Psychiatry

Psychiatry consists of a total of 4 weeks, where you spend a combination of 2-2, 1-3, 1-1-2, or even all 4 weeks at the same location (order varies as well). The different facilities are Valleywise (multiple locations), Mayo, VA Outpatient, VA Inpatient, and PCH (inpatient and/or ER and/or outpatient). The hours on this clerkship are much lighter compared to others, and while the SHELF is not conceptually difficult, the curve is difficult to beat since people generally do well on it. Refer to Bright Space for full details of content and requirements. 

• Students must score greater or equal to the 10th percentile on the NBME exam (110 questions) in order to receive a pass. 

• Students will be evaluated by the residents and faculty with whom they work through MedHub evaluations. The assigned faculty on their schedule will be sent an evaluation automatically, and the student can initiate additional ones if desired.

• During the later didactics, you will be asked to discuss/present 1-2 interesting patient cases with the group. There are no formal expectations, so it can be a casual discussion or a PowerPoint approximately 5 minutes in length.

• Lastly, you will have a video exam write-up on Bright Space. A link to the video exam will be available the Friday prior to the last week of your clerkship, and the write-up is due the Monday following the end of your clerkship. More details are on Bright Space.

1. NBME Subject (Shelf) examination: 25%

2. Video Exam Write-up: 35%

3. Clinical performance evaluations: 40%

Honors* = 90 - 100%

High Pass = 75 - 89%

Pass = Passing grades in all three elements.

*No limit to the number of Honors per rotation.

Here is what a typical student schedule might look like. 

You could start at any location during the rotation and you will be provided with your schedule ahead of time. The schedulers aim for a mix of inpatient and outpatient, but due to scheduling limitations that is not always possible. Your involvement may range from shadowing to leading rounding interviews, writing notes, and doing intake histories. This is also variable based on facility and preceptor.

The hours vary widely based on the location and preceptor. Specifically, PCH gives Fridays off and the inpatient/ED is generally mornings with or without afternoons, while Valleywise Mesa is preceptor-dependent but usually ends by 2pm. Mayo Clinic is an inpatient consult service which means the hours depend on the preceptor and consults. Make sure you email preceptors in advance asking them when and where to meet for your first day with that specific preceptor. You can also ask them for a dress code since inpatient units might be scrubs while outpatient is likely business professional. Note: If you are assigned to Valleywise, you do have to complete the EMR training and they historically forget to send the email -- reach out if you don’t hear from them the Wednesday prior to your first week at Valleywise.

Every week you must attend virtual didactics on Tuesdays 1-5pm. You will also have a virtual mid-clerkship feedback likely in the second week of the rotation. You may have additional didactic rotations depending on your rotation site, ex. Valleywise may hold Friday didactics tri-site (but make sure to ask as they are not always consistently held).

• Clinical Performance Evaluation

  • Make sure you email preceptors in advance to ask about when to meet, where to meet, and any preparation they expect you to do before you start working with them if it is not provided to you.

  • For clinic and inpatient rounds, it is helpful to preview patients in Epic before you see them. Have a good understanding of why the patient is being seen and any relevant past psychiatric history, as well as their medication list and any changes.

  • You may be allowed to do a lot or not that much depending on your site. Typically students can perform H&P with the caveat that you will leave the room if you feel threatened, or your preceptor might take over if necessary. Note-writing is a possibility everywhere, especially at PCH and Mayo, but they are only used for practice in the PCH EMR.

  • Lastly, familiarize yourself with Psychiatry abbreviations and common generic vs. brand name medications in advance. There are lots of different medications within Psychiatry, and both physicians and patients almost always exclusively use the brand names, so be sure to know the brand names of major medications (Lexapro, Prozac, Zoloft, Cymbalta, Wellbutrin, Abilify, Seroquel, etc).

• Weekly Didactics

  • Every Wednesday there are mandatory virtual 4-hour didactic sessions only with the AZ students. On Bright Space, some sessions list pre-work that is not tested upon during the session.

• Shelf Exam

  • The shelf exam consists of 110 multiple-choice questions

  • Tier 1 → You should aim to do all of the UWORLD for Psychiatry - that should be your main goal. If you have extra time you can redo your missed questions or redo the entire bank again. If you do all of UWORLD and nothing else, you will be able to pass and do quite well. Everything beyond this that you can do is a bonus. If you are having trouble with Neurological diseases, make sure to spend extra time studying these topics since they may appear on your SHELF as well.

  • Tier 2 → Once you near the last few weeks of the rotation you should do at minimum two practice NBME exams, ideally all four if possible.

  • Tier 3 → If you have time, I recommend reading First Aid for the Psychiatry Clerkship throughout your clerkship. This is its own stand-alone book, different from the Psychiatry section within the First Aid Step 2 book. Listening to Divine Intervention during car rides can also help drill HY facts.

  • Tier 4 → If you have extra time you can re-watch the SketchyPharm videos for Psychiatry medications before or during the rotation. If you are a fan, the Emma Holliday video is free on Youtube but may contain outdated criteria that are summarized here. 

  • Tier 5 → If you have even more time you can read through the USMLE STEP 2 CK First Aid Psychiatry sections that have some summary tables and diagnostic criteria. STEP1 First Aid has great references as well but just pick one resource.

• Video Exam

  • You will have access to a video of an incomplete psychiatry inpatient consult from which you are expected to write a well-supported history including mental status exam, differential diagnosis, diagnosis (presumed), capacity assessment, safety assessment, and treatment plan with specific acute and subacute management recommendations. Essentially, they want to see how you reason through a realistic interview scenario where you may not get all the data you want. 

  • The syllabus and Bright Space lay out clear criteria that they want, but the key to this assignment is to address each of their questions in detail. Of note, you can discuss the assignment with other students on the clerkship, but you may not use any of their written work.

  • My write-up ended up being several pages long with fleshed-out differential diagnoses or at least differential diagnosis categories. This assignment leaves a lot of room for style and judgment, but it may be helpful to use a Psychiatry HPI Template.

  • HIGHLY RECOMMEND you use the following headings to stay organized (you may not need to use all of them): 

    • Subjective: Chief Complaint, History of Present Illness, Past Medical History, Past Psych History, Safety Assessment, Health Maintenance, Social History (alcohol, smoking, other substances, etc.), Past Surgical History, Family History

    • Objective: Mental Status Exam 

    • Assessment/Plan: Biopsychosocial Factors, Differential Diagnoses (with each diagnosis listed out individually), treatment plan (with each differential diagnosis explored individually) with acute and subacute plans 

    • Extra: Capacity Assessment, Safety Assessment, Additional Questions 

*most important resources are in red that you should do at minimum to pass

• UWORLD

  • You know where to find that!

  • Question bank is about 369 total questions

  • Do it all at least once!

• NBME Practice Exams

• Emma Holliday videos with corrections

• Online Meded or Osmosis Videos 

• Use this template and adjust to your own needs! 

• Psych HPI Template

  • Print out a few copies and keep them in your pocket, or you can use an iPad to conduct interviews

  • The original template was made by Meagan Tran with annotations from Ning McKenzie. This fits our needs but may not fit yours! The red highlights are critical pieces of information to gather, the yellow highlights are the information you must ask directly, and the Social History written-in sections are mostly for pediatric/adolescent patients. The ROS questions don’t usually seem to be asked in psychiatry.

• Psych Abbreviations

  • SI/HI/AVH = Suicidal Ideation, Homicidal Ideation, Audio/Visual Hallucinations

  • Med SE = Medication side effects

  • MDD = Major Depressive Disorder

  • GAD = General Anxiety Disorder

  • BPD = Borderline Personality Disorder

  • ECT = Electroconvulsive therapy

• Questions to ask During Rounds

  • SI/HI/AVH

  • Medication Side Effects

  • Sleep

  • Appetite

Psychiatry Pearls

• Have a mental checklist of what information you need to be gathering since these interviews tend to flow more erratically than what you may be used to. An experienced psychiatry interviewer will follow the patient’s flow and fill in their history checklist out of order.

• The challenge of discussing and writing about psychiatry is using the correct terminology for the mental status exam or just to describe symptoms you witnessed. Use the following resources to help with the MSE and descriptions/distinctions:

• Mayo Clinic MSE Handout

• MSE Teaching Resource with many descriptors

• Detailed questions for MSE, specific diagnostic questions are also available on this site

• Familiarizing the generic names of common drugs will be helpful since preceptors tend to use both

• Schizoaffective vs. MDD with psychotic features vs. Bipolar I with psychotic features: This is a distinction that confused me, as they all present with psychosis/mania which just reads to me as “something major is off”. Focus on what the underlying diagnosis is, since schizoaffective can be basically psychosis + depression on top, while MDD with psychotic features is the opposite. Always know your mania criteria well.

• Attestations on Bright Space (no proof needed):

  • Electroconvulsive therapy (ECT) Video

  • Alcoholics/Narcotics Anonymous (AA/NA) Meeting Attendance

  • Mid-Clerkship Feedback Session Attendance

  • Eight Patient Write-Ups Completion

• CEX evaluation form in Medhub

• Complete required Mid Clerkship Feedback form in Medhub

• NBME shelf exam

• Log work hours in Medhub

• Log cases & procedures in Medhub

• Video Exam (due Monday after rotation ends)