Transcript Disaggregating and Measuring Implementer Adherence and

Developing
Competence
in
Jennifer C. West, PhD.
University Psychology
of Rochester Medical
Center
Pediatric
within
a
Departments of Psychiatry and Pediatrics
17, 2009
General April
Child
Internship
Objectives
Describe an elective rotation designed to
promote emerging competence in
pediatric psychology
 Describe the challenges associated with
integrating a specialized elective
experience within a generalist internship
program
 Highlight outcomes of the elective
experience

University of Rochester Medical Center
Internship – Child and Adolescent Track
 4 interns
 12 months outpatient (10-12 weekly patient contacts, groups)
 6 months acute psychiatry (testing/consultation/treatment)
 6 months elective with higher outpatient caseload
8 hours Pediatric Psychology
 8 hours Research
 4 hours Pediatric Psychology/ 4 hours Research
 Seminars: Psychotherapy, Diagnostic Clinic, Group Therapy,
Multicultural (1/xmo), Teaching/Case Conference (1x/mo),
Professional Development (1x/mo)
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Pediatric Psychology Elective
 Development of the elective was guided by 2003
Society of Pediatric Psychology Task Force Report on
Training of Pediatric Psychologists (Spirito et al)
 Also informed by training experiences of faculty
supervisors
 What was positive about their training experiences and
what they would have changed
Taskforce Recommendations
(Spirito et al, 2003)
 Training in a variety of skills – direct service, research,
consultation, program development and evaluation
 Focused training in 1-2 areas of interest with goal of
developing specialization
 Practice in primary care
 Interdisciplinary training
 Mentoring
Domains of Training (Spirito et al., 2003)
 Life-span Developmental
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Psychology and
Psychopathology
Child, Adolescent and Family
Assessment
Intervention Strategies
Research Methods and
Systems Evaluation
Professional, Ethical and
Legal Issues Pertaining to
Children, Adolescents, and
Families
 Issues of Diversity
 Role of Multiple Disciplines
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in Service Delivery Systems
Prevention, Family Support,
and Health Promotion
Social Issues Affecting
Children, Adolescents, and
Families
Consultation and Liaison
Roles
Disease Process and Medical
Management
Pediatric Psychology Elective
 Supervisors: Psychology Faculty and Psychology
Fellows
 Provide consultation, assessment, and short-term
treatment in the following ambulatory clinics at the
Golisano Children’s Hospital at Strong:
 General Pediatrics
 Pediatric Diabetes Clinic
 Pediatric Gastroenterology Clinic
 Pediatric Pulmonology Clinic
 Provide psychological treatment to patients with
chronic illness in the outpatient psychiatry clinic
Pediatric Psychology Elective
 Aims to promote development of foundational and
core competencies that are integral to the internship,
within a specialized context (Kaslow, 2004)
 And, development of specialty competencies
 Developmental model of competence
 Interns arrive with varying levels of experience and
different training goals
 Minimum threshold of competence, yet tailor to the
individual training/ professional development goals
 Training that combines didactic, experiential, and
mentoring components
Internship Competencies
 Professional Skills and Competencies
 Diagnostic and Assessment Skills
 Treatment, Consultation and Administrative Skills
 Professional Standards and Behavior
 Ethical Understanding and Behavior
 Professional Development and Demeanor
 Academic Competencies
 Teaching and Supervision
 Scholarship
Pediatric Clinical Experiences: Goals
and Domains of Training
 Training in a variety of skills: direct service, consultation
 Some opportunities for program evaluation and development
 Fewer opportunities for research
 Training in 1-2 specific areas of interest
 Interdisciplinary training
 Interdisciplinary settings (medicine, nursing, social work, nutrition,
education-liaison, Child Life)
 Some joint training opportunities with pediatric residents
 Mentors
 Paired with faculty, postdoctoral fellows
 Developmental process
Clinical Experiences: Goals and
Domains of Training
 Emphasis on primary care
 Provide consultation and service in general pediatric clinic
 Involved in mental health screening initiative to enhance
detection of behavioral/emotional health concerns
 Provide evaluation/treatment to patients/families who are atrisk
 Educate primary care providers re: psychosocial treatments
 Consultation, didactic lectures
 Provide psychoeducation, anticipatory guidance to prevent
mental illness
 Identify/refer patients who need ongoing mental health
treatment
Clinical Experiences: Goals and
Domains of Training
 Lifespan Developmental Psychology
 Supervised clinical cases across the lifespan that focus on
issues related to chronic illness (e.g. adherence, procedurerelated anxiety, illness management at transition to college)
 Area for improvement: Infancy
 Lifespan Developmental Psychopathology
 Participation in routine mental health screening initiative to
identify youth at risk for mental illness
 Observe and conduct supervised clinical activities with
patients presenting with range of psychopathology
 Area for improvement: acute medical illness
Clinical Experiences: Goals and
Domains of Training
 Child, Adolescent and Family Assessment
 Multiple opportunities for assessment related to adherence, quality
of life, coping, pain, weight control, health beliefs
 Assessment of family functioning – strengths, vulnerabilities
 Area for improvement: Increased use of empirically based
assessment tools
 Intervention Strategies
 Opportunities to observe supervisors conduct interventions
 Opportunities to deliver interventions with children with chronic
medical and behavioral health conditions (e.g., encopresis,
recurrent abdominal pain, procedure-related anxiety, adjustment
issues, adherence to medical regimens)
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Fewer opportunities for bereavement counseling, group
interventions
Clinical Experiences: Goals and
Domains of Training
 Research Methods and Systems Evaluation
 No current formal opportunities
 Professional, Ethical, and Legal Issues Pertaining to
Children, Adolescents, and Families
 Multiple experiences focused on developing appropriate
communication in healthcare settings (progress notes, evaluation
summaries, interdisciplinary team meetings)
 Issues of Diversity
 Multiple opportunities for supervised service delivery to patients of
diverse ethnic and cultural backgrounds, sexual orientations and to
conduct evaluations using interpreter services
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Area for improvement: Currently only in one setting (ambulatory)
Clinical Experiences: Goals and
Domains of Training
 Role of Multiple Disciplines in Service Delivery
 Participate in multidisciplinary staffings
 Lectures to medical students and residents, observed
visits
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Area for improvement: participation in regular team mtngs
 Prevention, Family Support, and Health
Promotion
 Supervised experience in promoting healthy lifestyles,
especially related to physical activity, diet, sleep hygiene,
family violence, effective discipline
Clinical Experiences: Goals and
Domains of Training
 Social Issues Affecting Children, Adolescents, and Families
 Service in primary care aimed at reducing barriers to accessing
mental health care
 Consultation and Liaison Roles
 Multiple opportunities to observe and provide consultation to
medical providers (primary care and subspecialty), as well as to
educators
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Area for development: no current involvement on inpatient C-L team
 Disease Process and Medical Management
 Clinics provide multiple opportunities to gain knowledge of disease
process and treatment
Pediatric Supervision Group
 Meets weekly for one hour
 Participants: All trainees (interns, fellows) providing
service in the Pediatrics Department
 Case discussions weekly (30 min)
 Weekly didactic presentations (30 min)
 1st week of month: Guest Lecturer
 2nd week of month: Treatment presentation
 3rd week of month: Journal article review
 4th week of month: Multicultural presentation
Pediatric Supervision Group
 Case discussions
 Provide additional opportunities for trainees to gain
knowledge about chronic illness and related
psychosocial factors beyond clinics where they are
providing service
 Case-based learning – focus on assessment strategies,
differential diagnoses, treatment planning,
interventions, ethical issues, issues related to diversity,
systems issues
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Role modeling by supervisors
Role plays
Discussion of community resources
Pediatric Supervision Group
 Directed readings focused on domains of training (Spirito et al,
2003)
 Handbook of Pediatric Psychology (Ed. Roberts)
 Binder of articles – general issues, illness-specific
 Web-based resources –Bright Futures toolkit, American Academy of
Pediatrics, community resources
 Journal of Pediatric Psychology – series of review articles on EBTs,
current volumes
 Attendance at Pediatric Grand Rounds
 Additional instructional techniques could include videotapes,
demonstrations with standardized pts, virtual-reality based peds
psych interactive training materials
Guest Lecturer Topics
 Psychological Consultation  Education Liaison Services
in Medical Settings
 Psychosocial Aspects of
Chronic Illness
 Neuropsychological
Sequellae of Chronic
Illness
 Child Life Services
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in the Medical Center
Sickle Cell Disease
Eating Disorders
Understanding Behaviors
of Families in Poverty
Motivational Interviewing
Nutrition and Pediatric
Diabetes
Treatment Presentation
 Emphasis on empirically validated treatments of
common behavioral health conditions
 Topics have included:
 Encopresis
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Procedure-related anxiety
Recurrent abdominal pain
Enuresis
Pica
Adherence
Vocal cord dysfunctionHabit cough
Feeding Difficulties
Sleep Problems
Adjustment to Illness
Weight management
Multicultural Topics
 Multicultural Factors
 Working with Families of
Related to Engagement
and Attrition
 Working with Amish
Families
 Jehovah’s Witnesses and
Medical Procedures
 Working with Refugee
Families
Greek Heritage
 Culture of the Single
Father
 Cultural Issues Related to
the Use of Physical
Punishment
 Working with Families of
Latino Heritage
Assessment of Competence
 Interns receive oral and written feedback after each
patient contact, at mid-way point of the elective, and
at the conclusion of the elective experience
 Formative and summative feedback
 Development and periodic review of learning plans
 Attempt to incorporate self-assessment informally
 Additional assessment tools
 Portfolios
 360-degree evaluations
 Standardized patients
Formative Assessment of Competence
Date:
Supervisor:
Child (1st init):
Activity:
Trainee:
Clinic:
Strengths:
Goals/Areas for Continued Development:
Feedback
 Interns provide written feedback on the elective,
(clinics, supervision group, supervisors) bi-annually
 Feedback is solicited by supervisors and during
monthly meetings with the Training Director
 All training faculty and interns have a bi-annual
retreat during which trainees can provide feedback
about all aspects of the training program, including
the pediatric elective experience
Challenges
 Funding
 Competing demands (for interns and faculty)
 Scheduling constraints – interns may not be able to
participate in some clinics
 Range of prior experience among interns
 Requires high degree of individualizing to ensure that
each trainee’s goals for the experience are met
Challenges
 Meeting intern expectations
 Importance of truth in advertising
 May require modifying some goals (some may become a
focus of postdoctoral training)
 High no-show rates in some clinics
 Mental health stigma (patients and medical
providers)
 Continuing need to re-educate medical providers
about training of interns and role of psychologists
 Mentorship of faculty
Future Directions
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Inclusion of inpatient and community settings
Clinical experiences with neonatal populations
Research experiences
Group therapy experiences with children with medical
illness
 Increased opportunities for program development and
evaluation
 Obtain funding for the elective
 Increase networking with other training programs
Outcomes
 Popular elective
 2000-2008: 26 interns have participated (74%)
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10 did a blended elective
 Interns give highly positive evaluations of supervisors,
supervision group, practica settings
 Evaluations of interns indicate that they attain or
exceed expected level of competence
Outcomes
 14 interns obtained fellowships with a pediatric
psychology focus
 7 former interns work in settings that include a
pediatric psychology focus
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4 trainees obtained faculty psychologist positions at
medical centers
2 have psychologist positions within a school-based
health clinic
1 has a psychologist position within a pediatric
practice