End of Rotation End of Rotation Feedback – SummariesFeedback – Summaries

November 2009November 2009 Dr. Shari KirshDr. Shari Kirsh

Dr. Susan AbbeyDr. Susan AbbeyDr. Claire De SouzaDr. Claire De Souza

Dr. John LangleyDr. John LangleyDr. Cliff PoselDr. Cliff Posel

Dr. Pamela StewartDr. Pamela StewartDr Wayne BaiciDr Wayne BaiciDr Justin DelwoDr Justin DelwoDr Adam EnchinDr Adam EnchinDr Jason JoannouDr Jason Joannou

Dr Jennifer NguyenDr Jennifer NguyenDr Brittany PoynterDr Brittany PoynterDr Jennifer RusselDr Jennifer RusselDr Steven SelchenDr Steven Selchen

Baycrest CenterBaycrest CenterAreas of strength Areas of

ConcernSuggestions for

ChangeMidterm update

1. Strong site coordinator committed to education and meeting residents’ needs

2. Variety of clinical experiences including opportunities in multiple psychotherapy modalities

3. Excellent multiprofessional teams and good support from administrative staff

4. Excellent seminars especially interview and formulation seminars

NO MAJOR CONCERNS

1. Low turnover on inpatients

2. Dictation turnaround improved but still slow

3. Could better optimize balance of new assessments vs. workload

1. More residents at site to take advantage of underutilized learning opportunities and ensure critical mass for seminar attendance

2. Optimize rotations to even better balance workload vs. opportunities for new assessments

1. Residents on inpatient psychiatry are doing 2 -3 new assessments per week and following patients on the community outreach team concurrently.

2. Residents continue to have transcriptions done by admin staff and the turn around time has improved

3. We continue to run our local seminars regardless of the number of attendees

CAMHCAMHAreas of strength Areas of Concern Suggestions for

ChangeMidterm update

1. Educational program; many positive innovations;- 3 month chronic care split mood and psychosis rotation. (CAMH) - Thunder Bay Chronic Care rotation. - Flexibility to attend speciality clinics at CAMH. 

2. Mock orals-easy to complete.

3. Seminars -well regarded; Dr. Voore’s PGY 5 seminar “excellent”.

4. RN staff in GPU and ER- highly professional and competent.

5. The administration of the residency program at CAMH is excellent “ kudos to Peter Voore and Ksenija Hotic”

1. Commuting for educational activities between the sites; Taxi chits appreciated, but much time lost in transit, or events not attended as too time intensive.

2. Identifying cases for CBT, on occasion for psychodynamic psychotherapy.

3. Psychotherapy coordinator involvement; residents appreciated greater involvement but still limited accessibility.

1. Consolidate education and Grand Rounds on same day

2. Psychotherapy coordinator involvement- at orientation day; more than one day for initial and final meetings with psychotherapy coordinator.

3. Safety issues(offsite)- float office at Clarke site for psychotherapy patients; cameras on geri/2-2; greater efforts at vermin control. The importance of documenting concerns highlighted

1. Discussion continues regarding the consolidation of Grand rounds, Chronic Care teaching and CAMH teaching on one day to decrease commuting time and increase resident attendance .

2. Dr. Flett- Resident coordinator working with Dr. Malat to identify CBT and IPT cases for residents through the CBT and IPT clinic.

3. Psychotherapy coordinator increased involvement at orientation day, increased time for initial and final meetings with psychotherapy coordinator.

CAMH – page 2CAMH – page 2Areas of Concern Midterm update

4. Safety and health issues; at Richmond St. site b/c the building shut down at 4:30 pm resident alone to see psychotherapy patient(s);

5. Safety concerns on the Geri and 2-2 floors due to aging building

6. Occasional complaints that security at the Clarke site not responded to safety concerns; problems with rodents still QS site.

4. For Richmond St. site a float office at Clarke site is available for residents to see psychotherapy patients during the day or after hours. Furthermore residents will only be placed at Richmond St. if agreeable to that rotation- voluntary placement.

5. Geriatrics wards and Unit 2-2 visited by Drs. Zaretsky and Flett with Cheryl Peever Safety Coordinator at CAMH in March 2010. Safety audit completed and planned changes to physical space to improve safety underway. Changes include security cameras, mirrors, improved lighting, code white buzzers in all offices and interview rooms.

6. The importance of documenting concerns regarding Security responses highlighted and specific events to be reported to Dr. Flett and/or Emergency management- Dr. Kurdyak.

7. Postgrad coordinator liaised with facilities staff and vermin control increased in many units at Queen St. including Unit 4 and Unit 2-2. Residents provided contact CS-x4045, QS- 2846, to report any vermin issues for further assistance.

Mount Sinai HospitalMount Sinai HospitalAreas of Strength Areas of Concern Suggestions for Change Midterm update

1. Site- Collegial and very welcoming

2. PG Site Coordinator – Supportive and understanding

3. PGY 2 – strong psychotherapy supervision and teaching ( Drs Kay and Rawkins)

4. PGY 5 seminar – practical teaching

5. CL Staff -very accessible

6. Senior resident interviewing/formulation seminar excellent

1. Outpts PGY2;Heavier workload, new medication clinic, unbalanced distribution and no limit of new patients(esp. for medication clinic)

2. Inpts PGY2; Workload, remains heavy, long days

3. Geriatrics; Expectation to follow patients for psychotherapy; heavy workload, staff supervision lacks expertise in the specific modality (ie. IPT, CBT)

4. Shared Care on CL;Communication with family medicine residents; underutilized, limited educational value or overwhelming, medical legal concerns.

1. Outpts PGY2;Cap on # number medication clinic pts; Improve communication with admin. staff to balance workload and new referrals; Consider screening medication clinic patients for resident psychopharmacology learning needs.

2. Inpts PGY2; Decreasing lengthy psychotherapy sessions

3. Geriatrics;Orientation- residents should be informed of expectation to take on patients from assessment clinic for psychotherapy. New psychotherapy patients-optional dependent on resident workload, learning needs, access to supervisor with expertise in psychotherapy modality.

4. Shared Care on CL;more structure and discussion of medicolegal issues

1. The inpatient unit has been a focus of attention in terms of educational improvement with better planning of the day, supervision time, clearer expectations re patient care, operations analysis etc.

2. Ambulatory PGY 2 rotation patient volume adjusted

3. Geriatrics ambulatory rotation has added more detail re supervision and expectations

North York General North York General HospitalHospital

Areas of strength Areas of Concern Suggestions for Change Midterm update

1. Educational coordinator- very helpful

2. Staff responsive, flexible, supportive

3. On call- good educational opportunity; high volume/workload balanced by call ending at 11pm

1. Teaching is less than at other sites

1. Formal interview/ formulation seminar-weekly

2. On call- clarify the role of the resident

3. Educate on call staff about role of resident

1. Interview/formulation skills should be taught primarily with the primary supervisor.  Residents should take every opportunity to have supervised interviews and feedback with other non primary supervisors, for variety of experience.  I may consider adding a few sessions on interview/formulation to next year's seminar series.

2 and 3.  With staff and residents getting used to the new experience of call at NYGH, I believe these issues are getting worked out with time.  Recent feedback at a resident lunch was that the wrinkles have been smoothed out.

St. Michael’s HospitalSt. Michael’s HospitalAreas of

strengthAreas of Concern Suggestions for Change Midterm update

1. collegial atmosphere

2. Outpatient psychiatrists “fantastic”

3. Excellent interviewing course

4. Good diversity and variety of patients

5. Good psychotherapy supervisors

6. 20 hr rule and least restraint policy- good communication to residents

Inpatient Rotation1. Lack of social work /

discharge planning 2. Stressful work-sick

patients and high turnover 3. insufficient informal

teaching on inpatients

Inpatient Rotation1. Hire another social

worker assist with d/c planning

2. Support for inpt stresses;

3. More time for debriefing with residents re; serious incidents

4. M&M rounds 5. More formal time set

aside for reflection

6. Once/ month teaching with residents & staff

7. More informal teaching

Inpatient Rotation1. Journal club/reflection

group for PGY2 residents

2. Inpatient staff aware of work load issue and addressing with residents in supervision, and keeping in mind case loads/workload when assigning work

3. Unable to hire more staff given hospital cutbacks

4. We considered taking on another PGY2 inpatient resident in the coming year to help distribute workload, but we were not able to do this because of insufficient supervisors.

St. Michael’s Hospital – St. Michael’s Hospital – page 2page 2

Areas of Concern Suggestions for Change Midterm update

Outpatient Rotation1. Insufficient discharge planning

between inpatients and TAC and inpatients and outpt residents

Psychotherapy1. Psychotherapy patient list is

outdated 2. No secretarial support for

residents with offsite supervisors.3. Psychotherapy co-ordinator - not

enough assistance in helping senior residents secure CBT and/or IPT supervisors.

Outpatient Rotation1. The TAC schedule should be

available to in-patient team.2. The in-patient team e more

notice when referring to TAC 3. Increase discharge planning

support from inpts.4. Orientation include

administrative details (forms, schedule etc)

Psychotherapy1. Update list of psychotherapy

patients.2. Secretarial support for offsite

supervisors.3. More CBT and IPT supervisors

Outpatient RotationIssue regarding referrals from TAC

discussed with outpatient coordinator. Referrals to TAC seem to be running more smoothly. Inpatient staff have been asked to provide more advance notice of referrals and this seems to be happening.

A more detailed orientation to TAC has occurred in the outpatient rotation orientation

In the orientation in July for new residents, we will have more detailed orientation re administrative details.

PsychotherapyThe central list of psychotherapy

patients is used to find patients. Our psychotherapy coordinator continues to assist in finding suitable patients. He will also ask psychotherapy supervisors to assist in this task

St. Michael’s Hospital – St. Michael’s Hospital – page 3page 3

Areas of Concern Suggestions for Change Midterm update

Psychotherapy1. Psychotherapy patient list is

outdated 2. No secretarial support for

residents with offsite supervisors.3. Psychotherapy co-ordinator - not

enough assistance in helping senior residents secure CBT and/or IPT supervisors.

C-L / Geriatrics1. Staff comment about residents

being away & the need to stay on top of the workload.

Geriatrics1. No enough clinical teaching

around cases

Psychotherapy1. Update list of psychotherapy

patients.2. Secretarial support for offsite

supervisors.3. More CBT and IPT

supervisors

C-L / Geriatrics1. Supervisor should consider

entire clinical /educational responsibilities & adjust expectations

Geriatrics1. Increase case-based Informal

teaching

Re secretarial support, the main issue is that residents need assistance in ensuring their patients are registered in the St. Michael’s patient database. We have arranged for the administrative assistants of the resident’s primary supervisor to do this.

We have sufficient CBT supervision for upcoming academic year.

IPT supervision continues to be an issue.

CL and geriatric staff are working to ensure that residents are able to maximize time spent with their primary supervisors.

Geriatrics staff is working with residents to maximize time spent together in order to allow for more case-based teaching

St. Michael’s Hospital – St. Michael’s Hospital – page 4page 4

Areas of Concern Suggestions for Change Midterm update

ER1. Lack of a crisis clinic – difficult to

send some patients home with no follow up.

2. Variable experiences with the crisis nurses

3. Variable staff expectations on morning handover

ER1.A crisis clinic might decrease admissions to the CSU and referrals to the assessment clinic2.More consistent protocols for staff who fill out forms3.Orientation-expectations for morning handover

ERCrisis clinic is being developed

The site coordinator met with the psychiatric emergency service director to discuss the issue of filling out the forms. Rather than establishing a strict protocol about who should fill out which parts of the form, we decided that it is best to allow for variability depending on the needs during a particular on call shift. The hope is that the PES team works collaboratively on all cases. Keeping this in mind, the PES director discussed the issue with PES staff in order to ensure that they are aware that there is the expectation that decision making around this issue be collaborative. Residents have not raised this as a concern recently.

Sunnybrook Health Sunnybrook Health Sciences CtrSciences Ctr

Areas of Strength Areas of Concern Suggestions for Change

Midterm update

1. CBT – good supervisors, list of patients works well

2. Seminars : Excellent Psychopharm, Formulation, IPT, interview course (Rapoport) interview seminar (Gerber)

3. Mockrals- well organized4. PGY-2 outpatients supervisors

excellent( day groups, OCD group Dr Richter)

5. Geriatrics rotation- experienced teachers with niches

6. CL rotation- great, continuity among supervisors

7. Adolescent psychiatry-great team 8. On Call-great, crisis nurses,

bridging to facilitate discharge9. Good rapport with staff - 2 social

events10. Safety-office furniture rearranged,

both patient and resident can sit next to entrance

1. Inpatient nursing suboptimal care (orders can be missed). Process to speak with psychiatrists, new inpatient director is responsive

2. Transitioning inpatients to outpatients difficult due to lack of outpatient services (pts d/c to family doctor)

3. ER- no ability to hold patients causing suboptimal dispositions( ie admitting to hospital) medical patients placed in the 2 dedicated psych rooms

4. Behavioural Neurology rotation late days (up to 8-9pm)

1. Orientation Day- information about different therapeutic modalities (eg OCD group); orientation to different services by diagnosis (eg anxiety, mood etc.)

2. M&M rounds3. PMAB course at

CAMH offer earlier

1. Orientation to include more info about staff and services offered by dept

2. M&M rounds continue to be part of GR schedule

UHNUHNAreas of strength Areas of Concern Suggestions for

ChangeMidterm update

1. On call-very positive; staff, clinicians, safety, call room, PESU unit

2. Strong biological focus3. Post Grad director-

approachable, comes to events

4. IMPACT – friendly, collegial

5. PG assistant (Maulah) - very helpful, good at coordinating

6. PGY 2 selectives7. Dr. Abbey- both as PGY

1 coordinator and on CL8. Dr. Waddell great ECT

course and Inpt groups9. Dr. Hawa- amazing

teacher, very committed10. Dr. Novick -excellent

psychodynamic supervision

11. Geriatrics( TG) - balanced between service and teaching

1. Psychotherapy some deficits in accessing supervision – although they have recruited CBT staff

2. On call disposition- residents sometimes feel caught in the middle when am staff don’t agree with the staff on call, also occurs with ER staff and inpatient staff

3. CL disposition-residents caught up on” turf wars fuelled by nursing staff”

4. CL issues about transferring patients between hospitals

5. Blend – very variable investment in teaching

6. CL service – concerns supervisor (see Narrative Report)

7. Geriatrics rotation (TW) –not enough inpt supervision, transportation takes excessive time, TAXI chits scarce/unreliable carrier.

1. Centralized list for psychodynamic and CBT patients and screen for PGY2

 2. Plan for CL-

transferring pts between hospitals

3. TTC pass for Geriatric resident

4.  Geriatrics (TW- inpts) weekly scheduled supervision

1. Created central psychotherapy patient referral process; Increased CBT supervisors

2. On-call disposition issues – monitoring

3. C-L transfers now staff-to-staff focused

4. C-L transfer policy forms modified

5. Improved TWH geriatric supervision

6. Taxi chits available for geriatric residents

7. CL service -Supervisor issue addressed

8. Response to previous site survey concern (June 2009) - Increased resident book/conference stipend

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

1. Inpatient/outpatient blend- very positive

2. Inpatient component- very positive experience, staff very available and supportive

3. Collegial work environment

1. Minimal formal teaching/seminars/grand rounds

2. Outpatient referrals -considerable difficulty accessing (supervisor dependent)

3. Psychotherapy supervision – good quality but unpredictable schedule

1. Keep the blend!

2. Increase teaching/educational opportunities

3. Increase planning of outpatient experience

4. Facilitate regularity of psychotherapy supervision

5. On call should end no later than midnight

Toronto East General Toronto East General HospitalHospital

Areas of strength Areas of Concern Suggestions for Change

Midterm update

1. Outpt- residents enjoy extensive autonomy

2. Outpt -two observed full interviews per week

3. Inpt- good supervision/feedback, supervisors available/supportive

4. Inpt- collegial environment

5. Mock orals organized in advance for entire year

6. Responsive staff –re; previous resident feedback and ongoing suggestions

7. Good psychodynamic supervision

1. Not able to do call on site

2. Minimal formal teaching/seminars/grand rounds (lots of cancellations)

3. Outpt supervisors- frequently offsite , no clear discussion on how to get supervision in an urgent situation

4. CBT supervision- does not always reflect core curriculum teaching

1. to do call on site

2. Increase opportunity for formal teaching/seminar/grand rounds

3. Outpt supervisor contact improvements; clarity regarding contacting supervisors in urgent situations at the beginning of the rotation

4. Review CBT supervision to be able to offer more standardized experience( with core curriculum)

1. Emergency room renovations have been expedited to accommodate psychiatry resident’s needs and wish to do call on-site. Renovations due to be complete din July 2010.

2. A TEGH staff lecture series has been organized for residents focused on topics relevant to General Psychiatry.

3. Videoconferencing has been organized at TEGH for residents to participate in the weekly Woman’s College Seminar Series.

4. We have incorporated supervisor information details including contact information to the initial orientation package.

5. Mary Thompson, CBT supervisor will be liaising with U of T CBT psychotherapy staff to better standardize teaching in accordance with core curriculum. Dr Gili Adler- Nevo, Psychiatrist and CBT therapist has expressed interest in offering further supervision and teaching to TEGH psychiatry residents

CAMH - ChildCAMH - ChildAreas of strength Areas of Concern Suggestions for Change Midterm update

1. Site coordinator- very organized; aware of rotation’s objectives

2. New patient assessments- volume good; opportunities for observed interviews

3. Specialty clinics- wide variety; excellent diversity /access of cases; available for residents to round out child/adolescent experience

4. CBT - “best experience so far in residency” well-organized wait-list (patients available for residents from start of rotation)

5. Exposure to variety of psychotherapeutic modalities (CBT, psychodynamic, parenting, motivational interviewing)

6. Good case-based seminar by Dr. Beitchman

7. Supervisors- excellent support, flexibility, and autonomy for residents

1. Family therapy seminar-few available families; theory taught disconnected to clinical experience; residents unclear about communicating to families what therapy would be like within the seminar

2. Assessing PDD cases in speciality clinic- residents still unsure about their skills; assessments felt “unstructured”; many tools used (ie. questionnaires) did not feel rooted in evidence-based medicine

3. Difficulty scheduling ADHD experience with Dr. Jain

1. Family Therapy seminar-more families on wait list; change time slot to later in afternoon; more relevant and systematic articles

2. PDD Clinic - more staff supervision/guidance to help enrich residents’ experience

3. List of CAMH child and adolescent clinics; times for new assessments available; instructions for how to become involved ( at beginning of rotation)

4. Site coordinator should schedule resident for Dr. Jain’s clinic prior to rotation

1. Seminar time changed to better accommodate families. The seminar articles and organization was reviewed.

2. PDD clinic staff are aware of the residents concerns.

3. A list of service activities was circulated prior to the rotation.

4. All residents were assigned to Dr. Jain’s clinic prior to the rotation to minimize scheduling difficulties.

Hincks-DellcrestHincks-Dellcrest

Areas of strength Areas of Concern Suggestions for Change Midterm update

1. Multidisciplinary teams 

2. Excellent site coordinator

3. CBT supervision (Dr. T Zarb)

4. Neuropsychiatry clinic

5. “IPI” clinic assessments with Dr. D. Philipp

1. Summer very slow

2. Supervisors on vacation at the same time; no backup

3. Teams are large; numerous students; residents spend too much time watching others interview

1. Coordinate supervisor vacations

2. Intake assessments - with supervision by primary psychiatry supervisor

3. Psychopharmacology clinic

4. Clearer orientation-administrative duties, procedure for booking patients, clinical expectations

5. Wait list- CBT, family, and psychopharmacology cases

6. Cases- more screening for resident suitability

7. Supervision given by other disciplines( ie psychology for psychotherapy cases)

1. In summer residents: i) will join second IPI team ; ii) Summer Family Therapy Institute – includes didactic & brief intervention component iii) one week rotation at residential camp available iv) one week rotation at Sheppard site forensic program available v) encouraged to complete Telepsychiatry and Psychopharmacology requirements during summer.

2. Every effort is made to coordinate staff vacations; Coordination in place now with other disciplines as well.

3. Feedback mixed; “Multidisciplinary Teams” also cited as Area of strength. However, reduced time spent on some of the largest teams.

Hincks-Dellcrest – page 2Hincks-Dellcrest – page 2Areas of Concern Midterm update

1. Minimal psychopharmacology experience

2. Can be disorganized

3. Too much administrative work for cases

1. i) Psychopharmacology Consultation Service: residents assigned new and follow up medication assessments off streamlined wait list; Site coordinator oversees streamlined wait list and assigns cases ii) Neuropsychiatry Service: Each resident assigned to service for three months – includes medication assessment, initiation and follow-up. iii) Rapid Diagnostic/IPI Team: provides opportunity for residents to pick up new psychopharmacology referrals directly from intake.

2. Referral processes as well as wait lists have been streamlined by site coordinator; “Road map” for administration developed by medical records

3. “Road map” to administrative procedures developed to clarify and simplify resident responsibilities; The centre in the process of simplifying procedures as well.

YouthdaleYouthdaleAreas of strength Areas of Concern Suggestions for

ChangeMidterm update

1. Inpatient and outpatient rotations - variety of experiences

2. Family therapy seminar- “phenomenal”

3. Psychotherapy supervision- excellent

4. Group supervision- excellent; evidence-based

5. Psychopharmacology- good opportunity to learn in clinic setting

6. Support staff (administrative help for dictations, etc.)- excellent

1. Patient population - narrow, focus on children > 12 yrs( most with disruptive behaviour problems)

2. PDD - no exposure (although attempts were made by staff ), one reason is patient no-shows

3. CBT/family therapy – no established system to find pts (residents were responsible)

1. Wait list for CBT/ family therapy cases -residents have access to at start of rotations

1. Residents have not seen children under age 10 they get this via Telehealth and /or at TS Clinic at TWH.

2. 2 /3 residents have seen a child with PDD. All will get this experience during the rotation.

3. 3/3 residents began their CBT case

4. 3/3 residents have been involved in family therapy =/- group therapy

5. This group of residents is not interested in changing supervisors at mid-term.

The Hospital for Sick The Hospital for Sick ChildrenChildren

Areas of strength Areas of Concern Suggestions for Change

1.  Rotation – “Perfect for the core”

2.  “Bread and butter” child psychiatry

3.  CBT cases- easy assess

4.  PDD and ADHD good exposure

5.  Mock orals scheduled

6.  Interview sessions- good feedback

7.  Good seminars

1. Inpatients- slow in summer

2. One month rotations – residents unsure about roles/expectations

1. Limit scheduling inpatient rotation during summer

2. Orientations for each rotation (incl clinical expectations)

George HullGeorge HullAreas of strength Areas of Concern Suggestions for

ChangeMidterm update

1. Staff very flexible-accommodate residents educational/clinical duties( i.e. on call, offsite seminars)

2. Psychotherapy- supervision very good; easy to find cases

3. Learning/service balance

4. Diversity of diagnoses/ age groups

1. No inpatient exposure

2. No exposure to eating disorders (may be seen on call)

3. Family therapy course (September to March) too basic for residents’ needs in July to December rotation

1. Blended rotation to incl. inpatient experience

2. Ensure residents aware that GH is outpatient setting with limited inpatients (unless opportunities sought out at other sites )

1. Consideration of a blend to allow in-patient exposure

2. Ensuring residents are aware of George Hull as an outpatient setting with limited inpatient exposure

NYGH-ChildNYGH-ChildAreas of strength Areas of Concern Suggestions for Change

1. diversity of exposure to diagnoses and age groups, with more adolescents seen while on inpatients and more children on the outpatient service

2. teaching by staff is excellent3. the multidisciplinary teams are

integrative and highly functional

4. CBT supervision is very good and cases are easy to find

5. overall excellent site

1. could be more exposure to patients with PDD

2. sometimes difficult to schedule mock orals

1.having supervisors for the mock orals provide that supervision while residents are at that specific site (for example, if a supervisor is at the outpatient site, they should supervise the resident’s mock oral while the resident is also at the outpatient site, not while the resident is at the inpatient site)2.consider assigning residents to work with multiple supervisors to allow residents to see a variety of patients (? divided rotation or just the flexibility to choose half-days with different supervisors for exposure)