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...
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.
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:
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
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:
Self management
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.
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.
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...
