If you were designing a psychiatry clinical rotation...

[MBK2003]

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to improve the experience of MS3's during their psychiatry experience and potentially increase the interest in psychiatry as a career (and ideally even C&A psychiatry), what kind of experiences would you include?

The reason I ask is that my institution has a new medical school partnership starting in 18 months that will change the way that medical students spend their 2 clinical years at our facility. They're seeking to highlight certain high-need specialties and target interested students for mentorship and possible specialized MS3 clinical rotations. Psychiatry and child psych are on the list, so we've been asked "what kind of clinical experiences will foster interest in the field and allow a medical student to identify psychiatry as their preferred field?"

So tell me, what were your MS3 or MS4 clinical psychiatry experiences that you felt were important in fostering your interest in the field? Also, please let me know if there were experiences were overwhelmingly negative from the perspective of a MS3.

Thanks for letting my pick your collective brains 😀

 

[Anasazi23]

I have a lot of thoughts on this. I'll try to write later.

I'll start with this:

--Do not relegate med students to 4 weeks of inpatient and note writing. It's death for interest except in relatively rare cases.

 

[PeeWee137]

my psych rotation was very structured. it was at a free-standing psych hospital. everyone was assigned unit that they stayed on for the 6 weeks - mostly it was inpt but a couple of students got C+L in the main hospital.
the chief residents had weekly classes for us on a variety of topics. we had class for an hour or two almost every day.
small-group pt interviewing, where we would do a supervised interview and then receive feedback
2 classes that was geared toward the shelf/boards - one we just went over multiple choice questions, the other was pt cases where we discussed ddx, work up, treatment etc
evidence based medicine class where we analyzed current research articles and had to write a paper comparing articles of our choice
child rounds once a week with a fellow where we would go over major topics and then interview a kid on the unit
geriatric rounds once a week, same setup as child
C+L rounds once a week, same as above

i had additional supervised pt interviews with my attending on the unit and participated in group sessions. i was also required to do 3 pt write-ups, detailing their entire psych/social/family history and how it contributed to their pathology.
on my unit i was treated like an intern, carrying pt's and writing their notes, calling consults, coordinating with social work. but other units gave different experiences.

i loved my rotation (obviously) but you could tell that the people who werent interested in psych hated being there. they liked the classes and got alot out of them, but they felt they were mostly shadowing on the units. and they also didnt like that we had to be there 8-5, most people expect psych to be a blow-off rotation...

one way i thought they could improve that rotation would be to give a longer exposure in each of the specialties. maybe 2-3 weeks inpt, 1 week C+L, 1-2 weeks child, 1 week geri, 1 week emergency, etc. or tailor it to each students needs (which i imagine could be difficult). i would have liked to spend more time in a child or adolescent unit since thats what im considering down the line.

 

[diosa428]

I really liked my psych rotation, but it wasn't the "standard" rotation for an academic institution - I was working at one of our affliate hospitals which had no psych residents, so it was just me and the attending. The attending did inpatient, outpatient and C&L work throughout the week, so I got exposure to all 3 while still working with the same attending. I thought that seeing 3 different areas was helpful to me because I could see the flexibility of psych, whereas my classmates at our main hospital were either on inpatient or C&L (or they were doing inpatient at our state institution) and that was all they saw.

I agree that incorporating all 3 (and maybe throw in some child) would be great, but as I am generally slow to get used to what's going on, I could see myself just starting to get comfortable with inpatient and then getting moved to something else and then having to get used to that. How long is the rotation you're planning? If it's on the longer side, I think PeeWee's idea of breaking it up into weeks is a good idea. If it's shorter (ours is only 4 weeks) and you could manage it, I'd say have the students spend like 3-4 days per week on inpatient and 1-2 on C&L for 3 weeks and then maybe a week of child if you want to fit that in. You could also do mornings on inpatient and afternoons on C&L. We did our emergency at night - we took call in the ED from like 6-11 one night per week and then we also had to do one weekend day from 10am-10pm (once during the rotation, not every weekend). I think the variability of psych is what's so great about it, and exposing students to that is going to give them a better idea of what they'd like.

I also agree that having students get involved, interviewing patients and writing notes is key. That is definitely one thing that sold me on psych.

 

[diosa428]

I forgot to add - I think that giving students exposure to outpatient is also a good idea. I personally found outpatient kind of boring because I didn't get to do anything generally (as the patients were my attending's private patients) so I just sat there and watched, but maybe a couple of half days of outpatient at some point in the rotation, just to give students an idea of what someone in private practice might do all day.

 

[billypilgrim37]

Our M3 curriculum just got revamped for my class, and I think our 6 week psych rotation is the best of all possible worlds.

1.5 weeks inpatient.
1.5 weeks c/l.
3 weeks outpatient, with 1 day each week for child and addictions, half day geri, and 2.5 days various adult general resident clinics.

Exposure to everything you can jam into 6 weeks, and a much more relevant experience for people not going into psych. The ONLY drawback was that it was hard to have enough experience with any one attending for a LOR. But that's what M4 year is for!

 

[duiplfrog]

I’ve found that for any rotation the absolute KEY is the people you are working with and their attitude toward teaching medical students. It’s no fun if you are just a shadow and get ignored by your residents nor is it a great time if you are working with a malicious pimper. I’ve had both experiences (neither in psych!) and I’m sure that swayed my attitudes regarding those specialties.

I would say my ideal psych rotation would be a mixture of inpatient, outpatient and C/L. Throw in a half day a week of child/forensic/neuropsy/geri or whatever specialized psych might be available or of interest to the particular student. That would have been an awesome 3rd year rotation!

 

[mgdsh]

Yep IMO I think the more variety the better (settings, subspecialties, etc).

I'm not sure how I'd exactly structure it (not an easy task), but the time shouldn't be equally balanced between every setting/subspecialty. There needs to be some sort of a focus on one of them so students can actually follow some patients for a decent amount of time.

 

[marie337]

I have a huge problem with the psychiatry exposure at my school. If I didn't already know that I was interested in psychiatry, I would have no exposure prior to application time. I chose the rotation schedule with the earliest psych rotation and it isn't until Sept. of 4th year. So, I wanted to do an elective rotation during my ambulatory care rotations, only to be told that there are no outpatient rotations available because of the nature of the field. I did manage to work out a child psych outpatient rotation, but that was only because I sought it out.

This was very frustrating for me because I went into 3rd year knowing that I was interested in psychiatry and I felt like I was being deterred from it. One of my colleagues at my base hospital also has a strong interest in psych so they were really perturbed when both of us were asking for these rotations.

I think that there needs to be more flexibility in the scheduling of rotations, at least at my school, because the current system basically guides people into the more common specialties. But, that's just my experience.

I'm really hoping to get in contact with the inpatient unit attending and hope to be able to spend a few days there before september. I just don't think it's fair to make a decision on a specialty without having a chance to experience it.

 

[nancysinatra]

My rotation was at a large inpatient psych hospital, and it was designed so that we spent 4 weeks in one unit, and 2 weeks in another unit. We also had an interviewing class where we had to interview patients from units besides our own.

I loved being in one place for 4 weeks. I got pretty good at working with those patients, which told me that I would probably like psych for the long term. I actually liked having the chance to polish my note writing skills. (Good notes are one of the things I admire about the field!) I got to know my attending there too. I've found in other rotations where we switch around more often that I barely get oriented before we have to move on.

I went into my rotation knowing I was interested in psych, but thinking I wanted nothing to do with C/A. Then I got some exposure to eating disorder patients (with their myriad comorbidities) while I was there, and that completely changed my mind. I didn't mind not having any outpatient time--what mattered to me was getting to see patients with a variety of psychiatric disorders.

I guess I think the ideal rotation would give students a choice--you can either do a 4/2 week thing like I did, all inpatient, or something broken down by IP/OP/CL, with 2 weeks of each.

 

[Anasazi23]

In a nutshell, and in a perfect world, I think an ideal psych rotation would look something like:

1. The requisite inpatient rotation. Not just shadowing or rote note writing. Have them get involved in the treatment --> gather collateral, get involved in the medical problems. Have them fully understand the medications selected by the resident or attending and how they came to their decisions.

2. Perform an ECT. I mean...actually push the button/press the foot pedal. Scare the student a little the day before by telling them they're doing it the next day, and need to be up on the entire process, from the anesthesia induction and paralytic agent, to the possible treatments for on-the-table arrythymias. Have them follow up in recovery, and read the eeg with the attending. Have them follow the patient a week later to see the results of their labor.

3. Spend some times on C/L and ER. Oftentimes, one or the other is neglected. C/L catches the eye of a lot of potential psychaitry go'ers and ER can be just plain fun and interesting.

4. If possible, have the MS spend a day or more on outpatient psych. This is actually what caught me. I had the great fortune to shadow a neuropsychiatrist when I was only in college, and it was amazing. The seamlessness with which he went from an underweight homosexual male anorexic patient to a chronically paranoid yet successful OCD stockbroker was magic to me at the time.

5. Have the MS do a call (at least one, if not weekly). This allows the MS to see the psych resident in the doldrums of night, and gives the opportunity to witness a good sundowning case or a crafty ER malingerer.

 

[OldPsychDoc]

This is tough--because as the posts above clearly show, different students are looking for different things. The OP is looking for ways to interest prospective psychiatrists in the field. Med schools are looking to fill requirements for their students. As a site director, I'm looking to identify and challenge the few--future psychiatrists-- as well as ensure that my future colleagues in other disciplines are well trained in what they need to know about psychiatry to pass their boards and not embarass themselves when one of "our" patients crosses their path.

So for the vast uninterested majority, I want to emphasize the following:
1) interviewing skills--learning to listen so you can ask what you really need to know.
2) an appreciation for the psychosocial part of the biopsychosocial approach--appreciating what makes the individual patient who they are.
3) some basics of psychopharmacology.

There's also a tension here between wanting to maximize exposure to the many varieties of psychiatric work-- acute vs. chronic, inpt vs. outpt, consultation vs. continuing care, the various subpopulations, the diversity of diagnostic groups-- and wanting students to be immersed in the slower pace of treatment and be able to appreciate the subtler changes in recovery that we see in our patients. Because of this, I think we want to resist the temptation to carve the rotation up into too many "mini experiences".

I think we also need to be aware that it takes a few days to get used to being on any new rotation, maybe especially in a hospital we haven't worked in before, but especially psych--where again the rhythms are different. I think a 4-week clerkship is useless, as you lose the first week getting oriented, and the last week with testing, etc.

We have a 6 week block, typically split into 3 week sub-rotations to allow exposure to at least 2 attendings and different services. We have no child inpt on site (but do encourage a day in outpt clinic for the interested few). We try to get most students 3 weeks of consults. Call is a few evenings of admitting with a resident. For the truly interested, we'll bend over backward to accomodate special interest. It's been working OK for several years this way, but I'd love to find ways to make it more interesting. I really think that hospital psych is the best for training purposes--higher acuity patients, more impressive mental status exams, more team-centered approach. Seeing outpatient psych is usually better with the "truly interested few"--and its easier to extrapolate from inpatient/consult patients to outpatient presentations than vice versa, IMHO.

 

[Anasazi23]

Seeing outpatient psych is usually better with the "truly interested few"--and its easier to extrapolate from inpatient/consult patients to outpatient presentations than vice versa, IMHO.

I agree that four weeks is too short.

The only reason that I emphasize an outpatient experience is simply because I feel that a solely inpatient rotation can deter students from entering the field in some cases. I've heard from many med students, "these people don't really get that much better, right?" after having sat through rounds hearing "54 y.o. homeless, unemployed, single, black male with history of schizoaffective disorder and multiple psychiatric hospitalizations. Recently released from Bellevue last week..."

Seeing functional, working people in a somewhat more pleasant setting compared to the normalls smelly, dingy inpatient unit may, in some cases, attract a group of students that would otherwise not consider it. After all, the majority of psychiatrists practice in outpatient settings.

But, I completely understand your points also.

 

[futuredo32]

This was very frustrating for me because I went into 3rd year knowing that I was interested in psychiatry and I felt like I was being deterred from it. One of my colleagues at my base hospital also has a strong interest in psych so they were really perturbed when both of us were asking for these rotations.


I'm really hoping to get in contact with the inpatient unit attending and hope to be able to spend a few days there before september. I just don't think it's fair to make a decision on a specialty without having a chance to experience it.

I think that if you contact Dr.Richards at MSU she'd be very willing to help you out with spending a few days on the inpatient unit. They hosted a dinner last August for students interested in psychiatry and they are so willing to help students interested in psychiatry- whether they want to do a psych residency at MSU or not. (I'm not sure how they knew that I was interested in psychiatry, but luckily, my name got on the email list and I was really glad that I went to the dinner and I learned a lot and left thinking very highly of the MSU psych program).

I've found that for any rotation the absolute KEY is the people you are working with and their attitude toward teaching medical students. It's no fun if you are just a shadow and get ignored by your residents nor is it a great time if you are working with a malicious pimper. I've had both experiences (neither in psych!) and I'm sure that swayed my attitudes regarding those specialties.

I would say my ideal psych rotation would be a mixture of inpatient, outpatient and C/L. Throw in a half day a week of child/forensic/neuropsy/geri or whatever specialized psych might be available or of interest to the particular student. That would have been an awesome 3rd year rotation!

This sounds like the ideal psychiatry rotation.👍
None of the rotations at MSUCOM are 6 weeks in length. I agree with OldPsychDoc that 6 weeks would be better for the reasons he stated. (However, I am very glad general surgery is only 4 weeks😀)

 

[marie337]

I think that if you contact Dr.Richards at MSU she'd be very willing to help you out with spending a few days on the inpatient unit.

Yes, thanks for the tip. I will be working with Dr. Richards next month during the child psychiatry rotation. She seems like a great resource. I"ve been told the residents that Dr. D'Mello would probably let me hang out with the team at St. Lawrence on one of my days off. So, I'll probably try to do that over the summer.

futuredo32--I will PM you. We could have some things to talk about.