Clinical Rotations

Consistent with our drive to be innovative and creative, our residents and faculty strive to continually improve our Adult Psychiatry Residency Training Program.  Thus, change in the structure and organization of the residency during your potential tenure with us is always a possibility.  Feel free to ask us about exciting details of potential changes and organization of the program, and please know that planning for change routinely includes active involvement of both residents and faculty.  The current configuration of the training program is described below: 

PGY-1 Year

The PGY-1 Year consists of four 3 month blocks.  Residents have a total of six months combined experience in the UCSF Departments of Medicine and Neurology and six months of psychiatry training at San Francisco General Hospital (SFGH). The order of the rotations is split evenly as in the table below:

	6/21-9/21	9/22-12/21	12/22-3/21	3/22-6/21	6/22-6/30
Half of the class (n=8)	3 mo of med-neuro	3 mo of psych	3 mo of med-neuro	3 mo of psych	All interns are off each year from 6/22-6/30 prior to starting PGY-2 year on 7/1.
Half of the class (n=8)	3 mo of psych	3 mo of med-neuro	3 mo of psych	3 mo of med-neuro

The Med/Neuro rotations include a total of four months of Primary Care (Ward Medicine, Emergency Medicine, and Outpatient Medicine) and two months of Neurology.  For most interns, one month of the Neurology experience emphasizes the behavioral and neuropsychiatric aspects of neurology and is based in the UCSF Memory & Aging Center and the other is an inpatient neurology rotation.  For those residents interested in a Child Psychiatry career, one of the Primary Care months can be Pediatrics, and one of the neuro months can be Pediatric Neurology.

The other six months of the first year are spent learning principles of psychiatric evaluation and treatment planning on the psychiatric inpatient units at San Francisco General Hospital (SFGH) in two separate 3 month blocks.  The SFGH inpatient units treat patients with acute psychiatric emergencies in a multi-disciplinary, short-term inpatient setting.  At SFGH, residents are introduced to the principles of care for the chronically mentally ill in the public psychiatric sector.  Uniquely, SFGH has Ethnic/Minority focused inpatient treatment teams. These teams serve Asian, Black, Latino, women, HIV positive/AIDS, lesbian, gay, bisexual and transgender, and forensic patients and provide training in cultural, ethnic minority, sexual orientation and gender-related issues.  During their months at SFGH, interns rotate between several different treatment teams.

Residents also have a three-week Emergency Psychiatry rotation at some point during their 6 months of psychiatry.  The Psychiatric Emergency Service (PES) at SFGH is a 24-hour, 7 day-a-week, acute psychiatric emergency service which provides almost all of San Francisco’s psychiatric emergency care.  In addition, residents are introduced to principles of Assertive Case Management for severely mentally ill by participating in “hotel rounds” and visiting the Community Focus Program.

Every Wednesday afternoon, interns are not on their Med/Neuro and inpatient psychiatry rotations, and instead, they all come together for psychiatry residency core didactics, including "Intern Clinic" which is a seminar series organized by Psychiatry Chief Residents that addresses the experiential aspects of internship, with particular attention paid to the intern’s developing medical and psychiatric identity.  PGY-1 didactics also include Theories of the Mind (an introductory course to psychotherapy), Neuroscience, and core topics focused on inpatient psychiatry.  In addition to didactics, the PGY-1 Resident Group, facilitated by a volunteer faculty member, also meets on Wednesdays. 

PGY-2 Year

The PGY-2 year includes three months of inpatient consultation/liaison at either SFGH or the UCSF Medical Center, three months of inpatient psychiatry at Langley Porter Hospital and Clinics (LPPH&C), and six months of full-time outpatient psychiatry at the San Francisco VA Medical Center (SFVAMC).

Consultation/Liaison – During this 3-month rotation, residents learn how to provide psychiatric consultation in the acute inpatient medical settings at either the UCSF Medical Center or San Francisco General Hospital.  On both C/L services, second year residents work very closely with faculty and learn how to complete thorough evaluations and manage psychiatric presentations in the acute hospital and in the emergency department.  Residents also learn how to work successfully as a consultant to the primary team caring for the patient.

Langley Porter Adult Inpatient Program (AIP) – This service offers comprehensive inpatient treatment on an acute locked psychiatric inpatient unit. Residents learn how to conceptualize inpatient treatment within a large and complex system of mental health care.  This objective is facilitated through a unique collaborative relationship between the inpatient service and a local large HMO organization (Kaiser Permanente) combined with a diverse mix of patients with multiple other types of insurance coverage.  The patient population is extremely broad including ages 17 and above and all socio-economic classes.  Residents assess and treat a wide range of clinical presentations on the AIP including major depression, psychotic disorders, bipolar disorder, personality disorders, and delirium.  The AIP also has an active electroconvulsive therapy (ECT) service, and residents gain direct experience working directly with patients receiving this treatment. 

SFVAMC – Psychiatry Outpatient Service – This six-month full-time rotation has been designed to give residents exposure to the principles of outpatient psychiatry evaluation and treatment at an early point in their training.  PGY-2s focus simultaneously on a number of major outpatient treatment components: Substance Abuse Treatment Clinics, Psychopharmacology Clinics, Outpatient Consultation/Liaison Program and Specialty Outpatient Clinics including PTSD Clinical Team, HIV, Family Therapy, Brief Therapy, Psychotic Disorders, Women’s Mental Health and Affective Disorders.  In these settings with close supervision, residents conduct comprehensive diagnostic evaluations and learn a variety of treatment modalities, including time-limited individual psychodynamic psychotherapy (TLDP), pharmacotherapy, group psychotherapy and family/couples therapy.

If interested in the research track (described in more detail in the PGY-3 year section below), residents have the option to designate 4 hours/week while at the VA during their PGY-2 year to take courses in research methodology and/or begin meeting with potential PIs and begin developing a research project.  The 4 hours/week that are released for research take the place of the family/couples therapy module which can then be made up during the PGY-4 year if a research track-bound resident selects this option.

PGY-3 Year

The PGY-3 Year is an exclusively outpatient experience located primarily at Langley Porter Hospitals and Clinics (LPPH&C) on the Parnassus Campus of UCSF. It is comprised of teaching modules within the Adult Psychiatry Clinic (APC) that include: an intake clinic called the Specialty Assessment Clinic, brief and long-term individual psychotherapy, brief and long-term group psychotherapy, and the Medication Management Clinic.  Special attention has been given to the educational experience of residents in the APC to provide comprehensive training, supervision and support in the application of diverse treatment models.  Third year residents also learn about the evaluation and treatment of children, adolescents, and families in the Child and Adolescent Services (CAS).  To promote professional development, all third year residents present a critical appraisal of a journal article at the Department’s monthly journal club.

APC Overview – Residents in the Adult Psychiatry Clinic are assigned to one of three outpatient teams, each of which has 3-5 PGY-3s and 3-5 PGY-4 members plus 3 faculty.  In weekly team meetings, residents present cases and learn how to integrate a variety of different treatment modalities. Residents receive expert training in long-term psychodynamic individual psychotherapy, long-term psychodynamic and brief cognitive behavioral group psychotherapies, individual cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT) and pharmacotherapy.  Intensive weekly individual and small group supervision is provided for all of these activities; supervision includes extensive use of videos.  All residents have digital cameras as part of their computer work stations in their offices to facilitate teaching using video.  Each computer has a digital video camera installed, and the videos are stored on a secure server for review during supervision sessions.

Specialty Assessment Clinic – This service consists of state-of-the-art general psychiatry and specialty focus assessment clinics. These clinics are designed to provide comprehensive teaching and “real time” supervision in diagnostic evaluation, outpatient consultation-liaison and brief psychiatric interventions. Specialty clinics include a host of selective training opportunities including: Medical Psychiatry, Women’s Mental Health including a sub-specialty clinic, the Women’s Mood and Hormone clinic, Anxiety and Affective Disorders, Psychopharmacology Consultation, Geriatric Assessment, and HIV/AIDS consultation.  Patients evaluated in the SAC are seen for a 90 minute intake appointment with both a PGY-3 and a faculty member in the room together.  The patients are then referred back to their clinician (if a consultation) or are often referred to PGY-3 or PGY-4 residents for continued treatment in formal brief therapy (individual or group), long-term psychotherapy (individual or group), and/or long-term medication management.

Medication Management Clinic – Each PGY-3 treats a caseload of patients receiving pharmacotherapy in a medication management clinic.  During clinic, residents have real-time supervision from faculty members, and each clinic uses evidence-based medicine techniques routinely to answer clinical questions (a computer with web access and large monitor are in the clinic’s meeting room). In addition, each third year resident participates in a regular pharmacotherapy supervision small group. These groups use case material brought by residents to master the skills of evidence-based clinical practice, including question formulation, information acquisition, critical appraisal, and application to the individual patient. Finally, all third years attend a series of workshops that focus on the essential skills of pharmacotherapy.

Child & Adolescent Psychiatry – This training module includes didactics and a 6 month experience observing and conducting supervised comprehensive psychiatric evaluations of children, adolescents and their families. In addition, residents have a one-year longitudinal experience with a child or adolescent outpatient including weekly individual supervision.  Seminars teach residents about child therapy, childhood psychopathology and normal development. Electives in the Tourette’s and Pervasive Development Disorders (Autism) Clinic are also available. A limited number of residents interested in obtaining experience working with children and families in a community mental health/public setting may elect an alternative year-long Child Psychiatry rotation at SFGH (see below for more information).

Tracks within the PGY-3 year:

Research Track – The research track is for trainees clear in their goal to pursue a research career post-residency, including a research fellowship. Residents in this track have their PGY-3 year tailored to accommodate their research interest. Thirty percent of their time is allocated for research training, and the remaining 70% is the core outpatient training experience.  In the PGY-4 year, significantly more time is allotted for research (see below).

Residents with M.D., Ph.D. degrees who are pursuing basic science research will begin working with their research faculty during this PGY-3 year. Those pursuing clinical research will begin a series of experiences including course work and literature reviews aimed at helping them acquire the necessary tools for understanding clinical research design and methodology, or if they are further advanced having taken courses during the PGY-2 year or coming to residency with prior research training, they will begin work on their specific project. The overall objective for residents in either the basic or clinical research track is to define an area of research that they can continue to investigate following the completion of residency as post-doctoral fellows. Residents in both the basic or clinical research tracks are mentored closely with respect to obtaining post-residency research funding including several opportunities for such funding within the department at both the VA and Langley Porter sites. Past trainees have been highly successful in competing for fellowships in Clinical Research offered by the VA, as well as others offered locally by UCSF, or, nationally, by other institutions and foundations. For trainees who choose to progress into fellowships at UCSF, emphasis is given toward development of a NIMH mentored career award application that will facilitate the transition to status as an independent investigator and full-time faculty member.

An annual Department of Psychiatry research retreat and periodic evening meetings allow faculty, research fellows and research residents to present findings from their studies and to form collegial relationships through networking.

Community Psychiatry Track – At SFGH, a part-time community psychiatry elective is offered during the PGY-3 year to those residents wishing to develop additional expertise working with multicultural public sector patients. Residents treat high-risk pregnant and postpartum women within an integrated multidisciplinary Women’s High Risk OB Clinic located at SFGH one day a week for 6 months.

PGY-3 residents can also choose to complete a one year child psychiatry rotation at SFGH treating children and adolescents (rather than doing the child experience at Langley Porter described above). The Child and Adolescent Service at SFGH is the recipient of a grant to establish a Multicultural Clinical Training Program to serve ethnic minority, disadvantaged children and families with multiple traumas. Residents also have opportunities to learn about consultation, co-management and treatment of Community Health Network patients (the S.F. public health provider clinics).

Psychotherapy Track – This experience provides residents with additional in-depth training in the theoretical basis and experiential aspects of psychodynamic as well as other psychotherapies, in both individual and group modalities.  A cadre of specially selected supervisors, many of whom are psychoanalysts or psychoanalytic candidates, are made available to residents selecting this track.  Psychotherapy track residents gain experience treating a greater number of psychotherapy cases than their peers in the community or research tracks, have additional hours of individual supervision, and also have priority in choosing a Specialty Assessment Clinic. 

PGY-4 Year – Senior Residency

The PGY-4 year is primarily elective in nature and is designed to ensure that the experiences residents select have a coherent theme. These experiences aim to advance professional development by promoting growth as a leader and/or pioneer, an educator, an expert in a specific area, and an outstanding clinician. During the second half of their PGY-3 year, residents (with support from advisors and mentors) develop personalized learning goals for their fourth year and then construct an individualized set of elective experiences to meet those goals. During the fourth year, each resident presents a department talk on an area of special interest. This Senior Talk experience promotes leadership, scholarly inquiry, and professional development.

In addition to providing continuity of care to a portion of their outpatients from the PGY-3 year, residents choose from a variety of Senior Resident rotations drawing from several broad areas of concentration, e.g., Community and Public Psychiatry; Outpatient Psychotherapies; Pharmacotherapy; Inpatient Care; Consultation/Liaison; and Partial Hospitalization. Elective options exist across all three of UCSF’s training sites: SFGH, SFVAMC, and LPPH&C/UCSF Medical Center. Senior residents assume leadership roles in the administrative and educational processes of the elective rotations, functioning, for example, as team leaders. Within these broad areas, senior residents may participate in a variety of clinical endeavors, while also meeting their overall professional development objectives.  As an example, a schedule for a senior resident focusing on outpatient psychiatry may include a caseload of diverse patients receiving a variety of different psychotherapeutic treatments, work in the UCSF Student Health Clinic, co-leading supervision groups for third year residents, &/or co-leading a CBT group with a PGY-3, and receiving specialized training with their long-term psychodynamic psychotherapy cases.  In contrast, a resident in the clinical research track may continue psychotherapy with 6 patients, attend supervision, team meetings, and didactics and then spend the rest of their time working on their research project.

The community psychiatry focus at SFGH recognizes the general psychiatrist’s need for advanced knowledge of psychopharmacology, consultation skills, a thorough understanding of the interface of clinical medicine and clinical psychiatry, and familiarity with the major modes of contemporary psychotherapy. The Department of Psychiatry at SFGH offers a wide array of innovative services to pubic sector patients. A PGY-4 could select, for example, a part-time senior resident experience on a particular service (inpatient, outpatient, or consult/liaison), during which time he/she would further develop administrative and teaching skills. Emphasis on the appreciation of social and cultural factors relevant to psychiatric illness, and on the understanding of how systems impact care for the public, multicultural mentally ill, are important educational objectives of senior resident electives at SFGH.

Numerous options exist for PGY-4 elective experiences at the SFVAMC including working in specialized PTSD, substance abuse, and women’s mental health clinics, joining the active consult service or working as a junior attending on the inpatient service. In addition, the VA is an active hub for clinical research, and residents can potentially gain valuable research experience if they so choose.  Research opportunities exist at the VA for all residents, including both research and non-research track trainees.

Numerous other specialized electives also exist for fourth year residents, including electives that focus on medical education, quality improvement, or mental health policy, and some electives in the community.

Fourth year residents also supervise 3rd year medical students and teach in a medical student course and in annual workshops for junior residents. These experiences are viewed as important components of each resident’s professional development.

Chief Residents – In the Spring of each academic year, a total of four rising PGY-4s are selected to be Chief Residents for the upcoming academic year across all sites, two at LPPI, one at SFGH, and one at the SFVAMC. These residents receive a special opportunity to develop teaching, leadership and administrative skills and play crucial roles in all aspects of the training program.  Chiefs are selected by the Director and Associate Directors, with input from service chiefs.  They meet weekly with the Program Director as a group and also individually with their site director.  Chiefs also meet regularly with the junior residents at their assigned site.  The four positions are: