Psychiatric residency training in the management of emergencies.

As a psychiatry resident on the Emergency Service or on call at night, the resident learns to function on several levels, as consultant, liaison, colleague, and occasionally as primary physician. At the outset, the resident needs to know that he or she is not expected to know all that yet. It is especially necessary to emphasize to a beginning resident that it is acceptable and important to ask for help. The resident is never the only physician caring for an emergency department patient. There should always be other psychiatry residents, psychiatry attending physicians, other house staff, and emergency medicine attending physicians who can help and often have an interest in each patients. The resident has an obligation to involve other physicians if there is uncertainty about the proper moves to make, and an obligation to discuss the management of a patient with the physician who initially consulted, as well as any other doctors responsible for the patient. Emergency cases can be discussed at morning rounds as well as at various seminars. The resident should also know that an interested or helpful ear can always be found among more experienced residents and attending physicians. The supervisor may present the option to the resident that he or she is available to see the patient with the resident, afterwards, or not at all, and can teach by watching and commenting, by modeling, and by supervision of the observations and reactions that the resident presents. There are a number of benefits to these models of emergency psychiatry training. In the first place, all of the drawbacks seen in present systems are addressed or avoided. The psychiatry resident retains his or her identity as a physician, working in consultation and cooperation with other physicians in a medical facility, rather than in a community clinic or psychiatric hospital. When a resident sees an emergency patient in revisit one or two days later, the resident has the opportunity to observe the effect of the psychotherapeutic intervention. One outcome of this observation is a decreased reliance on medication, and an increased use of outpatient modalities. The resident also gains an appreciation of the mental health system as he or she must work with many agencies and many levels of care.