For the last 15 years interns are posted for one month in
Psychiatry Department. They are supposed to do 2 things:
1.
Learn to diagnose and manage common psychiatric
disorders
2.
Learn to counsel patients and manage psychiatric
emergencies.
Without proper supervision many interns are unable to
achieve these two goals. An intern can
inform himself/ herself in advance about the methods of learning and take
measures to make sure they spend the Psychiatry posting learning something
worthwhile about Psychiatry, even if they do not get proper supervision. This
write- up will describe how you can do so. You will not need anyone to teach
you if you regularly see patients and try to make sense by reading relevant
topics from any basic textbook- there is nothing that is not covered.
The first goal:
Almost all persons (not only doctors) are able to recognize
severe psychiatric disorders like schizophrenia. But this is neither a common
mental disorder nor is it really so difficult to diagnose (as to spend lot of
time learning about it). One should instead try to diagnose depression,
anxiety, sleep disorders, alcohol and nicotine dependence and learning problems
of children in the outpatient department. Every intern should become expert at
treating insomnia, mild to moderate depression/ anxiety, detoxification in alcohol
dependence.
The ideal way to learn is to independently work up 1-2 cases
in OPD everyday and try to arrive at diagnosis and treatment plan. ‘Hutchison’s
clinical methods’ gives an excellent proforma which can be used for the
work-up. You can then discuss it with the consultant/ resident. In any
department you are likely to find at least one interested person, who will
discuss the case with you.
You can work up 1-2 cases in wards similarly and compare
your findings during rounds or from notes. Try to read up relevant chapters
from a basic textbook such as Ahuja’s textbook or Oxford’s short text
book. Davidson’s textbook of medicine
gives excellent coverage about mental illnesses. In the wards try to observe
how and when patients recover. It is very important to understand the process
of recovery from psychiatric disorders. Don’t miss any opportunity to witness
special procedures like ECT, Amytal interview. In every case, read up on non
psychiatric disorders causing similar symptoms and non- pharmacological methods
of management of symptoms and disorders.
The second goal
Interns should accompany residents to the casualty which is
the place where psychiatric emergencies are managed. Most Interns want to know
which drug is to be used- that is really of secondary importance and can be
read later. (An elegant list of drugs is usually given in every hand-book of
medicine- which you will anyway have with you throughout your practicing life).
But the real thing is to learn the skill in management. One should learn how to
talk and establish a quick diagnosis with appropriate care to rule out organic
factors at the same time making the patient feel comfortable. So observe your
resident carefully- his tone/ gestures/ postures/ words and questions used, how
examination of patient is done. Learn very carefully the ‘performance’ of
management- because it is partly a show to demonstrate empathy-competence-
safety to the patient. If you learn this essential skill you will be a success
in your practice as a doctor.
One must constantly practice counseling by interacting with
patients and their families. First learn to listen and find out the patient’s
problems and their point of view about the matter under discussion- which may
be diagnosis/ symptoms/ side-effects, etc. Then learn the art of communicating
empathy and confidence. Then learn to give information to patients and check
whether they have understood correctly. WHO gives an excellent booklet about
‘Emotional first- aid’. You may refer to it and learn how to manage emotional
reactions. These skills together are called ‘counseling’.
Interns should also learn to diagnose social problems like
abuse, domestic violence and marital discord. Every doctor should know about
the laws and duties related to management of these cases. They should try to
interact with other team members in Psychiatry such as Social workers,
counselors, psychologists, rehabilitation managers, NGOs to find out their role
in Psychiatric interventions.
Finally interns should get a clear idea about the types of
cases to be referred to Psychiatrists. They should also learn the threshold at
which common mental illnesses become complicated and need specialist
intervention.
No matter what type of medical practice you do, management
of psychological problems and mental illness will form a part of your work. In
fact, it is a running joke- that those who don’t know anything about mental
health will be managing a majority of mental health problems. Managing mental
health issues is important and gratifying. Your internship rotation will be the
only chance for you to get hands- on experience in Psychiatry.
As a further step- one can learn specific techniques like-
problem- solving methods, Rogerian counseling, breathing techniques, relaxation
training, differential reinforcement, sleep hygiene measures, diary
maintainence, and use of common rating scales for depression and anxiety and
CAGE questionnaire. A smart intern will be able to collect enough data to be
able to assemble a small research paper or even make an important discovery in
Psychiatry. There is no harm in excelling in internship training, even if you
don’t take up Psychiatry eventually. No honest labour ever goes waste.
