Ericka L. Crouse, PharmD, BCPP, BCGP, FASHP, FASCP
Associate Professor, Department of Pharmacotherapy and Outcomes Science Virginia Commonwealth University School of Pharmacy Richmond, VA
In 2016, the American Society of Health-System Pharmacists (ASHP) updated the PGY2 Psychiatric Residency Standard; for many Residency Program Directors this is the first year implementing the new Standard and Required Competency Areas, Goals, and Objectives. Before revamping the entire residency, it is important to review what is similar and what has significantly changed. Links to important ASHP documents are included at the end of this article. Some of the suggestions I have included are items VCUHealth has implemented as well as things I learned from other programs when participating in ASHP Surveys and CPNP Residency Program Director (RPD) Community discussions.
Many of us are familiar with the seven principles of the previous standard. Now condensed into six standards, ASHP developed a “crosswalk” linking previous principles to updated corresponding standards (Table 1). Major changes include deleting Principle 2.2 (over reliance on the resident to fulfill practice obligations), all of Principle 3 (obligations of resident to the program), and Principle 4.2.d (preceptors ensure completion of all assessments, primarily removing resident self-assessment). Approximately ten new standards were added.
Of importance, revised standard (1.6) requires a written policy documenting consequences if a resident does not obtain licensure within 90 days of start of residency. For Veteran’s Affairs PGY2 programs, this may be less relevant versus programs requiring new state licensure. One program I surveyed moved the start of their residency from July to August given repeated delays in licensure within their state. At VCUHealth our policies outline requirement of licensure prior to start of first patient care rotation (30 days), and outlines procedure for Academic Probation and dismissal if they fail to do so by the second patient care rotation (60 days). In 2012, amendment to the previous standard focused on duty-hour rules, which appear in the new standard (2.2). The new standard requires an initial resident assessment (3.4.b). At VCUHealth, in addition to the PharmAcademic assessment of all PGY2 goals and objectives, the resident completes a separate initial assessment using Likert Scales to rate their exposure to patient care activities and topic areas during their PGY1 as well as identify personal and professional goals. The new standard also includes provisions for Preceptors-In-Training (4.9).
The standard still requires both inpatient and outpatient learning experiences, however time requirement in each is not delineated. Our program developed an ambulatory elective in addition to the required longitudinal ambulatory experience to expand the time spent in outpatient psychiatry.
The standard lists required disease states that all graduates of PGY2 Psychiatric programs should be proficient in by end of residency. The new standard separates these required disorders from others which instead can be achieved through didactic discussion, reading assignments, case presentations, written assignments, and/or through direct patient care. Four disorders (eating disorders, delirium, dual diagnosis, pregnancy/post-partum psychiatric disorders) were added to the 12 psychiatric disorders already included (e.g., schizophrenia, depression). Inpatient rotations at VCUHealth previously covered delirium (geriatric psychiatry), mental health during pregnancy, and dual diagnosis. To incorporate eating disorders, this year’s resident presented her annual CE on Eating Disorders; it is also a potential lecture opportunity in the Psychiatry elective at the school of pharmacy. For disease states a practice site may not encounter, a CPNP University’s Psychiatric Pharmacotherapy Case Series: Teaching Edition is a great source of education. We maintain a running list of the core psychiatric disease states the resident encounters on each rotation and document whether via direct instruction, direct patient care, lecture (given or attended), reading, or other.
Selected Learning experiences (requirement of 2 of the 8 areas) largely remained the same with the addition of pain management. At VCUHealth, we recently hired a Pharmacy Pain Management Specialist and approached her about developing an elective for the next psychiatric resident.
The terminology changed from required Outcomes to Competency Areas. Previous Outcome 2 regarding patient care is now Competency Area 1 and remains largely unchanged. Previously focused on treating patients with psychiatric and neuropsychiatric disorders, the new goals and objectives focus on psychiatric and neurologic disorders. VCUHealth is fortunate enough to have a Neurology pharmacy specialist, therefore to meet this we now require a Neurology rotation. A recent publication by Dopheide et al. regarding pharmacy advanced pharmacy practice experiences (APPEs) identified psychiatry APPEs outnumbered neurology APPEs 5 to 1, highlighting the potential to further develop neurology sites.1 The new goals (R2.1) give clearer expectations for resident involvement in monograph or protocol development, medication-use evaluation, and adverse event reporting and expanded the major project (R2.2) to be met by completion of a quality improvement or research project. A new competency area on responding to psychiatric emergencies has been added (R5.1). During orientation our resident completes Therapeutic Options™ training, and utilizes (and is evaluated on) this knowledge on inpatient rotations.2 The previous outcome of serving as the resource for psychiatric medications focusing on literature review, technology and automation, drug information requests and compliance with accreditation, legal and regulatory standards has been removed. Many activities are now intermingled with other objectives. For example, utilizing literature now appears under objectives R1.1.5, R3.2.2, R4.1.1, and R4.1.3. Laws and regulatory standards are incorporated into the new objective regarding pharmacy enterprise (R3.2.1).
An informal survey of the CPNP RPD Community confirmed others, like myself, were unfamiliar with the term “pharmacy enterprise.” “Pharmacy enterprise” was first used by the ASHP Section of Pharmacy Practice Managers executive committee in 2006.3 The term’s goal is to embrace the idea that pharmacy is much more than just the pharmacy department in terms of impact on the entire health system, encompassing both clinical and financial outcomes.3-6 Garbarz (2016) suggests priorities include improving patient care, reducing inpatient pharmacy costs, and expanding outpatient revenue.6
Responses from RPDs as to how they are addressing and interpreting this new objective include discussions with pharmacy administration during orientation, understanding all roles of pharmacy throughout the institution from admission to discharge, and reviewing legal requirements during substance use or inpatient rotation. Some evaluate this during orientation, clinical rotations, administration, and/or staffing. Other ideas included having residents propose and potentially initiate a new clinic as well as utilizing the MUE project to fulfill this objective as the resident is addressing medication-related issues within the pharmacy enterprise. Like the majority, we have incorporated this into orientation, substance use clinic, and inpatient rotations (e.g., Virginia laws governing commitment and forced treatment).
Ultimately at VCUHealth, we have taken this time to reevaluate our program, restructure learning descriptions, and develop new learning opportunities.
I want to thank the CPNP Members involved in developing the new Competency Areas, Goals and Objectives! The updated list definitely includes many things most of us were already doing to ensure PGY2 Psychiatric Residents develop into successful Psychiatric Clinicians.
Cydreese Aebi, June Griffith, Beth Hall, Lindsey Hedgepeth Kennedy, Kelly Lee, Sandy Mullen, Carol Ott
|Table 1: Important Links:|