End of Rotation Feedback – Summaries May 2010

Dr Shari KirshDr Susan Abbey

Dr Claire De SouzaDr Kenneth FungDr John Langley

Dr Cliff Posel Dr Pamela Stewart

Dr Wayne BaiciDr Jason Joannou

Dr Mark LachmannDr Chloe Leon

Dr Judy LinDr Ajmal Razmy

Dr Oshrit WanonoDr Justin Weissglas

Baycrest CenterNumber of residents 2Total number of residents:

Areas of strength Areas of Concern Suggestions for Change

1. Very strong educational experience (under-utilized)

2. Very professional3. Excellent Teaching Site4. A lot of seminars5. Work balance is excellent6. Assigned 2 supervisors: all

resident-oriented;7. Flexible, approachable

1. Previous complaints of dictation not commented on as typed own notes

2. Option to dictate but not used

3. Good work balance created:

4. Community with inpatient;

5. C/L with day hospital worked well

6. Addressed all previous concerns

1. Increase utilizations: more residents should go there

CAMHNumber of residents 7

Areas of strength Areas of Concern Suggestions for Change

1. Multiple areas of subspecialization

2. Responsive & supportive to resident issues with excellent chief residents, postgrad site coordinator & admin assistant.

1. Teaching is not consolidated and requires much travel and time with disturbance/fragmentation in clinical care and other activities

2. Call has been very busy in recent months related at least in part to “Transforming Lives” media campaign & and worsened by ED form.

3. On call rooms are noisy and unpleasant.4. Safety concerns about exiting CS from

Spadina at night (front door locked b/c of construction)

5. Grand Rounds technology is poor, detracts from the experience and compromises resident’s ability to deliver optimal presentations

6. Geriatric rotation - 3 month rotation is fraught with challenges in terms of meeting requirements and attending educational events. Limited scope in outpatient geriatric rotation (e.g. not Rx-ing Cog. En.).

7. Family Tx seminar problematic – poor quality, poorly organized, little value

8. Facilities at QS are lacklustre.

1. Review teaching schedule in terms of: a) potential consolidation of teaching on same day as grand roundsb) review of teaching activities in light of core curriculum and prune current schedule to offer only high yield activities c) consider consolidating teaching into one or two whole days per month

2. Review emergency on call with respect to:a) resident coverage for on-callb) options for triagec) ED Alliance Form to be reviewed – residents uniformly describe it as cumbersome and not clinically useful

3. Suggestion of moving a call room to the 12th floor.

4. Suggestion to put a #1 key lock on the front door so that residents could come and go through front door at night.

5. Review technology options for grand rounds to allow Power Point presentations to be delivered in acceptable manner

6. Geriatric outpatient rotation – supplement with extra-rotation experiences

7. Suggestion to stop family tx seminar

Mount Sinai HospitalNumber of residents: 11 Total number of residents ?

Areas of Strength Areas of Concern Suggestions for Change

1. Site-positive atmosphere, supportive, responsive to feedback (change happens), clean

2. Chief resident- great3. Site coordinator

approachable4. Interviewing seminar-

excellent, 5. Supervisors-overall good,

supportive and flexible 6. PGY2 workload improved on

the inpatient rotation. Limited number of medication clinic patients.

7. Great psychotherapy opportunities

1. Key concerns related to CAMH call. Please see Narrative report.

2. PGY2s- Outpatient rotation- patient load not adjusted when there are fewer incoming residents than out going residents.

3. GERIATRICS: Some improvement, staff more receptive/understanding but concerns continue. These include: -Expectation to follow outpatients and complete psychodynamic assessments on all patients; -Staff supervision lacking expertise in specific modalities (ie CBT)

4. CL – limited variety of patients (but this is offset with less workload and more time to spend with each patient)

1. PGY2s- Site should try to assign the same number of residents to each rotation; or adjust patient load according to changes.

2. GERIATRICS: Staff should review resident’s goals/needs and case assignment should be informed by learning needs.

North York General HospitalAreas of strength Areas of Concern Suggestions for Change

1. Busy and useful inpatient experience

2. Good medication experience

3. Good family therapy supervision

1. Branson outpatient not very well organized

2. Only new out-outpatient assessments are on Tuesdays, unclear what opportunities there are for residents on outpatients

3. No office for resident

1. On in-patient unit book protected time for staff-resident supervision

2.  For out-patients having a clear schedule and clearly communicating what opportunities are available for residents

St. Michael’s HospitalNumber of residents: 10 Total number of residents 14

Areas of strength Areas of Concern Suggestions for Change

1. Staff is very supportive and responsive to feedback. They seem to enjoy teaching and respect that residents have other obligations.

2. The work environment is very positive.

3. Every rotation is consistently strong - there is no sub-department that detracts from the whole.

4. The senior interviewing course is excellent, a tremendous opportunity to improve your skills for STACERS

1. Residents on in-patient felt that they focus more on service than on their learning needs.

2. PGY-2’s feel they don’t get teaching around interviewing and formulation.

3. On call, there is a lack of clarity about the role of the nurses in assessment, and in general, residents feel overworked overnight.

4. Residents on outpatients take on patients for short term therapy but end up carrying them for much longer due to no GP.

5. Junior female residents feel intimidated to turn down a male patient if they do not feel safe seeing him, although when they do approach supervisors about his, supervisors are generally supportive

1. Site co-ordinator to organize mock-orals, perhaps even assign a mock oral supervisor, to ensure these get done every two months.

2. Staff to attend and present at Thursday general psychiatry rounds

3. PGY-2 interviewing/ formulation seminar as protected educational time.

4. Integrate ‘how to discuss feeling unsafe with supervisors’ into the initial orientation.

5. O/P supervisors to take REP patient’s back after six sessions if need ongoing care.

6. Neutral resident present at resident eval committee to ensure fairness and transparency.

On CallAreas of Concern Suggestions for Change Midterm update

1.Good on call supervision; supervisors always available by phone

1. Very quiet on most nights; not felt to be a valuable learning experience

2. Morning handover rounds with crisis team: Concerns about one supervisor who can be judgmental about referral sources and some patients; non-collegial atmosphere; residents sometimes feel they are being attacked for their clinical decisions such as admitting a patient, even after discussion the previous night with on call staff

1. May be worthwhile to consider an on call model wherein residents are on call only until 11 pm

2. Resident concerns should be raised with the particular supervisor in a forum where feedback can be accepted and real change is possible

Sunnybrook Health Sciences CtrNumber of Residents: 11PGY1 – 4 ; PGY2 – 4; PGY3 – 1; PGY4 – 1; PGY5 -1

Areas of Strength Areas of Concern Suggestions for Change

1. Staff – friendly, good teaching, approachable, accessible; no internal politics affecting residents

2. On-call – collegial, available, supportive; good crisis nurses; Dr. Gerber – great teaching & helped out hands-on when busy

3. Great teaching seminars: interviewing skills (Senior – Dr. Schaffer; junior – Dr. Gerber), formulation (1st block), couples therapy, psychopharm (extra, open to all years) & IPT (1st block, Dr. Barakat)

4. Psychotherapy – great supervision - dynamic (Dr. Gerber), IPT, and CBT (Drs. Fefergrad, Shin and Chandler); CBT centralized pre-assessed patient list

5. Geriatrics – Dr. Rapoport - flexible, observed interviews, good teaching with EBM

6. Safety - “Spider” system safety buttons (on ER, F1 and F2); newly rearranged family room

1. ER – systems issues - pressure from ER to move people quickly; only 1+ “½” dedicated psych beds; often assessing patients in the family room

2. Inpatient nursing - improved but problems & errors still occurring (e.g. medication administration, CIWA, charting). People are responsive (incl inpatient director). Improvement in progress.

3. Difficulty getting medical consults on inpatient psychiatry (esp orthopedics)

4. Behavioural Neurology rotation – Good rotation, but late days (8 – 9 PM); lot of time wasted while waiting around to review cases

1. Increase PGY1 call stipend. ($50 – discrepant from other sites.)

2. Improve clinical training of nurses.

3. Code white training earlier in the year.

4. Have a replacement program for Stage Program; improve flow and referral to outpatient programs on discharge

5. Consider in-pt groups

Sunnybrook Health Sciences Ctr – pg 2Areas of Strength Areas of Concern

7. WCH Shuttle convenient for residents living downtown8. ECT exposure – booked in, 3 sessions, good teaching9. Nancy Gribbon, post-grad admin - phenomenal,

organizes mock orals10. Site coordinator– approachable, meets with residents11. Social events – staff come, pub night, movie night at Dr.

Levitt’s

5. Transitioning inpatient to outpatient will get even worse, because Stage Program (day-hospital) is closing down.

6. Commute (not downtown); parking limited (due to construction) and expensive (but cheaper than downtown).

7. Temperature control in the offices (either too hot or cold) and thin walls (concerns of pt confidentiality).

8. Outpatient – sees less psychotic disorders; mostly mood & anxiety

9. Addictions resources lacking

UHNNumber of residents 12

Areas of strength Areas of Concern Suggestions for Change

1. Excellent site coordinator: very responsive to resident concerns

2. Very organized academic program with easy access to psychotherapy supervisors and mock orals; Maluah Dewhurst (admin ass’t) is seen as key to this excellence in organization

3. Inpatient ward is excellent: general experience, good diversity of pts, goo support

4. C/L: excellent supervisors at both sites, and great learning environment

5. Call: excellent overall. Very supportive morning rounds (especially Dr. Brar), nurses are helpful, PESU is a safe and functional environment, good # of cases

6. Resident book amount was increased to $250/6 months

1. Feedback to residents needs to be more timely

2. Chief residents to be involved as often as possible in critical resident issues

3. Travel between TWH/TGH is time consuming

4. Geriatric inpatient rotation could be improved in terms of diversity of patients seen, & flexibility of supervisor’s schedule

1. Geriatric inpatient rotation: supervisor’s schedule should be more flexible; more opportunity for seeing patients on other services (C/L, memory clinic at TWH) since diversity not always present on the inpatient ward (note: this may be unique to this cohort of residents doing only 3 months of geriatrics)

St. Joseph’s HospitalAreas of strength Areas of Concern Suggestions for Change

1. Excellent orientation with 1GNorth staff at retreat

2. Well organized in-patient unit

3. Great diversity of cases4. Good psycho-pharmacology

experience5. Great office (large, however

far from outpatient psychiatry department)

6. Set up mock orals easily7. Supervision – easily

accessible (ie available), approachable, and supports other academic activities

1. So much going on that difficult to get an out-patient experience

2. Limited number of psychotherapy (psychodynamic and CBT) supervisors

3. Difficult to set door lock code (system issue)

1. Block time off (maybe half a day of week) for protected out-patient assessment and follow-up times

2. Increase number of different psychotherapy supervisors and organize prior to beginning rotation

Toronto East General HospitalNumber of residents: 2 of 2 present

Areas of strength Areas of Concern Suggestions for Change

1. Good site co-ordinator2. Residents enjoy autonomy3. Mock orals organized4. Responsive staff5. Broad exposure to general

psychopathology

1. Not able to do call on site2. Formal

teaching/seminars/grand rounds still improving (WCH and local seminars helpful, grand rounds often not very academic, Wednesday lunches cannot be attended)

3. Informal, everyday teaching, around clinical cases could be stronger with more emphasis on formulating and psychopharm

4. Quality of CBT education may require some standardization. This is being looked into by the CBT people at U of T.

5. Inpatient house staff (allied and RNs) still becoming familiar with role of resident MD on team

1. On site call2. Continue to improve

opportunities for more formal/informal teaching

3. Provide inpatient team with information re: expectations/objectives of resident education/training

4. Provide out-patient orientation package to residents containing contact information

Women’s College HospitalNumber of residents: 1

Areas of strength Areas of Concern Suggestions for Change

1. In general good experience2. Responsive to concerns: quick3. Excellent Life-Stage Program4. Little exposure to psychotic

illness5. Excellent mindfulness and

trauma program6. Excellent Supervision

1.Would like to observe interviews of staff2.No Email Reminders of coming events (done at other sites)3.Only one resident doing outpatient therefore isolated

1.Possible linking with other hospitals to create more seminars2.More residents assigned to site to reduce isolation3.More Email reminders 4.Observed interviews of staff

CAMH - ChildAreas of strength Areas of Concern Suggestions for Change

1. Good psychopharmacology experience

2. Lots of opportunities for observed interviews

3. Good variety of patients4. Strong psychotherapy supervision

1. Scheduling ADHD clinic with Dr. Jain remains difficult. Younger children are assessed only on certain days.

2. Primary and secondary supervisor roles sometimes not clear. For, example one secondary supervisor insisted that the resident do too many PDD assessments.

3. Some residents feel overwhelmed when starting family therapy. Didactic teaching and assigned readings still disconnected from clinical experience.

1. Residents should be assigned specific days for ADHD clinic at start of rotation, ensuring that they assess younger children and that the supervisor is aware that they are attending the clinic

2. More careful matching of primary and secondary supervisors to better round out the resident experience. Scheduled check-in with site coordinator after one month to address any supervisory issues

3. Better coordination between teaching, readings, and clinical experience. Assign two residents as co-therapists for each family

Hincks-DellcrestAreas of strength Areas of Concern Suggestions for Change

1. Psychotherapy supervision: opportunities for reviewing tapes of play therapy sessions

2. Opportunities for feedback during multidisciplinary team assessment

3. Collegial work environment4. Opportunity for ½ day/week

at primary school/day care5. In Person Intake

Assessments (“IPI’s”) for residents

6. Exposure to multidisciplinary clinicians and students

1. disproportionate amount of time observing other clinicians and students versus active interviewing

2. little experience initiating and following up trials of pharmacotherapy

3. families on wait lists for psychopharmacology and therapy too often outdated and/or inappropriate

4. residents spend a lot of time completing paperwork and trying to contact waitlist patients

1. Increase opportunities for residents to do IPI assessments

2. Ongoing review of therapy and psychopharmacology wait lists to ensure potential cases are appropriate for residents

3. Shift administrative duties to appropriate staff

YouthdaleAreas of strength Areas of Concern Suggestions for Change

1. Well organized structured schedule2. Excellent supervision, including CBT

and psychotherapy(individual and family)

3. Good experiences with medications4. Great learning environment

1. Minimal exposure to initial assessment of common mood and anxiety problems

1. Think of ways to improve resident exposure to mood and anxiety concerns – possibly increasing use of telepsychiatry either at Youthdale or at HSC

The Hospital for Sick ChildrenAreas of strength Areas of Concern Suggestions for Change

1. good balance between supervision and clinical autonomy

2. variety of both outpatient and inpatient rotations

3. opportunity for residents to complete plenty of new assessments

4. good family therapy and CBT supervision

5. regular supervision with psychology staff on neuropsychiatry outpatient rotation

1. some trouble integrating ongoing outpatient responsibilities with schedule of inpatient rotations

2. residents “feel like visitors” on short, one month inpatient rotations

1. more communication between inpatient and outpatient supervisors in advance of transition between rotations

2. longer inpatient rotations (ex. 2 months plus 1 of crisis), perhaps at the expense of experience on all inpatient teams

NYGH-ChildNumber of residents 4 Total number of residents

Areas of strength Areas of Concern Suggestions for Change

1. Overall good experience2. ON CALL: Residents

enjoyed Variety, business of call, exposure to different populations

3. Call only until 11:00pm.4. Child Supervision excellent

(inpatient)5. Variety of exposure in child 6. Child experience good for

self-directed resident 7. General Outpatient8. Site has been responsive to

concerns9. Psychotherapy supervision

excellent10. CBT groups with

opportunities for observing and conducting

1. Not much teaching or individual supervision on child rotation

2. Diminished opportunity for observed interview on outpatient

3. No children seen under age 10 in child rotation

4. No office for resident at Branson Site, and less opportunities on Outpatient experiences (resident has to recruit opportunities)

5. Need more communication on requirements and rotation expectations between Postgraduate and community sites (ST. Joseph’s, TEGH and NYH)

6. No switch of outpatient supervisors for six months

7. Too heavy outpatient service: ie. 6 outpatient consultations per week plus 2 elective consultations at the expense of education

8. Pressured to see more patients quickly than level of training

9. Seminars at site are minimal

1. Primary Supervisor, with exposure to other assessments from another supervisor to create variety within six months

2. Introduce more teaching and protected time for supervision

3. Need maximum on number of consultations per week with clear guidelines from Postgraduate (suggest 3/week)

4. All potential supervisors have goals and objectives of rotation RE: level of training

5. Better standardized supervision

George HullAreas of strength Areas of Concern Suggestions for Change

1. very supportive multidisciplinary team

2. * great supervision & flexible staff psychiatrists

3. * encourage attendance at supplementary conferences, workshops, etc.

4. * good exposure to community clinic practice

5. * opportunity to participate in parent/ child groups of varying modalities

6. * opportunity to be involved in teaching medical students

7. * opportunity to be exposed to a wide variety of age-groups

1. away from downtown core & not as accessible by TTC (access to a car would be preferable)

2. predominance of initial assessments, with less opportunity for follow-up in contrast to other sites (ie. med management)... although opportunities still available

3. no dictation system - all reports hand typed

1. Nil - I believe that my negatives were unique to my particular experience and timing of the rotation.  The site is very receptive to feedback (so much that we (myself & staff) had weekly feedback sessions, which were great!).

2. consider using a dictation system