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The Royal College of Psychiatrists Improving the lives of people with mental illness

 

Foundation Doctor

Blogs

Imogen Ptacek

 

"I didn’t choose Psychiatry,

but I might do now that I’ve experienced it"

Reflections on how foundation training in mental health may just change your mind

By Dr Imogen Ptacek, FY2

 

Pre-conceptions

 

Two months before starting FY2 I received an email apologising for an administrative error; I was informed that the surgical job I had applied for had been incorrectly advertised, I would be starting in psychiatry instead. I was horrified. In medical school there had been a general feeling that psychiatry wasn’t worthwhile. The history taking seemed obvious and there were so few diagnoses that it felt better spending your time on other subjects. The stigma of psychiatry being a “pseudo-science” persisted into FY1; senior colleagues would take a heavy sigh when referring to psychiatry. Psychiatrists were criticized for avoiding work or not being able to manage physical health problems. When I told other doctors about my situation they commiserated me. Interestingly, none of these doctors had ever done a job in psychiatry. I think the prevailing fear was that I would be missing out on experiences that could actually help me in the future. I already knew that I didn’t want to be a psychiatrist so why would I want to do a placement in it?

 

There were several factors that saved me from being so closed minded. I spoke to three close friends who had done foundation placements in psychiatry.  To my surprise, all three waxed lyrical about their placements and one even wanted to BE a psychiatrist. Shortly after getting the email, my consultant contacted me to welcome me to the post. This, in itself, was a first. It turned out that I’d be working in child and adolescent mental health (CAMHs) with on call work in adult psychiatry. The variety in the workload intrigued me and I was surprised to have a consultant who seemed genuinely interested in my training.

 

The Reality of Foundation Psychiatry and the potential benefits to your training

 

The first thing that strikes me is how wrong I’d been. Psychiatry wasn’t easy. In fact carrying out a psychiatric assessment often posed a greater challenge than any medical examination I’d performed. Imagine sitting in front of a depressed teenager at 2am following an attempted suicide. She has been cleared as “medically fit” and you have to decide whether she is safe to send home. In addition, she has decided that she doesn’t want you tell her parents what happened. Or, imagine how you might manage a discussion with a family of a child with anorexia nervosa who have recently gone through a messy divorce. The child has relatively few pleasures anymore except dancing and you have to tell them that because of her weight she can neither dance nor go to school. The skill of history taking is often undervalued; coaxing out a history of delusionary thoughts or an auditory hallucination without colluding or distressing a patient requires mastery in communication. Regardless what career you choose, good communication will be a prized skill, and in psychiatry, unlike other specialities, you have the time to hone your practice.

 

The training opportunities in psychiatry are substantial. In my post I had 4 hours of group teaching, 2 hours of one-to-one clinical supervision and a weekly Balint Group (to discuss difficult cases) per week. It was refreshing to work in teams that supported learning and development. I found it frustrating that in other foundation posts I was always being asked to “chase” things and my lists of jobs seemed endless. Psychiatry isn’t task oriented, each patient contact can take 1-2 hours and you have time to think things through and discuss ideas. I found that my input was genuinely valued at CAMHs and the experience gave me a good insight into the function of an MDT. I worked with psychologists, nurses and occupational therapists and sought their advice and experience when managing my cases. Likewise they would often seek my opinion on cases they’d seen.

 

My training was incredibly varied; during normal working days I would attend clinics for new CAMHs referrals, perform medication reviews and observe different therapy sessions including CBT and systemic therapy. I also assisted assessments at the paediatric unit and in local schools. During my on calls I covered adult mental health; performing assessments in A&E, admitting new patients and providing liaison advice to the wards for working age, forensic and old age patients. The diversity in the job was challenging but gave me an independence that I hadn’t experienced before. I appreciated being able to experience the full spectrum of mental health services.

 

Despite the significant need for psychiatrists, psychiatry remains an unpopular speciality. One attempt to increase recruitment rates is by increasing foundation trainees. BMJ careers found that 15% of FY2s who had rotated in psychiatry applied for core trainee positions compared to 1.8% who applied after having had no foundation placement1.  Whilst these figures aren’t astounding, they do represent a correlation between exposure to psychiatry in foundation and choosing psychiatry as a career. I can personally attest to this; psychiatry was never a career I had remotely considered, but it now sits up high in my top choices. The fact that psychiatry is relatively unpopular is actually one of its more appealing features. The speciality values its trainees and offers many opportunities for research, travel and flexible training. Ultimately, I’ve opened up to the idea of psychiatry because I found the job interesting and thoroughly enjoyable. In retrospect I suppose I’m quite grateful for the admin error.

 

1.     JacquesH.  Psychiatry experience in foundation years is linked to higher rate of application to specialty training in the discipline. BMJ Careers2013; 16Jan

 

 


 

A Psychiatry Post During The Foundation Years

by Dr Kris Roberts, Foundation Year 2

A foundation year placement in psychiatry is a richly rewarding post, regardless of your chosen specialty.

I entered my first placement as a junior doctor in psychiatry with an open-mind and was rewarded with a diverse placement offering insight into many different areas of mental health and interaction with a truly fascinating patient group.

There are so many benefits for a junior doctor and so many opportunities to take advantage of.

I experienced regular senior feedback, ease of completion of foundation year competencies and a sense of being part of a genuinely patient-centred multi-disciplinary team which is lacking from other specialties. The high level of patient contact offered daily challenges that required a rational approach to address rapidly fluctuating doctor-patient dynamics or declining physical health states.

Indeed, there is no better environment to learn about the complexities of the interface between mental health and physical health than in psychiatry. By implanting myself into the various mental health teams I encountered patients with genetic abnormalities, learning difficulties, addiction or terminal diagnoses, for example, in the same week.

Part of that experience was also identifying what I could not manage on the typical mental health ward; another key skill I developed more readily during my post in psychiatry.

Additionally, I did not appreciate the gravity of the decision to detain under the Mental Health Act and the surrounding processes until I had been involved in the discussions or witnessed a tribunal. This automatically exposes you to the relevant professional bodies. Regular, direct interaction with them breeds improvement in communication skills that is consolidated by negotiating compliance on the ward or delivering difficult news to a family member.

Psychiatry is a very human specialty.

Finally, there are no areas of medicine that are free from the scope of mental health issues; a psychiatry post has benefitted. In my subsequent cardiology and general surgical jobs I have had countless opportunities to utilise the skills honed during that first placement: the patient with anxiety presenting with sinus tachycardia; the patient with long-QT syndrome secondary to diuretic excess in order to control their weight; the patient with chronic, unexplained abdominal pain. There are many more.

If you are entering into a Psychiatry placement, embrace it with open arms; it will reward you throughout your post and beyond in ways you didn’t think possible beforehand.

 


 

Experience of a Foundation psychiatry post

by Dr Charles Eakin, Foundation Year 2

Charles Eakin, FY2

When I tell colleagues, family and friends that I want to be a Psychiatrist, I am often met with a range of reactions ranging from curiosity to astonishment with some degree of sceptical enquiry about my career choice in-between.  I’m also quite certain that the first year medical student version of myself may also be surprised at my decision to pursue psychiatry as a career. As with anything in life; it is our experiences that shape our understanding of the world and how we wish to contribute to it.  As a foundation doctor, I have worked in general adult inpatient psychiatry as well as older persons community and liaison mental health; both at the same hospital where I attended my final year psychiatry attachment as a medical student. Although I have met hundreds of people with mental illness across these rotations; I feel I can best summarise my positive experience of psychiatry by reflecting on my first encounters of it. Please note that some details have been altered to protect patient confidentiality.  

My first introduction to Psychiatry as a student was standing in a corridor of an NHS inpatient mental health unit, reading the words “The voices are just thoughts?” etched onto a plasterboard wall with black permanent marker. The handwriting was barely legible and appeared to have been scribbled frenetically in a moment of great distress by one of the service users receiving treatment there. 

As it transpired, the person behind that jarring written declaration was an eloquently spoken young lady of my age with an arts degree and an enviable travel history.  The consultant spoke at length with her about her adventures abroad and I began to wonder if the wrong person had wandered into the ward round. She began to tell us about her time abroad and after a few interesting anecdotes about the local cuisine she told us about how she wished she hadn’t swam in the lake near her resort for that was how she became infested with larvae which burrowed into her brain and told her to do things. She spoke with utter conviction about this and appeared unable to rationalise the impossibility of such a scenario. From discussion with her family, it became apparent that she had become extremely withdrawn, concentrating poorly at work and neglecting to take good care of herself at home. In all respects, she was struggling to live an independent life. 

As time went on during my placement, she was fully treated and by the end of her 2-week stay on the unit was no longer hearing voices.  She had also regained insight, meaning that she realised the impossibility of infestation with talking larvae.  Witnessing her recovery made me realise how challenging it must have been for her to be so assured of a different reality, which is completely at odds with carrying out her daily functions of living.  

 It then struck me that 100 years ago in this country, or even today in some other countries around the world, this young lady with a bright future may have been committed to a psychiatric institution and may have had little hope of ever being released. Today, people can and do get better from psychiatric conditions when the correct treatment for that patient is used, but public misunderstanding and stigma towards mental illness is a real barrier to progress for many of those living in the community with poorly understood diagnoses.  Treatment is most successful when it is person-focused and collaborative, involving input from a wide array of different professionals alongside the psychiatrist; including social workers, community mental health nurses, psychologists, occupational therapists and others. The effects of mental illness are often devastating to a person’s life as well as their aspirations and not to mention the great impact on their loved ones.

I soon realised from meeting other patients on the ward that every person I encountered had an entire narrative surrounding them and although some service users had the same diagnosis written in their notes; the effects and treatment of that diagnosis differed greatly between individuals. I favour this individualised approach over formulaic guidelines which are often used in medical and surgical jobs.  This is best summed up with a maxim used frequently by one of my bosses: “to know your patient is to know their illness”.   

Psychiatry is a young medical specialty which satisfies the itch for those of us who favour a hospital specialty with added emphasis on the humane aspects of medicine and use of bespoke treatment plans for each patient.  It affords vast opportunities for research into new treatments as well as building evidence for existing therapies. Sadly, it is still sometimes seen as a marginalised medical specialty and the wider problems of social stigma of mental illness within the public view remain an ongoing cause for concern. Regardless of stigma, 1 in 4 people in the general population will be affected with mental illness at some point in their life and a proportion of those people will need significant intervention to facilitate recovery. I am delighted to have gained a training post in core psychiatry to build my skills in providing these interventions as well as giving hope to those distressed by mental illness.  I would urge others to consider the same! 

 


 

Psychiatry from a junior doctor’s perspective

by Dr Mitesh Patel, Academic Foundation Year 2

I had the pleasure of completing a four month rotation with an innovative liaison in patient psychiatry team in Birmingham. After medical school, it was the post which I was most excited about as it offered me the opportunity to build upon my undergraduate psychiatry experience and learn about a fast developing, increasingly recognised speciality.

Diverse opportunities in work

Working in a busy, inner city hospital allowed me to see a range of presentations including acute psychosis, drug overdose, depression, delirium and dementia. My role included clerking patients in the emergency department, managing patients on the wards, discussing the need for mental health assessment and prescribing medications. This was unique compared to my medical and surgical rotations as I also undertook clinics on a weekly basis.

 

Multidisciplinary care

I was often asked by my non psychiatry colleagues for a review of their patient, including those in the intensive care unit, which was always a challenge! My input would be needed in best interest meetings and psychiatry involvement was key in the handover in the emergency unit. I would work in a memory clinic alongside an elderly care consultant which would integrate physical and mental health care for elderly patients, with the Alzheimer’s Society representative also being present. Dermatologists would refer patients to my general psychiatry clinic for patients starting isotretinoin with a mental health background.  

 

Memorable case

I will always remember a case of psychomotor retardation in severe depression which was initially diagnosed as advanced Parkinson’s disease. Alongside this difficult diagnosis, a conflict arose with the nearest relative for the need for electroconvulsive therapy. Psychiatry provides challenging scenarios where your learning grows exponentially.

 

Research opportunities

Psychiatry offers huge research opportunities, especially in old age psychiatry which is an area that I focused on. I had the opportunity to carry out a psychiatry screening study in the acute medical unit and an observational study looking at the effect of haemodialysis on cognition. There are also opportunities to overlap research projects with other specialities.  I was shortlisted to present my memorable case at a national geriatrics meeting. Alongside this my research gained me four prizes including a national psychiatry trainee award and a deanery foundation year 1 award.

 

Royal College of Psychiatry Award Nomination

I was honoured to be shortlisted for the junior doctor of the year award 2014 and it was recognition of my hard work and ambition to improve the overall care within mental health. The awards ceremony was a humbling experience and it was fantastic to see all members within psychiatry being recognised for their tremendous work.

 

Conclusion

The skills and experience I learnt throughout my psychiatry rotation were fundamental to my achievements in the foundation programme. I enjoyed seeing a variety of clinical presentations, managing my own case load, making decisions and being involved in research. I would certainly advise that all trainees get postgraduate experience working within mental health, as the increasing incidence of mental health presentations means that we will all manage such patients in our duty of work.

 

Dr Mitesh Patel is an academic FY2 in Birmingham has completed four months of psychiatry working with an inpatient liaison team. He led a research team identifying cognitive decline amongst haemodialysis patients and has applied for NIHR funding for a multicentre psychiatry project. Mitesh has submitted three first authored psychiatry papers, presented this research at two conferences and attained a national psychiatry prize and FY1 Deanery Trainee Award.

 

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Contents

Psychiatry from a junior doctor’s perspective by Dr Mitesh Patel, Academic Foundation Year 2

Experience of a Foundation psychiatry post by Dr Charles Eakin, Foundation Year 2

A Psychiatry Post During The Foundation Years by Dr Kris Roberts, Foundation Year 2

"I didn't choose psychiatry, but I might do now I've experienced it"   by Dr Imogen Ptacek, Foundation Year 2