BEH PGY3

The BEH training during PGY-3 focuses on advancing residents':

• Clinical Interviewing Skills Training  - advancement of equitable, collaborative, culturally-informed, and patient-centered approach to clinical interviewing with focus on the following communication skills: informed consent/documentation, agenda setting, interviewing techniques, electronic health record integration/documentation, working with interpreters, working with companions, culturally informed interviewing, and steps for completing the interview (i.e. teach back).

• Behavioral Medicine Interventions/Techniques- development of knowledge and skills for implementation of behavioral medicine techniques to promote illness management and wellness across a range of medical and psychiatric conditions.

• Psychiatric Condition Management -  with focus on the diagnostic criteria, assessment, and management strategies for the following: anxiety disorders, post traumatic stress disorder, obsessive compulsive disorder. Please note that substance use disorder management and depression management are integrated within PGY-2 training.  Please review relevant materials on these topics.

• Professionalism - including but not limited to the following:

• Self-reflection in clinical practices, impact of personal attitudes and behaviors on patient care

• Ethical issues: informed consent/documentation, patient autonomy/working with companions, confidentiality, quality of care,

• Punctuality, timely communication, and self-directed learning

Residents are expected to maintain professionalism during all in-person and remote components of the rotation. This includes but not limited to:

• Complete of assigned readings, Q&A, and online trainings prior to scheduled review date(s)

•  Demonstrate  self-directed learning - determining learning goals in line with rotation's scope/focus/training opportunities available

• Work collaboratively with faculty to complete patient encounter video recordings and/or communicate proactively about direct observations

• Demonstrating familiarity with observed/recorded sessions at the time of the review meeting(s)

• Complete and document patient care sessions for review in line with guidelines 

• Demonstrating responsiveness to feedback provided by the faculty 

• Timely attendance of all rotation-specific meetings, didactics etc is expected. Proactively communicate about any delays, schedule changes etc.

• Promptly respond to all email communication 

•  Discuss any schedule changes and any training-related needs as early as possible 

• For any meetings conducted remotely, residents need to ensure that they are located in a setting which is conducive to discussion/learning - private with any noise minimized

BEH training aims to deliver clearly defined, behaviorally-anchored skills as well as metrics for learners’ self-assessment. Training will be delivered via the following:

Self-Study and Completion of Q&A: 

Residents will complete weekly self-study materials and accompanying Q&A (See 'Weekly To Do List' section for specifics)

Format: Asynchronous/self study materials, Center for Practice Innovations (CPI) training modules

When? Self-study materials should be completed prior to each week's meeting with faculty (Wednesday am/pm - see schedule)

CPI completion certificates for relevant week(s) should be submitted to rotation faculty before the end of the second training block

Q&A Review/Didactic Meeting:

Q&A Review/Didactic Meeting will build on the completed self-study materials per week's training focus. Meetings aim to consolidate knowledge in each domain and discuss related topics and questions.

Format: In-Person (Wednesday am/pm - check schedule) or via Zoom

Video Review:

Weekly recording of patient care sessions is expected for review and feedback.  Each observed/recorded encounter will be reviewed. 

Feedback will be provided per Direct Observation/Video Review Form. Residents should be familiar with both Direct Observation/Video Review Form and Direct Observation/Video Review Comprehensive Form (see Google drive folder).

 At the end of the rotation, summary feedback will be reviewed. This summary feedback will directly inform performance evaluation.

Residents are expected to complete a minimum of 3 sessions for each FHC5 and FHC6 blocks.

Format:  Recording at Farrell CFCM

When? Check Orange schedule - any/all FHC sessions should be used for recording, until required number of recorded sessions is reached.

Self-Assessment of Performance:

#1  Complete pre rotation survey 

#2  Complete post rotation survey 

Format: Qualtrics Survey - links located in Google Drive folder- PGY3 - Behavioral Medicine

Supervising Faculty: Dr. Amit Batta

Location: The Allen Hospital, 3RE-207 (subject to change January 2024)

Schedule:  

No nursing home coverage:  CL psychiatry Tuesday 8:30 am - 12 pm

If nursing home coverage:  CL psychiatry Thursday 8:30 am - 12 pm

Meeting with Dr. Batta at Allen Hospital - 3FE 176

Contact Dr. Batta (email: ab5638@cumc.columbia.edu) on the first day of the rotation to confirm schedule (location, time) and discuss any planned changes.

Core Topics

Legal Aspects of Psychiatry

Informed consent and evaluation of decision-making capacity

1. Informed Consent Protocols: review informed consent protocols, referencing the elements required for a patient to make an informed decision about their treatment

2. Assessment of Decision-Making Capacity: examine tools and methodologies used to assess and evaluate a patient's decision-making capacity, considering both legal and ethical dimensions

3. Shared Decision-Making: Discuss academic insights into shared decision-making, involving patients in their treatment plans while respecting their autonomy and preferences

'Difficult' Patients

 Types of 'Difficult' Patients:

1. Psychodynamic Understanding: Explore psychodynamic perspectives on understanding and managing difficult patient interactions

2. Therapeutic Approaches: Introduce therapeutic approaches tailored to different types of difficult patients

Management of staff and 'difficult' patient dissonance:

1. Team Dynamics: Address challenges in team dynamics when dealing with 'difficult' patients, referencing research that emphasizes effective communication and collaboration among healthcare staff

2. Conflict Resolution Skills: Equip healthcare professionals with conflict resolution skills, supported by academic literature, to navigate dissonance between team members and 'difficult' patients

3. Staff Well-being: Discuss strategies to support the well-being of healthcare staff dealing with challenging patient interactions, referencing studies that explore the impact on staff mental health

Delirium

Examination of delirium:

1. Diagnostic Criteria: Provide a comprehensive overview of the risk factors and diagnostic criteria for delirium, how to differentiate it from other conditions.

2. Multifactorial Causes: Explore the multifactorial causes of delirium, including medical, psychiatric, and environmental factors, with references to relevant research.

Specific management strategies:

1. Non-Pharmacological Interventions: Discuss evidence-based non-pharmacological interventions for managing delirium such as environmental modifications, sensory interventions, and therapeutic communication.

2. Pharmacological Approaches: Explore the appropriate use of pharmacological interventions in the management of delirium, citing studies that consider the underlying causes and patient-specific factors.

Long-term outcomes:

1. Post-Delirium Care: Discuss the long-term outcomes and potential sequelae of delirium, referencing academic studies that explore cognitive impairment and functional decline.

2. Rehabilitation Strategies: Explore rehabilitation strategies to optimize recovery and enhance the overall quality of life for individuals who have experienced delirium, with references to relevant academic literature.

Resource Materials

All articles are available via Columbia library. Please ensure that your access (via UNI) is up to date.

Legal Aspects of Psychiatry

• Appelbaum P. S. (2007). Clinical practice. Assessment of patients' competence to consent to treatment. The New England journal of medicine,  357(18), 1834–1840. https://doi-org.ezproxy.cul.columbia.edu/10.1056/NEJMcp074045

• Capacity evaluation table on UpToDate -  https://www.uptodate.com/contents/image?topicKey=NEURO%2F98592&view=machineLearning&search=capacity%20evaluation&sectionRank=1&imageKey=NEURO%2F100356&rank=1~150&source=machineLearning&sp=0

• Appel J. M. (2022). A Values-Based Approach to Capacity Assessment. The Journal of legal medicine, 42(1-2), 53–65. https://doi-org.ezproxy.cul.columbia.edu/10.1080/01947648.2022.2162171

• Serdenes, R., Arana, F., Karasin, J., Kontos, N., & Musselman, M. (2023). Approaching differential diagnosis and decisional capacity assessment in the context of COVID-19 conspiracy beliefs: A narrative review and clinical discussion. General hospital psychiatry, 83, 75–80. https://doi.org/10.1016/j.genhosppsych.2023.04.008

Delirium

• Breitbart, W., & Alici, Y. (2008). Agitation and delirium at the end of life: "We couldn't manage him". JAMA, 300(24), 2898–E1. https://doi-org.ezproxy.cul.columbia.edu/10.1001/jama.2008.885

• Franco, J. G., Trzepacz, P. T., Velásquez-Tirado, J. D., Ocampo, M. V., Serna, P. A., Giraldo, A. M., López, C., Zuluaga, A., & Zaraza-Morales, D. (2021). Discriminant Performance of Dysexecutive and Frontal Release Signs for Delirium in Patients With High Dementia Prevalence: Implications for Neural Network Impairment. Journal of the Academy of Consultation-Liaison Psychiatry, 62(1), 56–69. https://doi-org.ezproxy.cul.columbia.edu/10.1016/j.psym.2020.04.002

• Carayannopoulos, K. L., Alshamsi, F., Chaudhuri, D., Spatafora, L., Piticaru, J., Campbell, K., Alhazzani, W., & Lewis, K. (2024). Antipsychotics in the Treatment of Delirium in Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Critical care medicine, 52(7), 1087–1096. https://doi.org/10.1097/CCM.0000000000006251 

• Andersen-Ranberg, N. C., Poulsen, L. M., Perner, A., Wetterslev, J., Estrup, S., Hästbacka, J., Morgan, M., Citerio, G., Caballero, J., Lange, T., Kjær, M. N., Ebdrup, B. H., Engstrøm, J., Olsen, M. H., Oxenbøll Collet, M., Mortensen, C. B., Weber, S. O., Andreasen, A. S., Bestle, M. H., Uslu, B., … AID-ICU Trial Group (2022). Haloperidol for the Treatment of Delirium in ICU Patients. The New England journal of medicine, 387(26), 2425–2435. https://doi.org/10.1056/NEJMoa2211868

'Difficult' patients

• Beach, S. R., Taylor, J. B., & Kontos, N. (2017). Teaching Psychiatric Trainees to "Think Dirty": Uncovering Hidden Motivations and Deception. Psychosomatics, 58(5), 474–482. https://doi-org.ezproxy.cul.columbia.edu/10.1016/j.psym.2017.04.005

• Groves J. E. (1978). Taking care of the hateful patient. The New England journal of medicine, 298(16), 883–887. https://doi-org.ezproxy.cul.columbia.edu/10.1056/NEJM197804202981605

• Appel JM. Taking care of the beloved patient. Clinical Ethics. 2023;18(1):13-17. doi:10.1177/14777509221094484

• Firman, G. J., & Kaplan, M. P. (1978). Staff "splitting" on medical-surgical wards. Psychiatry, 41(3), 289–295. https://doi.org/10.1080/00332747.1978.11023985

Note: Training overview is presented in consecutive weeks and includes materials for both FHC5 and FHC6. Residents should anticipate completing Weeks #1 - 2 during the first block (FHC 5 or FHC 6, whichever comes first) followed by Weeks #3 - 4 materials during the 2nd block (FHC 5 or FHC 6, whichever comes last).

Week #1 Topic: Anxiety Disorders - Generalized Anxiety Disorder and Panic Disorder 

Prior to Week #1 Meeting:

Read:

• Gaudiano, B.A. (2017). Cognitive-behavioral therapies: achievements and challenges. EBMH, 11(1), 5-7. 

• Hunter, J. L. Goodie, M. S. Oordt, & A. C. Dobmeyer (2017). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention. (pp 61- 72) Washington, DC, US: American Psychological Association 

• Borza, L. (2017). Cognitive-behavioral therapy for generalized anxiety. Brief Report. Dialogues Clinical Neuroscience, 19, 203-207. 

Review:

• The Fight Flight Freeze Response (2016). Braive. From: https://www.youtube.com/watch?v=jEHwB1PG_-Q

• Complete Week 1 Q&A 

• Complete CPI registration

• Complete pre-rotation survey 

All materials/documents are located in the Google drive folder

Week #1 Agenda:

• Establish learning goals in line with PGY-2 clinical interviewing feedback per MedHub

• Discuss scheduling - including changes/concerns, learning materials, CPI registration

• Week #1 - Q&A

• Admininter SCID-5 Anxiety section pp 63-72

• Review/confirm CPI module registration

Week #2 Topic: PTSD and OCD

Prior to Week #2 Meeting:

Read:

• Hunter, J. L. Goodie, M. S. Oordt, & A. C. Dobmeyer (2017). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention. (pp 72- 75) Washington, DC, US: American Psychological Association. 

• Foa, E. (2010). Cognitive behavioral therapy of obsessive-compulsive disorder. Clinical Research. Dialogues in Clinical Neuroscience, 12, 199-207. 

• Pampaloni, I., Marriott, S., Pessina, E., Fisher, C., Govender, A., Mohamed, H., Chandler, A., Tyagi, H., Morris, L., & Pallanti, S. (2022). The global assessment of OCD. Comprehensive psychiatry, 118, 152342. https://doi-org.ezproxy.cul.columbia.edu/10.1016/j.comppsych.2022.152342

Review: 

• PTSD Treatment: Know Your Options. National Center for PTSD. US Department of Veterans Affairs. https://www.ptsd.va.gov/appvid/video/index.asp

Complete Week 2 Q&A 

Week #3 Agenda:

• Administer SCID-5 PTSD and OCD sections pp 73-86

• Video review

• Week #2 Q&A

• Ensure that CPI registration is completed - module completion due Week #3 . See Registration guidelines in Google drive folder

Week #3: Pharmacotherapies: Depression, OCD, PTSD, GAD

Prior to Week #3 Meeting:

Complete following CPI modules:

• Treatment Resistant and Late Life Depression: An Update for Prescribing Clinicians

• Pharmacological Treatment of Obsessive-Compulsive Disorder: Nuts and Bolts

Read:

• Clinician's Guide to Medications for PTSD US Department for Veterans Affairs. 

https://www.ptsd.va.gov/professional/treat/txessentials/clinician_guide_meds.asp#evidence

• Carlat D. (2023). Pharmacotherapy  for Panic Disorder: What therapists need to know. Clinical Update. Carlat Publishing.  https://www.thecarlatreport.com/articles/4430-pharmacotherapy-for-panic-disorder-what-therapists-need-to-know

Listen to:

• Approaching a case of Generalized Anxiety Disorder: The basics (published 2019). Pharmacology Institute: https://psychopharmacologyinstitute.com/publication/approaching-a-case-of-generalized-anxiety-disorder-the-basics-2486

• Complete Week 3 Q&A here

Week #3 Agenda:

• Video review

• Week #3 Q&A

• Administer any outstanding SCID-5-CV modules

Week #4: Wrap Up

Prior to Week #4 Meeting:

Weiner S. J. (2022). Contextualizing care: An essential and measurable clinical competency. Patient education and counseling, 105(3), 594–598. https://doi.org/10.1016/j.pec.2021.06.016 Weiner_2022.pdf

Answer Week #4 Q&A

• Submit CPI module certificates via email

• Complete post-rotation survey 

Week #4 Agenda:

• Video review & summary

• Week #4 Q&A

• Feedback review

Follow instructions for video recording steps - all materials are in Google drive folder: Video Recording and Review

CONSENT:

1. All patients (and companions recorded) must sign consent forms before starting video recording. Consent form must be filled out fully, in pen, and include a session ID sticker in the top right hand corner.

2. File consent forms in a red folder next in the DVD filing cabinet (office #214). Do not remove completed consent forms off site. 

3. Statement of video recording consent must be included in your sessions' documentation using the following EPIC smart phrase: .VIDEORECORDINGGENERAL (under N. Pilipenko) . Please seek consultation if you are unsure about utilization of smart phrases in EPIC.

TROUBLESHOOTING ISSUES:

1. For any technical issues, contract rotation faculty via email the day of the event

2. Follow instructions for video recording - following documents in the Google folder

RECORDING FOR VISITS CONDUCTED IN LANGUAGES OTHER THAN ENGLISH

1.  Consent form and visit documentation must include interpreter ID #

2. Per NYP policy, only residents who achieved LLC certification in the respective language can see patients without an interpreter.

• Curriculum is designed based on the guidelines of the American Academy of Family Physicians: https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint270_Mental.pdf

• Residents are strongly encouraged to review all portions of the evaluation and discuss concerns with faculty during Week #4 meeting. Evaluation can be found here:  BehavioralMedicine_MedHub_July2021.docx  (or PBWiki site)

• Residents are responsible to complete all rotation-specific tasks and submit any completed documentation within 1 week following the end of the rotation.

• Any didactic content (e.g. Q&A) which was not reviewed directly with the faculty during the course of the rotation should be submitted within 1 week following the end of the rotation, via email.

• During Week #4 meeting, summative feedback will be provided and discussed.

Evaluation will include the following:

• Video review observation summary (commutative). Each recorded/observed session will be reviewed using standardized checklist. Any additional pertinent feedback will be noted.

• Participation in learning activities and completion of learning content (in line with expectations as outlined in Learning Goals Summary and Rotation Expectations sections)

• Participation in CL learning activity - along with feedback provided by Dr. Batta

•  Feedback will be submitted via MedHub