Psychiatry Training
Relationship Of MMHC Programs To
The Harvard Longwood Residency Training Program
The MMHC Partial Hospital is a major clinical venue in which medical
students, residents, other trainees, attendings, and MMHC non-faculty
staff members interact daily. Thus it serves to propagate the unique blend
of service, teaching, and research opportunities which characterize the
modern American teaching hospital. The sophisticated utilization of manualized,
empirically validated forms of psychotherapy, e.g. dialectical behavior
therapy (DBT) and social skills training, simultaneously provides state-of-the-art
psychosocial treatment for the complex and seriously ill patients on that
service, teaches the use of these modalities to Harvard residents, interns,
and medical students assigned to the Partial Hospital teams, and provides
an opportunity for study of the impact of these modalities upon patient
care in general, e.g. decreases in inpatient hospitalizations for patients
with borderline personality disorder who have had DBT when compared with
their own pre-DBT history. Similarly, the availability of high-level psychopharmacology
consultation services with Dr. Salzman and others provides superior patient
care, excellent teaching, and multiple research opportunities. Thus, the
Partial Hospital provides integration between the clinical, educational,
and research missions of MMHC.
Like the Partial Hospital, the MMHC Continuing Care Service provides
an integrative milieu for clinical, educational, and research missions
and personnel. Within the CCS, residents serve on outpatient teams, perform
triage and other emergency evaluations, and act as collaborating psychopharmacologists
for non-medical trainees and staff taking care of MMHC patients as psychotherapists.
When clinically appropriate, residents also make home visits or go with
clients to other appointments, thus learning the model of community psychiatric
service delivery. Supervision is provided by faculty attendings who are
assigned to the same outpatient teams. These attendings carry their own
caseloads as well so their teaching is by role-modeling and example as
well as by supervision and didactic instruction.
As described elsewhere, residents, psychology interns, and other trainees
are also assigned to the Southard Clinic, where they treat under supervision
patients without major mental illness but still in need of treatment,
e.g. those with obsessive-compulsive disorder, dysthymia, uncomplicated
post-traumatic stress disorder, and so on. Consultation in sub-specialty
areas, e.g. forensics, cognitive-behavior therapy, psychopharmacology,
and neuropsychology, is readily available and, again, contributes simultaneously
to excellent service delivery and high quality education.
Although not physically housed at MMHC, the exposure of residents, interns,
and medical students to Boston’s Health Care for the Homeless service
provides another opportunity for integration of service delivery and education.
Trainees on this service see patients in a number of locations, including
Boston Medical Center, the McInnis House (a step-down unit for homeless
people discharged from inpatient medical units but still too ill for shelter
living), the Cardinal Medeiros House, and (literally) under a highway
bridge near Fenway Park. Supervision addresses both clinical and socio-economic
issues. This rotation has become one of the major “drawing cards”
of the Longwood residency and forms the basis of the HMS course, Psychiatry
525, Community Psychiatry.
Research projects well integrated
into clinical service delivery (often including trainees) include a
variety of medication trials (Risperidone, Seroquel, Ziprasidone and
Clozapine). For example, the use of the atypical antipsychotic agent,
clozapine, with which MMHC staff and trainee clinicians have become
quite expert, began as a set of research protocols within the MMHC Commonwealth
Research Center. Papers written by MMHC research and clinical personnel
on this subject have focused both on its psychopharmacologic properties
and on its psychosocial implications. The advantages and complications
of the use of this agent have been one unifying theme at this institution
over the past decade.
Another example of seamless integration of research and clinical service
is exemplified by the clozapine alcohol/substance abuse studies (A. Green,
PI), which require a manualized group treatment. This psychosocial treatment
was provided by Day Hospital staff, who were trained by Dr. Kim Mueser
of Dartmouth Medical School to facilitate the implementation of Dr. Green’s
studies funded by NIAAA and NIDA. This treatment benefitted both clinical
service and research.
One more example is in the treatment of first episode patients. The principles
for treating these patients and the use of parent groups in this treatment
program have been delineated by members of the CRC staff as they care
for patients within Dr. Green’s funded clinical investigations of
these first episode patients.
The Continuing Care Service has also participated in service-wide psychosocial
research projects. One, with Norma Ware, Ph.D. of the HMS Department of
Social Medicine, studied Continuity of Care in Mental Health Services
and interviewed MMHC clients and clinicians over time. Dr. Ware developed
her working definition of “continuity of care” by observing
team meetings within CCS. Another, headed by Barbara Dickey, Ph.D. of
the HMS Department of Psychiatry at McLean Hospital, studied outcomes
of care in managed care (Medicaid) vs. non-managed care (Medicare) clients.
A third, representing a doctoral dissertation by a Boston University psychology
graduate student and MMHC psychology fellow, examined quality of life
issues and cognitive-behavioral therapy in clients with schizophrenia
who had responded to Clozapine.
In addition, trainees have
multiple opportunities to work with senior staff and faculty members
on academic projects. Dr. Salzman regularly collaborates with residents
in writing psychopharmacology papers, a recent example of which is on
the somatic treatment of late-life depression. Dr. Goisman as co-editor
of the “Clinical Challenges” column of the Harvard Review
of Psychiatry regularly offers residents and interns the opportunity
to write up cases which have been presented to senior faculty members
at conferences for submission; while not “research” in the
sense of independent laboratory investigation, these case reports are
often accepted for publication, represent the first peer-reviewed published
work for many residents, and offer a rewarding and demystifying experience
through which residents may gain confidence to attempt other kinds of
academic projects.
In addition, the activity of so many
MMHC clinical faculty members in the Longwood residency program has
direct effects on clinical service delivery at Beth Israel Deaconess
Medical Center (BIDMC) and at Brigham and Women’s Hospital (BWH),
our closest Longwood neighbors. MMHC attendings regularly consult at
the other two institutions, e.g. as consulting attendings to whom trainees
and staff present patients at case conferences.
Thus, the clinical service delivery system at MMHC works to potentiate
the academic mission of the Department in a number of inter-related ways.
Its three major components (Partial Hospital, Outpatient Service, and
off-site) provide clinical experience for trainees, opportunities for
supervision and teaching for faculty, and fertile ground for significant
and clinically meaningful somatic and psychosocial research and writing.
Trainees are given multiple opportunities to work with faculty mentors
on research projects and case reports. Attendings and other clinical staff
collaborate extensively with their counterparts at other Harvard Longwood
institutions through organizational work and as consultants. The result
of all of this is a rich, exhilarating atmosphere in which clinical and
academic work are mutually respected and flourishing.
Medical Student Teaching
Medical student teaching at
MMHC occurs in several forms. Robert M. Goisman, M.D., MMHC Director
of Residency Training and Medical Student Education, is the site director
for Psychiatry 700 M.J, Psychopathology and Introduction to Clinical
Psychiatry, the basic psychopathology course for HMS second year students.
This course, given in collaboration with Beth Israel Deaconess Medical
Center (BIDMC) West Campus, has served 25-30 students every fall since
its inception in 1986; in some years a second course enrolling 9-12
students has been given in the spring as well with Dr. Suzanna Zimmet
as site director. In this course, lectures on psychiatric syndromes
are followed each week by small group interviews with patients illustrating
the disorders described in the lectures. Unique features in MMHC’s
section of the course include a “field trip” to a local
psychosocial rehabilitation day treatment facility and residential program,
and also the fact that the MMHC Outpatient Chief Resident can act as
a section leader or “T.A.” for the course, with supervision
on pedagogy from Dr. Goisman. In addition to Drs. Goisman and Zimmet,
MMHC faculty members participating in this course have included Drs.
Eileen Wong, James Feldman, James Beck and others. For the 2004-2005
academic year Dr. Beck will be the site director.
MMHC is one of four sites
utilized by the Harvard Longwood Psychiatry Clerkship Program, mounted
in collaboration with BIDMC and Brigham and Women’s Hospital (BWH),
directed by Dr. Goisman and with its administrative headquarters at
MMHC. Utilizing a format similar to that of the award-winning Harvard
Longwood Psychiatry Residency Training Program, clerks are assigned
to the MMHC Partial Hospital, the BIDMC inpatient or consultation-liaison
service, the Faulkner Hospital inpatient service, or the BWH consultation-liaison
service. Primary assignments to these sites are combined with clinical
experiences at Children’s Hospital and at the BIDMC emergency
department and Urgent Care services. The didactic program is extensive
and, using a format like that of the sister residency program, fences
off four consecutive hours for didactic instruction off-site, allowing
for a relaxed, graduate school-like atmosphere without interruptions
for service demands. These are supplemented by other lectures and conferences
across the week. The rotation is very popular, with 74 students out
of about 160 in each class rotating through the Longwood clerkship.
In addition to Dr. Goisman, MMHC faculty members participating in this
course as attendings, didactic teachers, or supervisors have included
Drs. Eileen Wong, John Dundas, Elizabeth Simpson, Eileen Reilly, James
Feldman, Thomas Gutheil, Gordon Harper, James Beck and others.
Finally, a number of 4th year
medical students, typically those wishing a look at the residency program,
elect one-month rotations at the various Longwood sites. These rotations
are structured so as to meet individual student needs and requests,
so that combinations such as consultation-liaison plus emergency room,
or Partial Hospital plus outpatient department, are common. A new elective
in Community Psychiatry was recently developed (see below). A large
number of students electing such rotations in recent years have gone
on to matriculate in the residency program. In addition, from time to
time MMHC faculty member Dr. Carl Salzman has offered fourth year didactic
electives.
Changes And Innovations Over The
Last Five Years
A significant addition has
been that of Psychiatry 525, Community Psychiatry. This innovative fourth
year elective places students on an MMHC outpatient team, allows participation
in triage evaluations, sends students to the very popular Health Care
for the Homeless programs, and teaches about psychosocial rehabilitation
through on-site experiences in MMHC-affiliated residential and day programs.
This elective also centers on ambulatory patients rather than on admitted
inpatients, with students assigned to outpatient and Intake and Evaluation
teams.
In addition, the use of a
partial hospital as a primary teaching site for clerks is relatively
infrequent in this country. Students on this service learn a great deal
about contemporary forms of psychosocial treatment and rehabilitation,
including making supervised home visits and co-leading groups of empirically
validated forms of treatment such as dialectical behavior therapy and
social skills training. Further, the typical length of stay of one month
for Partial Hospital patients allows students the unfortunately infrequent
experience of getting to know their patients in great depth.
Residency Training Program
After having had a separate MMHC residency
training program for many years, a decision was reached in 1994 to merge
the MMHC program with a number of other educational and clinical facilities
in the Longwood medical area to form the Harvard Longwood Psychiatry
Residency Training Program. This report will focus on the specific contributions
of MMHC to this highly sought-after, award-winning program which has
consistently been considered one of the premier training programs in
the US since its inception.
Having the primary responsibility for public psychiatry within the program,
Longwood residents rotate through three clinical services at MMHC: the
Partial Hospital, the Outpatient Department, and the Primary Care service.
All PGY-II residents spend 35 hrs/week for three months on the Day Hospital,
where they learn about the diagnosis and partial hospital treatment
of patients with psychotic disorders, comorbid substance abuse, trauma
histories, and/or severe personality disorders in a highly structured,
very active treatment milieu with a typical length of stay of one month.
Residents serve both as primary clinicians and as collaborating psychopharmacologists
with their patients. The resident learns elementary principles of learning
theory, behavioral analysis, cognitive therapy, dialectical behavior
therapy, social skills training, and psychodynamic psychotherapy as
well as psychopharmacology with severely ill and socio-economically
challenged patients. The resident is also exposed to the concept of
structured (manual-based), empirically validated forms of psychosocial
treatment.
Each PGY-II resident in the program is assigned to one of three outpatient
sites at which he or she is stationed for all three years. The MMHC
outpatient department has consistently been the most popular of these
three sites within the program, due in part to its unique bimodal distribution
of ambulatory patients with serious mental illness combined with higher
functioning patients in need of psychodynamic or cognitive-behavioral
psychotherapy with psychopharmacology. Residents learn about multiple
therapeutic modalities, including group and family treatment, and close
attention is paid to achieving balance and diversity in the individual
resident’s caseload. The residents spend 5 hours weekly on the
outpatient service as PGY-II’s, 20 hours weekly as PGY-III’s,
and 15 hours weekly as PGY-IV’s. In general, there are 5 residents
per year on the MMHC outpatient service, with a full complement thus
being 15 residents at a time; from time to time the number of PGY-IV
residents is less than 5 because some residents elect to enter child
psychiatry fellowships after the PGY-III year, thus leaving an unfilled
slot in the PGY-IV year.
Finally, about 50% of Longwood PGY-III residents spend 20 hours weekly
for 6 months providing direct and consultative psychiatric care to homeless
patients on our Psychiatry and Primary Care service, mounted in conjunction
with Boston’s Health Care for the Homeless program. Residents
will literally treat patients on the streets of Boston, in the Public
Library, on winter evenings on Boston Common, and so on. This rotation
is one of the major features attracting talented and dedicated medical
students to our residency program. Chief residencies on all three MMHC
services are offered.
It is difficult to separate
out research and educational activities from clinical aspects of the
residency program, since by their nature all residency programs involve
both training and service. Relatively unique among residencies is the
teaching day, in which all residents are in class for 6½ hours
each Wednesday. Dr. Goisman is course director for two core courses
within the residency, and many other MMHC faculty members direct courses,
teach, or supervise in the program. Dr. Goisman is also Chair of the
Curriculum Committee of the residency program and is thus ultimately
responsible for the quality of formal didactic teaching within the program.
There are a number of research
opportunities within the MMHC component of the Longwood residency program.
Dr. Goisman has had residents co-author papers with him in the area
of anxiety disorders, as has Dr. Salzman in the area of psychopharmacology.
The MMHC outpatient chiefship contains a research or writing requirement;
topics in recent years have included forensic assessment, novel antidepressants,
job satisfaction among public sector psychiatrists, and the heterogeneity
of presentations of schizophrenia. In addition, under Dr. Goisman’s
mentorship as “Clinical Challenges” column co-editor for
the Harvard Review of Psychiatry, residents have the opportunity to
write up their clinical cases with faculty members or other trainees
as case discussants; this represents a user-friendly way for residents
to begin their writing careers and is exceptionally gratifying for all
concerned. Additional research opportunities are available to Longwood
residents from other faculty members at all three sites.
A significant program development
in the last five years has been the rotation of Longwood residents through
the Boston Health Care for the Homeless program. This program was established
by Dr. Ken Duckworth, former MMHC Medical Director and present Medical
Director of the National Alliance for the Mentally Ill (NAMI) and represents
a significant recruitment point for talented and socially conscious
resident applicants across the country to the Longwood residency. Most
unique here is the fusion of clinical and educational missions; despite
initial resistance, the Boston community of homeless mentally ill persons
and their shelter workers now embrace this program, help train our residents,
and are themselves benefited by the residents’ interventions.
Allied to this development
has been an increased emphasis on cultural competence within the program.
A new course for PGY-III residents, “Social Systems in Psychiatry,”
takes a serious look at cross-cultural issues in psychiatry and has
become very popular in a short time. Directed by three Longwood faculty
members, including Dr. Seth Rafal from MMHC, this course aims both to
help psychiatrists practice in multiple cultural settings and also to
apply the scholarly disciplines of cultural anthropology and history
to psychiatric diagnosis and treatment.
On a more practical level,
the configuration of sites within the program has changed as the parent
health care systems have themselves been altered. When the program opened
in 1994, MMHC was joined by Beth Israel, New England Deaconess, and
Brigham and Women’s (BWH) Hospitals, and by the Harvard Community
Health Plan (HCHP). In the last five years, the first two hospitals
have merged into Beth Israel Deaconess Medical Center, HCHP has withdrawn
from the program, and Faulkner Hospital (now merged with BWH) has been
added. The role of MMHC as the primary locus for public sector training
within the program, however, has never changed.