Education

My Training Experience at the Department of Psychological Medicine, National University Hospital (Ward Rotation)

Introduction

Having just finished my year of housemanship, I joined the department in May 2009 as a newly turned medical officer, with a keen interest in the field of Psychiatry. Despite my inclination towards the discipline, I had minimal prior experience in the management of psychiatric patients. The department was savvy to the varying experience levels of medical officers and able to cater to our needs at different stages of our training. I was assigned to a ward rotation, to help care for the hospital’s psychiatric inpatients.

Inpatients

The psychiatric inpatients offered a rich variety of learning materials, with adequate volume to keep one gainfully occupied, yet without being overwhelming to cause one to be swamped.

Ward consultants are both available and approachable, to take medical officers through the cases from admission to subsequent discharge. Medical officers are given fair exposure to the duties involved in caring for patients with psychiatric conditions in an inpatient setting, from obtaining a corroborative history from family members to arranging the necessary social support systems to prepare patients for going back to life outside of the psychiatric wards.

At the same time, these inpatients had primarily psychiatric issues, but classifying diseases as such was artificial at best. In a general hospital setting, there was a fair amount of medical comorbidities, which required clinical acumen to determine whether the breathless patient was having an asthmatic exacerbation or a panic attack, whether the confused, forgetful patient was depressed, demented or perhaps even delirious. The range of cases also allows for an overlap of care with other medical/surgical disciplines, where appropriate.

Grand Ward Round Presentations

Challenging cases best highlight the need for a multidisciplinary approach towards the management and medical officers are, at times, required to present some of such cases of learning value to the rest of the department.

Live interviews with the patients are sometimes conducted, with the patients’ approval, allowing the department’s staff to have a better firsthand idea of the patient and directly clarify certain doubts they may have with the patient.

The process of preparing allows the medical officer to familiarize oneself with details of the cases, and the input of other healthcare workers with varying perspectives often provides useful contributions towards the care of these patients.

Psychotherapy Supervision

The medical officer working in the ward will quickly come to see that pharmacological treatments are merely one of the treatment modalities available. Whilst some might feel uncomfortable with taking on psychotherapy alone for selected patients, the department’s psychologists are more than happy for doctors to sit in with them for their therapy sessions.

I had asked to sit in for some of the cases, and the therapists graciously tried their best to accommodate my timings to see the patients together. After the sessions, they took the time to discuss the cases with me, and this helped me to feel a lot more involved in the holistic care of the patient, and better equipped to take on psychotherapy by myself in the future if need be.

Outpatient

A ward rotation does not limit the medical officer from seeing inpatient cases. Ward Medical Officers also run a MO clinic on a weekly basis, where they sometimes follow up on cases discharged from the ward and other patients with relatively more stable psychiatric conditions.

Teaching

There are weekly Journal Club sessions, which help the medical officers to keep up to date on various topics by means of article reviews, debates, or sharing sessions by external guest speakers.

Medical officers also get supervision in the cases they see an emergency whilst on duty and a better insight on psychiatry for child and adolescents, from other weekly teaching sessions.

Conclusion

The posting was helpful for me in establishing a foundation in caring for psychiatric patients, under adequate supervision. The variety of cases to learn from offered good mental stimulation, and I would recommend a posting at the Department of Psychological Medicine at National University Hospital to residents deliberating over where to choose for their training rotations.

Department of Psychological medicine

National University Hospital

My training experience in National University Hospital, Department of Psychological Medicine

My first encounter with psychiatry was in NUH when I was a medical student. Although it was a very short rotation in the department, they were able to make me feel like a member of the family. Hence, for my first Medical Officer posting, I chose to return to the department. My interest in psychiatry grew as I was guided with close supervision from the enthusiastic tutors and the many friendly and approachable allied health members.

Patients

Practicing psychiatry in a general hospital has more benefits than I could list here. The range of cases never fail to amaze me, and my interest grew as I learnt to manage cases ranging from the mild cases of adjustment disorders, mood disorders, schizophrenia which even include catatonic schizophrenia, to complex cases with multiple medical problems and organic causes. I also had the privilege of working closely with the other departments in NUH including neurology, paediatricians and geriatricians for our child and adolescent as well as elderly patients, and those with medical problems. These discussions, guidance and teachings were invaluable, and with all the professional advice given, we learn to face new challenges and achieve a greater sense of satisfaction.

Other experiences

Psychotherapy is a field where learning has to be through experience and close supervision. I was fortunate to be able to select my own patients for psychotherapy and work closely with the psychologist. I was also given many opportunities to present and discuss my cases during the weekly psychotherapy interest group, where I gather great insight into my cases.

The guidance and hands-on experience for the different procedures such as electroconvulsive therapy has made me confident in conducting the procedure independently within a short period of time. Of course, knowing that help from seniors is always available makes me feel at ease in seeking advice at all times.

The interest in research in the department has allowed me to explore my own interest in this area. There was no lack of cases to stimulate ideas for research. I was allowed to present my ideas so that everyone in the department can brainstorm and fine-tune it. There were more help and advice than I could ask for from the various colleagues who were trained in research.

Colleagues

After doing my various rotations, I have chosen to return to this family. I am still very glad for the guidance from the various seniors, including the Head of Department himself. They are approachable and very concerned about all aspects of my learning and development. This has made my learning so much easier as I feel so at home and comfortable in seeking advice and asking for help.

I am glad I returned, and we are all ready to welcome people with the same passion with open arms.

My posting in Consultation-Liaison Psychiatry, Department of Psychological Medicine, NUHS

As I write this in Oct 2009, I am coming to the end of a 6-month posting with the Consultation-Liaison (CL) team. During this posting, my understanding of mental health issues in the patient population of a general hospital has grown tremendously. Because NUH is a tertiary hospital with a very wide spectrum of disciplines under her roof, our CL team receives referrals for patients spanning the different stages of life, from diverse social backgrounds, with eventual diagnoses that may be “common” – such as depression – but with presentations that are unique due to the interaction with their admitting problems. On the other hand, I managed to encounter varying unusual cases – various neuropsychiatric manifestations of organic illness, unusual somatoform syndromes, come to mind – that kept my mind active with trying to figure out “the problem”.

As a trainee, I appreciated the way the CL team is set up here in NUH. The concept of a multi-disciplinary team, comprising doctors with different levels of expertise, senior nursing practitioners and a psychologist, resonated with me as it allowed me to understand their individual perspectives. A weekly discussion of cases, the “Board Round”, is the forum where trying to figure out “the problem” takes place as a group – I never found groupthink to be a problem here, as we each had the opportunity to propose possible differentials. This system “forced” me into a habit of formulating cases holistically and enabled me to consolidate my grasp of the diagnostic criteria across a wide range of conditions.

The liaison aspect of CL work, which most acknowledge being harder to achieve than the consultation aspect, is an area which I had some opportunity to practice. Because I was a member of the CL team for the duration of my posting, I became quite familiar with some of the ward medical and nursing staff and had the opportunity to provide some education on an informal basis.

Outside of CL itself, I benefited much from the training provided by the department. The training schedule is rather busy, but nearly all of the sessions I attended were relevant and pitched at an appropriate level. In addition to weekly case presentations and journal club sessions, there were 2 weekly tutorials conducted by the department’s visiting consultants – 1 in general psychiatry and 1 in child and adolescent psychiatry. As a trainee, I am well aware that modern trends in psychiatry can emphasize the biological aspect of mental illness over the psychological and social aspects. Hence, I found it very valuable to attend the weekly psychotherapy interest group that brings together psychiatrists, psychologists, therapists and counsellors to discuss psychological work with featured patients. Finally, my personal supervisor was very helpful whenever we met weekly, facilitating discussions of interesting topics or trial OSCE stations.

Although not a large department, Psychological Medicine in NUHS has psychiatrists representing most subspecialty interests – general adult, CL, child and adolescent, women’s mental health, psychogeriatrics, addiction medicine, psychopharmacology, research, etc. I found that this broad mix allowed me ready access to subject matter experts when I had questions; at a departmental level, this enables both depth and breadth of discussion when cases are presented.

CL Psychiatry is not a posting to come to if a trainee is looking for an “easy posting”. However, it is a rewarding posting, in a department that emphasizes thorough training, and this would help prepare you in your journey to be a psychiatrist.