Sacred Heart Medical Center
on M, T, Th, F
Ph: (509) 474-4744
Fax: (509) 474-4746
Spokane Teaching Health Clinic
Ph: (509) 626-9963
Rotation Structure by Year
Updated for 2019-20 Academic Year
Emergency Medicine – SHMC (4 wks)
Internal Medicine - Ambulatory- STHC (4 wks)
Internal Medicine – Inpatient – STHC (8 wks, 1 block can potentially be split into 2 week blocks)
Internal Medicine – Night Float – SHMC (4 wks, can potentially split in 2 week blocks)
Neurology – Inpatient Consults – DMC (4 wks)
Neurology – Inpatient Consults – SHMC (4 wks)
Pediatrics – Inpatient – SHMC (4 wks) (Optional, can choose another Inpatient IM block instead)
Psychiatry – Consultation-Liaison – SHMC (4 wks)
Psychiatry – Inpatient Adult – ESH (6 wks)
Psychiatry – Inpatient Geriatrics – ESH (6 wks)
Psychiatry – Inpatient Adult – SHMC (4 wks)
Half-day didactic teaching per week
Psychiatry – BEST (K-6 Intensive Day Program) – SHMC (4 wks)
Psychiatry – Consultation-Liaison – SHMC (12-14 wks)
Psychiatry – Emergency – SHMC (6 wks)
Psychiatry – Inpatient Adult – SHMC (10-12 wks)
Psychiatry – Primary Care/Collaborative Care – STHC (10-12 wks)
Psychiatry – Psychotherapy Continuity Clinic – Gonzaga University – (1/2 day per wk)
Systems of Medicine (QI) – 2 wks
Half-day didactic teaching per week
Year-long 1 day per week rotation at Frontier Behavioral Health for Outpatient Child and Adolescent Psychiatry
Year-long 1 day per week rotation in Psychiatry Specialty Clinic at Spokane Teaching Health Clinic (STHC)
Year-long ½ day per week of collaborative care consults.
Year-long ½ day per week of rural Telepsychiatry
Year-long 1 day per week longitudinal psychotherapy clinic at Gonzaga University
Year-long 1/2 day per week Addiction Psychiatry at STHC
Half-day didactic teaching per week.
Four-week rotation of Forensic Psychiatry at ESH - 3 ½ days per week
Four-week rotation of Emergency Psychiatry at SHMC – 2 ½ days per week
Year-long ½ day per week rotation at Gonzaga University Continuity Therapy Clinic
Year-long 1 day per week rotation in psychiatry specialty clinic at STHC
Year long 1/2 day per week of collaborative care consultation
Year long 1/2 day per week Addiction Psychiatry at STHC
Six months ½ day per week of rural Telepsychiatry
Required for Chief Resident, otherwise elective: 4-week rotation as Junior Attending at SHMC, either on Inpatient Adult Psychiatry Unit or on Consultation-Liaison Service: 3 total days per week
Five 4-week blocks of elective time: 2 ½ total days per week
Half-day didactic teaching per week
Elective options can include any of previously completed required rotations
Elective options selected by AY 18-20 PGY4s
8 week 0.5 FTE elective in PGY 4 alternating weeks between ECT and TMS
Frontier Behavioral Health E&T elective
Frontier Behavioral Health Child & Adolescent Clinic
Frontier Behavioral Health Crisis Services elective
Gonzaga University Primary Care elective
Gonzaga University Psychiatry Clinic
Healing Lodge of the Seven Nations psychotherapy elective
Residents provide psychotherapy to male and female adolescents in a 45 bed residential chemical dependency treatment center. This is a Native American treatment center founded by a consortium of tribes: Confederated Tribe of the Colville Reservation, The Spokane Tribe of Indians, The Kalispel Tribe of Indians, and The Kootenai Tribe of Idaho, The Coeur d’Alene Tribe of Indians, The Nez Perce Tribe, and The Confederated Tribes of the Umatilla. The treatment center is one of 12 Indian health Services Regional Youth Treatment Centers around the country.
Junior Attending – Inpatient or consult liaison psychiatry elective
Pediatric Neuro-developmental clinic
½ to full day elective per week for 2-3 months
½ day longitudinal 2-3 month elective
Curriculum development and teaching Elective
½ day a week for a variable rotation duration, expected to develop a curriculum for implementation at the end of the elective, and to teach at least 2 of those sessions themselves
Advanced Motivational Interviewing Elective
Advanced QI/Scholarly work elective
Native Health (Kalispel Tribe Camas Path Clinic, Spokane Tribe of Indians Clinic)
Sports medicine psychiatry elective
VAMC Addiction group process Therapy Elective
A variety of psychotherapy electives (ISTDP, ACT, DBT, Group, Harm Reduction)
Numerous additional electives are available to residents in addiction (Spokane Regional Health District, Daybreak adolescent addiction services), child and adolescent (Adolescent medicine clinic, Daybreak, CHAS, FBH), community psychiatry (FBH Adult Outpt, FBH Elder Services, FBH ACT team, CHAS Integrated Care), eating disorders (Emily Project), jail/correctional psychiatry, LGBTQ+ care (Odyssey Youth Movement), Native Health (Kalispel Tribe Camas Path Clinic, Spokane Tribe of Indians Clinic), neurology clinics (TBI, movement disorders), neuropsychiatry, psychotherapy (BAP, CBT, DBT, Group, MI, ISTDP), sports medicine psychiatry and quality improvement. More are available and can be developed!
QUALITY IMPROVEMENT CURRICULUM
Three four week 0.2 FTE block rotation in QI was added for 2017-18 to further augment QI experience (present in the systems of medicine PGY2 rotation) and address ACGME common program requirements effective July 1, 2017.
Residents now meet weekly with a faculty mentor and implement a QI project during their rotation in collaborative care.
PGY3 and PGY4 residents continue QI with requirement for an individual or group QI project. Expectation is that work will be presented at regional symposiums or conferences (NW regional research symposium, or Primary Care Update) or national conferences.
During the PGY-1 year, on psychiatry rotations, each resident is required to have one hour per week of direct supervision with his or her inpatient attending, in addition to rounds.
The resident also has one hour per week of direct individual/group or peer consultation supervision with an “off ward” supervisor. This is a member of the faculty who meets with the resident or residents (if on a rotation in which there is a more senior resident working alongside a junior resident) to discuss cases from the resident’s inpatient caseload, case formulation and differential diagnosis, issues involved in working with the multidisciplinary inpatient team and with families, approaches to treatment, and/or papers from the psychiatric literature, depending on the resident’s needs and preferences.
In the PGY-2 year, each resident is required to have at least one hour per week of direct supervision by the attending supervising him or her of the clinical service (e.g. inpatient, consultation liaison, emergency psychiatry), in addition to rounds.
One hour per week of individual psychotherapy supervision.
PGY-3 through PGY-4
In the PGY-3 and PGY-4 years, each resident is required to have one hour of direct supervision (usually group) for outpatient clinic rotations, or one hour per week of direct supervision by the supervising attending for the rotation.
At least one hour (with two preferred) of individual psychotherapy supervision per week.
On rotations in which there is a PGY-2 resident working alongside a PGY-1 resident (inpatient adult psychiatry) or where there is a PGY-3 resident working alongside a PGY-2 resident (inpatient child and adolescent psychiatry), they are required to have 1 hour per week of peer consultation supervision. Both residents use each other for consultation with direct supervision from an attending, either on the service or an “off ward” supervisor.
The Residency Program believes that it is important that psychiatrists understand the contribution of their own psychological and interpersonal characteristics to the doctor-patient relationship.
To foster such self-awareness, each psychiatry resident is required, by the time of Graduation, to have completed six months of either:
Weekly personal psychotherapy
Weekly supervision focusing on the resident’s own contributions to doctor-patient relationships
Psychiatry Residency Spokane works with several institutions in the Spokane area to provide clinical opportunities for our residents.
Providence Sacred Heart Medical Center and Children’s Hospital
Mann-Grandstaff Veterans Administration Medical Center
Eastern State Hospital
Frontier Behavioral Health
Spokane Regional Health District Opioid Treatment Program
Washington State University Spokane
Inpatient Psychiatry at Sacred Heart Medical Center
The residency team serves 6 beds on the inpatient service located at SHMC. Residents spend time in the inpatient setting throughout their four years in residency training. In PGY-1, residents are paired with R2s for 2 weeks, and then act as the senior resident for 2 weeks. In PGY-2, residents spend 4 months on the inpatient service. Most PGY-4 residents will serve as a Junior Attending on the service for a total of 4 weeks. The inpatient unit has both an acute and open side which allows for capacity to care for individuals who require higher level of care including the need for involuntary medications for non-compliance with oral medications, and the use of seclusion and restraints when indicated. ECT is a service available at SHMC. During PGY-4 residents will complete an ECT rotation where they will become certified to administer ECT at SHMC.
Emergency Psychiatry Rotation at SMHC
During the Emergency Psychiatry rotation, residents take unscreened patients from psychiatric triage. This setting allows residents the opportunity to interview, obtain collateral information, plan treatment, coordinate care, and discharge patients directly from the ED or arrange for higher level of care when indicated. Residents spend a total of 6 weeks in the emergency department throughout training. The initial introduction to ED Psychiatry occurs in PGY-2 for 4 weeks, and the final 2 weeks during PGY-4 year.
Consultation-Liasion Psychiatry Rotation (CL) at SMHC
With 644 beds, Providence Sacred Heart Medical Center (SHMC) is one of the largest hospitals in the Northwest and is the only level II trauma center between Seattle, WA and Missoula, MT. SHMC boasts a 26-bed medical/surgical ICU and a 32-bed cardiovascular ICU designated to support a high complexity cardiovascular program that includes cardiac transplant, LVAD, and ECHMO. SHMC also has a kidney and pancreas transplant program and Level 3 Epilepsy center that helps support a large catchment area that includes nearly 1.5 million people.
Residents gain experience with a wide variety of consultation questions, including safety evaluations (> 25%, of which > 10% were admitted s/p suicide attempt), management of agitation related to delirium or major neurocognitive disorder (>20%), alcohol/substance related issues (>15 %), management of bipolar disorder/psychosis (> 5%), depression/adjustment/demoralization (> 5%), anxiety disorders (5%), somatoform and functional neurological disorders (4%), and capacity consults. Residents also receive experience evaluating for catatonia, acute stress/PTSD, peripartum depression/psychosis, buprenorphine inductions, etc.
Addiction Rotation at Spokane Teaching Health Clinic (STHC)
In the light of the opioid epidemic, training psychiatrists that are competent in delivering evidence based treatments for patients with use disorders is imperative. We have worked hard to ensure we are providing excellent training to our residents in addictions. During addictions rotation at the Spokane Teaching Health Clinic, residents provide medication assisted treatment for opioid, alcohol, stimulant, and tobacco use disorders. All residents receive eight hours of training in buprenorphine during their second year and start prescribing buprenorphine during their Addictions rotation. Residents are trained in the following interventions and then provide these services as part of their ambulatory addictions clinic:
Medication Assisted Treatment (MAT): Buprenorphine, Naltrexone, Disulfirum, Acamprosate, Nicotine replacement, Chantix
Harm Reduction Education/therapy
Psycho education about SUD’s
Screening for Hepatitis and HIV
Referrals to CD assessments for IOP/IP CD treatment, AA/NA meetings
Measurement based guided treatment (based on UDS)-Point of care UDS coming in October 2019
Contingency Management coming in 2020
OD education and free naloxone
Additionally, residents visit an Intensive Outpatient Program, a methadone clinic and watch a Chemical Dependency Assessment done by a Chemical Dependency Professional. The Spokane Teaching Health Clinic has MA support to assist residents in collecting UDS, checking the scheduled medication prescribing databases, pill counts, vital signs and scales. Residents frequently cite the Addiction clinic as their favorite clinic at the Spokane Teaching Health Clinic.
Psychiatry Speciality Clinic at STHC
R2, R3 and R4’s all have personal medication management clinics at the Spokane Teaching Health Clinic. Supervision gradually gives way to independence and autonomy as residents develop. The clinic is noteworthy in several ways. Each of the rooms is equipped with safety alarms (although we haven’t had to use them yet), and audio/video equipment to allow observation by faculty to enable safety as well as clinical feedback. The clinic has MA support to assist residents with rooming patients, collecting vital signs, scales, review of systems and scheduling. Resident patient appointments start with 90 min for an intake for R2’s and then transitions to 60 min intakes and 30 min return visits for R3’s and R4’s. Patient appointment time is limited to 2.5 hours in a half day to enable learning and diminish burn out. Residents are trained in coding and practice throughout residency. 100% of their notes are reviewed by a coder to ensure they become competent in accurate coding by the time the graduate. The clinic has ample free parking and is biker/walker friendly with a pedestrian bridge leading towards the hospital and rail to trail for cyclists. We have two showers at the clinic for staff that like to rinse off after their work out.
Collaborative Care Primary Care Consultation at STHC
Primary care consultation in a high fidelity collaborative care training model is a unique feature of our program. We have a mature, longitudinal training in collaborative care psychiatry, staring in PGY2 and threading through PGY and PGY4. Our training includes curriculum content, developed by the AIMS center at the University of Washington, and taught by psychiatry residency program faculty who are educators in the Community Based Fellowship at the University of Washington. Clinical rotations embed all principles of collaborative care, including patent centered treatment, population focused training, training in evidence based treatment and therapy for the primary care setting, outcomes based treatment, with use of a population based registry for care and a paradigm that uses a stepped care model so that those who are the most ill, get the most access to care, accountability, and quality improvement. You will consult to a range of primary care clinics across Providence Spokane and Steven’s County, working with patients from teenage years to the very elderly.
Child and Family Services at Frontier Behavioral Health
Frontier Behavioral Health (FBH) Child and Family Services clinic is a community mental health organization that cares for individuals ages 3 to 18 who are on state insurance (Medicaid). Each patient at FBH is assigned to a clinician who provides case management and developmentally appropriate therapy. If the clinician suspects that a patient could benefit from a medication treatment, they refer the patient to a psychiatrist and/or psychiatric ARNP for psychiatric evaluation and treatment.
During this rotation, residents are directly or indirectly supervised by board certified Child and Adolescent psychiatrists. Patients are scheduled for 90 minute intakes, and 30 minute follow ups. Residents practice obtaining thorough histories that include maternal obstetrical history, and developmental history.
Inpatient Rotation at Eastern State Hospital
Eastern State Hospital (ESH) is a state psychiatric hospital located in Medical Lake, WA that serves patients in the eastern part of Washington. ESH has civil, forensic and geriatric units. The average length of stay is 181 days, and the civil side admits about 240 people a year.
On this rotation, a resident works with an attending physician who carries between 15-17 patients. Patient are seen, on average, between two to three times weekly. The resident / attending team can expect 2-3 admissions a week. ESH does not currently have an electronic medical health record, and relies on paper charts where residents learns to write orders, and document legibly, and efficiently.
At this facility, common treatment modalities include medication management (antipsychotics, antidepressants, mood stabilizers), in addition to delivery involuntary medications. Residents work closely with a treatment team including a psychologist, social worker, activity therapist, occupational therapist, and speech therapist.
Our primary site for outpatient psychotherapy is currently located at the Health and Counseling Services of Gonzaga University, a private, religious university located on 152 acres near downtown Spokane.
Residents begin working at Gonzaga University starting in PGY-2. During PGY-2 and PGY-4, residents spend one half day per week at the counseling center. During PGY-3, residents spend 1 full day at Gonzaga.
On ½ day rotations, residents follow 3 therapy patients. On full day rotations resident treat 5 therapy patients. Treatment modalities include supportive therapy, cognitive behavioral therapy, harm reduction strategies, problem solving techniques, acceptance and commitment therapy which mirror psychotherapy didactic sessions occurring throughout the resident training.
Motivational Interviewing Training
Training in Motivational Interviewing is a strength of our program. Residents are introduced to the principles of the therapy in didactics and quickly move towards coached practice with the aid of coding. They are expected to provide approximately 8 tapes for coding during their R2 year. The coding of their tape provides specific feedback to support their practice in providing high fidelity Motivational Interviewing to patients. The curriculum has evidence for increasing MI skill acquisition. During Addiction rotation residents are required to practice Motivational Interviewing and have their MI skills coded again. An elective in Motivational Interviewing is available in the fourth year as well.
Quality Improvement and Patient Safety Curriculum
All residents and faculty mentors participate in quality improvement projects annually. Projects are encouraged to be clinically focused, small, passion projects. Residents are given allotted QI time during their R2 year to work on QI to minimize risk of burnout. These projects have resulted in permanent changes in our system and have improved patient care. Our graduates are comfortable and quick at setting up and implementing QI projects as part of their practice.
Patient Safety Curriculum
Patient safety projects form a longitudinal thread through the entirety of the residency experience, blending into quality improvement projects for the more advanced residents. An introduction to root cause analyses occurs during the R1 year, with a focus on identifying modifiable causes for adverse events that allows for the proposal of systematic changes. During R2 year, root cause analyses are reviewed in more detail during the Systems of Medicine rotation, and residents have dedicated time to initiate QI projects that may address identified systematic patient safety issues. Further QI opportunities during R3 and R4 year allow for ongoing involvement with patient safety concerns, and R3’s demonstrate their mastery of the root cause analysis by presenting a case at one of our quarterly Morbidity and Mortality conferences (which everyone attends across all four years).