Welcome. Please ask questions when in doubt. Here’s an outline of the key features of our outpatient-based rotation. Inpatient folks, read on, please. Several of the tools below should be of use to you, e.g. Maps and One-pagers. And do read the section on Seminar, Required Reading.
We expect that about two thirds of your day should be involved in some sort of patient care: either providing it yourself, or watching someone else do so from whom you can learn. The remaining one third of the day is available to you for reading and pursuing any learning issues that you’ve identified (a burning question sparked by your work with and observations of patients) or projects you’ve gotten involved in. As you’ll discover, there’s a lot to read and consider. You’re expected to do some of this work outside of clinic hours.
Unless other arrangements have been made, start each morning by checking in with your supervisor (Health Psychologist or Attending Psychiatrist) regarding the day’s schedule. You will:
- interview patients to help assemble the database used by the Health Psychologist;
- conduct phone follow-ups and “medical sleuth” chart reviews as needed for the Psychologists and Case Coordinators;
- administer health screenings for mental health problems (mood, anxiety, substance use);
- assist with outpatient psychiatric visits, both initial evaluations and follow-ups
- other tasks as assigned, all of which are selected for their value in your education as well their contribution to the Clinic’s patient care.
Maps and Direction
You will have two Maps to guide your learning, a copy of which you should print and carry with you on this rotation. The Diagnosis Map lays out, by category, most common mental illnesses. Likewise, the Medications Map categorizes psychiatric medications (in part simply to help you see all the generic names and trade names side by side, by category).
As you see patients with a given diagnosis, put a check-mark alongside that diagnosis on your Map. Similarly, when you see a patient being prescribed a new medication you’ve not encountered before, look it up and compare the PAR you hear the doctor give to the Up-to-Date presentation, or other similar reference (e.g. warnings, contraindications, common side effects, starting dosage and titration), then put a check-mark alongside that one on your Medication Map. Thus you’ll have an ongoing quick reference for what you’ve seen and what you’ve not seen yet. One of your colleagues made a table of dosing/side effects/warnings-considerations for each major class and filled that in for specific medications as she went along; consider that.
At the end of every day, think about the patients whom you saw that day. Pick a diagnosis from your map, based on a patient whom you saw, and take 20-30 minutes to review basics about that diagnosis. DSM criteria and treatment options are the most important, but you can include things like
- Epidemiology (particularly prevalence)
- Etiology/Pathogenesis (what’s the current working understanding of what causes this condition?)
- Differential Diagnosis (what looks similar that you have to rule out or differentiate from?)
- Risk Assessment (how dangerous is this condition? How do you evaluate that, in a given patient?)
- Practical Challenges (what are some of the things that make handling this condition tricky, in practice? How can those be handled? E.g. contraindications, warnings, roadblocks to good outcomes)
Having taught yourself some of these basics (and maybe not so basics), now create a 1-page summary of what you learned. This is for you, not for us. This is to help you pass your Boards. This is to drive this material far enough into your hippocampus that some of it will still be there a year from now. This is to allow you to be creative and follow your nose in terms of what you want to learn. Hopefully the patient whom you saw will make you want to know some or a lot of these things. Use that.
Depending on how busy things are, you and your supervisor may go over some of your 1-pagers but remember, this is for you, not for your evaluation. (Yes, of course it will have an impact on your overall evaluation if you don’t follow through on this. But DO NOT go hog-wild here trying to impress. This exercise is for you. Use whatever you think will help make it stick (pictures, diagrams, comparison tables, stars, arrows — or text). Have some fun and think of that patient.
After you finish your one-pager, circle that diagnosis. We’re aiming for circles around all the diagnoses that appear in Bold on your Map; at least a few more circles beyond that.
Primary Care and Specialty Clinics
Our inpatient psychiatry program and staff is very good. Feedback from students rotating there has been very positive.
At the same time, consider: Twice as many people with mental health problems see a primary care physician than see a psychiatrist (NEJM, 2005). Few of you will become psychiatrists, but many of you will become primary care physicians. So where does it make more sense to learn about mental health care, a primary care clinic or a psychiatric inpatient unit?
That is our logic for this outpatient rotation: about half of your time will be in a primary care setting, working with the Health Psychologist who is an integral part of the clinic team. You’ll may also work with the Care Coordinator who delivers many of the psychosocial support services in the clinic. The rest of your time will be in one of several psychiatry specialty settings, to give you a sense of how psychiatrists work.
You will be given a schedule for the first two weeks as you begin the rotation, indicating the clinic where you’ll be expected, on what day, and who your supervisor will be for those days. If in doubt, look for the Health Psychologist at the Primary Care Clinic, or the Attending Psychiatrist at Samaritan Mental Health.
On other mornings you’ll go instead to a psychiatric setting which will be noted in our first emails to you. These include Child, Outpatient Adult, Linn County Mental Health, and others we’re still generating.
Your teaching team is well aware that “doing” beats “watching” much of the time. We are also aware that this rotation can be long on watching and short on doing. On a psychiatric inpatient unit, where students have commonly rotated in the past, there was often more doing than you may encounter on this rotation, but far less breadth or relevance to the general practice of medicine. In exchange, our intent is to expose you to problems more likely to be relevant in your future practice, and to the treatment of mental health problems by a primary care team, the cornerstone of our emerging new medical care system.
Nevertheless, our hope is to provide you with multiple opportunities to interview patients and apply some of what you’re learning about basic psychotherapies. We will help you expand your ability to connect to patients as you gather information; and do so using good reflective listening skills and “good GEW”: genuineness, empathy and warmth. Ask for feedback from your supervisors (including residents) about your skills so that you may improve them as you go.
One half day a week you’ll all gather at the Home Office (i.e. Samaritan Mental Health. What, you don’t read British murder mysteries?) We’ll review cases you’ve seen, and thorny questions that arose as you were writing up 1-pagers, and we’ll do some psychotherapy exercises to help you work on your skills (easier than you think, perhaps). Some of you may attend these Seminars using televideo equipment, depending on how far away you are. These sessions will be led by Dr. Phelps and friends, including current Psychiatry residents and Behavioral Specialists from primary care clinics.
These seminars will also give you an opportunity to talk with your MS3 colleagues who are flung about in other clinics.
Aside from a basic guide to Psychiatry such as the Blueprints guide, we have only one required book. We think it’s so important, we’ll give you a copy to use on this rotation: Motivational Interviewing, by Stephen Rollnick. Read the whole thing. You should see it happening in interviews you observe, on a daily basis. This skill takes a while to learn, and when you’re interviewing patients, you may not have any extra brain bandwidth for working on this (in addition to Good GEW and reflective listening, although as you’ll see, those are a significant part of Motivational Interviewing). However, as noted below, the ability to recognize MI is required for your examination performance.
How You’re Evaluated
- An evaluation from your primary rotation contact(s) (Psychologists, Attending Psychiatrists)
- Diagnosis and Medications Maps maintained and used
- 1-pagers created
- Project contributions, if any
- Exit examination
Maps: the idea is to see what you’ve learned. There is no grade attached nor penalties for having uncircled diagnoses or un-checked medications! Our expectation is that you’ll have circles around the Bold diagnoses, and at least a few more, with one-pagers to match.
One-pagers: your supervisor may look at your collection and pick out 2-3 for review, also random, and based on her/his interests. If there is time you may review them with your attendings but not for grandstanding purposes (we’re therapists, we will probably know).
Projects: if you were involved in any particular Clinic projects, please write a brief (like one page) summary of what you did. This includes passing along any instructions or guides for your MS3 colleagues who follow behind you. You can get a passing grade without doing a project. But it is a way to feel like you’re making a contribution to the Clinics.
Use the Resources on the Medical Students Home page for further information.