Dr. Nazir is post-doctoral fellow and Dr. Sedky is associate professor of psychiatry at the Hershey Medical Center in Pennsylvania. Dr. Paladugu is an observer and Dr. Lippmann is professor of psychiatry at the University of Louisville School of Medicine in Kentucky.
Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Karim Sedky, MD, Department of Psychiatry, Hershey Medical Center, 500 University Drive, Mail Code H073, Hershey, PA 17033; Tel: 717-782-2180; Fax: 717-782-2190; E-mail: email@example.com.
Residents benefit by being prepared for their outpatient rotation. Coming to the clinic with an understanding of the procedures, challenges, and how to meet educational objectives should promote confidence and a better educational experience. Learning how to adjust to this setting, arrange their office, get supervision, and provide good clinical service are important steps in the resident’s training. Assuring access to faculty guidance at pharmacotherapy and psychotherapy facilitates expertise and safety for the patient and trainee. Understanding administrative and practical aspects of psychiatric care in this setting fosters a good clinical approach and education in a supervised, productive manner.
• Office design is important and includes a focus on safety.
• Charting is important for clinical, insurance, and medico-legal reasons.
• Missed appointments are frequently encountered in outpatient settings.
• It is important to learn pharmacotherapy and psychotherapy.
• Patient care is individualized to specific patient needs.
The outpatient clinic is one of the principal sites for training psychiatry residents. The Accreditation Council of Graduate Medical Education for psychiatry requires at least 1 year of outpatient experience for trainees.1
Most residencies start psychiatric training on inpatient services in the first postgraduate year. There, the resident acquires an understanding about psychopathology. Risk assessment, diagnostic evaluation, and formulating a differential diagnosis are mastered during this phase of training. It also offers an opportunity for prescribing medication under supervision and learning about aftercare options.
Residency may vary with respect to when residents begin to see outpatients. Before starting, it is important to learn about the clinic policies. Ambulatory patients exhibit a wide range of exposures. Certain conditions, such as obsessive-compulsive disorder (OCD), are seen in this setting more often than in a hospital service. Having residents continue clinic work as long as possible improves patient and physician satisfaction through a longer-term relationship. Therapeutic alliances are enhanced and it affords the resident an opportunity to observe the course of mental illness over time.2
Residents typically have at least one outpatient supervisor. Especially during the adjustment phase, supervisors provide orientation to the clinic. They offer professional advice, clinical guidance, and other assistance throughout the rotation. Discussion may include guidance on study of appropriate educational materials; prescribing pharmacotherapies; and help in handling referrals, complaints, and so forth. Residents also meet with their supervisors to review psychotherapeutic techniques and alternatives. Self-educational reading and attending lectures or conferences is usually required.
What About Your Office?
For safety reasons, the clinician’s chair should ideally be nearer to the door than is the patient’s chair. Some clinics place an emergency alarm button at the desk or some other alert system to call for help, if protection is needed. Extra seating is made available for family. A box of tissues should always be available.
The room should be well illuminated. There is controversy about whether to display pictures of one’s family. From a psychoanalytic point, this may not be advisable. Pictures on the wall should have a calmative theme. Plants beautify the room and promote a pleasant atmosphere, as long as they are healthy.
Clinics differ in respect to scheduling of team meetings where referrals, clerical issues, and other problems are discussed. These meetings often review clinically difficult cases and administrative issues.
In cases of conjoint treatment with a psychotherapist, frequent contact between both clinicians is expected for information sharing. Billing is usually new to residents, but it is essential to learn the coding system for intakes, medication checks, psychotherapy sessions, and other patient contacts.
How To Chart
Legible documentation is important. Typing is clearer than handwriting, and printed clinical recording sheets for patient data also can simplify charting. Maintain appropriate eye contact with the patient when recording information. Note the date and time of each session, including the start and ending time and the duration of the visit. Document general content of the session, complaints, concerns, and therapy utilized. Include details about patient progress, efficacy of pharmacotherapy, and any side effects. Clinical data should support the type of session noted on the billing forms.
The chart should reflect a discussion of safety concerns and decisions about management. Safety includes suicidal or homicidal thoughts, inability to take care of oneself, abuse, or noncompliance with medical treatment. In these situations, consultation with the supervisor is advised and documented before ending the appointment. Child Protective Services must be notified whenever there is possible abuse to a minor. Adult Protective Services are informed if an adult is unable to care for him- or herself or is being abused.
It is important to be familiar with the Tarasoff ruling. In cases of expressed dangerous threats to others, clinicians have the duty to protect the potential victim by a direct warning to that individual and to the police; this can often be done without compromising the therapeutic relationship.3 When a patient refuses to reveal information about the possible victim, inform the local police department. These facts must always be documented in the chart.
Clinics differ with respect to who schedules the initial appointments, provides the clinic’s address and phone number, and answer questions, such as how to access parking. The first 1-hour session is dedicated to evaluating the patient with a history and mental status examination, followed by discussion of treatment plans. Laboratory tests may be ordered as needed. Therapeutic decisions are postponed in complex cases until the required information is obtained and reviewed with the supervisor. Collateral information from family members or a previous treatment team might be beneficial. Some patients may require more intensive treatment with referral to specialty clinics, as for persons with dangerous self-mutilation or substance abuse.
Written consents are obtained from patients before information is revealed to a third party, even to family or an insurance company. Special consents are obtained for video or audio taping a session.
Treatment discussions include pharmaceutical options as well as psychotherapy selections. Always tell patients whom to call in case of emergency, during working hours or when the clinic is closed. If there is overt concern for patient safety, involve family for monitoring. Although assessments are more accurate when the supervisor and the trainee conduct concluding parts of the initial interview together, this is usually not done for practical reasons.4
A follow-up visit is mutually agreed upon by the patient and resident. Some clinics depend on secretaries to schedule appointments, but the doctors must inform staff about their available times and planned visit dates. The clinic phone number, emergency contacts, and physician’s name should be provided to every patient. The next follow-up date and time should be given to the patient in written form.
Residents should be aware of clinic policy towards individuals who frequently miss appointments. Every outpatient facility has its own way to deal with missed visits. Failure to appear for an appointment is most common among people seen by a resident, in younger patients, and for those individuals with a record of missed visits or living far from the facility.5
Prescribing medications is a frequent part of treatment. There are algorithms available for treatment of different syndromes6 and the American Psychiatric Association offers downloadable guidelines.7 Drug interactions between psychopharmaceuticals and other co-administered medical treatments must always be considered. Avoid polypharmacy when possible.8,9 The physiologic impact of medications must always be considered; for example, avoid lithium during pregnancy, lactation, renal dysfunction, or hypothyroidism.
Residents should know which medications cause weight gain.10 Patients taking antipsychotics should be monitored for the metabolic syndrome according to the current guidelines. Side effects should be discussed and charted.
Always consider the prospect of pregnancy to avoid teratogenicity from pharmaceutical exposure in female patients of child-bearing age. Pharmacotherapy is avoided if possible during pregnancy or lactation. The risk versus benefit of using medications during pregnancy mandates explicit indications and thorough discussion; consultation with a supervisor and an obstetrician is essential. Be aware that efficacy of oral contraceptives in preventing pregnancy is reduced when co-prescribed with hepatic enzyme-inducing drugs, like carbamazepine.
For patients taking benzodiazepines or other controlled substances, continued benefit should be consistently and specifically charted; taper off such medications when possible. Controlled substances, as in treatment for insomnia, should ideally be prescribed only for short periods. For patients with alcohol and/or drug abuse, sobriety is consistently stressed. Alcoholics Anonymous or Narcotics Anonymous are encouraged, buprenorphine administration is considered, and/or other chemical dependency intervention plans are implemented. Some programs offer special training to residents at handling drug abuse cases.11 Any controlled substances in the clinic, like buprenorphine, must be kept in a locked location. Needles and injectable medicines should be stored in secure places, with refrigeration as needed.
Always consider the cost of medication and insurance coverage in planning treatment. Pharmaceutical sales representative visits often inappropriately influence resident prescribing habits. Thus, this practice is now discouraged.12
Individual Versus Conjoint Treatment
Residents can do both medication management and psychotherapy. This allows more time to understand the patient and improves the therapeutic alliance. However, having two people share a case can also be clinically beneficial, and is often the reality.
After the assessment, the clinician and supervisor determine the type of psychotherapy indicated. Consider patient education, motivation, energy, and functional capacity. Availability, times for sessions, and financial aspects should be reviewed.
Supportive therapy is indicated, especially for those recently discharged from the hospital, after an acute relapse, or those with compromised function. Cognitive-behavioral therapy is a frequently chosen treatment that focuses on cognitive distortions and automatic thoughts.13 In cases of phobias, posttraumatic stress disorder, or OCD, exposure with response prevention is a frequent option. If there is a concern about self-harm, dialectical-behavioral therapy might be selected.14 This includes teaching interpersonal effectiveness, stress tolerance, acceptance skills, and emotional regulation.15 Mentalization therapy is an alternative for treating patients with borderline personality disorder by helping them develop stability within a secure attachment relationship.16 Learning psychodynamic psychotherapy is a core training requirement and utilized in selected cases.17 For those who have chemical dependence issues, one can encourage abstinence by motivational enhancement therapy through a guided review of ambivalences.
Other therapeutic options include group approaches, family or marital counseling, hypnotherapy, or other traditional or even less conventional therapies. It can be advantageous when different supervisors suggest alternative approaches, even in the same patient.18 Electroconvulsive therapy may be indicated as a somatic treatment in certain cases. Transcranial magnetic stimulation and vagal nerve stimulation are newer considerations.
Crisis Assesment And Community Treatment Team
During a psychiatric emergency, a crisis team or the regular clinical staff must provide an immediate assessment and/or referral to inpatient hospitalization. For chronically ill, low-functioning individuals, a referral to a community treatment program is appropriate since these agencies have an intense assistance program provided by multidisciplinary professionals.
Forms And Letters
Some patients may have forms for physician signature. Others may ask for social security or insurance papers to be filled out. Excuses for job or school absences are often requested. The same applies to notices about returning to work and clarifying occupational restrictions. Place copies of all forms and similar papers in the chart to document the transaction. An appreciation of disability regulations can be an aid in assisting patients.19
It is important that residents know how to access other services. These may include physician referrals such as securing a psychologist, social worker, nurse practitioner, Meals-on-Wheels, transportation services, or vocational rehabilitation. Knowledge of community resources is expected.20
At the initial evaluation, laboratory screening is considered. This may include a complete blood count, lipid profile, comprehensive serum chemistry profile, urinalysis, or thyroid hormone assays. A serum pregnancy test is conducted in women of childbearing potential. Various tests may be repeated over time, eg, serum glucose or lipid monitoring when metabolic syndrome is a concern. Neuroimaging is requested when brain disease is in the differential. Syphilis or other infectious disease testing is indicated in demented or other selected people. Clozapine prescribing mandates hematologic follow up regularly with special attention to the neutrophil count. Lithium requires attention to serum levels, renal effects, and antithyroid properties as well as pre-treatment testing. Blood counts, liver or renal function tests, hepatic enzyme assays, or electrolytes are monitored regularly in patients taking medications with adverse potential in these areas. The procedures for ordering tests vary from clinic to clinic.
It is important to be familiar with the policy for handling medication samples. Many clinics do not allow sampling of pharmaceuticals, but some facilities still do, under tight regulation.
Training residents about cultural differences is important.21-23 For example, African-American populations reportedly are often overdiagnosed with schizophrenia.24 Hispanic populations may have a higher incidence of anxiety disorders.25 Interpreter services are required in cases with a language barrier. Adjustment disorders and non-acceptance by family are frequent complaints by homosexuals.26 Training guidelines exist for women’s issues.27 When treating children or adolescents, family therapy is an integral part of the plan.28-30
Transfering Or Terminating
Sometimes a resident might need to transfer a patient. These situations could include transference or counter-transference issues, concern about physician safety, lack of progress, and always at times when the resident will no longer be available. It is important to explain the reasons for transfers. In long-term therapeutic relationships, discussion focuses on analysis of feelings and future plans. Self-esteem and abandonment issues should be addressed. At the end of the outpatient rotation, detailed discussions should ensue and consider even introducing the patient to the new therapist to avoid feelings of abandonment. A review of the newly arranged follow up is mandatory with names, dates, times, and phone numbers listed on a new appointment card.
The outpatient clinic is an important part of the psychiatric education. Preparing residents before they start the ambulatory rotation reduces anxiety and improves the educational experience. Understanding the practice policies of the clinic helps the resident to be comfortable and productive. Following patients for long duration offers trainees a long-term view of patient pathology, problems, and coping skills. Performing medication management and psychotherapy with expertise are important objectives. Education also focuses on forming therapeutic relationships, monitoring disease progression and/or effectiveness of treatment, and competently handling mental health emergencies. Learning about ambulatory care comes from practical experience in the clinic. PP
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