Core Competencies for Pediatric Consultation Liaison Psychiatry in Child and Adolescent Psychiatry Fellowship Training

Abstract

Background

Learner development of competency-based skills, attitudes, and knowledge through the achievement of defined milestones is a core feature of competency-based medical education. In 2017, a special interest study group (SIG) of the American Academy of Child and Adolescent Psychiatry (AACAP) convened a panel of specialists to describe pediatric Consultation Liaison Psychiatry (CLP) best educational practices during child and adolescent psychiatry (CAP) fellowship.

Methods

An expert working group developed a list of candidate competences based on previously established educational outcomes for CL Psychiatry (formerly Psychosomatic Medicine), CAP, and general Psychiatry. A survey was distributed to members of the AACAP Physically Ill Child Committee to determine CAP fellowship educational needs on pediatric CLP services and generate consensus regarding pediatric CLP competencies.

Results

Most survey respondents were supportive of the need for a national consensus on core competencies for pediatric CLP. Consensus from a panel of experts in the field of pediatric CLP generated a list of proposed core competencies that track the ACGME six core competencies.

Conclusions

Consistent learning outcomes provide the foundation for further development of tools to support training in pediatric CLP. There is a need to develop further tools including include outcomes assessment tools and self-directed learning materials that can be used to support lifelong learning.

Background

Consultation-Liaison Psychiatry (CLP) has been an Accreditation Council for Graduate Medical Education (ACGME)-accredited subspecialty of Psychiatry since 2003, with the first ABPN board certification examination in 2005 (Worley et al. 2009). Training and ongoing work in the subspecialty focuses on the care of patients with comorbid psychiatric and medical/surgical conditions, and there is recognition that the specialized skills and knowledge of the CL psychiatrist can improve both medical and psychiatric outcomes for these patients. Similar complexity exists in pediatric patients with comorbid medical and psychiatric/behavioral concerns, with the added challenges of intersecting issues of the process of development, family concerns, and the role of school and other community connections. However, to date there has been little operationalization of the core knowledge and skills that should be expected of the child psychiatrist caring for these complex patients.

Currently, training in pediatric CL psychiatry (PCLP) in the US largely occurs within Child & Adolescent Psychiatry fellowships, where the ACGME requires fellows have “consultation experience with an adequate number of pediatric patients in outpatient and/or inpatient non-psychiatric medical facilities” (ACGME, 2018). However, the expected educational outcomes of these experiences have not been defined to date, a fact which is a clear deficit given that there are approximately 270 CAP fellows each year on average that match into two year child and adolescent psychiatry fellowship training programs (National Residency Match Program, 2018).

Identification and operationalization of core knowledge and competencies in adult CLP has extended over many years. An initial set of core competencies for adult CLP was published in 2009 after many years of iterative work (Worley et al. 2009). We sought to initiate this process for PCLP with the goal of better defining training and clinical competencies.

Process

A Pediatric Consultation-Liaison/Psychosomatic Medicine Curriculum Special Interest Study Group (SISG) was convened at the American Academy of Child and Adolescent Psychiatry (AACAP) Annual Meeting in 2017. The group identified the following goals: (1) to articulate core child and adolescent psychiatry learning objectives in PCLP educational experiences; (2) to collate educational “best-practices” for PCLP clinical and didactic learning that should be disseminated widely; and (3) to identify gaps in current curricula at different institutions and identify targets for cross-institution collaborative curriculum development. The initial focus of our work was on the first two goals.

A workgroup was formed to move forward with identifying core learning objectives for PCLP. Candidate objectives were identified by reviewing the Core Competencies for adult CLP previously published by Worley et al. (2009) and the ACGME Milestone sub-competencies and curriculum requirements for Psychiatry, Child & Adolescent Psychiatry, and Psychosomatic Medicine (now Consultation-Liaison Psychiatry), adapting language as necessary to be child- and family-specific. The full SISG (25 members) reviewed the compiled list and proposed additional learning objectives based on their clinical and educational experience and agreed on a final candidate list of potential learning objectives. The candidate list was sorted among the six core competencies established by the ACGME: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Systems-Based Practice, Practice-Based Learning and Improvement, and Professionalism.

Broader input was then sought from the AACAP Physically Ill Child Committee (PICC) Listserv. The PICC mission is to: (1) enhance the visibility, commitment and productivity of child psychiatrists involved in research with children in the pediatric setting; (2) foster collaborative research between child psychiatrists at different children’s hospitals through exchange of ideas, instruments, diagnostic clarification and treatment options; (3) facilitate contact between child psychiatrists and other groups and organizations involved in relevant research; and (4) ensure a programmatic focus in this area at the Annual Meeting where interested child psychiatrists can predictably gather. The PICC listserv is comprised of more than two hundred national and international child and adolescent psychiatrists, most of whom direct programs in pediatric CL, belong to AACAP or the Academy of Consultation-Liaison Psychiatry (ACLP), or work in the area of CLP. The SISG is a subset of the listserv members. A survey link regarding the project was sent to the PICC listserv with a reminder six weeks after the original mailing. Respondents were asked to rate their agreement with the need for inclusion of each item using a Likert scale from 1 to 5. There were 44 responses received to the survey which is an estimated 22% (44/200) response rate, and the SISG reviewed the compiled responses.

Survey respondents strongly agreed with the utility of shared learning resources in pediatric consultation-liaison psychiatry, with 88% answering “Agree” or “Strongly Agree” to the utility of nationally-established model competency-based learning objectives. Agreement on the development of other learning resources was also high: 88% were interested in learning modules or self-study resources, 91% in a core set of reading materials, and 74% in milestone-based assessment tools.

There was widespread consensus on the relevance of most of the proposed competencies in the areas of Patient Care, Professionalism, Interpersonal and Communication Skills, Practice-Based Learning and Improvement and System-Based Practice. Disagreement on the importance of being able to provide expertise and guidance on the use of restraints and one-to-one sitters and on how to facilitate referrals to appropriate outpatient services may reflect differences in the deployment of resources and allocation of responsibilities at a local hospital level.

There was less consensus in the category of Medical Knowledge, with less than 70% of survey respondents supporting the establishment of core competencies in the areas of mood disorders, anxiety disorders, psychotic disorders, PANS/PANDAS, Child Abuse and Neglect, Autism, Pediatric Feeding Disorders and Palliative Care. This perhaps reflects the belief that while these clinical entities may be core competencies for the child and adolescent psychiatrist, responsibility for training in these areas should occur in training sites other than that of PCLP. The final list of competencies includes those with endorsement by more than 70% of survey respondents (see Table 1).

Table 1.

Core Competencies in PCLP

Patient Care:

Psychiatrists practicing in the PCLP setting should be able to:

1. Clarify the chief complaint and consult question

2. *Assess adjustment to medical illness in the child and family members

3. *Assess the functional impact of medical illness and the response of children and family members to illness and medical treatment

4. *Assess the role of family factors in the triggering and amplifying physical and psychological symptoms

5. *Work effectively with parents with psychiatric illness and personality disorders

6. *Conduct a developmentally appropriate mental status examination

7. Recognize signs and symptoms of drug intoxication and withdrawal, polypharmacy and drug-drug interaction

8. Assess and manage suicide risk and suicidal behaviors

9. *Assess for potential neglect or abuse and make appropriate referrals to Child Protective Services

10. Assess for nonadherence with medical treatment

11. *Develop a developmentally appropriate case formulation

12. *Develop a developmentally appropriate diagnostic plan

13. Recognize the need for and utilize medical consultation

14. *Identify and use appropriate pharmacological treatments for medically ill children and adolescents

15. *Identify and use appropriate psychotherapeutic treatments for medically ill children and adolescents, including psychodynamic, CBT, guided imagery/hypnosis

16. *Develop and help implement developmentally appropriate behavioral plans

17. *Utilize techniques to help children and adolescents cope with stressful medical and surgical procedures

18. *Provide guidance to caregivers of medically ill children and adolescents after discharge

Medical Knowledge:

Psychiatrists practicing in PCLP settings should demonstrate knowledge of:

1. *Nature and prevalence of psychiatric illness in medically ill children and adolescents

2. Impact of psychological factors and psychiatric illness on the course of medical illness

3. Psychiatric complications of medical illness

4. *Role of developmental factors and their relationship with medical illness and coping

5. *Psychiatric and neurodevelopmental effects of toxins, medical/surgical treatment and medications

6. *Indications for the use of psychiatric medications in medically ill children and adolescents

7. Impact of medical illnesses on pharmacology and appropriate adjustments to prescribing

8. Adjustment Disorders

9. Acute Stress Disorders/Medical PTSD

10. Delirium

11. Catatonia

12. Neuroleptic Malignant Syndrome

13. Serotonin Syndrome

14. Anti NMDA Encephalitis (Autoimmune encephalitis)

15. Psychiatric Disorders Due to a General Medical Condition or Toxic Substance

16. Somatoform Disorders

17. Pain Assessment and Management including the use of psychiatric medications and nonpharmacological interventions

18. *Factitious Disorders and Factitious Disorder by Proxy

19. Psychological Factors that Affect Physical Illness

20. Eating Disorders

Professionalism

Psychiatrists practicing in the PCLP setting should consistently:

1. Respond to communications from patients and health care professionals in a timely manner

2. Document encounters and treatment recommendations promptly and comprehensively in the patient medical record

3. Coordinate care with other members of the multidisciplinary team

4. Arrange for back up coverage when necessary

5. Ensure continuity of care for patients

6. Manage countertransference reactions of the medical team

Interpersonal and Communication Skills:

Psychiatrists practicing in the PCLP setting should be able to:

1. *Establish rapport with a culturally diverse population of medically ill children and adolescents and their families

2. Communicate effectively and collaborate with consulting providers

3. Use clear written and verbal skills to communicate information to referring providers and family members

4. Provide guidance to the referring multidisciplinary team regarding the implementation of the recommended treatment interventions

5. Abide by HIPAA regulations and state laws to protect patient privacy

6. Lead a multidisciplinary treatment meeting to facilitate patient care

Practice Based Learning and Improvement:

Psychiatrists practicing in the PCLP setting should consistently:

1. Locate and critically appraise the medical literature for questions applicable to patient care

2. Use medical libraries and information technology to identify resources to facilitate patient care

3. Maintain current knowledge base in the literature specific to the practice of consultation-liaison psychiatry

Systems-Based Practice:

Psychiatrists practicing in the PCLP setting should have a working understanding of:

1. Insurance benefits and limits

2. System resources

3. Healthcare economics and financing

4. *Contexts of care provision in the pediatric setting

5. *Impact of parental and child mental health issues on the pediatric team

6. Impact of consultation recommendations on the larger hospital system

7. Effective liaison with outside agencies

^*indicates pediatric-specific competencies

Future Directions in PCLP training

The establishment of core competencies is a first step towards defining expected areas of expertise in child and adolescent psychiatry fellowship training programs. The PCLP education community expressed interest in the shared development of model curricula and suggested readings. This workgroup intends to continue to work towards cross-institution collaborative curriculum development.

The question of how to reliably assess the accomplishment of training milestones is one that is still under development. Sargent et al. (2004) have outlined the principles of a reliable, multidimensional method to assess resident progression. Dingle and Sexson (2007) have similarly described the development of a program to develop and assess core competencies in child and adolescent psychiatry fellowship training. However, reliable and valid measures of assessment are still not clearly established and Simmons et al. (2018) have drawn attention to the need to establish a nationwide forum for the creation and sharing of best practices as well as formalized assessment tools.

Even as efforts continue to improve the reliability of assessments of the current milestones and competencies, the ACGME is already beginning discussions of “Milestones 2.0” in hopes that study and refinement will improve validity and utility of the Milestones in GME.We suggest that incorporating subspecialty-specific input into the next version of the Child and Adolescent Psychiatry milestones may allow a more robust and nuanced articulation of the breadth of competent practice.

We believe that this document offers a useful starting point for the specialty of PCLP. We anticipate that publication of these Core Competencies will provide training directors, PCLP directors within the CAP fellowships, directors of CLP and PCLP-specific fellowship training programs and trainees a set of standard training goals for PCLP service experiences. Review of these goals at different points during PCLP rotations has the potential to help ensure that trainees are exposed to a set of required training experiences and obtain a greater awareness of the skills required to practice in this growing specialty as integrated medical and psychiatric care receive increasing attention by healthcare delivery organizations and the public.

Appendix

Special Interest Group for Pediatric Consultation Liaison Psychiatry Core Competencies, Physically Ill Child Committee, American Academy of Child and Adolescent Psychiatry.

Albdah	Ayman
Al-Mateen	Cheryl
Altaha	Bahar
Andreu	Maria
Crawford	Jessica
Dalope	Kristin
Dell	Mary Lynn
Derish	Nicole
Fuchs	Cathy
Geertsema	Jannie
Guber	Kevin
Jacobson	Julie
Kelly	Pat
Meadows	Amy
Namerow	Lisa
Ortiz-Aguayo	Roberto
Pao	Maryland
Plioplys	Sigita
Rackley	Sandy
Russell	Ruth
Samuels	Susan
Shaw	Richard
Stubbe	Dorothy
Vasile	Alexandru
Walker	Audrey