"The Nuts and Bolts" - resident perspectives on program rotations

Below are short summaries about our different rotations years’ one through four. These blurbs are meant to accompany the longitudinal rotation map provided during interviews. Hopefully, the information provided can better illustrate “what a typical day” looks like during each rotation.  These are written by residents, and do not necessarily reflect the views of administration.


Inpatient Psychiatry on Deaconess 4
Residents spend two months in each of the first two years at Beth Israel’s acute psychiatric in-patient unit. There, they treat a wide variety of mental illness including acute and chronic psychosis, acute mania, depression, and severe personality disorders.  Residents get experience with geriatric patients and dual diagnosis treatment, including detoxification from alcohol and opiate use. ECT is an on-site option for our patients, and as such residents learn how to properly evaluate ECT as a potential treatment option.

BWH/BWFH Medicine
Residents spend a total of four months, in two two-month blocks, on this rotation.  They spend time both at the main Brigham and Women’s hospital on the Longwood campus and at Brigham and Women’s Faulkner Hospital, a smaller community hospital associated with BWH and accessible by shuttle from the main campus.  Residents usually rotate on the general medical services at both sites, both of which offer varied and well-liked experiences. At BWFH, PGY1s spend up to 4 weeks on a general medical service led by a BWH medicine resident and attending hospitalist. The day usually starts at 6:30 for pre-rounds, then meeting at 7am for signout from the night team, followed by rounds with the attending during the 8am hour. There are daily noon conferences for residents with catered lunch provided. Afternoons are spent finishing tasks outlined during rounds. BWFH has a Q5 call schedule plus a night float system, so PGY1s are not expected to stay overnight on call days. During the 2 week BWFH ICU experience, we are paired with a senior medicine resident for a 1:1 learning experience in this smaller, community ICU. The teaching is outstanding.  ICU shifts are 7a-7p with no “call” days. At BWH, we rotate on two or three different services for several weeks each, one of which is the Integrated Teaching Unit (ITU), a general medical service with a specialized structure for trainee education. We also rotate on general medical services and in-patient cardiology services at BWH. The daily structure mirrors that at BWFH medicine, with rounds and noon conference with plenty of food provided. While BWFH tends to admit more “bread and butter” medicine patients, BWH provides the opportunity to participate in management of complex and rare illnesses due to its tertiary care status. Psychiatry interns are held to the same standard as categorical medicine interns in terms of patient load and responsibility; however, supervision and teaching are prioritized, and PGY1s finish their medicine rotation regarding the experience highly.

NWH Medicine
PGY-1s rotating at NWH for medicine typically spend 4 weeks on medical wards (a general medicine floor, oncology floor, or cardiac/telemetry floor), and 4 weeks on night float covering these wards. Inpatient days can be quite busy, usually starting at 6:30 AM with pre-rounds, followed by morning report at 7:15 AM, and rounding with your team around 8:30 AM. There are daily noon conferences with interesting talks from MGH or NWH faculty and good food! Afternoons are spent doing tasks for patients, consulting other services, writing progress notes, and doing admissions if it is a call day. PGY-1s are on call to admit every other day. You get one day off each weekend.

The night float is split into two separate sessions of 6 nights, for a total of 12 nights. These 6 nights alternate with 1 week each of either back-up or vacation, so the schedule for that month is one week on, one week off (unless one is called in for back-up). Most PGY-1s will also get 2 weeks of medicine elective at NWH during the course of the 4 months of medicine, and you can pick between pulmonary, ID, radiology, and palliative care, among others.

NWH is an MGH affiliate, thus most of the residents (and some PGY-1s) you work with are MGH medicine residents. You also rotate with other transitional year and prelim PGY-1s who are spending their intern year at NWH, prior to going into anesthesia, radiation oncology, and other fields. The vibe at NWH is very warm and friendly, and the staff is excellent! Everyone is very supportive, and while it is an intense and demanding rotation, it is also a great learning experience and can be a lot of fun!

Emergency Psychiatry & Night Float BIDMC - ED 2 months
During Emergency Psychiatry, you will work in the Emergency Department as a Psychiatric Consultant. The hours are 8am to 6pm Monday through Friday. The number of patients carried can vary depending on the day and the time of year. On average you typically see 2-4 new consults a day. As PGY1s, we see the patient individually and present our findings to the attending. The population of patients varies widely, ranging from homeless to young college students to elderly nursing home patients. You see many different pathologies including depression, bipolar, schizophrenia, substance abuse, personality disorders and eating disorders. The structure of the ED rotation is that the PGY-1 carries the consult pager and answers any pages that are called in. As new consults are called, you interview the patient and come up with an assessment/plan and then staff with the attending. The PGY-1 is the glue of the ED consult team during the day as attendings often change at noon. The team consists of 1-2 interns, a chief resident, a nurse, and an attending. This rotation is a great way to learn how to interview acute patients and learn to manage a busy department.

BIDMC Night Float
During night float, you are working in Deaconess 4, the locked inpatient psychiatric unit. The hours are 6pm- 8am Monday night to Saturday morning (alternating every two weeks with ED days). The number of patients carried depends on how full the unit is, with the max being 25 patients. The population of patients served also varies greatly. There can be acutely psychotic schizophrenic patients, depressed elderly dementia patients, and suicidal college students. During night float, you receive 2-3 teaching calls with an upper level and then you are the only resident on the unit during the night. You always have a PGY-2 in the ED and a PGY-4 on call if any concerns or questions come up. The night team consists of nurses, mental health workers, and some security guards. Your responsibilities are to do any admissions that arrive, respond to any emergencies on the unit, and assess any patient complaints. This rotation gives you a great deal of autonomy and creates a large learning curve. After a week or so, you are able to handle most situations that arise by yourself.

Addiction Psychiatry
The Addiction Psychiatry Rotation is comprised of two different experiences, one on the inpatient detoxification unit at Brigham and Women's Faulkner Hospital and the other as part of the Addiction Consultation-Liaison (CL) service at Brigham and Women's. On the detoxification service at Faulkner, each intern carries approximately four patients. Patients on the detox service are admitted for medical detox from any combination of alcohol, opioids, or benzodiazepines. As the primary physician for these patients, the intern meets with patients daily, manages the medical aspect of their detoxification, presents and participates in interdisciplinary rounds, and leads a group once weekly. On the Addiction CL service at Brigham and Women's, the intern works directly with an Addiction Psychiatry fellow evaluating patients in initial consults and follow up visits who are admitted to medical, surgical, and cardiovascular units. Pathology can be quite diverse on the Addiction CL service, and can include complicated alcohol withdrawal, substance induced mood disorders, and Suboxone maintenance induction therapy. Interns have the opportunity to work with Dr. Carol Garner at Faulkner Hospital and Dr. Joji Suzuki at Brigham and Women's.

BIDMC Neurology
During your time on Neurology at BIDMC, you will be on the Neurology Consult West team. Your hours are from 8am to 5pm Monday through Friday. The team consists of 1-2 Neurology residents, 1-2 Psychiatry interns, at times 1-2 medical students/Sub-I's, and occasionally a medicine resident. The duties expected of you are to see new consults as they are called in, round on your old patients if you have any, and attend any lectures/conferences. You will also round formally with the attending 1-2 times a day. You will see anywhere from 1-3 patients a day depending on the week and the size of your team, and will carry 1-3 patients on average. The population of patients seen varies. You will see patients with movement disorders, seizures, dementia, syncopal episodes and various others. The rotation is very fun and the Neurology residents are great teachers. The conferences are excellent and a lot of learning goes on during them.

BWH Neurology
During the Brigham neurology rotation, you join the team as a member of the consult team.  During the rotation, you and the BWH neurology residents take turns seeing consults for a myriad of neurologic presentations that arise in medical, surgical, or obstetric patients. We evaluate 1-2 new patients per day, and we participate in rounds for our patients and others on the service.  The attendings on service always love to teach, and it’s a great opportunity to just “learn” since we’re in consultant role (not primary clinicians).  There are daily conferences for neurology residents, which we attend, and which always have great food. Though the service is fast-paced and highly educational, the typical day ends between 4:30 and 6:30 depending on service volume.


Inpatient Psychiatry at BWFH 2South
PGY2s spend three months on the inpatient unit at BWFH, working with multidisciplinary teams to treat patients with a variety of acute and chronic mental illnesses.  Similar to Deaconess 4, BWFH 2South provides an opportunity to work closely with other trainees in psychology and social work to facilitate comprehensive patient care both during the acute hospitalization and after discharge.  Residents carry between 6-8 patients (depending on resident vacation coverage), but a subset of those patients are designated “med back up,” wherein a psychology/social work trainee provides primary therapy and suggests non-pharmacologic treatment recommendations. Residents work closely with seasoned attendings for psychopharm supervision and ECT experience.

MMHC DBT or CBT partial
Second year residents spend 3 months working at either the DBT or CBT partial, located at Mass Mental Health Center near BWH. At the DBT partial, residents learn the core principles of DBT through weekly didactics with the chief resident and faculty specializing in this treatment modality. The DBT partial is a unique treatment setting aimed to provide daily structure and skills-based learning for patients with chronic affective dysregulation and histories of self-harm/suicidal ideation, with the goal of minimizing inpatient hospitalizations. Residents carry between 4-7 patients (combination of primary and med-back up), providing both weekly therapy and psychopharm evaluations. Residents also lead several group sessions throughout the week for the patients.  Residents receive supervision from both PhD and MD clinicians.

CBT Partial
At the CBT partial hospital program, residents work with patients diagnosed with psychotic illness, and learn how to employ both psychopharmacologic and cognitive-behavioral therapy modalities to manage symptoms such as hallucinations, delusions, and affective instability. As with the DBT partial, one of the primary goals at the CBT partial is to work closely with patients, outpatient providers, and community resources to minimize inpatient hospitalizations. Residents typically carry 3-5 patients as either the primary clinician (providing both therapy and medications) or med backup, and also lead group sessions throughout the week. Residents attend weekly CBT and psychopharm didactics, and participate in a weekly case conference that provides a psychodynamic perspective on psychotic illness. Individual and group supervision are provided by MD and PhD clinicians, CBT group leader, and chief resident.

Child/Adolescent Inpatient Psychiatry at BCH
PGY2 residents spend two months rotating at BCH’s inpatient unit (Bader 5). There, residents carry between 4-5 patients, a combination of both primary and med-back up patients. Patients range in age from 8-18 years old and carry diagnoses ranging including depression, anxiety, eating disorders and a combination therein. Bader 5 is very team oriented with multiple disciplines present at most meetings (rounds, family meetings, individual therapy). Bader 5 often has many trainees from social work and psychology programs, which serves to enrich our experience.  We also work with BCH child/adolescent fellows who take call on the unit overnight and on the weekends (Longwood residents do not take call at BCH; rather we have weekend shifts at BIDMC).

BIDMC Nightfloat
PGY2s spend two 2-week blocks working in the BIDMC Emergency Department as a consultant providing acute psychiatric evaluations and facilitating disposition of these patients. We evaluate patients presenting for acute depression, mania, suicidal ideation, and psychotic decompensation. Residents work with a representative from the Boston Emergency Services Team (BEST) who assists with disposition to an inpatient unit, crisis stabilization units, or detox facilities. This rotation is often regarded as transformative, as residents sharpen their evaluation skills and work autonomously in a busy, Level 1 emergency department. Residents are also consulted by medical teams to provide capacity and safety evaluations on patients currently admitted to the medical floor.

Second year residents spend two 2-week blocks, alternating with BIDMC nightfloat, on elective. This is a wonderful opportunity for residents to do pretty much anything that piques their interest, provided it’s cleared with their faculty advisor. Many residents use this time to visit other subspecialty clinics (women’s health, neuropsych, cognitive neurology). Some residents use the time to work on their scholarly project or completed a mentored reading elective. It’s a great month to “try on” areas of interest that haven’t been explored yet.

Inpatient Psychiatry on Deaconess 4
Similar to PGY1 inpatient psychiatry, Deaconess 4 provides an excellent opportunity to work with and treat both acute and chronic mental illnesses. As a PGY2, your patient load increases by a couple of patients, but a year of experience definitely makes a difference. Residents continue to work closely with multiple disciplines and receive regular supervision from attendings and the chief residents.


Mentally-Ill/Problematic Sexual Behavior
One PGY3 per semester can rotate through this MMHC outpatient clinic that serves both adjudicated and non-adjudicated sex offenders who have a significant mental-illness who qualify for Department of Mental Health Services. Many patients have lengthy forensic histories and multiple hospitalizations. This program was created by DMH to facilitate community-based treatment of this population in order to mitigate risk and decrease recidivism. Residents work closely with Dr. Feldman, attending, and other team members to provide psychopharm evaluations and recommendations. This rotation also provides an excellent opportunity to generate a comprehensive risk assessment that serves as an example of forensic writing for future forensic psychiatry fellowship applications.

Health Care for the Homeless
On this rotation, residents spend one day per week at the psychiatry clinic at St. Francis House, a day-shelter for the homeless in the heart of downtown Boston. This clinic sees a wide variety of patients, but mostly deals with mood disorder, anxiety disorders, and PTSD. Many patients have a history of substance abuse. Here, the resident is part of a large multidisciplinary team including therapists, case managers, and an on-site Suboxone treatment program. Residents in this rotation also spend a half day each week with a DMH homeless outreach team, which primarily serves the chronically psychotic homeless population. This day is spent walking around the city visiting homeless psychotic patients to offer housing and other services.

MMHC Continuing Care Clinic
The continuing care rotation is centered on the outpatient care of a caseload of chronically mentally ill patients living in the community, some independently, but most in DHM group homes. Residents are given flexibility to schedule outpatient appointments with patients with frequency of visits ranging from weekly to monthly depending on the patient needs. Residents are in charge of prescribing, collecting collateral from group homes, providing therapy, and coordinating care as needed. The patients are have often been in the DMH system for a while so are used to new residents every six months although there may be new intakes as well although few in number and not overly burdensome. Residents will gain a solid understanding of outpatient management and psychopharmacology of the chronically mentally ill during this rotation.

Center for Early Detection Assessment and Response (CEDAR) Clinic
On this rotation, PGY-3 residents evaluate and treat adolescents (average age 15-25) displaying symptoms that put them at high risk of developing psychosis. Often patients are referred by their established outpatient treaters for confusing signs and symptoms that do not have a clear etiology, and the CEDAR team is responsible for helping to determine if these symptoms are an indication of psychosis or alternative etiology. Other patients receive their primary psychiatric care at the clinic, and the resident helps to manage the medications and perform frequent evaluation while other trainees provide primarily CBT and skills based training. In addition to working with other trainees, you get direct supervision by the medical director Dr. Zimmet MD as well as the team leader Dr. Friedman PhD.  This is an excellent rotation for residents hoping to gain experience in sorting through complicated and unclear diagnostic pictures, and for those interested in psychosis or child & adolescent psychiatry.

Prevention and Recovery in Early Psychosis (PREP)
Two PGY3 residents per semester rotate through this treatment program where a transitional age youth population with established psychotic illness is treated within an intensive outpatient adolescent and young adult milieu. Patients come to PREP two full days a week where they receive psychiatric care, psychotherapy, group treatment and have the chance to engage with other transitional age youth in both structured and unstructured activities. We residents carry a complex caseload of patients. We function as primary therapist for some cases and the medical back up in others. We do comprehensive intake assessments with new patients and their families. We lead group treatments and engage with patients within the milieu setting.  All care at PREP involves a multidisciplinary team and embodies a wrap-around approach to treatment for high acuity patients that involves families, schools and any related social system whenever possible. We receive supervision from child and adolescent trained psychiatrists who specialize in treating this population of patients with early onset psychosis. We are exposed to the clinical research studies that involve many of their patients which are run by the Commonwealth Research Center and participate in regular case conferences and journal clubs that are facilitated by experts in the field of early psychosis treatment and research.


During PGY4 year, we have the opportunity to apply for several chief resident positions (such as Deaconess 4 chief, BWH or BIDMC C/L chiefs, BWH or BIDMC outpatient clinic chiefs, BWFH inpatient chief, MMHC PHP chief, or administrative chief) or several PGY4 selective rotations (including a Women’s Health Selective, Healthcare for the Homeless Selective, Neuropsych Selective, and many more). PGY4s split their time between these year- long positions and continuing care in the outpatient clinic in which they’ve been working since PGY2 year. They also continue to have weekly didactics and weekly time for their scholarly projects.