Psychiatry clerkship

Psychiatry overview

What is psychiatry?

  • Psychiatry is a medical specialty that focuses on the workup, treatment, and prevention of various mental disorders, which affect mood, cognition, perception, and behavior.
  • Mental health issues affect approximately 1 in 5 adults and 1 in 6 young people aged 6–17 in the US each year. So a basic understanding of psychiatric conditions and their management is essential for all medical specialties. [1]
  • Knowledge of widely-prescribed psychotropic drugs is also vital because of their potential multisystem adverse effects and interactions with medications used in the treatment of other medical conditions.
  • Psychiatric disorders present heterogeneously and affect a diverse variety of individuals. This is reflected by the large number of subspecialties that psychiatrists can engage in after a 4-year residency program, including:
  • Although psychiatry is an incredibly diverse and interesting field to work in, it is still associated with stigma and fear, thus making it less popular amongst medical graduates.

What does a psychiatrist do?

  • A psychiatrist can choose their area of focus based on the following:
    • Population (e.g., adolescents, elderly patients)
    • Disorder (e.g., bipolar disorder, post-traumatic stress disorder)
    • Setting (e.g., open inpatient unit, secure inpatient unit, outpatient unit)
  • To ensure long-term therapeutic success, psychiatrists work alongside a multidisciplinary team, which includes psychologists, nursing staff, general practitioners, social workers, and occupational therapists.
  • They also collaborate closely with patients' family and friends to provide the best care for each of their patients.
  • Clinical examination is considered a psychiatrist's primary diagnostic tool since a comprehensive clinical evaluation is often enough for establishing a final diagnosis.
  • Psychiatry specialists also use additional diagnostic tests (e.g., cognitive testing, neuroradiologic imaging) in order to differentiate between primary and secondary psychiatric disorders.
  • Diagnosing psychiatric conditions can be extremely challenging since objectifiable findings used in other medical disciplines (e.g., ST elevations on ECG and positive troponin levels that indicate a STEMI) are not as common in psychiatry. This is why psychiatrists rely on diagnostic manuals, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), which include standardized criteria for different mental disorders.
  • When elaborating diagnostic and management plans for their patients, psychiatrists use the latest recommendations of national and international society guidelines such as those from the American Psychiatric Association (APA).
  • Common treatment options used by the psychiatry specialists include noninvasive tools (e.g., psychotherapy, group meetings, psychotropic medication), as well as invasive procedures (e.g., transcranial magnetic stimulation, electroconvulsive therapy).
  • The use of custodial measures (e.g., physical restraint during involuntary hospitalization) remains a controversial topic. Despite this, such measures are still used by mental health specialists to prevent individuals with violent/aggressive behavior from hurting themselves and/or others.

Psychiatric clerkship overview

Clerkship structure

  • The length of a psychiatric clerkship usually varies between 4–6 weeks.
  • Depending on the medical school or hospital, you will be able to work in the following inpatient settings:
    • Adult psychiatric facilities
    • Child and adolescent psychiatric facilities
    • Forensic psychiatry hospitals
    • Psychiatric residential centers
    • Alcohol and drug rehabilitation facilities
    • Nursing homes
  • The outpatient settings can include:
    • Community mental health centers
    • Facilities offering partial hospitalization programs (PHPs) and/or intensive outpatient programs (IOPs)
    • Private clinics

Clinical skills

Daily schedule

Please note that the following schedules are meant to provide a general idea of a psychiatry clerkship timeline and will vary among different medical institutions and programs.

  • Inpatient service schedule
    • 07:00–09:00 a.m.
      • Arrive early for pre-rounding.
      • Check on assigned patients.
    • 09:00–09:30 a.m.: Attend meetings with the interdisciplinary team.
    • 09:30–noon: Attend roundings.
    • Noon–01:00 p.m.: lunch break
    • 01:00–02:00 p.m.: Finish patient notes/other tasks.
    • 03:00–05:00 p.m.:
  • Outpatient service schedule
    • 07:30–08:00 a.m.: Review patient charts with upcoming appointments.
    • 08:00–noon: Attend a.m. appointments.
    • Noon–01:00 p.m.: lunch break
    • 01:00– 04:00 p.m.: Attend p.m. appointments.
    • 04:00–05:00 p.m.: Finish patient notes/other tasks.

Evaluation and grading

  • Varies among institutions but usually is pass/fail, and (typically) also high pass and honors. It consists of:
    • Clinical grade
    • Examination (usually shelf exam)
    • Possibly other assignments

AMBOSS study plan

  • AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including psychiatry: https://go.amboss.com/psychiatry [2]

Clinical tasks

Objectives

By the end of the psychiatry rotation, a medical student is expected to have a good understanding of the following:

  • Practical skills
    • Conducting a systematic psychiatric interview
    • Performing and documenting a comprehensive MSE
    • Providing psychiatric patient counseling (including motivational interviewing)
    • Displaying professional conduct and empathic attitude towards all psychiatric patients and their families
    • Establishing a therapeutic alliance with less compliant psychiatric patients (e.g., psychotic, aggressive, or suicidal patients)
    • Accessing and interpreting psychiatric evidence-based data and scientific literature
    • Performing a differential diagnosis between primary and secondary causes of psychiatric disorders
    • Being able to collaborate with each member of the multidisciplinary team involved in psychiatric patients care
  • Clinical knowledge
    • DSM-5 criteria for the most common mental disorders
    • Pathophysiology, clinical findings, diagnosis, and treatment of the most common primary and secondary mental disorders
    • Mechanisms of action, major side effects, indications, and contraindications of the most commonly used psychotropic drugs
    • Common drug interactions
    • Most common drugs of abuse and their side effects

Pre-rounding

  • See “Pre-rounding” in the “Clerkship guide” article for more information.
  • When seeing a psychiatric patient, focus on the following:
    • Targeted history and MSE
    • Any changes in symptoms and/or clinical findings compared to previous encounters
  • If you are seeing a patient with previous history of violent/aggressive behavior, remember: safety first!
    • Always leave the exam room door open and/or ask for a sitter or chaperone to be present in the room.
    • Always position yourself near the door and make sure the patient is not blocking the exit.
    • Never wear items such as scarfs, ties, earrings, and/or necklaces, as some patients may try to grab them.

When seeing a patient with a history of violent/aggressive behavior, remember to leave the door of the examination room open, position yourself near the door, and make sure the patient does not block the exit. Also, never wear items that the patient could easily pull or grab.

Rounding

  • See “Rounding” in the “Clerkship guide” article for more information.
  • Because of the nature of the psychiatric clinical examination, rounding will usually take longer during this rotation compared to other disciplines.
  • Consider the advice you receive from the multidisciplinary team and be respectful to each of its members; they can offer great insight into your patient's condition.

Notes

General information

  • Clinical notes will usually follow the SOAP format. See “SOAP format for patient presentation” in the “Clerkship guide” article for more information.
  • Ask your attending and resident for the preferred note format.
  • Create your own templates for future notes to save time.
  • Ask for guidance and feedback on your notes.
  • Review any changes made to a note once signed by the attending to identify areas you could improve on.

Common abbreviations for patient notes

Example

  • Subjective: The patient states “They tried to abduct me.” when asked how she was feeling. She denies any problems sleeping indicating that she slept “two lifetimes.” She also mentions that she has not been eating her meals. The RN (registered nurse) notes indicate that the patient was seen talking with herself last night.
  • Objective
    • Vital signs
      • T: 98.0°F
      • P: 80/min
      • RR: 18/min
      • BP: 130/70 mm Hg
    • MSE
      • The patient is dressed in a dirty t-shirt, hospital gown, and mismatched socks. She smells of urine.
      • She makes intrusive eye-contact but cooperates with the examiner.
      • No abnormal movements; psychomotor retardation.
      • The speech is slurred, of slow rate and volume.
      • Her insight is poor and her judgment is impaired.
      • Her stated mood is “exhausted,” and her affect is congruent with her stated mood.
      • She denies having any SI/HI and VH/TH .
      • The patient confirms the presence of AH , stating that she hears “the aliens talking through the chip in my brain.”
      • She indicates that the voices she hears tell her they “want to perform scientific experiments” on her.
      • She displays delusions of control (“They can put thoughts in my head through the chip.”).
    • Cardiovascular
      • RRR
      • No m/r/g/S3/S4
    • Lungs: CTAB
    • Abd: soft, NT , ND , + BS
  • Assessment
    • The patient is a 46 yo F with paranoid schizophrenia who has not improved on medications.
    • She is willing to attempt activities of daily living today (an improvement since yesterday).
  • Plan

Presenting your patient

Orders

Attending conferences

  • Since special group meetings and/or programs play a key role in the treatment of psychiatric conditions, it is highly recommended that you attend those as well (if your program allows it).
  • Some of the meetings and programs you might be able to attend include:
    • Group therapy sessions
    • Family therapy sessions
    • Support groups (e.g., Alcoholics Anonymous)
    • Partial hospitalization programs (PHPs)
    • Intensive outpatient programs
  • See “Attending meetings and conferences” in the Clerkship guide” for more information.

Clinical skills (H&P)

History taking

General information

  • History taking is a very important part of the psychiatric patient encounter and it usually takes longer compared to other rotations.
  • The etiology of every patient's psychiatric condition is unique and thus requires a unique approach to history taking.
    • Familiarizing yourself with the specifics of your patient's disease and its contributing factors (e.g., certain stressors, family history) will help you to understand your patient better and allow you to construct a more well-rounded management plan.
    • Make first observations regarding the patient's behavior, as this will be important for the MSE later.
  • An important goal of history taking is building rapport with the patient.
    • Make the patient comfortable:
      • Choose an appropriate location: quiet room, comfortable seating options
      • Minimize disturbances: If possible, mute your telephone and put up a “do not disturb” sign.
      • Limit the number of people present: If possible, it should only be you and the patient.
    • Be compassionate and respectful.
    • Start with open-ended questions (e.g., “How are you feeling today?”), as this will encourage the patient to speak freely.
    • If you want to learn more about a specific detail of the patient's history or guide the patient during the interview, use close-ended questions (e.g., “Do you feel guilty about what happened?”).
    • Make use of reflective listening to ensure that you have understood everything correctly and to show the patient that you are listening.
    • Avoid using overly complicated language/medical terminology.

An important goal of psychiatric history taking is building rapport with the patient.

Interviewing psychiatric patients usually takes longer than interviewing patients during other clinical rotations.

History of the present illness

Keep in mind that the order given below is not fixed. If the patient does not feel comfortable talking about their psychiatric symptoms, you can start the interview with less intimate topics that would help establish a connection with the patient (e.g., social history, family history).

  • General information: age, gender, ethnic and cultural background
  • Source of information: patient or a family member/friend
  • Chief symptoms: should include the patient's own words
  • History of the present illness
    • Symptoms
      • Presentation
      • Duration
      • Severity
      • Longitudinal development: episodic, chronic
      • Modifying factors (e.g., stress)
    • Reason for patient's visit
    • Effect on social and occupational functioning
    • Neurovegetative symptoms: changes in appetite, weight, sleep, energy, sexual functioning
    • Features of specific psychiatric illnesses (e.g., pertinent positives and negatives)
    • Current substance use
    • Suicidal ideation or homicidal ideation
  • Psychiatric history
    • History of psychiatric conditions
    • Previous psychiatric hospitalization: when, where, and why
    • Use of psychotropic medications: drugs, dosages, effectiveness, and side effects
    • Suicide attempts or self-harm: why, when, how
    • Past medical records available to consult
  • History of substance use
    • For each used substance:
      • Age of first use
      • Recent and lifetime usage
      • Frequency and quantity: minimum, maximum, average
      • Route of administration: oral, IN, IV, IM
      • Consequences of use: health issues, family problems, job demotion, civil disobedience
    • Association between substance use and psychiatric symptoms
    • History of withdrawal symptoms
    • Attempted sobriety/participation in rehabilitation programs
  • Medical history
    • Current medical problems
    • Neurological history (e.g., head trauma, seizures)
    • Medications: both prescribed and over-the-counter
    • Allergies
  • Developmental history
  • Social history
    • Education and employment
    • Place of residence and who they live with
    • Relationships: marital status, friendships
    • Number of children
    • Support system: family, friends
    • Religious or spiritual beliefs
    • Sexual history and sexual orientation
    • History of trauma or abuse: verbal, physical, sexual
    • Legal history
  • Family history
    • Background: ethnic, socioeconomic, religious
    • Psychiatric disorders
    • Familial diseases
  • Emergency contact information

Adjust the interview on a case-by-case basis, as each psychiatric patient is unique and thus requires a unique approach.

Mental status examination (MSE)

Do not confuse the Mental Status Examination (MSE) with the Mini-Mental Status Examination (MMSE). The MSE is used to thoroughly assess the behavioral and cognitive functioning of psychiatric patients, whereas the MMSE is used as a screening tool for dementia.

Physical examination

Top 10 psychiatry topics

Appropriate professional conduct

  • Be compassionate and respectful: Under no circumstances is it acceptable to make fun of the patients.
  • Do not worry if a patient asks you to leave the room: Some patients might feel ashamed about their condition or specific details and do not want students involved in their care.
  • Patients may lie to you
    • Try to remain objective.
    • Report back what the patient told you and explain to your team why you think the patient may have lied.
    • Do not confront the patient, but try to understand why the patient may have concealed the truth.
  • Under no circumstances confront patients about their delusions: It is more advisable to express confusion and ask for clarification in the politest way possible (e.g., “I am confused, I thought ….; could you help me clarify that?”).
  • Try not to be easily offended: Psychiatric patients may speak to you in a disrespectful manner. Remind yourself that it has nothing to do with you, and is most likely because the patient is in a bad place at the moment.
  • Try to de-escalate tense situations: Remain calm and try your best to calm down agitated patients.
  • Be aware of your language and affect: If you look anxious, patients might feel similar and respond to that with aggression.
  • Do not hesitate to ask for help if you are unsure about something.
  • Listen to the nurses: They spend more time with patients than you do and therefore may have a lot of valuable information. It is possible that patients have told the nurses something they did not tell you.
  • Never forget to do a risk assessment: While it may be uncomfortable, it is absolutely essential to ask patients about thoughts of suicide, self-harm, and thoughts of harming others.
  • Remember that safety comes first: Be cautious with patients who have a history of violent/aggressive behavior. Ask the staff for guidance when you are about to interview a patient with such a history.
  • Humor, when appropriately applied in the clinical setting, can help build patient rapport and trust. Remember, though, that this approach might not be applicable to every psychiatric patient and therefore should be used with caution.
  • See “Appropriate professional conduct” in the “Clerkship guide” article for more information.

Evaluation and grading

General considerations

  • Determinants of your psychiatry clerkship grade vary both by school and program but generally comprise:
    • The clinical grade, which consists of:
      • Evaluation of clinical performance by preceptors (attendings, residents, and interns)
      • Observed H&P
      • Patient presentations
      • Patient write-ups
      • Admission orders
      • Clinical logs
    • Examination: consists of a standardized shelf exam and/or sometimes in-house exams
    • Additionally, programs may have graded final projects for the clerkship, such as a case report or lecture on a patient's rare disease/presentation.
  • See “Evaluation and grading” in the “Clerkship guide” article for more information.

Top tips to impress your preceptors

General tips

  • Ask about the dress code: in most psychiatric facilities, residents and attendings will not be wearing a white coat in order to avoid stigmatization and reduce the power dynamic between patient and physician. In some settings it is advisable for students not to wear a tie; patients may become aggressive and seek to grab it.
  • Master performing an MSE as you will be conducting it on a daily basis. Remember that you will only learn how to do it properly by actually doing it.
  • Do a thorough assessment of social history since it often yields essential information that will help you in establishing the right diagnosis and treatment options.
  • Respect the less hierarchical structure of the psychiatric multidisciplinary team. Besides gaining your preceptor's trust and respect, you will also learn a lot from them, allowing you to take better care of your patients.

Preparing for questions from attendings

  • A comprehensive review of patients' charts is often the key to answering several questions that may come up during rounds (e.g., questions about the patient's current medications or medical/psychiatric history).
  • Read supplemental information about your patient's working diagnosis (e.g., if your working diagnosis is schizophrenia, you can anticipate being asked about the risk factors, diagnostic criteria, exam findings, workup, and treatment of schizophrenia).
  • Familiarize yourself with psychotropic medications: You will most likely be quizzed on the side effects, mechanisms of action, and the most frequently used drugs for specific conditions. This will also help you in your psychiatry shelf exam and in Step 2 psychiatry questions.
  • See the “Clinical evaluation: how to impress your preceptors” section in the “Clerkship guide” article for more information.

Psychiatry shelf exam

General information

  • The psychiatry shelf exam assesses a student’s ability to diagnose and treat psychiatric illnesses.
  • Success on the exam depends on what is learned during the psychiatry clerkship in addition to coursework and dedicated study time.
  • It is generally regarded as the least challenging shelf, although that does not mean students should limit their study time.
  • The exam will also incorporate knowledge from other shelf exams (e.g., pediatrics, internal medicine, OB/GYN, geriatrics) and touch on psychiatric medications and their adverse reactions.
  • The shelf exam shares a similar interface as the USMLE or COMLEX exams, with each question presented as a hypothetical clinical scenario.

Shelf exam content [3]

The knowledge tested during your psychiatry shelf exam can be grouped according to the following criteria:

Tips for the psychiatry shelf exam

Remember the differences between schizophrenia, schizophreniform disorder, schizotypal personality disorder, and schizoid personality disorder.

AMBOSS study plan

AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including psychiatry: https://go.amboss.com/psychiatry [2]

Resources

AMBOSS

Use AMBOSS both as a clinical companion on the wards and a reliable study guide for your psychiatry shelf exam.

  • Access about 60 articles related to psychiatry in the knowledge library when you are with patients or rounding with your team.
  • Practice for the shelf exam with more than 270 questions in the Qbank.
  • Curated study plan (see AMBOSS study plan above)

Reading material

  • American Psychiatric Association (APA) Practice Guidelines [4]
  • Diagnostic and Statistical Manual of Mental Disorders, 5th edition: DSM-5
  • First Aid for the psychiatry clerkship, 5th edition
  • Memorable Psychiatry/Psychopharmacology, 1st edition
  • CURRENT Diagnosis & Treatment Psychiatry, 3rd edition
  • Case Files Psychiatry, 5th edition
  • Lange Q&A Psychiatry, 11th edition
  • Clinical Psychopharmacology Made Ridiculously Simple, 8th edition
  • JAMA Psychiatry
  • The American Journal of Psychiatry
  • Psychiatric Quarterly

Phone apps

  • Free apps
    • APA Journals
    • Clinical scales
    • Depression
    • Drugs.com Medication guide (paid “pro” version)
    • PAR Assessment Toolkit
  • Paid apps
    • DSM-5 Diagnostic Criteria
    • The Concise Cognitive Screening Exam
    • PsycEssentials

Websites