This article provides guidelines for training in emergency psychiatric settings that reflect the current changing nature of crisis management in American psychiatry. The American Association for Emergency Psychiatry (AAEP) strongly advocates that all psychiatrists-in-training become competent and comfortable in crisis situations. The AAEP is a multidisciplinary organization promoting timely, compassionate, and quality mental health services in all crisis and emergency settings through education, training, and research. The Education Committee of the AAEP developed this curriculum to assist program directors in designing experiences that will train residents to be competent in modern emergency psychiatry.
The psychiatric emergency service is often an intense, busy program that provides assessments and care to severely ill psychiatric patients. The shift toward community-based psychiatric treatment (1) and the growth of managed care (2) have resulted in increasing numbers of patients in acute psychiatric distress seeking urgent and appropriate treatment in the emergency setting. By the early 1980s, the psychiatry emergency service had become, and remains, a main entry point into the mental health system for many patients and the only treatment setting for many of the chronically mentally ill (1).
Since a busy psychiatry emergency service provides many opportunities to view a wide range of acute psychopathology, it is an excellent setting for resident training. In addition to developing assessment skills, residents in a psychiatry emergency service can work with many patients who present risks for suicide attempts or violent acts. Important specialized skills and knowledge are acquired by working in and studying emergency psychiatry.
The value of the psychiatry emergency service as a training site is recognized by the Residency Review Committee (RRC) for Psychiatry of the Accreditation Council for Graduate Medical Education. Presently (3), the official requirement for residency education in emergency psychiatry is:
supervised responsibility on an organized 24-hour psychiatric emergency service that is responsible for evaluation, crisis management, and triage of psychiatric patients. Instruction and experience should be provided in the evaluation and management of suicidal patients. A psychiatric emergency service that is a part of or interfaces with other medical emergency services is desirable because of the opportunities for collaboration and educational exchange with colleagues in other specialties. There must be organized instruction and supervised clinical experience in emergency psychiatry that lead to the development of knowledge and skills in the emergency evaluation, crisis management, and triage of patients. This should include the assessment and management of patients who are a danger to themselves or others, the evaluation and reduction of risk to caregivers, and knowledge of relevant issues in forensic psychiatry. There should be sufficient continued contact with patients to enable the resident to evaluate the effectiveness of clinical interventions. While on-call experiences may be a part of this training, such experiences alone will not be sufficient to constitute adequate training in emergency psychiatry. A portion of this experience may occur in ambulatory urgent care settings but must be separate and distinct from the 12 months of training designated for the outpatient requirement.
This set of requirements must be implemented in an evolving system of care. In the past, the only model of care in the psychiatry emergency service was a triage model. This focused on rapid evaluation, containment, and referral. With recent changes in the way mental health services are provided, including a new emphasis on diversion away from hospital services, this model is inadequate for current teaching in psychiatry emergency service settings. In contrast to the triage model, these more complex services now utilize a treatment model of emergency care (2). The treatment model requires reliable and specific diagnoses to support the initiation of definitive treatment in the psychiatry emergency service before disposition is arranged. Since many patients are released from the psychiatry emergency service back into the community, it is most efficient and medically prudent to initiate treatment for them in the psychiatry emergency service. Patients requiring only brief intervention may not even need referral. In addition, the psychiatry emergency service can provide brief interim care for unstable outpatients until they are seen by the appropriate clinic. Furthermore, even for patients who require inpatient care, thorough assessment and initiation of treatment in the psychiatry emergency service may reduce delays and shorten hospital length of stay (2).
With this shift in psychiatric care delivery from a triage to a treatment model, the teaching of patient disposition is no longer sufficient. Acute and short-term treatment modalities, including crisis intervention, crisis psychotherapy, emergency medications for behavioral control, and initiation of psychopharmacological treatments must be taught as well. Throughout the early 1980s, a number of articles appeared in the literature focusing on the exciting learning opportunities in the psychiatry emergency service and discussing ways to optimize learning experiences (4—11). The educational approaches written about at that time, however, must be adapted to the varying volume of patients, time constraints, and the often chaotic environment in the psychiatry emergency service. Little exists in recent psychiatric education literature to guide emergency psychiatry curricula development. This paper is the AAEP’s response to the resident’s changing role in the psychiatric emergency setting.
These guidelines were developed by consensus. Initially, members of the AAEP Education Committee outlined their ideal training objectives, which were compiled and discussed. Since many AAEP members are responsible for emergency psychiatry curricula at their home institutions, a draft of the model curriculum was published for comment in Emergency Psychiatry, the AAEP journal, in the winter of 1998 (12). The curriculum was also presented at the annual meeting of the American Association of Directors of Psychiatry Residency Training (AADPRT) in Santa Monica, California, in March 1999. The education committee reviewed and incorporated suggested changes and recommendations. The curriculum outlined in this paper is the result.
A search of the literature from 1980 to the present was also conducted using both the MEDLINE and the PsychInfo databases. All articles addressing issues of education in psychiatric emergency services were reviewed. Few were recent, and none dealt specifically with learning outcome objectives in psychiatric residency training in the emergency setting, as does the curriculum presented here.
It is the position of the AAEP that by the end of residency training all residents should demonstrate the attitudes, skills, and knowledge necessary to provide emergency assessment, diagnosis, and treatment of individuals suffering from acute psychiatric illness. The overall goal is for each trainee to develop the decision making capacity to provide good patient care in crisis situations in all clinical settings. These objectives are intended to be adopted to the training environment available, not to focus on "ideal" but unavailable resources. The objectives can also be used when developing or modifying a psychiatry emergency service training environment for residents.
These objectives are outcome-focused. Programs can best determine the clinical experience, time, direct teaching, and supervision needed to ensure that their trainees meet these objectives.
At the completion of a psychiatric residency, the resident will be able to demonstrate the skills and knowledge presented in t1.
Setting of Training Experience
The recommended setting is a multidisciplinary psychiatric emergency service affiliated with a medical emergency department offering 24-hour service. If this setting is unavailable to a training program, alternative sites that provide opportunities for residents to achieve the objectives previously outlined can be considered. The essence of an emergency setting is: the unplanned nature of the visits, the urgency, the severity, the briefness of assessments, and the intensity of the intervention. These criteria can be found in crisis clinics, crisis residential units or mobile crisis units, and medical emergency departments. A combination of time in a crisis or walk-in clinic and time in a medical emergency room (a setting to which many patients with psychiatric problems initially present), with supervision from psychiatric faculty, may allow residents to meet the training objectives. Mobile crisis units have also been used successfully by some programs for residency training (13).
Depending on the setting, programs may be able to ensure that their residents can achieve all of these objectives through clinical exposure in psychiatry emergency service. However, some programs may choose not to implement all objectives in the clinical setting and to provide alternate learning opportunities (e.g., a seminar on crisis phone calls rather than clinical exposure).
The AAEP recognizes that residents may not intend to work in a psychiatry emergency service or other resource-rich environment after completing their training. However, the rapid assessment and decision making skills that these objectives emphasize will prepare future psychiatrists to handle crises in any mental health setting.
Timing and Length of Training Experience
Residents should begin focusing on these objectives early in their training since crisis management skills are needed throughout residency. While on-call time after hours provides invaluable experience, the AAEP does not believe there is sufficient opportunity for supervision and teaching associated with these responsibilities and supports the RRC’s position that call should not be a resident’s only emergency psychiatry training experience.
The AAEP recommends that residents complete a rotation in emergency during the first or second year of training. A minimum of 2 months full-time on a dedicated emergency psychiatry rotation is suggested. This length of time provides sufficient exposure for residents to meet the training objectives and to become comfortable working in a crisis-oriented environment. A longitudinal experience that provides the same number of hours in the emergency setting may be considered. Programs may expect residents to achieve some objectives early in their residency (e.g., emergency assessment skills) and others that will be attained later in training (e.g., leadership skills).
Psychiatric emergency services may, in addition to the basic training for residents described, offer the possibility of elective, chief resident, and fellowship experiences. Psychiatry emergency services may also be used as training settings for learners in other health care disciplines. These objectives can be adapted for other trainees.
Faculty and Supervision of the Training Experience
Residents need to work directly with supervising attending psychiatrists who can both teach the residents and evaluate their skills to assure that the training objectives are met. Supervising faculty should be board eligible or certified in psychiatry and should have sufficient experience in the emergency setting to provide supervision. Psychiatrists often cover the psychiatry emergency service in shifts, much the way physicians work shifts in a medical emergency room (ER). Attending psychiatrists must be able to work exclusively in the psychiatry emergency service during a shift to ensure that they can dedicate sufficient time for clinical duties and teaching. If psychiatrists must cross-cover other services, it is unlikely that they will be able to provide an adequate educational experience for residents in the psychiatry emergency service. While other mental health professionals are important members of the multidisciplinary treatment team and can help residents in attaining many of the competencies listed, they cannot substitute for the role modeling a psychiatrist can provide.
The AAEP recommends that the medical director of the psychiatric emergency service (or designate) be responsible for developing the educational program for residents in emergency psychiatry and monitoring trainees closely during their rotations to ensure that they complete the recommended training objectives. Supervision should ensure that each resident has the opportunity to: 1) observe assessments performed by faculty and other clinicians; 2) interview patients with psychiatrists and other clinicians; 3) be observed interviewing patients and receive feedback on interviewing techniques and style; 4) receive daily supervision, preferably immediate review of each case seen; 5) have all charts read and co-signed; and 6) assume clinical responsibilities gradually.
In addition to case-based supervision, a structured curriculum is needed to provide a review of essential topics in emergency psychiatry during the residency. This will ensure that residents obtain the necessary knowledge base to meet the objectives and familiarity with rare but emergent situations. The core curriculum in emergency psychiatry can be provided in any instructional format, depending on the program’s needs and resources. Topics could be presented in lectures, reading assignments, seminars, literature reviews, discussion groups, problem-based learning formats, or other teaching method. Didactic topics can be addressed entirely during a resident’s rotation through the psychiatry emergency service or incorporated into regular education sessions provided for residents, thus providing reviews or updates of emergency topics throughout the residency. This list comprises the essential topics for residents as identified by consensus of the AAEP Education Committee.
Essential Topics: 1) assessment and management of the suicidal patient; 2) assessment and management of the violent or agitated patient; 3) assessment and management of character pathology and parasuicidal behavior; 4) medical causes of behavioral symptoms including acute psychosis and delirium; 5) psychotherapeutic and psychopharmacological management of crisis situations; 6) recognition and management of drug intoxication and withdrawal states; 7) approach to the patient with concurrent disorders in the ER setting; 8) approach to the anxious patient in the ER setting; 9) approach to the depressed patient in the ER setting; 10) medicolegal issues in the ER (commitment, competency, reporting abuse, and threats of violence); 11) recognition of and assistance to victims of domestic violence; and 12) how to be an effective consultant.
Many other topics could be addressed as part of the curriculum on emergency psychiatry. Possible topics could include crisis-oriented psychotherapy, assessment and management of the geriatric or pediatric patient in crisis, and debriefing the victim of sexual assault. Programs are encouraged to address topics relevant to their psychiatry emergency service and the needs and interests of their residents.
Programs will need to develop an evaluation system to ensure that residents achieve the training objectives described in this article. The purpose of these objectives is to provide clear expectations for training and evaluation purposes. Resident evaluation in the psychiatry emergency service may be more difficult because of the high-stress environment and difficulty in choosing what to evaluate and how to evaluate. Observing a resident assess and manage a psychiatry emergency service case can serve as material for evaluation, but this does not include other psychiatry emergency service skills. In particular, leadership skills and communication skills may not be evaluated in other settings and are crucial for competence in the psychiatry emergency service. If an observed assessment is part of the formal evaluation, the attending psychiatrist may not have time to observe the entire case unless a physician who is not on duty in the psychiatry emergency service is to observe the resident. Programs where the majority of work in the psychiatry emergency service is performed on-call also face the challenge of little direct supervision on which to base an evaluation and reluctance by residents to be evaluated for on-call work. Programs may wish to require residents to record all patients seen on-call in a "log book," which can be incorporated into an evaluation and review.
Some programs may have a standard evaluation form for all rotations that can be adapted to the psychiatry emergency service rotation, whereas other programs may choose to use these objectives to develop a specific evaluation form for the psychiatry emergency service rotation. The AAEP recommends that evaluation include as many aspects of performance in the psychiatry emergency service as possible, including direct observation of resident’s clinical work, supervision and review of patients, review of written notes, input from multidisciplinary team members, on-call performance, and any presentations at psychiatry emergency service rounds. Programs in which residents work in the psychiatry emergency service over an extended period should provide ongoing review and evaluation of the resident’s performance.
These training objectives focus on core competencies needed for safe work in the psychiatry emergency service and any clinical setting where a psychiatric emergency may arise. While they were written prior to ACGME’s endorsement, in 1999, of six general competency areas for residents (14), they can easily be sorted into those that deal with patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. For example, professionalism is addressed in objectives including II.A.6 (demonstrating respect and empathy for the patient in the assessment process), II.C.5 (demonstrating respect for the patient’s dignity in managing the patient), IV.D (demonstrating professional attitudes toward others), IV. E (honoring professional obligations and responsibilities), IV. F (completing required documentation appropriately), VI. (developing leadership skills), and IX. (demonstrating self-knowledge and an awareness of one’s own reactions to patients).
The objectives emphasize acute assessment and intervention skills, the required knowledge in emergency psychiatry work, and the meta-skills of managing several acutely ill patients simultaneously. Although broad guidelines about rotation length and didactic components are presented, programs will need to develop emergency psychiatry training programs to meet their individual needs. Resources that can assist in program development include an overview of training issues by Brasch and Ferencz (15), an approach to teaching residents about alternatives to hospitalization (16), and a guide to training in the hectic and sometimes frightening psychiatry emergency service environment by Muhlbauer (17). It is important to provide emergency psychiatry training in a supportive setting that minimizes stress and promotes enthusiasm.
The training objectives reflect the current reality of the evolving psychiatry emergency service. It is more than a triage center, as patients may receive brief, intensive therapy or the initiation of longer-term treatments. Patients may remain in the psychiatry emergency service for more than 24 hours and require care throughout their stay. Residents need to be prepared to manage these situations, which is consistent with the emerging treatment model for the psychiatry emergency service. All graduating residents must be capable of handling psychiatric emergencies in any clinical setting. Well-developed, structured training programs in psychiatric emergency skills will encourage residents to view the psychiatry emergency service not as a distasteful environment to be avoided whenever possible, but as an opportunity for challenging clinical work.
The authors thank the members of AAEP and AADPRT for their input and Dr. Michael Allen for editorial review and assistance.
The Education Committee of the AAEP: Michael Allen, M.D.; Jennifer Brasch, M.D.; Peter Forster, M.D.; Rachel Glick, M.D. (Chair); Douglas Hughes, M.D.; Jodi Lofchy, M.D.; Karen Milner, M.D.; Laura Pieri, M.D.; Janet Richmond, M.S.W.; Victor Stiebel, M.D.