Ashraf Muzwagi MD
The UF Health Shands Psychiatric Hospital houses a general child and adolescent psychiatry inpatient unit 8-15 beds for children 9 through 17 years old with mental disorders severe enough to require a secure, structured hospital environment. On this unit, the resident will learn to serve as a member of the multidisciplinary therapeutic team with increasing responsibility over time to eventually assume the leadership role of the team. The therapeutic milieu provides behavioral therapies, group therapy, family therapy, individual therapies, and pharmacotherapy as appropriate to the patient’s individual treatment plan, and also includes onsite school activities.
A. This is a required 4 to 6 months rotation occurring in the first year at Institution 1, requiring 80% of the resident time.
B. Faculty consists of two full-time child psychiatrists who rotate coverage of the service and one consulting child psychologist. Other staff includes one full-time social worker, one full-time occupational therapist, nursing staff, counseling interns, and Medical Psychology trainees who are either at masters or post-doctoral levels. Family medicine consultation is available daily, and dietary/nutritional consults and physical therapy consults are available on an as needed basis. Residents spend approximately two hours in attending treatment rounds and team meetings every day. Faculty members are available on-site for supervision and monitor the caseloads for breadth and variety of experience. Residents also receive exposure to group therapy and family therapy sessions up to three hours per week.
C. This program serves on average 8 inpatients. The unit usually has about 40 % male and 60% female patients, and serves children 9 to 17 years of age, with about 10% of patients below the age of 11. The patient mix consists of approximately 75 % Caucasian, 15 % African-American and 6 % of various other racial backgrounds. Average length of stay is 5 to 7 days. The main problems requiring admission are: affective disorders (consisting of predominantly unipolar depression) (90%), post-traumatic stress disorder, disruptive disorders, comorbid eating disorder, and schizophrenia or other psychotic disorders. In excess of 50% of teenage patients have comorbid substance use disorders. Treatments include milieu and group therapy, family therapy, occupational therapy and recreational activities reinforcing mindfulness-based dialectical behavioral therapy (DBT-informed), cognitive behavioral therapy (CBT), interpersonal therapy (IPT), individual and supportive therapy, medication treatment, and onsite educational activities. The general child and adolescent psychiatry curriculum is based on DBT informed therapies.
D. Average caseloads range from 5 to 9 inpatients at any given time with a maximum capacity for 15 patients on the inpatient unit. The attending child psychiatrists directs the multidisciplinary team, which consists of representatives from psychology, social work, nursing, and occupational therapy, and dieticians as indicated in addition to medical, nursing and counseling students. Residents also participate in individual, family, and group therapies with children adolescents and their families.
E. Residents have at least two hours of weekly individual supervision with the faculty, in addition to daily case supervision. These hours are in addition to the teaching conferences, rounds, and seminars.
Following are the goals and objectives for this rotation:
Goal: To become capable to provide basic inpatient clinical care, in the areas of assessment and inpatient treatment, to children and adolescents with a range of psychiatric disorders, at a level consistent with his/her first year training.
The resident should demonstrate knowledge underlying the basic clinical approaches to the assessment and inpatient treatment of children and adolescents with psychiatric disorders and their families, including the areas of:
- Exposure to a broad range of severe child and adolescent psychopathology as well as appropriate therapeutic modalities as indicated.
- Didactic and practical discussion regarding formal psychological assessment.
- To serve as the primary psychiatrist for his/her patients from admission to discharge, with a focus on comprehensive diagnosis, crisis management, and appropriate multimodal treatment. This will include collaboration with other physician and allied health professionals.
- Exposure to the fundamentals of inpatient family assessment and family crisis management with sensitivity to cultural issues and diversity.
- Exposure to the principles of nursing and milieu management of psychiatrically hospitalized children and adolescents (including behavioral intervention).
- Supervised involvement in core legal issues as they apply to psychiatrically hospitalized children and adolescents (e.g., abuse, custody, informed consent, confidentiality, intent to leave, involuntary commitment, and Department of Children and Families involvement).
The resident should demonstrate ability to:
- Perform an inpatient admission interview, with focus on the development of rapport, interview structure, diagnostic skills, and the comprehensive Mental Status Examination.
- Work effectively with children, adolescents and families in crisis.
- Formulate a differential diagnosis and a multi-disciplinary treatment plan tailored to the individual needs of the patient, i.e., crisis intervention, evaluation and diagnosis, stabilization on medication, and/or preparation for long-term residential psychotherapy placement, or treatment of emotional or behavioral disorders.
- Conduct a family interview and assessment.
- Formulate and present a case history concisely.
- Work collaboratively and effectively with a multi-disciplinary team.
- Attend and participate in family therapy sessions of their patients with social worker/co-therapists
- Attain exposure to group therapy with adolescents.
- Interact with utilization management personnel related to issues in managed care.
- Teach medical and other students how to evaluate and treat inpatients as well as understand the psychopathology and psychodynamics of the patients and their families across a spectrum of diagnoses, because an important part of the learning process is teaching others.
- Participate effectively in multidisciplinary quality and operations monthly meeting while on rotation.
The resident should demonstrate:
- Professionalism by arriving in a timely and prepared manner for daily rounds and unit meetings, with appropriate dress and demeanor.
- Timeliness in completing daily assignments regarding all aspects of patient care, including the prompt dictation of discharge summaries within hospital guidelines.
- Willingness to learn from treatment team members from multiple disciplines.
- Respect for others while participating in clinical activities.
- Commitment to learning how to provide the highest standard of patient care, including the use of the literature to guide treatment and quality parameters to evaluate treatment.
- Commitment to act as the patient’s advocate when clinically indicated.
- Commitment to legal and ethical principles pertaining to the provision or withholding of clinical care, confidentiality of patient information, informed consent and business practices.
- Sensitivity and responsiveness to cultural differences, including awareness of their own cultural perspectives.
- Experience and appreciate the strength and diversity of the various perspectives of the multidisciplinary team in providing comprehensive care to the patients.
- Appreciate the strengths/ weaknesses and challenges of each patient and develop creative ways to capitalize on the various resources available.
- Recognize the psychiatrist’s own strengths/ weaknesses as a physician and to identify and anticipate issues of transference/counter-transference across domains (patient, family, group, and team dynamics).