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Aimed at optimizing training for all residents, including those who will pursue a C-L Psychiatry fellowship
Recommendations for updates to ACLP’s residency training in C-L Psychiatry have been prepared by a workgroup of eight Academy members who are leaders in residency and fellowship education on local and national levels.
They have made 34 recommendations across four domains, including structural issues, faculty supervision, formal curriculum and evaluations, and elective experiences.
“These recommendations are intended to guide residency program directors towards optimizing C-L Psychiatry training for all residents, including those who will eventually pursue C-L Psychiatry fellowship,” they say.
“Establishing a strong C-L Psychiatry foundation for all residents is essential for ensuring competency in providing psychiatric care for medically complex patients and collaborating with our colleagues in other specialties, as well as fostering trainee interest in pursuing a career in C-L Psychiatry.”
The recommendations are summarized in an upcoming edition of the Journal of Academy of Consultation-Liaison Psychiatry (JACLP) together with comparisons between prior guidelines and new recommendations.
The key proposals are:
Existing guidelines: The Accreditation Council for Graduate Medical Education continues to require a minimum of two months of C-L Psychiatry training for residents, despite the Academy previously recommending three months. Core C-L experiences should take place in the latter half of residency.
New recommendation: “Given increasing recognition of the bidirectional influence of mental health and medical or surgical outcomes, a minimum of three months’ training for residents is still recommended.” Residents should be on service at least four days per week during that time. Interspersed blocks of at least two, and ideally four weeks, may optimize learning. Encouragingly, 46.6% of programs have increased the amount of core C-L Psychiatry training for residents between 2010 and 2021.
Nearly 20% of programs have moved C-L Psychiatry from the second half of residency to the first half since 2010. Placement of core C-L Psychiatry rotation in PGY-1 is not recommended. Placement of core C-L Psychiatry experiences in the second half of residency remains preferred. If programs need to place C-L Psychiatry in PGY-2 for structural reasons, residents should be given an opportunity and encouraged to return to C-L Psychiatry in the second half of training. Dividing the core experience over multiple years may optimize learning.
Experiences on addiction consultation services and in the emergency department should not count towards core C-L Psychiatry time. Outpatient C-L Psychiatry experiences, if present, should supplement the inpatient experience.
Existing guideline: Exposure to multiple faculty members is preferred and the minimum faculty-to-resident ratio should be 1:1.5-2.
New recommendation: The minimum ratio for faculty-to-resident staffing remains the same, and exposure to multiple faculty members is still preferred. Additionally, services should use a full-time or block staffing model, rather than a longitudinal or attending-of-the-day model, which creates challenges for patient continuity and supervision of residents, especially junior residents. If a ‘teaching rounds’ staffing model is used, residents should have access to ad-hoc supervision throughout the day.
Service chiefs should be board-eligible or -certified in C-L Psychiatry, and faculty should ideally be as well. Concerningly, nearly 20% of programs nationally currently have no board-certified C-L Psychiatry faculty. If board-certified faculty are not available, dually trained faculty or those with proven experience and proficiency in C-L Psychiatry are acceptable supervisors.
Advanced practice providers should not supervise resident cases. If fellows are supervising residents, a faculty member should still provide oversight on all cases.
Existing guideline: Didactic curriculum on the rotation should focus on C-L Psychiatry topics and supplement the core didactics. Alternative forms of teaching, including journal clubs and case conferences, are encouraged. Feedback should be given on a regular basis and should occur face-to-face.
New recommendation: A formal and separate C-L Pyschiatry-dedicated didactic curriculum should exist, ideally during the rotation or at least in the years in which the rotation exists. Novel delivery methods for didactics, including service rounds, self-directed learning, journal clubs, and case conferences should be included, and elements of DEI should be incorporated. Formative feedback should be provided on at least a weekly basis. The summative evaluation should be delivered at least monthly and reflect ACGME psychiatry milestones.
Existing guideline: Residents should be able to use elective time to pursue additional training in C-L Psychiatry.
New recommendation: Electives in C-L Psychiatry should be offered to supplement training, and may include outpatient experiences, telepsychiatry, collaborative care, and proactive consultations. A chiefship or junior attending opportunity in C-L Psychiatry should be offered to senior residents.
The workgroup to create new recommendations was approved by the Academy’s Executive Council. The same workgroup had previously conducted a 2021 national survey of residency training—all were former or are current members of the Academy’s Residency Education Subcommittee. The Executive Committee are expected to discuss findings. When/if approved they will be passed to the Board for a decision.
If implemented, residents will be required to spend sufficient time on C-L Psychiatry rotations to achieve milestones. “Given that consultants are expected to offer unique insight, the ideal placement of core C-L Psychiatry rotations comes at a time in residency where residents are able to provide expert opinion and lead teams,” say the workgroup. “Faculty expertise in C-L Psychiatry and availability to provide direct supervision and oversight to trainees are essential.
“Establishing a strong C-L Psychiatry foundation for all residents is essential for ensuring competency in providing psychiatric care for medically complex patients and collaborating with our colleagues in other specialties, as well as fostering trainee interest in pursuing a career in C-L Psychiatry,” says workgroup member Scott Beach, MD, FACLP.