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Psychiatry Clerkship
Tips and Tricks
Objectives for today
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Overview of sites
Clerkship requirements
Daily schedule
What do you learn on psych?
Self-care
How to study
Extra resources
Location Assignments
3 Weeks of inpatient + 3 weeks of other
• Spruce 4: schizophrenia, bipolar disorder, mood
disorder; 3 weeks of inpatient + 2 weeks HUP
consults + 1 week pediatrics
• Spruce 6: predominantly mood disorders and
geriatrics + 3 weeks of community health
OR
• 6 weeks of inpatient at VA
Additional requirements
• Observe outpatient clinic with a resident
• Outpatient intake at the VA
• On Call 2-3 evenings at either at psych
emergency room (PEEC or CRC)
• 1 formal patient write-up
• 1-2 topic presentations
Daily Schedule - Inpatient
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Generally arrive between 7-8 am
Prepare progress notes for that day
- Record patient vital
- Record diagnoses
- Record any changes
Round with your team on patients
Sit-down interdisciplinary rounds, discharge planning:
present each pt
Finish up any work for the day
Intake new patient if applicable
Daily Schedule - Consults
Team Rounds generally at 8 am
- ask about pre-rounding on your patients
- give a quick 2-3 sentence update about
what happened between yesterday and
today, and what the plan is going forward
Consults: See 1-2 new patients every day
Follow-ups: Follow your old patients daily
New Patient H&P
Intake: On inpatient, outpatient VA, and psych ED, you will be doing new patient in-take. This
includes:
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Full psychiatric history
Mental status exam
Consult: on consult services you will be completing an assessment of a medical patient about a
psychiatric question. You will include in your presentation:
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Chart review, read previous progress notes, use Medview for previous admissions/discharge
summaries
Full psychiatric history
Full medical history
Discussion with team about why you are being consulted
Physical Exam = VITALS + Mental Status Exam
GOALS for the Rotation
Even if you are not going to be a psychiatrist, this rotation is critical to every
facet of medicine (and life). The academic goals of this rotation should be
to:
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Learn to perform a Mental Status Exam
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Learn to conduct a psychiatric review of systems
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Learn to risk-stratify patients with psychiatric disorders
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Learn to recognize drug toxicities and overdoses
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Learn more about the psychiatric system within the city of Philadelphia
Long term goals of the rotation should include:
• Learning self-care
• Learning how to prioritize
• Learning how the hospital works
The Psychiatric Review of Systems
History of present illness
Depression screen: Sleep, interest, guilt, energy, concentration,
appetite, psychomotor agitation, suicidality, homicidality
Manic screen: Awake for many nights, more sexual encounters than
baseline, more gambling, more drugs than baseline
Anxiety screen
Schizophrenia screen: Tricks of the mind, auditory hallucinations
Past hospitalizations
Medications
Mental Status Exam = ψ PE
ABC STAMP LICK
Appearance
Behavior
Cooperation
Speech
Thought process/thought content
Affect
Mood
Perception
Language
Insight/Judgment
Cognition (Mini-mental status exam)
Knowledge
Mini-Mental Status Exam: 30
pts
Time (Year, season, month, day, date) - 5 pts
Location (State, country, town, hospital, floor) - 5 pts
Ask the pt to repeat 3 objects and remember them - 3 pts
(ATP: apple, tree, penny)
Subtract by serial 7’s or spell WORLD backwards - 5 pts
Ask for all 3 objects named above - 3 pts
Point to 2 objects and have pt name them - 2 pts
Repeat “No ifs, ands, or butts” - 1 pt
Follow command: “Take the paper in your right hand, fold it in half and put
it on the floor.” - 3 pts
Read and obey the written words: “Close your eyes” - 1 pt
Write a sentence - 1 pt
Copy a design (interlocking pentagons) - 1 pt
Patient Interactions
Be open
Be honest
Be non-judgmental
Be PATIENT
Stay safe
Don’t wear a tie or a stethoscope
Never put the patient between you and the door
Topic Presentations
• Start with a summary source (UpToDate)
• Be focused! Brevity is the soul of wit here
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more than ever.
Make a handout. But say more than is on the
handout
Incorporate actual evidence: UpToDate is a
great place to find references, then you can
quote the actual papers
End strong: Zinger, 3 take away points
WHY Self Care
Self care is key in psychiatry. Many parts of psychiatry can
be emotionally exhausting because:
• Patients are often your age and very ill
• Patients may have refractory illness
• Patients may do or say things that seem insulting or
offensive
• Patients may be the victim of offense or insults
• Patients can lose their decision power
• Patients’ experience may conjure up personal
experiences for you.
WHAT Self Care
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Develop good patterns now: If you set up good patterns of selfcare now, they will help you in prioritizing the rest of your year.
You have more time on Psych to continue both self-care AND
study.
Tips include:
- Continue to exercise
- Continue to eat/food shop
- See friends, loved ones, family
- Make time for reflection
- Seek out mental health providers if needed/desired
- Discuss with Dr. Dube etc. events
- Don’t study if you are not studying.
Will I have time?
YES.
Schedule on inpatient:
- Inpatient time from 7-3PM
- Study/patient research 3-4:30PM
- Free time from 4:30-10PM
- Study on Saturday, 12-3PM
Schedule on consults:
- Inpatient time 8-5PM
- Study/patient research 5-6PM
- Free time 6-10PM.
Study Tips
• Pay attention in didactics
• Ask attendings to teach you in their
downtime
• Do questions
• Become familiar with the question format
• Understand the medical causes of
psychiatric issues
Example Shelf Questions
An 18-year-old male presents to the emergency room after being
found in his room, unconscious. The male had been out at a party
according to his parents and had been “acting strangely” on his
return. On exam, he was obtunded, yelling random babbles. His
temperature was 102.6, RR 12, HR 110, BP 140/90. His pupils
measured 8mm bilaterally. His abdomen was tense and a foley
catheter put out >1 L of urine. His skin was warm and dry and. The
patient’s symptoms are most consistent with:
a. Alcohol toxicity
b. Heroine withdrawal
c. Acute psychotic episode
d. Amitriptyline toxicity
e. Cocaine toxicity
Example Shelf Question
A 24 yo male presents to the ED after being brought in by his parents.
According to his family, for the past 2 months, the patient has been
acting strangely. He has become highly suspicious of his meals, only
eating them upstairs, in his room. He has become convinced that he
is being poisoned and refuses to bath for fear that the showers will
poison him further. On exam, the patient is foul-smelling, with
matted hair. His HR is 90, temp 98.6, BP 120/70 and pupil size of
4mm. He is muttering to himself and to the corner of the room and
refuses to make eye contact. The patient’s condition is most likely:
1. Bulimia, complicated type
2. Schizoid personality disorder
3. Schizophreniform
4. Crystal meth toxicity
5. Schizophrenia
Resources
Outline Books:
First Aid for the Psychiatry Clerkship
NMS
BRS
Blueprints
Case files
Question books:
PreTest
Kaplan Q book
A&L
UWorld questions
Supplemental stuff
Supplemental stuff
● UpToDate from Home
● Access the hospital's Extranet at
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https://extranet.uphs.upenn.edu/
Use your MedView username / password to log in
Create a bookmark on your home page for UpToDate
Click on the "+" that's on the far right side of the "Web
Bookmarks" heading
Name your bookmark and put this URL in the URL spot:
http://uphsxnet.uphs.upenn.edu/uptodate
Click on new bookmark that's now on your home page
Use UpToDate like you would from on campus
Don’t let your empathy
get fatigued!!
Taking an extra moment to listen to your
patient is a good way to improve patient
care, help your team, and make the
experience more fulfilling for you.
From your upperclassmen-and-women
It all became worth it when…
“...When I could sit and listen to an elderly man with severe dementia
and depression for as long as he needed to talk.”
“...When a very depressed elderly woman who was a retired librarian
kept mentioning that she wished she had something to read while
inpatient, and during a break I ran out a bought a few books from a
nearby used bookstore for her. It was the first time I had seen her
smile in days.”
Support Systems
Clerkships can be stressful and emotional, but you are never alone.
Suite 100:
- JoMo, Barb, Helene
- Tutors set up through suite 100
Organized counseling:
- CAPS: http://www.vpul.upenn.edu/caps/
- Therapists in the community (Barb from Student Affairs can provide names and contact info)
- Paired mentoring: SNMA, LMSA, Elizabeth Blackwell, House mentors
Other people to turn to:
- Doctoring preceptors
- Advisory deans
- Clerkship directors (it’s really ok to talk to them!)
- Mentors you have connected with in pre-clinical years (through clinics, volunteering, etc)
Friends and family outside of medicine
- Me: [email protected]