Caguas, Puerto Rico Clinical Sciences

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1 Caguas, Puerto Rico Department of Psychiatry and Behavioral Sciences Course PSYCHIATRY 320 Student Syllabus Author: Preparation Date: June 2008 Revision Date: July 2011 Revised By: Approved by: Myrta N. Sifonte, MD Department of Psychiatry and Behavioral Sciences Myrta N. Sifonte, M.D. Psychiatry Coordinator Curriculum Sub-Committee Year III Academic Year Escuela de Medicine San Juan Bautista 1

2 Department of Psychiatry and Behavioral Sciences PSYCHIATRY 320 THIRD YEAR Credits: Six (6) Duration: 6 weeks Classroom: First Hospital Panamericano San Juan de Capestrano Hospital Corporacion SANOS San Juan Bautista School of Medicine Schedule: Monday to Friday 8:00a.m. to 4:30 p.m. Previous Requirements: Approved Basic Sciences Program COORDINATOR AND PROFESSORS INFORMATION Myrta N. Sifonte, M.D. Coordinator Office: Cellular : Dr. Francisco Sanchez-Longo Office: Cellular :

3 Carmen Martinez Cotto, MD Office: ext Sergio Matos, MD Office: ext Raul Rivera Mendez, MD Office: ext Lilliana Bicchi Consuegra, MD Office: ext Sylvia P. Johnson, M.D. Office: ext Lydia Fernandez Abalde, MD 3

4 Office: ext Luis H. Negron, M.D. Office: ext Hilda Rivera Cartagena, M.D. Office: ext Carmen Tejada, M.D. Office: ext Celestino Flores Carmona, M.D. Office: ext Liaison SJBSOM-SANOS: Coordinator at First Hospital Panamericano: Dr. Myraida Rivera, Corporacion SANOS Ms. Aida Santiago 4

5 RULES See Description in the Clerkship General Rules File PSYCHIATRY CLERKSHIP I. General Description The Psychiatry Clerkship is a six week clinical course that provides third year medical students with a solid foundation in the fundamentals of the evaluation, diagnosis, treatment, and appropriate referral of patients with mental health disorders. II. III. Prerequisites The first four semesters of the required EMSJB curriculum must be successfully completed prior to starting clerkship rotations including the Behavioral Medicine Course. Purpose The purpose of the Psychiatry Clerkship is to develop the student s clinical skills in the diagnosis and treatment of patients who have mental disorders. Students will develop their skills in a variety of diagnostic and treatment procedures that are commonly involved in psychiatric care. IV. Course Objectives By the completion of the Clerkship, the student will be expected to master the following objectives: A. Skills: 1. Based on the observations of clerkship faculty and/or the clerkship director, the student will demonstrate the ability to: a. Perform a complete psychiatric evaluation that will include identifying data, history of present illness, a psychosocial history, past psychiatric history, past medical history, current medical problems, alcohol/substance abuse history and mental status exam, summation and differential diagnosis b. Perform a problem focus exam c. Perform a mini mental status exam 5

6 d. Do a risk assessment for suicide or potential to do harm to others and discuss an intervention plan e. Verbally present a case, the presentation will include present and past history, an assessment, differential diagnosis, a provisional diagnosis and treatment plan 2. Based on the review of the clerkship director and clerkship faculty, the student will demonstrate the ability to: a. Write a case in a form satisfactory for a medical record b. Use technology to locate evidence based psychiatric information 3. Based on the observations of clerkship faculty and/or the clerkship director, the student will demonstrate the ability to: a. Demonstrate respect, empathy, responsiveness, and concerns regardless of the patient s problems or personal characteristics. b. Keep boundaries, recognize transference issues and set limits with patients. c. Verbally communicate in a manner understood by the patient and effective for gathering history. d. Be able to use basic strategies for interviewing disorganized, hostile/resistant, mistrustful, circumstantial/hyperverbal, hypoverbal, and potentially assaultive patients. 4. Using a PDA, computer or other technology that accesses current evidence based medical information; the student will research topics of relevance to the clerkship. The information discovered will be of sufficient clinical utility to be included in evaluating and diagnosing a patient, formulating a treatment plan or composing reports/presentations on psychiatric topics. B. Knowledge: 1. Based on the observations of clerkship faculty or the clerkship director during patient rounds, case presentations and small group discussions, the student 6

7 will demonstrate the knowledge in the following core areas: a. Mental illnesses to include major depression, dysthymic disorder, bipolar disorder, adjustment disorders, generalized anxiety disorder, panic disorder, social phobia, obsessive compulsive disorder, substance and alcohol use, the three clusters of personality disorders with a particular focus on borderline personality disorder, schizophrenia/psychosis, dementia and delirium, somatoform disorders, factitious disorder, malingering and sleep disorders. b. Criteria A for the illnesses listed in the 4 th edition of Diagnostic and Statistics Manual of Mental Disorders for the conditions listed above. Demonstrate an understanding of the use of DSM IV c. Psychopharmacology to include the usage of anxiolytics, antidepressants (and ECT), antipsychotics, mood stabilizing agents, anticholinergics, acetylcholinesterase inhibitors, and namentine, psychostimulants, and beta blockers in treating the mentally ill. 2. During discussions with faculty, the student will demonstrate and analysis of the role of the following in the comprehensive evaluation and management of a psychiatric patient: a. The comorbidity of mental, neurological and medical illnesses. b. The use of laboratory and various types of scans (CT, PET, MRI, etc.) to evaluate for mental illness or for the ongoing monitoring of medications. 3. The student will construct and present to faculty an organized treatment plan addressing the findings of the evaluation. In addition to recommending medications using the principles of psychopharmacology, this presentation will demonstrate to the faculty: 7

8 a. Recognition of the signs, symptoms, and risk factors for suicide, homicide and withdrawal from drugs and alcohol. b. The ability to asses the need to be hospitalized, versus treatment as an outpatient. c. The ability to utilize the basic concepts of various psychotherapies and propose ways to incorporate them into a treatment plan. 4. For either incorporating into the treatment plan or using to assist in solidifying a difficult diagnosis, the student will demonstrate to the attending: a. A conceptual understanding of the indications for psychological testing. 5. From the collection of information about the patient, the student will demonstrate to faculty: a. Recognition of the signs of abuse in all ages b. The differing presentations of mental illness over the life span. C. Attitudes and behaviors: 1. In case presentations, patient write-ups and discussions with clerkship directors and preceptors, demonstrate the ability to remain objective and nonjudgmental toward a patient regardless of lifestyle and life choices. Empathy is a quality worth acquiring and diversity is rarely boring. 2. No matter the setting (inpatient wards, ambulatory care centers, hallways, waiting rooms) the importance of confidentiality of psychiatric information will be demonstrated in discussing and interactions with attendings, colleagues, nurses, office staff, etc. 3. During post evaluation discussions with attendings and/or intake personnel the student will be able to discuss the basic ethical issues in psychiatry such as involuntary treatment, the duty to warn about risks, reporting abuse (especially in children and elderly), and acceptable as well as unacceptable interactions with patients. 8

9 4. Explain to faculty when and why to refer to a psychiatrist a patient being seen in a primary care setting for a mental condition. 5. The student will demonstrate in case discussions with faculty and/or participation in multidisciplinary treatment team meetings, the role these next three items play in aftercare planning, compliance with treatment and maintaining a mentally ill person in the community: a. The biases in society, medicine in general, the law, and other arenas toward the mentally ill and how to be an advocate when necessary b. The barriers to treatment placed by society, the system, the mentally ill person himself, third party payers, etc. c. The need to work with community resources available for all age groups and know to which organization to contact for this type of assistance. (Social Services, Council on Aging, Children Services, etc.) V. Community Medicine Since our School is defined as a community-based institution, Community Service is an institutional project that involves all constituencies with different actions and activities related to the community initiative. It is expected that through diverse strategies, the student will realize his\her original commitment to society in their roles as citizens and professionals COMMUNITY PROGRAM Is a Community Medicine Service-Learning activity developed in response to community-identified concerns in which third year medical students have an active participation. Students are involved in a direct intervention with patients (drug users, homeless, HIV, mental diseases), family, and community throughout outreach programs. There is a 9

10 connection between their academic coursework (psychiatry rotation) and service combined with reflection. OBJECTIVES Community Medicine Emphasis o Apply the general concepts and practice of community medicine Medical Knowledge Emphasis o Apply basic sciences knowledge and Clinical Medicine Professionalism Emphasis o Demonstrate professional attitudes, behaviors, compassion and humanism. o Recognize the world of practicing physicians throughout a variety of common community medical situation. o Understand the interactions between physicians, patients, families, community leaders, and community. Clinical Skills Emphasis o Communicate and interact effectively with the patients, families, community promoter, both verbally and in writing. o Obtain and record medical information Research and Information Literacy Emphasis o Increase the skills in critical review of literature EVALUATION The process of intervention with the patient and family in the community will be encouraged and evaluated through the following aspects: 10

11 o Professionalism: Evaluation of Student Professionalism by Health Co-workers (see form CE-016) (20%) o Each student has to perform a clinical and psychiatric history to each patient seen and discuss the case with the psychologist or case manager (20%) o Evaluación de Profesionalismo del Estudiante por pacientes y familiares (CE- 014) (10%) o Student written report of community activity (see form CE-022) (20%) o Information Literacy (each group MUST analyze a scientific article of Additive disorders) (10%) o Attendance and punctuality: Student should attend every day schedule: 8:30 am to12:00n; except Tuesday 1:00 pm to 4:00 pm. Every day you MUST sign the attendance list. (20%). Failure to comply will decrease in 5% your grade VI. Curriculum A. The curriculum consists of: 1. Performing clinical activities under direct supervision 2. Observing clinical activities by faculty 3. Reading assigned material 4. didactic presentations 5. Performing other assigned duties that are designed to assist the student in learning to perform core psychiatric skills with increased proficiency B. The students will typically have the opportunity to: 1. Observe and/ or conduct diagnostic evaluations with psychiatric patients 2. Observe the presentation of patients who meet diagnostic criteria for many of the major DSM-IV-TR categories. 3. Identify the essential and associated features of the relevant DSM-IV-TR diagnoses. 4. Observe and/or participate in diagnostic decision making 5. Observe and/or participate in the process of designing a treatment plan for psychiatric patients 11

12 6. Observe and/or participate in a multi-disciplinary treatment approach for psychiatric patients. 7. Observe and/or participate in the psychopharmacological treatment of patients within the major DSM-IV-TR diagnostic categories. 8. Study the clinical use of psychotropic medications, including indications and contraindications, dosage scheduling, and modes of action. 9. Study the clinical presentation and treatment of common pharmacological side effects, such as extrapyramidal symptoms and tardive dyskinesia. 10. Observe and/or conduct patient education about psychotropic medications. 11. Document and/or observe documentation of diagnostic and management activities utilizing the medical record system employed at the clerkship site. VII. Topics to be discussed Patient Type or Core Condition Mental Status Examination DSM IV TR Major Depressive Disorder Bipolar Disorder Methodology Person in Charge 12

13 Dysthymia and Cyclothymia Schizophrenia Schizoaffective Disorder Panic Disorder Post Traumatic Stress Disorder Obsessive Compulsive Disorder Generalized Anxiety Disorder Delirium, Dementia and Amnestic Disorders Substance Use Disorders 13

14 Alcohol Abuse, Dependence Personality Disorders Eating Disorders Somatization Disorders Malingering, Hypochondriasis, Factitious Disorder Psychotherapies Pharmacotherapy Children and Adolescent Psychiatric Disorders 14

15 METHODOLOGY The third year clerkship will consist of direct clinical instruction through the following list but limited to: o Short topic discussions as scheduled by attending physicians o Conferences o Lectures o Case based discussions with coordinator o Standardized patients o Ward rounds o Bedside teaching o Case presentation o Computer assisted instruction o Library study, search of literature on specific topics o Student participation in community program HOMEWORK: All students must read and study the required reference for the assigned topic as they are expected to be prepared for the discussion of these topics. OSCE: All student s are required to take one formative and one summative examination in the psychiatry clerkship. During both encounters the student is required to hand in a written history including a mental status examination, diagnosis, and treatment plan. Attendance to these exams is compulsory. Students who score below 70% in the summative examination must take a make-up exam, after a remedial session. The summative examination score represents 15% of the final grade and the score for written report for the case represents 5% of the final grade. Subject Exam: All students must take and pass and end-of-clerkship exam (SHELF). Students, who obtain a failing score in the subject exam, must take it again at a specified later date. A student who fails to pass the Subject Exam on three occasions must repeat the clerkship. A remediation plan will be implemented for any student who fails to pass the Subject Exam on the first attempt. Participation in the remediation 15

16 program is compulsory. The Subject Exam score represents 40% of the final grade. Patient type or core condition Psychiatry Clinical Encounter Grid Number required Level of to be seen (real Student or simulated) Responsibility Clinical Setting (O,I, SU) Major Depressive 3 OB, P O,I,SU Disorder Bipolar I 2 OB,P O,I,SU Bipolar II 1 OB,P O,I,SU Dysthymia 1 OB,P O,SU Other Affective 1 OB,P O,SU Disorders Schizophrenia 3 OB,P O,I,SU Schizoaffective 1 OB,P O,I,SU Disorder Psychosis NOS 1 OB,P O,I,SU Other Psychotic 2 OB O,I,SU Disorders Panic Disorder 1 OB O,I,SU Post Traumatic Stress Disorder Obsessive Compulsive Disorder Generalized Anxiety Disorder 1 OB O,I,SU 1 OB O,I,SU 1 OB O,I,SU 16

17 Patient type or core condition Number required to be seen (real or simulated) Level of Student Responsibility Clinical Setting (O,I, SU) Other Anxiety 1 OB O,I,SU Disorders Alcohol 2 OB,P O,I Dependence Alcohol 1 OB O,I Withdrawal Cannabis 1 OB,P O Dependence Cannabis 1 OB O Withdrawal Opioid 2 OB,P O,I Dependence Opioid 1 OB O,I Withdrawal Cocaine 2 OB,P O,I Dependence Cocaine 1 OB O,I Withdrawal Benzodiazepine 1 OB O,I,SU Dependence Benzodiazepine 1 OB O,I,SU Withdrawal Anorexia 1 OB O,SU OB= Observation (CR only) P= Participation (Hx/PE and CR) O= Outpatient I=Inpatient SU: Stabilization Unit VIII. Student Responsibilities Please refer to Clerkship General Rules File IX. Course Evaluations and Grading Procedures Please refer to Clerkship General Rules Guide 17

18 X. Work Schedule 8:00am Hour Arrival Daily Work Schedule Activity 9:00-10:00am Morning Report 8:30-12:00 m Assigned patient interview and evaluations (inpatient) or conference 12:00-1:00pm 1:00-2:00pm 2:00-3:00pm 3:00-4:30pm Lunch Clinical case presentation and discussion with the staff psychiatrist or conference Psychiatry consulation evaluation or conference Patient Interviews 18

19 XI. Learning Resources A. Textbook: Title: On Call Psychiatry Author: Carol A. Bernstein Publisher: ISBN: X Publication Date: 2006 Edition: Third Library Code: Approximate Cost: $54.95 Considerations: Elsevier Health Sciences This book is the ideal text for practical acute psychiatric intervention. The book emphasizes the most common psychiatric management of acute psychiatric patient. Exceptionally effective in teaching you how to handle the complex interplay of psychological and biological factors in human development in a very simple structuring action. B. References 1. Kaplan, Harold and Benjamin Sadock. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 9 th Edition. Williams and Wilkins, ISBN: Library Code: WM 100 K Vol. Set: Vols. 1 & Kaplan, Harold and Benjamin Sadock. Synopsis of Psychiatry, Behavior Science-Clinical Psychiatry. 10 th Edition. Maryland: Williams and Wilkins, ISBN: Library Code: WM 100 Fr VIII American Psychiatric Association. 3. Diagnostic and Statistical Manual of Mental Disorder (DSM IV-TR) 4 th Edition. Washington, D.C., American Psychiatric Press, ISBN: Library Code: WM 15 D American Psychiatric Association. A Psychiatric Glossary. 8 th Edition; Washington, American Psychiatric Press, ISBN: Library Code: WM 13AM VII

20 C. Supplementary Readings: 1. High-Yield-Behavioral Science, 3 rd Edition. Lippincott Williams & Wilkins, Behavioral Sciences Pre-Test, 9 th Edition. McGraw-Hill, Psychiatry Pre-Test, 12 th Edition. McGraw-Hill, First Aid for the Psychiatry Clerkship, 3 rd Edition. McGraw-Hill, 2011 D. Journal Materials E. Videos: 1. The American Journal of Psychiatry, American Psychiatric Association, American Psychiatric Association Press Washington, D.C., Journal of the American Academy of Child and Adolescent Psychiatry, The American Academy of Child and Adolescent Psychiatry, Washington, D.C., The Hidden Nature of Man 2. Controlling Aggression and Hostility in Psychiatric Patient, The Psychosis Heralding a New Era, Milestone Medicine,1997, Janssen Pharmaceutical 3. The Clinical Implications of Neuroreceptor Occupancy in the Management of Psychosis, Psychlink, Interactive Medical Network, 2000, Janssen Pharmaceutical 4. Treatment Options in the Psychosis, The Psychosis Heralding a New Era, Milestone Medicine, 1997, Janssen Pharmaceutical 5. Using Antipsychotic Agents in Bipolar Disorder, The Psychosis heralding a new Era, Milestone Medicine, 1996, Janssen Pharmaceutical 6. A Guide to Prevention, Recognition and Treatment in the Era of Atypical Antipsychotics, Brown University School of Medicine, I am Still Here (The Truth of Schizophrenia),Janssen Pharmaceutical, 1997, Jansen Pharmaceutical 8. Understanding Obsessive Compulsive Disorder, Solvay Pharmaceutical,

21 9. Minimental State Examination, Pfizer, Understanding Social Anxiety Disorder, SmithKline Beecham, Preserving Cognitive Function in Schizophrenia, The Psychosis Heralding Area, Milestone Medicine, 1998, Janssen Pharmaceutical 12. The Pathophysiology of Schizophrenia and Implications for Drug Therapy, Milestone Medicine,1996, Janssen Pharmaceutical 13. Identification and Management of the First Episode of Schizophrenia, The Psychoses Heralding New Era, Milestone Medicine, 1996,Janssen Pharmaceutical 14. Antypsyhotic Agents and Adverse Events, The Psychoses Heralding a New Era, Milestone Medicine, 1996, Janssen Pharmaceutical F. Internet Resources: URL American Psychiatric Association American Academy of Child & Adolescent Psychiatry American Medical Association National Institute of Mental Health Content Find news, research, clinical resources, education, guidelines and public information Home page of AACAP. Information on developmental, behavioral, emotional and mental disorders Professional and advocacy organization for the medical profession. Find news and events, research, clinical trials and information for practitioners. Text of Supreme Court Decisions 21