Neurology Consults: University Hospital
This is an eight-week rotation that involves covering consults at IU Hospital from 8 am - 4 pm on Monday through Friday. A typical day consists of morning rounds, composing progress notes and staffing patients with the neurology attending, Dr. Snook. There is also a senior neurology resident on service who will inform you of new consults. The team is made up of two-three residents (from neurology, psychiatry and occasionally internal medicine)as well as two-three medical students. Psychiatry residents do not cover any call while on Neurology and are encouraged to attend the Neuroscience Grand Rounds on Wednesdays from 5-6:30pm at our Neuroscience Center. Weekends are completely free from clinical duties. There tends to be many interesting patients to be seen on this service as the patients at this hospital are typically the more medically complex (there is a transplant center and cancer center on site). This is a great month to prepare for the neurology section of the PRITE exam!
Emergency Medicine: Eskenazi
EM rotation is four-weeks at Eskenazi Hospital. Residents will have a combination of day, evening, and overnight shifts, including 1-4 “obs” shifts for covering high acuity/trauma cases. Days off are scattered throughout the month. Residents will typically have around 18 nine-hour shifts over the rotation. The majority of shifts will be covering triage. Residents staff cases with attendings and/or upper-level EM residents and continue to follow patients through disposition. At the end of the shift residents can change over patients to an oncoming resident, but effort is made to have disposition completed as much as possible before leaving. Do not feel pressured to know what to do during complex cases, especially trauma cases! There are always staff and an upper level resident to help. This rotation tends to be a favorite among our residents due to the variety of cases seen, ease of working with staff, and often getting to do procedures that we usually wouldn't do in a psychiatric practice.
Medicine: VA Inpatient Wards
Psychiatry interns rotate on Internal Medicine at the VA for eight-weeks. There are four inpatient medicine teams at the VA and psychiatry residents are assigned to various teams. Long call is q4 but interns never stay overnight. A team is made up of the attending, upper-level IM resident, two interns, usually a 4th year medical student doing a sub-internship who carries his or her own patients, and around three third year medical students. Each team also has a social worker assigned to them and is capped at 18 patients. These teams cover patients on the regular wards and in the medical step-down unit. Days officially start by 7am which is when the night float signs out to the regular teams. Interns and medical students will pre-round on their patients. Rounds usually takes place around 9am and is a mix of table rounds and walking rounds. On call days, admissions are taken until 6pm. There is also a short call day that up to four admissions can be taken until 4pm. When you leave you will sign out to the on call team or the night float team if it is after 6pm. On weekends and holidays, all of the teams except the on call team can actually sign out at noon. On the whole, this is a busy rotation but is manageable to get through. Psychiatry residents often comment about how much they have enjoyed working with the Internal Medicine department at IU.
Medicine: Eskenazi Inpatient Wards
Psychiatry interns rotate on internal medicine at Eskenazi for four weeks. Days start at 7am with receiving sign out from the night float team. Interns will review labs and overnight nights and then round on their patients. Each team is composed of the attending, an upper-level IM resident, two interns, usually a 4th year medical student doing a sub-internship who carries his or her own patients, and around three third year medical students. There is also a case manager on each team and various social workers assigned to patients depending on their location in the hospital. Rounds will usually start around 9am and will be a mix of table rounds and walking rounds. Each team carries a maximum of 20 patients. The team will cover patients on the general medicine wards and the PICU. Call on this service is q5 with the call team taking six admissions during the day time and the upper-level resident staying overnight and him or her admitting another three patients to the team during the night. On non-call days, interns are usually able to sign out around 4-5pm, and usually earlier on pre-call days and weekends. Residents tend to report being busy on this rotation but that they also have a good experience and gain a good deal of confidence as physicians.
Adult Inpatient Psychiatry: Larue Carter
Larue Carter is a state psychiatric hospital located in Indianapolis. The two units that residents rotate in are the largest units in the hospital, 29 and 27 beds for the two units. You will be assigned one unit for the entire two-month rotation. A typical day starts by 8am. You and the medical students (usually three) check in with nursing staff for any immediate orders or acutely ill patients. Medical students usually pre-round on the patients with the resident helping the students with any particular concerns they have. Morning report starts at 9am with a full treatment team and table rounds on all patients. The rest of the day consists of interviewing specific patients depending on needs, attending group therapy with patients, helping the attending put in orders for medications or consultations with primary care, and teaching medical students. You are welcomed and encouraged to attend groups on other units, and help attendings admit patients on their units, as admissions at Larue are not a daily occurrence. There are loads of interesting groups to attend at Larue Carter. Some groups that residents have been found to be beneficial include communication groups, DBT, schema therapy, recreational therapy (don't miss the chance to play volleyball with the patients!), and substance abuse. Your day ends around 5pm, unless you need to leave earlier for call at Eskenazi. When you are scheduled to be on call on a Friday at Eskenazi, you are also expected to cover Larue on Saturday and Sunday (once every 5-6 weeks). This consists of coming to the hospital both Saturday and Sunday to sign orders for patients who received a verbal order from the attending overnight. This takes roughly 30 minutes per day.
Adult Inpatient Psychiatry: Eskenazi
Eskenazi moved into their brand new facility in December 2013. The Psychiatry inpatient unit is comprised of 20 beds which are virtually always full. There are two teams on the unit, 10 patients each. Interns are assigned to one team at a time while on this two-month rotation. Residents greatly enjoy this rotation due to the interesting patients that are seen as well as the collaboration with great support staff. The patient population is about half (or more) psychotic spectrum illnesses with the remainder being a mixture of depressive disorders, mania, anxiety disorders, personality disorders, and dementia. Interns typically arrive around 8am M-F to check for updates and to research new patients. Interns will pre-round on the 10 patients on the team, but will usually leave new patients for group interviews. There are usually two medical students on each team that will pre-round as well. Team meeting rounds will occur at 9:30 or 10:30 depending on the team. This will be table rounds with a full treatment team. Each team has its own social worker. After rounds, each team will work on interviewing new patients together and then, interns will work on orders, notes, and following up on anything left to talk about with patients. Days typically end by 5pm.
Adult Inpatient Psychiatry: VA
This rotation lasts for two-months on the 16-bed adult psych unit at the VA and is a busier service than the other psychiatry rotations of the intern year. This unit sees a mix of affective disorders, PTSD, substance abuse, and psychosis. Interns typically will arrive around 7-7:30 to receive sign-out from the overnight covering resident and to read overnight notes/check labs. Residents will typically cover around eight patients on the unit with the others being cared for by the attending. There are usually medical students on the team and they are expected to be heavily involved in the care of the patients they have. The intern and students will pre-round on his or her patients. Rounds will typically be held around 9:30am with the full treatment team. These will be table rounds with new patients being seen by the attending, intern, and medical student afterwards. Once rounds and new interviews are completed, interns will work on orders, notes, supervising medical students with tasks that need to be completed, and sometimes attending family meetings. The intern and medical students will work on any admissions to the unit that come before 4:30pm.
Child Psychiatry Consults
The Riley Hospital for Children Child and Adolescent Psychiatry Consultation-Liaison team consists of an attending Child Psychiatrist, Clinical Psychologist, Psychiatry resident, two social workers, and two-three medical students. Consults are covered by this team M-F 8:00-4:30. Table rounds are usually held at 8:30am and tasks are split amongst the team then. Pathology seen on this rotation is primarily anxiety disorders along with depressive disorders, eating disorders, autism spectrum disorders, substance use disorders, and occasionally psychosis. This is a one-month rotation.
Child Psychiatry Inpatient
This rotation is done at Methodist Hospital Child and Adolescent Psychiatry which is a 10 bed unit. Residents find this as a highly enjoyable unit to work at with a great variety of patients and strong support staff. Hours for this rotation are typically 8am-5pm. The team consists of the attending, Dr. Litwiller, a resident, and possibly one-two PA students. A daily routine includes checking for morning updates with nursing and on Cerner (the EMR), staffing at treatment team (Mondays and Thursdays), rounding on patients (no pre-rounding), doing orders, calling parents, writing notes, and then dealing with any problems that come up during the day. There are opportunities to go to group therapy sessions with the therapists and there are many family meetings that residents are encouraged to take part in. Patient problems that are commonly seen include depression, psychosis, disruptive behavior disorders, eating disorders, and patients with strong traits of personalities disorders. Overall this is a great rotation to learn how to manage many child and adolescent psychiatry disorders and how family dynamics often play into them.
Forensic Psychiatry is one of the most interesting and flexible rotations of the PGY-2 year. It’s unlike anything you’ve done before! There is one resident on at a time and occasionally a fourth year medical student doing an elective. On Mondays you will work at the Marion County Jail in a clinic setting doing diagnostic assessments and medication management for inmates with a variety of mental health diagnoses. The remainder of the week will be filled by a variety of both criminal and civil experiences. Expect to visit a number of jails and to be part of the forensic evaluations that determine competency to stand trial. You will also likely be invited to observe an expert psychiatrist testifying in court – typically providing an opinion regarding a case involving not guilty by reason of insanity or guilty but mentally ill. You will also help provide organized training to law enforcement officers regarding mental illness and, during the academic year, will be invited to attend sessions of Psychiatry and the Law. This is a class that the attending psychiatrist teaches at the law school located right next to the hospital campus. The civil side of the rotation includes workman’s compensation evaluations and fitness for duty. It is an action-packed month.
The PGY-2 Emergency Psychiatry experience is awesome! You will be working in a psychiatric emergency area called Secure Holding. SH is directly attached to the main emergency room at a large, tertiary referral and trauma 1 hospital in downtown Indianapolis. Needless to say, things are always busy. While in Secure Holding, clinicians will staff with you and you will be in charge of determining treatment and disposition for patients. Of course the attending is there to help, but there is a significant amount of autonomy during this rotation. On Monday, Wednesday and Friday mornings you will assist with ECT prior to your shift in Secure Holding. During this time you will learn the neurophysiology behind ECT and will be in charge (with supervision) of administering this treatment to patients. It’s a unique opportunity to work alongside nursing staff and anesthesia to get involved in one of the few procedures psychiatry has to offer!
The PGY2 rotation in Addiction Psychiatry consists of two days per week for six-months at a substance abuse clinic at the Veterans Administration Hospital. The clinic consists of two supervising physicians, two addiction nurses, and numerous clinicians who run therapy groups and act as case managers. There is a methadone program, large buprenorphine population, and patients with other substance use disorders. The model is a dual diagnosis approach with treating the patient's addiction and psychiatric illness concurrently. Residents are involved in methadone and buprenorphine inductions, follow up appointments, and tapers. Additionally, residents supervise detox from alcohol, benzodiazepines, and opiates in an outpatient setting. There is good continuity of patients since it's for six months and it is a very busy clinic allowing for variety of educational experiences.
This rotation occurs one full day a week, during the six-month outpatient focused block. Residents see patients in the older adult clinic (OAC) at the VA medical center. A wide variety of pathology is seen. Cases are staffed throughout the day and discussed in further detail at the end of the day when residents meet with their supervisor and other staff in the OAC. Didactic topics are also discussed at this time. Several times throughout the rotation the resident will make home visits with a home-based care provider. Overall, it provides a good introduction into the care of geriatric patients.
Patient Safety and Quality Improvement
Currently this rotation is focused at the VA Hospital. During the PGY2 year, residents participate in a training in process improvement in the schema of Lean manufacturing which originated in the Japanese auto industry. Essentially the idea is to produce the most value for the consumer (patient) with the fewest resources by eliminating wasted time, resources, etc. Residents then apply these skills to actual real time problems in the mental health or other departments by participating in a three to five-day workshop. They work with systems design managers, supervising faculty, nurses, department managers, and often the Chief of Psychiatry. Residents also attend peer review meetings a few times per month and hear about patient safety issues that have been brought to the attention of the review committee. This rotation continues to grow and develop with chart review and quality improvement projects being initiated at some of the other sites that will involve residents of all PGY levels.
Adult Psychiatry Consults
This is a two-month long rotation at the VA that takes place during the six month inpatient focused block. Residents provide psychiatric consultation services to patients on the inpatient medicine services and in the ER. The C/L service also, at times, provides ECT evaluations and treatment which residents may be involved in. A wide variety of pathology is seen. Cases are staffed with the C/L attending and didactic learning takes place throughout the rotation. This rotation helps residents obtain experience dealing with acute psychiatric concerns as well be an advocate for patients with mental illness navigating through the medical system.
This is the first structured therapy clinic that residents will participate in. For six-months, during second year, residents spend one half day per week seeing patients in the role of the therapist, specifically practicing CBT. The second half of the same day is spent reviewing assigned readings and learning about CBT with the two other residents on rotation with you in conjunction with the faculty supervisor. In addition, residents spend this time staffing the cases with the supervisor and discussing the case amongst the entire group. It's a great environment for additional reflection and suggestions on how to improve and proceed with your therapy patients.
Adult Outpatient Psychiatry
The third year of the program is dedicated entirely to adult outpatient psychiatry. There are a variety of clinics to choose from that can cover almost any specialty type clinic. The main sites residents rotate at are Midtown (psychiatry services through Eskenazi), the VA, and Goodman Hall. Residents request the clinics that they will work in. One full day per week is elective time which can be set up at
a site outside of these typical clinics. Call in 3rd and 4th year is only back-up call and it is extremely rare that residents are actually called in.
Psychodynamic Psychotherapy is part of the PGY3 12-month curriculum and many residents choose to continue seeing psychodynamic patients into their 4th years. Residents carry a variable number of psychodynamic psychotherapy patients and typically see them on a weekly basis. Most residents have this experience at Goodman Hall (the new IU neurosciences building) where the weekly Psychodynamic Psychiatry lecture series is as well.
Fourth Year Electives
The fourth year is literally 100% electives. Residents have many different options for “typical” places to rotate at, such as Eskenazi inpatient, Consult Liaison at the VA, outpatient work at any of the available clinics. Rotations can be done on a monthly basis similar to PGY-2 (inpatient type) or on a half-day set up such as PGY-3 for those interested in tuning up the skills learned the previous year. Additionally residents are free to set up electives of their choice. In the past, residents have created clinics focusing on women’s health in an OB clinic or women’s shelter, focusing on psychopharmacology with specialized faculty, additional training in rTMS and ECT, and developing skills in telepsychiatry. PGY-4 year is an open slate giving the resident the opportunity to perfect techniques and skills they feel will be most useful for them upon graduation.