Geriatric Psychiatry--what makes a good program?

[SuperSoccer19]

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Currently looking at geriatric psychiatry fellowships. How can you determine how "good" a program would be? Are there any places to find rankings or applicant stats? Any other underground websites with graduate feedback?

Or, if anyone has any exposure based on their residency or fellowship experience specific to a program, I would love to hear it. Thanks!

 

[whopper]

I used to run a geriatric inpatient unit and worked hand-in-hand with the fellowship and U of Cincinnati and the geriatric fellowship at St. Louis U.

1-Good non-psych medical coverage. There are plenty of geriatric psych patients with serious medical problems. A very troubling sign is when you got a patient on the unit with a serious medical problem that should've been caught before he/she was admitted but made it through and is now on your unit but the consultant refuses to show up.

I had one case where even one of the head IM doctors was trumpeting with me that one of the geri patients should've been transferred off the unit or the consultant should show up and they still refused.

Here are just a few examples of cases where the consultant refused to show up.
1-Pt had delirium, likely from a UTI. We had her on an antibiotic. She cleared but literally about 1-2 days alter she had delirium again-another UTI. This patient it turned out had UTI after UTI after UTI. I suspected she had scarred ureters from repeated UTIs and would pretty much be in delirium time after time but needed urology to double check to confirm. They refused to show up. We had to discharge her in delirium after we kept her there literally 2 weeks waiting for urology to show up and after telling her family what was going on they opted to take her out of the hospital.

2-Older woman suffering from status-epilepticus stabilized with Keppra. Keppra makes people psychotic about 5% of the time. The Keppra made her psychotic. Neuro transferred her to us after they stabilized her seizures. When trying to transfer her I specifically asked did she had a history of psychosis before the Keppra? They lied to me and said yes (she did not), I also asked "If it turns out the Keppra is making her psychotic will you send us a consultant or allow us to transfer her back to your unit?" They lied again and told me yes.

Turned out it was the Keppra. How do I know? Patient was on the unit for literally 3 months while I tried to stabilize her psychosis, found out she never had psychosis before from her family and then Neuro refused to take her back or send us a consultant. Thankfully one of the top neurologists in the world specializing in status epilepticus helped us with the case (we had to call him up, Neuro didn't send him to us), and he told us that her seizures were so treatment resistant that despite that the convention was to stop the Keppra we should try antipsychotics despite that there is no data showing that antipsychotics are useful in this type of psychosis.

Now at this point about 6 weeks have passed before that neurologist was helping us (again the neuro consultant refused to show up and the neuro floor refused to take her). I literally tried her on Seroquel, Risperdal, Olanzapine, and Abilify none of them causing any improvement whatsoever over the next 10 weeks. Finally after the patient's family, the head clinical doctor in the department and the neurologist helping us insisted that neuro take her back on the argument that she had no quality of life while psychotic and the family telling us she would rather risk occasional seizures than be psychotic 24/7 did they take her back.

All the while the neurology department accused me of being completely off with my Keppra-induced psychosis theory despite that I had strong evidence to back it up and that neurologist agreeing with me. Well guess what? They took her off the Keppra and about 1 day later she cleared up.

This case took 3 months with about 2.5 of it being all bureaucratic department turf-war.

2-Good geriatric attendings.
3-Research
4-Coverage in varied clinical settings such as inpatient, nursing homes, outpatient.
5-Good emphasis on maintaining medical skills.

I'm currently at St. Louis U and the PD of the fellowship here-George Grossberg is one of the top geriatric psychiatrists in the country and a heck of a nice guy. He's the type of guy that really looks after his fellows.

 

[SuperSoccer19]

Thank you, Whopper. This is very helpful. There is so little guidance out there on information and everything I have learned has been by word of mouth. So discouraging with the consulting services being jerks. Nuts that something like that would fly.

 

[splik]

I would imagine it depends on what you are trying to get out of it, but I would highly recommend a behavioral neurology component so you can get exposed to more uncommon dementia syndromes like FTD, PPA, PCA, PSP, MSA, CJD and so on. You also presumably want to get exposure to a variety of different clinical settings (inpatient, consultation to inpatient psychiatry, geriatric outpatient consultation, collaborative care [like IMPACT], nursing homes, memory clinic, domiciliary, geriatric addictions, telepsychiatrya) and there should be ECT training given how commonly used it is in this population. Opportunity for research projects, QI, and teaching residents/medical student. Palliative care or chance to join ethics consultation service. Learning something of forensic issues like testamentary capacity, undue influence, guardianship/conservatorship, abuse in nursing homes, elder abuse. Administrative/Leadership experience training in geriatric psychiatry and learning about policy issues related to aging and healthcare of older patients. Interdisciplinarity (for example share geriatric medicine and psychiatry conferences and opportunities to brush up on medical knowledge).

 

[whopper]

The consultation problem was the only major clinical problem I had while at U of Cincinnati. It is a good psych department with very good clinical doctors. What happened in short was to make more money they transferred the psych units to a different hospital about a mile away and turned the psych units in the main hospital into more profitable units. Doesn't sound like a big deal does it?

A mile in the Cincinnati traffic during business time could cost a doctor over 20 minutes of driving each way. Factor in the 10 minutes it'll take to park the car and get to the unit, the 10 minutes to get back to the car from the unit we're talking an hour of time wasted for 1 consult.

Now of course this doesn't justify a consultant that is needed to not show up but this is what was happening. Before psych was transferred to the new hospital the attendings demanded that consultation would still be provided and the administration promised but when the transfer happened guess what? None of the consultants showed up. They were even told by their department heads not to show up.

After this happened we were able to get neuro to provide us with consults, but we had to transport the patient off the unit to an outpatient office where a neurologist would see them then the pt would be transferred back. This case went into the 6 figures in wasted money.

 

[whopper]

Agree with everything splik said. ECT is very important in geriatric psychiatry.