Below are short summaries about our different rotations years’ one through four. These blurbs are meant to accompany the longitudinal rotation map provided during interviews. Hopefully, the information provided can better illustrate “what a typical day” looks like during each rotation. These are written by residents, and do not necessarily reflect the views of administration.
Inpatient Psychiatry on Deaconess 4
Residents spend 3 months in the first year and 3 months in the second year at Beth Israel’s inpatient unit. There, they treat a wide variety of mental illness including acute and chronic psychosis, acute mania, depression, and severe personality disorders. Residents get experience with geriatric patients and dual diagnosis treatment, including detoxification from alcohol and opiate use. ECT is an on-site option for our patients, and as such residents learn how to properly evaluate ECT as a potential treatment option.
Emergency Psychiatry, 1 ½ months
During Emergency Psychiatry, you will work in the Emergency Department as a Psychiatric Consultant. The hours are 8am to 6pm Monday through Friday. The number of patients carried can vary depending on the day and the time of year. On average you typically see 2-4 new consults a day. As PGY1s, we see the patient individually and present our findings to the attending. The population of patients varies widely, ranging from homeless to young college students to elderly nursing home patients. You see many different pathologies including depression, bipolar, schizophrenia, substance abuse, personality disorders and eating disorders. The structure of the ED rotation is that the PGY-1 carries the consult pager and answers any pages that are called in. As new consults are called, you interview the patient and come up with an assessment/plan and then staff with the attending. The PGY-1 is the glue of the ED consult team during the day as attendings often change at noon. The team consists of 1-2 interns, a chief resident, a nurse, and an attending. This rotation is a great way to learn how to interview acute patients and learn to manage a busy department.
BIDMC Night Float, 1 ½ months
During night float, residents work as part of a two person resident team to cover the BIDMC Emergency Department and Deaconess 4 Inpatient Psychiatric Unit on weekdays. The hours are 6pm- 8am Monday night to Saturday morning (alternating every two weeks with ED days). During night float, you receive 2-3 teaching calls with an upper level and then you are the only resident on the unit during the night. You always have a PGY-2 in the ED and a PGY-4 on call if any concerns or questions come up.
Addiction Psychiatry, 1 month
During the one month addictions psychiatry rotation at the VA (Jamaica Plain and Brockton campuses), trainees will learn how to effectively identify, assess, and treat patients with substance use disorders. They will participate in individual and group treatments of patients with substance use disorders in the residential setting and in an inpatient detox. They will become familiar with motivational interviewing techniques, psychopharmacologic management of substance use disorders, and appropriate referral and use of community resources such as 12-step recovery, SMART recovery, and methadone clinics.
BIDMC Neurology, 1 month
During your time on Neurology at BIDMC, you will be on the Neurology Consult West team. Your hours are from 8am to 5pm Monday through Friday. The team consists of 1-2 Neurology residents, 1-2 Psychiatry interns, at times 1-2 medical students/Sub-I's, and occasionally a medicine resident. The duties expected of you are to see new consults as they are called in, round on your old patients if you have any, and attend any lectures/conferences. You will also round formally with the attending 1-2 times a day. You will see anywhere from 1-3 patients a day depending on the week and the size of your team, and will carry 1-3 patients on average. The population of patients seen varies. You will see patients with movement disorders, seizures, dementia, syncopal episodes and various others, and participate in weekly teaching conferences.
Second year residents spend about 3 months on the consultation/liaison (C-L) team at BIDMC.
The C-L service is a busy academic service providing consultation to the medical and surgical inpatient floors as well as the emergency department. The hospital has several specialized services including advanced cardiac therapies, liver transplant, oncology, perinatal medicine, neurology, trauma ICU, and more. Residents will gain experience consulting to each of these services.
Massachusetts Mental Health Center: The Program at 20 Vining Streeet
Second year residents spend 3 months working at one of two teams at the Program at 20 Vining Street, located at Mass Mental Health Center.
On the DBT team, residents learn the core principles of DBT through weekly didactics with faculty specializing in this treatment modality. The DBT program is a unique treatment setting aimed to provide daily structure and skills-based learning for patients with chronic affective dysregulation and histories of self-harm/suicidal ideation, with the goal of minimizing inpatient hospitalizations. Residents carry between 4-7 patients (combination of primary and med-back up), providing both weekly therapy and psychopharm evaluations. Residents also lead several group sessions throughout the week for the patients. Residents receive supervision from both PhD and MD clinicians.
On the Chronic and Severe Mental Illness team, residents work with patients diagnosed with psychotic illness, and learn how to employ both psychopharmacologic and cognitive-behavioral therapy modalities to manage symptoms such as hallucinations, delusions, and affective instability. As with the DBT program, one of the primary goals at this partial is to work closely with patients, outpatient providers, and community resources to minimize inpatient hospitalizations. Residents typically carry 3-5 patients as either the primary clinician (providing both therapy and medications) or med backup, and also lead group sessions throughout the week. Residents attend weekly CBT and psychopharm didactics, and participate in a weekly case conference that provides a psychodynamic perspective on psychotic illness. Individual and group supervision are provided by MD and PhD clinicians, group leaders, and a chief resident.
Child/Adolescent Inpatient Psychiatry at BCH
PGY2 residents spend two months rotating at BCH’s inpatient unit (Bader 5). There, residents carry between 4-5 patients, a combination of both primary and med-back up patients. Patients range in age from 8-18 years old and carry diagnoses ranging including depression, anxiety, eating disorders and a combination therein. Bader 5 is very team oriented with multiple disciplines present at most meetings (rounds, family meetings, individual therapy). Bader 5 often has many trainees from social work and psychology programs, which serves to enrich our experience. We also work with BCH child/adolescent fellows who take call on the unit overnight and on the weekends.
Outpatient Neurology, BIDMC Cognitive Neurology Unit or Boston Children's Hospital, 1 month
During your PGY2 time on Neurology, you will elect to rotate at either the Cognitive Neurology Unit at BIDMC, or at the outpatient neurology clinics at Boston Children's Hospital. The Cognitive Neurology Unit rotation will focus on the neurologic assessment of patients who have cognitive difficulties, and is staffed by both neurologists and psychiatrists who specialize in this population. The clinics at Children's Hospital provide exposure to both subspecialty clinics for children with rare neurological conditions, as well as more common problems, such as epilepsy.
PGY2s take call as a member of the two-person resident team that covers the BIDMC Emergency Department and Deaconess 4 Inpatient Psychiatric Unit. In the ED, residents are consultants providing acute psychiatric evaluations and facilitating disposition of these patients. We evaluate patients presenting for acute depression, mania, suicidal ideation, and psychotic decompensation. Residents work with a representative from the Boston Emergency Services Team (BEST) who assists with disposition to an inpatient unit, crisis stabilization units, or detox facilities. Here, residents sharpen their evaluation skills and work autonomously in a busy, Level 1 emergency department. Residents are also consulted by medical teams to provide capacity and safety evaluations on patients currently admitted to the medical floor. On the inpatient unit, the night team consists of nurses, mental health workers, and some security guards. Your responsibilities are to do any admissions that arrive, respond to any emergencies on the unit, and assess any patient complaints.
Inpatient Psychiatry on Deaconess 4
Similar to PGY1 inpatient psychiatry, Deaconess 4 provides an excellent opportunity to work with and treat both acute and chronic mental illnesses. As a PGY2, your patient load increases by a couple of patients, but a year of experience definitely makes a difference. Residents continue to work closely with multiple disciplines and receive regular supervision from attendings and the chief residents.
Residents will spend half time in the third year caring for a panel of patients in the BIDMC outpatient psychiatry clinic. The panel will include patients for whom the resident is providing psychopharmacologic management and patients for whom the resident will provide integrated treatment (psychotherapy with medications as appropriate). Each resident is assigned a psychopharmacology supervisor and two individual psychotherapy supervisors who will meet one on one with the resident for an hour each on a weekly basis. Additionally, each resident has a case-load supervisor, responsible for overseeing the resident’s overall educational experience in the clinic.
In the clinic, residents will learn to use a full spectrum of interventions to treat ambulatory patients. Each resident will become proficient in used psychopharmacology, psychodynamic psychotherapy, cognitive-behavioral therapy, and supportive psychotherapy, with more specific supervision in Acceptance and Commitment Therapy, Dialectical Behavioral Therapy, and other psychotherapy modalities available for interested residents. Each resident will be expected run a group therapy and conduct a couples therapy during their residency.
The outpatient rotation also includes weekly group supervision in couples and group therapy and an outpatient case conference where trainees discuss the work they are doing with patients with peers and clinic supervisors.
Clinical Selective Opportunities at Massachusetts Mental Health Center
Mentally-Ill/Problematic Sexual Behavior
This outpatient clinic that serves both adjudicated and non-adjudicated sex offenders who have a significant mental-illness who qualify for Department of Mental Health Services. Many patients have lengthy forensic histories and multiple hospitalizations. This program was created by DMH to facilitate community-based treatment of this population in order to mitigate risk and decrease recidivism. Residents work closely with Dr. Feldman, attending, and other team members to provide psychopharm evaluations and recommendations. This rotation also provides an excellent opportunity to generate a comprehensive risk assessment that serves as an example of forensic writing for future forensic psychiatry fellowship applications.
Boston Health Care for the Homeless
On this rotation, residents spend one day per week at the psychiatry clinic at St. Francis House, a day-shelter for the homeless in the heart of downtown Boston. This clinic sees a wide variety of patients, but mostly deals with mood disorder, anxiety disorders, and PTSD. Many patients have a history of substance abuse. Here, the resident is part of a large multidisciplinary team including therapists, case managers, and an on-site Suboxone treatment program. Residents in this rotation also spend a half day each week with a DMH homeless outreach team, which primarily serves the chronically psychotic homeless population. This day is spent walking around the city visiting homeless psychotic patients to offer housing and other services.
MMHC Continuing Care Clinic
The continuing care rotation is centered on the outpatient care of a caseload of chronically mentally ill patients living in the community, some independently, but most in DHM group homes. Residents are given flexibility to schedule outpatient appointments with patients with frequency of visits ranging from weekly to monthly depending on the patient needs. Residents are in charge of prescribing, collecting collateral from group homes, providing therapy, and coordinating care as needed. The patients are have often been in the DMH system for a while so are used to new residents every six months although there may be new intakes as well although few in number and not overly burdensome. Residents will gain a solid understanding of outpatient management and psychopharmacology of the chronically mentally ill during this rotation.
Center for Early Detection Assessment and Response (CEDAR) Clinic
On this rotation, PGY-3 residents evaluate and treat adolescents (average age 15-25) displaying symptoms that put them at high risk of developing psychosis. Often patients are referred by their established outpatient treaters for confusing signs and symptoms that do not have a clear etiology, and the CEDAR team is responsible for helping to determine if these symptoms are an indication of psychosis or alternative etiology. Other patients receive their primary psychiatric care at the clinic, and the resident helps to manage the medications and perform frequent evaluation while other trainees provide primarily CBT and skills based training. In addition to working with other trainees, you get direct supervision by the medical director Dr. Zimmet MD as well as the team leader Dr. Friedman PhD. This is an excellent rotation for residents hoping to gain experience in sorting through complicated and unclear diagnostic pictures, and for those interested in psychosis or child & adolescent psychiatry.
Prevention and Recovery in Early Psychosis (PREP)
In this program, a transitional age youth population with established psychotic illness is treated within an intensive outpatient adolescent and young adult milieu. Patients come to PREP two full days a week where they receive psychiatric care, psychotherapy, group treatment and have the chance to engage with other transitional age youth in both structured and unstructured activities. We residents carry a complex caseload of patients. We function as primary therapist for some cases and the medical back up in others. We do comprehensive intake assessments with new patients and their families. We lead group treatments and engage with patients within the milieu setting. All care at PREP involves a multidisciplinary team and embodies a wrap-around approach to treatment for high acuity patients that involves families, schools and any related social system whenever possible. We receive supervision from child and adolescent trained psychiatrists who specialize in treating this population of patients with early onset psychosis. We are exposed to the clinical research studies that involve many of their patients which are run by the Commonwealth Research Center and participate in regular case conferences and journal clubs that are facilitated by experts in the field of early psychosis treatment and research.
Clinical Selectives at BIDMC and Affiliates
Berenson Allen Center for Noninvasive Brain Stimulation (BACNBS)
The BACNBS is a world leader in the research and development, clinical application, and teaching of non-invasive brain stimulation techniques. Under the direction of Dr. Adam Stern (an alum of HLPRTP), the center provides evaluation and treatment of a variety of psychaitryic and neuropsychiatric conditions with Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS). Residents will have the opportunity to participate in the evaluation and treatment of these patients while learning the principles behind its therapeutic action. They will also have the opportunity to participate in research projects.
Perinatal Psychiatry Service
Residents will participate in this outpatient service which works closely with the High Risk OB-GYN service to provide consultation, diagnostic evaluation, and treatment recommendations, including pharmacotherapy, psychotherapy and integrated treatment, to pregnant and postpartum women.
Cognitive Neurology Unit
The CNU is a multidisciplinary outpatient clinical unit that services a variety or neurological patients with sensory-perceptual, cognitive, attention and executive problems, some of whom also have psychiatric symptoms, specialized social service needs, as well as non-neurologic medical problems. The selective in the CNU provides the opportunity to build and maintain a patient following, composed of a combination of new evaluations and follow-up sessions. The resident will have the opportunity to participate in the educational program of the CNU. There will be weekly supervision for the resident which provides the opportunity to discuss new and ongoing cases, as well as questions which will generated out of one’s experience. In addition, informal collaboration with the other disciplines is encouraged and readily available.
Fenway Community Health
A selective in integrated care is available at Fenway Community Health. Their mission is to enhance the wellbeing of the lesbian, gay, bisexual and trangender community.
During PGY4 year, residents have the opportunity to apply for several chief resident positions or clinical selectives. Residents with dedicated interests not included in more “formalized” experiences are invited to collaborate with mentors to tailor a PGY4 experience that fits their educational needs and career goals. There is also the opportunity to spend the non-outpatient portion of the year on a research selective. PGY4s split their time between these year- long positions and continuing care in the outpatient clinic in which they’ve been working since PGY2 year. They also continue to have weekly didactics and weekly time for their scholarly projects.
Chief Resident opportunities include:
- Program Chief Resident
- Massachusetts Mental Health Center Partial Hospital Chief Resident
- Chief Resident of Ambulatory Service at Beth Israel Deaconess Medical Center
- Chief Resident of Inpatient Psychiatry at Beth Israel Deaconess Medical Center
- Chief Resident of Psychiatric Consultation/Liaison Service at Beth Israel Deaconess Medical Center
Clinical Selective opportunities include:
- Psychiatry Selective at the Cognitive Neurology Unit at Beth Israel Deaconess Medical Center
- Latino Mental Health Selective
- VA Boston Health Care System Center for Returning Veterans and National Center for PTSD
- Fenway Community Health Selective
- Boston Healthcare for the Homeless