Grand Rounds where nationally and internationally recognized experts present a variety of clinically relevant topics, and Resident Grand Rounds where senior residents present cases and a multidisciplinary faculty panel discusses the contemporary state of knowledge.  There are also quarterly workshops based on resident needs and interests.  There is also a Movie Night that addresses psychiatry’s portrayal in popular culture and the history of psychiatry in our society as it pertains to movies.  There is also a psychiatric review course where residents have the opportunity to lead an academic discussion about psychiatry-related topics.  Also a Schizophrenia Journal Club reviews both classic and break-through articles related to schizophrenia. 

During PGY1 residents will not be allowed to take more than 1 week leave during the neurology rotation or either of the psychiatry rotations respectively.

PGY1    PGY2    PGY3    PGY4    PGY5

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PGY-2

The second year expands on the inpatient experiences in both disciplines and offers the beginning of psychotherapy training.  The year is split into 4 months of Family Medicine at the beginning of PGY2 and 8 months of psychiatry, which continues directly into PGY3.

PGY-2 residents spend 4 weeks on Geriatrics, which includes a 2week introduction to geriatric assessment, home visits, nursing homes and the multidisciplinary care of the elderly.  The second two weeks are practical experience working with a busy family practice group seeing many geriatric patients.

A 4-week rotation in gynecology occurs at Mercy Hospital of Pittsburgh.  Residents spend most of their time in the gynecology clinic learning about common gyn problems and one day is spent in gynecological surgery. The rotation will emphasize outpatient management of women’s health issues frequently encountered in primary care, including osteoporosis, breast lesions, infertility, uterine fibroids, dysfunctional uterine bleeding, menopausal symptoms, recurrent bacterial vaginosis, and cervical dysplasia.   This will serve as another opportunity to develop basic wound management skills.

There will also be a further experience in Pediatrics with 4 weeks spent in Children’s ED.  This experience provides opportunities for the resident to care for large numbers of acutely ill children under the supervision of emergency trained pediatricians.  There will also be an additional 4 weeks spent in Outpatient Surgery or OB, depending on site.  Surgery will be primarily an ambulatory experience in office surgical procedures.  The OB experience will be an additional 4 weeks of obstetrics at either Magee Women’s Hospital or Mercy Hospital of Pittsburgh, where the resident will assume increasing responsibility for the care of women in labor.

Finally 2 weeks of radiology are included to help the resident understand the basics of radiologic interpretation.  These sessions include both practical experience and didactics.  They are held either at MCK or STM.

The PGY-2 resident continues to spend ½ day per week in the family health center except during the 20 weeks of inpatient psychiatry.

The psychiatry rotations occur in the latter 8 months of PGY2 and comprise two ten week rotations in inpatient psychiatry followed by a 12 month longitudinal ambulatory psychiatry experience which continues into the first 9.5 months of PGY3. The inpatient rotations will be focused on further developing the skills of the PGY2 residents in the assessment and management of common psychiatric conditions and preparing them for the twelve-month ambulatory experience.

In PGY-2 residents spend 10 weeks each on 2 specialty inpatient units at WPIC: Mood Disorders and Schizophrenia.  Each inpatient unit has “teaching teams” with one resident supervised by one attending.  Residents carry no more than 8 patients at any given time.  On each service, residents work closely with the supervising attending and the treatment team, comprising nurses, social worker and other clinicians.  Residents are given increasing and graduated independence in managing the assigned patients.  There is onsite medical coverage and specialty consultations are available through Presbyterian hospital, which is physically connected to WPIC.  The Mood Disorders unit has a special focus on cognitive therapy and pharmacotherapy of mood disorders.  Many patients have comorbid personality disorders so residents gain experience in combining psychotherapeutic and psychopharmacologic treatment modalities.  The Schizophrenia unit places emphasis on the diagnosis and treatment of psychotic disorders including pharmacotherapy, crisis management and community resource management. 

Beginning in the latter part of PGY-2 and carrying over into the early part of PGY-3 the residents work in several general and specialty outpatient clinics that provide the opportunity to learn about different models of care.  These models include following patients individually, seeing patients with counselors, and working closely with treatment teams. There are 2 year-long clinics, a Longitudinal Combined Psychotherapy and Psychopharmacology Clinic and a Longitudinal Psychotic Disorders and Chronic Mental Illness Clinic at Comprehensive Care Services.  There are also six 6-month long specialty clinics in Child and Adolescent (at Center for Children and Families), Neurobehavior, Neuropsychiatry (John Merck Clinic), Women’s (Magee Women’s), Dual Diagnosis (Center for Chemical Dependency and Psychiatric Services) and Geriatrics (Shadyside Senior Care Institute).  Faculty who are experts in their fields direct each clinic.  Residents continue psychotherapy training with additional patient assignments and individual supervision.  At the end of the fourth year, residents will be able to competently diagnose and treat patients and provide longitudinal care in a variety of outpatient settings.  They will also achieve increasing levels of competency in psychotherapy. 

The family medicine didactic curriculum continues as described in the PGY-1 section.

Psychiatry

The psychiatry formal didactic curriculum is closely linked to the clinical experiences during this year.  The curriculum includes lectures, seminars, case conferences, grand rounds and workshops.  These programs are directed and taught by faculty, many of whom are renowned experts in their fields.  The following is the list of courses:

            Anxiety Disorders

            Child Psychiatry

            Electroconvulsive Therapy

            Frameworks in Psychiatry

            Geriatric Psychiatry

            Interpersonal Psychotherapy

            Law and Psychiatry

            Mood Disorders

            Neuropsychiatry

            Psychodynamic Psychotherapy

            Schizophrenia and Related Disorders

            Spirituality and Psychiatry

PGY1    PGY2    PGY3    PGY4    PGY5

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PGY-3

The PGY-3 year expands on knowledge and skills gained in the first 2 years of both disciplines with a focus on Psychiatry.  There is an emphasis on and an expansion of the longitudinal outpatient experiences.  There are 9.5 months of psychiatry rotations at the beginning of PGY-3 followed by 2.5 months of family medicine.

The 4-week Family Medicine inpatient service will be similar to the PGY-1 year but with increasing responsibility and oversight over greater numbers of patients.  There will continue to be a 4-week block on family medicine inpatient during the PGY-4 and PGY-5 years with increasing responsibility.  The PGY-5 will truly be a chief of service.

The pediatric inpatient rotation will take place at Children’s Hospital of Pittsburgh, one of the nation’s most respected pediatric acute-care institutions.  During this 4-week rotation, residents will care for infants and young children.  Residents gain experience in the evaluation and management of common illnesses affecting this age group, including dehydration, apnea, asthma, bronchiolitis, urinary tract infections, sepsis, fevers of unknown origin, vomiting, diarrhea, seizures, apparent life threatening events (ALTE’s), feeding problems, gastroesophageal reflux, failure to thrive and child abuse and neglect.  This rotation includes daily teaching rounds, case-presentations, x-ray rounds and on-call shifts to hone residents’ diagnostic skills and management knowledge of pediatric medical problems.

PGY-3 residents either spend a second 4 weeks in the Intensive Care Unit of MCK or STM or doing night float as previously described.  While working with this team, PGY-3 residents manage the care of critically ill patients under the supervision of senior internal medicine residents and faculty physicians trained in critical care medicine.  This rotation is an opportunity to learn an interdisciplinary model of care, as pharmacists, nurses and social workers participate in the ICU’s daily teaching rounds.

There will also be 2 weeks in Urology.  This rotation is almost entirely outpatient with community physicians and the residents learn the basics of diagnosis and treatment of common problems in this field.

The PGY-3 resident will spend ½ day per week in the family health center for this entire year.

In psychiatry, residents also continue their psychotherapy training with their ongoing long-term psychotherapy cases as well as short-term cases of Cognitive-Behavioral Therapy, Family therapy and Group therapy.

The family medicine didactic curriculum continues as described in the PGY-1 section.

The psychiatry didactics are as described previously.  The courses offered in the PGY-3 year are as follows:

            Clinical Neuroscience

            Cognitive Behavioral Therapy

            Family Therapy

            Group Therapy

            Pharmacotherapy of Mood Disorders

            Advances Topics in Psychosis

            Introduction to Psychiatric Literature

            Advances Literature Seminar

PGY1    PGY2    PGY3    PGY4    PGY5

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PGY-4

The PGY-4 year will be more strongly biased towards strengthening residents’ skills in providing outpatient and inpatient medical care with a focus on the integration of Psychiatry and Family Medicine Skills.  During this year, most of the family medicine experiences will be focused on outpatient care. 

The 4 weeks of inpatient medicine, and 4 weeks of surgery/OB have been previously described.

The 4-week Dermatology rotation occurs in the office of two local dermatologists. It emphasizes diagnosis and treatment of common dermatologic illnesses as well as cutaneous manifestations of systemic diseases.

The PGY-4 resident will have 4 weeks of ambulatory family medicine/community medicine.  This rotation includes time on rehabilitation, occupational medicine, and public health and will help the resident become more familiar with community resources they will utilize in practice.

There is a Medical Officer of the Day (MOD) 4-week block in the PGY-4 year.  During this time the residents work at the Family Health Center and see acute problems or overflow.  They do not have regular patient schedules however because during this month they will be doing most of their continuity OB deliveries.  They have been following a panel of patients during pregnancy that will be due during this month.  In this way they can have a concentrated experience in obstetrics without having to spread their continuity patients out through the whole residency.  With no other specific duties, they will be available for their continuity OB patients.  Also during this month they have a schedule of administrative meetings in the MCK or STM to attend if possible.  These meetings are scheduled with the hospital Director of Graduate Medical Education and they are designed to help the resident better understand hospital administration and how hospital leadership deals with issues.

There will be 2 weeks in ENT.  This rotation is almost entirely outpatient with community physicians and the residents learn the basics of diagnosis and treatment of common problems in this field.

The 4-week rotation in Cardiology is spent working in MCK or STM on the cardiology service, admitting and treating patients, participating in cardiac evaluation and consultations and learning EKG interpretation.

There is a 4-week block in Orthopedics/sports medicine in the PGY4 year, where the residents learn the basics of this field working mainly in a local orthopedic office, and also with hospitalized patients and in the OR. There is also the opportunity to gain experience in sports medicine with time spent at the UPMC Sports Medicine Center.

The PGY-4 resident spends 4 weeks on geriatrics, which consists mainly of caring for patients in nursing homes, personal care homes and in their own homes.  This is a continuation of the rotation in the PGY-2 year.  The resident will perform regular geriatric assessments.  He or she will also work with nursing home administration to better understand the duties of the nursing home medical director.

In the PGY-4 year the resident increases the time in the family health center to two half-days per week throughout the year.

Psychiatry

In Psychiatry the PGY-4 residents will focus on the integration of their Psychiatric and Medical skills and will complete a 6-week part-time rotation in Neurology, and10 weeks in Consultation and Liaison Psychiatry,.

The Neurology training represents an overlap between Family Practice and Psychiatry requirements but is based within the Psychiatry component of this curriculum just as the medical requirements are placed within the Family Medicine components.  The Neurology rotation is conducted at MCK or STM and in private neurologists’ offices and is ambulatory in focus.

The Consultation and Liaison Psychiatry service provides psychiatric consultation to all units (medical, surgical, intensive care, emergency, transplant, oncology, obstetrics, gynecology etc.) at UPMC Presbyterian, Montefiore, Magee Women’s, and Shadyside Hospitals.  Residents are assigned patients for consultation and, under supervision, provide a set of management recommendations and follow these patients for the duration of the patients’ hospital stay.  There are daily lectures and seminars on C/L topics while on this service.  Residents on the C/L service are exempt from call at WPIC.  Instead, they provide evening and weekend coverage to the C/L service.

The family medicine didactic curriculum continues as described in the PGY-1 section. 

The formal psychiatry didactics reach their conclusion in the PGY-4 year and complete the courses described for PGY3 with additional teaching in Forensic Psychiatry and Community Psychiatry.

PGY1    PGY2    PGY3    PGY4    PGY5

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PGY-5

The PGY-5 year provides an opportunity for residents to further bring together knowledge they have gained in both disciplines and to explore electives designed to integrate the skills they have obtained in family medicine and in psychiatry.  Residents also have the opportunity to “round out” their training experience by choosing electives that integrate medical and psychiatric care in a single setting.

Several family medicine specialty rotations will further refine the residents’ skills in managing diverse problems encountered in primary care.  There will be 4 weeks in orthopedics/sports medicine spent at the UPMC Sports Medicine Center, 4 more weeks on the Family Medicine inpatient service and 4 more weeks on Pediatrics with a community pediatrician.  There are also two more weeks of night float as previously described.

The 4-week family medicine practice management rotation teaches residents the business principles needed to launch and maintain a career in primary care.  Residents immerse themselves in a community practice without responsibilities in the Family Health Center.  They experience how a busy practice runs and the many decisions required to mange a practice.  Specific topics pertaining to transitioning from residency to community positions, understanding contract language, managing an office hour schedule and determining staffing needs are covered.

There will also be 2 weeks in the specialty area of Ophthalmology.  This rotation is almost entirely outpatient with community physicians and the residents learn the basics of diagnosis and treatment of common problems in this field.

The PGY-5 resident will now have three half-days per week in the family health center throughout the year.

The Psychiatry curriculum in the PGY-5 year includes required experiences in Community Psychiatry and Forensic Psychiatry. Both of these experiences are ambulatory in nature.   Residents are also required to do a seniorship  on an inpatient unit serving as a junior attending, leading rounds, providing teaching to medical students and residents and organizing the case conferences. The resident may choose which inpatient unit at WPIC the join for this requirement.

Electives that integrate psychiatry and family medicine and thus meet requirements for both programs can consist of organized electives or resident generated ideas.  Some possibilities include Homeless Outreach Clinics, Palliative Care, Child Development Unit, Nursing Homes care, Center for Integrative Medicine, Narcotic replacement facilities or the State Psychiatric Hospital system.

There will be a specific 4 week elective in psychiatry in PGY-5, during which the resident can have an experience of their choice within psychiatry.

Residents will continue their longitudinal psychotherapy cases.

The family medicine didactic curriculum continues as described in the PGY-1 section.

The Psychiatry curriculum includes courses in:

            Advanced Forensic Psychiatry

            Social and Community Psychiatry

            Personality Disorders

            Psychodynamic Continuous Case Conference

            Professional Development

LONGITUDINAL SUMMATIVE PROJECT

Each resident will participate in a longitudinal scholarly project designed to cultivate their interest in applications of dual primary care and psychiatry training.  Early in their PGY-3 year, each resident will partner with a mentor from both the psychiatry and family medicine faculty to design their project.  Each project will involve disease state management, clinical service systems design or original research.  Residents will be required to submit their work for publication in a peer-reviewed journal or presentation at a professional conference.  The project will foster the development of disease management and research skills that graduates of the program will later use to become health care leaders. 

PGY1    PGY2    PGY3    PGY4    PGY5

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