Guest blog: part 1 of the Dr. Kevin Lally trilogy; telemedicine and telepsychiatry

Following on from the successes of guest bloggers Dr. Diarmuid Boyle and Dr. Noreen Moloney over the past two weeks, I'm delighted to introduce another guest blogger this week, Dr. Kevin Lally. 

Kevin is a Higher Specialist Trainee (HST) with special interests in Academic, Addiction and Liaison Psychiatry. He graduated from the University of Limerick Graduate Entry Medical School in 2014 and completed Intern training in the University of Limerick hospital groups. He stayed within the Midwest region for most of his Basic Specialist Training and spent an enjoyable year as University of Limerick Clinical Tutor in Psychiatry. 

Prior to his medical career, Kevin worked in a variety of fields from beekeeper to computer programmer. 

Kevin has won countless prizes for his research presentations in recent years and he is currently completing a postgraduate qualification in medical education, an area that he has also embraced enthusiastically and in which he has also excelled. 

I asked Kevin about artistic accompaniments to his blog and he suggested 'anything from Edmund Dulac'. Dulac (1882-1953) was a French-British artist, illustrator and stamp designer whose style has been described as 'Art Nouveau fantasy'. I had never heard of Dulac nor seen his work but, as you will see below, there is something very special about it.

Over the past few months, Kevin has been working hard with colleagues in UL to design a teaching programme for medical students for the coming academic year that will be feasible and effective in our ongoing pandemic world. The topics of medical education and postgraduate psychiatric training during COVID-19 will be covered in the next two blogs. 

Kevin has also reviewed the options available to healthcare workers and their patients to help keep clinical services functioning and that material is covered in this first blog.

So many thanks Kevin for this very comprehensive, helpful and timely piece - and now it's over to Kevin (with artistic support from Mr. Dulac!)

Telemedicine and Telepsychiatry

Telemedicine and in particular, telepsychiatry has been looming on the horizon for a number of years. Subspecialist services, for example, Child and Adolescent Addiction Psychiatry have viewed telepsychiatry as a practical and pragmatic approach to increasing the range of their services and addressing inequities in access especially amongst patients living in smaller towns around the country. You can listen to a discussion on this topic from members of the College of Psychiatrists of Ireland here: https://www.irishpsychiatry.ie/blog/telepsychiatry-dr-john-hillery-and-dr-bobby-smyth-on-rte-radio-one-drivetime/.

Many services have found telepsychiatry thrust upon them in recent months and have tried to rapidly adapt. While phone calls and occasionally video conferencing have been used by staff members to discuss clinical or team matters for decades the application of such technologies to patient encounters is significantly less common. A helpful review published online in 2013 in The American Journal of Psychiatry can be found here:https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2012.12081064

There are several key considerations:

• ·        Software / technical issues

• ·        Setting up an appropriate environment

• ·        Documentation

• ·        Clinical Indemnity

• ·        The patient’s perspective

Software

Many Psychiatry MDTs are using either Microsoft Teams (https://www.microsoft.com/en-ie/microsoft-365/microsoft-teams/group-chat-software ) or Zoom (https://zoom.us/) to facilitate MDT but there are varied approaches across the country.

There are a variety of different software tools in use and some guidance from a HSE body on same: (http://www.hsedigitaltransformation.ie/content/mental-health).

More recently the HSE has launched Attend Anywhere for Healthcare Provider video consultations: https://healthservice.hse.ie/staff/coronavirus/working-from-home/virtual-health/attend-anywhere-healthcare-provider-video-consultations.html

The HSE has also mentioned some other software is acceptable to use in certain circumstances:https://healthservice.hse.ie/staff/coronavirus/working-from-home/virtual-health/virtual-health.html

 

Informal enquiry amongst Senior Registrars across Ireland reported the following software in current use:

·        Zoom https://zoom.us/

·        Skype for business / Microsoft Teams https://www.microsoft.com/en-ie/microsoft-365/microsoft-teams/group-chat-software

·        Siilo https://www.siilo.com/professionals

·        Blue eye https://hse.blueeye.video/login

·        Cisco Webex https://www.webex.com/

·        WhatsApp https://www.whatsapp.com/

And the following used in General Practice

·        Nuahealth https://www.nuahealth.com/ (used in General Practice)

·        Doxy.me https://doxy.me/  (used in General Practice)

The College of Psychiatrists of Ireland has not issued (to my knowledge to this current date) specific guidance on the technical aspects of patient video conferencing.

The Medical Council’s Guide to Professional Conduct has a short section (43) on Telemedicine that is essential reading for anyone engaging in this activity. https://www.medicalcouncil.ie/news-and-publications/reports/guide-to-professional-conduct-ethics-8th-edition.html

Setting up an appropriate environment

In ideal circumstances the clinician implementing videoconferencing (VC) would have access to a reliable software that meets the medico-legal requirements of their employer, reliable broadband and a private, well-lit room with neutral background to conduct video calls. An initial question will be whether you are conducting the session from your normal place of work (e.g. your office in the Community Day Hospital) or from home due to perhaps self-isolation issues. Practical considerations are other household members consuming bandwidth concurrently (online gaming, Netflix, YouTube etc. etc.) or the wi-fi signal being weak.

A rule of thumb would be to dress and conduct yourself as you would in person during a VC review of a patient. Paraverbal communication, body language and facial expressions are all important in the psychiatry interview so video conferencing if reliable is preferable to audio calls alone.

While family or pet interruptions during BBC news interviews are humorous https://www.youtube.com/watch?v=Mh4f9AYRCZY they are likely to be inappropriate for the clinical setting. For this and other reasons I will discuss it is preferable to conduct clinical sessions from the workplace rather than from home.

Documentation

As doctors our patient notes should be up-to-date and accurate. The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Professionals: https://www.medicalcouncil.ie/news-and-publications/reports/guide-to-professional-conduct-ethics-8th-edition.html has a specific paragraph with regard to telemedicine. 

“If you are working in out-of-hours services, or telemedicine, you should make every effort to ensure that any notes you make about a patient are placed in the patient’s medical record with their general practitioner as soon as possible (see paragraph 43).”

This would be another reason why it is preferable to conduct telemedicine from your normal place of employment rather than home as you have access to the clinical records.

Clinical Indemnity

Issues relating to clinical indemnity will vary from clinician to clinician depending on their role and responsibilities as well as the expectations from the service. One indemnity service has published some brief advice for their members to consider: https://www.medicalprotection.org/uk/articles/covid-19-and-remote-consultations-how-we-can-help

In early March it looked likely that Trainees in Psychiatry would be redeployed to other parts of the Health Service due to exigencies https://healthservice.hse.ie/staff/coronavirus/policies-procedures-guidelines/redeployment-of-staff-during-covid-19.html but to my understanding this has not happened to any great degree. This obviously would have ramifications for an indemnity point of view.

The patient’s perspective

It has been difficult to capture the patient’s perspective on telemedicine during COVID-19. Prior work had suggest that telemedicine is in general effective and efficient with patient satisfaction levels similar to those of face-to-face contacts: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5629741/

The Mental Health Commission has made recent amendments to their tribunal procedure to allow remote assessment of patients by the Independent Psychiatrist through WhatsApp: https://www.mhcirl.ie/File/guidancedoc_MHT.pdf therefore maintaining their right to a legal and timely Mental Health Tribunal.

The Royal College of Psychiatrists have reported that while crisis and emergency assessments have increased, routine and elective assessments have reduced. They are anticipating a “tsunami of mental illness” due to COVID-19. While this doesn’t directly address patient’s perspectives on telepsychiatry we can infer that for multiple reasons uptake in telepsychiatry during this pandemic is insufficient: https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2020/05/15/psychiatrists-see-alarming-rise-in-patients-needing-urgent-and-emergency-care

Come back next week for part 2 of the Dr. Kevin Lally trilogy, covering the topics of medical education and postgraduate psychiatry training in pandemic times.

Guest blog: Dr. Noreen Moloney, on making the most of your Senior Registrar/HST years

For this week's guest blog, I am delighted to welcome Dr. Noreen Moloney. I asked Noreen to contribute because I knew that she would produce a really comprehensive and thoughtful guest blog, which is exactly what she's done.

Noreen graduated from the University of Limerick Graduate Entry Medical School in 2013. She entered the Midwest Vice-Deanery Psychiatry BST programme after her internship, at University Hospital Limerick. Before entering Higher Specialist Training (HST), Noreen had an extremely productive time working as Clinical Tutor in Psychiatry at the University of Limerick for 2 years. She is due  to complete her HST in 2 years, ultimately hoping to work in Rehabilitation Psychiatry.  She has co-authored a Psychiatry textbook that is due to be published later this year and she has a number of other academic publications, along with medical device patents that she holds from her previous life in Research and Development Engineering.  

And for some colour - and lots of mood - I've dipped into that JAMA link again for this blog: 
https://sites.jamanetwork.com/art-and-images-in-psychiatry/

This week I've included some examples of the work of Norwegian artist Edvard Munch (1863-1944). Munch famously said that he had 'inherited two of mankind's most frightful enemies - consumption (tuberculosis) and insanity', along with suffering the devastating loss of his sister Sophie (also from tuberculosis) when she was only fifteen. Two of the paintings included below relate to Sophie - The Sick Child and Spring and one is inspired by another Sophie.

I've started with the most famous Munch painting (curiously, not included in the JAMA series but so famous that it has now been emojified), then moved on to a few less famous ones and ended with (in view of our current pandemic) two very zeitgeisty Munch works.

So here's Noreen...

When you talk to Consultant Psychiatrists about their Senior Registrar years, they practically well up as they remember those carefree days!  OK, not quite...but you get the point. In this week’s blog we will discuss how to make the most of your HST years, thus paving the way to landing your first Consultant post. 

First, let’s get the application process and other technicalities out of the way.  Applications for Higher Specialist Training (HST or Senior Registrar) posts are accepted by the College of Psychiatrists of Ireland (CPsychI) in January each year with centralized interviews typically taking place in late February. Trainees who have successfully completed Basic Specialist Training (BST) with the College of Psychiatrists of Ireland (or have equivalent overseas experience) are eligible to apply. There are separate application forms and interviews for Adult Psychiatry related specialties and for Child & Adolescent Psychiatry (with or without a Special Interest in Intellectual Disability). You may apply and be interviewed for both streams. Successful candidates have an opportunity to express preferences for available Senior Registrar posts; posts are filled based on interview ranking and any other training considerations from the CPsychI. Candidates are informed in advance of their placements for the entire duration of HST. There is an opportunity to change your mind each year.

Higher Specialist Training usually lasts for three years for certification in a single recognized specialty and four years if dual certification is pursued. Following the successful completion of HST a Certificate of Satisfactory Completion of Specialist Training (CSCST) in your specialty/specialties is awarded. Specialties recognized by the Medical Council are Adult Psychiatry, Psychiatry of Old Age, Child & Adolescent Psychiatry and Psychiatry of Learning Disability.

Let’s now explore some tips and tricks to ensure you get the most from your HST years.

The Scream (1893)

The 'emojification' of Munch's haunting image

Ashes (1894) - thanks to Sophie O'Connell for this suggestion

Clinical areas

You’ve passed all your exams, you know stuff, lots of stuff, so be confident in that knowledge. The HST years provide an opportunity to hone your clinical skills but more importantly to develop and hone your decision making skills.  You are operating as a “Junior Consultant” with that wonderful safety net in-situ for when it all gets a bit too hairy and scary. On-Call can be a bit daunting as you operate as first-on-call for your Consultant.  It takes a leap of faith to trust and rely on a second hand account of a situation by a junior colleague over the phone, perhaps at 4 a.m., and be able to make a decision based on that information.  Certainly, for my first few calls, I had to resist the urge to say “ok, I’ll be there in five!”  Remember, you have an obligation to “teach and develop” your junior colleagues in an on-call situation so encourage them to be methodical and succinct in relating their assessment over the phone and encourage them to have a management plan in mind.  Ensure their risk assessment is thorough.  One more thing, never be afraid to ask your colleague to go back and clarify something.  I always like to get a collateral as well.  Sometimes there is resistance to getting this late at night but I always justify it by saying …”if a patient is sick enough to present to the psychiatric services out of hours, there is a concerned relative or friend out there somewhere that we should be engaging with”.  If a patient refuses to consent to this contact, it needs to be clearly documented.  In cases where a patient is suicidal, homicidal or a danger to others a breach of confidentiality needs to be considered.  This is probably above your pay-grade so call your Consultant at this point.  As a matter of fact, call your Consultant at any stage.  They will not think less of you for doing so, believe me.  It is a good idea to give feedback to your on-call junior colleague; this can be done in real-time or later as appropriate. 

The Sick Child (1885-1886)

Spring (1889)

Management skills

Where possible attend (and participate in) Consultant meetings, management committees, quality & service provision working groups etc. etc....Get to see and understand the nuances and challenges of running a psychiatric service.  Suggest improvements; volunteer to head up quality improvement or service development initiatives.  In essence, be thinking CV and Consultant posts all the time and start populating that CV from day 1 of HST so that you can demonstrate a commitment to engaging in management activities over a period of years.  Also, keep in mind that these projects probably can be published or presented in some forum; that’s another line in your CV.

Anxiety (Angst) 1894

Research

As part of your HST, you will be required to do research.  See also the earlier blog:
https://psychiatry7trainingtips.blogspot.com/2020/04/research-week-5-of-8.html
When it comes to research - do not panic!  You do not need to find a cure for depression or develop a new drug to treat psychosis.  You need to identify an area where you can add, in some way, to existing knowledge by systematically gathering information, analyzing that information, drawing conclusions and publishing that information.  If you can identify a modular project, all the better.  By modular, I mean a project that forms the basis for another project and another and so on.  This way for the minimal amount of effort, you maximize the outputs and maximize the number of publications.  It is really important to identify a research supervisor who is engaged and interested and who will drive you forward so devote some time to thinking about this before you start.  Do not be afraid of seeking ethical approval or presenting to ethics committees; they are there to maintain standards and often can help you by making suggestions or tweaks that make your research outputs even better.  People often get tied up in knots about statistical analysis…. Don’t…. often we overcomplicate analysis to the point of making the research inaccessible or even meaningless. Again, seek advice on statistical analysis early.

The Sun (1912-1916)

Special interest sessions

Enjoy the great freedom of being able to devote a half-day per week to an area or areas of “special interest”.  The list of potential areas is extensive.  From subspecialties like forensic, liaison, addiction, perinatal, rehabilitation, ADHD to teaching, writing, auditing, service provision…. the list goes on.  This is a great way to gather diverse experiences as well as explore and develop your own interests.  You will never have this opportunity again so, use it!  It could very easily steer your career in a different direction or teach you something valuable about yourself. 

Teaching

Whenever you get a chance, take the opportunity to teach, be it as a formal psychiatry tutor or guest lecturer or during the course of your clinical work.  It is a really good way to stay current, to explore subjects, to impart knowledge to “the next generation” and also to learn yourself.  It is also important for any job you go for in the future; get as much and as diverse experience as you can so that you can nicely populate that section of your CV.  If possible, seek out a formal qualification in clinical teaching.  There are an increasing number to choose from (taught and online) and you may be able to use your NDTP / HSE training support scheme CPsychI SR specialist training fund to pay or partially pay for it. You could also consider taking a year out of HST to teach and/or gain a qualification in clinical teaching; some even combine this with pursuing research in their chosen area. 

Self Portrait Between Clock and Bed (1940-1942)

Curriculum Vitae

Make your CV a living document.  See also the earlier blog: https://psychiatry7trainingtips.blogspot.com/2020/04/your-cv.html

Keep it on your desktop and update it several times a year or whenever you have achieved something significant.  It is a good exercise to periodically review it against what you think a good “Consultant CV” might look like and plan to fill whatever gaps you identify.

Learning Outcome Attainment Grid

I have yet to meet a trainee that delights in the completion of “the grid” (Learning Outcome Attainment Grid to give it its proper title), although I do admit to a certain satisfaction in ticking stuff off.  Like-it or loath-it, it is the college’s way of ensuring that the competencies you need in order to be a safe specialist are achieved.  My advice is to be “all over it” from day one.  If you are dual training and have a 4-year HST you need to aim to complete the grid by the end of year 3 or early in year 4.  If you are on a 3 year programme, you really need to be finishing it up early in year 3.  This allows you breathing space for your final ARP (Annual Review of Progress) and time to address any deficits.

Structured Assessment of Psychotherapy Expertise

Your Structured Assessment of Psychotherapy Expertise (SAPE) takes a long time.  Its 24 sessions so start early in the HST process as clients may well pull out of therapy for any number of reasons and you need to have that time buffer to complete the process with someone new. 

The Night Wanderer (1923-1924)

Personal Study

Identify time in your weekly schedule for personal learning.  Set aside an hour or more to read the latest edition of a psychiatric journal or enroll in an online course or just dip into your Maudsley or trusted psychiatry textbook for a refresher.

CPSychI Special Interest Groups

There are a number of Special Interest Groups (SIG) within the College and it is a good idea to get involved with one or more of these.  SIGs are very open to participation from trainees.  Not only does it give you a chance to explore the work and reach of these groups, it also informs you on the workings and governance of CPsychI groups.

SR Colleagues

While there are great benefits to being a Senior Registrar, it can be a bit of a lonely road as you are neither firmly in the Junior Doctor nor the Consultant camps! You need to take every possible opportunity to keep in contact with your SR colleagues, especially if you are physically removed from other SRs.  Do this via Balint sessions, conferences and other meetings, SIGs, WhatsApp, Zoom etc. etc.  It is important to have a network of peers to run things by, get advice from and share experiences with.

Good luck!




So many thanks again Noreen for your very helpful blog contribution and I will finish with some pandemic-related art by Edvard Munch...

Self Portrait with the Spanish Flu (1919)

Self Portrait after the Spanish Flu (1919-1920)

Guest blog: Dr. Diarmuid Boyle, on making the most of your early/BST years in psychiatry

This blog started with two introductory posts and then moved on to cover the areas of CV development, clinical experience, research, teaching, management and postgraduate qualifications. Over the past few weeks I have had very helpful feedback from numerous colleagues, especially those working in Laois-Offaly and in the Midwest. Overall, the blog has had over 1,600 reads, in over ten countries and on four continents.

And now I am glad to add on two extra guest blogs. This week's guest blog is written by Dr. Diarmuid Boyle, who is coming to the end of his Basic Specialist Training with the UL Midwest Deanery. Diarmuid has written a really useful and comprehensive reflection on his experiences during his first 3-4 years in psychiatry, and he has also demonstrated very impressive writing skills, possibly drawing on his origins in north Kerry, a traditional hotbed of penmanship.

To complement Diarmuid's piece, I have dipped into a nice JAMA resource entitled 'Art and Images in Psychiatry' https://sites.jamanetwork.com/art-and-images-in-psychiatry/ Here you will find a fascinating collection of paintings by various artists, relating to different aspects of psychiatry. 

Such is the quality of the collection that it is impossible to chose just a few samples. Instead, I have gone with the paintings of one artist only, Vincent van Gogh (1853-1890), who produced a series of masterpieces in his short and troubled life that highlight the triumph of his spirit and genius over the psychiatric problems that haunted him. You will note that all of the included paintings were completed within a year of his death. 

So I would like to again commend Dr. Diarmuid Boyle on his guest piece and thank him sincerely for this very valuable contribution to the blog.

And here's Diarmuid...

My name is Dr Diarmuid Boyle. I am in my 3rd year of the BST psychiatry training programme. I am due to finish the BST in July 2020. I have been accepted onto the HST starting in July. As I have managed to get through the BST with relatively few scars and no criminal record, Professor O'Connell has asked me to share my thoughts on how to make the best of the BST years.

I hail from Kerry and originally graduated as an engineer many years ago from the University of Limerick. The ESB kept me gainfully employed for most of the intervening years. After getting my fill of running around power stations and working in energy trading and project management it was time to find a new challenge. I graduated from UCD School of Medicine in 2016. I did one year as an intern mostly in Tallaght hospital and then started straight onto the psychiatry BST scheme.

Nearly 3 years in I have to admit that they have been the most eventful and interesting 3 years of my life so far. Before this my perspective  on life, people and society was blinkered by the soft padded walls of my safe and relatively mundane middle class upbringing. In psychiatry every day brings a revelation. Everyday a patient with a personality disorder (or insert any other disorder here) walks into my office and metaphorically (and some days literally) kicks a large gaping hole in my cloister walls. A little bit more light comes shining in with all its shining colour and chaos. I won’t bore you with the stories because if you are in this field you all have the same ones. Suffice it to say in the last 3 years I have been hugged, kissed threatened and assaulted,. I have had to wrestle a scissors from a patient actively and violently stabbing herself in the neck. I have been involved in a murder investigation. I have laughed and cried (multiple times). I have interviewed paedophiles, celebrities, drug addicts, business women, house husbands, and of course multiple Jesus’s. I have loved every minute of it. If you work in psychiatry you will have the best stories for the pub by far (which of course you will never be able to tell). I could not imagine myself doing anything else. The life of a surgeon or cardiologist is positively humdrum in comparison. For what it is worth here are my thoughts on the BST years.

Training Scheme

The training scheme is organised by the College of Psychiatrists of Ireland. There are 3 mandatory exams. Get them done early. The realisation that these were my last exams ever was a real motivation to get them completed. A life without exams can seem an unimaginable utopia to those weighed down by years forging through an oppressive doctor training scheme. Trust me, the end is so close and it is wonderful. Do this for you and your family. You can also do the CASC exam organised by the Royal College of Psychiatrists. Getting this membership may make working abroad if you are so inclined easier. I tried it once and failed. I may try again.

On Call

I will be glad to see the back of the dingy on-call rooms. Those rooms with beds, room temperatures and noise levels deliberately set by hospital management to keep you awake all night. I wonder if I will every unlearn the Pavlovian response to pager and nokia ring tones that set my heart racing and my gastric juices mining for ulcers within seconds of them going off. It doesn’t even have to be my pager, any pager within an audible distance will do. This can make for an uncomfortable day when you work in a hospital. Being on call however is invaluable experience. Do not waste this opportunity. Your first few calls will be difficult, stressful and thoroughly uncomfortable affairs. However this will quickly change as you learn the ropes. This is where you will learn the skills to confidently gather information, weigh it up and make a decision. These are skills that you will need to be independent in by the end of your training. Be thorough with your assessments. After all you have nowhere else to go. I cannot stress enough the immense learning experience being on call is. Don’t waste it drinking tea in the res.

Asylum at Saint-Remy, 1889

The Courtyard of the Hospital in Arles, 1889

The Hall of Asylum, 1889 - not from the JAMA resource 

but included here because it just reminds me of being on call!

Specialties

I have been struck by the number of conversations I have had with consultants expressing regrets about not having had experience in a particular psychiatry specialty. Patients can so easily highlight your lack of expertise in an area and leave you fumbling for the Maudsley guidelines or sifting through your rolodex for a colleague to ring. Your BST years are really your only chance to sample a wide variety of specialties. The experience gained in each specialty will be with you for a lifetime as a consultant. Most people don’t know what specialty they would like to work in as a consultant. Please don’t be shy. It is important to push for experience in areas you think you would like. By the time you are applying for the HST you will have decided what specialty route you are taking. From the first day of your BST scheme you need to be an effective advocate for your future career and try and get experience in specialties that you want.

Research and Audits

I have one simple rule for research and audits. Never say no (within reason obviously). You will be presented with numerous opportunities to do research and audits. As a trainee it is important to take opportunities as offered from colleagues. You can always decide to step aside from a project later. Often these opportunities will not work out but maybe 1 in 5 will. Trainees often complain about lack of research opportunities when in reality the issue is that they do not recognise and take these opportunities when they are presented to them. So be vigilant and don’t be too picky. You can find the cure for schizophrenia next year. Now is the time to learn your trade by working with colleagues who have experience in this area.

Learning outcome grid

The learning outcome grid can seem daunting when you first see it. How can you possibly tick off every box in this 38 page behemoth of a document. Just be diligent. You have literally years to finish it. Don’t stress, don’t leave it till the last minute.

Consultants

Consultants come in all shapes and sizes. You will have to work for at least 6 and probably a lot more if you consider on call work, the inevitable locums and the odd nervous breakdown. The rule is the consultant is always right. You may disagree with them but always be aware that there is so much that you don’t know. To quote Donald Rumsfeld, the “unknown, unknowns” are what you need to be wary of while being a trainee. You need to foster a healthy sense of self-doubt in your abilities. Consult your consultant even when you are nearly sure. You will be surprised how often you get a different perspective and course of action as a result. You are a trainee after all. You may be certain of a treatment or plan but always remember there is so much that you don’t know and even more dangerous so much you don’t know you don’t know. So for now the consultant is always right.

Portrait of Dr. Gachet, 1890

Self-Portrait with Bandaged Ear and Japanese Print, 1889

Look after yourself

You will get stressed. You will feel overwhelmed. You will be treated unfairly. You will be verbally abused. This will take its toll on you. Be able to recognise when it does. If you think it won’t then most likely you need to work on your self-awareness.

It is good to talk. Find a confidant, a colleague, a friend or a family member. Practice self-care even if you think you don’t need it. I have very deliberately prioritised 5 areas of my life that come before work. I only half-jokingly call them my 5 pillars of happiness. I first try to ensure I am getting exercise, have a good diet, am sleeping well, spending time with family and friends and get some time for myself. After these comes work. You will be a much better psychiatrist if you put psychiatry at least 6^th on your list of life priorities. Your job is mentally, physically and emotionally draining. You need to look after yourself first.

In this blog post I tried not to regurgitate the same advice you have heard many time before. This is not a step by step guide on the requirements for fulfilling the BST training scheme. I have deliberately kept the advice a little bit left of field. So hopefully it at least presents a different perspective. Everyone will have their own. And unlike when it comes to dealing with consultants we are all right in this case. I would like to finish with the advice that resonated the most from reading Professor O’Connell’s blog;

“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.”

This point is worth emphasizing. If you take this attitude to work with you every day everything else will come easily. 

Best of luck.

The Starry Night, 1889