Longitudinal Requirements

Mandatory Longitudinal Rotations

There are a number of longitudinal training activities that are carried out concurrently with other rotations but must be logged on one45 separately. These include SPMI (the treatment of severe and persistent mental illness during PGY2), psychotherapy training, adult developmental delay, ECT training, health advocacy, research, scholarly presentations and quality assurance and improvement (QA/QI).

Severe and Persistent Mental Illness (SPMI)

• Please refer to the detailed Rotation Specific Objectives of Training on one45

During their training, residents are required to participate in the longitudinal care of patients (and their families) with a severe and persistent (defined by disability and duration) psychotic and/or severe and persistent bipolar illness. This is incorporated into the PGY2 year. All residents will be provided with a schedule for attending SPMI clinics at the JGH, the MUHC (AMI), or DH.

SPMI patients need to be logged on one45.

Royal College requirements regarding SPMI during PGY2:

• This must include longitudinal care of at least one patient with severe and persistent (defined by disability and duration) psychotic and/or severe and persistent bipolar illness for the duration of the rotation, with twelve (12) months being preferred.

Psychotherapy Training

• Please refer to the detailed Rotation Specific Objectives of Training on one45

Psychotherapy sub-committee: Dr Robert Biskin and Dr Michael Bond, Co-Chairs

The McGill Department of Psychiatry has a long tradition of excellence in psychotherapy. The major psychotherapies are taught in didactic lectures, clinical seminars, and one-on-one or group supervision. As often as possible, the required training experiences should be carried out in an integrated fashion, embedded within clinical rotations (e.g. CBT during PGY2 outpatient rotation, family therapy during PGY3 child and adolescent psychiatry rotation). Elective psychotherapy training experiences are also available and include brief dynamic therapy, dialectical behavioural therapy, existential therapy, sex therapy, group therapy, crisis intervention, etc.

Logging psychotherapy hours (clinical and supervision) on one45.

Individual psychotherapy sessions and supervision must be logged (can be logged in blocks) on one45 on a regular basis.

REQUIRED TRAINING ACTIVITIES IN PSYCHOTHERAPY (classic program)

Supportive Therapy

During the course of their psychiatry training, residents are expected to develop proficiency in supportive therapy. In order for residents to acquire this basic proficiency, they must complete at least:

• 20 hours of clinical exposure as the primary therapist, and,
• 10 hours of clinical supervision, including a maximum of 2 supervised cases.

Clinical supervisors are expected to provide supervision for supportive psychotherapy. Residents are expected to discuss how supervision will be delivered at the beginning of their rotation. Supportive psychotherapy supervision should be specific to this therapeutic modality using the following resources:

• Winston, A; Rosenthal, R; Pinsker, H: Learning Supportive Psychotherapy: An Illustrated Guide (2011)
• Pinsker, H: A Primer of Supportive Psychotherapy (2002)

Supportive Psychotherapy Summary for Supervision

Supportive psychotherapy aims to improve symptoms and prevent relapses by targeting self-esteem, ego function (reality-testing, affect regulation, etc.), and adaptive skills. The focus of supervision should be on:

• Therapeutic alliance management, including identification and repair of misalliance
• Helping residents promote the patient’s trajectory towards autonomous use of new skills and knowledge rather than dependence on therapist, as much as possible
• Other key elements of supportive psychotherapy, including:

Therapeutic Stance

• Collaborative, active and affectively responsive; conversational
• Judiciously self-revealing (e.g. to validate reality, promote alliance, minimize transference)
• Oriented to present reality rather than projections from the past

Formulation

• Biopsychosocial formulation using any theoretical framework (dynamic, CBT, etc.)

Goal-setting

• Collaboratively set specific and realistic goals

Techniques

(Other interventions can also be borrowed as needed from CBT, motivational interviewing, etc.)

Alliance and Esteem Building

• Reflecting thoughts and emotions
• Empathizing
• Praise (must be realistic and linked to evidence)

Anxiety Reducing

• Signposting (giving patient notice of/rationale for anxiogenic questions)
• Naming the problem
• Reassurance and normalizing

Skill Building

• Encouragement
• Advice/suggestion (should transition to patient problem-solving ASAP)
• Teaching
• Reframing (can include use of CBT thought records)
• Problem-solving
• Anticipatory guidance (can include role-playing)

Awareness Expanding

• Clarification (can be a question or a summary statement)
• Confrontation (drawing patient’s attention to inconsistencies in goals/behaviours)
• Interpretation (rarely used)

Psychodynamic Psychotherapy

During the course of their psychiatry training, residents are expected to develop proficiency in dynamic psychotherapy. In order for residents to acquire this basic proficiency, they must complete at least:

• 140 hours of clinical exposure as the primary therapist, and
• 70 hours of clinical supervision, including ≥2 supervised cases of open-ended dynamic psychotherapy (required) as well as ≥1 case of brief dynamic psychotherapy (elective). I.e., hours must include open-ended dynamic cases but may also include any brief dynamic cases the resident undertakes.

Residents keep the same open-ended dynamic psychotherapy supervisor for a maximum of 12 months unless otherwise approved by site training directors and the program office.

Patients should be registered at the hospital where they are seen. If residents change hospitals, then the patients, their charting, and supervision should be transferred as well. If residents elect to pursue supervision at a site other than their current hospital, patients should be seen and charting should be done at the site where the supervisor works. Though this is logistically challenging, it is medicolegally necessary. Residents should ensure that their patients sign the Long-Term Psychotherapy Contract (McGill University Residents’ Clinic) before starting psychotherapy.

Residents who are rotating away from Montreal and wish to continue following their psychotherapy patients can do so via Skype, pending discussion with the psychotherapy supervisor. Psychotherapy supervision should be done at the site where residents are training, but supervision by Skype is possible only if suitable supervision is unavailable where they are rotating or during rotations of less than 7 periods at a rural site. Before starting Skype supervision, residents must make sure their supervisors in Montreal are in agreement with Skype-assisted psychotherapy. Moreover, patients are required to sign the Skype Assisted Psychotherapy Consent Form before starting Skype assisted psychotherapy.

Most patients for psychodynamic psychotherapy are obtained from the centralized referral program for "Open-ended psychodynamic psychotherapy with a McGill Psychiatry resident." This centralized referral service is based at the MUHC education coordinator's office (MUHC resident coordinator) and paper referrals are available there, although patients can come from any site. An anonymized database of clinical data is also stored online and managed by the MPRA Psychotherapy representative. The online database identifies which patients have been picked up by residents, the referring source, basic demographics, and a brief clinical summary. Please be sure to update the online database when you start therapy with a new patient off this list. For all other questions and to access this database, please contact your MPRA Psychotherapy representative. Finally, patients for psychodynamic psychotherapy can also be obtained during your clinical rotations and from other clinicians at the site you are working at. It is suggested to discuss the available clinical information with your current psychodynamic psychotherapy supervisor before you contact a new patient.

If you encounter a patient that you and your supervisor would like to send to the centralized "Open-ended psychodynamic psychotherapy with a McGill Psychiatry resident" clinic, please complete and send in the document "Psychotherapy Long Term Referral Form, 2012" that is available on one45, or contact the MUHC education coordinator for a copy. Please inform the patient that there is a long wait list (6-24 months) and that there is no guarantee they will receive therapy.

Cognitive-Behavioural Therapy

During the course of their psychiatry training, residents are expected to develop proficiency in CBT. In order for residents to acquire this basic proficiency, they must complete at least:

• 40 hours of clinical exposure as the primary therapist, and
• 20 hours of clinical supervision, including ≥ 2 supervised cases. Residents must treat at least one patient with an anxiety disorder and at least one patient with a depressive disorder.

Residents must also complete the half-year CBT course offered at the MUHC at some point during their residencies. It is scheduled on Thursdays from 2:30 to 4:00 and is offered twice each year. It is also available through teleconferencing at the DH and at JGH for residents who are based there.

Group or Family Therapy

During the course of their psychiatry training, residents are expected to develop proficiency in either group or family therapy and to achieve a working knowledge of the other. In order for residents to acquire this basic proficiency, they must complete a total of at least 10–15 sessions, with appropriate supervision, in which they are either:

• Acting as the primary therapist for ≥ 2 family and/or couple cases (at least 1 of each), or,
• Acting as the primary or co-therapist for group therapy (this may include social skills groups or inpatient groups provided that supervision emphasises principles of group dynamics).

As per Royal College rules, residents must be proficient in either group therapy and have working knowledge in family therapy or vice-versa (proficient in family therapy and working knowledge in group therapy)

Other Psychotherapies

During the course of their psychiatry training, residents are expected to develop a working knowledge in either group or family therapy (in whichever the resident did not attain proficiency), as well as in behaviour therapy, dialectical behaviour therapy, and interpersonal psychotherapy. In order for residents to develop a working knowledge of these therapies, they are expected to attend didactic lectures on these topics during the centralised teaching and to observe therapy sessions (live or videotaped) and/or act as co-therapist for cases treated with these modalities. The required CBT training will provide sufficient exposure to behaviour therapy.

Introductory knowledge is expected in brief dynamic psychotherapy, mindfulness training, motivational interviewing, and relaxation. In order for residents to develop introductory knowledge of these therapies, they are expected to attend didactic lectures on these topics during the centralized teaching.

Videotaping and/or Audio Recording Psychotherapy Sessions

Videotaping and/or audio recording might be required for psychotherapy supervision. It is imperative that patients sign a consent form before recording psychotherapy sessions (found on one45 and at the hospital where patients are seen). Cameras and/or recording devices that are the property of the hospital or program, as well as all physical or digital copies of the recordings, should always remain in the hospital in a locked room and/or safe. As with medical records, residents can face serious consequences if patient records/chart/information are used outside the hospital.

REQUIRED TRAINING ACTIVITIES IN PSYCHOTHERAPY (CBME program)

Summary

The majority of requirements in the CBME program remain identical to the classic program. As such, please refer to the specific details below for differences.

1) Open-ended psychodynamic psychotherapy will remain unchanged. Residents will start seeing patients in PGY2 and continue throughout residency with the same minimum required hours.

2) Cognitive-behaviour therapy will continue unchanged, with residents attending the CBT course in the PGY2 year and seeing patients in PGY2. The minimum required hours and diagnostic requirements remain unchanged.

3) Multiperson (group and/or couple and family psychotherapy) will occur in PGY3/4. Residents may have the option to participate in couple and family therapy during their child and adolescent psychiatry rotation in PGY3. Residents will also be able to participate in some form of multiperson psychotherapy during their PGY4/5 year. A psychotherapy rotation may be organized for PGY4/5 residents to complete this component of their training. The required hours remain unchanged.

4) Short-term psychodynamic psychotherapy will be offered in a psychotherapy rotation in the PGY4/5 year of residency. The required hours remain unchanged.

5) Other psychotherapies: Residents will be required to develop working knowledge in one other form of psychotherapy. This may include supportive psychotherapy, dialectical behaviour therapy, existential psychotherapy, or others. Residents will have the option of completing this requirement either during their fundamental and core clinical rotations, with options as well during the PGY4/5 psychotherapy rotation. The hours required remain the same as the hours listed for supportive psychotherapy.

Adult Developmental Delay

Rotation director: Dr Carol Brebion: drbrebion [at] cliniquespectrum.com

This training experience takes place in the PGY3 year and is located at Clinique Spectrum in Montreal. It consists of three days training: two to attend trans-disciplinary meetings and one for group home and day program visits.

Other training experiences are possible at the Douglas Hospital and the MCH. (Please discuss with the training directors of these sites your interest in further clinical exposure to the developmental delay population).

Health Advocacy Training

Health advocate leader: Dr Kia Faridi: kia.faridi [at] mcgill.ca

Health advocacy is a core skill in medical and psychiatric training. A health advocate needs to learn specific tools in order to be able to advocate for patients and their needs at different levels: individual, institutional and community. The health advocacy training consists of in-rotation skills, teaching module, and project-based involvement.

Health advocacy training is an integral part of the experience of every rotation. Supervisors and residents are encouraged to engage in discussions on this aspect of clinical practice, specifically addressing individual patients and their needs.

A formal centralized teaching lecture is given annually on relevant topics. Residents in the PGY2–4 years participate in a health advocacy training activity that is structured with a half-day educational session during the orientation period. Residents present on their health advocacy experiences, receive supervision on reflective practice on this topic, and plan a health advocacy activity such as giving an educational talk at AMI Québec, writing a newspaper article, or brainstorming on other options, in order to create self-initiated community-based activity.

Residents are expected to engage in at least one health advocacy activity in addition to attending our program’s annual Health Advocacy training activity (mandatory for PGY2-5, usually scheduled at orientation). Specific health advocacy activities include but are not limited to giving presentations for a community resources, such as TRACOM, Chez Doris, AMI Quebec, Open Door, Ometz, Saint Columba House, Maison-Bleue, Fondation du Dr Julien, Islamic centers, McGill Peer-student support, etc. Residents who would like to develop other health advocacy initiatives should contact the program office to ensure that their activity is appropriate. Residents should contact the MPRA’s VP Community for a list of community organizations who welcome psychiatry residents.

Health advocacy activities need to be logged on one45 (one presentation or health advocacy activity in the community and centralized annual health advocacy presentation at orientation).

Scholar Role

There are many opportunities to engage in scholarly activities throughout residency. An introductory module on basic research methods and seminars featuring residents from the research track option are included in the program. In addition, over the course of their training, residents must give a minimum of 7 academic presentations in order to complete their scholarly training. Presentations must be completed during psychiatry rotations and residents must be supervised by psychiatrists. These presentations can have a clinical focus, do not need to include research material but should provide a review of the literature on the selected topic. Included are: presentations at grand rounds, academic rounds of clinical services, Scholarly Report Day, Research Day, and organized conferences. One of the seven required presentations must be on the topic of QI/QA (EQIPS, M&M rounds, etc.). Each presentation must be logged on one45 and evaluated by a faculty member using the form “Assessment of Academic presentation”, that residents will have sent out ahead of time their supervising faculty.

Scholarly Report Day (SRD)

McGill has a long history of excellence in Consultation-Liaison Psychiatry. Some of the founders of psychosomatic medicine are from McGill. In the spirit of ensuring scholarly exchange and innovation, our program has for a very long time organized an annual Scholarly Report Day (SRD), which is traditionally held in period 13 of every academic year. Senior residents having rotated in CL in the last academic year are required to prepare a PowerPoint presentation on a topic of their choice (typically a 10–15min presentation). Residents who cannot attend the year they are required to present will be asked to present the following year.

ECT Training

Residents in the PGY2 year are required to complete ECT training during their inpatient psychiatry rotation. The required experience consists of observing 10 and performing 3 treatments. In many cases, fewer treatments are observed and more are performed. This is an acceptable alternative.

Quality Assurance – Quality Improvement

Residents are required to engage in a quality assurance and/or quality improvement initiative during the course of their training. This requirement can be fulfilled in various ways such as:

• Attending a minimum of three Medical Acts Committee meetings and/or Mortality and Morbidity rounds (ie. CAPA)

and

• Giving one academic presentation on the topic of quality (supervised and evaluated by a faculty member) and/or
• Participating in a QA/QI project under the supervision of the clinical supervisor (discuss this with each individual supervisor). A detailed project description must be provided to the training director and the program office. This description should include identifying the attending responsible (guide, supervisor and teacher) for overseeing the project, a description of the clinical or care deficits which have been identified and how they were identified (chart review, survey, feedback, etc.), how the proposed project will remediate those deficits, and how the project’s outcomes will lead to improving the quality of care and/or
• Creating a QA/QI research project under the supervision of a knowledgeable attending in our department, which can be used towards fulfilling research requirements (for residents having started training in 2015 and after). Rules and regulations set forth by the research subcommittee must be respected and members of the subcommittee need to review the proposed project.