Clerkship: Psychiatry

The goal of clerkship rotations is for students to acquire a defined body of knowledge, skills and attitudes necessary for the recognition, understanding and management of the common and unique health care problems. During each core clerkship and elective rotation, the PA student will participate, in a supervised capacity, in the care of patients presenting to the specific health care setting (Emergency department, Clinic, in-patient ward, etc).

Psychiatry

  • Location: Michael Garron Hospital
  • Length: 6 weeks

This rotation was an integral to my training. Read more about where I worked and the obstacles I encountered with the crisis team and inpatient ward.

A typical day

*I identified goals for myself prior to the start of this rotation, which was to be able to take a comprehensive psychiatric history and suicide assessment. I also wanted to be familiar with the medications used in psychiatry (eg. Antidepressants, Antipsychotics, etc). I translated these goals to my preceptors and they definitely spent some time to go over these with me.

brown-er-sign

CRISIS TEAM: I started my day around 8:30AM with the Crisis Team in the Emergency Department. I worked with three wonderful and experienced crisis social workers and the psychiatrist. I was allowed to see patients on my own after completing a personal safety and protection course. After seeing my patients, I would review with the crisis team first and then start typing up my consult note, leaving the management plan empty until I have reviewed with the psychiatrist. I liked how he would ask me what was my impression of the patient and what an appropriate management plan is for them.

 

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Picture taken from Google. Rooms generally look like this but with a dressor and washroom. There are no sanitizers in the hallway or anything sharp that can be used as a weapon. 

IN-PATIENT: In the afternoon, I work with an inpatient psychiatrist and a social worker. Since we spend more time with the in-patients (sometimes over an hour interview), the patient list usually ranged between 5-8 patients (compared to internal medicine where the physician has 20+ medical patients). I saw the non-complexed patients myself and the complexed or newly admitted patients with the psychiatrist. I did all the medical charting and dictations for the patients I saw. You have no idea how comfortable I am with medical dictations right now! #practicemakesperfect

 

Assertive Community Treatment (ACT) Teams

I spent a day with the ACT Team, which I thought was so valuable to my learning. This is an outpatient interdisciplinary team formed to assist patients who have a diagnosis of schizophrenia, bipolar disorder or major depression in their recovery and their desire to live in the community. With the stabilization of the patient’s mental illness, it will also help decrease the number of psych visits to ER and admissions. I followed a nurse for the day and we did home visits for the patients she was responsible for. We went to two group homes and I administered their long-acting injectable antipsychotic. We also visited a patient who was hospitalized in another hospital.

When these patients are well, I would not be able to tell you that they have an underlying mental illness. It just goes to show how an interdisciplinary team can contribute to the mental health population, assisting with the care that they need.

Obstacles encountered in this rotation

stock-vector-suicidal-commit-suicide-methods-stick-figure-pictogram-icons-244909888I saw a variety of patients who were referred to the crisis team. The majority of patients are known to the psychiatrist. Actually, part of my history taking was to check if the patient had been in our hospital before for the same chief complaint. The most common complaint? Suicidal ideation. The most common attempts? Drug + alcohol overdose and unsurprisingly, thoughts about jumping in front of the TTC. What I am surprised about is sometimes the patient would come in at 2 AM with the chief complaint of being suicidal (usually they call 911 and the police bring them in) but by the time I see them in the morning at 9 AM, they tell me that they are fine and demand to be discharged. Other times, the patient refused to go home, asking to be admitted. Based on the history and experience, I started to grasp who is safe to go home with follow-up, who needs an out-patient referral and who needs admission.

So, you might be thinking – if they want to leave, let them leave! The other part of the above obstacle is they cannot leave because they are usually under a Form 1. Form 1 is under the Mental Health Act and is an application by a physician who has examined the patient in the past seven days requesting a psychiatrist for a Psychiatric assessment in the next 72 hours. Until assessed by a psychiatrist, the patient cannot leave. Form 1 is initiated usually when the physician has reasons to believe the patient will harm him/herself or others – voicing suicidal ideation counts.

Patients with a personality disorder generally took a bit more time to with work  as they usually come into the emergency room with secondary intentions.

On the inpatient ward, I quickly learned that it is very difficult to discharge a patient from the inpatient ward. Sometimes the one obstacle from discharging a psychologically stable patient is housing. Other times, it is because the patient does not want to leave. I can name a few patients where with the assistance of the social worker, secured a bed in a shelter for them but the patient would refuse to show up at the housing unit – therefore losing their bed and place to stay.

Common medical conditions I encountered during my rotation

  • Personality disorders
  • Alcohol abuse and withdrawal
  • Bipolar I
  • Schizophrenia

Some of my most memorable cases

  • 54100f28bd0655f1b26155fe0174b2faSchizoaffective disorder – This patient was found in his home, disheveled and appeared threatening to his landlord. He exhibited psychosis: flat affect, heard construction noises, spoke in word salad eg. “Have you ever burger?”. My psychiatrist wanted to start him on clozapine, an antipsychotic. However, he was already exhibiting akathisia from the Abilify and there are tight regulations on who can be started on clozapine. The patient really wanted to leave. This patient also had a relative who have been so supportive and was trying to convince him to stay. It is unfortunate that sometimes those who really needs our help tend to leave.
  • Personality disorders – there are different types of personality disorders. I had difficulties managing with those who were manipulative. Although I did have some countertransference to one patient, I try to recognize my feelings and remain neutral.
  • Two cases of suicidal attempts – both were drug and alcohol overdose. One had left a suicide note, which is a red flag. The other one required ICU admission.

What I learned

  • Comprehensive suicide assessment
  • Common medications used in psychiatry
  • Side effects associated with antipsychotics (eg. Extra Pyramidal Symptoms)
  • Services available (social work is so important)

Overall

The goals I identified for myself at the beginning of the rotation were all met. My preceptor told me that I was more comfortable towards the end of the rotation with my histories and clinical judgment on what the management should be.

This rotation was definitely integral to my training. A large part of medicine focuses on the physiological and pathological aspect of the patient but we need to remember to take into account the psychosocial component. Sure, the patient is physiologically and psychologically stable but they would just relapse after discharge if their social stressors are not addressed.

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