Psychiatry and
Behavioral Sciences

III. CURRICULUM

The main educational objective of our program is to develop fellow’s clinical expertise through a combination of didactic, clinical, experiential, and research experiences and exposure to a wide range of patients in a tertiary, state of the art, academic medical center.

This is achieved through a combination of hospital-based (in-patient) and clinic (out-patient) experiences under the supervision of various board-certified psychosomatic medicine specialists.

These experiences should provide the skills and expertise necessary to independently evaluate and treat complex psychosocial, psychiatric and behavioral problems in the medically-ill patient in a multidisciplinary team approach.

The various clinical settings and sites (described below) should offer fellows a unique multidisciplinary experience. The idea is to provide trainees with a rich academic environment where a transition from resident to independent psychosomatic medicine specialist can take place and the integration of basic science and clinical practice can take place; while promoting the fellow’s development into a clinician-educator-researcher role.

Clinical Training Sites

Stanford University Medical Center

Stanford Hospital & Clinics is known worldwide for advanced treatment of complex disorders in areas such as cardiovascular care, cancer treatment, neurosciences, surgery, and organ transplants. It is currently ranked No. 17 on the U.S. News & World Report’s "America's Best Hospitals" list and No. 1 in the San Jose Metropolitan area. Stanford Hospital & Clinics is internationally recognized for translating medical breakthroughs into the care of patients. Stanford Hospital ranked among the top 25 in 10 specialties: cancer; cardiology and heart surgery; neurology and neurosurgery; nephrology; urology; orthopedics; ear, nose and throat; rheumatology; gynecology; and psychiatry.

The Stanford University Medical Center is comprised of three world renowned institutions: Stanford Hospital & Clinics, which includes the Comprehensive Cancer Center; the Stanford University School of Medicine, the oldest medical school in the Western United States; and Lucile Packard Children's Hospital <http://www.lpch.org/>, an adjacent pediatric teaching hospital providing general acute and tertiary care.

Psychosomatic Medicine Consult Service at Stanford University Medical Center – Inpatient Service

The inpatient Psychosomatic Medicine service provides consultation throughout the hospital’s 16 medical/surgical units for the management of psychiatric conditions arising within the context of medical and surgical conditions, including the critical care units, cancer center, and organ transplantation. The service consists of 4 Psychosomatic Medicine attending physicians, two fellows, 2 – 3 PGY2 psychiatry residents,0 – 2 internal medicine or neurology residents, and 0 – 2 medical students. Fellows learn to evaluate patients and provide a wide range of treatment recommendations, including pharmacotherapy, hypnosis, cognitive-behavioral management plans, brief supportive psychotherapy, alterations in the milieu, meetings with family or members of support system and recommend interventions by other disciplines such as neurology, social work, the clergy, or rehabilitation services. Fellows provide on-going supportive psychotherapy and family counseling, and may arrange and chair, focused, multidisciplinary staff conferences to deal with difficult management problems. They learn to communicate clearly, orally and in writing to medical and surgical colleagues and develop liaison relationships with other departments. They also participate in competency and conservatorship proceedings, as well as in initiating and extending psychiatric holds.

In addition to direct patient care, the fellow is heavily involved in educational activities on the service, providing teaching and peer supervision to other trainees on the team (medical students, residents).

Psychosomatic Medicine Clinic – Outpatient

The Psychosomatic Medicine Clinic specializes in the diagnosis and treatment of psychiatric syndromes associated with medical and surgical conditions and their treatment. The clinic provides assessment and management of the major psychiatric disorders encountered in the medical/surgical patients including: Adjustment Disorders, Anxiety Disorders (e.g., Panic Disorder, Post Traumatic Stress Disorder), Mood Disorders (e.g. Major Depression), Cognitive Impairment Disorders (e.g. Delirium, Dementia), Psychotic Disorders, and Somatoform Disorders (e.g. Pain Disorder), using combined psychopharmacology and psychotherapy. The clinic also provides pre-organ transplant psychiatric evaluation and post-transplant psychiatric follow-ups for various organ transplant services at SUH.

Elective Rotations

In addition to the required rotations, the fellow spends half day a week, on average, in up to three sub-specialty rotations. Available rotations include: Neurocritical Care, HIV/AIDS Clinic, Women Wellness Clinic, Pain Service, Transplant programs, GI Clinic, Psycho-oncology, and Clinical Research.

Transplant Medicine Service

The fellow will get experience working with organ transplant services participating in pre-transplant psychiatric evaluation, screening of prospective living donors, post-transplant management of psychiatric complications, and inpatient consults of transplantation patients.

Psycho-oncology Service

PM-Fellows have an opportunity to rotate on the Comprehensive Cancer Center (CCC) Psycho-Oncology Service. The exact duration of the elective and time invested is to be determined based on programmatic needs and fellow’s preferences.

During the course of this rotation PM-Fellows will learn to assess psychiatric symptoms and psychological distress and coping mechanisms in patients at various stages of a cancer diagnosis, including: diagnosis, treatment, and remission/survivorship or terminal disease; develop proficiency in using psychiatric medications in the context of various cancer treatments (e.g., chemotherapy, radiation therapy, surgery, bone marrow transplantation); develop competency in providing various form of psychotherapy (e.g., supportive, cognitive behavioral, couples/family, and end of life/existential) and dealing with family dynamics, grief, and countertransference amongst medical staff; and gain experience working in a multi-disciplinary setting (i.e. oncologists, nurses, social workers, chaplains) and utilizing liaison skills. Site Director: Edward Kilbane, MD.

HIV Psychiatry Clinic

The Stanford Positive Care Program serves approximately 2000 HIV+ patients in two multidisciplinary clinics located in Atherton and San Jose. The Psychosomatic Medicine Fellow will become experienced in the evaluation and treatment of new and returning patients for a wide variety of conditions, including HIV-Associated Neurocognitive Disorder (HAND), substance abuse (predominately methamphetamine), and neuropsychiatric presentations of opportunistic infections, sexually-transmitted diseases, and side effects of antiretroviral medications. Approximately thirty percent of the patients are infected with Hepatitis C, management of which involves close psychiatric assessment and treatment. Fellows will also become familiar with the latest treatments for HIV/AIDS, Hepatitis C, and the management of drug-drug interactions. Previous fellows have elected to participate more extensively in community activities, including HIV/AIDS support groups, research, and educational programs (e.g., telemedicine consultations and webinars for primary care providers). Site Director: Lawrence McGlynn, MD

Didactic Training

The fellow’s educational activities is an important part of the program and consist of daily rounds and bedside teachings, weekly seminar and supervision, weekly case conferences, monthly Psychosomatic Medicine Interest Group. In addition, fellows participate in joint Psychiatry-Medicine and Psychiatry-Neurology case conferences to discuss interesting, unusual and challenging cases. Fellows are expected to attend weekly Grand Rounds in Medicine, Neurology ,and Psychiatry. The fellow is also expected to be heavily involved in various teachings on the service to the residents and medical students.

Week Didactic #1
PM–Fellow
Mon 0900
Didactic#2
PM–Faculty
Wed 0900
Didactic #3
All Trainees and
Faculty
Fri 1000
1 Orientation
Principles of PM
NeuroPsych
Assessment
Maldonado
Q&A, Introduction to weekly quiz
2 Capacity and Suicide Risk Assessments Delirium/agitation
Maldonado
Presentation by trainee on CL topic of interest
3 Psychopharmacology in CL Etoh withdrawal
Dx & Management
Maldonado
Presentation by trainee on CL topic of interest
4 Dreadful side effects of psychiatric medications in CL setting

Depression in
medical setting. Personality &Psychodynamic issues. Brief bedside psychotherapy.
Kilbane

Formative feedback & evaluation Q&A Quiz
5 OB-GYN topics Management of
agitation in dementia
Sher
Presentation by trainee on CL topic of interest
6 Neurological Functional Disorders ID & CNS. Methamphetamines HIV psychiatry. Common drug interactions.
McGlynn
Presentation by trainee on CL topic of interest
7 Malingering & Factitious End of life issues. Psycho-oncology.
Kilbane
Presentation by trainee on CL topic of interest
8 Other substance of abuse PM & Issues in
OB-GYN
Sher
Summative feedback, evaluation, Q&A Quiz

Clinical Research Training

This is an opportunity for those fellows interested in clinical research to learn the process of conceiving and developing new research projects in the classic PM patient population.

Fellows will be given the opportunity to participate in any number of new and ongoing clinical research studies. They are expected to develop their own pilot project and to present data at national meetings.

Participating PM-Fellows are required to participate in an existing research project, develop a new research project, design and conducting a case series, or doing an advanced literature review on a particular topic of interest.

Fellows interested in developing their own research project will obtain training and mentorship in identifying and developing a research idea, delineating and carrying out the steps required to implement a clinical research project (e.g., write study proposal; compose and obtain IRB approval; literature review; search for funding), and writing and submitting a manuscript for publication, or poster presentation at scientific meeting.

In addition, PM-Fellows have the opportunity to enroll in the Methodology of Research in Behavioral Sciences Seminar in which the instructors review and discuss essential methodological topics in clinical psychiatric research, including randomized clinical trials and effect size, statistical hypothesis testing: significance & power; discussion of reliability, validity, and sensitivity; medical test evaluation and risk factor research. Instructors: Boil Jo, PhD, Helena Kraemer, PhD. Duration: 1 quarter.

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