4. Psychiatry Core Clerkship

Mission and Introduction

The mission of the core clerkship in psychiatry is to provide students a clinical experience that will prepare them to understand, evaluate and treat the entire spectrum of mental disorders in a context defined by an attitude that displays professionalism, compassion and cultural sensitivity. The clerkship builds on a foundation of medical knowledge; adding clinical and communication skills enables the student to understand behavioral problems using the bio-psychosocial-cultural model and to construct viable treatment plans.

After completion of the six week core clerkship during the third year, students will demonstrate sufficient strength in three domains – medical knowledge, clinical skills and professional behavior – required to evaluate and participate in providing care for people with mental disorders in a multidisciplinary setting. Additionally, students are expected to take from the psychiatric clerkship an appreciation of the multi-factorial aspects of health and illness in general and the relationship between biological, psychological, psychosocial, cultural and medical aspects of health and illness that will enhance proficiency in clinical situations with all patients. Finally, the clerkship offers students the opportunity to decide if a career in psychiatry is right for them and offers guidance on succeeding in residency training and in professional development.

Educational Objectives

Educational objectives are met by engaging in a combination of didactic study and supervised clinical experience. The specifics of the clinical experience are described more fully below. Essentially, students are assigned to one or more interdisciplinary clinical teams during their clerkship and will learn to perform a psychiatric evaluation, to construct a diagnosis and to formulate a treatment plan by participating in these activities along with other members of the team and under the direction of their preceptors.

Didactic study will include multiple activities, including classroom activities such as lectures, seminars, and student presentations, as well as self-directed learning activities such as reading and working from the Department’s web-based curriculum. Approximately 30% of the Clerkship should be allocated to protected academic time for teaching conferences and structured independent study. The curriculum includes an introduction and orientation to the clerkship and requirements of the clerkship; a review of the mission, goals, educational objectives and study topics described in this manual; study material and links to useful websites for further study; quizzes and practice tests; a description of the mid-core assessment and the written exam.

Medical Knowledge

• Identify and define a broad spectrum of psychopathology, taking into account multiple factors including age, phase of life, sex, ethnicity, culture, religious beliefs, co-morbidities and experiences of trauma including abuse.
• Construct a formulation and comprehensive differential diagnosis using a bio-psychosocial-cultural approach and applying principles of critical thinking to clinical material. Include a consideration of the direct impact of physical problems and substance abuse as well as of secondary psychological effects of these.
• Demonstrate knowledge of the major indications for the use and side effects of commonly prescribed psychiatric medications. Demonstrate knowledge of behavioral side effects of commonly prescribed medications and substances of abuse. Demonstrate awareness of principles of safe prescribing. Demonstrate knowledge of appropriate laboratory tests to be ordered.
• Demonstrate basic knowledge of concepts of psychotherapy, including supportive, psychodynamic and cognitive-behavioral.
• Demonstrate knowledge of when to make referral to psychiatry and how to utilize the input of the consultant.
• Demonstrate an awareness of system failures and disparities in health care delivery, for example, the influence of gender, race, immigration status and economic status on diagnosis and access to health care.
• Demonstrate knowledge of bioethical issues arising in psychiatry such as privacy, confidentiality and professional boundaries.
• Demonstrate knowledge for obtaining appropriate consents for treatments and procedures.
• Demonstrate knowledge of how to evaluate a patient’s capacity in meeting the requirements of everyday life.

Clinical Skills

• Conduct a diagnostic psychiatric interview demonstrating empathy and an ability to form a therapeutic alliance, to elicit valid and reliable information, including in potentially sensitive areas such as sexual history or history of trauma.
• Demonstrate ability to utilize a patient centered approach to care.
• Organize and present a full psychiatric history and mental status examination, including using critical thinking to construct a formulation, differential diagnosis and treatment plan.
• Evaluate and participate in the management of psychiatric emergencies, including the assessment of suicidal, dangerousness, intoxication and withdrawal syndromes. Demonstrate understanding of safety/risk assessment.
• Communicate with patients and families, as well as with other health care professionals, in an empathic, informative and professional manner.
• Function effectively as a member of the multidisciplinary treatment team.

Professional Behavior

• Demonstrate cultural competency and sensitivity to differences in all aspects such as race, ethnicity, immigration status, sex, sexual orientation and socioeconomic status.
• Demonstrate compassion towards patients and their families, even when presented with significantly disturbed behavior and verbalizations.
• Demonstrate awareness of one’s own limits and biases and ways in which these may affect relationships with patients and staff and delivery of patient care.
• Demonstrate awareness of and willingness to seek consultation and supervision and to incorporate these into future practice.
• Demonstrate a commitment to life long and independent learning.
• Demonstrate awareness of need to advocate for patients and to seek to reduce stigma associated with mental illness.
• Demonstrate behavior consistent with the setting and maintenance of professional boundaries.

Guidelines

In addition to general requirements expected of students in any rotation, students in psychiatry are expected to:

• Length: Six Weeks
• Attend all assigned clinical activities
• Attend all assigned educational activities, including in their clinical area, e.g., rounds, and in the department, e.g., Grand Rounds
• Be on call as assigned
• Complete two to four comprehensive case write-ups and one focused write-up, as assigned by the preceptor and submit them in a timely manner

Study Topics

The following list of study topics is intended as a guide for the student to supplement the basic curriculum of lectures. It is not intended to be an exhaustive or exclusive list.

Evaluation and assessment

• Bio-psychosocial-cultural model
• Psychiatric interview; collateral sources of information
• Mental status exam
• Capacity and competency with regard to medical decision making
• Indications for and interpretation of relevant laboratory testing, e.g., substance screening, endocrinological tests, and consultations with other physicians
• Medical and neurologic assessment
• Indications for and use of results of psychological and/or neuropsychological testing

Psychopathology

• Psychopathology of major disorders, including substance use disorders
• Classification systems and differential diagnosis

Management

• Psychopharmacology
• Psychotherapeutic approaches
• ECT
• Interdisciplinary treatment team
• Psychiatric emergencies, including assessment of suicidal and dangerousness
• Intoxication/withdrawal syndromes.
• Civil commitment and treatment refusal
• Management of psychiatric disorders in medical/surgical patients

Communication

• Communication in layman’s language and patient/family education
• Empathy, rapport, therapeutic alliance
• Communication with the interdisciplinary treatment team

Professional behavior

• The impact of culture and self-awareness
• Professional ethics, informed consent, confidentiality and privacy
• Professional boundaries

Reading

The most recent editions of the following textbooks are recommended:

• Synopsis of Psychiatry, Kaplan and Kaplan, Lippincott, Williams & Wilkins
• Introductory Textbook of Psychiatry, Andreason and Black, APPI
• Oxford Textbook of Psychiatry, Gelder et al., Oxford Medical Publications
• Psychiatry, (second edition), Cutler and Marcus, Oxford University Press
• DSM V, American Psychiatric Association, APPI

Students are encouraged to seek additional reading, including journals such as the American Journal of Psychiatry as well as web-based resources and recommendations from their preceptors.