The educational program during the consultation-liaison fellowship is composed of three elements: clinical experience, didactic instruction with both clinical supervision and formal seminars; and research training. Each of these elements is carefully balanced to allow the fellow sufficient time to pursue both clinical and research goals.

The clinical experience includes both inpatient and ambulatory consultations, liaison activities, and supervised psychotherapy cases. General hospital consultations are performed on a daily basis when advice about patient diagnosis and management are requested from the medical staff. Ambulatory consultation experience is provided through specialized clinics at Fairfax and GW. The fellow will have a unique opportunity to understand the genesis of a psychiatric consultation, the practice of consultation psychiatry, and the management of clinical problems within a wide variety of settings.

The second element of the clinical experience is that of liaison activities. These activities take the form of "applied medical sociology," wherein the fellow truly obtains a longitudinal perspective of the unique patient characteristics, stresses, and strains which arise on a medical/surgical unit. Such background serves to both complement and expand on the consultative experience. Liaison activities include working with clinical programs: oncology, organ transplantation, HIV, geriatric medicine, ob/gyn and pulmonary.

The final aspect of clinical experience is the opportunity to provide ongoing psychotherapy. Each fellow may manage approximately five outpatient psychiatric cases. Such cases are supervised and the fellow is responsible for arranging individually the treatment fees for such cases. This is, in essence, the beginning of an understanding of the private practice of psychotherapy, as well as furthering the development of psychotherapeutic skills. It underscores the psychiatrist's heritage as a sophisticated psychotherapist, as well as a physician who specializes in aspects of psychological medicine. Such patients may have a spectrum of psychological problems. Supervision is provided by senior psychiatrists sophisticated in psychotherapy.

Our didactic program complements the clinical experience (see Appendix 1). Regular attending rounds by a consultation-liaison faculty member ensure that every patient seen in psychiatric consultation is supervised. This serves as an important framework for the development of skills in consultation-liaison psychiatry. Opportunities for supervision of ongoing liaison projects are also readily available. Formal course work is included which covers a broad range of topics within and related to consultation-liaison psychiatry. This includes regularly scheduled seminars on classical C-L literature, current clinical practices and developments, C-L cases, behavioral neurology, and aspects of illness impacting pediatric populations. Furthermore, there is a research seminar designed to assist the fellow in developing clinical research skills. Overall, the curriculum will serve to build a solid foundation in consultation-liaison psychiatry for the fellow.

Lastly, the research portion of the fellowship is viewed as an important educational component of the program. It is included because of the essential nature of clinical research within psychiatry. Such activities teach organization, rigor, and better appreciation of investigatory studies. Research skills also provide the fellow with the basis for pursuing future academic interests.

Any fellowship within a medical subspecialty should offer a research experience. It is the philosophy of the Inova Fairfax Hospital Consultation-Liaison Fellowship Program that such research be done in a structured and supportive environment. Thus, various ongoing clinical research projects are made available to the fellow to choose from or the fellow may develop a project within a particular area of interest. Prior examples of studies include the role of psychiatric consultations among family practitioners; the relationship of alexithymia in abnormal illness behaviors; sexual dysfunction in the medically ill; compliance with psychiatric consultations; and a variety of other topics within consultation-liaison psychiatry. In addition to the more extensive, multi-subject investigations, interesting case reports have also been generated by previous fellows in our program.

The Department at Inova Fairfax offers ample support services to make such research activities feasible. Excellent library support, secretarial and manuscript capabilities, statistical consultation, computer and data-based help are all readily available to make such projects feasible and convenient. Instruction and supervision by faculty members are essential components to such activities. An ongoing research seminar where projects are evaluated, reviewed and discussed makes this an important and essential element of the fellowship. Many of the graduates of the fellowship have published at least one paper in a peer-reviewed scientific periodical. (See Appendix 2)