(193) Creating a Resident Elective in Psychiatric Management of Patients with Sickle Cell Disease: An Educational Case Report

Background/Significance: Sickle cell disease (SCD) is an inherited hemoglobinopathy that affects an estimated 100,000 patients in the United States. Access to mental health staff is recommended as an optimal component of comprehensive SCD treatment centers; however data defining the extent to which psychiatry is embedded into these centers is limited. While outpatient consultation-liaison (CL) experiences are expanding for psychiatry residents, nearly 80% of training programs do not include outpatient CL, and psychiatry resident experiences with SCD patients are generally minimal. The goal for this elective was not only to learn about the psychiatric needs of adult patients with SCD, but to explore how we as psychiatrists can become integrated into multidisciplinary subspecialty teams.

Methods: Initial development of the one-year-long half-day elective for a PGY-2 resident involved speaking with clinicians with experience in the psychiatric management of patients with SCD, both within and outside of Massachusetts General Hospital (MGH). Through these discussions, the following core elements of the elective emerged: 1) attending the MGH SCD Comprehensive Treatment Center team monthly clinical meetings, 2) identifying opportunities for direct care of patients with SCD, 3) seeking education about other integrated models of care, and 4) receiving mentorship from national experts in the field.

Discussion: Meeting with SCD treatment team members and attending general meetings facilitated better understanding of the needs of this patient population, including the lack of integrated adult psychiatry services at MGH. It became clear that patients with SCD have many psychiatric needs, including but not limited to depression, anxiety, trauma-spectrum disorders, substance use concerns, and demoralization. These are complicated by challenging experiences of mistreatment in medical settings and patient stigma towards psychiatry as a result of their pain not being believed. An opportunity was identified to begin treating a patient with SCD in the resident’s outpatient clinic. Elective supervision with program faculty elucidated models of integrated care, as well as barriers including funding and provider availability. Mentorship from national experts at outside institutions broadened understanding of clinical management and provided access to a model of psychiatric care in a large SCD center. Challenges of this experience included identifying experts in adult SCD psychiatry at MGH and in Boston. It will be helpful to continue to expand connections with other SCD centers. There are additional virtual resources that trainees can utilize, particularly if the population of patients with SCD is limited at their home institution, such as community healthcare telementoring programs.

Conclusions: Building this elective involved early collaboration with subspecialty treatment team members, identifying opportunities to engage directly with patients, and accessing experts in the field, which required identifying national contacts outside of the home institution. Next steps include identifying additional opportunities to treat SCD patients in clinic, engagement in research projects with the goal of better characterizing the extent to which psychiatry and mental health services are available to patients with SCD, and partnering with institution leadership to help shape future psychiatric services for adult patients with SCD at MGH.

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