The residency team serves 6-7 beds on the inpatient service located at SHMC. Residents spend time in the inpatient setting throughout their four years in residency training. In PGY1, residents are paired with PGY2s for 2 weeks, and then takes over as the solo resident for the next 2 weeks. In PGY2, residents spend up to 3 months on the inpatient service. The inpatient unit has both an acute and open side which allows for capacity to care for individuals who require higher level of care including the need for involuntary medications for non-compliance with oral medications, and the use of seclusion and restraints when indicated. ECT is a common treatment modality used at SHMC, for both inpatient and ambulatory patient care, with residents getting significant exposure to indications, consent and legal processes important in administering ECT.
With 644 beds, Providence Sacred Heart Medical Center (SHMC) is one of the largest hospitals in the Northwest and is the only level II trauma center between Seattle, WA and Missoula, MT. SHMC boasts a 26-bed medical/surgical ICU and a 32-bed cardiovascular ICU designated to support a high complexity cardiovascular program that includes cardiac transplant, LVAD, and ECMO. SHMC also has a kidney and pancreas transplant program and Level 3 Epilepsy center that helps support a large catchment area that includes nearly 1.5 million people.
Residents gain experience with a wide variety of consultation questions, including safety evaluations (> 25%, of which > 10% were admitted s/p suicide attempt), management of agitation related to delirium or major neurocognitive disorder (>20%), alcohol/substance related issues (>15 %), management of bipolar disorder/psychosis (> 5%), depression/adjustment/demoralization (> 5%), anxiety disorders (5%), somatoform and functional neurological disorders (4%), and capacity consults. Residents also receive experience evaluating for catatonia, acute stress/PTSD, peripartum depression/psychosis, buprenorphine inductions, etc.
Addiction training starts in PGY1/2 years, with both didactics and clinical experiences. PGY1/2 residents have extensive clinical experience managing substance use disorder and dual diagnosis patients in the hospital setting through PRS’s Addiction Medicine Consultation Service (AMCS). Providing consultation to medical, surgical, and specialty teams at Sacred Heart Medical Center, the AMCS cares for hundreds of patients with substance intoxication, withdrawal, dependence, and use disorder per year. These substances primarily include alcohol, tobacco, methamphetamine, opioids, and benzodiazepines, though we intermittently encounter essentially all illicit substances. We pride ourselves on providing patient centered care that is constantly adapting to innovative treatment modalities. As part of this innovation, residents have opportunities to join or lead the development of hospital-wide addiction paradigms. Examples include the development of a benzodiazepine-minimizing protocol for alcohol withdrawal and the creation of a low-dose initiation technique to transition patients from full agonist opioids to buprenorphine. The AMCS is a fully interdisciplinary team, with integrated daily collaboration with an addiction coordinator, pharmacists, and (at times) non-psychiatry residents.
With 177 pediatric beds, Sacred Heart Children's Hospital is the largest pediatric hospital in Eastern Washington. Over 120 specialists provide care to 28 pediatric medical and surgical sub-specialities, including the only pediatric ICU in Spokane, surgical specialties, cardiology, neonatology, endocrinology, gastroenterology, neurology, neurosurgery, psychiatry, nephrology, ophthalmology, orthopedic, psychology, pulmonology, urology, adolescent medicine, and developmental medicine. Residents and fellows gain experience with a wide variety of consultation questions including safety evaluation, management of agitation, management of primary psychiatric disorders and psychological factors impacting medical conditions, management of somatoform and functional neurological disorders, management of eating disorders, and providing psychological support to families and children with chronic medical conditions.
BEST (short for Behavioral Emotional Skills Training) is the highest level of psychiatric care available for 8–12-year-olds in Spokane, as well as regionally in Eastern Washington state. It is a combined partial hospitalization and intensive out-patient day-treatment program designed to treat school-age children with significant mental and behavioral health concerns. Children in the program are often at risk for inpatient hospitalization, being discharged from psychiatric inpatient care, or in need more intensive services than those available in the traditional outpatient setting. BEST is a trauma-informed program, and the therapy groups are based on Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT) principles.
While in close collaboration with an interdisciplinary team of therapists, social worker, and nurse, learners gain experience with a variety of common and serious child psychiatric disorders, including attachment disruptions, as well as trauma, behavioral, mood, and neurodevelopmental issues. Under the direct supervision of a board-certified child and adolescent psychiatrist, residents and fellows work with children and family to complete comprehensive psychiatric evaluation, diagnostic clarification, family system assessment, and treatment planning. Residents and fellows also learn to manage medications, and provide psychoeducation to children and family. Additionally, residents and learners have the opportunity to engage in individual supportive psychotherapy for children, take part in weekly family therapy, and lead parenting classes.
Eastern State Hospital (ESH) is a state psychiatric hospital located in Medical Lake, WA that serves patients in the eastern part of Washington. ESH has civil, forensic and geriatric units. The average length of stay is 181 days, and the civil side admits about 240 people a year.
On this rotation, a resident works with an attending physician who carries between 15-17 patients. Patient are seen, on average, between two to three times weekly. The resident / attending team can expect 2-3 admissions a week. ESH does not currently have an electronic medical health record, and relies on paper charts where residents learns to write orders, and document legibly, and efficiently.
At this facility, common treatment modalities include medication management (antipsychotics, antidepressants, mood stabilizers), in addition to delivery involuntary medications. Residents work closely with a treatment team including a psychologist, social worker, activity therapist, occupational therapist, and speech therapist.
Residents work on a variety of wards, including restoration of competency and NGRI (not guilty by reason of insanity). Residents work alongside experienced psychiatrists for a month long required rotation in PGY1/2. An embedded rotation forensic learning curriculum ensures that residents have exposure to key supreme court cases, and develop an understanding of civil and criminal law and its intersection with psychiatry.
Brian Sweatt, PRS 2020 graduate, is the lead attending supervisor role on this rotation and the site director for all ESH rotations. Residents rotate on the geriatric admissions ward at Eastern state Hospital, providing patient care daily, as well as developing medical knowledge through a formal geriatric psychiatry curriculum, facilitated by Dr Sweatt.
PGY2, PGY3 and PGY4 residents have psychiatric continuity clinics at the Spokane Teaching Health Clinic. Supervision gradually gives way to independence and autonomy as residents move through residency training. The clinic is noteworthy in several ways. Each of the rooms is equipped with safety alarms, and audio/video equipment to allow observation by faculty to enable safety as well as clinical feedback. The clinic has MA support to assist residents with rooming patients, collecting vital signs, scales, review of systems and scheduling. Resident patient appointments start with 90 min for an intake for R2’s and then transitions to 60 min intakes and 30 min return visits for R3’s and R4’s. Patient appointment time is limited to 2.5 hours in a half day for PGY2/3 residents to maximize the educational experience for residents. In response to resident feedback, patient care time is increased to 3 hours per ½ day in PGY4, to ensure that residents choosing ambulatory post residency positions, are ready for practice. Residents are trained in billing and coding requirements in the ambulatory setting. Notes are reviewed by an educational coding specialist to ensure coding understanding and requirements, to ensure that residents are competent in this important area of work life, post residency. The clinic has ample free parking and is biker/walker friendly with a pedestrian bridge leading towards the hospital and rail to trail for cyclists. There is an on-site small gym, and two showers at clinic for staff use.
Primary care consultation in a high fidelity collaborative care training model is a unique feature of our program. We have a mature, longitudinal training in collaborative care psychiatry, starting in PGY3 and continuing into PGY4. Our training includes curriculum content, developed by the AIMS center at the University of Washington (UW), and taught by psychiatry residency program faculty who are educators in the UW Community Based Fellowship. Clinical rotations embed all principles of collaborative care, including patent centered treatment, population focused training, training in evidence based treatment and therapy for the primary care setting, outcomes based treatment, with use of a population based registry for care and a paradigm that uses a stepped care model so that those who are the most ill, get the most access to care, accountability, and quality improvement. You will consult to a range of primary care clinics across Providence Spokane and Steven’s County, working with patients from teenage years to the very elderly.
Beginning in PGY2, residents start 1/2 day longitudinal psychotherapy clinic at the STHC. residents get experience selecting and consenting patients to core psychotherapies required in residency training. Treatment modalities are aligned with timing of psychotherapy seminars, with supportive and CBT focus in PGY2, and formal psychodynamic cases beginning in PGY3. residents gain experience in a variety of treatment modalities to include ACT, CPT, ERP and CBT for psychosis to name a few. Residents have on site core faculty video supervision as well as community mentors during all three years of psychotherapy training.
The STHC Recovery clinic is a low barrier, patient centered, harm reduction clinic that serves voluntary patients with any type of substance use disorder. Residents enjoy the support of nurses and medical assistants who facilitate the daily workflow by obtaining urine drug screens, checking physician prescribing databases and providing free naloxone/OD prevention kits to patients. As with the AMCS, the Recovery clinic is incorporating innovative treatment solutions to best serve the people of Spokane. Examples include the use of low-dose initiation techniques for buprenorphine, dissemination of fentanyl test strips to patients, and the development of a Contingency Management program for patients with stimulant use disorders . Residents frequently cite the STHC Addiction clinic as their favorite rotation at the Spokane Teaching Health Clinic. In addition to the clinical aspects of the rotation, residents have numerous patient interactions coded for fidelity to Motivational Interviewing. They participate in a weekly Addictions Learning collaborative. Residents also get brief exposure to a local Intensive Outpatient Program, a Sobering Unit and a Chemical Dependency Assessment done by a CDP.
In their fourth year, the residents spend half a day a week at the VA Substance Abuse Treatment program, honing their therapy skills for substance use disorders. At the VA they work alongside Psychology Interns and get supervision from staff Psychologists in evidence based psychotherapies for substance use disorders. Residents will also rotate at the Spokane Regional Health District, where they will get extensive experience prescribing and managing methadone.
Frontier Behavioral Health (FBH) Child and Family Services clinic is a community mental health organization that cares for individuals ages 3 to 18 who are on state insurance (Medicaid). Each patient at FBH is assigned to a clinician who provides case management and developmentally appropriate therapy. If indicated patients are referred in for psychiatric specialty treatment with PGY3 residents, who form an integral part of the treatment team at FBH.
During this rotation, residents are directly or indirectly supervised by board certified Child and Adolescent psychiatrists. Patients are scheduled for 90 minute intakes, and 30 minute follow ups.
Residents rotate at FBH E&T units in PGY2, and again as an elective in PGY4, learning the core skills of inpatient psychiatry. They work in a interdisciplinary team that includes a psychiatrist, nurse practitioners, therapists nurses and social workers.
This rotation was developed pre-COVID, to address rural health disparities in Steven’s county, a region north of Spokane, stretching all the way up to the Canadian border. PGY3 residents each spend six months providing one half-day per week of telepsychiatry services to the Family Medicine clinic in Colville, WA. During this rotation the residents provide remote medication management services to a rural, underserved population in Stevens County. Colville is a community with historically limited access to mental health resources and a significant mental health burden among its population; the demand for specialty psychiatry service is high among Colville’s primary care providers. Residents typically see one intake and several follow-ups during any given half day. In addition to gaining experience in outpatient medication management and navigating the technological advantages and barriers of telepsychiatry, they also learn about the policy, billing and regulatory aspects of telehealth services.
Gonzaga University Health and Counseling Services is home to a longitudinal psychotherapy 1/2 day clinic in PGY3 and PGY4. Supervision is provided in group format by the lead counseling Psychologist, as well as individual community mentorship. Residents love working with this transitional age population!
On ½ day rotations, residents follow 3 therapy patients. On full day rotations resident treat 5 therapy patients. The emphasis at this site is on brief psychotherapies, suited for the college age population. Treatment modalities include supportive therapy, cognitive behavioral therapy, harm reduction strategies, problem solving techniques, acceptance and commitment therapy which mirror psychotherapy didactic sessions occurring throughout the resident training.
All residents and faculty participate in patient safety and quality improvement, with QIPS being a core component of our training program and one which we are nationally recognized for. If you like QI and continuous process improvement, this is the program for you. The QIPS curriculum includes IHI online modules, on site didactic sessions led by core faculty and a systems of medicine rotation in PGY2. Knowledge acquisitions is paired with real world application with QI project work through all 4 years of residency. Residents are given dedicated QI time during PGY2 psychiatry specialty clinic rotations. Resident projects have resulted in permanent changes in our system and have improved patient care. PRS graduates are comfortable planning and implementing QI projects by the time they graduate.
Patient safety projects form a longitudinal thread through the entirety of the residency experience, blending into quality improvement projects for more senior residents. An introduction to root cause analyses occurs during the PGY1 year, with a focus on identifying modifiable causes for adverse events that allows for the proposal of systematic changes. During PGY2 year, root cause analyses are reviewed in more detail during the Systems of Medicine rotation, and residents have dedicated time to initiate QI projects that may address identified systematic patient safety issues. PGY3’s apply patient safety to actual cases, demonstrating mastery of root cause analysis by presenting at one of our quarterly Morbidity and Mortality conferences (which everyone attends across all four years). PGY4 residents complete a performance in practice (PIP) module, preparing for maintenance of certification requirements.
