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Psychiatry

Psychiatry takes place in the 2nd clinical year on the standard course, and in 3rd year on the grad course. On the grad course, it is a six-week placement during which you move through several subspecialties in the community and hospital, including a week in a forensic psychiatric institution in Northampton. There is no special psychiatry rotation in GPland.

 

How you will spend your time

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The rotations through the various subspecialties vary from person to person and not everyone gets to experience every single subspecialty. There is time on inpatient wards such as adult and elderly, time in the community (termed “IDT”s = integrated delivery teams), home treatment and liaison teams, child and adolescent services (CAMHS) and access&assessment teams (AAS). Everyone will spend a week in the St. Andrew’s Hospital in Northampton rotating through various medium security wards.

During your ward placements, you will usually attend meetings and ward rounds in the mornings and will then be able to talk to patients on your own. This can sometimes be tricky as their days can be quite timetabled or they are away on day-leave, or simply may be too unwell to speak to you. Some consultants insist that you stay on the ward the entire day, but some are more relaxed thankfully.

During the outpatient placements, you generally join a consultant in their clinics or during some of the meetings (e.g. FACT = flexible assertive community treatments). The clinics have much more time per patient (up to an hour) and the appointments can be quite spread out. As a substantial amount of patients don’t attend the clinic, you may be waiting around a lot with very little patient contact, so take something to read. Outpatient placements also usually require a lot of driving, from Ipswich to Cambridge and Thetford to Sudbury. The AAS placement was similar to that and in addition contained personalised tutorials delivered by the consultant in charge, which were extremely useful.

The Northampton placement in forensic psychiatry was a useful experience, even though in my case, patient contact in terms of writing up cases (see below) was limited. This was not the case for others though and depends on the weekly schedule. I managed to commute there from Cambridge despite the distance and found it feasible.

You also need to attend an ECT session and try to attend two on-calls, which you need to organise yourself.

All in all, I probably found my time on the ward to be most useful and productive in terms of learning from patients, but the outpatient time was very useful to do some book-work.

A final note on lectures: these usually take place on Monday afternoons and are compulsory, however not all of them are particularly useful and quite a few lectures didn’t take place due to lecturers not showing up. On more relaxed placements you will have the Monday morning for self-directed study.

 

How to fit in pathology

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Pathology is not an issue during the graduate course as the placement takes place after path exams, but I’d say there is plenty of time to revise the neurology-related pathology, in particular MS, delirium, the dementias and other neurodegenerative diseases as well as perhaps some haematology (some psychiatric drugs have haematological side-effects).

 

Which books to use

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I started with Psychiatry at a Glance, but soon found it too basic. I moved on to the Oxford Handbook of Psychiatry. A new version had just been released and I found it useful, but perhaps a bit wordy. I also used the BNF and Rang and Dales Pharmacology, as you may know by now that I think this is one of the best textbooks ever written. I used it to revise some neurophysiology/neuropharmacology from 2nd year, which was definitely worth doing. There are also plenty of NICE guidelines to look up if you want to be thorough.

 

How to use the resources on medportal

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(Medportal is a Cambridge University Medical Course online resource).

There are quite a few psychiatry podcasts on medportal and they are of varying quality. I talked to one of the consultants who recorded one of them. The contributors were apparently assured that errors would be edited out, which then didn’t happen. So be prepared to hear the lecturers say “Cut” without consequences, or ambulances and mobile phones ringing in the background. Don’t let it distract you, especially when driving!

As the placement involves a LOT of driving, it was a good time to listen to these podcasts, but did not find them particularly useful. The highlight is perhaps the lecture on “Adolescence Biology Mind Culture Ecology”, however the content is not really relevant to the exam.

What I did find really useful were the Oxford University Podcasts on Psychiatry. They cover the basics on the major psychiatry topics such as Schizophrenia, Bipolar, Depression and Dementia and are narrated in a really fluent dialogue between two psychiatry registrars. There are available from iTunes University.

When traveling, make sure you have some psychiatry podcast running the background, it really saves a lot of revision time, as you’ll be spending countless hours in the car!

 

Assignments

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During the placement, you need to take a psychiatric history of at least four, but ideally six or more patients and then present it to a doctor who grades you and signs you off for each individual case. I recommend starting as early as possible and make use of every opportunity – it can be quite tricky to see enough patients. The ward placement is the best time to do them, but patients are often on leave or have scheduled activities so it can be difficult. In the community it’s even more difficult, so it’s best not to leave it until the last minute.

You also need to tick off whether you’ve seen a set of conditions and activities on a log-book sheet and arrange observation of an ECT session and two on-calls. I found I had no problem completing the log-sheet (except for the prison visit) and see the ECT, but did not manage to do an on-call, which didn’t seem to be a problem in my exit interview on the final day.

 

What came up in the exam

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The exam format has recently changed, and it’s now a 1h MCQ (chose the best of five answers) with 60 questions in the form of vignettes. I’d recommend revising the following:

  • The major psychiatric illnesses covering adult psychiatry (Schizophrenia including epidemiology, depression, dementias including Huntington’s and reversible causes, phobias, grief reactions, delirium, conversion disorder/somatisation/Muenchhausen/…, eating disorders..)
  • Child& adolescent psychiatry (Autism, ADHD, oppositional defiant disorder, conduct disorder, depression, …)
  • Perinatal psychiatry
  • Pharmacological treatment of psychiatric conditions, including rapid tranquilisation regime and doses required (only for the latter)
  • Pharmacology of psychiatric drugs INCLUDING the side-effects and treatment of the side-effects
  • Legal basis of psychiatry: Mental Health Act of 2007 with the main sections (2,3,4,35,36,37,41 and deprivation of liberty safeguards DOLs including some sub-sections you may not expect)
  • Different types of psychological therapies and important catchphrases to do with them
  • Symptoms of drug withdrawal (as in recreational drugs including alcohol) and treatment – DO NOT SKIP THIS!

 

How to prepare for the exam

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However much work you put in, accept that there will be some questions you cannot prepare for – some of them are very strange! I found that I had done a lot of revision using the resources named above and it was not reflected in my confidence in answering the questions. Perhaps you will do better using my a posteriori advice!

The most useful tool I used was an online website called http://passmedicine.com, which is not free, unfortunately. Working through their MCQs helped me fill in some gaps of what I had not come across in my reading, and there was some overlap with what came up in the exam. Another useful resource are the feedback documents of past psychiatry exams (when it still used to be short answer questions), as you can conclude from that which topics are most important to revise. They should be kicking about on Medportal if you go to the archives of previous years, i.e. 2013 and backwards. E-mail me if you cannot find them and I’ll help. Finally, I found learning great detail on management from NICE guidelines was not useful, as the answers available did not seem to have been updated with the most recent management.

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