Liaison psychiatry is concerned
with meeting the mental health needs of patients in the general
hospital population.
The specific role of each
liaison psychiatry service varies from hospital to hospital and
will depend on local politics and funding issues, as well as the
services provided by other mental health services in that area.
Some liaison psychiatry teams see all patients presenting to the
emergency department with a psychiatric disturbance such as
following an episode of self-harm. Other teams will focus on seeing
patients on medical wards experiencing mental health problems. Most
liaison services will see a mixture of these patients.
The majority of referrals
to the liaison psychiatry team in which I worked came from the
emergency department. The team also spent a large amount of time
working to meet the mental health needs of hospital (medical or
surgical) inpatients. The work ranged from assessing an individual
with an undiagnosed delirium or alcohol withdrawal to supporting
the medical team in caring for a patient with complex medical
problems complicated by a history of mental ill health. The team
was often asked to see patients who presented with medically
unexplained symptoms, such as chest pain with no cardiac origin.
These patients often created a challenge for medical teams when
trying to put in place an appropriate discharge plan. In addition
the service offered advice, teaching and training to medical and
surgical wards regarding organic conditions common in hospital
inpatients including acute confusional state and alcohol
withdrawal.
A foundation year 1 (F1) post in
liaison psychiatry: trainee’s view by Jason Hancock
There are both advantages and disadvantages to
completing a foundation year 1 job in liaison psychiatry.
The responsibility given
to F1s working in liaison psychiatry is similar to other
supernumerary F1 posts, such as paediatrics or ophthalmology. For
example, I was unable to see a patient alone and formulate a plan
without a senior member of the team reviewing the patient on the
same day. This is understandable and it takes experience to do a
thorough risk assessment well and, particularly at the start of the
rotation, I was very grateful for the close
supervision!
It can be difficult to
complete direct observations of a procedural skill (DOPs) during
the placement and there are limited opportunities to develop your
prescribing skills, although your knowledge of psychiatric
medications definitely increases. In addition there is limited
exposure to acutely unwell medical patients, and no opportunity to
experience day-to-day ward work managing inpatients.
The lack of
responsibility and limitations in developing clinical and
prescribing skills must be balanced against the opportunities to
develop both your psychiatric experience and your skills in general
as a foundation doctor. To get an idea of how relevant liaison
psychiatry is in the foundation programme it is useful to refer to
the foundation curriculum.
http://www.foundationprogramme.nhs.uk/pages/foundation-doctors/key-documents
The main aim of the
foundation programme, and in particular the F1 year, is to be able
to distinguish when a patient is acutely unwell and initiate
management. This includes patients who have an acute medical
illness but also those with evidence of an acute deterioration in
their mental state.
The foundation curriculum specifically
mentions two situations where this is important;
- 7.1 (x) Understands and applies principles of managing a
patient following self-harm
Foundation doctors must
be able to take a history, perform a mental state examination and
carry out a risk assessment as well as formulating an appropriate
plan to minimise future risk for individuals who have self-harmed.
A post in liaison psychiatry gives foundation doctors the
opportunity to develop these skills and competencies in a very
structured and supportive multidisciplinary team under direct
supervision of, and through detailed discussion with, senior
colleagues.
- 7.1 (xi) Understands and applies the principles of management
of a patient with an acute-confusional state or psychosis
Liaison psychiatry teams
are often referred patients from acute medical wards who are
acutely confused or are experiencing psychotic symptoms. Doctors
working in the team often have the opportunity to perform first
hand assessments and advise ward staff on management of such
patients. In addition foundation doctors working in liaison
psychiatry can become involved in training other foundation
colleagues on the treatment of these common conditions and help to
encourage recognition of commonly missed diagnosis, such as
delirium and alcohol withdrawal.
Many other key elements
of the foundation curriculum can be met during a liaison psychiatry
placement. Working within a liaison service gives you the chance to
become a member of a truly multidisciplinary team. Discussing
clinical cases with other team members and performing joint
assessments with nurses, occupational therapists and psychologists
allows you to gain an understanding of the different skills each
professional brings to the team and the kinds of help and support
they can each offer the patient. In addition formulation of an
effective management plan and risk reduction strategy requires an
understanding of the services that community mental health teams
and outside bodies can offer.
Good communication is the
focus of your clinical work during a liaison psychiatry placement.
There is often the opportunity to receive detailed feedback on your
performance conducting an assessment in circumstances that most
doctors would find difficult. Feedback may come from any senior
team member and will often involve a one-to-one discussion with
your consultant.
Finally, there are many
opportunities to become involved in teaching, whether to medical or
nursing students, other foundation colleagues or members of the
liaison team.
In addition to achieving
many of the foundation curriculum competencies in your day to day
work, there is opportunity to complete numerous mini-clinical
evaluation exercises (CEXs) and case based discussions (CbDs), and
the mini-peer assessment tool (mini-PAT) becomes a truly
multidisciplinary tool.
Liaison psychiatry posts
offer a high proportion of one-to-one consultant based teaching
sessions (in my post one a week) around cases that you have seen
and on subjects you may have missed as an undergraduate. I also had
regular opportunities to present and discuss cases with the rest of
the team.
The F1 liaison psychiatry
job is supernumery and should be treated as a true training post,
with the chance to gain a wider understanding of psychiatric
subspecialities. It is easy to arrange day placements with teams
such as general adult, the crisis team and child and adolescent
mental health service teams through discussions with your
educational supervisor. In addition there are many opportunities to
attend teaching and training for psychiatry trainees such
as core trainee self-harm supervision, journal club and
mental capacity and mental health act training.
Finally I found it a
strange but refreshing experience attending ‘team-supervision’.
This gave me the chance to observe and take part in detailed honest
discussions about individual workers’ current difficulties with
patients and even other members of the liaison team. This is
something I could never imagine happening within the hierarchical
structure of the traditional medical firm.
A foundation year 2 (F2) post in
liaison psychiatry: trainee’s view by Daisy Robinson
I have had the unique
experience of working both as in the same liaison psychiatry team
as a Foundation Year 1 (F1) and Foundation Year 2 (F2) trainee. I
arrived in my first F2 post keen to build on my earlier experience,
but also slightly nervous of what I perceived to be the increased
responsibility of my role. I found it difficult to adjust at first
to the move away from directly supervised assessments to assessing
people alone before seeking supervision with the team. I was
encouraged to focus on diagnostic and management skills, and to
take the lead formulating discharge plans with patients including
comprehensive discharge letters to GPs and other professionals.
An F2 post in liaison
psychiatry provides many opportunities to meet the competencies
required in the F2 foundation curriculum. As well as building on
history taking skills expected at F1 level there is opportunity to
encourage and teach F1 colleagues and medical teams. In particular
there is the chance to encourage awareness of the impact of
physical illness on psychological wellbeing and the interaction
between physical and psychiatric symptoms. Weekly 1-1 supervision
with my consultant now focuses more on awareness of ICD10
diagnostic criteria to aid my skills in probability-driven
differential diagnosis.
In a liaison setting the
frequency of unrecognised delirium, alcohol withdrawal and
adjustment reactions soon become apparent. When patients have
attracted a diagnosis of schizophrenia or psychotic depression it
can be rewarding to communicate effectively with all members of a
hospital team to identify and encourage good management of
psychiatric presentations.
Teaching to small groups
and appraising research at a journal club is often expected as part
of F2 involvement in the core psychiatric trainee’s education
programme. These experiences can be linked to foundation curriculum
competencies in teaching and awareness of evidence-based
medicine.
There is ample
opportunity to develop patient centred care. As an F2 you are given
greater responsibility for discharge planning especially during on
call assessments, though you are still encouraged to discuss cases
with a consultant or senior team member. Following all assessments
your aim is to formulate a management plan with the patient. You
quickly develop skills in encouraging patients to retake control in
understanding the reasons for their psychological distress. Your
aim is also to communicate to the patient the importance of their
accessing appropriate help in future as part of a management plan.
As an F2 you are also expected to make a full risk assessment in
relation to self harm and are able to develop this ability through
a variety of supervised practice. Self harm and the risks
associated with this presentation can make any doctor
uncomfortable. An F2 post gives good opportunity to observe others
managing risk and thereby develop your own strategies for doing so
safely and with a focus on patient involvement and
choice.
Difficult issues that
foundation doctors are expected to have awareness of, and request
appropriate help for, include abuse, child protection and the need
for the mental health act – all of which are often part of a
liaison psychiatry presentation and assessment. There is also an
expectation at F2 level to be able to deal appropriately with angry
patients; this and other challenging situations are relatively
common in liaison psychiatry and the post requires you to quickly
develop these advanced communication skills with the help of other
members of the team.
Conclusion
Completing a foundation
post in liaison psychiatry is a unique experience and allows you to
develop your skills as a foundation doctor in areas that are not
possible in more general medical or surgical settings.
When applying for a
foundation year one post you must first consider the advantages and
disadvantages to completing a post in liaison psychiatry.
You may not develop
competencies managing acute medical illness presentations compared
to a more traditional house officer post, but you will learn much
about acute psychiatric presentations occurring on a medical ward.
In future foundation rotations (and beyond) this makes you an
invaluable team member, who can recognise and advise others on the
likely causes of ‘psychiatric’ presentations and make informed and
appropriate early referrals to mental health services where
necessary.
At F2 level, complex
assessments and on call work create a challenging but well
supported role with invaluable multidisciplinary feedback and
one-to-one consultant training which will be of use to any doctor
in their future career.
Dr Jason Hancock, foundation year
one doctor and Dr Daisy Robinson, foundation year 2 doctor
References
- The Foundation Programme Curriculum, accessed at
http://www.foundationprogramme.nhs.uk/pages/foundation-doctors/key-documents
- Chapter 19, Liaison Psychiatry, Oxford handbook of psychiatry,
Semple, D. & Smyth, R. second edition, 2009, Oxford medical
publishers.
- Thomas, G. & Knapp, J. “Bringing psychiatry training to the
next generation: a Foundation Year 1 doctor’s tale”, Psychiatric
Bulletin, Aug 2008; 32: 312 - 313.
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Page last updated
on 28 May by E Baker-Glenn