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Dr.
Thakur (Fellowship Training Director, right) with 2006-2007 Geriatric Fellows: Here’s what our graduates are saying about us: “The Duke Clinical Geriatric Psychiatry Fellowship offers exposure to both diverse patients and diverse clinical settings under the tutelage of some of the best geriatric psychiatrists and researchers in our field. Duke faculty care about your experience and mentor you long after the fellowship ends. The faculty embraces your clinical and research interests and structures a program that suits you. Duke has it all--this really isn't an exaggeration! My fellowship at Duke has definitely been a pivotal experience in my career.” – Dr. Warachal Faison, Clinical Services Director, Alzheimer’s Research and Clinical Programs, Medical University of South Carolina (Duke Geropsychiatry Fellow 2001-2002) “My experience at Duke was rich and varied, with exposure to the major thinkers in the field - who are as nice as they are famous. It was also great to get extra training in ECT at one of the premier ECT centers in the world - especially since ECT is a very marketable skill.” - Dr. Lea Watson, Assistant Professor of Psychiatry, UNC School of Medicine (Duke Geropsychiatry Fellow 2003-2004) Geriatric Psychiatry Fellowship Welcome Welcome to the Duke Geriatric Psychiatry Fellowship Web page. We are excited about our Program in Geriatric Psychiatry. Our faculty at Duke and at its allied facilities have many years of experience evaluating and treating patients and in mentoring trainees to prepare them for careers as geriatric psychiatrists. In this Website, we will provide an overview of the department, outlining its strengths and demonstrating the leadership positions that geriatric psychiatry faculty have taken within the department. You can learn more about our faculty at our link, Division of Geriatric Psychiatry. The Duke Department of Psychiatry first came to prominence in the mid-1950's under the chairmanship of Dr. Ewald Busse, who fostered an alliance between psychiatry and the Aging Center in the Department of Medicine, and established the nation’s first fellowship program in geriatric psychiatry. Dr. Busse, a past president of the American Psychiatric Association, is now emeritus professor of psychiatry and continues his longstanding work with the Division of Geriatric Psychiatry. All of his successors have recognized the importance of patient care, teaching and research in geriatric psychiatry, and many continue to be active contributors in this area here at Duke. The next chairman, Dr. H. Keith H. Brodie, also became APA president and then went on to lead the university as chancellor and president. Dr. Bernard Carroll, who followed Dr. Brodie as chairman, remains a major contributor to our understanding of the neuro-endocrinology of mood disorders and continues his research in geriatric depression through ongoing collaborations with investigators in the division. Dr. Dan Blazer, a pioneer in psychiatric Epidemiology who served as interim chairman and Dean of Medical Education at Duke, continues his research in Epidemiology with a new focus on the role of genetics in geriatric psychiatry. Dr. Allen Frances, who served as chair from 1992-1998, helped to expand the division by fostering the careers of Drs. Harold Koenig, Keith Meador and David Steffens. Our current chair, Dr. Ranga Krishnan, recognized for his research in geriatric depression and dementia, has always found education to be one of his most satisfying professional activities and is devoting considerable efforts to develop innovating ways to enhance our educational programs, including the Geriatric Psychiatry fellowship. Over the years, the department has changed dramatically in the size and scope of its clinical, educational and research endeavors. Our clinical programs in psychiatry have expanded to include a variety of inpatient and outpatient settings and modalities that provide training in all the forms of treatment a practicing geriatric psychiatrist is likely to conduct. We are the leading psychiatric research program in the Southeast and among the largest in the country. We believe that the best educational experiences occur in those departments that combine a strong dedication to teaching about geriatric psychiatry, an emphasis on clinical excellence, and the extensive resources of a modern research enterprise. Duke’s Department of Psychiatry has a strong tradition of commitment to these efforts. Overview of Mission, Objectives, and Methods The Department of Psychiatry, in cooperation with the Center for the Study of Aging and Human Development, offers a 12 month training program in geriatric psychiatry, designed to train psychiatrists who will be able to provide care, function as consultants, interpret research findings, and serve as educators in the subspecialty of geriatric psychiatry. To accomplish these objectives, the fellowship provides: (1) supervised clinical training in interdisciplinary inpatient, outpatient, and long term care settings; (2) a comprehensive conference/seminar program and didactic curriculum; and (3) the opportunity for supervised participation in funded clinical research projects in aging. These training methods emphasize scholarship and self-instruction, and foster acquisition of knowledge and clinical skills in geriatric psychiatry; emphasize biopsychosocial concepts and an interdisciplinary approach to assessment and management; and promote development of leadership and skills for educating other health professionals. Each component of the curriculum includes program and performance evaluations in areas corresponding to the program objectives. Clinical Experiences: an overview Considered together, the clinical experiences of this program are designed to foster the fellow’s development in the areas of: Clinical knowledge · Biological and psychosocial aspects of normal aging, illness, and disability in late life · Biological and psychosocial aspects of psychiatric disorders of late life · Interaction of medical illness and psychiatric symptoms/disorders in the elderly · Interdisciplinary team care concepts and function · Ethical and legal issues Professional development · Initiative in self-instruction · Reliability/thoroughness · Integrity/ethical conduct · Professional attitude toward elderly patients · Communication with primary care providers, medical specialists, and other health professionals · Leadership role on interdisciplinary health care team · Effectiveness as a consultant in the subspecialty Clinical skills · Interpersonal skills with patients and colleagues · Multidimensional assessment skills for geriatrics · Use of laboratory and neuropsychological testing · Integration of input from health professionals from other disciplines · Critical analysis of clinical problems/diagnostic skills · Clinical decision making · Psychotherapies · Pharmacotherapies · Electroconvulsive therapy While all clinical rotations address goals in all of these areas, individual rotations are designed to emphasize specific goals as described herein. Geriatric Psychiatry Inpatient ProgramUnder the guidance of Dr. Louann Crume, Director of the Geropsychiatry Program at John Umstead Hospital, and Dr. Jody Miller, attending psychiatrist and alumnus of this fellowship program, the fellows are expected to achieve the following goals during this rotation: development of clinical expertise in the comprehensive assessment and diagnosis of elderly patients with medical/psychiatric comorbidity; integrate the results of intensive medical, neuropsychiatric, and functional evaluation; gain expertise in behavioral, psychodynamic, psychopharmacologic, somatic, and family interventions as they are used in geriatric patients; coordinate concurrent management of co-morbid medical conditions and associated disabilities; develop competency in leadership of an interdisciplinary team; and develop skills for teaching and supervision of non-psychiatrist mental health professionals. These goals are achieved through a 6-month rotation that also allows for outpatient experiences. The fellow’s primary responsibility is for up to 10 patients with clinical supervision readily available, while allowing the fellow to be the primary decision maker. This encourages independent diagnostic thinking and decision-making, and provides ample opportunities for refining teaching and supervision skills with staff. The Inpatient Geriatric Psychiatry Unit is staffed with an interdisciplinary health care team, which affords trainees experience in team leadership. The patient population has a high prevalence of medical comorbidity and disability, providing fellows with extensive opportunities for interaction with consultants in internal medicine, surgical specialties, physical therapy, occupational therapy, and speech and language therapy. The high prevalence of cognitive impairment in patients on this unit requires frequent use of neuropsychological assessment services, providing fellows with many opportunities to learn from faculty in that discipline as well. This training experience is enhanced by individual supervision by faculty, regular patient rounds including multiple disciplines, weekly team meetings, and a weekly case conference. These teaching forums and others described below help direct and focus fellows' learning, while also facilitating consolidation of new knowledge, integration of new concepts, operationalization of new skills, and maturation of existing skills. The team meetings and case conferences provide further case-oriented teaching forums. The attending faculty supervisor also provides case related current literature and review articles to complement the clinical experience.
Geriatric Psychiatry Outpatient ProgramThe Geriatric Evaluation and Treatment Clinic (GET Clinic), The POPC (psychiatric outpatient clinic) at Duke, and the VA Geropsychiatry Clinic serve as the three outpatient sites for geriatric fellows. Dr. Harold Koenig at the GET Clinic, Dr Mugdha Thakur at the POPC, and Dr. Tracey Holsinger at the VA Clinic work closely with the fellows in these settings. The goals for the outpatient experience are to provide a setting for evaluating psychiatric outpatients and then following them longitudinally while developing evaluation skills for assessment and diagnosis of psychiatric and neuropsychiatric disorders of late life. Further goals include understanding of the appropriate use and interpretation of results of standardized assessment instruments used in the clinic and in neuropsychological testing batteries; an understanding of indications for use in the clinic and in neuropsychological testing batteries; an understanding of indications for use of laboratory testing and different technologies for brain imaging; ability to interpret and integrate clinical findings and results of laboratory testing, more refined clinical reasoning and decision making skills; an appreciation of neurological, medical, and psychiatric comorbidity and resultant disability in late-life; ability to develop treatment and management plans appropriate for geriatric patients; refinement of skills in pharmacotherapy, psychotherapy, behavioral management, and family interventions; and appreciation of the various roles of the geriatric psychiatrist as primary physician, consultant to referring physicians and agencies, and provider in a continuum of care. These goals are met through interaction with geriatric medicine colleagues in the GET clinic, where weekly patient conferences are held that are attended by all disciplines in the GET Clinic. The POPC clinic provides a yearlong longitudinal outpatient experience where fellows are primary providers for the patients. The VA clinic provides the opportunity to provide outpatient management of older adults in the VA system with its unique patient population.Electroconvulsive Therapy ProgramThe specific goal of this rotation is to develop expertise in this somatic therapy frequently used for treatment of severe depressive disorders in the geriatric population. Developing this expertise involves gaining increased skills in assessing patients for ECT; increasing knowledge about disorders usually treated with ECT in the geriatric population; gaining confidence in the techniques of administering ECT; increasing understanding of options for minimizing impact of treatments on cognitive functioning; gaining experience in using ECT in the medically frail elderly; and following outpatients receiving maintenance ECT for a longitudinal perspective. Supporting these clinical goals is the development of a greater understanding of the physiology and implications of seizure induced therapies. These goals are achieved through a structured 12-month, rotation with the fellows participating every other week. The rotation includes doing supervised consults, attending a didactic seminar, attending rounds with an experienced ECT attending, and following patients both inpatient and outpatient while administering their treatments. At the end of the rotation, fellows earn certification in ECT that may be required for future credentialing for hospital ECT privileges. Nursing Home ConsultationSpecific goals of this rotation are the development of an understanding of the psychosocial impact of nursing home admission and residence in a long term care setting; ability to perform comprehensive evaluation of the roles of environmental, psychosocial, medical, and psychiatric factors that cause or contribute to disturbances of mood, cognition, and behavior in nursing home residents; expertise in behavioral interventions, supportive psychotherapy, group therapy, and pharmacotherapy, and skill in supervising other health care providers in using these interventions; strategies for effective communication with primary care attending physicians; knowledge of the federal regulations that affect psychiatric care in the nursing home; and diversification of consultation skills that are applicable to patient care, staff liaison and training, forensic assessment, and administrative consultation. These goals are achieved through 12 month rotations at a tertiary care academic nursing home and two community nursing homes that are part of local retirement communities. Fellows spend equivalent to one day every other week in the academic nursing home (VA Extended Care and Rehabilitation Center-ECRC) and one half day every other week in the community nursing homes. They provide case-based consultation and staff-oriented consultation. They serve as a primary psychiatric educator in both of these settings, but that role is particularly central in the VA academic setting due to the multiple learners present along with the primary care staff. Their work in these settings involves direct evaluation of patients with psychiatric comorbidity, the majority of whom have cognitive impairment and/or mood disturbances, often complicated by behavioral disturbances. Fellows become experienced in the use of behavioral interventions, psychotherapy, and pharmacotherapy in the nursing home. In the staff-oriented consultation role fellows learn to use the clinical observations of nursing home staff, and help the staff become more effective and therapeutic in their daily interactions with patients. Fellows may supervise nursing home staff in their therapeutic interventions. Fellows may also provide in-service training for nursing home staff and may serve in a consultative role to nursing home administrators. Involvement of family members is emphasized. This training experience is supported by on-site supervision provided by faculty in geriatric psychiatry in all of the facilities and also by geriatric medicine faculty in the VA-ECRC. The fellow also gets supervised consultation experience in the general hospital as part of this rotation. Fellows also participate in didactics on long term care that covers such topics as consultation models, behavioral and pharmacologic management of complicated dementia, federal regulations, and ethical issues. The overall didactic program has several objectives. It:
While most components of the core seminar curricula in psychiatry and geriatric medicine address all of these goals, individual components of the conference/seminar curriculum contribute significantly to meeting the overall goals. Some of the most significant are: (1) Geriatric Case Conference at JUH where formal case presentations are made with in depth discussion of patients by multiple disciplines; (2) GET Clinic and VA-ECRC interdisciplinary case conferences with active participation by geriatric medicine: (3) JUH Geriatric Psychiatry Journal Club provides an opportunity to enhance skills for critical analysis of the research literature in geriatrics and gain increased sophistication in the appraisal of research methodology and statistical analysis; (4) Neuroradiology Review correlating clinical neuroimaging studies of patients at JUH with clinical presentation, case history and neuropsychological testing; lead by the unit clinical director; (5) Mental Health Clinical Research Center Seminars providing an opportunity to see current research in affective disorders in the elderly presented by primary researchers in a setting allowing for participatory discussion; and (6) Geriatric and Psychiatry Grand Rounds, both of which are held weekly. The objectives of this research experience are to introduce fellows to all phases of the conduct of clinical research including hypothesis generation, literature search and review, study design, data collection and analysis, and presentation and publication of research findings; and to teach methods for establishing the validity and reliability of clinical measures. These objectives are accomplished by faculty serving as research preceptors for fellows who express interests in the research and request to work with that faculty person. The Program Director reviews research options with each fellow and assists in locating the most appropriate preceptor as needed. At the conclusion of each clinical rotation, and at 6-month intervals during longer rotations, faculty supervisors complete a formal assessment of the fellows' performance in that rotation. The evaluation parameters correspond to the goals and objectives of the rotations as described above, and to the special requirements for clinical postgraduate training programs in geriatric psychiatry for accreditation by the ACGME. This training program uses a form that has been approved by the Residency Education Committee. It includes evaluation of the trainee in the areas of clinical knowledge, professional development, and clinical skills. Individual items in each of these areas are rated on a 7 point scale from unsatisfactory to excellent, along with narrative descriptions of performance in each category. This information in synthesized into an overall performance rating. Fellows are given continuous feedback during supervision by individual preceptors and the results of their performance evaluations are shared with them and discussed at the end of each rotation or at least every 6 months during longer rotations. The training program director also meets with fellows quarterly to review and discuss their progress in specific rotations and in the residency in general. Whenever necessary because of performance problems, the residency program director schedules additional meetings with the fellows to provide feedback and to develop an appropriate plan for remediation. The program director also solicits feedback regarding the program and fellows' training experience directly from each fellow on a quarterly basis, and more often if fellows desire or deem it appropriate. This feedback is considered essential in tailoring the fellowship to meet the training needs of fellows and to ensure the achievement of the objectives outlined above. The results of these evaluations are reported by the program director to the Residency Education Committee with recommendations for necessary changes and proposals for program improvement. The annual stipend for 2006-2007 is $49,308.00. Parking and uniforms are furnished free. Fringe benefits include malpractice insurance for those activities officially sanctioned by the department. A $100,000 term life insurance policy is provided by the hospital for each house staff member. An additional $10,000 in term life insurance is provided for spouses. Disability insurance is provided after the first 90 days of qualifying disability. It covers 60% of the annual salary or $2000 per month, whichever is less, to age 65. Hospitalization insurance, including maternity insurance, is available to members of the house staff and their families through a group plan. The premiums are covered by the university for individual house officers. Two weeks of sick leave annually and parental leave policies are provided. All fellows receive three weeks of vacation per years. An additional few days at either Christmas or New Year’s are also customary. Meals can be purchased at a discounted cost in the hospital cafeterias. Acceptance of a position in the Geriatric Psychiatry Training Program indicates agreement that no other positions of any kind will be accepted during the year without the expressed permission of the director of the training program. Instructions for ApplicantRequired application materials:
Contact information Ms. Judy Ridley, Program Coordinator Phone: 919-684-3746 Email: ridle001@mc.duke.edu InterviewsThe Geriatric Fellowship Selection Committee will interview applicants in the months of November, December, January, and February. To accommodate special circumstances, interviews can be set up at other times during the year, but most interviews will be held during the listed months. We look forward to seeing you during the coming months! |
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