Fellowship in Psychosomatic Medicine (Consultation-Liaison Psychiatry)
Beth Israel Medical Center

Background
Beth Israel Medical Center is an 899-bed tertiary care teaching hospital located in Manhattan near the Village, which has been serving New York City for the past century. In addition to the general medical-surgical units, Beth Israel boasts numerous specialty inpatient units covering Oncology, Physical Medicine/Rehab, Cardiology, Family Medicine, Nephrology, Intensive Care, Cardiac Surgery, OB-GYN, and Neurology. Beth Israel has an academic affiliation with the Albert Einstein School of Medicine and is a major clinical campus for the medical students' psychiatry rotation. Over the years, Beth Israel has developed a reputation for a caring involvement with its surrounding communities, such as the East Village, Gramercy Park, Union Square, Lower Eastside, SoHo and Nolita

The C-L Division at Beth Israel had its informal beginnings in the 1960's. Dr. Joel Wallack established the fellowship in 1986. Dr. Philip Bialer led the Division from 1992 through 2008. Dr. Nancy C Maruyama, the current Fellowship Training Director and Physician-in-Charge of the Division, is a graduate of the Memorial Sloan-Kettering Cancer Center Fellowship. Dr. Joel Wallack, a graduate of the fellowship program at Montefiore and Mount Sinai is presently Division Chief and Associate Director of the fellowship program. The program has trained over 40 fellows, many of whom have taken on leadership roles in Psychosomatic Medicine and C-L Psychiatry nation-wide.

The program received full accreditation from the American Council on Graduate Medical Education (ACGME) on July 1, 2004. We were one of the first of seven programs in the nation to receive such accreditation. There are thee full-time faculty members, and two half-time faculty. The length of training is for 12 months beginning on July1. All faculty are board certified in Psychosomatic Medicine.

Eligibility Requirements
All fellow candidates must be graduates of an ACGME accredited Psychiatry Residency Program. All candidates must have passed Part 3 of the USMLE. International Medical Graduates must have a valid ECFMG certificate for visa. Candidates must take the General Psychiatry Boards during fellowship, if they do not have board certification. Eligible candidates must commit to take the Psychosomatic Subspecialty Boards.

Application Process
Candidates are encouraged to submit applications starting in July prior to the year of fellowship. Candidates must submit an application, three letters of reference, and a personal statement. Appropriate candidates will be offered interviews starting in August.

Training Program
The training consists of several year-long activities:

1. Clinical and service activities (inpatient and outpatient)
2. Liaison activities and work with multidisciplinary teams
3. Didactics and supervision
4. Teaching and supervision of residents, medical students and non-medical staff
5. Administrative duties
6. Research

Inpatient Consultations
The consultation service at Beth Israel is a busy one with an average of 160 consultation requests per month. The fellows are assigned approximately four consults per week. Over the course of the year, they see a wide range of patients with varying diagnoses from all services in the medical center; the fellows are often assigned the more complicated cases. Daily work rounds, led by C-L Attendings, are held with the fellows and residents during which all cases seen the day before are presented and discussed. In addition, there are two clinical case conferences held weekly. The fellows receive abundant supervision, meeting individually with Dr. Maruyama weekly for formal supervision and review of their inpatient consults, and academic projects. The fellows receive daily supervision from Dr. Daniel Safin and Dr. Nancy Maruyama and Dr. Dickson Jean. As they progress, fellows take on greater responsibilities; they lead rounds and case conferences, and take an administrative role in running the CL service.

The Peter Krueger Clinic for the Treatment of Immunologic Disorders (PKC)
This is a required part-time, year-long outpatient rotation staffed by two attendings with expertise in the care of patients with HIV who are both board certified in Psychosomatic Medicine. Fellows work as part of a multidisciplinary team, and follow out-patients for a half day each week under the supervision of the attendings. Educational activities include an hour of weekly supervision where cases are reviewed and an HIV Journal Club where scholarly articles about the care of patients with HIV are discussed. The fellows participate weekly in an hour-long multidisciplinary Mental Health Care Team meeting and case presentation, consisting of psychologists, social workers, care coordinators, psychology interns and externs. Fellows will progress to lead the multidisciplinary team meeting.

Philips Ambulatory Care Center
Fellows are required to spend a half day a week for six months at an ambulatory primary care outpatient clinic. Patients are evaluated with the medical physicians and the Chief of the Division of Psychosomatic Medicine. Emphasis is placed on collaborating with the primary physician to evaluate psychiatric/ psychosocial problems and establish an appropriate diagnostic and treatment plan. An integrated care model is utilized which emphasizes teamwork and shared expertise. Additionally, the fellow gains training and hands-on experience in precepting medical interns and residents in the management of patients in the outpatient medical clinic. Medical interviewing, the doctor-patient relationship, and some motivational interviewing techniques are demonstrated by the attending psychiatrist with a goal of enabling the fellow to become a proficient teacher and role model and be able to precept independently with indirect supervision over the course of the rotation.

Outpatient Oncology
Fellows are required to spend a half day a week for six months of the year at an outpatient Oncology Center where they see patients in conjunction with a psychiatrist who specializes in the care of patients with cancer and their families. Two patients are seen each week and followed over the duration of the rotation. Fellows learn about issues related to being diagnosed, treated for and living with cancer (e.g. effects on sexuality, etc) and about psychiatric disorders as they present in cancer patients. The attending gives eight psycho-oncology lectures and uses case vignettes with questions. Patients are also treated for pain control and insomnia management.

Outpatient Psychotherapy
Fellows follow medical outpatients for weekly to several times per month psychotherapy. Therapeutic issues may involve adjustment to medical illness, how it impacts family or loved ones, existential issues, how to disclose to others and when, how to interact effectively with the medical team. Patients may be audio- or videotaped, which will be reviewed during supervision.

Electives
Electives may be arranged part-time. Electives may be in areas of particular interest to the fellow such as pain management, palliative care or women’s health.

Didactics and Supervision
The full-time faculty supervises all clinical work, teaching, administrative, liaison and academic activities. In addition there are several formal didactics. The first is a 22 week-long course on C-L psychiatry. Experts in this field are invited as guest lecturers for this course to complement our own faculty. The areas covered in this course include:

Introduction to Psychosomatic Medicine: History and Overview
Legal and Ethical Issues
Capacity
Delirium
Psychopharmacology of the Medically Ill
Substance Abuse
Neuropsychiatry of HIV/AIDS
Psycho-oncology
Coping, Personality Styles, and the Hateful Patient
Malingering and Factitious Disorders
The Patient-Physician Relationship
Psychiatric Aspects of Movement Disorders
Transplant Psychiatry
Death and Dying/ Palliative Care
Somatoform Disorders
Pain Evaluation and Management
Cross Cultural Issues
Reproductive Related Disorders
Psychogenic Non-epileptic Seizures

There is also a year-long, weekly Fellows’ Seminar, organized by Dr. Dickson Jean, with didactics on Research Design and Methodology, Adjustment to Medical Illness, Psycho-oncology, Pain Management, and a review of CL aspects of Cardiac, Renal, Endocrine, Gastrointestinal and other areas. Current text books, current and classic papers will be read. Journal Club meets monthly to critically evaluate recently published studies.

There is a weekly journal club centered on the care of patients with HIV. Journal articles, relevant chapters on the psychiatric care of patients with HIV are read.

Case Conferences
There are two weekly case conferences that focus on patients in the hospital. The first is led by the program director, chief of the division, or by visiting attendings with different expertise (for example, specialists in Movement Disorders, Geriatrics, Addictions, Psychotherapy, etc.). PGY2 Psychiatry Residents, medical students, Family Medicine Residents, and the entire faculty participate. The attending interviews an inpatient and the interview is followed by a group discussion of the issues raised by the patient’s case. Each week patients with diverse diagnoses and problems are evaluated.

The second case conference is led by one of the attendings who interviews an inpatient. The interview is followed by a group discussion. This case conference differs from the previous one because later in the year, the fellows will progress to become the interviewer. Another difference is that it provides the fellows with the opportunity to educate junior residents and medical students about depression in the medically ill, delirium, dementia, and adjustment to medical illness. Fellows learn how to teach in the case conference format, gain skills in interviewing in front of a group, and understand how and what to teach trainees of different educational levels.

There is one monthly ombudsman-type case conference with Oncology. These rounds are attended by oncology fellows, oncology nurses & social workers, and medical house staff. It is led by senior faculty from oncology and psychiatry. The Chief of the Division interviews a cancer patient. The focus of this conference is on how patients adjust to a cancer diagnosis and treatment and on educating the oncology team about psychosocial issues, patient adaptation to illness and their own experience of caring for cancer patients. The physician-patient relationship and factors that affect it are discussed, and team members share their experience of working with the patient.

Teaching and Supervision of Residents and Medical Students
Fellows serve as the primary supervisor for Family Medicine third year residents who rotate through C-L as part of their training. Fellows also supervise PGY-2 Psychiatry residents and third and fourth year medical students. Fellows teach in journal club, seminars, formal lectures, rounds and in the case conference format mentioned earlier. Formal lectures for medical students on topics such as Delirium or Depression are arranged during the course of the year.

Administrative Duties
The fellows will have a minimum of two months experience coordinating the consult service under the supervision of the attendings. This will involve working with non-psychiatry physicians, triaging of consultation requests being called in, assigning them to residents and staff, and maintaining the patient log and database. Fellows will also learn about the financial aspects of the C-L service and about billing for consultations, and clinical information systems. This will include learning proper diagnostic and CPT code documentation, as well as the process of working with Medicare, Medicaid, and other third party payers. Fellows participate in weekly Division Staff Meetings where they will learn about how the Division interfaces with the larger Psychiatry Department and the Medical Center. Fellows are members of the Psychosomatic Medicine Fellowship Graduate Medical Education Committee. They participate in educational program development, evaluation and improvement. They are integral members of the selection committee for new fellows.

Research
Fellows are required to participate in academic projects. They may participate in ongoing projects within the division, or develop their own project often based on clinical data or on complicated clinical cases. Past projects included “Documentation of Risk Factors for Cardiac Arrhythmias in the Treatment of Delirium with Neuroleptics,” “Death and Dying: Who Decides When, Where and How,” “A Case of Fulminant Neuroleptic Malignant Syndrome,” Fellows work on a joint research / academic project that will be presented at Grand Rounds. Each year the presentation has been submitted as an abstract and presented at the Academy of Psychosomatics Annual Meeting. For 2011-2012 year the division will be presenting five posters. Fellows are encouraged to write up their findings for publication.

Evaluation
Fellows are formally evaluated four times a year and at other points (following a presentation, after a patient encounter, etc.). Evaluators include attending supervisors, patients, non-physician staff, trainees whom the fellows supervise, peers, and him- or herself. Fellows are directly observed in their duties as clinicians, teachers, and administrators. Other trainees evaluate the fellows’ skills in handover of clinical information about patients, as well as communication, professionalism, and teaching skills.

Conferences
Fellows attend the Annual Meeting of the Academy of Psychosomatic Medicine (APM) in November each year. Expenses are paid for by funding from the Division. Fellows are encouraged to join the APM.

Benefits
Beth Israel Medical Center supports a generous package of benefits to its trainees and staff. The Fellowship stipend is described on the GME website. Housing is usually available through the Medical Center at attractive rates.

Beth Israel has an excellent full-service medical library, the Seymour J. Phillips Library. It is conveniently located on the 12th floor of Fierman Hall. Fellows have their own computer and may search the electronic databases available through the library (OVID, and PsychLit, Cochrane, etc.), and request papers. Papers typically arrive via email within 24 hours.

Finally, the Division of Consultation-Liaison Psychiatry as well as the Department of Psychiatry at Beth Israel is sincerely interested in fostering a pleasant and collegial working environment. The concerns of trainees are taken seriously. There are many opportunities to socialize within the department and with other medical colleagues.

For an application and/or other inquiries, please contact:

Nancy C. Maruyama, MD
Physician in Charge, Consultation-Liaison Psychiatry and Psychosomatic Medicine
Beth Israel Medical Center
First Avenue at 16th St., Fierman Hall, 5F09
New York, NY 10003
Phone: 212-420-4094
Email: nmaruyam@chpnet.org

or

Joel Wallack, MD
Chief, Consultation-Liaison Psychiatry and Psychosomatic Medicine
Phone: 212-420-2398
Email: jwallack@chpnet.org