Rotation Recap: Psychiatry

Although there is a critical need for more psychiatric practitioners across the entire United States, there are many barriers in federal and state legislation and reimbursement issues governing the practice of PAs in psychiatry. Because of this, many PAs do not even consider psychiatric care when applying for jobs. I am no exception to this and do not think I will work in this field however I learned more about patient care, bedside manner, and myself during this rotation than any other.

I am grateful for the preceptors I had during my month at Bryce Hospital, Alabama’s oldest, largest, and only state funded psychiatric institution. At 85 and 77 years old, these two men have truly dedicated their lives to the betterment of patient care in mental health. The providers at Bryce also work closely with Taylor Hardin, Alabama’s only secure medical facility which houses patients who have committed crimes but have either been found not guilty by reason of insanity or who are ordered to undergo pre-trial competency evaluations. Many of the patients have been there since the facility opened in 1981. Some of the patients here and at Bryce had committed violent crimes and we interviewed and treated people convicted of murder, rape, and everything in between. The way that my preceptors treated every single patient, regardless of their history, diagnosis, or behavior problems with dignity, respect, and kindness inspired and humbled me. During this month, I internalized one of the most powerful and profound lessons I have ever learned. My preceptor changed my opinion and preconceived notions about patients (and people in general) with one small sentence.. “Everyone is better than the worst thing they’ve ever done.”

Everyone is better than the worst thing they’ve ever done.

Bryce Hospital has a rich history and has stood the test of time. The original building even stood through the civil war. At one time it housed 5000 patients under the care of only 3 psychiatrists. These dismal conditions and lack of basic care for patients lead to the famous Wyatt v. Stickney trial which mandated minimal standards of care, established basic patient rights, and reduced patient populations. Of course, there are also dozens of reports of paranormal activity, hauntings, and the original building has been featured on Alabama Ghost Hunters and other paranormal sites. I’ll let you decide about that. Now, on to what you really came here for..

How To Prepare

MSE – Be familiar with how to properly perform a mental status examination. It is the psychological equivalent of a physical exam and includes both objective observations that YOU make and subjective descriptions that the patient gives. A good mnemonic so that you remember all parts is ASEPTIC: Appearance & Behavior, Speech, Emotion, Perception, Thought content, Insight & Judgement, and Cognition.

Terminology – Brush up on the difference between things like mood and affect, flight of ideas vs. looseness of associations, tangential vs. circumstantial speech. What does it mean if someone’s speech is “pressured?” There are a lot of words that are only used in psychiatry and might not be as fresh on your mind as basic medical terminology. I used thepocket guide to the DSM 5 and found it to be a very helpful and quick reference.

Ice Breaker – It never occurred to me to think about how I was going to interview these patients. In an emergency medicine or primary care setting you can always say, “What brings you in today?” But in a psychiatric ward where the patient has lived for 10 years that isn’t exactly appropriate. My preceptors often started off with something to the effect of “Tell me what’s on your mind.” The first patient I interviewed was coming from the county jail after a psychotic episode and we sat and stared at one another in silence while I tried to figure out what to say. Don’t let that be you.

Meds, meds, meds – Medication is the cornerstone of psychiatric care (my pharmacology professor said this once)… Many of these medications have a very narrow therapeutic window and require regular blood level monitoring to avoid adverse reactions. There are also very serious side effects associated with antipsychotics and mood stabilizers including irreversible extrapyramidal symptoms, drooling, and metabolic syndromes. Review which medications require kidney and liver function monitoring, blood level monitoring, early signs of developing adverse reactions, etc. Find out the reference ranges for therapeutic blood levels at your facility.

What to Expect

Keep in mind that what you should expect will be very different depending on where you’ll be rotating or practicing. The inpatient state facility will drastically differ from private practice, outpatient psychiatry, or community mental health centers.

Suicide – Get comfortable talking about suicide. It’s surprisingly difficult to ask someone if they’re considering taking their own life or about prior attempts. Be able to ask in a non-judgmental, objective way. Follow up and ask if they have a plan. Review your facility’s protocol regarding this topic.

Delusions – Delusional thinking can range from the plausible but improbable, to the impossible, to the absolutely bizarre. Don’t confront your patients about any delusions or tell them that they’re wrong. Instead, express confusion or interest in the delusion, encouraging the patient to divulge as much information about it as they’re willing to. It’s very helpful to guide therapy if you know the whole story.

Tackling Stigma – This rotation allowed me to explore my own stigma regarding mental illness. I realized after interacting with patients with varying psychiatric diagnoses that a lot of what I thought I knew (particularly what I learned through the media) was simply inaccurate. When people hear that you are working in inpatient psychiatry, many references to movies like Girl Interrupted and Sybil come up. It becomes your responsibility to advocate for patients and correct the inaccuracies that the media portrays and sensationalizes regarding mental illness.

As always, thanks for spending a little time in my corner of the web. Feel free to drop me comments below and follow this journey on the gram @coutureinclinic. If you’re currently rotating, check out my recaps on Emergency Medicine, Inpatient Medicine, Pediatrics, General Surgery, Family Medicine, Trauma ICU, Cardiothoracic Surgery, Plastic Surgery, and OBGYN!