Update on Kentucky’s Psychiatry Residency Programs

University of Kentucky by Dr. Sandra Batsel-Thomas

It is an exciting time of growth for the University of Kentucky Psychiatry Residency Program.  We started a new Integrated Child and Adolescent psychiatry track this year that allows applicants to match into the Adult Psychiatry and the Child Psychiatry Fellowship at the same time.  It also allows for more training in pediatrics and pediatric neurology.  The first two interns started in this track in July.   We also are staring recruiting this year for our newly improved  5 year combined Internal Medicine/Psychiatry Residency Program.  This will have 2 residents a year and will be a great complement to our Triple Board residency program.

We had 8 new interns start in our various residency programs this July.  We have 4 in our categorical program, 2 in the Integrated Child and Adolescent Psychiatry track and 2 in our Triple Board program.  We also had 4 new child and Adolescent Psychiatry fellows and one new Addiction medicine fellow start in July.  In our Categorical Psychiatry program and Integrated Child track we are holding true to our mission to train psychiatrists who want to stay and practice in the region.  Of our new interns – three are University of Kentucky COM graduates, one is a graduate of the University of Pikeville COM, one Lincoln Memorial University-DeBusk COM in Harrogate TN and one is a Kentucky native and a graduate or St. George’s University School of Medicine.

University of Kentucky @ Bowling Green by Dr. Todd Cheever

The University of Kentucky College of Medicine started a Psychiatry residency program in Bowling Green, Kentucky in 2016. Currently, there are twelve residents in the general adult program. At the conclusion of this past academic year, two residents graduated from the program. Both are now working in Tennessee as adult psychiatrists. Two residents were accepted into Child & Adolescent fellowships programs – one at the University of Colorado in Denver, and one at the University of Kentucky in Lexington.

University of Louisville by Dr. Geoffrey Jeyasingham & Dr. Greg Wykoff

The University of Louisville Psychiatry Residency Program began its new academic year in July and welcomed nine new PGY-1 residents to the program. The program completed another successful match and filled all nine available positions. The new intern class is comprised of five females and four males. Six of the nine are US medical school graduates and four have already passed their USMLE Step 3 exam. The average Step 2 score of the class is, once again, well above the national average for incoming Psychiatry interns. We have thoroughly enjoyed working with our interns thus far and anticipate they will continue to prove a wonderful addition to our department.

Although the pandemic has certainly affected our lives both at work and at home, our residency program has continued to prioritize residents’ education. To do so, our program has transitioned from weekly in-person didactics to virtual learning experiences via apps such as Zoom and BlueJeans.  This transition began in early March and has continued through the Summer and early Fall.  To accomplish this, residents have taken a greater leadership role in teaching their peers and facilitating a more active learning environment. While there certainly are some elements that are missed from the on-site learning experience, virtual didactics have provided several benefits.  Among these are increased safety and convenience, as well as improved opportunities for collaboration.

Finally, the program has continued to embrace the role of telepsychiatry and telemedicine in providing patient care. The University of Louisville has been at the forefront of implementing and utilizing telepsychiatry services for patients throughout the state of Kentucky for many years, and this history has proved to be very helpful in adjusting to a primarily telepsychiatric clinic. We anticipate that our program will continue to prepare residents to provide outstanding psychiatric care both in person and virtually as the practice of Psychiatry continues to evolve.

 Regarding community outreach, our program is excited to announce we have a new partnership with Park Duvalle that will allow PGY-3 residents the opportunity to work closely with an underserved and historically marginalized portion of the community.  We anticipate that this experience will help our residents to gain a greater appreciation for outpatient care at the community level, and feel experience at Park Duvalle will strongly complement other clinical experiences at the University of Louisville and Veterans Hospital.  

Overall, we feel that despite the many unanticipated setbacks related to the Covid pandemic, University of Louisville is well-situated to continue to adapt to the rapidly changing landscape of modern psychiatry.  We continue to attract an increasingly strong pool of applicants for residency and are working to improve the quality and variety of our clinical experiences, including our long history of promoting telepsychiatry and virtual learning.  As such, we believe the future of U of L Psychiatry to be bright, and believe things will continue to improve as time goes by, even in these uncertain times.  

Burning Out?

Are doctors burning out? Yes, indeed. In recent years, physician burnout is becoming a growing national issue, even a public health concern. Work-related stress heightens personal dissatisfaction, cynicism, and frustrates feeling accomplishment. That can result in compromise of professional function and home relationships. Depression and/or anxiety sometimes follows and the risk for substance abuse is greatly increased. Denial of such problems and feelings of inadequacy exist even when there is overt evidence to the contrary.

       Burnout negatively affects patient care and productivity while doctors become less professionally engaged or understanding of their patients. That also impacts physician recruitment, retention, and early retirements. <br>

Why is this? Loss of professional autonomy, too brief time with patients, and very cumbersome electronic medical record keeping are a big part of the problem. The intrusion of so many insurance company regulations; pharmaceutical access refusals; and similar hospital, billing, or other bureaucratic burdens at providing medical care harms the spirit and energy of doctors. Ethical and financial asymmetries between physicians and their leadership add to the dysfunction. Inefficient, rushed office practices are another concern. This is especially so since group practices are often controlled by outsiders and/or the influence of money making.

What to do? Intervention can follow two pathways: the local, individual approach and the organizational focus.

Every practitioner should be personally proactive at awareness for signs of trouble. Self-care and office management adjustments can help. Colleagues and office staff ought to be alert to aid one another and if indicated, to suggest outside assistance. The same applies within group practices. Less “bottom-line” objectives probably would be beneficial.

Medical schools and residency training programs should offer more guidance on these matters. Providing more staff assistance at data entry, transcription, patient follow up, and medication prescribing hurdles or reconciliations would free doctors to perform patient care.

Having a much shorter, focused, and simplified electronic medical records system is a great place to start remediation. Medical organizations should take a more active role in such corrective measures. Legislation can assist, particularly to facilitate reform of institutional rules and regulations; however, this requires physician input and advocacy. Universal, affordable health care and greater access to prescribed medications would also reduce stress. Obviously, this takes coordinated cooperation by many people, medical and health care organizations, big companies, and our government. Easier said than done.

Good luck!

Steven Lippmann, M.D.

Clinician Resilience and Well-Being Resources

Dr. Steve Lippmann is a Distinguished Life Fellow of the APA and is recently retired tenured Professor at the University of Louisville School of Medicine. He volunteers much of his time now working with refugees and victims of war. In his free time, he enjoys traveling with his lovely wife to visit their grandchildren.

TMS for Adolescent Depression Research Study – Participants Needed

Integrative Psychiatry is excited to announce the beginning of recruitment for participation in a research study to evaluate the safety, acute, and long-term effectiveness of transcranial magnetic stimulation (TMS) with depressed adolescents, age 12 to 21. Integrative Psychiatry is one of twelve leading TMS centers selected to participate in the first randomized, blinded, sham-controlled study of the NeuroStar TMS System with depressed adolescents who have failed to respond to at least one adequate course of antidepressant pharmacotherapy. 

The study included three phases. 

All participants will receive extensive psychiatric evaluations and close follow-up during the study and the TMS treatments are provided for free. In addition, a daily stipend for travel expenses will be provided. 

For further information on this study protocol and enrollment criteria, see CliniclaTrials.gov, Identifier NCT02586688. https://clinicaltrials.gov/ct2/results?term=NCT02586688&Search=Search 

 Contact Alex Schrodt, Study Coordinator at 502-930-7881 for more information. 

Risk-Based Managed Care in Kentucky: A Second Year Implementation Report & Assessment of Beneficiary Perceptions

How has Kentucky Medicaid managed care fared after our initial one-year report? Based on 18 stakeholder interviews, document review, and focus groups across the state, we provide insights about beneficiary experiences and their perceptions of changes to care. We find that many implementation issues have stabilized since the beginning of managed care, though issues of pharmaceutical access and behavioral health care remain.


Malpractice Litigation Prevention

By Renee Binder, M.D.

As a forensic psychiatrist, I have reviewed multiple malpractice cases. I have identified five common areas that arise in malpractice cases which have informed my own clinical practice. I am writing this article in the hope that these pointers will help my colleagues, young and experienced, avoid malpractice lawsuits.

(1) Excellent documentation is crucial.

Most of us give excellent care to our patients, but because of our busy schedules, we often do not document very well. When we are sued, experts on both sides look at thedocumentation. It is usually assumed by the fact finders (arbitrators, juries or judges), that when physicians testify in court or at depositions, they may say that they did something even if they did not, and therefore the best defense to malpractice is good contemporaneous documentation. It is especially important to document our thinking process when we are dealing with a high-risk situation, e.g. prescribing off label, discharging a suicidal patient or prescribing/not prescribing medications to a pregnant or lactating patient.

(2) It is especially important to document risk assessments for suicide or violence risk.

For example, in one casethat went to trial, a patient committed suicide one day after discharge from an inpatient unit. The patient had been on a voluntary status with suicidal ideation. In the medical records, there was excellent documentation by the psychiatrist about suicide risk during the hospitalization and on the day of discharge. The documentation included the risk factors for suicide as well as mitigating factors.The documentation included the risk factors for suicide as well as mitigating factors and that there was a reasonable after care plan. The documentation also included the rationale for discharge including the fact that the patient insisted on discharge and did not meet the criteria for an involuntary commitment. Since the patient was on a voluntary status, he could leave if he wanted. The jury agreed unanimously that there had not been a breach in the standard of care and that the subsequent suicide was unforeseeable at the time of discharge.

In another case, a developmentally disabled clientstabbed his roommate in a Board and Care home one week after discharge from a hospital. In this case also, there was excellent documentation about violence risk factors and the thinking process behind the decision to discharge the patient back to his Board and Care Home with supervision. The documentation included the rationale that the two clients had lived together for over ten years without any prior incidents of violence. The case against the psychiatrist was dismissed.

When following outpatients on a long-term basis who have shown minimal evidence of suicidality or violence potential, psychiatrists understandably do not assess for suicide or violence risk on every visit. It can be argued that the standard of care does not necessitate such assessments. However, when the patient’s situation changes, e.g. the loss of a job or relationship, or there is report of an increase in depressive symptoms, it is important to assess and document the risk of suicide. In cases where this was not done, the argument which has prevailed at times is that the situation of the patient had changed and the psychiatrist should have done a more detailed assessment of violence or suicide risk.

(3) It is important to only treat patients within our areas of expertise.

If we have any questions about how to use a specific medication, it is important to refer the patient to or to get consultation from a clinician with more experience with that medication.

In one case, a patient died after she was treated in an emergency room with a combination of medications that were contraindicated in her situation. When in doubt, it is useful to check a website like “drugs.com”,”Lexi-Comp“oranother reference about interactions and contraindications. In another case, a patient developed severe complications from neuroleptic malignant syndrome after being given high doses of antipsychotics with a rapid upward dose titration. The actual dosage and the rate of titration were significantly higher that what was recommended in the peer-reviewed literature. In another case, a patient died of fulminant liver disease secondary tovalproic acid. The patient had had a prior history of hepatitis, but this was not recorded in the review of systems or past medical history. In addition, liver function tests were not obtained before or after starting valproic acid, until the patient developed jaundice. The implication was the clinicians in these cases did not know how to use these medications and were unaware of the potential risks.

It can be argued that psychiatrists have the skills and knowledge to use medications above recommended doses and for off-label indications. However, if doing so, psychiatrists need to obtain written and informed patient consent and document their thought process and their rationale for their prescribing practices. Otherwise, it may appear that the psychiatrist did not know the risks of their treatment plan.

(4) It is important to be aware of the institutional policies in the setting where we work.

In one case, a psychiatrist admitted a depressed, suicidal patient to the hospital. The psychiatrist wrote for level 1 observations, which meant 30-minute checks in that hospital. The psychiatrist seemed unaware of what level 1 meant. Hospital policies said that if patients are admitted with a complaint of depression or suicidal ideation, they should never be put on level 1. The policies stated that such individuals should either be put on level 2 (15 minute checks) or 1:1 observation. The patient committed suicide on the unit in between the 30 minute checks. It was very difficult to defend the actions of the psychiatrist.

(5) It is important to consider the family’s wishes in important and risky decisions (with the patient’s consent).

When there is a bad outcome, such as a suicide, the family will bring the lawsuit. There have been cases where the family was consulted and agreed with the treatment plan to discharge a patient from a hospital or release them from an emergency room. In these cases, if a suicide subsequently occurs, family members can still claim that they did not know any better because they are not professionals and were swayed by the opinions of the psychiatrist. Nevertheless, psychiatrists are in a more advantageous position concerning why they made the decision if the family agreed with this action. There have been cases where the psychiatrist discharged a patient against the wishes of the family. The family members then said that the doctor should have listened to them. If psychiatrists disagree with the recommendations of family members, psychiatrists need to document their thinking process and the basis of their decision to go against the family’s wishes.

In summary, I have described some of the lessons that I have learned in consulting about malpractice cases. Although anyone can be sued, and we all may be sued, it is helpful to be aware of what we can do as busy clinicians to minimize the likelihood of lawsuits being successful.

Renee Binder, M.D. is the Forensic Fellowship Director at the University of California, San Francisco. She is both a Past President of the American Academy of Psychiatry and the Law and a Past Chair of the APA Council on Psychiatry and the Law.