Donna Sudak, MD
As the year ends, I wanted to highlight some regulatory changes that come into effect in the coming year. Several important Common Program Requirements will be subject to citation in July 2019, and we are nearing that deadline. Many of these are requirements that should be fulfilled in conjunction with the sponsoring institution, and fall in the areas of patient safety, quality improvement and well-being.
Some highlights include:
One other important change in the CPRs for Psychiatry is that scholarly activity will have a less restrictive definition such that multiple forms of scholarship by faculty, not just peer-reviewed publications, will be included. There are also changes in the eligibility for fellowship programs beginning July 1, such that AOA, ACGME-I Advanced Specialty Accredited Programs or RCPSC or CFPC Canadian Accredited Programs are eligible for training in ACGME Accredited Fellowships. There are also clarifications or new requirements regarding the need for lactation rooms, rest facilities, pain management education and training in end-of-life conversations.
Many of these new requirements have been the subject of AADPRT workshops at the annual meeting and workgroups within the organization, and the work product is available on the website. For example, in the Virtual Training Office you can peruse meeting materials from 2018 and find a PDF of a presentation called “The New face of Diversity Education”, or, in the 2017 meeting materials a “Quality Improvement Curriculum”. Several clicks away you can find a “Stress Management and Resiliency Training” model curriculum in the Model Curriculum tab on the website. We have charged the Wellness Task Force with compiling the resources they identified during their work and will be providing a link to these on the website.
The AADPRT list serv remains an extraordinary source of information and support from other training directors. We can help each other by sharing ideas and resources when fellow members ask questions. In addition, we have regular calls with the RC leadership to ask for clarification about issues you bring to AADPRT leadership and publish the results of these calls. Such access and open communication are both unusual and extremely helpful when navigating the regulatory maze. We are in this together!
Donna Sudak, MD
A 700-word blog post isn't going to do justice to the topic I have chosen. We have lots of work to do as a profession - we can, and should, get better at rectifying the inequities that exist in the delivery of health care. A commitment to diversity and structural and cultural competence in our training programs is vital to this effort. I'll argue for it as a significant enhancement to the quality of life for a residency director.
Too often being a training director means focusing on administrative minutiae - Web-ADS, evaluations that are delinquent, faculty who do not show up for lectures, a resident who offends the nursing staff. Such work often grinds a new training director down and leads her to abandon the position.
Diversity is one of the macro issues. Those macro issues are the reason I am in the business of training for the long haul. My way of changing a little piece of something. It gives my work meaning even when I am bean-counting.
Consider the following. The US has the worst health care outcomes of most developed countries in terms of infant mortality and life expectancy. We spend the most on health care. We also spend the least on social services. Not news to all of you, and certainly not news in mental health professions. Generally, the media and government blame the health system for the lack of bang for our health care buck.
Now consider that we may get worse outcomes because of social determinants of health and health inequality. There is an emerging body of research that supports this. Mc Ginnis et al (2001) cite education, employment, income, housing, crime and environment as having significant bearing on health status. And status it is - the richest 1% have greater longevity (Sklar 2018 ). Our patients may even be more affected by significant social and economic inequality, since psychiatry sits at the intersection between social justice and medicine.
That's where residency training comes into the picture. We can better health outcomes as training directors by recruiting a diverse health care work force, and by teaching our residents to understand the costs and remedies for health care disparities.
AADPRT formed a Committee on Diversity at this year's Annual Meeting. Chaired by Adrienne Adams, it has the following purpose statement:
Future psychiatrists will be best prepared to practice if they are trained in an environment embracing diversity. This committee will provide AADPRT with a venue for ongoing education regarding diversity, a clearinghouse for educational materials about diversity, and representation within the leadership of the organization to advocate for issues about diversity and health disparities. The committee may partner with similar committees already in existence in a number of our allied organizations, including the American Psychiatric Association. The committee may also work in concert with other AADPRT Committees (i.e., recruitment, curriculum) in order to accomplish its mission.
I'd love to know your views, or what you are doing about this area. Email me.
Sklar, DP Academic Medicine 93, 1, 2-3 January 2018
Mc Ginnis, JM, Williams-Russo,P, Knickman SR. Health Affairs (Millwood) 2002; 21: 78-93.
Sandra M. DeJong, MD, MSc
In 2002, the American Board of Internal Medicine (ABIM) and the European Federation of Internal Medicine (EFIM) issued a "Physicians Charter" entitled "Medical Professionalism in the New Millenium." The charter espouses three fundamental principles of professionalism: the primacy of patient welfare, patient autonomy, and social justice. It is the third principle I want to focus on here. What is "social justice" as it pertains to professionalism in psychiatry? What are the implications of how we define "social justice" for training and for AADPRT?
The Physicians' Charter includes in its definition of social justice improving quality of care, advocacy for a just distribution of resources, and promoting scientific knowledge. A recent resident retreat on social justice at my medical school, (organized by the Cambridge Health Alliance general psychiatry residency program), included topics such as diversity training, DACA, refugee mental health, privilege, racism in psychiatry, LGBT trainee experience, health care disparities, advocacy, the Goldwater Rule, and racial bias. Another retreat, this one for faculty members, focused on promoting respect across differences as part of improving the learning environment.
This year AADPRT's Steering Committee (SC) has been asked to support a variety of issues that might fall under social justice: Legislation to promote NIH funding for mental health research and education; advocacy efforts to support medical students and trainees affected by the DACA repeal; and an effort to promote language about diversity among residents, faculty, and staff in ACGME requirements. In the case of AADPRT, the SC weighed each request for support in the context of our educational mission "to promote excellence in the education and training of future psychiatrists," and supported initiatives that felt consistent with our mission.
Learning psychiatry through didactics and seeing patients is a contextual activity. ACGME has recognized the importance of the "learning environment" at an institutional level. Should the boundary stop there? This year, societal context has seemed more important and broader than ever; our allied organizations such as AAMC, AACAP and APA have issued statements in response to a number of political actions. AADPRT's leadership has actively considered how our mission and role as an organization of psychiatric training professionals fits into today's society. Where should the contextual boundaries of AADPRT and psychiatric training lie? How do we practice and teach "social justice" while respecting the different views--political and otherwise--of our residents and members? How do we protect what we believe is important in psychiatric training without overstepping our role as a non-lobbying organization? How do we come to consensus about, acknowledge, incorporate, and perhaps advance societal change?
Similar to the current debate about the Goldwater Rule, AADPRT will need to continue to think about its identity in relation to social justice. Will we narrowly define our role to what we have direct "expert" knowledge about? Or will we embrace a role in a "social contract," (as the Physicians Charter describes), in which affecting social context is part of what we do?
Warmest wishes to you all for 2018. See you in the Big Easy!
Sandra M. DeJong, MD, MSc
Information Technology (IT) has become a critical aspect of running any contemporary professional organization. Given greater needs for IT as our organization has grown and technologies have become more sophisticated, AADPRT moved to a different vendor two years ago. That vendor, Informatics, works in conjunction with our Executive Director (Sara Stramel Brewer) who works with the Information Management Committee (currently co-chaired by John Luo and Sanjai Rao).
AADPRT's IT needs continue to expand: Various AADPRT components (task forces, caucuses, etc.) increasingly request IT features to disseminate and perform their work. Members want to quickly and easily navigate our website to access materials. As components proliferate, requests for listserves increase.
In order to thoughtfully consider our current IT use as it relates to supporting our mission, and make recommendations for how to improve its functionality and efficiency for the future in the most cost-effective way possible, I have appointed an IT Taskforce. The Taskforce is co-chaired by Suzanne Murray and Bob Boland, and members include Adrienne Adams, Sheldon Benjamin, Rob Marvin, Ed Kantor, Sanjai Rao, John Luo, Kim Kirchner (Program Administrator) and Sara Stramel Brewer (Ex officio).
by Sandra DeJong, MD, MSc
May 31, 2017
Commuting to my office in Cambridge, MA, this spring, I listened with some shock to a National Public Radio story about a new problem in the neighborhood where I work: The cafes of Inman Square were struggling to cope with the rate of overdose deaths in their restrooms.1 Joshua Gerber, the owner of 1369 Coffeehouse where our residents and faculty regularly purchase their lattes and espressos, reported he had mounted a sharps box and is training baristas in naloxone use.
From 2002-2015, the number of deaths in the US due to all drugs increased 2.2-fold and the number of deaths due to opiates 2.8-fold (NIDA, drugabuse.gov). While New England and the Midwest have been particularly hard hit, the crisis is ubiquitous. In 2015 Everett, MA, a neighboring town to Cambridge and part of our catchment area, had a rate of 55 opioid-related deaths per 100,000 people. Princeton economists Anne Case and Angus Deaton have coined the term “deaths of despair” for the shocking increase in middle-aged deaths –- overdoses, suicides, alcoholic liver disease -- among non-Hispanic whites in this country, a trend not found in any other developed nation.
In 2016, Surgeon General Vivek H. Murthy, MD, MBA issued a report entitled “Facing Addiction in America.” The report, a call to arms for all of us, emphasizes the scientific understanding of addiction as a chronic disease and the availability of evidence-based treatments.
As a psychiatrist, I perceived a gap in this otherwise outstanding report: Where was the discussion of the important role of psychiatry in combatting the epidemic? What about the importance of treating those suffering from dual diagnoses, including mood disorder, trauma, and anxiety? Where was the call to arms for psychiatry to help our colleagues in primary care, addiction medicine, and addiction psychiatry confront the crisis?
With the important exception of subspecialists in addiction psychiatry and some general and child psychiatrists who treat patients suffering from addictions, psychiatry has seemed strangely absent from the national conversation about the addiction epidemic. Since 2001, ACGME hasrequiredgeneral psychiatry residents to complete only one month FTE of addictionstraining or addictions psychiatry;child psychiatry fellows have no specific requirement. Surveys of training programs indicate significant variability inthe settingand timing of current addictionstraining.2 Though experts suggest thatexposure to longitudinal treatment and recovery areideal in training, many programs rely on acute settings. A recent survey foundresidents’ attitudes towards Substance Use Disorders actually worsened over the course of their training.3
Efforts are underway in our allied organizations such as the American Psychiatric Association, the American Academy for Child and Adolescent Psychiatry, and the American Academy of Addiction Psychiatry to improve addiction training in psychiatry. AADPRT, through its new Addiction Taskforce chaired by Ann Schwartz, MD, from Emory, is committed to improving residency training in addictions by developing a strategic plan, formulating training goals, and providing a platform for disseminating educational resources and train-the-trainer sessions both in-person and virtually. Soon you will receive a survey asking about what you are doing now in addictions training and what you would need to have in place to be able to do more. Please help by responding to the survey.
For now, I ask you to consider these questions: What is our responsibility to our trainees in preparing them to help combat this addiction crisis? What is our responsibility to our patients and their families? What about our communities? What will it take for all of us in psychiatric education and training--what knowledge, skills, resources, and attitudes--to contribute to ending this unfolding tragedy?
As always, I welcome your thoughts. email@example.com
2.Shorter D andDematisH. Addiction training in general psychiatry training: A national survey.SubstAbus.2012; 33:392-394.Avery J, Han BHZerboE et al.
3.Psychiatry residents’ attitudes towards individuals with substance use disorders and schizophrenia. Am J Addict 2016;25.
January 4, 2017
2016 has been an eventful year for us all, including in the world of graduate medical education. I hope to reflect a bit on AADPRT over the last year, and our plans for the coming year.
I would like to thank all of our members for their patience and responsiveness as we have asked you to complete many surveys to guide our organization. The ACGME has asked us twice to comment on the Common Program Requirements, first to collect feedback about Sections I to V and then to obtain our review and comments on proposed changes to Section VI, including new requirements relevant to resident wellness and a revision of the duty hours. Your thoughtful responses helped us ensure that we accurately represented AADRPT’s collective position on these changes. Our responses to the ACGME, as well as the data from the surveys, is available on our website.
Speaking of our website, I am very pleased to report that our Virtual Training Office (VTO) is up and running. This marks the culmination of a process that began with (at the time) President Bob Boland, MD, and Information Management (IM) Committee Chair Sahana Misra, MD, and that was shepherded along by current IM Committee Co-Chairs Sanjai Rao, MD, and John Luo, MD. I am very thankful to our Committee Chairs and Co-Chairs, who helped determine what content should make it into the new VTO, and of course to our Administrative Director, Sara Brewer, for her overall management and for her close collaboration with Informatics, our IT consultants.
Please take a few minutes to check out our new VTO, which is in the member section of the website. After logging in, click on “VTO” in the menu to the left of the screen. Your first stop should be in the “AADPRT Guide to the VTO” folder, where you will find the “VTO Guide.” This Excel spreadsheet includes a list of all VTO documents, including where to locate them on the website.
You will notice that the VTO is organized using folders and subfolders – like your own computer – and you can navigate to find the particular file or files you are looking for. Many of the folders, subfolders, and files also include descriptions so that you have a better idea of their content. This new structure will make it easier for us to keep the VTO up-to-date, and hopefully will make it easy for you to find resources useful to running your residency program.
I would love to get your thoughts on the VTO. We will continue to update the website based on your feedback.
Looking ahead, our next big priority is the Annual Meeting. I look forward to seeing my AADPRT colleagues at the Hilton San Francisco Union Square on March 8-11, 2017. We are all privileged to have an outstanding Program Committee – Adam Brenner, MD (Chair), Donna Sudak, MD, and Melissa Arbuckle, MD, PhD – who are hard at work putting the finishing touches on the Annual Meeting, which will have the theme, “Define ‘Psychiatrist’: Merging Passions, Pressures, and Values.” Full meeting information is available here.
My last blog post listed AADPRT’s current initiatives. I do have two additional projects to present to you:
Please do not hesitate to contact me at firstname.lastname@example.org with any questions or suggestions for our organization.
September 14, 2016
I can’t believe it’s already been six months since we held our last Annual Meeting! This would be a good time to update you on what AADPRT has been working on …
Our priorities include sharing best educational practices across residency programs, helping program directors implement ACGME requirements (including the milestones), and fostering a community of GME educators. Our Annual Meeting serves these priorities, and the next one will have the theme, “Define ‘Psychiatrist’: Merging Passions, Pressures, and Values.” The Annual Meeting will take place on March 8-11, 2017, at the Hilton San Francisco Union Square. Our Program Committee, which includes Adam Brenner, MD (Chair), Donna Sudak, MD, and Melissa Arbuckle, MD, PhD, is developing an outstanding curriculum. Watch this page for more details.
In addition, our initiatives for 2016-17 include:
1. Resident Wellness. We are all aware of the mounting concerns about physician wellness and burnout, including among residents. Heather Vestal, MD, is Chairing our new Resident Wellness Task Force, which has been charged with identifying and disseminating best practices for residencies to adopt in terms of promoting resident wellness, addressing depression/anxiety, and reducing burnout. The work of this task force has just begun, with plans for dissemination at our next Annual Meeting, and beyond. We hope to partner with ACGME and other organizations in these critical efforts. We will be surveying you later this year about resident wellness activities in your own programs and institutions.
2. Faculty Development. Early career psychiatrists who are interested in GME face a bevy of challenges: increasing demands for clinical productivity, greater administrative burden and regulatory requirements, larger student debt, and higher rates of depression and burnout – and yet they are critical for training medical residents. Deb Cowley, MD, is Chairing our new Faculty Development Task Force, which will identify best practices for residencies and Departments of Psychiatry to promote the development of faculty interested in GME and to identify the next generation of residency training directors. We will present a symposium on “Promoting Faculty Development in Graduate Medical Education” at the next Association for Academic Psychiatry meeting on September 23, 2016, featuring Suzanne Murry, MD, and Don Hilty, MD; this is our fourth annual joint AAP-AADPRT symposium. Stay tuned for a survey coming from the Faculty Development Task Force in the next month or so.
3. Medical Student Preparedness for Residency. Anecdotally there has been increasing concern about how well prepared recently graduated medical students are for residency. Our Recruitment Committee, under the leadership of Glenda Wrenn, MD, is partnering with ADMSEP in their development of a model “boot camp” for fourth-year medical students to help increase students’ readiness for Psychiatry residency.
4. Residency Recruitment. As you all know, we have seen an increase in the number of applicants to our programs, which is welcome but which also has posed challenges. Our Recruitment Committee will be surveying you in the very near future regarding areas of concern in the recruitment process. We were also recently asked by the Organization of Program Director Associations (OPDA), to whom our liaison is Deborah Spitz, MD, for feedback about ERAS.
5. Virtual Training Office. AADPRT’s website has historically been a repository for curricula, assessment instruments, and administrative tools for residency training directors. We are currently vetting these educational materials with a plan of posting the most relevant and up-to-date materials on our new Virtual Training Office. We plan to have the VTO ready to go sometime in October 2016. This has been a monumental effort organized by the Co-Chairs of our Information Management Committee, Sanjai Rao, MD, and John Luo, MD, and involving the Chairs and Co-Chairs of many of our committees, e.g., Kaz Nelson, MD, and Jacqueline Hobbs, MD, PhD, of the Curriculum Committee.
6. PGY4 Fast Tracking. In response to ABPN’s request for our feedback about fast tracking into one-year subspecialty fellowships, we surveyed our membership and reported our findings to ABPN. A substantial majority of AADPRT members (77.3%) did not support fast tracking and would maintain the current PGY4 structure or increase the specialty content of four-year general psychiatry training programs. We continue to believe that the PGY4 year is necessary for integration of knowledge, skills, and competencies. We thus urged ABPN to not support fast tracking into one-year subspecialty fellowships.
7. Entrustable Professional Activities and Milestones. Both of these represent methods of assessing residents’ competence. We are now in the third year of implementation of the milestones for general psychiatry residencies, and in the second year for fellowships. Our EPA Task Force (chaired by John Q. Young, MD, MPP, PhD) and CAP Milestones Task Force (chaired by Jeff Hunt, MD) have been disseminating best practices in these areas. Our ACGME Liaison Committee has initiated regular phone calls with the leadership of the ACGME Psychiatry Review Committee to raise and address concerns related to ACGME requirements.
8. National Neuroscience Curriculum Initiative (NNCI). We continue to invest in the NNCI, which presents the day-long BRAIN conference during each Annual Meeting. NNCI, an NIH-funded program, is in the process of creating comprehensive resources to help train psychiatry residents and psychiatrists in modern neuroscience, specifically integration into clinical practice. We thank Melissa Arbuckle, MD, PhD, David Ross, MD, PhD, and Mike Travis, MD, for their efforts in leading the BRAIN conference.
9. GME Financing and Governmental Affairs Consultants. We are very pleased to announce that Jed Magen, DO, has kindly agreed to serve as the Chair of our GME Financing and Governmental Affairs consultants. It is important for program directors to be aware of funding, legislative, and regulatory issues that may impact GME, and so this new group will include internal experts who will educate AADPRT members about these topics. If you are interested in joining the group, either as an expert or someone interested in becoming an expert, please let me know.
Please do not hesitate to contact me at email@example.com with any questions or suggestions for our organization.
November 21, 2015
By three methods we may learn wisdom: first, by reflection, which is noblest; second, by imitation, which is easiest; and third, by experience, which is the most bitter.”
Having been through the introduction of several electronic medical record roll-ins, I had no illusions that our transition to a web management system would be a smooth one. But boy, it sure has been a bumpy ride (although, our hospital’s Epic roll-in was still way worse).
Our system was designed to automate many tasks that we previously had to do manually. And by “we” I mean, of course, Lucille. Having worked with Sara learning how this organization actually runs only gives me more respect for the amount of work Lucille did.
Just as I didn’t understand all the work Lucille had to do in the background, it is probably not apparent to most of you how successful the new system is. Really. Much of it is working great, and most of what we planned is happening more or less on schedule.
But, naturally, we are most aware of the things that are not working well. Most apparent recently are the glitches in the new abstract system – the one we use to submit proposals for workshops and posters for the annual meeting, evaluate them and then send out decisions. Some of the problems were programming errors, but others were misunderstandings between our conception of how it should work and the software engineers’ operationalizing of our non-technical explanations. Learning how to communicate exactly what we needed was quite the learning curve.
And we’ve learned. Lots of glitches have been discovered and fixed. But, certainly, the nicest thing I’ve learned is what a great group of members we have. Of course I already knew that, but this experience has just amazed me, as many of you have sent gracious letters of support and understanding in response to the several apologies and “oops” emails we have had to send.
When Neil Armstrong was asked by a reporter what he would have taken to the moon if he could have brought anything he wanted, he replied “more fuel.” If I was granted one wish for our system, it would have been more time for testing the system before we used it. But time is what we didn’t have – we have a meeting coming soon and time is a-wastin’. So we had to move ahead and discover through experience what worked and what didn’t in our system.
But, as Confucius also said, “it does not matter how slowly you go as long as you do not stop.” With each glitch and problem we are learning, and fixing things as we go.
I am confident that despite the annoyances and delays, we are slowly but surely moving forward toward a great annual meeting in March. Just as important, I am confident we will end up with a more efficient and user friendly web system for our members in the coming year.
So, as always, thanks for your patience and support and I’m looking forward to seeing you soon!
August 16, 2015
Hope you are enjoying a good summer and getting some relaxation in during this time.
I’m excited to tell you that soon, we will be rolling out our new website. Although our current site has served us well for many years, it is time for an update. The new site will have a cleaner interface that reflects our “modern” use that demands the kind of flexibility that will accommodate both wide screens as well as mobile devices. Along with the new look, it will help us automate many of the tasks that keep Sara very occupied now.
One of those tasks is keeping track of membership. We will be updating our system for keeping track. This will have many benefits, including the ability to personalize your page (and answer the call many have had for a directory that includes pictures), and allow more streamlined systems for membership renewal. This will be a great improvement; however the new system will be so radically different that we will not be able to import the old system. This means that, when it is up and running, when we renew our memberships this year, we will have to create a new profile for ourselves. A bit of a pain, but it is a onetime thing, and again the result will streamline many of the tasks that Sara currently has to do manually.
Speaking of Sara Stramel-Brewer, our Administrative Director will be much occupied helping to upload information and work with the webmasters to finish the site over the next month or so. I know this goes against her grain, but I’ve advised her that she should concentrate on this and become otherwise less available to us. Usually things are not too busy for now, but I’d encourage everyone to hold non-urgent questions and business until this job is done and we announce the roll out of the site. If there is anything I can help with, please don’t hesitate to contact me directly. If you do have to write her, please understand if the reply takes longer than usual.
Thanks all. Again, best wishes for the remainder of the summer and I’m looking forward to when I can announce the opening of the site!
I am honored and humbled to have been chosen to be this year’s President…
… and frantic! With only a year in the position, how is there time to do anything meaningful?
Fortunately, I’ve had a lot of help and guidance in considering this. I am, of course, not starting from scratch, but have the chance to build on the excellent work of previous presidents, my most recent predecessors being Chris Varley and Adrienne Bentman. I have learned greatly from their thoughtful and deliberate styles as well as their earnest desire to consider all members and voices.
I am also helped by yet another excellent meeting. Thanks so much to Chris, to Sandra DeJong and Sara Stramel-Brewer and to the many others who helped organize such a successful meeting. During the meeting, I tried to take some time to reflect on the major themes and concerns, rising above the usual day to day minutiae of our busy lives.
In thinking about that I was also aided by the amazing group of colleagues who make up our Steering Committee: Chris and Adrienne and Sandra as well as Art Walaszek, Mike Travis and Donna Sudak. While most of us were rushing off to catch flights, this group sat together to take a breath and consider these themes.
Of course there are many, but at least two things that came up a lot are the themes of wellness: both that of our residents and/or ourselves. Despite the many well meaning attempts to improve the lives of our residents, we seem to hear about the problem of burnout more than ever. And that burnout isn’t limited to the years of training: faculty seem increasingly stressed but such things as productivity, administrative and other demands, and even those who love to teach are finding it more difficult to find the time.
Fortunately I have a whole year, which is certainly more than enough time to solve all these things …
… sorry, just seeing who’s still paying attention. No, we cannot solve these things quickly or alone. But we have already done a good job of putting the focus on different aspects of these issues (note the many workshops directly related to these themes) and I think we can continue to expand our involvement in these issues, both within our organization, and by collaborating with interested partners. Building on the work of my predecessors, I hope to increase our involvement in these issues.
In the meantime, I would love your thoughts. The listserv remains a great place to brainstorm, but I am also eager to hear your concerns directly – please do contact me at firstname.lastname@example.org
Hope to see many of you in Toronto, where I dearly hope that by then it will be warmer and less snowy.
Robert Boland, MD
October 30, 2014
This message is to let you know that all the Psychiatry Subspecialty Milestones have been finalized. The Addictions' Milestones are in the process of being posted and should be available shortly. All the others are posted on the ACGME website, acgme.org.
These milestones are very much on a fast track and will be implemented beginning July 1, 2015. Now is a good time to start planning your Clinical Competency Committees.
There will be a session on Thursday morning, March 5, 2015 at our annual meeting in Orlando devoted to the Milestones for Child and Adolescent Psychiatry.
Chris Varley, MD