Psychiatry and Beyond

As 2017 draws to a close, it’s amazing to think of how much ground we have covered and how much we have learned since the start. We are now coming to the end of our eighth Specialist Clinical Placement this year, and once again it’s been a fascinating tour through a part of medicine that we’ve not had much exposure to up till now.

After spending the first three weeks of the block on a community psychiatric placement, we have spent the past two weeks learning about old age and acute psychiatry. Most of the care that we have had in these two sections has been ward-based, and we have had the opportunity to see some very interesting presentations of a more acute nature. These tend to be patients who have been asked to remain confined to a ward for their own good, as they pose a danger to themselves or other people and are in clear need of treatment. The legal process that doctors are required to go through in order to detain someone are very robust, and I think that this process is crucial to a beneficial and defensible medical service.

It’s easy to think of medicine in discrete blocks: a patient with a heart problem is only a heart problem, a patient with bipolar disorder is only bipolar disorder, etc. But what we have seen a lot of in this block is patients with multiple mental-health and physical-health comorbidities presenting at the same time. We have been able to see why psychiatry requires a strong foundation in physical medicine – doctors need an in-depth knowledge of physiology in order to understand side-effects of drugs and physical causes of mental ill-health, among many other things. Although my stethoscope isn’t getting much exposure during this block, the potential to use it is always there. Next week is our final week on psychiatry (and actually on Specialist Clinical Placements altogether!) and I’m really looking forward to what it will bring.

Along with several thousand other hopeful final-year medical students around the country, we sat our Situational Judgement Test exams last Friday. This is a relatively new assessment (in the past five or so years), which plays a large role in determining where we will go for our foundation-programme placements. We were presented with dozens of ethical scenarios and asked to respond to each, and even though Warwick Medical School do a really good job of preparing us for the exam (as much as they can), I think it’s fair to say that there’s no more preparation I could have done to have performed better or worse. It’s just so tough to prepare for this exam – I guess that’s the point, though! We’re expected to react instinctively and be evaluated based on this judgement. We won’t know the outcome until early March when we are given our foundation-programme placements.

And very soon our Specialist Clinical Placement blocks will draw to an end entirely, leaving us in the run-up for finals. It’s been a long road and a very busy year, but I’m looking forward to seeing what the next chapter brings!

Joshua Galvin : 13 Dec 2017 16:53 |  Tags: John Mbchb Student Warwick Wms |  Comments (0) |  Close comments |  Report a problem

One exam down…only a gazillion more to go

First exam done! All Warwick students sat the national Situational Judgement Test (SJT) last week. This is an exam that makes up 50% of our total score for our Foundation job applications so while it doesn’t test your medical knowledge it’s still very important! The SJT focuses more on the qualities expected of a doctor and how you handle difficult situations that we will be faced with such as confidentiality issues, explaining mistakes to patients and prioritising our workload. It’s a tricky test to prepare for so I’m glad it’s out of the way.

Apart from SJT practice I’ve still been enjoying my musculoskeletal block, we’ve been in the plaster room practicing putting casts on each other and I’ve also been in the trauma theatres. A day with the trauma team starts early with the 7.30am trauma meeting where all the traumas that came in the previous day are discussed and operations planned and prioritised. The team on call then head off to fracture clinic and the junior doctors respond to any trauma bleeps from A&E. The following day the same team then is in the trauma operating theatre doing any operations that are required on trauma patients that have come in over the previous few days. The day that I was in theatres we had a huge variety of different hip fractures, an unusual fracture in a teenager and then more common types of hip fractures that occur in the elderly. When we first learnt about falls in the elderly and hip fractures in second year I could not believe how much they cost the NHS with some studies suggesting they cost £1 billion per year, they are also a significant cause of mortality with a significant proportion of elderly patients not surviving even just 1 month after a hip fracture. All the studies show that if you treat a hip fracture quickly the mortality goes down no matter what the age of the patient is. For that reason, we had patients in their 90s on the trauma list to fix their hip fracture to preserve their mobility so they don’t become unwell and suffer any further complications.

Operations to fix hip fractures aren’t the most pleasant to watch and there is an awful lot of hammering and banging that makes you appreciate why people are so sore after their operation. I don’t have the best track record when it comes to fainting in theatres so I was slightly apprehensive about attending trauma theatres. So far during medical school I’ve hit the deck on a ward during a chest drain insertion as well as in theatre during a C-section, both times staff were lovely and understanding but both times I was completely mortified so I ate the biggest breakfast I could manage before heading into theatres. I must admit then when I was scrubbed up and quite close to the action I did feel quite queasy but I managed to stay standing! Hopefully I’ll have plenty of opportunities to further desensitise myself during our assistantship so I don’t continue to be a falls risk!

Joshua Galvin : 04 Dec 2017 09:57 |  Tags: Joanne Mbchb Student Warwick Wms |  Comments (0) |  Close comments |  Report a problem

Community Psychiatry and the SJT

All of us Phase-III students are now in the third week of our final Specialist Clinical Placement rotation. It’s hard to believe but we’re almost at the end of this year’s formal medical instruction. We’ve all been working really hard and I hope something comes out of it. 2017 has just flown by

We’re about halfway done with our Psychiatry block, and it’s proven fascinating thus far. Of the six-week block, three weeks are meant to be spent in the community, one spent with an old-age consultant, and two on acute care. Our community placement has been in a lovely clinical practice in the community (i.e., not at a hospital) with several psychiatrists (including consultants and registrars), psychologists, and care coordinators all working together for each patient’s wellbeing. I gather that most patients won’t be seen by a psychiatrist unless they are referred by a medical professional or a police officer, depending on the circumstances. We’ve seen lots of varying presentations in the clinics, including severe depression, emotionally unstable personality disorder, paranoid schizophrenia and many other things. And we’ve seen patients at various stages of treatment as well, including new-onset, follow-ups after initial therapy, and some patients who’ve been under treatment for decades and have come in for medication reviews. It’s fascinating to see all of these presentations at once, after having read about them for so long.

Most patients have been really open with me and my clinical partner when we ask them questions about their conditions, including symptoms, duration and treatment of their condition – and it’s great when they are able to help us learn. Elements of the psychiatric history can be quite personal, as they involve intimate details about a patient’s upbringing and social life, and so sometimes it takes some effort to get comfortable posing them, but when you realise that you need to handle an intimate psychiatric exam the same way you’d handle an intimate physical exam – with sensitivity and professionalism at all times, focusing on the patient’s wellbeing – it becomes easier with practice.

Over the next few weeks, we have old-age and acute psychiatric placements. I’m really looking forward to them, especially the acute part. About a year and a half ago, we had an introductory week on a psychiatric intensive-care ward and it was absolutely brilliant. Now that we have gained a lot more medical knowledge, and in particular have spent the past few weeks bolstering our knowledge of psychiatric conditions and how to treat them, I hope it will be that much better and more useful.

Very shortly, members of our cohort will also be sitting the SJT, or the Situational Judgement Test. This is a test that all final-year medical students are required to take before entering the foundation programme, which is hopefully at the end of summer 2018 after graduation. The SJT is designed to assess students’ ethical judgement through asking us to respond to various realistic scenarios. One common scenario presents us with a fictional but realistic hospital situation and asks us to rank, in order of appropriateness, the options on how to proceed. Although you cannot officially revise for this exam, its administrators issue official practice tests, and there is no shortage of revision courses and materials to help us get through. WMS have even included sample SJT questions at the end of our CBL cases as well, which has been very helpful. I’m looking forward to seeing what the exam contains, but more importantly, I’m looking forward to it being behind me!

Joshua Galvin : 27 Nov 2017 16:49 |  Tags: John Mbchb Medicine Warwick Wms |  Comments (0) |  Close comments |  Report a problem

To study or not to study…

Two weeks into my final block and my fellow students and I are counting the days, not until Christmas, but to our exams! I’m already a week behind on my revision timetable and I seem to spend more time thinking about all the time I’ve wasted rather than getting on with my revision!

My last block is the musculoskeletal block. Our year group is split into 7 groups and each one has done the blocks in a slightly different order, so everyone is finishing on something different. Some students are happy they are finishing on General Practice so they can practice and revise almost every subject, other people are glad they are doing Paediatrics or Obstetrics and Gynaecology so that all the information covered in those blocks stays fresh in their mind for exams. Musculoskeletal isn’t a bad block to finish on, this block covers rheumatological conditions which are a favourite of medical school clinical exams and covers orthopaedic surgery so we are seeing lots of patients with osteoarthritis and painful joints, which also come up a lot in our exams. Many rheumatological conditions don’t just affect the joints but have effects on other areas of the body so it’s actually very good revision for other organ systems as well as ensuring my anatomy hasn’t been completely forgotten.

One of our teaching sessions can be slightly nerve-wracking with a consultant who likes to sit in the middle of a circle of nervous students and swivel on his chair and directing questions at us about almost any subject in medicine and surgery! Trying to think of another side effect of steroids when all the ones I remember have been said already or been asked to name 4 causes of clubbing (a clinical sign of disease in the nails) is quite exhausting but it’s also helpful! Our consultant helps us if we are struggling with a range of comedic actions and facial expressions and we all leave with a smile on our face knowing that while we got some answers right, it didn’t matter which ones we got wrong as now we know which areas of medicine we need to work on!

We are also spending time with the orthopaedic team in fracture clinic, seeing new patients as they are sent round from A&E with a variety of injuries. We are getting lots of practice with our history and examination as well as getting the chance to look at some painful looking X rays!

Aside from our MSK block and revision I am also trying to fit in some revision time for the Situational Judgement test, a national exam that will determine 50% of the score I get for job application to the foundation programme. Fingers crossed for the start of exam season!

Joshua Galvin : 21 Nov 2017 09:21 |  Tags: Joanne Mbchb Student Warwick Wms |  Comments (0) |  Close comments |  Report a problem

High security….

With just one 6 week block to go before my last Christmas holiday of medical school its all getting a bit scary. My fellow final year students are all getting a bit jittery at the mere mention of exams and some of us are still in denial that exams are happening at all. Helping at my final societies fayre a few weeks ago it felt strange to be asked what my plans were after graduation, how I had found the course and if I had any tips from eager first years when it doesn’t seem that long ago that I was in their shoes! It was great fun welcoming new students and handing over to the new president of the Psychiatry Society, a society that I’ve enjoyed been part of since I started medical school. I’ve been involved in organising some great events, increasing the size of the society and getting the chance to promote a speciality I feel passionate about. I’ve also met lots of people that will hopefully help in future job applications-perhaps I’m getting a little ahead of myself but its preferable to thinking about exams!

Overall, I’ve really enjoyed my psychiatry block, I’m even more keen to pursue it as a future career and being interested in the subject makes it that bit easier to study! For the last two weeks we have been assigned to a community psychiatrist who specialises in psychosis. It was interesting to be in these clinics where the focus wasn’t on treating every single symptom but on improving their level of functioning so they could remain in the community. To my surprise this often meant that patients had untreated delusions or hallucinations but as the consultant pointed out if the patient is safe and is not distressed by these symptoms then is it worth the risk of unpleasant side effects? On one occasion, a patient presented to clinic acutely unwell and was very agitated, I must admit I was quite nervous and unsure if I should pull my personal alarm (to call for help) but the consultant was able to calm the patient down an arranged to follow them up at home with the rest of his team. I was glad I hadn’t called for help unnecessarily in contrast to the previous week when I accidently set my alarm off and only realised when several people burst into the room!

Dealing with difficult patients is a vital skill in all branches of medicine but especially important in psychiatry, and particularly in forensic facilities. A great thing about the psychiatry block is that we can organise additional placements within different subspecialties, I organised time with the eating disorders team, the perinatal psychiatry team and also arranged a 1 day placement at a local Medium secure hospital. Secure units aren’t just for people who have committed crimes that require psychiatric treatment, some have challenging behaviour that is difficult to manage in normal inpatient settings and there may be a high risk of criminal behaviours. Apart from additional security within the building the ward environment wasn’t very different. Forensic services are different in that patients tend to remain in hospital for longer periods of time and continuity of care is highly valued with the same consultant responsible for their care when they leave hospital as an outpatient. Following up patients over the course of their illness and see someone literally get their life back on track must be very rewarding and wasn’t something I expected to think after visiting a secure unit!

I’m sad to see my 6 weeks of psychiatry come to an end but time marches on-so off I go to my final block, musculoskeletal medicine here I come!

Joshua Galvin : 10 Nov 2017 09:15 |  Tags: Joanne Student Warwick Wms |  Comments (0) |  Close comments |  Report a problem