Psychiatry Clerkship Objectives

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Boonshoft School of Medicine Psychiatry Clerkship Objectives

Adapted from the Association of Directors of Medical Student Education in Psychiatry
July 11, 2007

The objectives listed are comprehensive, yet achievable during the psychiatry rotation.

Following each objective is the expectation for level of competence or achievement, using the following descriptions:
Knows – K (can state)
Shows – S (discuss application)
Shows How – SH (application under simulation)
Does – D (perform under actual conditions)
Adapted from MillerGE (Acad Med 1990; 65:S63-7) for the Clinical Curriculum Resource Guide for Psychiatry Education
The instructional methods utilized to achieve these stated goals include extensive clinical teaching and clinical experiences.  Additionally, performance feedback, departmental conferences, lectures, discussions and team-based learning sessions are utilized.  Individual projects may also be assigned.

After each competence level expected are numbers corresponding to the assessment methodsutilized corresponding to the ACGME glossary of assessment methods found at the end of these objectives.

Clinical Skills

History-Taking, Examination and Medical Interviewing

Rationale:  To evaluate and care for any patient, the clinician must be skillful with developmentally and culturally appropriate communication methods in obtaining relevant historical information and performing a complete examination.  Although the comprehensiveness of an examination may vary based on the situation, physicians should be able to perform a mental status exam and accurately describe the findings.For effective history taking and patient evaluation, a clinician must have an understanding, ability, and self-awareness to flexibly use a range of empathic interviewing techniques with patients a) across the lifespan including children, adolescents, adults, and the elderly; b) across cultures; and c) with persons afflicted with mental illness or experiencing considerable distress.

By completion of the clerkship the student will be able to:

1. Elicit and accurately document a complete psychiatric history, including the identifying data, chief complaint, and history of the present illness, past psychiatric history, medications (psychotropic and non-psychotropic), general medical history, review of systems, substance use history, family history, and personal and social history. D—1,2

2. Perform an appropriate physical exam on patients with presumed psychiatric disorders and:   a)  Recognize and discuss bodily signs and symptoms that accompany classic psychiatric disorders (e.g., tachycardia and hyperventilation in panic disorder); b) Discuss the extent to which a general medical illness may contribute to the signs and symptoms of a psychiatric disorder; c) Recognize and discuss the possible manifestations of psychotropic drugs e.g., medications and drugs of abuse) in the physical exam. D—1,2

3. Recognize the importance of, and be able to obtain and interpret, historical data from multiple sources including family members, community mental health resources, primary care providers, family clergy, old records, child’s teachers, primary care physician, etc. D—1,2

4. Perform and accurately describe the components of the comprehensive Mental Status Examination (e.g., including general appearance and behavior, motor activity, speech, affect, mood, thought processes, thought content, perception, sensorium and cognition, abstraction, intellect, judgment, and insight.  Describe variations in presentation according to age, stage of development and cultural background.  D—1,2, 12

5. Describe common abnormalities, and their causes, for each component of the Mental Status Exam.  D—1,2

6. Perform common screening exams for common psychiatric disorders (e.g., CAGE, MMSE, etc.).  D—1,2

7. Discuss and use basic strategies for engaging and putting patients at ease in challenging interviews (e.g., with patients who are disorganized, cognitively impaired, hostile/resistant, mistrustful, circumstantial/hyperverbal, unspontaneous/hypoverbal, potentially assaultive; when being assisted by an interpreter).  Describe different interviewing techniques for different ages.  D—1,2

8. Demonstrate an effective repertoire of interviewing skills including: appropriate initiation of the interview; establishing rapport; the appropriate use of open-ended and closed questions; techniques for asking "difficult" questions; the appropriate use of facilitation, empathy, clarification, confrontation, reassurance, silence, summary statements; soliciting and acknowledging expression of the patient's ideas, concerns, questions, and feelings about their illness and its treatment; communicating information to patients in a clear fashion; appropriate closure of the interview; and be able to perform these basic interviewing skills in performing a family assessment.  D—1,2

9. Discuss and avoid the common pitfalls in interviewing technique including: interrupting the patient unnecessarily; asking long, complex questions; using jargon; asking questions in a manner suggesting the desired answer; asking questions in an interrogatory manner; ignoring patient verbal or nonverbal cues; making sudden inappropriate changes in topic; indicating patronizing or judgmental attitudes by verbal or nonverbal cues.  D—1,2

10. Identify strengths and weaknesses in personal interviewing skills and discuss with a        colleague or supervisor.  D—1,2

Documentation and Communication
Rationale:  Regardless of the clinical specialty, a physician must be able to properly document clinical findings, diagnostic impressions, and clinical reasoning.  The physician must be able to communicate clearly and concisely to other professionals and to patients and their families, in both written and oral formats.  These skills are particularly important for communicating about psychiatric disorders where obvious laboratory or physical findings may not be present.

By completion of the clerkship the student will be able to:

1. Accurately document a complete psychiatric history and appropriate examination and accurately record and communicate the components of a comprehensive mental status examination.  D—1,2, 12, 18

2. Accurately document the daily or periodic progress of patients’ psychiatric disorders recording mental status changes and diagnostic impressions.  D—1,2, 18

3. Provide a clear and concise oral presentation of a) a complete psychiatric evaluation including relevant history, mental status findings and diagnostic impressions, and b) the daily or periodic progress of patients being treated for psychiatric disorders.  D—1,2, 12

4. Communicate clinical impressions, treatment recommendations including risks and benefits, and other relevant education to assigned patients and their families.  D—1,2

5. Document assessment of patient’s degree of risk to self and others D—1,2, 18

Clinical Reasoning and Differential Diagnosis

Rationale:  Accurately identifying a patient’s problems and the relevant signs and symptoms is basic to establishing a diagnosis in any field of medicine.  In psychiatry patients may lack insight to the problems they are having and insist that nothing is wrong.  Hence, to be skillful at discerning signs and symptoms of psychiatric disorders the physician must have a heightened level of suspicion, be knowledgeable about symptom clusters that are suggestive of specific disorders, and be able to formulate reasonable diagnostic hypotheses with plans for further evaluation.  To be successful, the physician must also be able to incorporate knowledge about the range of normal behaviors at various ages and stages of development.

By the end of the clerkship students will be able to:

1. Use the DSM-IV to identify signs and symptoms that comprise specific syndromes or disorders and construct diagnoses using the five axes system.  D—1,2,  12, 18

2. Formulate a differential diagnosis and plan for assessment of common presenting signs and symptoms of psychiatric disorders (e.g., insomnia, behavioral dyscontrol, confusion, hallucinations, delusions, etc.)  D—1,2, 12, 18

3. Discuss the indications for, how to order, and the limitations of common medical tests for evaluating patients with psychiatric symptoms (e.g., laboratory, imaging, projective and objective psychological tests, etc.)  D—1

4. Interpret basic test results and consultant reports relevant to working through a differential diagnosis of designated patients.  D—1

5. Assess, record and interpret mental status changes of designated patients, and alter diagnostic hypotheses and management recommendations in response to these changes. D—1, 18

Assessment of Psychiatric Emergencies

Rationale:  Psychiatric emergencies may occur in any clinical or non-clinical setting and are life threatening.  An effective physician must be able to recognize potential psychiatric emergencies and initiate an intervention.  Although suicide is the most common psychiatric emergency the list of emergent conditions is lengthy and diverse ranging from suicidality and homicidality, to catatonia, intoxication, delirium, and severe drug reactions.  It is important for physicians to be able to perform risk assessments, evaluate patients with altered mental status or behavioral dyscontrol, and recognize signs of potential assaultive behavior.

By completion of the clerkship the student will be able to:

1. Identify and discuss risk factors for suicide across the lifespan.  K—1, 13, 14

2. Conduct diagnostic and risk assessments of a patient with suicidal thoughts or behavior and make recommendations for further evaluation and management.  D—1,2

3. Identify and discuss risk factors for violence and assaultive behavior.   S—1,2, 13, 14

4. Discuss signs of escalating violence and review the appropriate safety precautions and interventions.  K—1

5. Discuss the differential diagnosis and conduct of a clinical assessment of a patient with potential or active violent behavior and make recommendations for further evaluation and management.  K—1

6. Discuss the clinical assessment and differential diagnosis of a patient presenting with psychotic symptoms such as perceptual disturbance, bizarre ideation and thought disorder, and make recommendations for further evaluation and management.  D—1,2

7. Discuss the clinical assessment and differential diagnosis of a patient with impaired attention, altered consciousness and/or other cognitive abnormalities and make recommendations for further evaluation and management.  K—1

8. Analyze risk factors and make recommendations for psychiatric hospitalization versus an ambulatory disposition in the management of designated patients. S—1,2

Psychopathology and Psychiatric Disorders
The typical signs and symptoms of common psychiatric disorders as outlined below should be learned and understood at each phase of the life cycle (i.e., children, adolescent, adult, and geriatric populations).  The clerkship learning experiences should build on an established understanding of basic principles of neurobiology and psychopathology derived from the pre-clerkship curriculum.

Cognitive Disorders
Rationale:  Cognitive impairment is a presenting sign or symptom for many medical conditions.  Regardless of medical specialty, a physician should be able to make an initial assessment of cognition with attention to possible emergent underlying conditions, be familiar with the common causes of cognitive impairment, and proceed with or refer patients for further evaluation and management.

By completion of the clerkship the student will be able to:

1. Differentiate and discuss the cognitive, emotional and behavioral manifestations of common Cognitive Disorders including Delirium and Dementia syndromes. K—1,2, 13, 14

2. Perform cognitive assessments to evaluate new patients and monitor patients with identified cognitive impairment, and discuss challenges to assessment related to the patient’s cultural background and developmental level.  D—1,2

3. Recognize the prevalence of Delirium in various clinical settings and across the lifespan, and discuss the clinical features and differential diagnosis of the delirious patient with recommendations for evaluation and management.  K—1, 13

4. Differentiate the clinical features and course of the common types of Dementia including Alzheimer’s, Vascular, Lewy Body and those syndromes caused by other neurodegenerative and infectious diseases (e.g., Parkinson’s, HIV infection, Huntington’s, Pick’s, Creutzfeldt-Jakob, etc.)  K--13

Substance Use Disorders
Rationale:  Substance use disorders are prevalent among patients in all clinical settings.  There is a particularly high co-morbidity between substance use disorders and other psychiatric disorders and medical conditions, which has a negative affect on clinical course and prognosis.  Regardless of medical specialty the clinician should be able to recognize signs and symptoms of possible Substance Use Disorders, make initial assessment with attention to possible underlying emergent conditions (e.g., withdrawal delirium), and proceed with or refer the patient for further evaluation and management.

By completion of the clerkship the student will be able to:

1. Obtain a thorough substance use history through the use of empathic, nonjudgmental interviewing techniques and established screening instruments (e.g., CAGE), accounting for the patient’s developmental stage and cultural background, and obtain information from collateral sources.  D—1,2, 12

2. Compare and contrast diagnostic criteria for substance abuse versus dependence. S—1,2, 13, 14

3. Know the clinical features of intoxication with cocaine, amphetamines, hallucinogens, cannabis, phencyclidine, barbiturates, opiates, caffeine, nicotine, benzodiazepines, alcohol and anabolic steroids.  K—1, 13, 14

4. Recognize the clinical signs and recommend management strategies for substance withdrawal from sedative hypnotics including alcohol, benzodiazepines and barbiturates. S—1, 13, 14

5. Discuss the epidemiology, course of illness, and the medical and psychosocial complications of common substance use disorders.  K—1, 13

6. Discuss management strategies for substance abuse and dependence including 12-step programs, support groups (AA, NA, Alanon), pharmacotherapy, rehabilitation programs, and family support.  SH—1

Psychotic Disorders

Rationale:  Patients with symptoms of psychosis can present in any clinical setting.  By their very nature the signs and symptoms of psychosis are often associated with impaired insight, considerable distress for the patient and their families, and the potential to evolve into an emergent, life-threatening situation.  Regardless of medical specialty, clinicians should be able to recognize the signs and symptoms of possible Psychotic Disorders, make initial assessment with attention to possible emergent underlying conditions, and proceed with or refer for further evaluation and management.

By completion of the clerkship the student will be able to:

1. Define the term psychosis and be able to discuss the clinical manifestations and presentation of patients with psychotic symptoms.  D—1, 13, 14

2. Recognize that psychosis is a syndrome and discuss the broad differential diagnosis, including both primary psychiatric as well as other types of medical conditions, which necessitates a thorough medical evaluation for all patients presenting with signs and symptoms of psychosis.  D—1

3. Develop a differential diagnosis and plan for further evaluation of patients presenting with signs and symptoms of psychosis.  D—1,2

4. Compare and contrast the clinical presentation of psychotic disorders in children and adolescents, adults, the elderly, patients in a general medical practice setting, the developmentally disabled, and accounting for cultural diversity.  K—1

5. Compare and contrast the clinical features and course of common psychiatric disorders that present with associated psychotic features.  K—1

6. Discuss epidemiology, clinical course, prodromal stages, subtypes, and the positive, negative and cognitive symptoms of Schizophrenia.  K—1, 13, 14

7. Recommend management of patients with Schizophrenia and other psychotic disorders including all relevant interventions.  D—1, 18

8. Discuss the theories of etiology and pathophysiology of Schizophrenia and other psychotic disorders.  SH—2, 13, 14

Mood Disorders
Rationale:  Mood Disorders are prevalent, serious and highly treatable conditions encountered in all clinical settings.  Although sometimes difficult to diagnose, unrecognized and untreated mood disorders are associated with considerable morbidity and mortality.  A physician should be able to recognize signs and symptoms of possible Mood Disorders, make initial assessment with attention to possible emergent underlying conditions and risk of suicidal and/or homicidal behavior, and proceed with or refer for further evaluation and management.

By completion of the clerkship the student will be able to:

1. Discuss the epidemiology of mood disorders with special emphasis on the prevalence of depression in the general population and in non-psychiatric clinical settings among patients with other medical-surgical illness (e.g., cardiovascular disease, cancer, neurological conditions) and the impact of depression on the morbidity and mortality of other medical-surgical illness.  K—1, 13, 14

2. Compare and contrast the features of unipolar and bipolar mood disorders with regard to clinical course, comorbidity, family history, prognosis and associated complications (e.g., suicide).  K—1,2

3. Discuss the differential diagnosis for patients presenting with signs and symptoms of mood disturbance, including primary mood disorders (e.g., Bereavement, Major Depressive Disorder, Adjustment Disorder, etc.) and mood disorders secondary to other conditions (e.g., substance use, underlying  medical-surgical illness) with regard to clinical course, comorbidity, family history, prognosis, associated complications (e.g., suicide), and plan for further evaluation.  D—1,2, 12

4. Discuss the subtypes of primary mood disorders including melancholic versus atypical features, with psychotic features, seasonal pattern, and postpartum onset.  K—13, 14

5. Compare and contrast the clinical presentation of mood disorders in children and adolescents, adults, the elderly, patients in a general medical practice setting, the developmentally disabled, and across cultures.  K—13, 14

6. Discuss the high risk of suicide in patients with mood disorders, risk assessment and management strategies.  D—1, 2

7. Recommend management of patients with primary or secondary mood disorders including all relevant interventions.  D—1,2, 12, 18

8. Discuss the theories of etiology and pathophysiology of mood disorders.  SH—13, 14

Anxiety Disorders
Rationale:  Anxiety Disorders are considered one of the most prevalent classes of psychiatric disorders and as such are likely to be encountered in all clinical settings. It is important for clinicians not only to recognize signs and symptoms of anxiety but also to be familiar with the diagnostic criteria for various anxiety disorders, be able to make an initial assessment with some precision and with attention to possible emergent underlying conditions, and proceed with or refer the patient for further evaluation and management.

By completion of the clerkship the student will be able to:

1. Discuss the epidemiology of anxiety disorders with special emphasis on the prevalence of anxiety in the general population and in non-psychiatric clinical settings and effect on total health care expenditures in the U.S.  K—13. 14

2. Discuss the differential diagnosis for patients presenting with anxiety, including primary anxiety disorders (e.g., Phobias, Panic Disorder, Adjustment Disorder, etc.) and anxiety disorders secondary to other conditions (e.g., substance use, underlying medical-surgical illness) with regard to developmental stage, developmental disability, cultural diversity, medical practice setting, clinical course, comorbidity, family history, prognosis, associated complications, and plan for further evaluation.  K—13. 14

3. Discuss the epidemiology and distinguish the clinical course, co-morbidity, family history and prognosis of Obsessive Compulsive Disorder relative to other anxiety disorders.  K—13. 14

4. Discuss the epidemiology and distinguish the clinical course, co-morbidity, family history and prognosis of Acute and Post-traumatic Stress Disorders relative to other anxiety disorders.  K—1, 13, 14

5. Recommend management of patients with primary or secondary anxiety disorders including all relevant interventions (e.g., relaxation, exposure-response prevention and other psychotherapies; psychopharmacology, etc.  D—1,2, 18

6. Discuss the theories of etiology and pathophysiology of anxiety disorders.  K—13, 14

Somatoform Disorders, Factitious Disorder and Malingering

Rationale:  By their very nature, Somatoform Disorders frequently present in non-psychiatric settings.  If the physician does not have an understanding of Somatoform Disorders, patients with these conditions are likely to be misdiagnosed, receive unnecessary treatments or become a focus of hostility.  All physicians should be able to recognize signs and symptoms of possible Somatoform Disorders, Factitious Disorder and Malingering, make initial assessment with attention to actual underlying pathology, and proceed with or refer patients for further evaluation and management.

By completion of the clerkship the student will be able to:

1. Compare and contrast the signs, symptoms, clinical characteristics and course, and prognosis of specific Somatoform Disorders including Somatization Disorder,  Conversion Disorder, Pain Disorder, Body Dysmorphic Disorder, and Hypochondriasis. K—13, 14

2. Compare and contrast the characteristic features of Factitious Disorder and Malingering and distinguish these conditions from the Somatoform Disorders.  K—13, 14

3. Discuss the principles and challenges to physicians of ongoing evaluation and management of patients with Somatoform Disorders, Factitious Disorder and Malingering.  K—1

Dissociative and Amnestic Disorders

Rationale:  Persons who experience trauma and patients with personality disorders may suffer dissociative symptoms.  These persons may present in any clinical setting.  Despite the disability associated with dissociative disorders they may go undetected and untreated.  All physicians should be able to recognize signs and symptoms suggestive of a dissociative disorder and refer patients for further evaluation and treatment.

By completion of the clerkship the student will be able to:

1. Define “dissociation”.  K—13

2. Discuss the hypothesized role of psychological trauma in the development of disorders characterized by dissociation and altered memory (e.g., Acute Stress Disorder, PTSD, Borderline Personality, Dissociative Identity Disorder).  K—1

Eating Disorders
Rationale:  Eating Disorders are potentially life-threatening conditions.  These conditions occur across the life span and despite their prevalence may go undetected and unaddressed.  Patients with eating disorders may present in any clinical setting.  Hence, all physicians should be able to recognize the signs and symptoms suggestive of an eating disorder and refer patients for further evaluation and treatment.

By completion of the clerkship the student will be able to:

1. Discuss the clinical features, course, complications including mortality, and prognosis of common Eating Disorders (e.g., Anorexia Nervosa, Bulimia, and Obesity).  K—13, 14

2. Propose plans for further evaluation, referral, and management, including discussion of clinical features suggesting the need for hospitalization of patients with possible Eating Disorders. K—13, 14

Sexual Disorders
Rationale:  Sexual Disorders are diverse and prevalent.  Patients with sexual disorders may present in any clinical setting.  Despite the considerable morbidity associated with sexual disorders, they may go undetected because of their sensitive nature.  All physicians should be able to obtain an accurate sexual history, recognize signs and symptoms suggestive of sexual disorders, and refer patients for further evaluation and treatment.

By completion of the clerkship the student will be able to:

1. Obtain and document a sexual history and interpret findings to formulate a differential diagnosis accounting for patient age, developmental stage, and cultural background.  D--2

Sleep Disorders

Rationale:  Sleep Disorders are prevalent, treatable conditions associated with considerable morbidity.  Persons with sleep disorders may present in any clinical setting.  Hence all physicians should be able to obtain an accurate sleep history, recognize signs of sleep disorders, and recommend management or referral for further evaluation and management.

By completion of the clerkship the student will be able to:

1. Discuss the signs and symptoms of common sleep disturbances that accompany psychiatric disorders and substance use including dyssomnias and parasomnias.  K--13

2. Review the effects of common psychotropic medications on sleep and discuss basic recommendations for sleep hygiene.  D--1

Personality Disorders

Rationale:  Personality Disorders are highly prevalent, chronic conditions.  Patients with personality disorders present in all clinical settings and by virtue of their personality disorders are often particularly challenging and frustrating for the treating physician.  Unrecognized or unaddressed personality disorders can complicate the course of any medical condition and lead to unsatisfactory outcomes.  Hence all physicians should be able to recognize signs and symptoms suggestive of personality disorders, be alert to how these disorders may complicate treatment efforts, and be able to refer patients for further evaluation and treatment.

By completion of the clerkship the student will be able to:

1. Discuss the concepts and relevance of personality traits and disorders in providing patient care.  K—1. 2. 12

2. Discuss the three cluster conceptualization of personality disorders as outlined in the DSM-IV-TR and describe typical features of each disorder.  K—1, 13, 14  

3. Recognize and discuss common clinical features and maladaptive behaviors suggestive of a personality disorder and make recommendations for further evaluation, referral, and management.  D—1, 18

4. Summarize the principles of management of patients with personality disorders in any clinical setting, particularly those with the most challenging behaviors (i.e., Borderline and Antisocial), including self-awareness of one’s own response to the patient, the benefit of outside consultations, the use of both support and non-punitive limit setting, and the indications for various forms of psychotherapy.  K--1

Disorders in Childhood and Adolescence
 Many psychiatric disorders are first manifested or diagnosed in infancy, childhood or adolescence.  These disorders are diverse ranging from mental retardation and behavioral disturbances to mood disorders and psychosis.  Children and adolescents manifesting signs and symptoms of these disorders often present in a primary care setting.  Hence all physicians should be knowledgeable about child development and be able to obtain an accurate developmental history and perform an age-appropriate mental status exam as part of a thorough medical assessment.  Clinicians should be able to recognize signs and symptoms suggestive of a psychiatric disorder and manage or refer patients for further evaluation and management.

By completion of the clerkship the student will be able to:

1. Recognize and distinguish the difference between behavior that is developmentally normal (e.g., stranger anxiety) from behavior that suggests psychopathology (e.g., Panic Disorder).  K—13, 14

2. Discuss the clinical assessment and differential diagnosis for children and adolescents  presenting with disruptive behavior and make recommendations for further evaluation, referral, and management.  K—13, 14

3. Discuss the epidemiology, clinical course, family history and prognosis of common psychiatric disorders in childhood and adolescence including Attention Deficit and Disruptive Behavioral Disorders, Learning Disability, Autistic Spectrum Disorders, Mood and Anxiety Disorders, Eating Disorders, and Substance Use Disorders.
          K—13, 14

4. Discuss the physician’s role in diagnosing, managing and reporting suspected abuse of children and adolescents.  K--1

Geriatric Psychiatry
Rationale:  The percentage of the US population over 65 years old is increasing dramatically.  There are many predisposing risk factors for psychiatric illness associated with aging.  As such, mental disorders in the elderly, ranging from cognitive to mood disorders are prevalent and the risk for suicide is particularly high in this age group.  Geriatric patients with psychiatric disorders may present in any clinical setting.  Hence all physicians should be able to assess mental status in elderly patients and recognize the signs and symptoms suggestive of mental disorders.  Physicians should incorporate knowledge of the physiological and psychosocial changes accompanying aging into treatment planning and be able to refer patients for further evaluation and treatment.

By completion of the clerkship the student will be able to:

1. Describe issues unique to the psychiatric evaluation of the elderly (e.g., changing sensory perception).  K--1

2. Compare and contrast the clinical presentation of psychiatric disorders in the elderly versus other adults (e.g., somatic focus in depression).  K--1

3. Discuss and assess the heightened risk of suicide in elderly patients.  K--13

4. Discuss the physiology of aging relevant to the prescribing of psychotropic medications.  K

5. Discuss the physician’s role in diagnosing, managing and reporting suspected elder abuse.  K--1

Adjustment Disorders
Rationale:  Adjustment Disorders are clinically significant reactions to stress.  Patients with adjustment disorders may present in any clinical setting in crisis with diverse symptomatology.  All physicians should be able to recognize signs and symptoms suggestive of an adjustment disorder, provide support, and be able to provide or refer patients for further evaluation and crisis intervention.

By completion of the clerkship the student will be able to:

1. Describe the essential features and course of Adjustment Disorders.  K—1, 13

2. Compare and contrast Adjustment Disorders with major Mood, Anxiety and Conduct Disorders and normal Bereavement.  K--13

3. Recommend plans for further evaluation and management of patients diagnosed with Adjustment Disorders.  D--1

Disease Prevention, Therapeutics, and Management

Prevention
Rationale:  Prevention is fundamental to medical practice.  Physicians must keep in mind the goals of decreasing the occurrence of illness, reducing illness duration, and minimizing the associated disability of medical conditions.  Preventive medicine is a particular challenge in psychiatry where the etiology and pathophysiology of many disorders is as yet unknown and patients may lack insight into their illness.

By completion of the clerkship the student will be able to:

1. Assess the effects of socioeconomic factors (e.g., culture, family stability, divorce, finances, lifestyle, etc.) on the course of psychiatric illness and adherence to treatment and counsel assigned patients and their families.  K--1

2. Describe the genetic and environmental risk factors for psychiatric illness including emotional, physical and sexual abuse, domestic violence, and co-morbid substance abuse.  SH--1

3. Discuss the risks of untreated psychiatric illness and the importance of early identification of major psychiatric disorders in at-risk youth.  K

4. Discuss factors that suggest need for psychiatric hospitalization and inpatient care. D—1,2

5. Provide education about psychiatric illness and treatment options to designated patients.  D--1

Pharmacological Therapies
Rationale:  Knowledge of psychopharmacology is critical to the practice of all medical specialties.  The field of psychopharmacology is best characterized as dynamic and the product of ongoing research and new drug development.  Students must be knowledgeable about indications, contraindications, presumed mechanism of action, pharmacodynamics, pharmacokinetics, and common and serious adverse effects of psychotropic drugs.  Students must also be knowledgeable about factors that will impact the use of psychotropic medications including drug-drug interactions, drug-disease interactions, and important considerations for drug use in special populations across the lifespan (e.g., children, pregnancy and lactation, the elderly).  During the psychiatry clerkship, students should review, prioritize and update the important principles first learned in the pre-clinical pharmacology, physiology and pathology curriculum.  Students should also become competent at accessing relevant information (e.g., results of large population based clinical trials, consensus algorithms, etc.) and maintaining an up-to-date knowledge base in the area of psychotropic pharmacotherapy.

By completion of the clerkship the student will be able to:

1. Discuss the common, currently available psychotropic medications with regard to clinical indications and contraindications, presumed mechanism of action and relevant pharmacodynamics, common and serious adverse effects, pharmacokinetics, evidence for efficacy, cost, risk of drug-drug interactions and drug-disease interactions, and issues relevant to use in special populations (e.g., pregnancy and lactation, childhood and adolescence, the elderly).  K—1,2, 13, 14

2. Propose selected psychotropic pharmacotherapy for designated patients and provide clinical reasoning that includes discussion of factors influencing treatment selection (e.g., patient-specific and drug-specific variables, scientific evidence).  D—1,2, 18

3. Discuss the factors relevant to implementing, monitoring and discontinuing psychotropic pharmacotherapy including drug dosing, treatment duration, and compliance, and make management recommendations for dealing with an unsuccessful treatment trial (e.g., lack of efficacy, intolerability).  D--1

4. Counsel patients about psychotropic pharmacotherapy including risks and benefits of recommended treatment, treatment alternatives, and no treatment.  D--1

5. Discuss special issues and concerns related to specific psychotropic drug classes:

a) Antidepressant Agents:  Be able to discuss the risk, early detection, relevance and interventions for Hyperserotonergic Syndrome, Hypertensive Crisis, suicidality and cardiac arrhythmias; b)Antipsychotic Agents:  Be able to discuss the risk, early detection, relevance and interventions for acute Extrapyramidal Side Effects (EPS), Tardive Dyskinesia, Neuroleptic Malignant Syndrome, metabolic derangements, cardiac arrhythmias, and anticholinergic toxicity; c) Mood Stabilizing Agents:  Be able to discuss the risk, early detection, relevance and interventions for lithium and anticonvulsant toxicity including plasma level monitoring; d) Anxiolytics and Sedative-Hypnotic Agents:  Be able to discuss the risk, early detection, relevance and interventions for toxicity, dependence and consequences of abrupt discontinuation; e)Stimulant Agents:  Be able to discuss the risk, early detection, relevance and interventions for toxicity and abuse;  f)Cognitive Enhancers:  Be able to discuss the clinical use, drug interactions and potential adverse effects.  SH—1, 2, 13, 14, 18

Brain Stimulation Therapies
Rationale:  Electroconvulsive therapy (ECT) remains one of the most effective treatments for mood disorders.  It is used widely and in many cases is considered to offer the most favorable risk: benefit ratio among available antidepressant interventions.  A variety of alternative brain stimulation therapies are either being approved for general use to treat psychiatric disorders or are in various stages of development.  Since patients with mood disorders may present in any clinical setting, all physicians should be able to refer patients for further evaluation for ECT. 

By completion of the clerkship the student will be able to:

1. Discuss electroconvulsive therapy (ECT) with regard to clinical indications and contraindications, presumed mechanism of action, common and serious adverse effects, evidence for efficacy, cost, and issues relevant to use in special populations (e.g., pregnancy, childhood and adolescence, the elderly).  K—13, 14

Psychotherapies
Rationale:  Evidence-based interventions for many disorders encountered in medical practice include psychotherapy.  Although a psychiatry clerkship does not provide adequate time for a student to learn to conduct psychotherapy, it does present an opportunity for students to gain familiarity with and develop and understanding of psychotherapy.  At the most essential level, psychotherapy is the process of helping people overcome problems by talking about them.  There are many types of psychotherapy, each with a theoretical construct that aims to help us understand human behavior and treat disturbances of emotion and behavior.  Regardless of medical specialty, an effective practitioner should have a basic understanding of psychotherapy, recognize the relevance of psychotherapy principles to the doctor-patient relationship, be aware of those psychotherapies with evidence-based efficacy for particular disorders, and be able to refer patients for psychotherapy.

By completion of the clerkship the student will be able to:

1. Discuss general features of common psychotherapies and recommend specific psychotherapy for designated patients in conjunction with or instead of other forms of treatment and provide clinical reasoning that includes discussion of factors influencing treatment selection (e.g., patient-specific and treatment-specific variables, scientific evidence).  SH--1

2. Counsel patients, provide education about psychotherapy, and promote the use of healthy coping strategies.  D--1

3. Identify and discuss the relevance of potential levels of verbal and non-verbal communication occurring in the uniquely intimate relationship between doctor and patient that occurs regardless of the medical setting or type of medical care being provided including therapeutic boundaries, therapeutic stance, therapeutic alliance, transference and countertransference.  K--1

Multidisciplinary Treatment Planning and Collaborative Management
Rationale:  Regardless of medical specialty, because of the complexity of our healthcare system, the complexity of peoples’ lives, and the impact of psychosocial variables on health and illness, it is critical that a physician be able to collaborate effectively with other physicians in different specialties and with other healthcare workers in different disciplines.  The effective collaborations necessary to bring about an optimal clinical outcome require an understanding and appreciation of what each discipline contributes to patient care.  An effective physician recognizes the importance of collaboration with the patient’s family and others in their life to increase the likelihood of a successful treatment outcome.

By completion of the clerkship the student will be able to:

1. Discuss the roles of different physician specialties and non-physician healthcare disciplines (e.g., case managers, addiction counselors, etc), demonstrate respect for these colleagues, and work collaboratively in the care of patients and their families.  D--1

2. Discuss the importance of working successfully with patient’s families and other agencies in the patient’s life (e.g., schools, employers, etc) accounting for cultural diversity, to bring about an optimal clinical outcome.  K--1

3. Discuss and propose appropriate community resources as part of a comprehensive treatment plan for assigned patients (e.g., support groups, residential facilities, vocational rehabilitation, etc).  SH—1,2, 18

Professionalism, Ethics and the Law

Professionalism
Rationale:  Professionalism is a broadly defined, critical component of medical practice and should be fundamentally present in all clerkship curriculums and throughout undergraduate medical education.  Elements of professionalism include integrity, honesty, responsibility, dedication to the best interests of the patient, and sensitivity to the diversity of patients and their disabilities.  Physician effectiveness, patient safety, and quality health care require a high level of professionalism.

By completion of the clerkship the student will be able to:

1. Demonstrate respect, empathy, responsiveness, and concern regardless of the patient's problems, personal characteristics, or cultural background.  D—1,2

2. Demonstrate sensitivity to medical student-patient similarities and differences in gender, ethnic background, sexual orientation, socioeconomic status, educational level, political views, and personality traits.  D—1,2

3. Discuss the prevalence and barriers to recognition of psychiatric illnesses in general medical settings and recognition of general medical conditions in patients with known psychiatric illness.  K--1

4. Discuss the concept of boundaries in the doctor-patient relationship and boundary violations.  S—1

5. Demonstrate integrity, responsibility and accountability in the care of assigned patients.  D—1

6. Demonstrate scholarship in the form of contributing to a positive learning environment, collaborating with colleagues, and performing self-assessment and self-directed learning.  D—1

7. Be able to assess one’s strengths, weaknesses and health (physical and emotional), and be willing to seek and accept supervision and constructive feedback.  D—2

Medical Ethics
Rationale:  All physicians confront ethical issues in medical practice.  In caring for patients with altered mental status, physicians must deal with the conflict between beneficence and autonomy, psychological development and personal history in the lives of patients.  In caring for patients with significant emotional disturbance, a physician must refrain from rejecting a patient or getting over involved. A thorough understanding of the ethical issues of confidentiality, informed consent, caring for special populations and the right to refuse treatment is critical to appropriate clinical practice.  For clinical excellence, a physician must be able to identify ethical features in a patient’s care, utilize self-observation and self-scrutiny, and implement focused strategies for approaching ethical issues.

By completion of the clerkship the student will be able to:

1. Identify and discuss issues of ethical concern in the care of assigned patients (e.g., autonomy versus beneficence and interpersonal boundaries).  D—1, 22

2. Identify and discuss ethically risky and problematic situations encountered in healthcare (e.g., duty to warn, reporting child abuse).  D—13, 14

Medical-Legal Issues in Psychiatry
Rationale:  All physicians must be knowledgeable about the legal obligations associated with medical practice.  Important legal obligations for physicians include duty to report, duty to warn, and least restrictive alternative treatments.  Particularly relevant in psychiatry are the issues of involuntary commitment, assessment of competency, seclusion and restraints, and criminal responsibility.

By completion of the clerkship the student will be able to:

1. Discuss the risk factors, screening methods and reporting requirements for suspected abuse, neglect and domestic violence in vulnerable populations including children, adults, and the elderly.  S—13

2. Discuss the physician’s role in screening for, diagnosing, reporting and managing victims of abuse.  K--1

3. Discuss the elements of informed consent and evaluation of decision-making capacity (i.e., the right to refuse treatment, assent versus consent in children and adolescents).  K—13

4. Discuss the principles and process of the physicians “duty to warn” obligation.K—13, 22

ACGME Glossary of Assessment Methods for Clinical Education (ACGME 2000) - Adapted for the Clinical Curriculum Resource Guide for Psychiatry Education

1. Clinical Performance Ratings – Weekly, monthly, end-of-rotation ratings of student overall performance

2. Direct Observation and Evaluation - Supervisor/attending observation of individual student-patient encounters, operations, specimen preparation, etc., and concurrent (same day) evaluation

3. 360 Assessments - Evaluation by MDs (supervisors, residents, medical students) and non-MDs (nurses, technicians, social workers, PAs ) using the same or similar evaluation forms

4. Evaluation Committee - Evaluation of student performance in a small group discussion format, e.g., Evaluation Committee

5. Structured Case Discussions - An informal structured mini-oral exam consisting of a small set of pre-determined questions; the exam occurs during a student's case presentation to his/her supervisor

6. Stimulated Chart Recall - Uses a student’s patient records in an oral exam-like format to explore decisions made and patient management; is conducted "after the fact" using patient charts to stimulate memory of the case

7. Standardized Patient - The student provides care to an SP as if (s)he were a real patient and is evaluated concurrently by the SP or another trained observer; the SP is a well person or actual patient trained to present a case in a standardized way

8. OSCE - A multi-station exam of simulated clinical tasks, which might include SPs, anatomical models, X-ray interpretation, lab test interpretation, etc.; a student performs the tasks and is evaluated concurrently by a trained observer

9. High Tech Simulators/Simulations - Students' performance of procedures on a high-tech simulator (e.g., Harvey) is evaluated; this may involve built-in evaluation by the simulator or observation and concurrent evaluation.

10. Anatomic or Animal Models - Students' performance of procedures on non-computerized, 3-dimensional models that replicate the properties of human anatomical structures is observed and evaluated concurrently

11. Role-play or Simulations - Students are evaluated based on their performance on assigned responsibilities in a staged replica of a potentially real situation, e.g., mobilization of medical team in a multi-victim accident, confrontation of an "impaired" colleague, negotiation with administration regarding facilities and equipment upgrade

12. Formal Oral Exam - "Mock" oral exam in which an examiner asks students questions about what to do in a clinical scenario presented verbally or role played by the examiner

13. In-training Exams - A multiple-choice exam developed by an external vendor

14. In-house Written Exams - A multiple choice exam developed by program faculty

15. Multimedia Exam - A computer based multiple choice or branching question exam in which authentic visual and auditory patient information is presented as question information

16. Practice/Billing Audit - Educational equivalent of physician profiling; this data-based process benchmarks individual student billing data against peers in the office, hospital, or managed care setting

17. Review of Case or Procedure Log - Review of number of cases or procedures performed and comparison against minimum numbers required

18. Review of Patient Chart/Record - Involves abstraction of information from patient records, such as tests ordered, and comparison of findings against accepted patient care standards

19. Review of Patient Outcomes - Aggregation of outcomes of patients cared for by a student and compared against a standard

20. Review of Drug Prescribing - Systematic review of drug prescribing for selected conditions to determine adherence to protocol

21. Student Project Report (Portfolio) - Evaluation of student work products, such as examples of clinical documentation including progress notes and History and Physical Exams, reports of research studies, practice improvement, or systems-based improvement

22. Student Experience Narrative (Portfolio) - Evaluation of performance based on students’ narratives of critical incidences or other experiences, usually accompanied by reflection on the event, e.g., what happened, why, what could have been done differently

Other Portfolio - Evaluation of student performance based on other work/performance products not included above, e.g., audiotapes, slide presentations