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REQUIRED WUMS3 PSYCHIATRY CLERKSHIP

First day info
Last day info
GOALS AND PURPOSE:
The required WUMS3 psychiatry clerkship is intended to coordinate with relevant courses in the 1st and 2nd year to help the student master the WUSM learning objectives in psychiatry (q.v.).
Please note that due to the limited time available for this rotation (4 weeks), much of the clinical material you need for this rotation (and the exam) are covered in the 2nd year, and you will need to learn some of the material by self-study. This is spelled out in the learning objectives .
 
COURSE DESCRIPTION
Summary
The clerkship is 4 weeks long. Students will be assigned to one of two sites for this rotation: Pavilion (BJH) or Metropolitan Psychiatric Center (MPC). However, you will be assigned to other sites ("variety rotations") during that time along with one field trip. Wherever you are assigned, you will (1) evaluate and treat patients, (2) keep a personal log of all patient contacts, (3) attend teaching conferences and lectures, (4) read and report on one book from an assigned list, (5) visit the ECT suite; (6) take an electronic pass/fail teaching "quiz," (7) self-directed study, (8) attend " interview skills " small group discussion and be individually evaluated by a psychiatrist (9) participate in an OSCE (observed, structured clinical examination), and (10) take the "boards shelf exam" in psychiatry at the end of the clerkship.
Pavilion
Each student on the inpatient psychiatry units at Barnes-Jewish Hospital (14th and 15th floors of the East Pavilion; i.e. "Pavilion" service) will work on a team with a full-time faculty attending psychiatrist and a psychiatry resident. The team will be on call every 5th night on average and will admit patients who fall into three groups: (1) ward service patients, (2) private patients of the attending on your team, and (3) other private patients. Your team will be responsible for all of the care for patients in the first two groups. Many patients seen on admitting nights will fall into the 3rd group. You will examine some of these patients and discuss their diagnosis and treatment plan with the resident and the private doctor. After that you are free to continue following the patient and working with the private attending physician (talk directly to the private MD about this for each patient), but at a minimum you need to maintain a personal patient log . I strongly suggest asking your attending when (s)he rounds and whether you can accompany him/her.
MPC
The Metropolitan Psychiatric Center (MPC) admits almost exclusively patients who cannot be admitted to area private hospitals. It is also probably the location in the area where the staff are most accustomed to managing severely ill patients with a primary psychiatric diagnosis. You will work with an attending physician (from our faculty) but more closely with 2nd and 4th year WU psychiatry residents. In addition, you will have weekly "teaching rounds" with the other MPC students and Dr. Rastogi-Cruz. Call is roughly once a week. You are expected to follow up on all patients admitted on your call night, whether admitted to your floor or not as described below under patient log.
Night call
Students take call with the resident to whom they are assigned at both locations, including on weekends. At MPC they will usually send you home between 10pm and midnight when the action slows down; weekend call is generally 8a-8p at MPC. At Pavilion you should go home at midnight. At either place you may wish to leave a beeper # in case the world's most interesting patient comes in at oh-dark-thirty. Note: You still do call at Pavilion or MPC even when you are on "variety rotation."
Patient log
Keep track of all patients you see on your patient log. For patients who are admitted, you need to follow up (1x/week is ok) on the patient &/or the medical record until discharge and keep notes on his/her response to treatment and changes in diagnosis. You need to have the information with you at weekly teaching rounds and at Professor's Rounds. No follow-up necessary for Prof Rd, ER or those in an outpatient setting. Then, turn the patient log in at the end of the rotation in order to receive a grade. Please note: For patients who are not on your team, check with the patient's attending physician regarding patient contact other than reviewing the chart. After 2-3 weeks check to make sure you will meet the patient requirements (e.g. write-ups on X # of patients) by the end of the course.
Conferences, lectures, etc.

Patient Presentations
For Professor's rounds, one student is assigned to present a patient each time. You are allowed to switch with each other as long as all agree and no one does two presentations for the same conference. If you want to shine, you should prepare your patient presentation as described in the last chapter of Goodwin and Guze's textbook Psychiatric Diagnosis (on reserve in the library). See also the handout we provide you. Inform the patient that s/he will be interviewed in a group of physicians and medical students. If you must use a patient not on your clinical team, seek the prior permission of the patient's attending physician.

Book report
I know it sounds corny but there is a purpose and most students have appreciated this. You are required to read one of the following books and submit a short (say, 1 page) written review briefly summarizing the content of the book, explaining how you personally reacted to the book, and telling what you gained from the book that is relevant to your future practice of medicine. The Clerkship Coordinator has some of each of the following for you to check out. Otherwise, you are responsible for getting your own copy from the bookstore or the library (or the main campus library). Most books are in the medical library's reserve collection and in the bookstore. Students who wish to report on a different book may do so with prior approval by Dr. Black.


Variety rotation / Field trips
You will be assigned to other sites during your rotation (such as Wohl [BJH] clinic, BJC Behavioral Health, and Child clinic [Montclair]). The goal is to let you see a wider variety of patient presentations and another aspect of psychiatry. Note: You still do call at Pavilion or MPC even when you are on "variety rotation."

Students are required to choose at least one “field trip” experience. We have compiled a listing of community psychiatry-related sites students may choose from. Once the student has chosen their site, the clerkship coordinator will either schedule the visit or direct the student to coordinate the visit on their own. Students are required to turn in a short paragraph evaluating the site. See below for how this may affect your grade.

ECT
Each student will spend one morning in the ECT suite at Barnes-Jewish Hospital (15500). On your designated day (see the schedule), you should arrive at 7:30 a.m. Before arriving you should have read the ECT chapter in the Wash. U. textbook . If you need to switch days (e.g. you're post-call that day), you can do so if you make sure no other student will be there on your new day. Contact Pamela Lacey at 362-3090 to reschedule.  The ECT suite runs Monday - Saturday.
Electronic "Quiz"
You will take an electronic "quiz." This uses your medical school Lotus Notes account. The point of the quiz is not testing but rather teaching. This uses your medical school Lotus Notes account so you can take it at the library or wherever you have access. The point of the quiz is not testing but rather teaching. One purpose is to make sure you are exposed to certain didactic information that the WU psychiatry faculty think is important but that is not covered on the required "shelf exam." It is also meant to substitute for faculty lectures, which in the past took students away from the wards. To meet these goals, the multiple-choice quiz is pass/fail and open book. It is set up so that after you answer a question, an explanation written by one of the WU faculty appears.  I think the quiz provides excellent teaching in psychiatry, but obviously you will only get out of it what you put into it. Instructions on how to take the quiz will be sent to you later on during your rotation.  Direct technical questions to Greg Robbins and feedback on content to Dr. Black.
Interview skills
There are two goals. (1) Teach you how to interview patients and conduct the mental status examination. (2) Make your grade less arbitrary and more dependent on actual skills rather than how you get along with your resident. At some point during the first 2 weeks of the rotation, you will meet with a psychiatrist from the part-time faculty or a fourth-year psychiatry resident for a total of 3 hours. This is to be used for didactic and practical instruction on how to interview a patient. At some point during the last 2 weeks of the rotation, you will have a one-hour appointment with this same doctor according to his/her schedule. Your resident should choose a BJC or MPC inpatient (depending on where you work during week 1) for you to interview in front of this doctor. The doctor will grade you according to a form, which we provide you at the beginning of the rotation. This forms a significant part of your grade. Therefore I encourage you to do two things. First, ask the resident you work with, or someone similar, to grade you on a similar interview during week 2. I would suggest asking them to observe you interviewing a patient you are admitting on call night so they don't feel it is a burden. Second, please share responsibility for making sure the doctor returns the grade form to me.

Self-directed study
We can't hope to teach you everything about psychiatry in 4 weeks. After 2-3 weeks you will reach a comfort zone. Beware! That comfort is based on seeing only a few patients. You need to read. We provide you with handouts on child psychiatry and interview techniques. Additionally, I recommend you read one psychiatry textbook. The following text is recommended. Rubin EH, Zorumski CF (eds), Washington University Adult Psychiatry (Bristol: Blackwell, 2005) http://books.google.com/books?id=RbwUsQSlM60C http://medcat4.wustl.edu/cgi/ece.cgi?931229772:2:WUM:2:1:2:B706498: Additionally, I recommend you read one psychiatry textbook. The following text is recommended. Guze SB: Washington University Adult Psychiatry (St. Louis: Mosby, 1997). There are other good textbooks and you can discuss their relative merits with me or your residents or attendings. My favorites include Winokur and Clayton's The Medical Basis of Psychiatry, Tomb's Psychiatry for the House Officer, and Andreason and Black's Introductory Textbook of Psychiatry . Goodwin and Guze's Psychiatric Diagnosis is an excellent introduction to psychiatry but would need to be supplemented by a text with broader scope. DSM-IV is a good reference but not a good first text. Also, some students prefer the NMS study guide in preparing for the final examination. Most of these books, plus a few others, are on reserve in the library.
Final exam
You will take the standardized "shelf exam" in psychiatry. WU students' median score is around the 75th percentile of students nationally. The school considers a score below 10th percentile a failing grade which, if not remediated on a re-take, will cause an automatic Fail for the rotation. A few students fail the exam each year. This seems to happen if (a) the student has failed other exams at WUSM or (b) the student thinks the psychiatry exam requires no study. The Dean's office has asked us to remind you that the questions on this exam are proprietary and confidential, and that you will be asked to sign an honor code statement at the exam.  The NBME web site provides students with information on subject exams and self-assessment services.  The web site addess is: http://www.nbme.org.  

OSCE
The last week of the rotation, you will participate in an OSCE (observed, structured clinical examination). This will include evaluating a "standardized patient" (actor/actress) the way you would for an inpatient admission or hospital psychiatry consultation, and watching a few video clips. Then you answer questions about your observations. The OSCE can affect your course grade. Specific information and instructions will be sent to students via email during the rotation.


GRADES FOR YOU AND FOR US
You will have the opportunity to evaluate the residents and faculty with whom you work, as well as the clerkship as a whole. We really read these and appreciate your feedback. Please fill out the evaluations during the last two days of the rotation and turn them in on the last day to Tammie Repko, Dr. Rastogi-Cruz, or Dr. Black. We will not share these with any of the residents / faculty until they have given us your grade. If we do not receive your patient log, book report, and your evaluations of the rotation, faculty and residents, it may affect your grade.
Below is a sample description of an Honors performance.
 


Honors

Knowledge

By the end of the rotation she could knowledgeably discuss several advanced topics (items with priority of "3" in the psychiatry learning objectives ). Her admission notes consistently provided an appropriate differential diagnosis. Scored at 90th percentile nationally on the psychiatry shelf exam.

Clinical skills

This student was able to interview even difficult patients. Her interviews both acquired relevant information and built rapport. After the first week of the rotation, her written notes were always clear and conveyed all crucial information. They usually included a reasonable treatment plan and were concise. By week 4, verbal presentations were excellent whether a thorough presentation or a relevant 60-second summary was required.

Professional
development

This student never showed a lapse of judgment or of reliability during the clerkship. She was an essential and helpful part of our treatment team. Did substantial outside reading pertinent to her patients. Patients often viewed her as their doctor. 

Here is how I will compute your grade:


20% shelf exam 
    <30th %ile = 0 
    30th-69th %ile = 1 
    70th-89th %ile = 2 
    90th %ile = 2.5 
    >90th %ile = 3

25% 0-3 interview skills (Observed Clinical Examination) grade 
The grade is computed by first averaging the scores on the grade form ("Describes mental status accurately" counts double). Then, if you have any 0 on the suicidality, dangerousness or delirium items, I subtract 1 point from the average.

5% 0-3 grade assigned by Dr. Black based on your patient log, book report, whether or not you turned in your evaluation of the clerkship, and P/F grades from "variety week" and quiz. Field trip evaluations may boost this grade slightly.

25% Clinical (Resident)
25% Clinical (Attending)

Translating that into a grade: 0-1 F; 1-1.7 P; 1.71-2.5 HP; 2.51-3.0 H. No grades are released to registrar until everything is turned in.
Exceptions: A student who scores below 10th percentile (nationally) on the shelf exam and ditto on a retake will receive a Fail grade for the course. A student who initially scores below 10th percentile (nationally) on the shelf will have an exam score of zero regardless of the re-take grade. If a given doc gives almost everyone the exact same grades (this is rare), I may adjust them all to “2’s” unless a higher or lower score is substantiated by specific comments. I may use an exceptionally good OSCE performance to mitigate a poor interview skills grade.. Students with a serious lapse of professional judgment at any time during the clerkship, or a clinical Fail from any doctor, will be graded at the Coursemaster's discretion after consultation with Dr. Whalen (also rare).
 BORING BUT NECESSARY DETAILS
ABSENCE from the psychiatry clerkship for a reason other than illness must be approved in advance by the coursemaster. Missed days for any reason may need to be made up.
FIRST DAY: all students
There will be a required orientation meeting with Dr. Black usually in room 3312 Renard (that's just east of the BJH cafeteria) on the first weekday of the rotation. BEFORE the first meeting, make sure to read the email that was sent out to your Notes account by Tammie (362-2469). It supersedes the default information.
    Barnes Jewish Hospital (Pavilion) students:  Page your assigned resident following the introductory lecture on the first day of the rotation to find our where/when to meet (see Tammie's email for the pager number). Lockers are available in the lounge, no lock is necessary. Keys may be obtained from the Inpatient Attending office (Cindy Bander), 17th floor, Suite 17301 Pavilion, with a $20.00 deposit by check. Deposit will be returned when key is returned. Please return your key promptly on the last day you are on the Pavilion in order to insure that keys are available for the next students.
    Metropolitan St. Louis Psychiatric Center (MPC) students : Further orientation will take place at MPC where students will be assigned to a resident. Dr. Rastogi-Cruz (or a 4th year resident) will explain activities such as ward assignments, on-call schedule, conferences for students, etc. Keys to Metro Psych wards (and parking tag if appropriate) may be obtained from MPC staff (Room 3300, Metro). Tammie will also make available the DSM-IV desk reference book at orientation for MPC students with a $20 deposit. Please return ALL materials promptly on the last day of the rotation in order to insure they will be available for the next students.
LAST DAY: all students
    Generally the shelf exam is at 10 a.m. on the last day of the clerkship (Friday morning). The med school will give you the exact details. You are excused from clinical work beginning at 12:01a.m. that day.
    Turn in your patient log, book report, and evaluations of the rotation to the clerkship coordinator, Renard 4408 (take the elevators right by the east entrance of the BJH cafeteria). (Don't turn them in to the proctor at the exam!) There is an in-box on the secretary's desk marked for student papers. Make sure you have completed all 9 activities listed under “Summary” at the top of this page.
 
ADVICE FOR ALL
Jump in and do stuff. In my experience, most residents will let you really help direct the patient's care to the degree you are up on the details of a patient's case, can articulate a reasonable differential diagnosis, share in the necessary scut work, and have a plausible treatment plan. But otherwise they will tend to treat you as an observer. Interview and examine the patients! Try to do some of the psychotherapy, LPs, or other procedures. You will naturally need appropriate supervision for these tasks but it will quickly get boring if you just watch everything.
Make an effort with each patient to think about his/her diagnosis and treatment using the principles of the scientific method rather than buying in 100% to any unproven theory about the patient's illness, whether biological, psychological or whatever. If you don't get into the habit now it will be very hard later, and it is very easy to come up with any number of plausible but unproven explanations for psychological symptoms.
If you find that the rotation isn't going well for you, please let me know early so I can try to help. I will give you my pager number at the orientation meeting (unless I forget; feel free to ask).
Finally, have fun! For many students the psychiatry clerkship is the most enjoyable part of medical school. It was for me.
 
Best wishes,
Kevin J. Black, M.D.
Coursemaster
362-2469
RepkoT@wustl.edu
Revised: January 29, 2008