Michael Dworkin, MD
How to crush the psychiatry rotation
Updated: Sep 27, 2018
Psychiatry is one of the easier rotations to honor... if you have a good game plan.
How to prepare for your psychiatry clerkship
As mentioned in the surgery, medicine, and pediatrics clerkship blog posts, it helps to be prepared. Start by reaching out to the resident on your service a week before the rotation.
Subject: Medical student starting on emergency psychiatry next Thursday. Body: Hello, I'm an MS3 starting on emergency psych on Thursday. I was wondering: what time and where should I meet you? Thanks! -Your Name
Before you start, review your pharmacology notes or Anki flashcards from USMLE Step 1. We recommend using the MedSchoolGurus Anki Decks which contains a USMLE Step 1 deck and a psychiatry clerkship deck which have everything you need in one place. The key is to focus on psych drug side effects.
In addition, check out our blog post on the best clinical resources to help you crush your clerkships and USMLE Step 2 CK exam, as well as our post on how to use Anki during medical school.
Two diagnoses to know before starting psychiatry - and how to screen for them
Before you start, you need to know how to diagnose mania and major depressive disorder.
A diagnosis of mania requires 1+ week of 3+ manic symptoms (DIGFAST: Distractibility, irresponsibility, grandiosity, flight of ideas, activity/agitation increase, sleep decrease, talkativeness). To diagnose mania, write down DIGFAST on a sheet of paper, and circle the letters as you interview the patient.
A diagnosis of major depressive disorder requires 2+ weeks of 5+ depressive symptoms (SIGECAPS: Sleep disturbance, loss of interest, guilt, energy decrease, concentration decrease, appetite changes, psychomotor retardation, and suicidality.
Understand the meaning of psychosis
A patient has psychosis or is said to be psychotic if they hear voices others cannot hear. Patients who see things others cannot see typically are not suffering from psychosis but rather hallucinogenic intoxication. Screen for psychosis by asking the patient "Do you hear things that others cannot hear?".
What to study early on during your clerkship
Doing the UWorld Step 2 CK psychiatry questions during the first week of the rotation will be key. It's also important to complete the UWorld medicine neurology, fluid and electrolytes, and endocrine sections early on during the clerkship, as these areas of medicine often can produce psychiatric changes in patients.
For video resources, check out the OnlineMedEd psychiatry videos (https://onlinemeded.org/psychiatry) and the psychiatry shelf review from Emma Holliday. For more information on any topic of weakness, First Aid for the Psychiatry Clerkship is a solid resource but does not require a thorough reading.
It is absolutely crucial to know the names, class, and side effects of all psychiatric medications, as well as any medicines whose side effects can cause psychiatric changes (such as any medicine that has anticholinergic properties).
Pay particular attention to the timing and chronicity required to make a psychiatric diagnosis. For example the difference in acute stress disorder and PTSD is largely one of timing: in PTSD, the stressor occurred at any time in the past and the symptoms have lasted over one month, whereas in acute stress disorder, the stressor and symptoms have all occurred in under one month.
Expect to be pimped on pharmacologic side effects and diagnostic criteria for psychiatric disorders. General tips for a successful psychiatry clerkship
Adjust your clinical technique to match that of psychiatrists.
Be a good student. Meaning, be on time, clean and well groomed, professional with everyone you encounter, and willing to work hard and help out. Men: don't wear a tie during your psychiatry rotation. Be straightforward and communicate clearly and deliberately with teammates. Don’t lie or make stuff up – if you didn’t ask the patient something something and are asked about it, just say you didn’t ask about it. Ask questions or for advice during downtime or when walking somewhere with your resident as opposed to when things are hectic.
If someone on your team suggests that you go home for any reason, say “Sounds good! I’ll see you tomorrow!”.
Ask for help when you need it. If you are asked to do something you have never done before and feel uncomfortable doing, ask someone on your team to walk you through it.
Become proficient at the mental status examination.
A complete mental status examination includes assessment of the patient's
Appearance (Body language, grooming, level of alertness, and cooperativeness.)
Behavior (Mannerisms, gestures, expressions, psycho-motor retardation, eye contact, ability to follow commands, and compulsions.)
Mood (The patient's response to the question "How is your mood today?", e.g., "Sad")
Affect (The emotional state you perceive in the patient, e.g., dysphoric/angry, the range of emotion from restricted to full, and the congruency of the affect with the mood. E.g., the patient's mood is "happy" with incongruent restricted and sad affect.)
Thought process (Normal thought processes seem logical, organized, and goal directed. Abnormal thought processes are disorganized and not logically connected. They can be circumstantial, in which the patient goes into excessive, unnecessary and unrelated detail, but ultimately returns to the point at hand, or tangential, in which the patient never returns to the point at hand. If the patient's thoughts quickly jump from one loose association another, this is called flight of ideas. Thought blocking refers to when a patient's thoughts seem to be interrupted and incomplete. Perseveration refers to the patient returning to the the same words or ideas over and over throughout the conversation.)
Thought content (Obsessions, compulsions, hallucinations, derealization (Questioning the reality of the outside environment), depersonalization (Questioning the reality of oneself), and delusions (fixed, false beliefs).
Cognition (Level of consciousness (awake and alert, lethargic: intermittently asleep or sleepy but arousable, obtunded: mostly asleep and difficult to arouse with incoherent speech, stuporous: largely unarousable with speech only consisting of moans/groans, comatose: unarousable), attention ("Spell the word WORD backwards"), orientation ("What is your name? Where are you? Why are you here? What year is it? What month is it? Who is the president?"), and insight (Does the patient seem to understand that their symptoms are abnormal? If so, they are said to have good insight. If the patient is steadfast in their belief that they are totally normal despite having concerning psychiatric signs and symptoms, they are said to have poor insight.)
Pay special attention to social history
It is extremely important to obtain a thorough social history in psychiatry. Ask where the patient lives (house, apartment, group home, prison), who the patient lives with, highest level of education, history of developmental delay, prior criminal convictions or psychiatric hospitalizations, current and former substance use and abuse, last substance abuse, history of remote traumatic events.
Patients may lie
While this statement is never true on your USMLE examinations, it may be true in clinic. Just report what the patient tells you to your team and how his/her actions make you suspicious of the veracity of his/her report. Be objective and nonjudgemental.
How to study for the psychiatry shelf
Do your incorrect UWorld questions once more and rewatch the OnlineMedEd and Emma Holliday Shelf review video. Make sure to do all of the NBME Clinical Science Mastery Series practice exams for psychiatry.
For more information about our shelf exam and USMLE tutoring services, or the MedSchoolGurus Psychiatry Anki Deck, check out medschoolgurus.com. To schedule a free 15 minute consultation session, visit medschoolgurus.com/contact.