Psychiatry treats patients with disorders of cognition, mentation, and mood. The psychiatry department hands out a great outline of the expectations for students on the first day of the rotation. As with all rotations, it is a good idea to ask your residents and attendings at the beginning of the rotation about their expectations for the course. All students are encouraged to ask for mid-term feedback and follow through on any suggestions.
The psychiatry clerkship can vary greatly depending on the site and service. Some psychiatry rotations are predominantly outpatient and others have more inpatient time. The psychiatry clerkship is on rotation that must be completed in Philadelphia, either at Jefferson, Belmont, or Einstein.
The Jefferson rotation has the following options:
- Consult & Liaison – Medical inpatients requiring psychiatric consults.
- 14 Thompson – Locked inpatient psychiatric ward.
- Geriatric psychiatry – Elderly inpatient service which is located in JHN.
- Outpatient, Drug & Alcohol – A mixture of outpatient counseling through rehab as well as general outpatient observation.
Jefferson splits the course into two three-week blocks of either Consult/Liaison & 14 Thompson or Geriatric Psychiatry & Outpatient. The outpatient/geriatric option has better hours while the inpatient service has more clinical responsibilities but is arguably better for preparing for the shelf exam. Belmont has only inpatient options, including an adolescent service.
How to Do Well
Letters of Recommendation
Third-Year Clerkship Guide
Guide to Fourth Year and Scheduling
Jefferson Fourth-Year Elective Survey
Away Rotation Primer
Away Rotation Surveys
Fourth-Year Specialty Mentors
Many students are intimidated by psychiatric patients. To do well on the rotation, spend as much time as possible with your patients. They may ally with you more than any of their treatment providers as you have time to spend and you are not making any of the unpopular decisions (like making them take antipsychotics). Psychiatry as a field has been revolutionized by pharmacology. A review of psychopharmacology will pay off during the clerkship. There is an opportunity at all sites to spend a day at Mental Health Court. This day is highly recommended; students have an opportunity to see how patients are involuntarily committed and retained.
Textbooks – bolded books are recommended
- Psychiatry for Medical Students (Waldinger) may be the best written textbook for any clerkship. It is a good read and very interesting. One caveat is the 3rd edition is a bit out of date and a newer pharmacology resource is recommended (i.e. the book states tricyclics are still the first-line therapy for depression).
- DSM-IV – The tomb of diagnostic psychiatry is available in a number of pocket, textbook, and online versions (STAT!Ref). Most students like to carry around a pocket version or some equivalent (the little green book is highly recommended).
- Blueprints or First Aid in Psychiatry – As always the Blueprints and First Aid series comes through with concise, yet perhaps superficial, review books.
- Human Behavior: An Introduction to Medical Students (Stoudemire) is not as easy (nor as fun) to read as Waldinger, but it is also recommended by the department.
- Psychiatry/Behavioral Science (Board Review Series) is an excellent review book. Easy reading.
- Review of General Psychiatry (Goldman/Lange) is well-organized and concise, with good illustrative cases.
- Psychiatry (Hahn) is a great pocket-sized book for quick and easy reference. By no means is it comprehensive, bit it does list general information in outline format.
The department holds a weekly half-day of lectures. Most of the lectures are very good. Keep in mind that the department now uses the NBME shelf examination so be sure to review from a standard book.
At Jefferson, you are required to take two or more nights of ER call depending on the number of students. Call is a great opportunity to work up a patient and provide Axis I-V diagnoses on your own. The residents you work with evaluate your performance for each call night and this grade factors into your final grade for the rotation. For Jefferson, no matter which service you are with during the day, you will take call with the team from 14 Thompson. Affiliates vary with respect to required call nights.
In psychiatry, the Mental Status Examination (not to be confused with Folstein’s Mini Mental Status Exam) replaces the physical examination. On an inpatient service you may be asked to perform a more comprehensive physical examination but your focus should be on the Mental Status Exam. There are great introductory lectures at the beginning of the clerkship. Another unique aspect of psychiatry is the five axis assessment (see example below). It is also a good idea to look at a few sample psychiatric H&Ps at the start of your rotation to get an idea of what is important.
In psychiatry, it is important to trust your feelings. There are usually no laboratory diagnostic tests to confirm your suspicions. Try to understand the patient's feelings and actions. Many times in psychiatry you may end up taking on some of these feelings yourself (this is called counter-transference). For example, if a Borderline Personality Disorder patient makes you feel angry during the course of the interview, the patient is most likely angry.
Follow the example assessment and evaluation below:
Identifying information - age, sex, marital status, race
Chief complaint - reason for consultation, a direct quote from the patient
HPI (History of Present Illness) - current symptoms, previous psychiatric symptoms and treatments, reason presenting now
Past Psych. History - previous and current psychiatric diagnoses, history of treatments (include both outpatient and inpatient), psychiatric medications, history of attempted suicides and potential lethality
Past Medical History - current and/or previous medical problems with treatments
Family History - relatives with history of psychiatric disorders, suicide or attempts, alcohol or substance abuse
Social History - source of income, level of education, relationship history, support network, individuals living with patient, current alcohol or drug use, occupational history
Developmental History - family structure since childhood, relationships with parents, peers and siblings, developmental milestones, school performance
Mental Status Exam
General Appearance and Behavior - grooming, level of hygiene, clothing characteristics, unusual movements, attitude, interactions with the interviewer, psychomotor activity (agitation or retardation), degree of eye contact
Affect - external range of expression (described in terms of quality, range and appropriateness). Types could include flat, blunted, labile, and wide range
Mood - internal emotional tone of the patient (dysphoric, euphoric, angry, anxious)
Thought Process - may include any of the descriptions below.
Use of Language - quality and quantity of speech. Note tone and fluency here
Common Thought Disorders:
Pressured Speech - rapid speech, especially with manic disorders
Poverty of Speech - minimal responses
Blocking - sudden cessation of speech
Flight of Ideas - accelerated thoughts that jump from idea to idea
Loosening of Associations - illogical shifting between unrelated topics
Tangentiality - thought which wanders from the original point
Circumstantiality - unnecessary digression which gets to the point eventually
Echolalia - echoing of words and phrases
Neologisms - invention of new words by the patient
Clanging - speech based on sound, such as rhyming and punning, rather than logical connections
Perseveration - repetition of phrases or words in the flow of speech
Ideas of Reference - interpreting unrelated events as having direct reference to the patient
Thought Content – may include any of the descriptions below.
Hallucination - false sensory perceptions (auditory, visual, tactile, gustatory, olfactory)
Delusions - fixed, false beliefs firmly held despite contradictory evidence
Persecutory - others are trying to cause harm or spy with intent to cause harm
Erotomanic - false belief that a person of higher status is in love with the patient
Grandiose - false belief of inflated sense of self-worth
Somatic - false belief of having a physical defect
Illusions - misinterpretations of reality
Derealization - feelings of unreality involving the outer environment
Depersonalization - feelings of unreality (being outside of your own body)
Suicidal and Homicidal Ideation - desire to harm self or others
Level of Consciousness
Orientation - person, place and date
Attention and Concentration - repeat 5 digits backwards or spell "world" backwards
Short-term Memory - recall 3 objects after 5 minutes
Fund of Knowledge - name 5 presidents or historical date
Calculations - subtract serial 7s, math problems (simple)
Abstraction - proverb interpretation
Insight - ability of patient to display an understanding of his current problem
Judgment - ability to make realistic decisions about everyday activities
Lab Evaluation of Psychiatric Patient - can include any of the following: Chem-7, CBC, TFTs, RPR (VDRL), Vitamin B12, Folate, UA, BAL, urine toxicology, medication levels, HIV
DSM IV Multiaxial Assessment
Axis I: Clinical Psychiatric Disorders
Axis II: Personality Disorders
Axis III: Medical Conditions
Axis IV: Psychosocial Problems
Axis V: Global Assessment of Function
Plan of Treatment
Progress notes in psychiatry differ depending on the service. Use your resident's notes as a guide and be sure to include a good assessment and plan formulation. Psychiatry stresses discharge planning (i.e. what needs to be done to discharge the patient, as well as subsequent follow-up from a bio-psycho-social standpoint).
The actual final clinical grade at Jefferson is based on clinical evaluations, call nights, and a final case report. The psychiatric case report (final H & P) is typically due the fifth week of the rotation. Try to select a patient you would like to write up early on. The nature of the report depends on the service you are on. Since it will be an attending on your service that evaluates the report, it is best to talk to him or her to know exactly what is being graded in the report.
Psychiatry uses the NBME shelf examination. A question book such as Pre-Test or Appleton & Lange is recommended. Many students comment that the test has a lot of “medicine” after taking the exam so it may be worthwhile to review some internal medicine.