REPORT for the ACADEMIC COMMITTEE, Royal College of PsychiatristsMargaret Slack award 2013.
Many thanks to the committee for this award, which enabled me to participate in the
CHILDREN’S HOSPITAL GLOBAL PARTNERSHIPS FOR PSYCHIATRY, Boston
Children’s Hospital, under the supervision of Dr. Patricia Ibeziako. I participated in the
programme offered by the hospital to international psychiatrists and psychologists (Aug- Sept
2013).
ABOUT THE PROGRAMME:
The Children’s Hospital Global Partnership for Psychiatry Programme is an interdisciplinary
programme aimed at both psychiatrists and psychologists. It aims to support Excellence and
innovation in education, consultation, research, and advocacy for the mental health of
children and families across the globe. The Psychiatry Consultation Service (PCS)
programme, under the direction of Patricia Ibeziako, MD, provides opportunities to observe
the evaluation and management of children and adolescents with psychiatric needs who
present in medical settings. Participants actively take part in the local teaching and training
events, case reviews and discussions, and any ancillary teaching/ training.
The PCS provides psychiatric consultations to all inpatient medical and surgical units at
Boston Children's Hospital. In providing these clinical services, the PCS targets the teaching
of consultation-liaison psychiatry to trainees in child psychiatry and psychology, and aims to
expand the academic knowledge base of paediatric psychosomatic medicine. Subspecialty
areas within the PCS include oncology, transplant, cystic fibrosis, and critical care services.
One of the largest in the country, the PCS conducts about 1000 consultations a year.
AIMS IN PARTICIPATING:
I had several aims in mind, from Clinical, Educational, Research and Advocacy perspectives,
and encompassing a wish to gain exposure to a different system of care and an understanding
of how psychiatry in the US “works”.
I am interested in the developmental and environmental approaches to Consultation- Liaison
psychiatry. Given the expert nature of the service, I was keen to gain exposure to specific
clinical skills, to enhance my understanding of, and expertise in, Consultation- Liaison Child
and adolescent psychiatry. Also I wanted to gain an understanding of systems of service
development and delivery, and to develop educational research collaborations in this area.
I have a long standing in C-L work, and wanted to see what sort of referrals the team accept
and what sort of pathways are in place. I was particularly keen to gain experience relating to
the management of psychiatric presentations relating to chronic disorders such as cystic
fibrosis, as I was aware of sub-speciality approaches within the C-L team. Previously as a
trainee I was involved in supporting a service from the local community child and adolescent
psychiatry team in conjunction with local psychiatrists and paediatricians for Cystic Fibrosis
patients. This initiative was an attempt to cater for recognised deficits in an area of Ireland
with no access to consultation liaison psychiatry, and I think experience in this area would be
really beneficial longer term in understanding how to best support young people with chronic
illnesses and their families. Additionally, I worked at Great Ormond St and the Feeding and
Eating Disorders service prior to taking up this fellowship, so I was keen to see how eating
disorder presentations were assessed and managed by the team.
CLINICAL:
I participated in case conferences, ward rounds, observed consultations while undertaking
this period at Boston Children’s Hospital. The team received a large volume of referrals
relating to both acute presentations of psychiatric illness, and the psychological and
psychiatric morbidity relating to more chronic disorders. In terms of systems and structures of
care, I participated in case based teaching, discussions about diagnostic assessments,
management and onward transfer of patients.
In terms of acute case presentations, I gained experience of different approaches to
multidisciplinary assessment and teamwork, including approaches that maximise/ support
team function to further support young people and their families. Through exposure to
different behavioural interventions e.g. biofeedback and relaxation training, I could see what
was provided to children struggling with the impact of medical procedures. Reviews were led
by Residents or Attending Psychiatrists, with subsequent discussion and feedback to families.
Children in hospital longer term engaged in longer term treatment, e.g. with the transplant or
CF services. Collaborations with other multidisciplinary clinicians in the hospital provided a
reflective opportunity. I observed the psychiatric input provided to the transplant service,
I found the management of children with complex presentations at this internationally
renowned centre to be very exciting, particularly as the team is often working at the frontiers
of new medical developments in collaboration with Paediatric colleagues. In particular
working in collaboration with the Cystic Fibrosis multidisciplinary team was rewarding, as I
was able to attend meetings of the team, attend reviews with the clinician leading this aspect
of the service (Dr. G. Garcia), and hear about research endeavours from a CL perspective in
this area at Boston Children’s Hospital. Dr Garcia was most generous with her time, talking
me through the development of the service over time and introducing me to colleagues who
have a particular interest in this area. I also met with Dr. Greg Sawicki, who is one of the lead
paediatric clinicians for the service, to get the paediatric perspective on the importance of CL
psychiatry in this context.
I attended Eating Disorders team meetings and participated in the assessment process for
young people with eating disorders in the CL service. This was especially interesting as the
model of care differed greatly from that at GOSH- for example, while the liaison team
provides initial consultation, subsequently the ED team is led by adolescent medicine (rather
than psychiatry at GOSH), and children need to be medically stabilised and off NG feeding to
be admitted to the psychiatric unit. I also worked with a clinical psychologist who is initiating
an FBT based programme, and who is interfacing between the CL team and the specialist ED
service, and was able to look a the benefits and challenges of managing Eating disorders in
the Liaison context. The opportunity to create links with the clinicians in Boston will long
term be helpful in further developing my academic career- they have been very supportive of
potential future collaborations looking at clinical issues.
EDUCATION
Psychology and psychiatry trainees are trained together in this programme, with some
separate training sessions for each discipline. This interesting model was thought provoking
in terms if the promotion of interdisciplinary learning. Additionally, training structures for
residents are very different to those in Britain and Ireland. The training scheme is very well
structured; the programme involves participation in clinical conferences, ward rounds and
other clinically related activities, affirming the need to practice and be conversant with the
evidence base for care.
There are weekly training seminars and teaching ward rounds occur 3 times a week. There is
also a weekly psychopharmacology seminar. I attended teaching sessions with residents and
attending clinicians, focussing particularly on emergency presentations for CL services.
Eating disorders are managed to a great extent by the Adolescent Medicine team, so I also
attended the Eating Disorders/ Adolescent Medicine teaching sessions, and occasionally other
sessions e.g. the psycho-oncology service weekly training sessions, the psychotherapy and
psychopharmacology teaching sessions. I provided a talk on International perspectives on
services at the CL Team meeting and participated as a guest speaker for the Eating Disorders
team.
ADVOCACY:
The programme emphasises the development of child mental health policy and advocacy for
child mental health care. Conceptually, this program places the clinical, programmatic and
advocacy efforts of the Boston Children's Hospital's Department of Psychiatry in a global
context through readings and discussion of comparisons with other context. Dr. Myron Belfer
and Dr. Patricia Ibeziako provided illuminating, thought provoking discussions about this
area. We discussed a broad range of issues in this regard, including availability of services in
different parts of the US and inequity of access across the globe. Cultural components of
psychiatry experience and assessment were discussed. First steps in considering scoping
service needs and developing evidence for hospitals and other stakeholders to demonstrate
the value of child and adolescent CL services, were outlined.
It was interesting to witness some of the universal challenges in child and adolescent
psychiatry. It is evident that in the US, just as in Ireland and the UK, close relationships
between CAMHS, liaison services, paediatric services and indeed in transition between child
and adult services are all crucial to improving outcomes for our patients. I consider an
international perspective important. Undoubtedly gaining awareness of how specialist areas
like this are managed internationally will be very helpful in informing future service
development and delivery. In particular it was helpful to hear about the genesis of CLpsychiatry for young people with Cystic Fibrosis, how CF multidisciplinary services work in
the US, and how these are funded. The perspectives on Eating disorder management in CL
settings was also very helpful.
I would be keen to develop future collaborations with international colleagues around
facilitating interdisciplinary learning in liaison settings. We also looked at my previous
experience of educational service development and advocacy- some of which I did not realise
fell into this category! I have significant experience in developing educational endeavours
supporting colleagues with limited access to child and adolescent psychiatry services, and we
considered how this might be combined with a clinical career. I hold a Masters in Medical
education. This is an area in which Boston Children’s Hospital excels, and potential research
looking at educational initiatives in consultation- liaison settings, as a means of improving
early detection and intervention in mental health disorders in children and adolescents, was
an area I explored with mentors in Boston. In terms of advocacy, I have gained some
awareness of how to manage such a role. These discussions provided not only a reflective
opportunity but will I believe provide me with a degree of confidence regarding my
approaches in the future as they consolidated my practical experience to date.
LONG TERM OUTCOMES:
This fellowship, coming at the end of training, and prior to taking up a consultant post, was
well timed to provide an interesting, dynamic yet reflective training experience. It allowed
me to consider clinical care, educational strategies, and to consider different approaches to
service provision and delivery. It affirmed for me that while mental health disorders present
in similar ways in different settings, cultural factors are significant in both assessment of
presentations and management. Comparing the US, the UK and Ireland, it is evident that
while diagnostic categories may translate across national boundaries for many disorders,
health systems and therefore management approaches are very different.
Long term, I envisage working as a Consultant Child and Adolescent Psychiatrist in
Consultation- Liaison Psychiatry, in a University affiliated service. This will involve roles in
service development and advocacy in addition to medical education responsibilities. I
envisage having an ongoing role in supporting such teaching and training opportunities. I
believe that participating in the Programme at Boston Children’s hospital has been very
formative in this regard. Additionally, I hope to establish longer term collaborations with the
PCS, especially in terms of the management of eating disorders in CL settings and with the
cystic fibrosis service provided by the psychiatry teams at Boston Children’s Hospital.
_________________________________________________________________________
Thanks to:
The Royal College of Psychiatrists’ Margaret Slack Travelling Fellowship made my
participation in this programme possible- many thanks to the Academic Committee of the
RCPsych for the award. Thanks also to Dr. Dasha Nicholls and Dr. Finbarr O’Leary, who
proposed me for the travelling fellowship.
I am immensely grateful to the PCS team Residents and Attending Clinicians, who included
me in so many interesting opportunities, Dr. Georgia Garcia and Dr. Melissa Freisinger in
particular made sure I met my aims in terms of CF/ Eating disorder service. Thanks also to
the administrative staff who managed to sort out all the visiting administrative issues!
Final thanks must go to Dr. Patricia Ibeziako, without whom this experience simply would
not have been possible. She runs a truly wonderful programme, which I would recommend to
any interested psychiatrist or psychologist.