Third Year Clerkship Review: Psychiatry

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Introduction

Ahh, third year…when 8-hour lecture days are a thing of the past; when your mornings are early and your coffee is strong; when you work longer and harder than you thought possible, and when it all becomes worth it because you’re finally participating in patient care. Third year, in my opinion, has been the hardest year of medical school thus far. It is physically exhausting. The hours can range from as little as 8 hours per day to as much as a 30-hour overnight shift, but generally land somewhere in the 12-14 hour range. It’s mentally taxing. You’re challenged intellectually on a daily basis, encountering new patient cases, seeing complications of ‘bread-and-butter’ cases you thought were simple, and still having to fit time in to study for standardized tests. It’s emotionally demanding. You finally feel a sense of ownership over your patients; you see firsthand the plight of the sick individual; you struggle to find time for your loved ones outside of work; and it might even be the time when you see your first patient pass away. However, it has also been the most rewarding year. Having an active role in patient care for the first time is truly intangible. It’s humbling, being the first face they see in the day when you wake them up at 0400 for pre-rounds. It’s invigorating when your treatment plan gets validated by the team and you see the patient improve. It’s worth the extra hours when you see a patient you’ve taken care of get discharged after a long hospital stay, who proceeds to thank you for your role in their care.

With your feelings being at the extremes, each rotation can feel like a whole new world. This special MedSchoolInsiders (MSI) mini-series aims to provide a 30,000-ft view of the various clerkships that you will encounter during your MS3 year to better prepare you for your time on the wards.

 

Psychiatry

One day, in retrospect, the years of struggle will strike you as the most beautiful.”

Sigmund Freud

 

Psychiatry is a unique world. It encompasses the management of mental, emotional, and behavioral disorders, but more practically, it introduces you to patients with unique manifestations of identical diagnoses. Though this can be true of other areas, it is more readily apparent in studying and practicing psychiatry. For example, if you have two patients with cholelithiasis, both will have stones inside their gallbladder. Two patients with myocardial infarction will both have some sort of ischemia within their hearts. Two patients with small bowel obstruction both have something obstructing their small bowel. But in psychiatry, two patients that carry the same diagnosis can present in vastly different ways. Two patients with major depressive disorder can range from mild depressive symptoms to inpatient hospitalization for suicidal ideation. Two patients with schizophrenia can range from atypical behavior that is well controlled on antipsychotic medication to command visual hallucinations telling them to harm themselves and/or those around them. In this way, psychiatry is different from every other rotation you will go through during your third year of medical school. Whether you choose to go into psychiatry or not, it is both a unique and extremely valuable experience.

 

The Rotation

As with most other rotations during your third year, you can expect to encounter both inpatient and outpatient psychiatric settings. I cannot speak to the variety of curriculums at other institutions, but at ours, we had 3 weeks of inpatient and 3 weeks of outpatient care. Full disclosure: Psychiatry was my first rotation of third year, meaning I had yet to figure out solid note-writing or presentation skills. So in addition to being thrust into this unique world of psychiatry, I was simultaneously navigating the new requirements and stresses of third year. I mention this because I fully recognize that some of what I write may be influenced by my experiences, though I do try to remain as objective as possible!

Inpatient: I’ll be the first to admit that I did not even know an inpatient psychiatric ward existed outside of “asylums” or “mental hospitals”. You may be surprised to figure out that most hospitals have a psych ward on the premises…if you’re not surprised by this, try not to chuckle at my naivety! Inpatient psychiatric stays are warranted for patients that are a danger to themselves, to others, or are so mentally ill that they cannot adequately meet their basic physiologic needs (which, ironically, also are the criteria for involuntary holds). I would lump these patients into 5 categories:

  1. The elderly population with severe neurocognitive disorders like Alzheimer’s or dementia
  2. The psychotic patient population: usually younger (20s-50s) patients that have severe, uncontrolled symptoms
  3. Suicidal/homicidal patients suffering from a variety of diagnoses
  4. Inpatient drug/alcohol rehabilitation. Not all hospitals are equipped with wards for this; or if they are, students may not be able to rotate within this niche area.
  5. Inpatient psych consult. These are patients not on the psych ward that warrant a psychiatric consult for reasons including severe depressive symptoms, hallucinations, suicidal ideation, or severe agitation.

If you are allowed to submit preferences prior to the start of your rotation, I would recommend obtaining as broad of an experience as possible. Inpatient psychiatry can be intimidating at first (it definitely was for me), but observe and learn from your residents and attendings, and get as involved as you can!

Outpatient: The outpatient psychiatric experience helps patients maintain control over their psychiatric illness(es). You will learn how to manage care for psychiatric patients long term including making medication adjustments, balancing side effects, and learning how to appropriately counsel patients that have a change in symptomatology. These are valuable skills to have, as you will encounter psychiatric medications in every other specialty; so knowledge of the medications and their adverse effects is crucial information. I did find some aspect of outpatient psych difficult to immerse myself into, as these patients often have long-term, trusting relationships with the primary psychiatrist that they are there to see, making it somewhat difficult to be fully involved. That being said, respect their boundaries and be proactive about trying to see new patient referrals to your clinic. Make it a point to learn ‘red flag’ symptoms in the patient history that would require escalation of care.

A note about student wellness: Some patient stories can be triggering to students rotating through psychiatry due to similar experiences in their own life. Be open with your faculty if you encounter this problem – they will understand! Do not hesitate to pull yourself out of a patient encounter if it is going to hinder your ability to objectively listen to and treat a patient, or if it will negatively affect your mental wellbeing later on.

 

Tips and Tricks

  1. Don’t be afraid of ‘difficult’ patients. The world of mental illness affects us all in some way or another. Many mental illnesses carry stigmata or have been overdramatized by mainstream media or Hollywood productions. Do not be afraid to get involved with patients regardless of their diagnosis. This is your education, and competent mental health care is an exploding need throughout the nation.
  2. Know your limits. Because you are participating in the care of these patients with mental health struggles, you may find yourself in a position where counseling them on a certain subject may be appropriate. But remember, you are not a psychiatrist, and you likely do not have experience in counseling patients. Be involved, but know your limits!
  3. Get to know the pharmacology. I cannot stress this point enough – it is extremely high yield information for the rotation, the shelf, your other rotations, and for life.

 

“Show me a sane man and I will cure him for you.”

-C.G. Jung

 

The SHELF

As mentioned in our other Clerkship reviews (Pediatrics, Medicine), you should absolutely check out the NBME website that breaks down the questions on the various Shelf exams, found here for Psychiatry. Per that website, the large majority of patient vignettes will take place in the ambulatory care setting (65%), with the Emergency Department comprising another 20-30%. That leaves just 5-10% of vignettes for the inpatient setting. Take this into account as you proceed through the rotation.

The best study advice I have for this block would be to tease out the nuances between different diagnoses. Many of them have identical symptoms, yet they are two different diagnoses based on the duration of symptoms. Though it may seem like a small deal, that could be the difference between a right and a wrong answer on the test. Familiarize yourself with what separates similar diagnoses so you will be able to do so on the exam. Furthermore, as mentioned at least 3 times previously in this post, familiarize yourself with the pharmacology for this block, especially side effects and contraindications to certain therapies. Handling these for your patients, asking thoughtful questions on rounds, and truly understanding the decision-making process that your residents and attendings use in practice will stick in your head much better than a couple of pharm tables from UWorld ever will!

 

Study Resources

As with all rotations, UWorld will continue to be high-yield. There is a very reasonable number to accomplish over your rotation – it was only 165 at the time I wrote this post. You will likely need to supplement your UWorld mastery with other study resources:

 

  1. First Aid for the Psychiatry Clerkship was a fantastic resource for me and many of my classmates during this rotation. It is short, succinct, and easy to read. It does not go into too much detail but still covers what you need to know.
  2. Case Files has its standard format of 60-ish vignettes that take you through the nuances of diagnoses and treatment. If this format has worked well for you for other rotations, it will likely work well on this one as well. Personally, I found it to have an excessive amount of detail.
  3. Pretest could be very useful for this block since the total UWorld questions for Psychiatry is less than other blocks. Pretest can supplement the total number of questions to get the repetition you need to succeed on the shelf.
  4. Online Meded will, again, provide you with videos, audio and awesome lessons from Dr. Williams to help you remember high-yield facts about psychiatry. At the time of this blogpost, there are 5.6hrs and 21 videos of Psychiatry content – great for watching during your morning breakfast or playing on your speakers during a commute! It is a fairly passive way of learning, yet some mnemonics and organizational tools still are stuck in my head. The videos and accounts are free, but they also offer other paid resources that you can explore on their website.
  5. If you have struggled with Shelf exams in the past, do not hesitate to ask MedSchoolInsiders for help! We offer an array of resources and tutoring from experienced physicians, who scored in the top percentiles of their class, to help you better prepare for this Shelf.

 

Reflection

Psychiatry was intimidating to me at first. On the third day of my rotation, a patient randomly started screaming at the top of his lungs, threatened my life, and slammed a door in my face. Prior to the rotation, previous students had warned me that we cannot wear ties on the rotation, as it’s a potential “choking hazard” or could be used as a weapon. Because of these reasons, I was definitely nervous about the rotation…but that rapidly changed. When I discharged my first patient from the inpatient psych ward, seeing the gratitude on their faces was invaluable. You can really hone your history-taking skills on this clerkship and truly give a patient the time to talk with you in-depth about their problems, which is often therapeutic in itself. It also provided me with the unique opportunity to reflect on my own experiences with regard to mental health and realize that there is a very fine line between myself and my patients – we are not so different after all. In this sense, it brought a newfound empathy for those who suffer from mental illness and broke down previous predispositions that I may have had towards patients with mental health. I am truly thankful for my time on the Psychiatry rotation and will carry many of the skills I learned throughout my career.

 

Final Thoughts

Psychiatry is emotionally and mentally challenging but provides a unique opportunity for understanding mental illness like you never have before. Master the intricacies of lengthy patient interviews and writing the most detailed notes you will ever write. Be introspective on this rotation and speak up if you need to remove yourself from a patient encounter if it is triggering to you. Cherish the unique perspective it will provide to your patient care, and approach it with an open mind to help breakdown any predispositions or stereotypes you may have toward the field or its patients.

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