psych precepting

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randomdoc1

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Hey all! I'll be precepting a student for a 4 week rotation. Never did this before but any tips? Some thoughts I had:
-is First Aid still a good read to have for them? Or am I outdated? What about a good source to find great clinical vignettes?
-where can I find some good pimping questions?
-any good places to find premade presentations/power points for when we have time to sit down and do more didactic work? I guess I can come up with some of this myself, but it's good to see what others have come up with.
-assuming this student will likely not go into psychiatry (or maybe they will, most of us take awhile to figure out our specialty), I'm trying to focus on areas more likely to be encountered in primary care and other non-psych settings. Some thoughts are MDD, GAD/phobias/OCD, AODA, psychosis, true bipolar disorder, personality disorder (esp borderline), safety and suicide risk assessment, psych versus non-psych ddx, basic med info (SSRI, SNRI, atypical, mood stabilizers and especially meds with more overlap with major SE), and whatever you do, don't ever start people on xanax or IR adderall. lol.
-gero turf (a weakness of mine, any feedback please)

I'd love more detail and feedback on your thoughts on this!

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I can't speak to pimping or specific resources, but you did a good job outlining the basics covered in psych rotation. FA for the psychiatry rotation is a decent resource. Uworld is always the king, but every student in the country should know that. Psychiatry tends to be an easier exam overall, which can make it difficult to reach certain percentiles for honors depending on how the school gives that out.

Some components of their exam you didn't cover include 1) delirium (AMS), 2) capacity, 3) suicide risk (i.e. risk factors, SADPERSONS). Luckily, these components are important for psychiatrists and non-psychiatrists alike to have at least a basic understanding. Schools also tend to leave delirium and capacity to be taught MS3/4 rather than in preclinicals, so that is very useful. The test also makes sure that students know specific timelines (i.e. unspecified schiz vs schizophreniform vs schizophrenia, etc). Also, any time the test asks for pharmacology, it almost always presents the less common drugs - i.e. they dont put sertraline down in the options for depression treatment in a stem, they put vortioxetine or vilazodone. So being able to recognize class of med by name is important.
 
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I can't speak to pimping or specific resources, but you did a good job outlining the basics covered in psych rotation. FA for the psychiatry rotation is a decent resource. Uworld is always the king, but every student in the country should know that. Psychiatry tends to be an easier exam overall, which can make it difficult to reach certain percentiles for honors depending on how the school gives that out.

Some components of their exam you didn't cover include 1) delirium (AMS), 2) capacity, 3) suicide risk (i.e. risk factors, SADPERSONS). Luckily, these components are important for psychiatrists and non-psychiatrists alike to have at least a basic understanding. Schools also tend to leave delirium and capacity to be taught MS3/4 rather than in preclinicals, so that is very useful. The test also makes sure that students know specific timelines (i.e. unspecified schiz vs schizophreniform vs schizophrenia, etc). Also, any time the test asks for pharmacology, it almost always presents the less common drugs - i.e. they dont put sertraline down in the options for depression treatment in a stem, they put vortioxetine or vilazodone. So being able to recognize class of med by name is important.
Oh yes, and the beauty of the state drug monitoring database! That's a priceless one too!
 
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Oh yes, and the beauty of the state drug monitoring database! That's a priceless one too!
Absolutely agree. If every attending modeled checking the database prior to any controlled script, or on admission, that would have profound effects down the road for students.
 
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When I work with students - which is essentially 100% of the time - my goals are:

1) Be able to confidently recognize, diagnose, and initiate treatments for mood and anxiety disorders
2) Be able to develop basic non-pharmacological skills for treating some symptoms and dealing with difficult clinical situations
3) Be passingly familiar with psychopharmacology - at least sufficiently so to be able to recognize common and catastrophic side effects of commonly used medications

For students that are interested in psychiatry, I'll dig into more detail. The simple truth, though, is that most students don't need to know the intricacies of bipolar disorder or schizophrenia management, and I've found that most don't really care. I try to focus on things that will actually be useful to them as clinicians, recognizing that the vast majority of them aren't going to become psychiatrists.
 
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First: thank you for having the humility and interest to ask the question. Psych attendings (at least at my institution) tend to be very with it, but... many in the world are not. So your students will thank you for your intesterst!

In all honesty: at my school, there are tight cutoffs for H/HP etc... so students really just want to leave and go home to do UW. I personally learned very little from attending-led didactics, even the most well-intended. Sad but true.

But! You could have a profound effect on students' abilities to diagnoses, assess and plan. What I've always found most effective (as a student) has been when the attending (or M4, or resident) at the end of the presentation discusses the assessment and plan. Why do you think that dx is at the top of the differential vs. y? What are the criteria? How can we treat it and what is the most appropriate level of care? Those questions are easy, make it seem like you're genuinely interested, and (as my grandfather says) never go out of style.

FA-psych is a good resource for the clerkship in addition to UW, the OME videos are okay, BnB I haven't used but have heard good things about. I would suggest in lieu of premade ppts etc just sending them home or to lunch/study/nap/whatever. You could make your own or maybe the students/residents have some, but... imo not worth it. Also for the shelf: timelines are super important. Differentiating between different primary d/os (mood vs psychosis) with all of the gray area is important. Broad classes of meds (MDD - SSRI) are important. Minutiae/specific side effects are lower yield. Yes, know the side effects for lithium, but which SSRI to pick for the pregnant lady with xyz comorbidity is less useful.
 
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Just adding to what others said, during my psychiatry rotation the attendings would often give me the patients that were related to the field I was interested in (PM&R). For example, on C/L if there was ever a consult to the rehab floor, the attending would always take me. My friend was interested in EM, so the attendings gave him a lot of patients with panic disorder and acute mania/psychosis. At the end of the rotation we had to give a presentation on a topic of our choosing, so I did mine on the management of post stroke depression. I ended up loving my psychiatry rotation and really gained an appreciation of the interface of psych and other fields. I'm not sure what practice setting you're in, but If you have a sense of what your student is interested in at the beginning of the rotation you can really make the rotation that much more engaging for them.
 
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There's a lot of really good advice and info in this thread already, but I'll add my thoughts since I take a fairly structured approach. Long post ahead, you've been warned, lol.

One of the first things I always do with the students is to ask if they have a specific area of interest and ensure them that not wanting to do psych is nbd. I try and cater the focus of our clinical discussions towards their interests when I can. They like ob/gyn? We're going to talk about side effects and risks of various medications and identification of peripartum conditions and treatment. Interested in anesthesia? We'll talk about CNS effects of our meds and interactions with commonly used anesthetics (and throw in ECT if they're interested). I've found the students engage a lot more and appreciate it when you give them things they feel will be relevant going forward.


For actual teaching, I break things down into 2 overarching categories: material and information relevant for the shelf, and clinically useful information. Some examples: on the shelf the number one risk factor for suicide attempts is past attempts, which is obviously important but not always the most telling (borderline patients with many minor "attempts" are less concerning than MDD with 2 major attempts that landed them in the ICU). However, on PRITE/ABPN the correct answer is going to be sleep deficits which students tend to not think about as much but IMO is hugely important for any field. Another is that for the shelf, agranulocytosis is the magic high-yield word for clozapine, but irl my biggest concern and leading cause of death from clozapine is constipation and the risk of SBO, which is relevant for anyone seeing any patients on a medical floor. It's probably my favorite pimp question that no med student or intern has ever gotten correct and is usually shocking to them.

For the clinical side, I expect everyone to have a basic grasp of the most common conditions and treatment. If a student finishes my rotation and can't identify MDD or GAD and doesn't know the first 2-3 treatment steps in the basic algorithm, I've failed as a teacher. If they can manage mood stabilizers or antipsychotics then great, but those are lower priority IMO. I think everyone should be able to identify alcohol withdrawal and how to test for Wernicke's since they can be so easy to identify with a little attention and make a massive difference in treatment. Another major thing that I try and emphasize, especially on consults, is being able to identify delirium and being able to initiate treatment for agitation. These are things we're often consulted for that the primary team should be able to identify and treat at least at the basic level. Capacity is another one that is woefully minimized in teaching and it sometimes blows my mind how clueless residents or even attendings can be, even with simple cases. Finally, something that I make sure is etched into everyone's brain is my biggest pet peeve: if you're going to consult us make sure we know why we're seeing the patient. There is no faster way to get on my bad side than to write a consultation that just says "capacity" or "suicidal". That is meaningless to me. It takes all of 10 seconds to write a sentence and can save me an hour of trying to track the consultee down to figure out what they actually want, and one-word consults are the quickest way for them to get on my s*** list.


For their shelf studies, I further break things down into 2 (or 3) categories: diagnoses and psychopharm/treatment (and everything else, which isn't much for the shelf):

As mentioned above, for diagnoses I want them to know the basic criteria for the major disorders like MDD, GAD, mania, schizophrenia, etc and emphasize timelines heavily. The shelf loooooooves testing timelines and throwing curveballs with them, so I always do a little pimp session on these. The other thing I mention is differentiating between similar conditions. What's the difference between avoidant PD and schizoid? OCD and OCPD? Bipolar vs. BPD? Things that seem pretty obvious to us that M3s may not have gone over much.

For the psychopharm/treatment side, I agree with some things mentioned above. They don't need to know everything about every med, but they should be able to identify what class the med belongs to. They should know what class is used for what condition (major indications) and the major side effects and concerns of each class. For individual meds, I like them to know if there is something that makes them unique compared to others in the class or in general (fluoxetine's long half-life, ziprasidone's QTc effects, lithium and clozapine specifically for SI, etc) as well as if a certain med or treatment is a gold-standard med, I specifically discuss clozapine and mention clomipramine for OCD. I do quick reviews of the meds that aren't in a true common class as well, bupropion, mirtazapine, and lithium are the big ones I hit for their shelf.

For the "everything else", I go over substance intoxication and withdrawal and "antidotes" if they have them. I focus on alcohol withdrawal here as well as basic treatment since it's highly relevant for shelf and irl. I briefly discuss the sleep cycle (BATS Drink Blood) and specifically sleep spindles and K complexes in stage 2 (almost guaranteed to be on the shelf). I tell them to do a brief read-through of coping mechanisms in FA and also discuss the specific indications for involuntary admission (SI/HI d/t mental illness and severe inability to care for self).


In terms of "lectures" or didactics, I have one or two that I almost always give. I like to sit down for 15-20 minutes and really hammer home everything with EPS, the 4 main dopamine tracts involved, when to look for each side effect, what it actually looks like, and the treatments for them. This is probably the highest yield lecture you can give in <30 minutes as there are always at least 3-4 questions on EPS and I actually remember having 8 or 9 on my shelf. It's just easy points for them if they know it and I often have students comment on this specific lecture in their evals of me. I also like to have a discussion about capacity, including the Appelbaum criteria, what is actually being evaluated (capacity to leave AMA, refuse a specific treatment, refuse a dispo plan, etc), and its fluctuating nature. If I have time, I like to do a short discussion about guidelines for insomnia treatment, as I've found that even most attendings don't have a good knowledge of these. I may also do a lecture or friendly pimp session on subjects they're interested in depending on the time available.

I sometimes use a whiteboard, but I've never used a formal powerpoint or slide on a rotation. If we're not doing something that's interactive, they can do that on their own and there's no point in me keeping them there just for that.


Uworld is always the king, but every student in the country should know that.

I could not disagree more with this point for psychiatry. I found it to be mediocre at best for psych and much less useful than for pretty much every other subject. I've been told by numerous people that Lange Q&A is the best resource for questions, but I've never used it myself.

I always tell my students that there are about 7-8 high yield chapters in FA that if they know then they will have a strong foundation for the diagnostic side of their shelf. In addition to that, I think Case Files is very useful for psych (and ob/gyn) as it hits pretty much everything that's high-yield for the shelf and clinically and nicely lays out treatment considerations in those cases. Plus it is mostly just case vignettes so IMO much more enjoyable to study than just pounding through anki or Qbanks. Probably my favorite psych resource for the shelf. Some students like OME, but I can't comment as when I had my psych shelf there was info in it that was flat out incorrect. Apparently, it was significantly updated but idk how good it is now.

100% agree with your second paragraph though, everything you mention is spot-on IMO.
 
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Second Lange QA. My experience was that UW was good enough to do pretty well (especially in combo w/ AMBOSS which is becoming more common currently) but the Lange really hammered everything home... given that it's like 1k questions it had better. However... it had a lot more detail than the shelf really cared about so not everyone loves it
 
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I make Cluster B personality disorders the focus for students. My lifetime goal is to help PCP's (and, omph, surgeons) make fewer bipolar diagnoses. I feel like the mood, anxiety and psychoses are pretty well covered in the study guides. It might just be my patient population.
 
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Lots of good advice here. I agree that uworld is not comprehensive for psych. I also like to teach very practical, clinically relevant things like delirium and capacity that aren't tested as much but every student will see. I also almost always teach the 'hateful patient'; awareness of the negative emotions patients produce in us and how to recognize and manage them without compromising care. This is one of my favorite things to teach.

It's OK if you don't have time to cover everything in didactic form though. The medical school should be providing some level of standard didactics. One thing that is good to consider is what presentations is the student NOT seeing because of your setting--for example an outpatient rotation isn't going to turn up much delirium, and a CL rotation isn't likely to see the bread and butter outpatient presentations. It's helpful to identify those absences in their experience and tailor some focused teaching to those things.

I don't do much customization to students interests during clerkship bc there is so much basic stuff they all need to know. I customize my teaching much more when I have elective students going into something other than psychiatry.
 
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