1. ® Assessment of Resources Identify faculty We met with the director of the psychiatric clerkship, Dr. Jason Shillerstrom, our associate dean of student affairs who is also the Child and Adolescent Psychiatry residency director, Dr. Thomas Matthews, and the founder and faculty advisor of our Student-Run Free Clinics, Dr. Richard Usatine. All of the faculty we approached were very enthusiastic about the idea of a psychiatry clinic and willing to work with us to make this clinic a reality. Dr. Matthews committed to being the attending physician at SAMM and he suggested another psychiatrist, Dr. Camis Milam, to be the attending physician at Alpha Home. Meet with shelter or clinic directors We next met with the directors of the two shelters at which we were most interested in starting the psychiatry clinic, Alpha Home and SAMM Shelter. Both directors were fully supportive of the idea, and excited to offer an additional resource to their residents. With them, we discussed their perception of the need for psychiatric services, potential scheduling, and space options. Consider the setting We attempted to chose settings in which we felt our patients would be the most comfortable. Exam rooms are a rather sterile environment, but reinforce the fact that mental illness is a medical condition. A more casual area such as a conference room, meanwhile, may make patients more relaxed. We ultimately chose a combination of the two based on our available resources. Assess costs The costs of implementing Psych Night at two of our existing clinics were very low. Malpractice insurance for the attending physicians was covered by the UT Health Science Center. Supplies for the associated medical care, such as blood pressure cuffs, were already available at the general medicine clinics at each location. Psychiatric medications, however, were not among the medications stocked at the clinics. This was ultimately not an issue because most of the children that would be seen are on Medicaid, and most of the adults are covered under Carelink, a local health insurance provided by the county. These health care plans allowed patients to obtain medications from local pharmacies for little to no cost. Handouts, including a template for psychiatric history taking, are provided to students during each Psych Night, and were a small cost to the clinics. The 2010-2011 officers of the Student-Run Free Clinics Organization at The University of Texas Health Science Center at San Antonio recognized the need for psychiatric care at our clinics. The students and physicians at our general medicine clinics were treating many patients with depression, anxiety and numerous other mental illnesses, and we felt that our organization could provide better care to these patients by offering a psychiatry clinic. It was also noted that at one of our clinics, Alpha Home, a non-profit residential and outpatient substance abuse treatment program for women, it was psychological disorders that often lead to the substance abuse that the women were recovering from. We realized that a psychiatry clinic would allow providers to spend more time with these patients and fully address patient’s psychiatric illnesses. This would allow us to treat the whole patient rather than just the acute condition that would bring them to the general medicine clinics. Background Implementation of “Psych Night” at a Student-Run Clinic Caroline A. Camosy, Caitlin L. McAllister, Lisa A. Sawyer The University of Texas School of Medicine at San Antonio Implementation Scheduling We scheduled Psych Nights around general medical clinic nights and faculty availability. Psych Night is held at each clinic on one evening, every other week. Many of our psych night patients are referred from the general medical clinic, and others are referred by counselors or shelter directors. Appointment times are scheduled by shelter administrators, who also make sure each patient shows up at his or her designated time. Have a “test run” with student leaders The first two sessions at each clinic were attended by student leaders in order to ensure that the Psych Night procedure ran smoothly. We evaluated scheduling practices, estimated the number of patients who could be seen in an evening, and established the role students would play in providing psychiatric care. Training sessions for student volunteers We next held a required training session, led by our attending and one of his residents, for all students interested in volunteering at Psych Night. The training was geared toward first and second year students who have had minimal patient and psychiatric exposure. It provided an introduction to psychiatry, including brief descriptions of some of the most commonly seen disorders, as well as instructions on how to conduct a psychiatric interview and a discussion about special concerns that may present with psychiatric patients. Discussion and Conclusion Each of our two Psych Night clinics operates under a slightly different model, depending on its patient profile and physician preference. At SAMM Shelter, a shelter for homeless families, Psych Night operates under a more student-run approach. Three patients are seen simultaneously, and students perform the initial psychiatric interview. Each student presents his or her findings to Dr. Matthews or one of his residents, who then re-enters the room with the student to provide counseling and prescribe medications if needed. At Alpha Home, a residential treatment center for women with substance abuse, Psych Night becomes more of a shadowing experience for students. These women tend to have more severe mental illness than seen at SAMM, and substance abuse complicates their psychiatric picture. Therefore, Dr. Milam performs the psychiatric interview and counseling in the presence of up to two students, and the team has a “debriefing” session after seeing each patient to discuss the case, address questions, etc. The psychiatric clinics at the Student-Run Free Clinics have been extremely beneficial to both the students and the patients. Students are able to gain valuable history taking skills, exposure to patients with psychiatric illnesses, and the opportunity to watch skilled physicians handle difficult and sensitive cases. Furthermore, Psych Night provides students with experience presenting to residents and attendings and navigating the environment of psychiatric care, which will help them adapt to the clinical years of medical school. The benefit has been especially discernible at Alpha Home, which has a large number of residents suffering from mental illness, as this is commonly seen among homeless individuals and those who are recovering from substance abuse. It had been noted previously that more time to simply talk with these patients would be advantageous, and the psychiatric clinics have made this a reality. Common illnesses that have been treated are depression and anxiety, which are extremely common in the homeless population and in persons suffering from addiction. The psychiatric clinics at SAMM shelter have been able to assist in several childhood and adolescent psychiatric conditions such as ADHD and conduct disorders. The transition from having a home to living at a homeless shelter can be extremely difficult and confusing, especially for children, so the services provided by the students and faculty at this location have been very valuable. In addition to the illnesses discussed above, patients with personality disorders and bipolar disorder have also come to the psychiatric clinics for treatment. These are serious conditions, and it is important that these patients receive the medications and counseling they need, especially when living in close contact with so many other individuals. Additionally, some of the patients have been previously diagnosed with illnesses such as depression, and the clinics have ensured access to the necessary medications and counseling. For most first and second year medical students, this is the first exposure to patients with psychiatric illnesses, and they are gaining important skills to use in their clinical years: “Participating in SRFC’s psychiatric sessions reinforced the importance of caring for the whole person, mind and body, and the experience I gained will make me much more comfortable working with psychiatric patients as I enter my clinical years of medical school,” says one year medical student. Another adds, “The psychiatric interview is so different from the physical exams we practice over and over throughout medical school. I think the time we’ve spent with these patients is invaluable to both us as students, and to them as residents in these shelters trying to make their lives better. We really haven’t had this training anywhere else in our medical school curriculum thus far, and I found it enlightening and educational to watch how well the psychiatrists are able to understand and help these patients.” Future directions Since these clinics have been deemed beneficial to both students and patients, we are hoping to expand in the future and possibly recruit more psychiatric attendings at each clinic. Furthermore, we would like to see psychiatric clinics added to some of our other student run free clinics, including our refugee clinic, where residents could greatly benefit from psychiatric resources. Results: A Typical Psych Night “Participating in SRFC’s psychiatric sessions reinforced the importance of caring for the whole person, mind and body, and the experience I gained will make me much more comfortable working with psychiatric patients as I enter my clinical years of medical school.” -- a second-year medical student