The following describes an algorithm-oriented psychopharmacology course for residents in psychiatry.
Time: Wednesdays, 1:00 to 2:30 P.M.
Location: Building 2, Learning Center
Attendance: Required
Prerequisites: This conference is designed to follow the summer course on basic principles of psychopharmacology. The latter covers key concepts in the properties and behavior of medications, in the lectures and in the assigned readings from the Sadock and Kaplan handbook. The faculty expects that residents will have completed their reading of this text and attended the lectures before beginning this conference. There will be frequent reference to and further discussion of these basic principles as they come up in the case conferences, algorithms, and literature reviews.
1. Case-centered learning, with a coupling of literature with the cases reviewed.
2. Strong emphasis on evidence-based medicine and its direct application to clinical practice:
3. Active participation of the trainee in the learning process is another important value of the course.
4. Trainee participation is tailored to the PGY level of the trainee. Although all residents read the algorithms and participate in the discussion, the analysis of algorithm papers is assigned to the more advanced residents, because their greater clinical experience gives them more ability to place the algorithms into perspective.
This program has two components: (1) Case conferences. (2) Literature reviews. In this category, we review two kinds of literature: (a) systematic overviews of decision-making in clinical psychopharmacology, organized by diagnostic categories, which will focus on published evidence-based treatment algorithms, practice guidelines, and similar overviews of treatment, and (b) major research papers addressing psychopharmacological treatment of patients seen in case conference. There will also be some papers connected with the psychobiology of the disorders, but this will mostly be covered in a separate course organized by Xiangyang Li, M.D.
Component (1): Case conference and associated paper. The case conferences will be presented by all residents (in rotation) to the course faculty and selected guest experts, and will occur on alternate weeks. Residents will provide written case summaries, copies of which will be distributed at the case conference. The assigned resident will also choose (in consultation with the Chief Resident and faculty) and bring to the conference, copies of a clinical research paper pertinent to the case, that will be discussed on the following week. All residents will be expected to read this paper to prepare for the discussion.
The case summary should contain the following information: Questions for the conference, History of Present Illness, Past Psychiatric and Substance Abuse History (with emphasis on the course of the illness and the medication treatment history, which should be plotted on a "life history chart"), Medical History and Lab Results, Pertinent Family History (e.g. - family history of mental illness and psychopharmacological treatment, displayed in a genogram), Mental Status, Other Testing (e.g. neuropsychology), Multiaxial Diagnoses, Most Recent Treatment Plan.
The organization of the 90 minute conference is as follows: In the first 30 minutes, the resident should succinctly present the most pertinent clinical data and the questions for the conference. Some of this time will be allowed for those attending to read the full written presentation and ask questions. In the next 30 minutes, the patient will be interviewed. The interview may focus on obtaining history or mental status information which required clarification or expansion as determined by the discussion during the initial presentation, or may stress other issues important in developing a psychopharmacological treatment plan. In the final 30 minutes, there will be discussion and analysis with consultative input to the presenter regarding diagnosis and psychopharmacological treatment, with opportunity for questions from the other conference attendees.
After the conference, the resident puts an electronic note in the patients record with (1) a brief summary of the case and the final diagnoses and (2) the recommendations. Dr's Levitt and McCarley will review both the case summary and final note.
Component (2): Literature Survey.
(a) Psychopharmacological Treatment Algorithms. This component of the course will occur every other week for 45 minutes. The algorithm papers may be found in the attached syllabus. Residents will be assigned from the PGY III and IV years to lead the discussion of these papers. The assigned resident will be expected to read the paper carefully and be prepared with questions for group discussion. The presenter should not read the paper to the group.
(b) Paper selected by the resident who presented the case the previous week. The paper is selected by the resident after reviewing the literature, consulting the Internet (learning to use search engines, etc.), library, texts, and other sources as needed. The presentation will last 45 minutes. The resident will summarize the contents of the paper rather than simply reading from the paper. Most importantly, the resident should be prepared with questions about the paper for group discussion. Questions may include requests for explication of parts that were not understood (strongly encouraged), points of disagreement with any of the contents of the paper, problems noted with the methodology, biases detected, or even questions on related topics stimulated by material in the paper. The faculty will respond to these questions and make critical observations about the paper and try to place the findings in the perspective of other work. Other members of the conference should also bring their questions and comments about the paper.
The empirical research papers and the series of algorithms/review papers in the syllabus complement each other: taken together, they comprise a way of conveying the evidence basis for practice. Once this is mastered, trainees will be able to recognize significant variations from current evidence-based care, and be able to evaluate the potential merits of new and alternative approaches. Therefore, in order to maximize the learning opportunities in this training experience, it is essential that all residents read every paper carefully. Indeed, it may be profitable to read the syllabus papers more than once, since it is impossible to remember all the information in these content-laden manuscripts after one reading.