Residency Program in Psychiatry

Clinical Overview

The Mount Sinai Hospital

Inpatient
Outpatient
Psychiatric Emergency Service

Inpatient Psychiatry Service

The inpatient service at The Mount Sinai Hospital is the oldest general hospital psychiatric inpatient service in the nation and is designed to address the full range of acute psychiatric issues. Located in Mount Sinai's most modern buildings, the 103 beds of the Psychiatric Care Center are organized into six discrete locked units: General Adult (2), Dual Diagnosis, Geriatric, Adolescent, and Child. Each is self-contained, with its own staff, beds, and nursing. This division of duties facilitates the promotion of expertise within each of these subspecialties.

Medical Students Mount Sinai serves a vastly diverse patient population. Approximately 2,300 individuals receive treatment in the psychiatric care center at Mount Sinai each year. Genders are approximately equal, and ethnic makeup is approximately 45 percent white, 30 percent Hispanic, 20 percent black, and 5 percent other. The hospital serves both the affluent Upper East Side of Manhattan and the socioeconomically challenged East Harlem community. In addition, many admissions are transferred directly from affiliate hospitals (including Pilgrim Psychiatric Center, a long-term state hospital affiliated with Mount Sinai which preferentially contracts Mount Sinai Psychiatry to evaluate and treat patients in a "Second Chance" program), nursing homes, community mental health agencies, and residence programs. Many patients are homeless and seriously disenfranchised. Others are severely and persistently mentally ill, and in need of comprehensive psychiatric, medical, and social services.

Ages range from 6-13 years old on the child unit, 13-18 on the adolescent unit, and over 18 on the adult units. Given Mount Sinai's expertise in geriatric medicine and psychiatry, patients are frequently well into their 80s and 90s. The diagnostic range of patient presentations is also extremely diverse. Residents gain experience in the evaluation and treatment of all the major psychotic, mood, anxiety, cognitive, and substance use and induced syndromes. Most common diagnoses include Schizophrenia, Bipolar Disorder, Major Depressive Disorder, Personality Disorders, Dementia, Delirium, and Substance Use and Induced Disorders. Acute psychiatric care, crisis intervention, establishment of a therapeutic alliance, maintenance of safety, and rapid psychopharmacological stabilization are learned intensively. Experience with electroconvulsive therapy and with serious medical comorbidity is common.

Residents rotate through all of these services during their first two years of residency at Mount Sinai. Architecture There are between one and two teams on each unit, depending on the number of patients. A treatment team consists of an attending psychiatrist, one to two psychiatric residents, nurses, and a social worker. As the average length of stay on the inpatient units is approximately 14-15 days, residents have the opportunity to get to know their patients relatively well. Residents carry up to eight patients of their own and are on call until 10:00 P.M. approximately four times per month. PGY-IV residents return to the inpatient floors as Chief Residents with managerial, supervisory, and didactic duties.

Residents provide essential patient care, participate in daily interdisciplinary team meetings, daily patient rounds, and receive ongoing direct one-on-one supervision by full-time inpatient attendings in an apprenticeship model. Emphasis is placed on psychiatric and medical evaluation, formulation, treatment intervention and acute psychiatric care of serious mental illness. Evidence-based psychopharmacological practices are stressed. Psychiatric interviewing and mental status examinations are routinely performed with the unit attending. Case formulation, differential diagnosis, and treatment planning are discussed daily.

Group Therapy Besides the daily presentations of their patients in morning rounds, residents present each patient's condition and care plan status at weekly interdisciplinary team rounds. Residents also formally present selected inpatients at weekly case conferences. Techniques of psychopharmacologic therapy, milieu therapy and individual and group psychotherapy are emphasized. Residents also occasionally treat patients participating in research studies, thereby becoming familiar with research methodology and protocols. Residents provide medical student supervision and education, gaining invaluable experience as teachers themselves early in their training. Psychiatric interviewing skills and mental status examinations are further refined by this experience.

Outpatient Psychiatry Service

The Ambulatory Care Division has three primary outpatient divisions through which residents rotate:

The Adult Psychiatry Outpatient Division (OPD) is a general clinic, providing all modalities of treatment to its patients, including medication management and all forms of individual and group psychotherapy. The total number of yearly visits to the adult clinic exceeds 65,000, surpassing any other Mount Sinai clinic in any specialty.
The Geriatric Psychiatry OPD provides ongoing clinical care for more than 3,000 patients annually and is the setting for the evaluations of all patients entering studies in the Alzheimer's Disease Research Center.
The Child and Adolescent Psychiatry OPD provides treatment to children of all ages, with more than 10,000 visits annually. A range of therapeutic modalities is offered, including psychiatric and psychological diagnostic evaluation, individual and group psychotherapy treatment, psychopharmacologic evaluation and treatment, and parent guidance and family treatment.

The outpatient department is the site of PGY-III and PGY-IV training, though residents may elect to begin a long-term psychotherapy case while at the PGY-II level. At Mount Sinai residents learn integrated pharmacological and psychodynamic approaches to psychiatric outpatient management. Residents' offices are located in a modern renovated space on Fifth Avenue where treatment is overseen by both the extensive voluntary faculty (many of which are faculty at the New York Psychoanalytic Society & Institute) and by dedicated full-time senior faculty. An average adult outpatient caseload consists of 30-35 patients in various modalities and phases of care. Over time, the full range of diagnoses are encountered in evaluation and management.

Distribution of Patients

A typical distribution of these patients at any one point in time would include:

15 patients receiving continuation and maintenance phase care with psychotropic medication (these patients also receive parallel verbal therapy) seen 1-2 times per month
2-5 patients in psychodynamicpsychotherapy seen 1-3 times weekly
2-4 patients in individual supportive psychotherapy seen every 1-2 weeks
3-5 patients in evaluation/short-term crisis intervention and stabilization
2-4 patients in cognitive/behavioral therapy, and 1 couple/family
2-3 child or adolescent patients for long-term treatment, with several child or adolescent patients undergoing diagnostic evaluation at any given time
5-6 patients in the Day Treatment Program (these severely and persistently mentally ill patients are seen in a weekly group)
Additionally, each resident manages a caseload of 15-20 patients in the geriatric service typically seen on a monthly basis

Supervision of Residents

Each PGY-III resident receives mandatory scheduled supervision in every area of practice continuously throughout the years of their involvement. This includes:

Weekly direct attending supervision of all patients seen in evaluation and stabilization: 2 hours/week
Caseload supervision: 1 hour/week
Cognitive-behavioral supervision: 1 hour/week
Long-term psychodynamic psychotherapy supervision: 1 hour/week per patient (a resident may have a different supervisor for each patient treated in this modality)
Brief treatment supervision: 1 hour/week
Couple/family supervision: 1 hour/week
Group therapy supervision: 1 hour/week
Child and adolescent evaluation: 1 hour/week
Child and adolescent ongoing treatment: 1 hour/week
Geriatric psychiatry: 1 hour/week
Day treatment supervision: 1 hour/2 weeks

Additional clinics which are available for elective rotations but through which residents are not required to rotate include the Alcohol and Other Drugs outpatient day treatment program, Vocational Services, Infant Development programs and the World Trade Center Medical Monitoring and Mental Health Program.

Psychiatric Emergency Service

Mount Sinai Buildings A dedicated facility separate from though adjacent to the medical ER, the Psychiatric Emergency Service (PES) provides rapid, comprehensive assessment and treatment to nearly 3,000 patients per year. The PES prides itself on providing a safe environment for patients and staff and is staffed by an attending and resident 24 hours / 7 days per week. There is also a dedicated security guard for the PES at all times. The physical environment of the PES is one that allows for intimate therapeutic contact with patients in quiet interview rooms while at the same time providing for the absolute safety of staff members.

Residents are instructed in the practice of assessment, crisis management and community psychiatry. Residents evaluate and present cases, teach medical student rotators, and work one-on-one with an attending. PGY-II residents spend one to two months in the PES. PGY-III residents cover the PES overnight and on weekends under the supervision of an attending psychiatrist. Residents have the option of returning to the PES as Chief Residents during their PGY-IV year.

Craig Katz, M.D., Assistant Clinical Professor of Psychiatry at Mount Sinai, is a dynamic teacher and mentor for residents rotating through the PES. Dr. Katz facilitates a weekly journal club in the PES and serves as on off-unit supervisor for residents rotating in the PES, providing weekly, individual teaching to help residents develop their clinical skills in the acute care setting. Dr. Katz is also Co-Founder and President of Disaster Psychiatry Outreach (DPO), an organization that serves as a disaster mental health team, providing on-site psychotherapeutic and psychopharmacologic services in coordination with government agencies and public, private, and charitable organizations involved in disaster relief. DPO was and continues to be instrumental in the psychiatric follow-up to the World Trade Center disaster. Many residents work and volunteer in ongoing DPO projects both domestically and internationally.

Patrick Runnels, M.D., (PGY-IV) teaching mental health workers in Belize Additionally, Dr. Katz founded the Global Psychiatry Elective for PGY-IV residents at Mount Sinai as part of the Global Health Residency Track at Mount Sinai (http://mssm-ghc.org/). Through a rigorous public health didactic curriculum and a carefully selected field project, the Global Psychiatry Elective is a unique experience among psychiatry residency programs, providing participants with a foundation of knowledge, skill and experience in global mental health.

Department of Psychiatry