Pediatric Consult-Liaison Rotation-at SLCH-CAP 2

 

Rotation Director: Eric Spiegel MD

Other Faculty: John Constantino MD, Anne Glowinski MD, MPE, Joan Luby MD, John Pruett MD, PhD, Angela Reiersen MD, Cynthia Rogers MD, Brooke Ayden MD, Natasha Marrus MD, PhD, Ginger Nicol MD, Mini Tandon DO, Paul Glaser MD, Chad Sylvester MD, PhD, Eric Wittrock, DO

Number of residents per rotation: One

Length of Rotation: 2 blocks of 5.1 weeks

Time of Rotation: Second year of training

Please contact C/L Director at least 2 weeks  before the beginning of this rotation.to discuss orientation logistics (communication) and round times.

Goal

The goal of this rotation is to provide advanced second year residents with an in-depth exposure to the interface between pediatric and psychiatric care in an academic hospital setting, where both common pediatric illness and complex pediatrics specialty care co-exist.  The nature of child psychiatry consult-liaison at SLCH is team based including rotating attending faculty, C/L director, the fellow and trainees supervised by the fellow (medical students and Child Neurology residents on child psychiatry).  Although teaching (rounds, recommended readings, participation in c/l specific multi-disciplinary care meetings, case based) is prominent on this rotation, it is also expected that this rotation will allow second year fellows to show case their advancing skills and to have a significant level of autonomy.

Objectives

To develop competence in the following areas:

Patient Care

The resident will learn provision of consult-liaison services at SLCH including:

  • Clarification of consult question and of goals and objectives of consult as a dynamic process which starts at the outset and continues throughout the consultative process
  • Approaching hospital patient and family who may or may not be enthusiastic about psychiatric consultation
  • Assessing the impact of chronic disease on children, adolescents and their families
  • Refinement of child and family therapeutic interviewing skills in a busy hospital setting
  • Observing and interpreting family, ward, health care and other relationships and their pertinence to the presenting consult question
  • Producing recommendations which are clear and practical for healthcare team, patient and family to be implemented in hospital and beyond
  • Assessment of risk and appropriateness of outpatient (vs. more intensive) treatment post SLCH stay
  • Prevention of self-harm and harm to others
  • Assessment of psychiatric follow up needs and facilitation of follow up care arrangement
  • Familiarity and competence with psychopharmacological interventions in children with multiple medical problems and often on multiple medications, including attention to drug-drug interactions and drug contraindications
  • Psychoeducation of patients, families, and health care team members
  • Supportive therapy and grief/loss counseling
  • Hospital behavioral management

Medical Knowledge

The resident will gain medical knowledge through working in a clinical team and accompanying didactics and reading of the pertinent consult CAP or related literature.  Knowledge developed on this rotation will include:

  • Presentations of major child psychiatric disorders in acute pediatric settings including knowledge of epidemiology, known etiological or risk factors, disorder phenomenology, diagnostic criteria, predictive value of diagnosis (e.g., adjustment disorders, depressive and anxiety disorders, abnormal illness behaviors, psychological factors complicating medical conditions, psychiatric disorders secondary to medical factors, delirium, cognitive and behavioral impairments related to medical factors)
  • Understanding the appropriate use of laboratory testing and adjunctive data collection in the elucidation of clinical presentation in the hospital setting
  • Understanding the appropriate elicitation of information from pediatric colleagues to appreciate fully the medical phenomenology of illness
  • Basic knowledge of pediatric disorders which commonly affect patients fellows are consulted on (e.g., overdoses and sequelae, diabetes, sickle cell, cystic fibrosis, dystrophies, epilepsy)
  • Critical knowledge of effective treatment strategies including psychopharmacological and psychotherapeutic approaches and strengths and limitations of approaches (combined or not combined with one another)
  • Knowledge of consultation role and its boundaries
  • Use of electronic systems to access hospital care, medical, and scientific information

Interpersonal/Communication Skills

The resident will effectively communicate with the members of the pediatric care team including key members of the team responsible for consult initiation, patients, their families and all other members of the treatment team

  • Conducting age appropriate interview techniques, as well as comprehensive mental status examination on children and adolescents in hospital settings; this may include use of less anxiety provoking observational settings such as play room and SLCH garden.
  • Effective communication with all involved in care of patient including verbal, non-verbal and written communication and oral communication of written recommendations to key individuals
  • Ability to efficiently summarize findings and recommendations in a timely manner, respectful of the rapid pace of hospital care
  • Leadership and teaching of medical students and neurology residents assigned to consult team (e.g., allowing these trainees to progress during their one month rotation to an evaluative role under the supervision of fellow)
  • Develop and maintain therapeutic alliances with health care team, patients families and troubleshoot difficulties encountered in the maintenance of therapeutic alliances (e.g., splitting, blaming, triangulations, poorly understood perspective differences)
  • Empathy and understanding for role and burdens of different members of the health care team as applicable (e.g., pediatricians, nurses, pediatricians in training, ward staff, social workers, child abuse team members, psychology staff)
  • Collaborative relationship in particular with psychology

Practice Based Learning

The fellow will develop competence in continuous learning and improvement through practice and related activities including

  • Active participation in didactics and conferences which are particularly salient to practice in the hospital setting (e.g., as applicable psychotherapy seminar, early bird rounds, pediatric grand rounds, interdisciplinary conferences)
  • Active case based learning in the hospital
  • Critical review of patient’s records
  • Integration of literature findings into patient care and/or communication with others
  • Ability to research and troubleshoot complexities and difficulties that arise in consultation

Professionalism

The resident will demonstrate sensitivity and compassion to children and adolescents affected by psychopathology and to their families or their caretakers and will continue to develop in relationship with other professionals or professionals in training, including supervisors, colleagues, students and allied professionals.  In the c/l rotation, major aspects of professional development will include:

  • Perform a consultation which respectfully addresses the specific questions paused by the referring physician
  • Developing intra-professionally by managing adaptively their own emotional reactions to other medical providers and health care team members, youth and families seen in the hospital
  • Responsibility for consultation role as demonstrated by timely response or communication with families, attending(s), and other health professionals and passing on of salient information to other fellows (e.g., before weekend call)
  • Acknowledgement and remediation of errors
  • Intra-professionalism: ability to understand and remedy factors which interfere with one’s proper professional conduct

System Based Care

A quintessential rotation to gain competence on system based care by providing consults requested by multiple systems and participating in interdisciplinary meetings where multiple systems of care intersect

  • Understanding the roles of other professionals including pediatricians, sub-specialists, psychologists, nursing staff, social workers, occupational therapists, child abuse team
  • Development of time management skills including management of other clinical responsibilities during the c/l rotation
  • Familiarity with consult billing procedures
  • Appreciation of perception of psychiatric systems of care by others
  • Understanding the limitation of community mental health care for children and its impact on mental health care at St. Louis Children’s Hospital

Measurement of Objectives

  • Feedback by other professionals
  • Standard Program evaluations
  • Medical Records Review by Faculty
  • Clinical Skills Exams

Description of Rotation

This hospital based rotation involves managing all consults from the hospital staff (inpatient) including consult clarification, timely initiation of consult (within 24 hours of request), timely recommendations, communication with primary c/l attending and consult director, management of hospital staff’s expectations regarding consults, facilitation of transfers to psychiatric hospitals if needed, weekly attendance at the Behavioral Response Team meeting and leadership of other trainees on child psychiatry rotation.  Rounds with primary attending occur daily.