PGY: Postgraduate Year
SEH-DMH: Saint Elizabeths Hospital/ D.C. Department of Mental Health: This includes the inpatient units on the civil and forensic sides of Saint Elizabeths Hospital, as well as the clinics run by the D.C. Department of Mental Health/ Community Services Agency, the Comprehensive Psychiatric Emergency Program (CPEP), and the Homeless Outreach Services.
WSP: Washington School of Psychiatry
UDC: University of the District of Columbia
CHNMC: Children’s Hospital National Medical Center
NIMH: National Institute of Mental Health
UMD: University of Maryland Medical Center

THE CURRICULUM IN DETAIL

PGY-I

PGY-I consists of 4.5 months of internal medicine, 3 months of neurology, 3 months of inpatient psychiatry and 1.5 months of geriatric psychiatry. During this year, residents begin to develop skills in evaluation, differential diagnosis, pharmacotherapy, supportive psychotherapy and treatment planning. In addition, during the PGY-I year residents become familiar with the range of facilities and services available to the mentally ill in the District of Columbia. Such knowledge and experience greatly facilitates the learning, which occurs in the PGY-II inpatient year and improves the quality of care provided to hospitalized patients. By the end of the PGY-I year the resident has solidified his/her identity as a physician and learned basic psychiatric and neurological skills. Residents with prior residency training in medicine, pediatrics or family medicine who enter the program at the PGY-II level may be required to complete some PGY-I rotations.

Internal Medicine

This is a PGY-I rotation of 4.5 months duration (100% FTE) that occurs either at Prince George’s Hospital Center or Providence Hospital, both of which have ACGME-Accredited Internal Medicine Residency Training Programs. Residents are supervised by Board-Certified internists and medical specialists who spend on average 50% of their time teaching residents. Teaching takes place in seminars, case conferences, rounds and in individual/ group supervision. These inpatient rotations usually consist of 3 months of general medicine and a month in the ICU or emergency room. Both of these hospitals are large general hospitals that serve predominantly urban populations (primarily African Americans with some Latinos and European-Americans). The average case load is 10 patients; the maximum case load is 12 patients. Residents have supervised experiences in assessment, treatment, disposition, management of emergencies and consultations.

Neurology

This three-month rotation offers residents an experience in neurology directly relevant to their careers as psychiatrists and, unlike conventional neurology rotations, provides a superb opportunity to evaluate disorders at the interface of neurology and psychiatry. The Neurology Service, which is directed by John Stiller, M.D., provides consultation to physicians throughout the Department of Mental Health, including Saint Elizabeths Hospital. Patients with dementias, neuropsychiatric sequelae of stroke or head trauma, acute confusional states, epilepsy, tardive dyskinesia and other psychotropic-induced movement disorders, as well as neurological problems common to the general population, are seen during ward consultations and in the neurology clinic. In addition, there are weekly didactic sessions covering a broad array of neurological topics, including in-services on EEG and MRI and a monthly brain cutting conference at the Medical Examiner's Office.

General Inpatient Psychiatry Rotation

This rotation occurs at Saint Elizabeths Acute Care Hospital, which is the only public psychiatric hospital in the District of Columbia and receives the full range of patients requiring hospitalization. Most patients are severely and chronically mentally ill with co-occurring substance use disorders, medical illnesses and severe stressors. Many patients in the Acute Care Hospital are patients who have been involuntarily committed to the Hospital.

Under the supervision of attending psychiatrists, residents on acute inpatient units have the clinical responsibility for the evaluation and treatment of acutely ill patients. Particular emphasis is placed on obtaining a thorough psychiatric history, evaluating the many physical illnesses that may be causing or contributing to the patient's psychiatric signs and symptoms, reaching an accurate psychiatric diagnosis and developing a comprehensive treatment plan. Through formal conferences and supervision, residents learn to use psychopharmacological and psychotherapeutic approaches with hospitalized patients. During the inpatient rotation, a resident's caseload is limited to up to eight patients.

Geriatric Psychiatry

This rotation is a 1.5-month FTE rotation that occurs in the Geriatric Psychiatry inpatient unit at Saint Elizabeths Hospital.

The patients are older adults or individuals with co-morbid medical illness. Diagnoses include the psychotic disorders, the major affective disorders, posttraumatic stress disorder, substance dependence and many kinds of dementia. Types of treatment include pharmacotherapy, individual psychotherapy, group therapy, crisis intervention and family therapy. An average caseload is 6-7 patients; the maximum caseload is not to exceed 12 patients.

Electro-Convulsive Therapy (Dr. Frank Moscarillo): This four- to six-session course is a part of the Geriatric Psychiatry rotation. Residents attend the sessions at Sibley Hospital and are introduced to ECT under the supervision of Dr. Moscarillo.

Evening and Weekend Overnight Call

PGY-I residents in the General Inpatient Psychiatry and Neurology rotations take evening and weekend overnight calls on the inpatient units. They are supervised by attending psychiatrists on call and have morning rounds where they present all the cases they have either admitted or seen during their call period. – Weekday call begins at 5:00pm and ends at 10:00pm---.They also learn how to perform the evaluation and treatment of more severely and acutely ill patients. Particular emphasis is placed on obtaining a thorough psychiatric history, evaluating the many physical illnesses that may be causing or contributing to the patient's psychiatric signs and symptoms, and reaching an accurate psychiatric diagnosis.

Building on the West Campus

Didactic Program

Interviewing/Case Presentations (Dr. Kolansky): Dr. Kolansky initially interviews patients to demonstrate how to interview. The interviews take about 30 minutes and residents are specifically directed to NOT do an Initial Assessment. Subsequently, each resident interviews a new patient. There is a discussion with the peers about how the interview went. The focus is on the interview, not the patient.

Supportive Psychotherapy and Introduction to Group Psychotherapy (Dr. Baughman): Introductory lectures about Supportive Therapy, including a contrast with exploratory therapy. In addition, there will be some lectures on group therapy. Residents must begin treatment with patients and may present their cases in the seminar. Discussions about clinical group therapy are also invited.

DSM-IV TR (Dr. Mohyuddin): Major diagnostic categories of DSM-IV-TR are reviewed with clinical textbook examples after each diagnostic category has been discussed. There is a patient interview in the acute care building to illustrate the pathology studied.

Introductory Psychopharmacology (Dr. Livingood/Dr. Palladino): The new residents are introduced to broad classes of medications including antipsychotics, antidepressants, mood stabilizers, and anti anxiety agents. There are seven sessions which cover each of the four broad classes mentioned above. In addition, residents learn medication indications, choice of medications, pharmacokinetics and side effects.

Pre-school Child Observation (Dr. Kolansky): Residents have an opportunity to observe normal children in a preschool setting with supervision from our child psychiatrists

Molecular Psychopharmacology (Dr. Apud): Course taught by Dr. Apud, a psychopharmacology researcher at the NIMH in Bethesda, Maryland. The course will be given on the N.I.H. grounds.

History of Psychiatry (Dr.Peele): Will focus on the last 200 years in American Psychiatry, using the history of Saint Elizabeths Hospital as a mirror of the history of the field.

St.Elizabeths’ New Hospital Building courtesy of Einhorn Yaffee Prescott Architecture & Engineering P.C. & Dikong Song, Renderer. In 2005, Saint Elizabeths Hospital began site preparation for a new, state of the art hospital building. The building will have an auditorium, housing units with ready access to outdoor areas, two treatment malls each with a gymnasium, library, classrooms, and numerous other facilities where civil and forensic patients will spend the day participating in a broad range of recovery based treatment activities.

PGY-II

PGY-II consists of 3 months of General Inpatient Psychiatry, 3 months of Consultation-Liaison Psychiatry and 1.5 months each of Addiction Psychiatry, Forensic Psychiatry, Emergency Psychiatry and Night Float.

During the second year, residents will move to a more advanced level of utilizing foundation received during their first year of training and will demonstrate the ability of evaluating and treating patients with complex medical and psychiatric issues requiring inpatient psychiatric care. Such knowledge and experience greatly facilitates the learning which occurs in the PGY-II inpatient year and improves the quality of care provided to hospitalized patients.

General Inpatient Psychiatry Rotation

Residents consolidate and expand the skills they learned during their General Inpatient Psychiatry rotation during PGY-I. The appropriate use of individual psychotherapy, group therapy and family therapy is integrated into a ward environment that emphasizes the therapeutic community and its role in helping patients to achieve rapid recovery. While assigned to the inpatient service, the resident functions as part of a multidisciplinary system, including nurses, psychologists, psychiatric social workers, occupational and recreational therapists and others. Since psychiatrists are often called upon to work with other medical and nonmedical disciplines, the development of collaborative skills is essential to the overall development of psychiatric residents.

Residents also work with and teach medical students from George Washington University, the Uniformed University of the Health Sciences, Howard University, Ross University, and the American University of the Caribbean, supervising their clinical work and reviewing their written case studies.

Forensic Psychiatry Rotation

This is a 6 week rotation during the PGY-II year in forensic section of Saint Elizabeths Hospital. Residents rotate on a pre-trial unit where, under the supervision of an attending psychiatrist, they perform assessments for competency to stand trial or mental status at the time of the offense. Residents are involved in the assessment and treatment of no more than 12 patients. Residents may also co-lead a restoration to competency group and may attend DC court hearings.

Addiction Psychiatry

This is a 1.5-month FTE PGY-II rotation that takes place in Providence Hospital’s Dual Diagnosis Unit. Faculty consists of 2 psychiatrists who are on staff at Providence Hospital, both of whom are 90% FTE. Residents spend 6 hours weekly in seminars and case conferences; faculty is always available for consultations and case loads are closely monitored for breadth and variety of experience. Residents schedule should allow them to elect to participate and see every aspect of modern substance abuse and dual diagnosis treatment from inpatient to outpatient programs. In addition they attend 6-7 hours/week of didactics scheduled for all PGY-II residents.

The patients are primarily dually diagnosed adults (60% men; 40% women). Approximately 30% are diagnosed with co-occurring psychosis, 45% with co-occurring mood disorders and 5% with co-occurring anxiety disorders. Residents learn assessment and treatment planning for dually diagnosed patients and detoxification protocols for patients in withdrawal.

The average caseload is 3 patients with an anticipated maximum of 5 patients.

Consultation - Liaison Psychiatry

This is a 3 month rotation at Providence Hospital. The aim is to teach residents the process of psychiatric consultation and the ongoing clinical management of medical and surgical patients who have concomitant psychiatric and behavioral problems.

Residents see a maximum of 4 new patients per day with no maximum limits to follow-ups. They rarely carry more than 5 or 6 patients because of patient turnover. All patients must be presented to an attending. The latter is done individually and in groups such as rounds or case conferences. Residents triage their own cases and are responsible for them from initial consultation to discharge.

Emergency Psychiatry:

This is a 6 week rotation that takes place at the Comprehensive Psychiatric Emergency Program (CPEP), a 24-hour psychiatric emergency room run by the Department of Mental Health. Under the supervision of attendings, residents are involved in crisis intervention, acute treatment of patients in the 72-hour observation facility and community-based crisis intervention with a mobile outreach team.

Night Float:

During this rotation residents work from 9:30 PM to 8:00 AM six days a week for 6 weeks, covering admissions and emergencies at Saint Elizabeths Hospital. Night float residents then attend Morning Report from 8:00 AM to 9:00 AM five days a week. On Wednesdays, the Night Float resident stays until 11:30 AM to attend didactics. On other days they leave at 9:00 AM. They are supervised by attending psychiatrists and have morning rounds where they present all the cases they have either admitted or seen during their call period.

Evening and Weekend Overnight Call

PGY-II residents take evening and weekend overnight call at Saint Elizabeths Hospital during their General Inpatient Psychiatry, Forensic Inpatient Psychiatry and Addiction Psychiatry rotations. They are supervised by attendings on call. They cover Saint Elizabeths Hospital and admit patients/ attend to emergencies until the Night Float resident arrives.

Didactic Program

Forensic Psychiatry (Drs. Stevens and Klein)

Consultation-Liaison Psychiatry (Dr. Haracic)

Learning to Teach (Dr. Mohyuddin)

Residents spend the entire PGY-III in outpatient psychiatry; 80% of this time is spent in adult outpatient psychiatry and 20% in child outpatient psychiatry.

Adult Outpatient Psychiatry

This rotation involves:

1) The Residents’ Clinic at 35 K Street NE (includes pharmacotherapy and psychotherapy experience)
2) Psychotherapy experience in one of the following settings:
     a. University Health Services Clinic at the University of the District of Columbia
     b. Meyer Treatment Center of the Washington School of Psychiatry
     c. Providence Hospital Psychiatry Clinic
     d. Georgetown University Counseling and Psychiatric Service
3) Community Psychiatry Experience is arranged with the DMH Homeless Outreach Service. Residents are assigned to one of several shelters to which they provide psychiatric consultation and referral services.

The faculty is very eclectic, representing strengths in psychoanalysis, group therapy, cognitive behavior therapy, family therapy and psychopharmacology.

Caseloads are monitored for diagnostic variety and breadth of experience.

Caseload: The caseload requirement for PGY-III residents is 8 to 12 patients in therapy (seven hours per week of insight-oriented psychotherapy; 4 hours per week of supportive psychotherapy and one patient in CBT). Residents must also have at least one group, 16-20 patients on medication management and spend two hours per week on intakes. Residents spend 4 hours a week evaluating homeless persons in various shelters for whom psychiatric consultation was requested and discussing the cases with supervisors to determine the appropriate disposition.

Scheduled Supervision: All residents have a minimum of two weekly supervision hours with two different psychiatrists, at least one hour of which should be individual supervision for psychodynamic (brief and long-term, supportive and explorative) psychotherapy. In addition there is supervision for group psychotherapy and cognitive behavior therapy.

Child and Adolescent Psychiatry Outpatient Psychiatry: This rotation takes place at Children’s Hospital National Medical Center or the Jackie Robinson Center. Residents have a minimum of one hour individual child and adolescent clinical case supervision and 1/2 hour administrative child and adolescent supervision every two weeks. Supervision for medication management occurs on site.

Evening Calls: PGY-IIIs take evening calls from 5:30 PM-10PM at the Comprehensive Psychiatric Emergency Program (CPEP), where they are involved in crisis intervention, acute treatment of patients in the 72-hour observation facility and community-based crisis intervention with a mobile outreach team. On weekdays following call at CPEP they arrive to work at 8 AM.

Teaching Experience: Psychiatrists are often called upon to teach as a part of representing themselves and the profession to community and professional groups. This year,PGY-III residents build upon their PGY-II experience teaching medical students. With guidance, they prepare and present, on a regular basis, a formal lecture on a psychiatric topic to medical students, and sometimes to staff. Residents also provide supervision to medical students doing an in-depth case study. In these ways, they learn new skills and appreciate the connections between being a good teacher and a good clinician.

Didactic Program

Basic Psychodynamic Seminar (Dr. Baughman): This weekly seminar runs throughout the year after Labor Day. The theory of psychoanalytically oriented psychotherapy, both brief and extended, is the major focus of this course. Regularly assigned readings in each session successively review the development of the psychoanalytic theory of therapy beginning with Freud's early writings and continuing with the elaborations of ego psychology. An extended study of Franz Alexander and other revisionists of classical theory are also presented. The course is illustrated with clinical vignettes from the work of both the instructor and the residents.

Cognitive-Behavioral Seminar (Dr. Scrofani): A seven week summer didactic seminar is followed by a year-long cognitive behavioral therapy supervision.

Individual Psychotherapy Seminar (Dr. Baughman): This weekly conference utilizes process notes presented by residents to senior faculty members to focus on various aspects of the case material. Such subjects as anxiety, defense, interpretation, transference and countertransference are explored, with a particular emphasis being placed on therapeutic techniques.

Continuous Case Conference (Faculty): Four residents, rotating on a weekly basis, present material from an ongoing case to one of four senior consultants. Residents thus have an opportunity to study the longitudinal development of four treatment cases throughout the year and to gain a sense of the variation in personal technique among four experienced psychiatrists. One of the four cases is a child, and one of the cases is treated with cognitive-behavioral techniques. This conference is given throughout the year, after Labor Day.

Child Psychiatry, Psychopathology, and Psychopharmacology (Dr. Kolansky): This course meets weekly all year and uses readings from the recent and classical literature to provide an overview of the major areas of the psychopathology of children. It alternates with child/adolescent diagnostic and disposition conference through the year. Emphasis is placed on the development of practical treatment interventions based on a biologic and dynamic understanding of the child's psychopathology. Topics considered include childhood psychosis, retardation, organic brain syndromes, arrests of psychological development, enuresis and encores syndromes, neurotic conflicts, learning problems, attention deficit hyperactivity disorders, adoption, drug abuse and mood and anxiety disorders, and pediatric liaison. There is a separate child/adolescent psychopharmacology component by Dr. Mohajan..

In the Child/Adolescent diagnostic conference, residents present recently evaluated cases and hone diagnostic skills in assessment of children and learn to work with parents of children they see. In addition to diagnostic evaluation, these sessions develop the resident’s ability for thoughtful treatment planning. There is also a monthly child case conference headed by Dr. Kolansky where, therapy issues including work with parents, transference and countertransference issues are discussed.

Psychopathology, Biological Psychiatry and Psychopharmacology (Dr. Livingood): This weekly course meets for six months. Residents learn more clinical psychopharmacology, focusing on outpatient medication work, and the biological theories of non-psychotic conditions.

Behavioral Neuroscience Principles (Dr. Schwartz): Course meets for four months. Emphasis is on ethologic and neurobiological data about affect. Readings by Drs. LeDoux, Kandel, and Schwartz focus on how associative learning provides a model for psychopathology as well as a model for how therapy can ameliorate symptoms.

Community Consultation

Ethics Seminar (Dr. Baughman)

Building on west Campus

PGY-IV

During PGY-IV, residents continue to follow their outpatients on a half-time basis. The other half of their time is spent as a junior attending psychiatrist on Saint Elizabeths Hospital inpatient units and doing elective rotations.

Outpatient Psychiatry: PGY IV Residents spend time about 50% FTE following their outpatients. They usually continue in their assigned site for adult outpatient, namely the Student Health Center of The University of the District of Columbia, the Washington School of Psychiatry, the Residents’ Clinic or Providence Hospital. They also continue with at least 1 of their child patients in psychotherapy in the fourth year. Supervision for psychotherapy occurs on site and at Saint Elizabeths Hospital as detailed in the PGY-III section.

Junior Attending Inpatient Psychiatrist: This is a 3month, five half days per week rotation at Saint Elizabeths Hospital.

Faculty usually consists of four board-certified psychiatrists on the wards. In addition, Residents are assigned a faculty member as an off-ward psychiatrist. There are 3 training wards and 1 or 2 Residents are assigned to each ward, where typically each Resident is assigned to a staff team, usually comprised of one junior Resident, a medical student, an extern, a social worker, and nursing personnel. Residents are primarily responsible for the patients under their care, and supervise/ teach junior Residents, externs, and medical students providing direct care.

Each Junior Attending Resident will be responsible for the care of up to 4 patients and will supervise a junior Resident who will be assigned to these patients. Supervision of the Junior Attending Psychiatrist (Resident) is by the ward attending psychiatrist and the Director of Psychiatric Residency Training, with whom they have scheduled supervision of one hour a week.

Junior Attending Outpatient Psychiatrist: This is a halftime rotation at the Residents’ Clinic.

Electives: A wide range of elective experiences is available to the resident. Some residents have chosen an elective in research at the NIMH or University of Maryland. Specific areas in which our residents have worked include clinical studies of schizophrenia and affective disorders and research on sleeping and dreaming. Other elective rotations include SEH inpatient junior attending psychiatrist, addiction psychiatry, outpatient work with a multidisciplinary team in a community mental health center, Assertive Community Treatment, research with infants and their psychiatrically impaired mothers, a rotation in electroconvulsive therapy, further work in group psychotherapy and family psychotherapy, psychiatric work with the deaf and an advanced medical student teaching elective. Residents are encouraged to develop elective experiences that best meet their needs and interests. In addition, each year PGY-IV residents are chosen as chief residents, and gain experience in administrative psychiatry and supervision. Some of the electives are described on the next page.

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Elective	Duration	Training site	Supervisor	Rotation overview clinical exposure
Child psychiatry	1 to 6 months Up to two full days a week	Children’s Hospital National Medical Center	Child psychiatrists on site.	Experience in evaluating and treating children and adolescents with psychiatric conditions.
Research	1 to 6 months. Up to half time per week.	1.NIH,Bethesda Clinical Brain Disorders Branch 2.University of Maryland, Baltimore	Jose Apud,MD Joel Kleinman, MD Teodor Postolache,MD	Experiential training in research methodology. Experience in conducting structured clinical diagnostic interviews with patients and healthy controls.
Forensic Psychiatry	1 to 6 months Half time per week k.	Saint Elizabeths Hospital	KyleeStevens, MD Abayomi Jaji. MD Ramia Gupta, MD	Residents will improve their ability to evaluate and treat mentally ill patients in a forensic setting and gain in-depth experience in competency evaluations
Child Psychiatry Court Clinic	1 to 6 months Half time per week.	DMH Court Clinic	ABPN certified child psychiatrists.	Experience in providing evaluation and referral services for children coming to the attention of the courts.
Teaching Elective	1 to 6 months Half time per week	Saint Elizabeths Hospital	Paula Palladino, MD	Residents interested in academic careers will be mentored to be Junior Faculty

Didactic Program for PGY-IV

Administrative Psychiatry & Mental Health Systems (Dr. Canavan): This seminar meets is on every other week and considers cases seen on the consultation service. Assigned readings are also discussed. It .is headed by the CEO of Saint Elizabeths Hospital and the Director of the Department of Mental Health. Cases are discussed with particular emphasis on the administrative and systems aspects.

The Advanced Psychodynamic Literature Seminar (Dr. Baughman): This seminar focuses on further readings in Freud, including dreams and dream interpretation, character development symptom formation, narcissism and masochism. Freud's earlier ideas are compared with more current authors, such as Arlow, Brenner, Kohut and Kernberg. The seminar meets weekly for three months.

Clinical Psychopharmacology Seminar (Dr. Livingood): This weekly seminar is an open discussion supervisory seminar about clinical psychopharmacology centering on the PGY-IV residents' current patients.

Advanced Child and Adolescent Psychiatry Continuous Case Seminar (Dr. Kolansky): A continuing focus on treatment issues utilizing resident presentations of their clinical work. This seminar lasts all year, alternating with a Literature Review of Child and Adolescent Psychiatry, an advanced course looking at issues of ongoing and current importance in child development, psychopathology and treatment, and with an Advanced Child Psychopharmacology Seminar taught by Dr. Mohajan. .

Critical Appraisal of Scientific Literature & Research Mentorship. Dr. (Postolache): supervises residents from all 4 years in various research activities, and also teaches a class on research methodology.

Journal Club: A resident discusses an article of his or her choice with the colleagues in presence of a faculty member with experience in research.

FOR ALL RESIDENTS

Resident-Faculty Case Conference - Several times a month residents and faculty participate in a 1 and a 1/2 hour conference in which a second, third or fourth year resident presents a clinical case. The format may vary, and the resident may present individual work with children or adults or ongoing therapy with a group or family. The resident selects a consultant who serves as moderator and discussant.

Residents will present at this conference at least once during their residency.

The Psychiatry Overview/Review, Interviewing Technique, and PRITE Preparation Seminar. This is a weekly seminar on review of psychiatry organized by the chief residents. It is open to all residents from July through September.

Grand Rounds Lecture Series . Once a month, invited speakers, usually from outside the residency program, give a 1 and a 1/2 hour presentation on a selected psychiatric topic. This meeting is open to the entire staff of the Department of Mental Health (DMH).

Mini-Boards . Each spring, all residents participate in the Mini-Boards, which is an experience similar to the American Board of Psychiatry and Neurology Oral Examination. Each resident interviews a patient for 30 minutes. The interview is observed by one or two faculty members. After the interview, the resident presents the case for 30 minutes, after which the interview and presentation are critiqued.

Psychiatry Residency In-service Training Exam (PRITE ) . This written five hour exam is given each year and is used to evaluate the strengths and weaknesses of the residents and the residency. It is a national examination in which many psychiatry programs participate.

Resident Peer Meeting . Each week residents have a meeting where they discuss issues of special relevance to their own training.

Resident/Faculty Other educational events occur regularly on the St.Saint Elizabeths Campus and are available to residents as time permits.

Open Meeting . Three times throughout the year, residents and faculty have an open meeting to discuss any issues of general concern.

Residents’ Special Event Day . Each spring, the residents are responsible for creating a day for the Residency Program, including a special topic, a visiting speaker for the day, and other activities, such as special movies.

Clinical Rotations and Sites
Abbreviations are expanded below