Contents:
1. Editorial
2. The role of the alcohol nurse
specialist
3. Assessing capacity: practical
tips
4. Psychiatry for beginners: the foundation
year 1 rotation
5. Tackling the Psychiatric OSCE Station
– counselling a patient on starting lithium
6. Warwick
medical school Psych Soc – how we set it up
7. Psychiatry
as a medical student
8. Book review: "In search of memory: The
emergence of a new science of mind" by Eric Kandel
9. Book review: "Human traces" by Sebastian
Faulks
10. Review: “Bounce’s insane in the
brain”
11. Articles for the next issue
1. Editorial
Sacha Evans, Foundation Year 2 doctor,
Imperial College Healthcare Trust
Welcome to the
latest edition of the foundation doctors and student associates’
newsletter. As a foundation doctor, I routinely come across
patients with alcohol problems, ranging from binge drinking to
Korsakoff's syndrome, so much of my time is spent referring to
Neal Richardson, our Alcohol Nurse
Specialist. He has kindly written a piece
about his role and why it is important to involve him early.
Bibi Leila Parahoo has written about
her experiences as a foundation year one doctor in psychiatry and
offers some tips on how to make the most of the attachment.
Capacity is another topic that comes up
frequently both in my role and in medical finals so the Dean,
Professor Robert Howard, helped me come up with some pointers that
I hope you will find useful. Continuing in that vein, we also have
a piece on counselling the patient who is about to start to taking
lithium.
The Royal College offers
a number of prizes and bursaries to medical students and I would
encourage you to take a look at the full list which can be found on
the RCPsych
website.
The coming months are an
exciting time for student associates with the International
Congress in June and the Summer School in July. There will also
be some exciting developments for foundation doctors, so watch this
space!
Finally, good luck to all
those sitting finals in the next few months; we hope you will
continue your involvement with the Royal College of Psychiatrists
once you graduate.
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2. The role of the alcohol nurse
specialist
Neal Richardson, Alcohol Nurse
Specialist, Imperial College Healthcare Trust
I work as
an Alcohol Nurse Specialist (ANS) at Charing Cross Hospital,
London. My background is in psychiatric nursing and I’ve worked in
various addiction services for the past decade. I’m employed by
Central and North West London NHS Foundation Trust and linked to
the local statutory drug and alcohol service.
The post began in late
2007 and the initial focus was to provide an A&E based service,
although since that time the work has expanded to cover all
hospital wards and clinics. In April 2009 another nurse joined me
at the hospital, after additional funding was agreed by the
PCT.
A&E staff are
encouraged to use the Paddington Alcohol Test (PAT) to identify
alcohol misuse and to highlight the link between identified
patients’ A&E attendance and their drinking. Alcohol related
hospital attendance can be seen as a ‘teachable moment’, with
patients more likely to reflect on their drinking and respond to
advice at this time.
Any patients identified
as drinking in a risky fashion can be offered referral to the ANS
for brief intervention. Patients can be seen whilst in the
department or they can be booked into the alcohol nurse clinic,
held each weekday morning. Other hospital wards and clinics can
also refer and we aim to see patients on the day of referral.
The ANS brief
intervention consists of assessment of the patient’s drinking
pattern and history, as well as questions related to physical and
mental health and social circumstances. This information is used to
provide personalised feedback about risks associated with excessive
drinking. The aim of the brief intervention is to elicit change in
harmful drinking behaviour. If appropriate, patients are directed
towards specialist services for ongoing support or treatment. We
also offer outpatient follow-up sessions when appropriate. Other
aspects of the ANS role includes advice on alcohol withdrawal
management and staff training on alcohol related issues.
It’s a really interesting
job from both a clinical and service development point of view. We
get to see a broad range of patients, from weekend ‘binge drinkers’
ending up in A&E, to patients with complex physical and mental
health problems. The role involves working with staff from a wide
range of disciplines and it’s satisfying to see the service expand
as more staff come to see the benefits of ANS referral. The general
hospital is a prime setting to offer ANS interventions around
alcohol misuse and hopefully reduce some of the associated
harms.
Contact: neal.richardson@nhs.net
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3. Assessing capacity: practical
tips
Sacha Evans,
Foundation Year 2, Imperial College Healthcare Trust and Professor
Robert Howard, Dean, RCPsych
As a
foundation doctor, I am frequently asked to assess the capacity of
a patient. Often simple; however, when patients appear to be
confused or have some minor memory loss it can be less
straightforward.
Abbreviated Mental Test
Score (AMTS) and the Mini-Mental State Examination (MMSE) are
helpful to understand cognitive functioning. The premise is that
all adults have capacity and cognitive impairment does not
necessarily indicate incapacity. It is useful to speak to nursing
staff and allied health professionals to understand their concerns.
The assessment can be carried out with the social worker if there
are practical considerations such as how the patient will cope at
home.
Allow a reasonable amount
of time (20-40 minutes) to conduct the assessment and choose a
location free from background noise to mitigate any
hearing-impairment. It may be necessary to assess capacity more
than once to ascertain whether cognitive deficits are fluctuant.
The capacity assessment is specific to the scenario under
discussion; it is also time-specific.
It is important to
explain to the patient how the capacity assessment will take place,
i.e. that there will be a discussion about the decision to be
made.
The key questions that have to be answered to
assess capacity are:
- Does the patient absorb and understand the
information central to the decision being made?
- Can the patient retain the information long
enough to come to a decision?
- Is the patient able to
weigh-up the information to make the decision? This relies on the
doctor providing sufficient (i.e. understandable and appropriate)
explanation about what will happen to the patient, the pros and
cons of any decision along with associated risks and
consequences.
- Is the patient able to communicate their decision?
Practically, it is
important to elicit what the patient has understood about the
procedure or decision, what their decision is and how they came to
it. It is a two-way dialogue and, as clinicians, we are responsible
for ensuring a patient's understanding is optimal; this can involve
written information and allowing the patient time to process the
information and ask questions.
If, by the end of the
consultation, it is not clear whether the patient is capacitous
then it is preferable to get help from a senior colleague. At this
point we often involve the liaison psychiatry team who can provide
additional input.
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4. Psychiatry for beginners: the
foundation year 1 rotation
Dr Bibi Leila R Parahoo, Foundation
Year 1, University Hospital North Staffordshire
Nowadays many of the
deaneries are offering psychiatry as a foundation year 1 (FY1)
rotation. However, still no-one is sure what an FY1 can or cannot
do in psychiatry. I was certain of one thing: there would be no
on-calls; therefore it would be an unbanded job.
My first FY1 rotation was
psychiatry. I was not too sure what was expected of me. However, I
was lucky. My supervisor let me do my outpatient clinics, provided
I discussed any new patients with her before initiating any
treatment. I had a good exposure to the acute ward environment and
outpatient clinics.
Here are some tips as to
how you can make the utmost of this golden opportunity if you
happen to get psychiatry as a rotation:
1. I had most of my
case-based discussions (CBDs) and mini-clinical evaluation
exercises (mini CEXs) done during this rotation: No-one is too busy
for an assessment. Just ask your higher trainee or consultant to
assess you in any aspect ranging from history taking, mini mental
state examination, mental state examination, or any examination
testing the different lobe functions.
2. There are not many
direct observation of procedural skills (DOPS) in Psychiatry, so
just concentrate on the CBDs and mini CEXs, although you still need
to do two DOPS before signing off your end of placement review
sheet. Simple things such as venepuncture or administration of
Pabrinex (im/iv) are ideal for DOPS.
3. Do an audit. The audit
department has a lot of resources. It is often easier to get an
audit done during a psychiatry attachment as it can be less hectic
than medical and surgical jobs.
4. Do some teaching. The
nurses and nurse practitioners will be more than willing to attend.
It is a golden opportunity to get feedback sheets filled out; this
will definitely impress your supervisor.
5. Furthermore, do as
many reflective practices as you can in your portfolio. You won’t
have the time or energy to do it once you start your medical or
surgical rotation.
Last but not least, enjoy
it. It is a great speciality to begin with and gives you so much
insight into psychosocial issues any patient may have. You will see
the world through different eyes!
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5. Tackling
the psychiatric OSCE (objective structured clinical examination)
station – counselling a patient on starting lithium
Declan Hyland, Foundation Year 2,
Aintree University Hospital
Lithium has
been a first-line treatment for bipolar affective disorder for over
50 years and is regarded as the gold standard long-term agent. A
common psychiatric OSCE station is counselling a patient on
commencing lithium therapy.
Formally introduce
yourself and check the patient’s name and date of birth. Commence
the interview by explaining that you’ve been asked to talk to them
because he/she needs to be started on lithium and you wish to
explain what its side effects are and the need for regular blood
monitoring.
Explain that lithium is a
“mood stabiliser” that will help to maintain the patient’s mood at
a stable level (i.e. prevent it going too high – resulting in
mania, or too low – resulting in depression). The exact mechanism
of its action is unknown.
You should explain that
the patient will most likely need to remain on lithium long-term,
but will be regularly reviewed by a psychiatrist to determine
whether he/she is on an adequate dose and/or formulation.
Explain that because
lithium is a potentially toxic substance, safe and effective
therapy requires regular monitoring of its levels in the blood. The
major dose-related side effects of lithium that you should mention
include: polyuria, polydipsia, weight gain, fine tremor,
gastrointestinal disturbance (nausea, dyspepsia). When taken
long-term, lithium may affect the kidneys and thyroid gland. If the
patient is female, warn her of the adverse risks of becoming
pregnant whilst taking lithium.
You must explain to the
patient that lithium is a drug with a narrow therapeutic index i.e.
patients can easily become toxic. Warn the patient of the early
signs and symptoms of lithium toxicity: marked coarse tremor,
vomiting, diarrhoea and associated lethargy and dehydration. If the
patient develops any of these clinical features, he/she should seek
urgent medical attention.
Advise the patient that
prior to commencing lithium therapy, a series of tests need to be
done: an electrocardiogram and blood tests, including full
blood count, thyroid and renal function tests (U and Es). If the
patient is a female of child-bearing age, they will require a
pregnancy test. The patient should have their lithium level checked
five days after the initial dose. Their dose of lithium may then be
titrated up as required until a suitable maintenance dose is
acquired. Explain that the patient will require weekly measurement
of the serum lithium level until a therapeutic level has been
stable for a month since commencing therapy. The lithium level will
then need to be checked every three months. Inform the patient that
he/she should have his renal function and thyroid function checked
every six months.
Finally, tell the patient
that he/she needs to inform any doctor that he/she sees that he/she
is taking lithium, as it interacts with many different drugs (e.g.
anti-epileptics, diuretics).
As with any OSCE station,
you will be awarded marks for using appropriate open body language
and using lay terms for the benefit of the patient. Regularly check
that the patient has understood everything you have told him/her
and explain in simple terms anything the patient is unclear
about.
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6. Warwick Medical School Psych
Soc: How we set it up
Katherine Moody
(President), Sammy Chowdhury (Vice-President), Katya Cogan
(Secretary) and Sue Boyers (Treasurer)
Being a
new and small graduate-only medical school, a group of us realised
we had a shared interest in psychiatry. So we decided to set up
Psych Soc! We had all independently joined as RCPsych student
associates, and decided to look on the student webpages about how
to set up our society. This gave us access to a step by step guide
of how to start a society. We decided to email all psychiatry
consultants and trainees to ask for their support, to which we got
a good response. One consultant in particular, who was new to his
post, was especially interested and we met with him to start the
ball rolling.
Our next hurdle was to
get students to sign up, at the freshers’ fair where everyone kept
asking if the Psych Soc was psychology! However, despite this we
were encouraged by the interest and went ahead with our launch
event. We had emailed extensively and put up posters in the medical
school as well as all hospital sites. We were worried about the
turn out to the event but, with the promise of a glass of wine and
some nibbles, the turnout was better than expected. At the launch
event we tried to give people an insight into what Psych Soc hoped
to achieve and about careers in psychiatry from four different
perspectives. These included our local ‘grandfather of psychiatry’,
two general adult psychiatrists with different special interests,
and a specialist trainee, which students really enjoyed. Despite
the hurdles we encountered and our personal prejudices about lack
of interest, we are really glad we persevered and are looking
forward to our second year. Whatever reservations you may have, we
would encourage you to set up your own society as hurdles are never
too hard to overcome so long as you are determined.
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7. Psychiatry as a medical
student
Verity Bradley, fourth year medical
student, Manchester Medical School
As I finally embark upon the psychiatry teaching
module of my medical degree (albeit only for four weeks) I have to
say that I am disappointed by the lack of enthusiasm for psychiatry
and generally less than complimentary remarks about the
specialty.
Psychiatry is a complex
and fascinating area of medicine. Unlike many other specialties
where you may be able to order a scan or a blood test to aid
diagnosis, psychiatry relies on a thorough history and the skill of
the doctor being able to observe a patient and pick up clues from
how they act, their body language and what it is they say.
With mental health
problems thought to affect around one third of the population at
some point of their lives, psychiatry is therefore a specialty that
many people may come to encounter. In every branch of medicine,
whether a patient has a cardiac problem or a fractured limb, it is
always important to consider the psychological impact that the
condition may be having on a patient. It is easy to get overwhelmed
by the physical manifestations of an illness, but it is important
to always consider the psychosocial implications.
Mental illnesses can be
hugely debilitating conditions and make it incredibly difficult for
patients to maintain a ‘normal’ day to day existence. One of the
most common remarks I have heard in relation to psychiatry is that
it is all about patients ‘feeling a little bit down’. I don’t know
whether this is due to sheer ignorance or just a lack of
understanding about the specialty, but psychiatry is much more than
this. And I think that this misunderstanding is one of the main
struggles that mental illness and psychiatry has.
For several years now I
have decided that psychiatry is an area that I would like to
pursue. Upon telling this to doctors or tutors I tend to get the
response of ‘Oh psychiatry, are you sure you don’t want to do
anything else?’ Of course there are those that congratulate me on
wanting to pursue a career in such a ‘worthwhile specialty’, but
unfortunately the majority seem to give the former response.
Initially this response used to disappoint me, but now I try to
take it in my stride and attempt to make my peers ‘see sense’. I
have come to terms with the fact that pursuing a career in
psychiatry and getting people to understand that a) it is a
worthwhile and highly complex subject and b) that,
yes…psychiatrists are ‘proper’ doctors (!!) may be a struggle.
It is a challenge I look
forward to and I feel that if, by embarking upon this career, I am
able to go even some little way towards educating others about
psychiatry and change their views about the specialty then I will
be happy!
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8. Book review: In search of memory:
The emergence of a new science of mind by Eric Kandel
Simon Vann Jones, stage four medical
student, Newcastle University
In his
article for the February edition of the Student Associate
newsletter, Dr Jeremy Holmes referred to the work of Professor Eric
Kandel, the Nobel Prize winning neuroscientist. One Amazon search
and two weeks later, I had read the most interesting book of my
life and the three career options I had been pondering had been
reduced only to one. Psychiatry. This fascinating book, an
autobiographical essay coupled with a history of neuroscience and
psychiatry, starts with Kandel’s life as a Jewish boy in
Nazi-occupied Vienna, describing how the vividness of those early
memories prompted a life-long interest in memory and the brain. He
would go on to discover where, how and why such long-term memories
are stored. The book describes the evolution of our understanding
of mind and the progression of neurobiology from the discovery and
mapping of the neuron to identifying the function of different
parts of the brain – think Brocha and Wernicke - and ultimately to
our current understanding of the biochemical changes associated
with mental illness.
Originally Kandel’s
interest was in psychoanalysis and, despite his life work focusing
on the basic science of the synapse, he never lost sight of the
value of psychoanalysis and psychotherapy. He details recent
research that demonstrates the potential to use imaging and
biochemical measurements to assess the impact of
non-pharmacological therapy as well as the indisputable role of
medication, something I had always questioned in the past.
Kandel entertainingly describes the
fascinating laboratory and psychological experiments that have
taught us so much about how the mind works and convincingly argues
that any disorder of mind is fundamentally due to the structural
changes in the brain.
The book concludes with a
discussion on the future of the biological approach to mental
health and how current findings are leading us inexorably towards
new treatment options. Kandel finishes by suggesting three
questions that science must try to answer in order to progress our
understanding of mental health:
1. How the unconscious processes sensory
information and how conscious attention turns that into memory.
2. How the unconscious relates to conscious
mental processing.
3. How genes relate to behaviour.
This book is not a
textbook, having been written for a broader popular audience, yet I
feel I have learned more from it than any previous reading on the
subject. Kandel’s enthusiasm is unrelenting and infectious. For
evidence of his clear passion for his subject, type his name into
YouTube and watch his series of lectures on mapping memory. If you
like what you see, order this book - I promise you won’t regret
it!
Rating: 10/10
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9. Book review: Human traces by
Sebastian Faulks
Maria Casserly, Foundation Year 2 in
Old Age Psychiatry
Beginning in
the late 19th century, Human Traces follows the lives of two young
men through a time of great innovation in medicine and the
emergence of psychiatry. Jacques Rebiere, an impoverished farmer
from Brittany, whose beloved brother Olivier lives locked in the
stables because of his so-called “madness”, becomes fascinated by
medicine under the tutelage of his local curé. In England, a
wealthier Thomas Midwinter is developing an interest in the study
of the mind. As teenagers, at a chance meeting in Deauville, they
pledge to devote their lives to the study of the meeting of mind
and body in the hope of one day understanding ‘Olivier’s disease’.
Following medical school, Thomas works in an English asylum,
presiding over the care of hundreds; an impossible task. The
stigmatisation and often barbaric treatment of those with
misunderstood mental illnesses is vividly described. Jacques
studies under Charcot at the Salpetriere in Paris. Eventually their
lives converge with the marriage of Thomas’ sister to Jacques and
the opening of a clinic together in Austria. Their obsession in
researching the basis of mental illness, Thomas considering its
neurobiology and heritability and Jacques studying psychoanalytical
theory, drives their lives and dominates their relationships.
As in his previous works,
Sebastian Faulks addresses complex moral and social issues, whilst
successfully making the reader feel as though they are living
alongside the characters, experiencing their hopes and dreams. This
is a fictional masterpiece with a strong basis in medical fact, a
heady mixture which will never appeal to all audiences. At over six
hundred pages in length, and littered with scientific lectures, it
is a challenge to the reader, particularly, I imagine, those
without a medical background.
This novel is primarily
concerned with humanity and the complexity of the human mind. The
budding psychiatrist will enjoy musing over many themes including
the history of psychiatry, family dynamics and the personal and
social impact of mental illness. It is peppered with theories from
leading psychiatrists, research findings and descriptions of cases
both men encounter. We can all identify with the ambitions of
Thomas and Jacques as we strive to ‘make a difference’ to the
management of our patients. Ultimately, Human Traces reminds us how
far psychiatry has advanced, the debt we owe innovators such as
Thomas and Jacques and the important role we have in medical
research.
“One day such poor unfortunates will be cured,
as modern medicine has cured so many illnesses that baffled our
ancestors.”
Rating: 8/10
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10. Review: “Bounce’s insane in
the brain” Sadler’s Wells Theatre, London
Chrishanthy Grace Thambyrajah,
Foundation Year 2, King Georges Hospital, Ilford
As
an aspiring psychiatrist and lover of the cultural arts, I was
immediately drawn to the upcoming production of “Bounce – insane in
the brain” at Sadler’s Wells Theatre in London. It is a hip-hop
dance inspired adaption of the Ken Kesey’s classic book and famous
film “One flew over the cuckoo’s nest”. With some mixed reviews and
a medical background, I was keen to see it for myself and formulate
my own opinion.
The first thing you
notice are the clientele at the theatre. Off the sophisticated
Strand, young urbanites and dance school tweenies flood the
auditorium. The theatre was packed with a buzz in the air and the
opening scene did not disappoint. Full of dramatic lighting with
intelligent darkness, and blaring sound systems, it was designed to
be attention grabbing from the jump.
The play is a tale of mischievous
Randle Mc Murphy’s run in with a mental state hospital and the
experiences within the four cushioned walls. Break dancing with a
message, the actors were able to dramatise the dilemmas of mental
health institutions without being insensitive or patronising. It
explores the relationship and apparent “battle” with the hospital
staff/”enemy”, (namely the power struggle between McMurphy and
Nurse Ratched) and the deep friendships formed with the other
mental health patients. Each character was recognisable, from the
happy manic to the shy obsessive compulsive. It brought back fond
memories from psychiatry clinical rotations as I could see a little
of each patient in every character on stage.
The choreography is
immaculate; tight yet fluid, flexible yet defiant. The dancers are
possibly the best I have ever seen, (even better than the Strictly
Christmas Special 2007) effortlessly moving from break dance to
ballet in a single scene. I praise them highly, not just for their
ability to dance, but their ability to story tell so beautifully
without the power of speech. The way they used the stage and props
was simple and effective; from straight jackets and crutches to
queuing for medication and climbing up walls, it was fun and
elegant. The hospital bed routine was my favourite, where a row of
hospital beds and a single light bulb above each created the most
unusual and innovative feast for the eyes.
The soundtrack for the
production is modern, edgy and big on the bass, sampling Cypress
Hill (hence the title), Missy Elliot, Ludacris and the Prodigy to
name a few. Songs more likely to be found on a medical student
i-pod then a West End production, it was yet another big green tick
of approval.
With shows like “Bounce’s
– insane in the brain” gracing our London nightlife it is a wonder
to me how anyone can say that our city is experiencing a cultural
arts crisis. The show was a massive hit and will be showing again
next summer, and I urge anyone involved in the medical profession,
especially psychiatry, to go and watch it live on stage for a show
that is not only educational, but also enjoyable. With the growth
of mental illness in young London, I strongly believe this show is
one step (or bounce) forward in tackling the stigma attached to
mental health, making talking about it more approachable, relevant,
and “cool” to the next generation.
10 out of 10, five stars,
A plus. This play is the best musical I have seen – I highly
recommend it and cannot wait to see it again.
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11. Articles for the next
issue
Please send your articles for the next edition
to sacha01@doctors.org.uk
Back to top
The RCPsych
Student Associate Newsletter Editorial Team February
2010:
Sacha Evans
Fizzah Ali
Samyami Chowdhury
Vivek Datta
Jude Harrison
Emma Hogan
Jonathan Nicol
Hannah Short
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Page last updated on 1 June 2010 by E
Baker-Glenn