Clinical Rotations

Required, 3-month rotation, 0.6 fte.

Educational Goals and Objectives

By the end of the rotation, fellows will be able to medically detoxify patients from multiple drugs of abuse (e.g., opioids, cocaine, alcohol, benzodiazepines) and engage patients in the process of recovery and motivation for change.

Educational Methods

Pt screening:  Patients arrive to the detox unit in several ways.  Most patients arrive from CATC triage.  Fellows will become familiar with screening potential Detox patients for appropriateness for Detox admission, with a focus on substance withdrawal symptoms and medical comorbidities.  Patients are also transferred from other hospital units or CPEP and the fellow will become familiar with communicating with other MDs and other hospital staff regarding patient screening for Detoxification.

History and Physicals:  Fellows will become familiar with doing a history and physical on admitted patients.  The focus will be on getting a good substance abuse history, including past withdrawal symptoms, amount and type of substances used, periods of abstinence, prior treatment, etc.  Fellows will also become familiar with the physical sequelae of substance abuse by doing physicals on the unit. 

Patient Management and Detox protocols:  once patients are admitted to the unit, they are started on a specific detox protocol (Ativan, Librium, clonidine and methadone).  Fellows will become familiar with different types of detox modalities and managing the withdrawal syndrome.  Fellows will also become familiar with managing psychiatric and medical comorbidities as well as biological treatments for alcohol dependence.  Fellows will work within a team of attending physician, the physician assistant, nurses and support staff and make clinical decisions regarding patient care.  Fellows will round on a subset of patients with the attending and will follow up on recommended treatments and lab tests.  Fellows will have a longitudinal component when they do psychiatric evaluations and follow up care of detox patients referred to the Chemical Dependency clinic.

For patients admitted to the ambulatory detox fellows will become familiar with buprenorphine induction and taper.

Group Therapy:  Fellows are required to observe or co-lead at least two groups per week.  Fellows are supervised by an experienced group therapist.

Grand Rounds: Fellows are expected to attend weekly Departmental Grand Rounds

Journal Club:  Fellows will be responsible for presenting a scholarly article to staff once during the rotation.

Fellow Lecture:  Fellows will be expected to give a lecture on a topic of interest to staff once during the rotation. This will take place during the Departmental Grand rounds

Administrative:  participate in bi-weekly team meetings

Inservice Education:  Fellows are required to participate in the inservice education sessions which occur monthly.

Required, 3-month rotation, 0.6 fte.

Educational Goals and Objectives

1. Develop skill with the induction and stabilization of Opioid Maintenance Therapy (OMT), specifically methadone and buprenorphine
   1. Understand rationale for and gain experience with dosing for induction
   2. Understand rationale for and gain experience with dose adjustments for stabilization, maintenance, and detoxification
   3. Be aware of common side effects and drug interactions
2. Be able to complete the initial evaluation (psychiatric, medical, psychosocial, and addiction parameters) of new patients to the program [Please note that this includes a basic physical examination and placement of a PPD test.]  and to determine level of care for opioid and co-occurring illicit substance uses (e.g., outpatient, medically supervised residential tx, medically managed inpatient tx).
3. The evaluation of patients already in clinic treatment, now requesting psychiatric consultation or seeking consultation at the recommendation of clinic staff
4. NDRC:  Evaluation of dual diagnosis patients, the initiation and continuation of psychotropic medications in the treatment of addiction-related, or non-addiction-related psychiatric disorders, and of pharmacological interventions for addictive disorders (e.g. Buprenorphine, antabuse, naltrexone, acamprosate) including for smoking cessation.
5. Become proficient in facilitating therapy groups for patients in recovery.

Other educational components:

1. Follow four MMTP admissions, including progress in treatment, by keeping a brief record of key measures (e.g. dose, primary and secondary substance use, admissions to detox, engagement with medical or psychiatric care)
2. Supervision/feedback with preceptor
3. Observation with counselor
4. Inservices/Teaching

Required, 3-month rotation, 0.6 fte. 

Clinical Rotation Components

1. Evaluation, consultation, and treatment of:
   1. Patients with primary Substance-related Disorders and their families.
   2. Medical and surgical patients in the emergency department, intensive care units, and general wards of the hospital with acute and chronic Substance-related Disorders, including acute intoxication and overdose.
   3. Psychiatric inpatients with chemical dependencies and co-morbid psychopathology to include a broad range of psychiatric diagnoses, such as affective disorders, psychotic disorders, organic disorders, personality disorders, and anxiety disorders as well as patients suffering from medical conditions commonly associated with Substance-related Disorders such as hepatitis and HIV/AIDS.
   4. Medication dependent patients with chronic medical disorders/conditions (such as patients with chronic pain).
   5. Evaluation of neuropsychiatric complications of addiction
2. Exposure to patients with Substance-related Disorders related to the following substances:
   1. alcohol
   2. opioids
   3. cocaine and other stimulants
   4. cannabis and hallucinogens
   5. benzodiazepines
   6. other substances of abuse, including s
   7. miscellaneous/unusual, e.g., nutmeg, designer drugs, organic solvents/inhalants
3. Rotation should provide fellows with experience in evaluating acute and chronic patients in the inpatient setting.  There should be an identifiable structured educational experience in neuropsychiatry relevant to the practice of addiction psychiatry that includes both didactic and clinical training methods.  The curriculum should emphasize functional assessment, signs and  symptoms of neuropsychiatric impairment associated with Substance-related Disorders, and the identification of physical illnesses and iatrogenic factors that can alter mental status and behavior.
4. The program must provide specific experiences in consultation to acute and chronic medically ill patients with Substance-related Disorders who are being treated on emergency, intensive care, medical and/or surgical services of a general hospital.  Supervision of addiction psychiatry fellows in their clinical evaluation of such patients, as well as in their consultative role, is essential.  The program should provide fellows with the opportunity to function at the level of a specialist consultant to primary care physicians and to intensive care specialists.
5. Experience in working with multidisciplinary teams as a consultant and as a team leader, including the integration of recommendations and decisions from consulting medical specialists and other professionals in related health disciplines.
6. Experience in working with patients who are participating in self-help programs.
7. Experience with opiate replacement therapy.
8. Addiction-related consults are requested by other departments on an ad-hoc basis, so the concept of “caseload” does not easily apply.  Addiction Psychiatry Fellows receive 4-8 addiction-related consults  per week.  The fellow provides initial consultation and follow-up visits.  The fellow will make the initial contact with the patient and the referring clinician, and having received supervisory input will be directly providing the consultative input to the requestors.
9. The Addiction Psychiatry Fellows will be given opportunities to develop evidence-based knowledge through exposure to current  literature and to formulate and articulate their knowledge through teaching opportunities.

Educational Goals and Objectives

1. Develop greater skills in obtaining an accurate substance use history and making appropriate substance use disorder diagnosis(es).
2. Develop skill in recognizing various stages in patients’ readiness to change addictive behavior.
3. Develop skill in identifying alcohol, opiate, and sedative withdrawal in the medically ill.
4. Develop skill in assisting the house staff in the management of withdrawal states in the medically ill.
5. Gain knowledge in the use of benzodiazepines and other appropriate medical interventions in treating alcohol withdrawal.
6. Gain knowledge in the use of clonidine, methadone, buprenorphine and other medications in treating opiate withdrawal in the medically ill.
7. Gain knowledge in assessing patients for methadone maintenance and the appropriate use of methadone for detoxification in patients who are not on methadone maintenance.
8. Gain knowledge in managing acute and protracted sedative withdrawal states.
9. Gain knowledge in the management of pain in opioid dependent patients.
10. Gain experience in the liaison work involving difficult to manage patients as it relates to their drug use.
11. Gain experience with patients who have severe, disabling, chronic addictions and the psychological and social factors which contribute to the chronicity of the addiction.  This includes attention to countertransference issues and how it impacts his/her own and other hospital staffs’ interaction with the patient.
12. Gain experience with addressing relapses and various states of recovery.
13. Learn about the drug treatment resources available in our community and how to make referrals.
14. Gain experience in educating the nursing and medical house staff about issues related to the management of the addicted medically ill patient.

The fellow’s responsibilities while here include:

1. Completing 5 full consultations on patients, as requested by the primary team, per week, including substance use history, psychiatric history, mental status and physical examinations.
2. Discussing diagnostic and treatment considerations with the consulting medical teams.
3. Following up with the patients and medical teams as needed for desired outcomes.
4. Participating in daily rounds, including presenting new patients and reporting developments in previously discussed patients.
5. Providing education to medical students and residents who are on the Addiction Consultation service when possible.

Required, 3-month rotation, 0.6 fte. (includes Adolescent Component at DoSA)

Montefiore Behavioral Health Center @ Westchester Square – Dual Diagnosis Assessment and Continuity Clinic

Educational Goals and Objectives (Adult)

During the rotation at MBHC MICA Component of the Glebe Adult OPD,  the fellow will have ample opportunity to enhance skills in diagnostic assessment, provide individual, group and pharmacologic treatment of individuals with a variety of substance use disorders co-occurring with one or more other serious psychiatric disorders, as well as teach and supervise psychiatry residents and non-medical professionals. 

1. The initial evaluation (psychiatric, medical, psychosocial, and addiction parameters) of patients new to the program.
2. The evaluation of patients with ongoing involvement in any clinic, new psychiatric consultation at the recommendation of requesting psychiatric consultation or seeking psychiatric consultation at the recommendation of the patient’s primary therapist.
3. The assumption of ongoing psychiatric consultation and treatment responsibilities (with supervision) for patients who have been previously followed in our clinics and have a combined substance abuse history and psychiatric illness.
4. The provision of support/liaison to clinic counselor and/or social work staff seeking psychiatric input or supervision.
5. Participation in group therapy in the MICA clinic.

The fellow’s responsibilities while here include:

1. Completing three to six combined psychiatric and addiction assessments each week.
2. Formulating and implementing the treatment plans for each patient assessed, following the patients for the duration of the rotation.
3. Obtaining random urine and breathalyzer samples for toxicology screens on all patients in the program, logging results and refusals and communicating those to the other relevant care providers.
4. Participating in substance use groups already established as part of our program as well as initiating and running at least one group that will meet weekly.
5. Preparing two case conferences with supporting literature to be given to the staff.
6. Attend daily rounds, weekly clinical team meetings, biweekly in service conferences and MICA staff meetings.
7. Present and review cases in weekly supervision with the medical director, as well as seek and provide informal supervision with professional staff and trainees as needed.
8. Write and discuss a case of one patient he/she has become familiar with.  Aim is to educate other clinical staff about substance use disorders in adolescents (case presentation to be on Wednesday AM, regular Child Unit team meeting).
9. Discuss a review article in reference to the substance used in case presentation.

Required, 3-month rotation, (Adolescent Track, 0.1 fte., during MBHC MICA Rotation)

Educational Goals and Objectives (Adolescent)

Addiction Fellow to become familiar with assessment of youth with substance use problems.

• During rotation with child psychiatrist at Montefiore DoSA Adolescent Rotation, Addiction Fellow will:
• Interview/screen high risk adolescents for substance use/abuse
• Participate in treating psychiatric disorders in youth with history of substance use
• May provide individual therapy to 1-2 adolescents with known substance abuse
• May initiate and conduct a substance abuse related group therapy for youths with h/o substance use/or abuse (adolescents to volunteer participation with parental consent)
• Participate in family meetings – of youths with active substance use
• Assist in disposition/referral of teens with active substance use to substance abuse rehabilitation programs when necessary

Required, 12-month rotation, 0.2 fte.

Educational Goals and Objectives

1. the evaluation of patients with ongoing involvement in the clinic, now requesting psychiatric consultation or seeking psychiatric consultation at the recommendation of the patient’s counselor or social worker; includes patients with a variety of psychiatric diagnoses.
2. will provide psychotherapy or pharmacotherapy as needed for selected patients.
3. the provision of support/liaison to clinic counselor and/or social worker staff seeking psychiatric input/supervision
4. the provision of support/liaison to clinic non-psychiatrist physicians seeking psychiatric input/supervision
5. The provision of Dual Diagnosis consultation on patients referred from Bronx Psychiatric Center with serious and persistent mental illness (SPMI)

As part of the required training for the Addiction Psychiatry Fellowship Program, fellows are required to go to weekly continuity clinics.  Here are the tasks and goals the fellow should be proficient in by the end of their fellowship:

• Carry a full caseload of patients (20-30) including at least one weekly psychotherapy case, new patient intakes and regular medication management patients. (5-10 patients in a given day, both new evaluations and follow-ups to build a minimum caseload of 20-30 patients)
• Must be proficient in proper documentation and filling encounter forms.  (This includes being legible.)
• Able to order labs/tests and coordinate patient care with clinic staff and outside providers.
• Able to order and renew medications for patients that are on DOT.
• Proficiency in board style interview.  Fellow should be able to interview patient, do a mental status exam, formulation and assessment/plan and present it to attending physician.
• To participate and run groups.  This includes making presentations and associated paperwork.
• To attend IDC and other clinic meetings.
• Fellows are encouraged to prepare educational presentations for staff.
• Fellow will be open to constructive feedback from staff and attend weekly supervision sessions with assigned attending physician.