Psychiatry

- This EPA verifies the medical school skills of obtaining a psychiatric history and synthesizing information for diagnosis. - This includes clinical assessment skills, including performing a mental status examination and a focused physical or neurological exam, if clinically indicated, and synthesizing a preliminary diagnostic impression in a patient with a common psychiatric disorder in any case type. - This EPA may include obtaining and synthesizing collateral information, if clinically indicated. - This EPA may be observed in any psychiatry setting. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct observation by psychiatrist, Core/TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Case type: anxiety disorder; mood disorder; obsessive-compulsive and related disorders; personality disorder; psychotic disorder; substance use disorder; trauma and stressor related disorders; other (write in) - Observer: psychiatrist; Core/TTP Psychiatry resident; Psychiatry subspecialty resident Collect 3 observations of achievement - At least 2 different case types - At least 2 different observers - At least 2 by psychiatrists

Suggested observations: 3

- This EPA verifies the medical school skills of presenting a case in a succinct and systematic manner, including all relevant details (such as mental status exam, risk considerations, information relevant to handover). - This EPA includes providing written/electronic documentation of the encounter using a relevant structure, headings and appropriate psychiatric terms and phenomenology. - This includes documenting the management plan discussed with the supervisor; however, independent development of the management plan is not required for this EPA. - The observation of this EPA is based on an oral presentation of an assessment and review of written/electronic documentation. - To ensure the accuracy of the presentation, at least one observation must be based on an interview that was directly observed by the supervisor. - This EPA may be observed using a clinical patient encounter, a standardized patient, a recorded encounter, a written case, or other formats. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct observation of verbal presentation and/or review of written/electronic communication by psychiatrist, Core/TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Portion observed: verbal presentation; written/electronic documentation - Interview observed: no; yes - Observer: psychiatrist; Core/TTP Psychiatry resident; Psychiatry subspecialty resident Collect 3 observations of achievement - At least 1 of each presentation format, verbal and written - At least 1 observation must be based on an interview that was directly observed by the supervisor - At least 2 different observers - At least 2 by psychiatrists

Suggested observations: 3

- This EPA focuses on management of medical presentations relevant to psychiatry, and recognition and initial management of acute medical presentations. - This EPA includes performing a medical assessment, including a general physical exam and neurological assessment, and interpreting relevant investigations. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct observation by attending physician, or non-psychiatry Core or TTP resident or non- psychiatry fellow Use form 1. Form collects information on: - Case type: acute cardiorespiratory condition; delirium; endocrine or metabolic disorders; hypertension; neurological conditions (seizure, movement disorder, stroke, traumatic brain injury); overdose and/or withdrawal; substance intoxication; other presentation - Setting: emergency; inpatient; outpatient - Service: neurology; any medical service; family medicine; on-call experiences; emergency; other - Observer: attending physician; non-psychiatry Core or TTP resident; non-psychiatry fellow Collect 6 observations of achievement - At least 2 patients with acute cardiorespiratory or neurological conditions - At least 1 patient with substance intoxication or overdose and/or withdrawal - At least 1 patient with endocrine or metabolic disorder - At least 3 different observers - At least 3 by a supervising staff physician

Suggested observations: 6

- This EPA focuses on establishing rapport and therapeutic alliance and performing psychiatric assessments using a biopsychosocial approach to develop a differential diagnosis which reflects an understanding of common psychiatric conditions. - The biopsychosocial approach is expected at a foundational level and will be elaborated in the Core stage. - This EPA is intended to be observed in inpatient, outpatient, and emergency psychiatry settings. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct observation by psychiatrist, TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Case type: anxiety disorder; cognitive disorder; mood disorder; personality disorder; psychotic disorder; substance use disorder; other - Setting: emergency; inpatient; outpatient - Demographic: child (4-12) or adolescent (13-17); adult (18+) - Observer: psychiatrist; TTP Psychiatry resident; Psychiatry subspecialty resident Collect 6 observations of achievement - At least 2 inpatient settings - At least 2 outpatient settings - At least 4 adult patients - At least 3 different case types - At least 3 different observers - At least 4 by psychiatrists

Suggested observations: 6

- This EPA includes the development and implementation of a management plan, using a biopsychosocial approach which reflects an understanding of common psychiatric conditions. - The observation of this EPA is based on the review of a management plan, observation of the resident’s communication of the management plan to the patient, and a review of the complete accompanying documentation. - The biopsychosocial approach is expected at a foundational level and will be elaborated in the Core stage. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct and indirect observation by psychiatrist, TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Case type: anxiety disorder; mood disorder; OCD; personality disorder; post- traumatic stress disorder (PTSD); psychotic disorder; substance use disorder; other - Setting: emergency; inpatient; outpatient - Demographic: child (4-12) or adolescent (13-17); adult (18+) - Observer: psychiatrist; TTP Psychiatry resident; Psychiatry subspecialty resident Collect 6 observations of achievement - At least 1 patient with a mood disorder - At least 1 patient with a psychotic disorder - At least 1 patient with a personality disorder - At least 1 patient with an anxiety disorder, PTSD, or OCD - At least 4 adult patients - At least 3 different observers - At least 4 by psychiatrists

Suggested observations: 6

- The focus of this EPA is the appropriate assessment of risk and safety issues. - This EPA includes developing an acute safety management plan using a biopsychosocial approach which reflects an understanding of common risk and safety issues. This includes focussing on risk factors for suicide, self-harm, and violence towards others in the assessment. - This EPA involves consideration of mental health law and its application to patients at risk of harm to self or others. - The biopsychosocial approach is expected at a foundational level and will be elaborated in the Core stage. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct or indirect observation by psychiatrist, TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Patient history: non-suicidal self-injury; history of violence or forensic involvement; active suicidal ideation or behaviour; violent behaviour or active homicidal/violent ideation; other issue - Setting: emergency; inpatient; outpatient; other - Demographic: child (4-12) or adolescent (13-17); adult (18+) - Observer: psychiatrist; TTP Psychiatry resident; Psychiatry subspecialty resident Collect 5 observations of achievement - At least 1 patient with non-suicidal self-injury - At least 1 patient with active suicidal ideation or behavior - At least 1 patient with violent behaviour or active homicidal/violent ideation - At least 4 adult patients - At least 3 direct observations - At least 3 different observers - At least 3 by psychiatrists

Suggested observations: 5

- This EPA focuses on the application of foundational knowledge in psychotherapy to assess and determine suitability of patients with uncomplicated presentations for cognitive behavioural therapy (CBT), establish an appropriate and professional relationship with the patient, and select and apply appropriate interventions aligned with the needs of the patient and the goals of CBT. - This includes identifying and empathizing with the patient, developing a collaborative relationship, and recognizing the importance of the therapeutic alliance. - This includes educating the patient on the basics of the rationale and therapeutic components of the prescribed psychotherapeutic intervention. - This includes recognizing, avoiding, and addressing boundary concerns or crossings. - The assessor should include details in the narrative assessment regarding which CBT interventions were correctly utilized and may include: cognitive restructuring or reframing, exposure therapy, journaling and thought records, activity scheduling and behavioural activation, behavioural experiments, relaxation and stress reduction techniques, role playing, and/or successive approximation. - The observation of this EPA is based on individual patient encounters that occur while providing foundational psychotherapy, specifically CBT; it is divided into two parts: a) assessing suitability and establishing the therapeutic relationship in CBT; and b) utilizing CBT interventions with entrustability. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity. - Longitudinal elements relevant to this EPA may be assessed using an ITER/ITAR 2.

Part A: Assessing suitability and establishing the therapeutic relationship in CBT Direct observation or review of audio, video, or transcript by psychiatrist, or other mental health professional trained in the modality Use form 4 (narrative form) Collect 2 observations of achievement of establishing the therapeutic relationship and assessing suitability for CBT Part B: Utilizing CBT interventions with entrustability Direct observation or review of audio, video, or transcript by psychiatrist, or other mental health professional trained in the modality 2 ITER/ITAR is not available on the eportfolio platform Use form 4 (narrative form): Collect 2 observations of achievement

Suggested observations: 2

- This EPA focuses on pharmacological interventions and includes the prescription, management, and monitoring of medications for adult patients (18+). - This EPA assesses the application of evidence-based guidelines to prescribe indicated medications that are tailored to the patient’s clinical profile, including prescribing agents to treat side effects (focusing on extrapyramidal side effects), and agents used as an add on or adjunct for partial response. This includes considering initial dosing principles and addressing side effects. - This EPA involves monitoring and managing medications. Monitoring includes reviewing bloodwork, metabolic parameters, and side effects such as extrapyramidal side effects. Managing involves titrating, switching, augmenting (add on or adjunct) for partial response, or discontinuing medications as appropriate to the patient's evolving circumstances. - It also includes shared decision-making, obtaining informed consent, providing education for medication, and facilitating access to medication as appropriate in the adult population. - This EPA may be observed using a clinical patient encounter, including inpatient or outpatient settings, or simulation, if required. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct and indirect observation by psychiatrist, TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Activity (select all that apply): starting; monitoring (review bloodwork, side effects and metabolic parameters); managing (titrating, switching, augmenting, or discontinuation) - Medication (select all that apply): agent to treat extrapyramidal side effects; lithium; long-acting injectable antipsychotic (LAI); monoamine oxidase inhibitor (MAOI); mood stabilizer other than lithium; oral antipsychotic; sedative/hypnotic; serotonin- noradrenaline reuptake inhibitor; serotonin specific reuptake inhibitor; stimulant; tricyclic; other antidepressant; other medication (write in) - Observation: direct; indirect; simulation - Observer: psychiatrist; TTP Psychiatry resident; Psychiatry subspecialty resident Collect 13 observations of achievement Starting: - 1 LAI - 1 lithium - 1 oral antipsychotic - 2 antidepressants (2 different classes) - 1 mood stabilizer other than lithium - 1 sedative/hypnotic or other non-benzodiazepine for sleep - 1 agent to manage extrapyramidal side effects Managing: - 2 antidepressants (2 different classes) - 1 stimulant - 1 oral antipsychotic - 1 lithium With: - At least 8 direct observations - At least 3 different observers - At least 6 by psychiatrists

Suggested observations: 13

- This EPA focuses on the critical appraisal of literature to make appropriate clinical decisions and to encourage lifelong learning and acquisition of new knowledge and skills in the specialty, and to a lesser extent, on the presentation of the relevant material. - This EPA includes posing a clinically relevant question, performing a literature search, critically appraising the literature, and presenting in a group setting. - This includes presentations such as grand rounds, service rounds, journal club, case conference, M&M rounds, or QI rounds. - The observation of this EPA is divided into two parts: Critical appraisal, and Presentation. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Part A: Critical Appraisal Review of critical appraisal submission by faculty supervisor Use form 1. Collect 2 observations of achievement Part B: Presentation Direct observation of presentation by faculty supervisor, with input from audience Use form 1. Collect 1 observation of achievement

Suggested observations: 2

- This EPA builds on the skills of the Foundations EPAs to focus on performing a psychiatric biopsychosocial assessment in adult patients with challenging psychiatric presentations and associated comorbidities. - This also includes the development and communication of a differential diagnosis and a comprehensive biopsychosocial treatment or management plan. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct observation, case discussion, and/or review of consult letter or other documents by psychiatrist, TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Case type: anxiety disorder; autism spectrum disorder; bipolar disorder; intellectual disability; major depressive disorder; personality disorder; psychotic disorder; trauma; other - Challenging presentation: no; yes - Setting: emergency; inpatient; consultation liaison; outpatient - Observation (select all that apply): direct; case discussion; review of clinical documents - Observer: psychiatrist; TTP Psychiatry resident; Psychiatry subspecialty resident Collect 8 observations of achievement - At least 4 different case types - At least 3 complicated cases - A variety of settings including at least 2 consultation liaisons - At least 5 direct observations - At least 4 different observers - At least 5 by psychiatrists

Suggested observations: 8

- This EPA builds on the skills of the Foundations EPAs and focuses on the development of a biopsychosocial formulation, including utilizing psychological theories and theories of personality development, and applying knowledge of neuroscience, neurodevelopment, aging, genetics and epigenetics, and socioeconomic determinants of health. - This EPA includes integrating predisposing, precipitating, perpetuating, and protective factors across the formulation in a coherent narrative that illustrates how different psychological constructs apply to a patient. - This EPA involves presenting a comprehensive biopsychosocial formulation in oral or written/electronic form. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity. - The observation of this EPA requires direct observation of the patient assessment in at least 3 cases.

Direct observation of patient interview and oral presentation or indirect observation through the oral presentation or review of written documentation of the formulation by a psychiatrist/psychiatric subspecialist, TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Demographic: child (4-12) or adolescent (13-17); adult (18+); older adult - Assessment directly observed: yes; no - Observer: psychiatrist; child and adolescent psychiatrist; geriatric psychiatrist; TTP Psychiatry resident; Psychiatry subspecialty resident Collect 8 observations of achievement - At least 2 child or adolescent - At least 2 adults - At least 2 older adults - At least 3 cases in which the supervisor has directly observed the assessment of the patient, of which at least 1 is an adult patient - At least 3 different observers - At least 6 by psychiatrists - At least 1 by a child and adolescent psychiatrist 3 for formulation of a child or adolescent - At least 1 by a geriatric psychiatrist 4 for formulation of an older adult

Suggested observations: 8

- This EPA focuses on performing a developmentally informed psychiatric assessment, using knowledge of neurobiological, cognitive, behavioral, emotional, family and personality development to perform a comprehensive biopsychosocial interview involving the patient, family, and others. - This also includes synthesizing the information to develop a differential diagnosis and management plan that integrates psychopharmacology, psychotherapy and social interventions as appropriate. - The management plan should include considerations of parent or guardian guidance, referral resources, and basic pharmacological and psychotherapeutic interventions. - This EPA does not include delivery of the management plan. - This EPA may be observed in simulation. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct or indirect observation by child and adolescent psychiatrist, psychiatrist, TTP Psychiatry resident, or Child and Adolescent Psychiatry subspecialty resident 5 Use form 1. Form collects information on: - Case type: abuse, neglect, or trauma; ADHD; anxiety disorder; gender issues; mood disorder; neurodevelopmental disorders; personality disorder; psychotic disorder; other presentation - Setting: emergency; inpatient; outpatient; simulation; other - Demographic: child (4-12 years); adolescent (13-18 years) - Observation (select all that apply): direct; indirect; simulation - Observer: child and adolescent psychiatrist; psychiatrist; TTP Psychiatry resident; Child and Adolescent Psychiatry subspecialty resident Collect 6 observations of achievement - At least 1 mood disorder - At least 1 anxiety disorder - At least 1 ADHD - At least 1 other neurodevelopmental disorder - At least 1 abuse, neglect, or trauma - At least 1 case with gender dysphoria - At least 1 child 4-12 years 5 If not a certified subspecialist, the majority of their experience is in the domain of CAP. - At least 2 adolescents 13-18 years - At least 4 direct observations - At least 3 different observers - At least 3 observations by a child and adolescent psychiatrist or psychiatrist with special interest in child and adolescent patients

Suggested observations: 6

- This EPA focuses on performing biopsychosocial psychiatric assessments in older adults, with appropriate adjustments made for patients with cognitive and sensory decline. This includes developing and communicating a differential diagnosis and a comprehensive biopsychosocial treatment or management plan in older adult patients. - This EPA may include younger patients with early onset neurodegenerative or neurocognitive disorders such as Alzheimer’s, and patients with Behavioural and Psychological Symptoms of Dementia (BPSD). - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct observation, case discussion and/or review of consult letter or other documentation by geriatric psychiatrist, psychiatrist, TTP Psychiatry resident, or Geriatric Psychiatry subspecialty resident 6 Use form 1. Form collects information on: - Case type (select all that apply): anxiety disorder; bereavement; bipolar disorder; BPSD; major depressive disorder; neurocognitive disorder; personality disorder; psychotic disorder; other - Setting: emergency; inpatient; consultation liaison; outpatient; community; assisted living; palliative - Additional concerns: rationalization of polypharmacy; elder abuse; other; n/a - Observation (select all that apply): direct; case discussion; review of clinical documents - Observer: geriatric psychiatrist; psychiatrist; TTP Psychiatry resident; Geriatric Psychiatry subspecialty resident Collect 6 observations of achievement - At least 4 different case types - At least 3 patients with neurocognitive disorders, including at least 1 patient with BPSD - At least 1 case with rationalization of polypharmacy - At least 4 direct observations, including review of documentation - At least 2 different observers 6 If not certified subspecialist, the majority of their experience is in the domain of geriatric psychiatry. - At least 3 by a geriatric psychiatrist or psychiatrist with special interest in older adult patients

Suggested observations: 6

- This EPA focuses on the assessment and management (i.e., pharmacological and non- pharmacological) of any psychiatric emergency, maintaining safety, and minimizing risk to patients, self, and others. - This includes presentations involving risk of harm to self or others, acute agitation and aggression as well as other behavioural and emotional disturbances and medical emergencies, such as acute dystonic reactions, delirium, catatonia, serotonin syndrome, neuroleptic malignant syndrome (NMS), etc. - This EPA may be observed in simulation. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct and indirect observation by psychiatrist, TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Case type: active suicidal ideation; acute agitation and aggression; acute dystonic reaction; catatonia; homicidal/violent ideation; medical emergency related to delirium; NMS; other behavioural or emotional disturbance; risk of harm to others; serotonin syndrome; other condition - Setting: emergency; inpatient; outpatient; simulation; other - Observer: psychiatrist; TTP Psychiatry resident; Psychiatry subspecialty resident Collect 8 observations of achievement - At least 2 patients with acute agitation and aggression - At least 2 patients with active suicidal ideation - At least 1 patient with homicidal/violent ideation or risk of harm to others - At least 2 patients with medical emergencies related to delirium - At least 1 patient with acute dystonic reaction, catatonia, serotonin syndrome, or NMS - At least 5 direct observations - At least 4 observations by psychiatrist

Suggested observations: 8

- This EPA focuses on activities that require clinicians to apply mental health legislation and ensure a legally defensible approach in evaluation, diagnosis, and communication. - Examples include the following: capacity to consent to treatment, fitness to stand trial, financial capacity, testamentary capacity, capacity with respect to long-term care, restrictions/limitations relevant to disability, disclosure of information, need for mandatory or discretionary reporting (driving, child protection services), initiating involuntary treatment or hospitalization. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct and indirect observation by psychiatrist, TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Case type: capacity to consent to treatment; capacity with respect to long-term care; disclosure of information; fitness to stand trial; financial capacity; initiating involuntary treatment or hospitalization; need for mandatory or discretionary reporting; restrictions/limitations relevant to disability; testamentary capacity; other issue - Setting: emergency; inpatient; outpatient; simulation; other - Observer: psychiatrist; TTP Psychiatry resident; Psychiatry subspecialty resident Collect 6 observations of achievement - At least 2 capacity to consent to treatment cases - At least 2 initiating involuntary treatment and/or hospitalization - At least 1 evaluation for restrictions/limitations relevant to disability - At least 1 need for mandatory or discretionary reporting - At least 4 direct observations of assessment - At least 2 different observers - At least 4 by psychiatrists

Suggested observations: 6

- This EPA builds on the skills of the Foundation stage to focus on the application of safe prescribing practices in the provision and optimization of comprehensive pharmacological management for the breadth of psychiatry patients, including children, adolescents, older adults, and adults with challenging presentations, such as pregnancy, polypharmacy, medical and psychological comorbidities, serious and persistent mental illness, and patients with varying levels of capacity. - This EPA focuses on prescribing, monitoring, and managing medications. Monitoring includes reviewing bloodwork, metabolic parameters, and side effects. Managing involves titrating, switching, augmenting (add on or adjunct) for partial response, or discontinuing medications as appropriate to the patient's evolving circumstances. Deprescribing medication may also be included in this EPA. - This EPA also includes managing side effects of medications which may include metabolic syndrome (e.g., with metformin), cognitive impairment (e.g., with stimulants) or sexual side effects (e.g., with bupropion, mirtazapine). - It also includes patient education and addressing ethical and legal issues related to informed consent, patient capacity, and decision-making in patients with varying cognitive abilities or legal concerns, as appropriate. - This EPA may be observed using a clinical patient encounter, or simulation, if required. - It is recommended that observations of this EPA be scheduled in advance.

Direct and indirect observation by psychiatrist, TTP Psychiatry resident, Psychiatry subspecialty resident Use form 1. Form collects information on: - Activity (select all that apply): starting; monitoring (review bloodwork, side effects, metabolic parameters); managing (titrating, switching, augmenting, and discontinuation); de-prescribing - Medication (select all that apply): agent to treat side effects; benzodiazepine; cognitive enhancer; clozapine; lithium; long-acting injectable antipsychotic (LAI); mood stabilizer; oral antipsychotic; serotonin specific reuptake inhibitor; serotonin- noradrenaline reuptake inhibitor; stimulant; tricyclic antidepressant; other - Challenging factors: pregnancy or breast feeding; multiple medications; other - Setting: inpatient unit; outpatient; consultation liaison; simulation - Demographic: child (4-12); adolescent (13-17); adult (18+); older adult - Observer: psychiatrist; TTP Psychiatry resident; Psychiatry subspecialty resident Collect 10 observations of achievement Starting: - 1 clozapine - 1 stimulant in child and adolescent population - 1 agent for side effects other than EPS Managing: - 1 clozapine - 1 stimulant in child and adolescent population - 1 benzodiazepine Monitoring: - 1 clozapine - 1 LAI Monitoring or managing: - 1 stimulant in adult population Starting or monitoring or managing: - 1 cognitive enhancer in the older adult population With: - At least 1 patient on multiple psychiatric medications - At least 2 patients in the CL setting - At least 2 children/adolescents - At least 2 older adults - At least 1 pregnant or breastfeeding patient - At least 8 clinical (not simulated) cases - At least 5 different observers - At least 5 by psychiatrists

Suggested observations: 10

- This EPA applies the knowledge and skills developed in psychotherapy to inform an assessment and provide appropriate psychotherapeutic interventions amongst various modalities, as well as ongoing assessment of the patient’s response to the intervention. - This includes the delivery of individual psychodynamic therapy, and family or group therapy. - This includes identifying and empathizing with the patient, maintaining a collaborative relationship with the patient (and family), fostering the therapeutic alliance, recognizing and repairing tensions or ruptures in the alliance, and adapting the psychotherapeutic intervention to the individual patient context (trauma, culture, spiritual, social, biological). - This also includes educating the patient and/or family on the rationale and therapeutic components of the prescribed psychotherapeutic intervention. - The assessor should include details in the narrative assessment regarding which Psychodynamic Psychotherapy interventions were correctly utilized and could include exploration of transference/ countertransference, interpretation, working through resistance, promoting insight, recognize maladaptive patterns and link to past experiences, recognize defenses, exploration of object relations, encouraging emotional expression - The assessor should include details in the narrative assessment regarding which Group Psychotherapy interventions were correctly utilized and could include establishing group norms, facilitating cohesion, exploring relational dynamics, managing conflict, using group feedback, facilitating group process, managing group dynamics - The assessor should include details in the narrative assessment regarding which Family Psychotherapy interventions were correctly utilized and could include enhancing communication, identifying and restructuring family roles, exploring family dynamics, conflict resolution, strengthening emotional bonds, reframing, setting boundaries and addressing dysfunctional patterns, emotional regulation, strength-based interventions - Observations of achievement should be entrustable to the level of a generalist psychiatrist. - Longitudinal elements relevant to this EPA may be assessed using alternate methods e.g., ITER/ITAR 7. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct observation or review of audio, video or transcript by psychiatrist, or other mental health professional trained in the modality Use form 4 (narrative feedback) 7 ITER/ITAR is not available on the eportfolio platform Collect 4 observations of achievement - At least 1 of family or group therapy - At least 1 observation of psychodynamic psychotherapy of the more foundational interventions (e.g., recognize defenses, recognize maladaptive patterns and link to past experiences) - At least 1 observation of psychodynamic psychotherapy of the more advanced interventions (e.g., exploration of transference/ countertransference, working through resistance)

Suggested observations: 4

- This EPA applies the knowledge and skills developed in psychotherapy to inform an assessment and provide appropriate psychotherapeutic interventions into regular clinical care, as well as providing ongoing assessment of the patient’s response to the intervention. - This EPA includes the integration of psychotherapeutic principles into patient care in the hospital or in outpatient settings (e.g., Consultation-liaison, substance use psychiatry). - This may also include educating the patient and/or family on the rationale and therapeutic components of the prescribed psychotherapeutic intervention. - This includes identifying and empathizing with the patient, maintaining a collaborative relationship with the patient (and family as necessary), fostering the therapeutic alliance, recognizing, and repairing tensions or ruptures in the alliance, and adapting the psychotherapeutic intervention to the individual patient context (trauma, culture, spiritual, social, biological). - This may include any psychotherapeutic intervention, except supportive therapy. - Every milestone may not be applicable to every observation. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct observation by psychiatrist Use form 1. Form collects information on - Intervention: CBT; DBT; emotion focused therapy (EFT); family therapy; group therapy; IPT; MI; mindfulness; psychodynamic (short term or long term); other (write in) Collect 2 observations of achievement - At least 2 different interventions - At least 2 different observers

Suggested observations: 2

- The focus of this EPA is the assessment and management of patients with substance use disorders and concurrent psychiatric disorders. - This EPA includes gathering a patient history, including substance use patterns, other mental health disorders, and social factors and using screening tools to assess the severity and impact of addiction. It also includes requesting appropriate laboratory investigations (e.g., urine drug screen, liver enzymes, hepatitis, sexually transmitted infections) and inquiring about physical manifestations of substance use disorders (e.g., skin infections, history of pancreatitis, endocarditis, etc.). - Substances may include alcohol, opioids, sedative hypnotics, cannabis, stimulants, tobacco, hallucinogens, inhalants and others. - It includes developing management and follow-up plans for ongoing monitoring and support. - This EPA also includes recognizing legal and ethical considerations, and relevant available community resources. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct and/or indirect observation by psychiatrist, TTP Psychiatry resident, or Psychiatry subspecialty resident Use form 1. Form collects information on: - Substance use disorder: alcohol; opioid; sedative hypnotics; cannabis; other - Therapy: motivational interview; other - Medication: naltrexone; suboxone; acamprosate; methadone; other - Concurrent psychiatric disorder: no; yes Collect 2 observations of achievement - At least 2 substance use disorders with concurrent psychiatric disorders

Suggested observations: 2

- This EPA focuses on the application of neurostimulation modalities in the management of adult and older adult patients. - This includes identifying suitable candidates and completing pre-procedure work-up which includes informed consent discussion; delivering neurostimulation; managing and interpreting electroencephalography (EEG); providing follow-up care; and managing complications. - This EPA also includes communicating with the patient or substitute decision maker and family about the procedure to guide consent and dealing with stigma or cultural resistance related to acceptance of the proposed procedure. - The observation of this EPA is divided into two parts: suitability for neurostimulation; delivery of neurostimulation. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Part A: Suitability for neurostimulation Direct and indirect observation by psychiatrist Use form 1. Form collects information on: - Case type (write in): - Modality: ECT; rTMS; other evidence-based form of neurostimulation - Setting: inpatient unit; outpatient; simulation - Demographic: adult; older adults Collect 3 observations of achievement - At least 1 of each demographic - At least 2 ECT cases Part B: Delivery of neurostimulation Direct observation by psychiatrist or neurostimulation provider Use form 1. Form collects information on: - Case type (write in): - Modality: ECT; rTMS; other evidence-based form of neurostimulation - Demographic: adult; older adults Collect 3 observations of achievement - At least 2 ECT cases

Suggested observations: 3

- This EPA focuses on the psychiatrist’s role in the overall delivery of patient care. - This includes evidence–informed decision-making across the breadth of psychiatric presentations and case complexity and running the service or practice efficiently and in a manner consistent with sustainable practice and work-life balance. - This also includes the administrative aspects of practice such as quality assurance and improvement, patient advocacy, resource management, and financial management including billing, and the other responsibilities of an attending physician such as supporting the interprofessional team and maintaining a professional work environment. - This EPA may be assessed following a minimum of one month (full time) of any psychiatry training experience. - This EPA may be observed once based on a full-day afterhours/on-call experience (12 hours or greater) with sufficient patient volumes. - It is recommended that EPA observations should be planned collaboratively before or at the time of the activity.

Direct or indirect (case review) observation by supervising psychiatrist with feedback from other health care professionals including other physicians, social workers, nurses, OT/PT, administrators, peers, junior residents, or subspecialty residents, as relevant, collated by supervisor Use form 1. Form collects information on: - Setting: emergency; inpatient unit; consultation liaison; outpatient; afterhours/on- call (full-day) Collect 2 observations of achievement - No more than 1 afterhours setting - At least 1 following a month of any psychiatry setting

Suggested observations: 2

- This EPA focuses on providing appropriate supervision and opportunities for autonomy: triaging the level of supervision according to acuity, setting, and trainee and patient needs; delegating appropriately; and being available in case of emergency. - This EPA also includes coaching junior trainees, assessing the performance of others, and providing feedback.

Direct observation by psychiatrist, with input from other health care professionals and learners Use form 1. Form collects information on: - Setting: emergency; inpatient unit; consultation liaison; outpatient; community; afterhours/on-call Collect 4 observations of achievement

Suggested observations: 4

- This EPA focuses on formal teaching and presentations to diverse audiences such as patients, families, junior and senior learners, and other health professionals. - This EPA builds on the skills of the Foundations EPA (Performing critical appraisal and presenting psychiatric literature) and includes higher expectations for critical appraisal of relevant literature, adaptation of language and material to the needs of the audience, and effective presentation skills. - This includes identifying learning objectives, synthesizing information effectively, and demonstrating understanding of the chosen topic.

Direct observation by psychiatrist, with input from the audience Use form 1. Form collects information on: - Topic (write in): - Audience (select all that apply): residents/medical students; peers; psychiatrists; patients and/or families; public; other health care professionals Collect 2 observations of achievement - At least 2 different psychiatrists

Suggested observations: 2