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.