Emergency Clinical Guide Presents The Psychiatry Clerkships

The Psychiatry Clerkships

There are five possible psychatric rotations at UVM - Smith 3, Smith 4, Consult, Crisis, and the State Hospital. Students are assigned to two blocks of one month each - rotations are assigned at random, and requests cannot be made. Students are free to trade rotations, however.

During the psychiatry rotation, you'll learn how to recognize, diagnose, and treat mental illness.

Call is generally q7-14 - you take call at Fletcher Allen regardless of which rotation you're doing.

Be aware that social workers, nurses, and staff all have a great deal of input into your evaluation.

Basic expectations by house staff:

This is totally dependent on the resident to whom you're assigned - there seems to be more variablity of resident expectations on this service than on any other. Generally, you're expected to see the patients in your case load every day, and to write a full progress note in the chart.

It's assumed that you'll have a basic familiarity with common psychiatric diagnoses.

The Rotations
Smith 3

This is the "locked" psychiatric unit at Fletcher Allen - that means that patients are believed to pose a risk to themselves or to other people, and they need permission (and often an escort) in order to leave the floor. Both doors onto the unit are always locked, and are controlled at the nursing station. Common diagnoses on this floor include depression, schizophrenia, bipolar disorder, delirium, and personality disorders (particularly borderline).
Benefits of this floor include the exposure to major mental illnesses. You'll gain skills and confidence in working with a patient population you may not have had much prior experience with.
Drawbacks include the difficulty that often arises in treating difficult cases, and the awkwardness you may initially feel with patients whom you don't understand.

Smith 4

This is the "unlocked" pscyhiatric unit at Fletcher Allen - that means that patients are free to enter and exit the floor at their own discretion, and they're not believed to pose a significant threat to themselves or other people. Common diagnoses on this floor include depression, anxiety disorders, substance issues, and personality disorders.
Benefits of this floor include an "easier" patient population, as the patients tend to be cogent.
Some students feel the personality disordered patients can be more difficult to work with than those with major mental illness. Also, many people eventually find that the population on the floor doesn't tend to change much, and that they don't get enough exposure to major mental illness - the floor becomes "boring" to them.

Consult Service

The consult service works with patients who are admitted under other services at the hospital. For example, a patient in the hospital for gallbladder surgery (and therefore a patient of the surgical service) may develop delirium after the surgery, or an underlying mental illness may present itself while the patient is in the hospital. In cases like this, the surgical service may ask the consult service to become invloved and to manage the psychiatric aspects of the patient's care. Any diagnosis is possible on this service, although delirium vs dementia questions are very common.
Benefits include exposure to a wide variety of potentially interesting cases. If you plan to specialize in an area other than psychiatry, this rotation gives you experience in the types of mental illness you may encounter in your practice.
Drawbacks include a very unpredictable patient load and patient population. Your patients can be spread out all across the hospital, and some students feel that much of the work becomes of the "rubber stamp" variety once patients have stabilized.

Crisis Service

The crisis service handles psychiatric emergencies that present to Howard Mental Health via phone calls, the emergency room, the police, or other agencies. Common diagnoses on this service include depression, schizophrenia, anxiety disorders, and personality disorders, although patients with almost every diagnosis are seen.
Benefits include high adrenaline, interesting cases, and the satisfaction of quick turnaround with your patients and resolution of their problems.
Drawbacks include lack of follow-up, lack of much direct clinical experience, and many students have complained in the past that they spend much of the month as an observer rather than a participant. The new leadership of this team may change that experience for the better, however.

Vermont State Hospital (VSH)

The state hospital is located in Waterbury, Vermont, and houses patients with major mental illness who cannot be treated elsewhere for any of a variety of reasons. Patients must pose some sort of danger to themselves or to other people in order to be admitted to VSH - in the population we deal with as students, this danger usually translates to the patients being suicidal or not being able to care for themselves. The violent patients tend to be placed on floors where students are not allowed. There are, however, occasionally some violent patients in the population we treat. Common diagnoses at VSH include schizophrenia, bipolar disorder, depression, and many patients also suffer from personality disorders &/or substance abuse comorbidly with their other diagnoses.
Benefits include a fairly short work week, well-delineated responsibilities, and the opportunity to work with a population that many students find fascinating.
Drawbacks include a daily commute, and an occasional sense of frustration from dealing with very difficult patients.

The Important Topics

Know the five axes of DSM-IV.
1. Clinical Disorders - do they have a major mental illness? (depression, bipolar, schizophrenia, etc)
2. Personality Disorders or Mental Retardation
3. General Medical Conditions - do they have diagnoses other than psychiatric ones?
4. Psychosocial and Environmental Problems - what's going on in their lives that can be causing stress?
5. Global Assessment of Functioning (GAF) - use the chart to find out what number to assign to their current level of function. The scale goes from 0 - 100 - if they're suicidal, it's below 50.
Know the basics of Depression, Bipolar Disorder, Schizophrenia, the Personality Disorders, Anxiety Disorders, and Substance Abuse/Dependence. Know the differential diagnosis ("what could it be?") of psychotic symptoms - mania, depression, schizophrenia, drugs, delirium, dementia, etc.
Although we don't get much (if any) involvement with child psych issues, know about ADHD, Oppositional Defiant Disorder, and Conduct Disorder.
Know the basic classes of antidepressant, antipsychotic, and anxiolytic (anti-anxiety) drugs, and when they're indicated. Drugs seem to be a favorite area for pimping.
Understand the distinction between delirium and dementia.
Know the criteria for "EE" (Emergency Evaluation - admission to the state hospital) and for a basic psych admission to FAHC.
You'll be asked to perform mini mental status exams, to record daily impressions of a person's general mental staus, and to conduct psychiatric interviews.
If you work on Smith 3 or 4, you'll be asked to participate in ECT (ElectroConvulsive Therapy - "shock treatments"). Learn what you can about it.