Management (week 7 of 8)

For this week's blog, I will focus on the area of management - of yourself, your career, your team and wider service. I have also thrown in some random images of key figures from the history of psychiatry, all of whom did groundbreaking work leaving lasting imprints within our profession. The range of work of these different individuals is interesting from a historical and scientific perspective while also serving to highlight the rich and varied nature of our profession, from the very 'biological' neuropsychiatric work of Alzheimer and Pick through to the psychotherapy and psychoanalysis of Yalom and Storr. Furthermore, scanning over the achievements of any one of them should be enough to fill you with stunned admiration and inspire you to make the most of your career. 

But back to the topic at hand. First and foremost, 'management' is not just for senior clinicians. You should be developing personal self-management and general management and leadership skills from your earliest days as a Trainee.

So always consider the ‘big picture’ in your everyday clinical work, e.g. ‘Why is this clinic so busy?’, ‘Why are there always people waiting to be seen here?’, ‘Are there ways in which we can improve the system to make things better for patients and clinicians?’, ‘What is the purpose of this clinic?’, etc. Asking and answering these questions will help motivate you to optimize your work performance and to make changes to ineffective and redundant practices, thus improving the service for your patients and improving the work experience for you and your colleagues.

Ugo Cerletti (1877-1963), the Italian neurologist 

who first developed electroconvulsive therapy (ECT) 
for use as a psychiatric treatment

Think also in terms of doing small quality improvement (QI) projects that are focused, feasible and with a clear end point and try and generalize the principles to other areas of a service. Think in terms of ‘bottom up’ and ‘top down’ perspectives, e.g. how does a small project relate to national strategy and, vice versa, how can we harness national strategy (e.g. clinical programmes) to develop local initiatives. For any management initiative, big or small, try and write it up, publish it and add it to your CV.

Think broadly in getting support and input from senior colleagues (e.g. Clinical Director) and from allied healthcare professionals; ‘early adaptors’ will jump in and help and their enthusiasm can be infectious and help mobilize others to get involved.

Also consider a formal management course at e.g. Diploma or Masters level, with a group of colleagues. Working with a group will help ensure that you complete the project, that you get the qualification and that the project is feasible and relevant to your particular service.

Alois Alzheimer (1864-1915), the German psychiatrist who first described, 
in a case of presenile dementia, the neurodegenerative 
process that would be named after him

As with teaching and research skills, management skills are developed constantly throughout one’s medical career and vary in terms of scope and complexity depending on your level on the medical career ladder and your personal levels of ambition and initiative.

Effective management skills begin and end with good self-management.  Unless you can safely and effectively manage your everyday clinical workload, you cannot move on to even consider leading a team, supervising junior doctor colleagues or developing and improving the service you provide for your patients.

Management of everyday clinical work should involve the development of one or two key review and new patient clinics during the week during which time maximum energy and resources are applied.  Other parts of the week should be assigned to inpatient work and don't forget to block off protected time for administrative work, teaching, clinical audit, research and service development.

An advertisement campaign in the US for Maytag washing machines used to present the Maytag repair man as someone who (because of the high quality of the product) was never busy or overwhelmed but always ready and alert to respond to crises. Likewise, you should plan your clinical working week as if you were ‘the Maytag man’, i.e. in control, alert and vigilant but never overwhelmed by the volume of problems. (I owe this analogy to Dr. Declan Murray and Dr. Pat Devitt and, I guess, to Maytag washing machines).

The Maytag Man - ready, equipped and waiting 
for the next problem (but never overwhelmed)

And now some for some more history:

Arnold Pick (1851-1924), Czech psychiatrist whose name 
is associated with a variant of frontotemporal dementia 
and some of the underlying pathology 

As outlined above, the weekly timetable should be designed to allow for prioritizing inpatient ward rounds, outpatient clinics (for new, review and emergency assessments) and also leaving time for administration (paperwork, telephone calls, etc.) and clinical and educational supervision time between the Consultant and Junior Doctor. A typical working week in a General Adult Psychiatry service is outlined below.

A diary - get one and use it every day 
(either electronic or an old fashioned paper version)

Monday

a.m. Multidisciplinary community team meeting

p.m. Inpatient ward round


Tuesday 

a.m. Outpatient clinic (reviews)

p.m. Outpatient clinic (new patients)


Wednesday

a.m. Outpatient clinic (new patients)

p.m. Administration work


Thursday

a.m. Emergency outpatient assessments

p.m. Inpatient ward round


Friday

a.m. Teaching and clinical/educational supervision - include time for audit, research, involvement in service development

p.m. Administration

Once you have established a stable bedrock of self-management you can then move on to managing and leading junior doctors and members of the multidisciplinary team, depending on your level of clinical seniority.  At a junior doctor level the key challenge is to work as a member of the team in an effective way, while also leading out on medical related issues.  At a Consultant level there is an expectation to act as the Clinical Team Leader and also in most cases as the manager and overall leader of the team.

Standard advice for those at Higher Specialist Trainee (HST)/Senior Registrar level is to attend management meetings that look at service wide issues and developments. Approach such meetings with a critical eye and a degree of caution and disentangle yourself early if the group is inefficient, poorly led or dysfunctional in other ways. Avoid the pitfall of attending dysfunctional management meetings just for the sake of attendance. An effective meeting/group should have clear terms of reference, useful and achievable goals, a strong chairperson and a membership that is active and takes responsibility. The meeting/group should also have a place in the overall context of service planning and delivery, with clear reporting and feedback lines to all management levels. 

And a few final points...

Remember that individual management styles vary depending on the personality of the individual doctor and I would advise that you become aware of your strengths and weaknesses as early as possible in your career. You may then need to e.g. increase your levels of assertiveness or, at the other end of the spectrum, tone down the intensity of your interactions with colleagues. Try and identify your core values and characteristics and remain as true as possible to these in your dealings with all colleagues, regardless of discipline or level of seniority.

Furthermore, some important basic principles include starting and finishing early, leading by setting a good example, being enthusiastic and open to new ideas and supporting team members in as much as possible. A simple rule to managing paperwork is that you should touch a document only once before it is either disposed of or filed; this simple strategy will help you avoid accumulating anxiogenic piles of paper on your desk (and that general principle applies to management of emails too).

Gerald Russell (1928-2018), British psychiatrist 

who first described Bulimia Nervosa

Once you are confident that your own self-management and team management is optimized you may then consider interactions with other services and outside agencies and you may start to see how your particular service fits in with regional and national strategy and developments.

And finally, some more historical figures, this time from the psychotherapy sphere:

Anthony Storr (1920-2001), British psychiatrist and psychoanalyst and author of 'The Art of Psychotherapy', my very first book on that particular topic

Irvin Yalom (born 1931), American psychiatrist, early pioneer of Group Psychotherapy and author who is still with us and is as productive as ever, his latest book being published in 2017.

Next week, for the last planned blog posting, I will focus on postgraduate qualifications. 

But after that, thanks to the contributions of two Trainees, I will have guest bloggers for the following two weeks, who have written their own personal reflections on how to make the most of your years as a Trainee in Psychiatry. 

Teaching (week 6 of 8)

Active involvement in medical teaching forms another of the key pillars of a medical career. As mentioned in the blog on developing your CV, if you have held a formal teaching role with undergraduate medical students, then emphasize in your CV your key roles and responsibilities and how the experience has helped with your overall career development, e.g. helping your communication skills and helping you keep abreast of new developments. Even if you have not held a formal teaching role, it is likely that you will have had at least some contact with medical students and students from other disciplines on clinical attachments or in delivering occasional lectures and tutorials: think about these experiences and how they have made you a better doctor, and include them in your CV.

Being involved in teaching therefore helps to keep one up to date on new developments and (especially in the case of graduate entry medical programmes) to learn in a two way process about the many different educational backgrounds from where modern medical students come (e.g. different branches of science and the arts).

Teaching also provides a sometimes welcome change and contrast from everyday clinical work and a potential for connection with academic colleagues in the university setting, thus bringing new and alternative clinical perspectives and opportunities for involvement in curriculum development, examining and research. 

Along with improvements in levels of theoretical knowledge and resultant improvements in clinical skills, involvement in medical teaching/education fosters a tendency to engage in more thoughtful and reflective practice, with undoubted improvements in communication skills that are likely to help in working with patients, their families and with colleagues from medical and other backgrounds.

Moreover, while being involved in medical teaching helps keep us abreast of new developments, such involvement can also help us make sense of earlier experiences as a medical student and as a more junior doctor. Sometimes it is only years later that a clinical learning experience starts to make sense and, as the years go by, I have found that there is a tendency to reflect and learn more and more in a retrograde way, based on earlier career experiences. 

Regarding the delivery of teaching, this occurs in a number of ways and with various types of student groups.  In the most classical teaching context, you may be involved in providing didactic lectures for undergraduates in medicine or allied healthcare professions.  Likewise, you may have given didactic or more informal lectures to patient, family or carer groups.  You may have been involved in providing small group tutorials. The likelihood is that you will at least have been involved in having medical students and/or students from other healthcare professions shadow you for their clinical attachments.

A traditional medical teaching context: the lecturer delivers a 

didactic presentation to a large group of passive students

Old fashioned 'bedside teaching': just imagine being the 

unfortunate patient in this scenario

Professor Ronald Harden - a Scottish pioneer in medical education, developing the now widely adopted Objective Structured Clinical Examination (OSCE) and the SPICES model of medical education (Student centredness, Problem-based learning, Integrated curricula, Community based learning, Electives with a core and Systematic curricula)



For more detail on the SPICES model, see link below to my brief article on the topic:

https://www.bmj.com/content/339/bmj.b2779

A modern 'Problem Based Learning' (PBL) scenario, with students taking responsibility for their own learning, defining 'learning objectives' and doing their own self-directed reading between sessions 

‘The three Es’ is another simple and useful rule to bear in mind when planning any individual teaching session or course or indeed in any teaching interaction, however informal and passing it might seem. The three Es relate to desirable characteristics of the medical teacher/educator. 

1. Expertise (i.e. know your material well enough so that you can confidently say 'I don't know' if asked a question to which you don't actually know the answer);

2. Enthusiasm (i.e. even if you're tired, bored or stressed, try and convey to your students that what they are learning is important, useful and interesting);

3. Empathy (i.e. with the educational background of your students, so don't set the bar too high or too low in your expectations for what they should know, but tailor your teaching sessions to build on their current knowledge base and gently bring them along to the next level). 

In summary, the more involved you are in teaching in your everyday work (formally or informally) the more reflective you will be in your own practice, with resultant improvements in your levels of background theoretical knowledge, clinical and communication skills.

Therefore, I would encourage you to examine all areas of your career in which you have been involved in medical teaching/education (think tutorials, lectures, clinical attachments, involvement with written and clinical examinations and curriculum development) and summarize these in your CV.  I would also advise that you pursue formal qualifications in medical education such as part-time Postgraduate Diploma or Masters level courses; the field of medical education is rapidly evolving and teaching methods are likely to have changed significantly since your medical student days (depending on how old you are). Signing up for such medical education courses will force you to take time out from normal clinical activity and focus on the principles and practices of medical education. 

Medical education courses will also likely involve the completion of a research project in the area of medical education, thus additionally helping develop your research, analytic and writing skills and possibly providing you with publication opportunities.

Finally, immersing yourself in the world of medical education will also make you a more reflective, thoughtful and effective clinician and help to keep you open minded and humble enough to realize that your learning and development as a doctor is lifelong and never ending. 

Research (week 5 of 8)

The classic scientific research career is possibly based (unconsciously at least) on the work of individuals such as Newton, Einstein, Darwin or Freud, involving extended periods of research, reflection and writing in a broad range of areas leading to an increasing focus on some key novel and overarching principals and findings. In the case of Charles Darwin, for example, he famously spent five years in his late twenties aboard the HMS Beagle travelling the oceans of the world. He collected huge amounts of data from his observations of animal life and geology, in the form of writing, drawing and animal specimen collections. On returning to England he went on to spend several years longer studying humble little molluscs and other organisms in his own home-made laboratory. He wrote up, published and presented his findings all along. Ultimately, his careful scientific scrutiny, classification and writing, combined with an unintended push from Alfred Russel Wallace (who independently co-discovered the ‘theory of evolution’) led Darwin (together with Wallace) to together publish their grand theory in 1859 and assume their places in the great scientists' hall of fame.

Charles Darwin (1809-1882), English naturalist and co-discoverer of the theory of evolution by natural and sexual selection

Darwin's voyage aboard the HMS Beagle (1831-1836)

Alfred Russel Wallace (1823-1913), Welsh Naturalist and (sometimes overlooked) co-discoverer of evolutionary theory

Map combining the research travels of Darwin and Wallace 

In contrast to the heroic careers of Darwin and Wallace, involvement in modern psychiatric research tends (for most Psychiatrists) to be brief, painful, tedious, trivial and both unrewarding and unrewarded. Starting from this assumption, I would advise that you take a humble and pragmatic approach to engaging in psychiatric research. Think of the end results before you begin, i.e. you may be lucky enough to end up with a few lines of publications in your CV or, at best, an MD or PhD.

If you want to have a research career like Darwin, then stop reading this blog and go to a good university where you can do a very sciencey PhD and then start off on a pathway of several decades of poorly paid post-doctoral research with a university or (better paid) similar work with a pharmaceutical or medical devices company. Please note that you are still extremely unlikely to enter the stratosphere of Darwin, but you will at least be doing full-time ‘proper’ research away from the pragmatic world of clinical Psychiatry.

'I've done NO research!'

In preparing for movement up the different rungs of the medical career ladder, perceived weakness in the area of research causes a lot of undue anxiety among NCHDs in Psychiatry, as already alluded to in the blog on the CV:
https://psychiatry7trainingtips.blogspot.com/2020/04/your-cv.html

And while it is an advantage for interviews to be able to report a successfully completed piece of research or a postgraduate research degree such as an MD or PhD, the importance of research tends to be overemphasized by NCHDs and by Consultants who have been successful in and hence enjoyed this aspect of their career. In fact, in interviews for senior clinical posts, an overemphasis on research at the cost of neglecting to emphasize clinical aspects of career development may be detrimental. And interviewers for particular posts (some of whom are your potential new colleagues if your interview is successful) may be less than impressed at the prospect of working with someone who seems to be preoccupied to narcissistic levels with research to the detriment of good old fashioned honest and collegial clinical work and service development.

Also as already mentioned in the blog on your CV, while some experience of clinical research is helpful for overall career development, it has been my experience that research achievements rank low down in the priority list for interviewers for standard Consultant posts, but there will obviously be much more emphasis on your research record if you are applying for a senior academic post.

I have also alluded in the CV blog that for any research in which you have been involved, make sure to emphasize the ultimate outputs and remember the maxim ‘no research without action; no action without research’, i.e. your research should have important clinical implications and your clinical work should be 'researchable' or at least 'auditable'. Outputs should include academic products such as posters, oral presentations, papers, grant applications and grant awards. You should be able to describe the new skills you have developed from the research journey, such as the use of medical statistics, and the development of skills in literature review and critical appraisal of medical evidence. On the research journey you should also learn how to write clearly and ‘scientifically’ (perhaps for the first time) and learn how to communicate your ideas through poster and oral presentations. Most importantly, you should be able to highlight the clinical relevance of your research and how it has helped to improve patient care and clinical services. Finally, you should describe briefly how your research may have helped in the development of your clinical skills and everyday practice. For example, you may have used diagnostic tools or questionnaires in your data collection that have proven useful in your clinical practice.

So the next time you’re asked in an interview or on a plane journey about the relevance of doing medical research, go above and beyond the ‘bottom line’ and key findings from your particular project and list off the above additional ‘incidental’ learning from being involved in research.

Levels of exposure to research vary widely, from brief and peripheral involvement in a single small project right through to completion of an MD or PhD with associated publications in the medical literature.

The traditional MD or indeed PhD used to involve a Trainee taking a break from their usual clinical training posts and working as a full or part-time Researcher or Lecturer for a period of 2-3 years. Such positions often involved a number of clinical sessions during the week combined with the research project. The MD or PhD was ultimately achieved (or not) in a semi-structured way, through one of two ways. In the more conventional approach, the Trainee would write (and hope to publish) papers based on a literature review of the area of research interest, followed by a proposal for MD or PhD and any necessary application for ethics approval followed by an extended period of data collection (through e.g. clinical interviews, biometric assessments, etc.) and ending with a hurried write-up and submission to the university of their final thesis. The three hardbound copies of the thesis would then serve as dust gatherers on the shelves of the research supervisor, the researcher and the proud mother of the researcher.

In contrast, in more ‘structured’ MD and PhD programmes (traditionally more associated with training in Clinical Psychology), the research project is carefully planned out from literature review through to ethics approval, data collection, analysis and write-up, with the candidate submitting sections of their overall thesis in stages and thus avoiding the last minute rush. Each stage of the research project must be approved by a formal meeting with the research supervisor and relevant individuals in the awarding institute. These meetings serve as useful milestones and prompts for all involved, especially the researcher and the research supervisor. The intensity of the researcher-supervisor relationship is thus diluted and ‘chaperoned’ by the research board meetings, with the responsibilities of both individuals highlighted in the process. Therefore, the research project becomes less a vanity project for the supervisor and/or the researcher and more a collaborative piece of work with a beginning, middle and end. A disadvantage of this type of approach is that there is less flexibility on how the project is completed and less available ‘shortcuts’ for the candidate to take.

So when it comes to planning that ‘research’ part of your career and CV, consider your purposes for engaging in research and your estimated likely outcomes from the process. Consider whether you would like to be a ‘real researcher’ and aim for Darwinian heights or (like most of us) aim to do just enough to have a few paragraphs and discussion points for your CV and for interviews, while also learning some new analytical and clinical skills that will make you a better doctor in the longer term. I would then advise that you consider an area that you are interested in researching and link up with an established researcher or research institute and try and collaborate with them on a current research project or programme that relates to your interests.

Collaboration with an established researcher or research institute means that you may have the opportunity of coming in at a particular and discrete phase of the project (e.g. ethics application, literature review, data collection, analysis or write-up) and not have to plan and execute an entire project on your own from beginning to end. You will also have the benefit of supports from a multidisciplinary research team (e.g. different medical specialties, psychology, medical statistician, librarian support, IT support, etc.). Trying to embark on a big research project on your own or in a service setting that has no tradition or track record of research is likely to lead to a long, lonely and endless voyage (using the HMS Beagle analogy again) with a shipwreck before you get even close to the finish line. In contrast, being involved with an established research team means that you can have a limited but focused input into a project with maximal support and the opportunity to be credited on papers and other research outputs for years after you have finished working with the group.


So that's the research section done - next week, I will be writing about the importance and relevance of teaching experience in your development as a Psychiatrist...

And the upshot of all their travels, research, reflections and writing - 

the joint presentation of Darwin and Wallace at the Linnean Society meeting in 1858

Clinical experience (week 4 of 8)

For this week's blog, I will focus on the area of clinical experience - how to make yourself as useful as possible to your patients while also optimizing what you can learn from your everyday clinical work. I have some guidelines on managing your clinical commitments and then some specific pointers on key areas such as making a diagnosis, biological treatments, mental health legislation and risk assessment. From a historical viewpoint, I've also included some historical images, beginning with good old Bedlam:

A 17th Century iteration of the Bethlem Hospital London

And a plaque at the site of the first iteration...

Back to clinical experience...

It might seem obvious, but clinical experience is the first and most important component of your development as a Psychiatrist. I would advise that you immerse yourself in clinical work from your first day in Psychiatry and get busy. Avoidance of clinical work (for reasons such as lack of confidence, fear or downright laziness) is far more time consuming and stressful than getting stuck in (not to mention being the more professional and ethical approach). You will find clinical work more stimulating and rewarding if you are busy looking for new challenges and not hiding in the wings hoping to avoid work and responsibility. Furthermore, being work avoidant cuts down your chances of learning opportunities and leads to a poor reputation among your colleagues. 

I’m not advising that you work at break-neck speed for the entire week; pacing yourself and working within your limits of expertise and energy is essential. However, there will always be busy times during your week, with certain outpatient clinics or on-call sessions, when it is important to throw yourself into the situation with the hope of helping your patients and colleagues and learning something in the process, assuming that you have an appropriate level of supervision and support from senior colleagues.

Whether you are a CPsychI Trainee or on a CPD-SS programme, you will likely start your career by rotating through a number of different 6 month clinical attachments in a particular training Deanery, geographical area or hospital. As a CPsychI Trainee, your training plan will be mapped out for 3-4 years in advance. If you are on a CPD-SS programme, then you are less aware of where you will be from post to post. However, being on a CPD-SS programme gives you more control over where you work and in what specialty, depending on the current demand and competition for posts.

The majority of your initial posts should be in General Adult Psychiatry with 6 month posts in Child and Adolescent Mental Health Services (CAMHS), Intellectual Disability (ID), Rehabilitation Psychiatry and Old Age Psychiatry once you have a foundation of at least 18-24 months in the General Adult world. Because of the relatively small number of posts nationwide, Forensic Psychiatry and Liaison Psychiatry are more difficult to access but I would recommend that you try and do at least one six month post in each of these areas too.

In terms of longer term career choices, I would strongly advise that you think carefully about the sub-specialty in which you want to work. There is a world of difference between many of the psychiatric specialties, with resultant impacts on your career, quality of life and even your earning potential. Therefore, watch and learn from Consultant colleagues and get lots of experience and advice before you start to focus on one particular area. I say this based on my own experience. After completing my MRCPsych examinations in 2001, I took up a three year research post in Old Age Psychiatry. Before starting down the Old Age Psychiatry route, I asked advice of one Consultant who had experience in both General Adult and Old Age Psychiatry as to what specialty he would recommend. ‘It doesn’t matter’, he said.

Unfortunately, I took his glib advice and followed the Old Age Psychiatry route.  Inspired by my Old Age Psychiatry Consultant supervisor, I began to think of Old Age Psychiatry as being the only specialty for me. I took up my first post as Consultant in Old Age Psychiatry in 2008 but, five long years later, I was glad to leave the specialty and move back to my natural home in General Adult Psychiatry. The reality of working as a Consultant in Old Age Psychiatry in a rural clinical service was very different from the heady days of my research post in Old Age Psychiatry, working with a large and talented team of Old Age Psychiatrists and Geriatricians in a tertiary referral centre. It took two or three years for me to realize that being in a non-academic rural Old Age Psychiatry post would never compare. Even though I was trying my best, working hard and doing as good a job as possible, I was not suited to the area and if I persisted there I’m sure that I would have become unhappy both professionally and personally. Another lesson I learned from this experience was the importance of having at least two or three wise mentors on whom you can call for advice regarding topics varying from career choices to clinical advice on treatment of complex cases - actively look out for such mentors from your early days in Psychiatry and keep in contact with them as you will need them at different times, regardless of what level you're at. 

Remember also the many advantages of working in clinical practice in Psychiatry compared to other medical specialties. While the on-call work can be busy and stressful, it is nothing as stressful in comparison to some areas of clinical medicine or surgery. The weekly hours are also more forgiving, with most services designed along the lines of a Monday to Friday, 9 a.m. to 5 p.m. service. Psychiatry is also one of the few (if only) medical specialties where you have the opportunity to really get to know your patient and their family and help them take care of their overall health, lifestyle and wellbeing.

From the earliest stage of your career in Psychiatry, try and identify what you think are the core areas of knowledge and the essential skills and competencies that distinguish Psychiatrists from other doctors and indeed from nursing and allied healthcare professionals working in the mental health field. Once you have identified these areas, make sure that you work frantically and obsessively on them to the point where you excel.

If I were to boil down these areas of knowledge, skills and competencies, I would say that they are the ability to clarify and ‘defend’ a psychiatric diagnosis, the use of biological treatments (primarily psychopharmaclogy and ECT), a good working knowledge of legislation relating to mental health treatment and, finally, risk assessment. I have outlined these four key areas in more detail below. Once you have mastered these key four areas, then you can build on your repertoire of knowledge and skills. Conversely, until you can diagnose, prescribe and assess risk with confidence, you will struggle.

Therefore, get going on these key areas from the start of your time in Psychiatry. Even if you have been working in Psychiatry for a number of years, reviewing your knowledge and skills in these key areas will help you to continuously reestablish your credentials and help your confidence as a clinician. 

But first, a brief break for some more history:

St. Patrick's Hospital Dublin, opened in 1747 and established using money bequeathed by Jonathan Swift (1667-1745)

Clinical training: four fundamental areas of knowledge and competence

1. Diagnosis:

Confident and evidence based diagnostic assessment comes from careful history taking, collateral history taking, mental state examination and concise formulation. All of this can only be achieved through highly practiced clinical interviewing skills combined with a deep knowledge of phenomenology and psychopathology. And this reminds me of the maxim of my old wood-work teacher in secondary school: ‘It’s not practice that makes perfect – only perfect practice makes perfect’. Sims’ Symptoms in the Mind is a key classic text in this area and the one that I would recommend.

Phenomenology and psychopathology: get a text that you like and read it over and over - as a Trainee, Symptoms in the Mind was my favourite

1911 census data relating to Maryborough Asylum, Queen's County (subsequently St. Fintan's Hospital, Portlaoise, Co. Laois). The diagnostic categories listed in this census entry for residents are not dissimilar to now and they include 'acute mania', 'recurrent mania', 'melancholia' and 'dementia' (the latter referring to 'dementia praecox' or schizophrenia). There's also a case of the now defunct 'mania a potu' thrown in; see link below for more detail:
http://www.census.nationalarchives.ie/pages/1911/Queen_s_Co_/Maryborough_Rural/Beladd/



2. Knowledge of biological treatments:

I would recommend that you obtain a brief manual of psychopharmacology, read and annotate it and then start on a longer one, making a list of what you read as you go along. You could even write brief critiques of these texts and try and get them published as book reviews, thus improving your knowledge levels through systematic reading and adding to your publications list at the same time. Once you have established your favorite brief psychopharmacology textbook, I would recommend that you try and read and reread it every year (mine was always Concise Guide to Psychopharmacology, by James M. Martinez and Lauren B. Marangell, unfortunately now out of date).

Concise Guide to Psychopharmacology, by Marangell and Martinez: my all-time favourite psychopharmacology guidebook, now sadly out of date (2006) - a new edition would be most welcome!

But while waiting for the next edition of the Concise Guide to Psychopharmacology, there's always the ever reliable Oxford Handbook - 

no Trainee should be without their own well read and dog eared copy

3. Legislation:

The Mental Health Commission website (www.mhcirl.ie) provides excellent training modules for all aspects of the Mental Health Act, for beginners and experienced clinicians. I would recommend that you complete these online training modules and use them to inform your everyday practical experience of using the Mental Health Act. Also, print off and get familiar with the actual Mental Health Act, especially the sections relating to involuntary admission. 

4. Risk assessment:

Competent and confident risk assessment is more difficult to learn and comes primarily through the accumulation of the right type of clinical experience, working with Consultants who are calm, measured and methodical in their approach to managing risk. Such Consultants are usually recognizable by their small number of inpatients and infrequent admissions, not to mention a confident and content breeziness in how they manage their everyday work. Try and work with someone like this for as long as possible, watch how they deal with risky and complex clinical scenarios and ask them lots of questions on how they manage risk of self-harm, suicide, neglect and harm to others. Dr. Declan Murray is one such clinician and his overview of risk assessment is well worth a read: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4998936/

Self management

The Psychiatrist, by Jose Perez

As you progress through the MRCPsych and CPsychI examinations and different clinical posts, you will start to develop more composure and control in how you manage your focus and energy during the week. With advancement through to Senior Registrar or equivalent positions, you will have more autonomy to plan and manage your week. As a Consultant, your ability to manage and plan your week will be key to how your service and multidisciplinary team works and, ultimately, the quality and sustainability of the service received by your patients.

At a junior level you will have relatively little control over how your week is planned out. However, if you notice recurring mismatches between the amounts of time you have available and/or your level of expertise and the type of work you are expected to complete then you should highlight this with your Consultant. Most Consultants will be glad to hear constructive feedback on how the service is operating as they will be ambitious and keen to improve things. Therefore, your Consultant supervisor may well agree with you and make the necessary changes. Allowing yourself to work away with an insurmountable volume (e.g. huge outpatient clinics that go on all day) or in areas where you feel undertrained is a recipe for burnout and, unless you have flagged such problems with your Consultant, you may make errors that could lead to adverse patient outcomes and censures for yourself such as complaints or reports to the Medical Council.

Working closely with a multidisciplinary team including Nursing staff, Psychology, Occupational Therapy and Social Work is probably unique to Psychiatry as a medical specialty. Find out early on what each discipline can offer to your patients and enlist the help of these colleagues whenever needed. While the multidisciplinary team functions as a seemingly democratic entity with an equal say from all disciplines, the Consultant Psychiatrist is the clinical lead (as defined in Vision for Change, Department of Health 2006) and is ultimately medico-legally responsible for all clinical outcomes. You should always remember this latter fact when making team-informed decisions about patient care.

During your movement through different 6 month posts there will be times when you feel you are learning and progressing fast and there will be times when you feel like your career is at a standstill. Always try and keep the big picture in mind, i.e. what you can get from this post that’s worth including in your CV; what happens after this post; when will you be finished with your examinations; how is your CV looking at present and what’s your target date for starting as a Consultant (if that is your ultimate aim). As you progress through your career you may even get to a point where you ask yourself how your net contribution to Psychiatry would be viewed if you were to stop working right now, in terms of how you have developed clinical services, advanced research or helped with undergraduate and postgraduate teaching and training.

Clinical note-keeping

Regarding everyday clinical work, it is vital to be clear, comprehensive and concise in your clinical note-keeping. For my current clinical service, I issue this email to all new Non-Consultant Hospital Doctors (NCHDs) at the start of their time working with me.

Dear NCHD colleagues,

Our medical note keeping and medication recording in our service is of a high standard, thanks to the excellent work of our NCHDs. 

However, I think it's helpful to outline again our systems, in order to update clinical notes and medication kardexes as needed, bearing in mind this change in NCHDs and the fact that many of the kardexes in the outpatient files are now in need of updating and there is also a need to review the level of correspondence for each patient between our service and their GP and other relevant agencies. It should also be helpful for our MDT colleagues to be aware of the systems we use, hence I am copying them on this email.

The clinical entry in outpatient files should follow this system, as we are currently using:

Diagnosis (include the ICD code)

Meds.: see kardex (and ensure this is updated on the day of assessment, with generic names and also physical meds included)

Relevant recent results (e.g. Lithium levels, renal function tests, etc.)

Then the SOAP system, i.e.

Subjective problems/complaints (i.e. symptoms)

Objective findings (i.e. on mental state examination)

Assessment (i.e. the clinical impression)

Plan: consider biological/medical, social and psychological aspects. 

Using this system not only ensures clarity and clinically safe note-keeping, but it is also a useful discipline for NCHDs to become familiar with from their earliest days in psychiatric training and will stand you in good stead for your future careers. A clear system also makes our notes easier to interpret by our nursing and allied healthcare colleagues and improves MDT communication. 

3 final points:

1. Regarding the drug kardexes: during the course of clinics, if you come across any kardexes where, due to their length of time in use, there is writing on both sides, please rewrite the kardex. 

2. As we are already doing, please specify the length of your prescription issued and any repeats, along with the prescription book number, e.g. 'prescription issued X 3/12 with monthly dispensing, book 555'. Please also specify if no prescription is needed/issued for a particular outpatient assessment by writing e.g. 'no prescription issued: has supply of meds until next OPD'. This is a helpful practice for our Admin. colleagues dealing with telephone and other inquiries after clinics.  

3. Please also add an extra page or two of continuation notes to the file if your clinical entry ends on the last blank page. 

Regarding the system for communication with GPs and other referrers to our service, please note the following guidelines. 

1. A report is generated for all new patients seen, directly after their initial assessment: see below an outline for this report. 

2. For review patients, please check for correspondence in the file, at the end of your assessment. If no communication has gone to the GP or other referrer in the previous 6 months, then please complete and send one of the proforma review patient summary sheets (see Appendix 1 below).

3. If a significant change is made to a patient's treatment, the GP may need to be informed before the usual 6 monthly update: please check this with your supervising Consultant. 

Regarding new patient assessments, individual clinicians will have slightly different approaches. I have outlined a system below (not in exhaustive detail) that covers the minimum information required in a new patient assessment and gives a structure to how the information is collected and presented in the clinical notes and subsequent report. 

This may also be useful to nursing staff and other healthcare professionals who are conducting new patient assessments. 

Should you have any queries on this, please let me know. I am also happy to do some training sessions on this issue for NCHDs and nursing and other healthcare professionals if needed. 

Format for new patient assessments and reports

History:

1. Demographic details (name, age, date of birth, occupation, marital status, etc.)

2. Presenting problems (nature, severity, etc.)

3. History of presenting problems (duration, precipitants, etc.)

4. Past psychiatric history (drug treatments, admissions, etc.)

5. Family history (family structure, relationships, etc.)

6. Family history of psychiatric illness

7. Personal history (birth, development, education, employment, relationships, etc.)

8. Social history (alcohol and drug use, relationships, etc.)

9. Past medical and surgical history 

10. Current medications (psychotropic and physical meds)

11. Forensic history 

12. Premorbid personality 

Mental state examination:

·         Appearance 

·         Behaviour

·         Cognition 

·         Mood and affect

·         Perceptual abnormalities 

·         Speech and thoughts 

·         Suicidal/DSH/homicidal ideation

·         Collateral history

Formulation:

·         Differential diagnosis (ICD11 codes)

·         Aetiology (consider biological/medical/social/psychological factors)

·         Investigations planned (consider biological/medical/social/psychological factors)

·         Management (consider biological/medical/social/psychological factors)

·         Prognosis

·         Follow-up plan

Appendix 1 - review patient summary           

                                                                

Community Mental Health Centre,

 Street,

Town,

County.

Telephone, etc.

 ___________________                                                       Date____________

____________________             

____________________            

           

________________________                               

                                   

Dear Dr.______________

The above named patient attended our review clinic today.

Diagnosis:_________________________________________________

Medication ________________________________________________

_________________________________________________________

Subjectively: ______________________________________________

______________________________________________________________________________

Objectively: _______________________________________________

______________________________________________________________________________

Impression: ________________________________________________

_______________________________________________________________________________

Plan_______________________________________________________

Yours sincerely,

________________________

Dr.

And one final bit of more local history...

District Asylum, Maryborough, Queen's County completed in 1833 and later to become St. Fintan's Hospital, Portlaoise, Co. Laois 

Next week (week number 4 of 7 in total), I will be covering the thorny topic of research...