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

Postgraduate qualifications (week 8 of 8)

So we are now at week 8 of the blog, where I will cover the seventh of the planned seven training tips or areas for career development. This week I look at postgraduate qualifications, emphasizing the primary importance of the MRCPsych and CPsychI examinations and I will then share some thoughts about other aspects of postgraduate qualifications. There will also be two bonus blog installments over the next two weeks, with one guest piece from a Trainee who has just completed Basic Specialist Training and another from a Trainee who is currently immersed in the wonderful world of Higher Specialist Training. 

But back to this week...

Several years ago a good friend of mine, a fellow Trainee in Psychiatry who is now working as a successful and accomplished Consultant Psychiatrist, started a new six month training post.  When his Consultant asked him what his plans were for the next year or two he replied that he was planning to do a course in film studies and that he was hoping to make a short film. After a pregnant pause, the Consultant asked him what his plans were for completing his psychiatry membership examinations and he was met with a vacant look. The Consultant strongly encouraged my friend to prepare for and complete the MRCPsych examinations as a matter of priority, highlighting that he could revert to film and any other type of artistic endeavour once he had obtained his MRCPsych qualification, and thus earned his stripes in the world of psychiatry.

I have often thought about this interaction and I now give the same advice to any Trainee working with me. The emphasis in postgraduate training should always be on trying to pass the relevant membership examinations as soon as possible. Once this has been achieved the Trainee may go on and do further qualifications in whatever particular area of psychiatry (or indeed the arts) in which they are interested. 

Incidentally, I checked this morning with the above mentioned friend if it was okay with him that I share the film anecdote and he very kindly agreed. He also told me that, after passing his MRCPsych examinations, he went on to complete a Masters in Film Studies. And he managed to make a film that was shown in an actual cinema. So congratulations, my anonymous friend!

And that happy little anecdote provides the theme for this week's pictorial inclusions, all involving films that depict some aspect of psychiatry. 

So let's just get it out of the way and start with the psychiatry film that everyone thinks of first:

Jack Nicholson as Randle McMurphy in 'One Flew Over the Cuckoo's Nest' (1975) 

And another film heavy with psychiatric themes...

Russell Crowe as John Nash in 'A Beautiful Mind' (2001)

And of course there's this one...

'Fight Club' (1991) 

But back to postgraduate qualifications. Following the MRCPsych and CPsychI examinations, possibilities for further postgraduate work in psychiatry includes Diploma, Masters and even doctoral level studies in particular areas of research, teaching/medical education or healthcare management.  

You may find as the years progress that your interests become narrowed, more focused and more specialized, but try and keep an open mind at least until well into your HST years. 

I would advise as a general outline that you aim to complete the MRCPsych examinations (with or without formal CPysychI BST training) within four to five years of graduating from medical school. People who ‘do medicine first’, i.e. work for 3-4 years in general medicine and obtain their medical membership examinations before entering psychiatry may advise you to do just that; those of us who have not worked in general medicine before entering psychiatry will advise you to do what we have done – such is the nature of advice.

The best advice is probably somewhere in between, e.g. consider a year in a relevant specialty such as Neurology (and thus follow in the career footsteps of Sigmund Freud). After completing your membership examinations I would advise that you embark on Higher Specialist Training (or an equivalent portfolio of activities if you are working on a Continuous Professional Development Support Scheme, CPD-SS) and complete this within the next three to four years. This will facilitate your inclusion on the specialist register of the Medical Council and improve your employment prospects considerably. The pronouncement from Justice Peter Kelly in early 2018 regarding Consultants working in Ireland who are not on the Medical Council Specialist Register means that the days may be numbered for any other arrangements such as Consultants working in locum or temporary posts who are on the General Register only.

And now for a few darker psychiatry-themed films...

Jodie Foster (playing Clarice Starling) and Anthony Hopkins (playing the cannibalistic psychiatrist, Dr. Hannibal Lecter) in 'Silence of the Lambs' (1991)

And this one tends to get mixed reviews, but I like it...

Leonardo DiCaprio with the lead role in 'Shutter Island' (2010)

You may have realized from an early stage that your interests lie within research, teaching or healthcare management.  However, it is often not until later in one’s career that these ideas are generally crystallized. A pitfall that I would advise you to avoid is that of frantically trying to complete several disparate and trivial audits and research papers that have no coherent overarching narrative and that do not lead to an ultimate qualification or product that you can add to your CV. You are much more likely to produce well written and publishable research and other types of medical literature if you are doing such work as part of an overall structured and well supervised postgraduate programme.

During HST (or CPD-SS equivalent) years, I would advise that you use the extra time for personal development to focus on postgraduate courses and qualifications in at least one if not two or three areas. Consider signing up for courses at Diploma, Masters or doctoral levels with small groups of like minded colleagues - a cohesive team approach will help guide you through the tougher and lonelier times on such courses and also help with the quality and ultimate utility of any course related projects. At a very practical level, obtaining these postgraduate qualifications also ensures extra points on Public Appointments Service Consultant interviews and may be the difference between getting the job you want and not. 

And I will finish this week's blog with one more film that's full of psychiatry - the truly hilarious 'What About Bob?', starring Richard Dreyfuss as the quite uptight psychiatrist Dr. Leo Marvin and the almost painfully funny Bill Murray playing his patient, Bob. 

Bob trying to arrange an unscheduled home-based 

appointment with Dr. Leo Marvin, his psychiatrist. 

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.