Dr Harriet Jeffery, from North London, reflects on the four months she spent in on-call psychiatry.
"On my first night at a placement on an on-call psychiatry liaison team, honestly, I was terrified.
The week previous, I’d been an FY2 in general medicine – and now, I was to join an out of hours service for four months at a hospital in Scotland, covering all mental health wards.
Liaison teams like ours tend to comprise of a junior doctor – either FY2 or core psychiatry trainee – and a mental health nurse practitioner, with a consultant on call from home. Our roll is to take all the referrals from A&E, out of hours GP, the police and the acute hospital wards, so I knew I’d see a broad range of patients – including paediatric, general adult, addictions, perinatal and old age."
A helping hand
"I remember the first referral well.
We headed to A&E and I felt woefully inexperienced clutching my Oxford Handbook of Psychiatry, and desperately try to recall the components of the mental state exam. I was immensely relieved when the nurse practitioner suggested she takes the lead, and listened in awe as she skilfully weaves her way through the assessment with kindness and empathy. It was wonderful to watch the patient’s visible relief at being able to talk openly without judgement.
Over time, her and her colleagues would take subtle steps back, and I would gain confidence in leading these assessments on my own."
Finding my feet
"As my placement progressed, I found myself beginning to enjoy the job, having time to sit and listen to a patient, and to think of and formulate a plan (in addition, I stopped getting palpitations when the on-call bleep went off!). As well as the psychiatric assessment, I also needed to ensure the patients’ physical health was cared, for and there were times when a patient would disclose self-harm or overdose to me. I was responsible for the emergency management of this and liaising with the appropriate specialty regarding admission or management.
Although working directly with patients was very rewarding, I found the liaison with other healthcare professionals particularly interesting. As an FY2, the majority of these were with people more senior than me and I found it was a delicate balance between maintaining positive interdepartmental relationships and having the confidence to voice any concerns that I had."
The emotional toll
"One thing I was not prepared for was the emotional impact of the job. I was used to the hustle and bustle of acute medicine and A&E – rushing between sick patients, missing breaks and finishing late, but ultimately leaving it all behind as you walk out the door.
This was different. I found myself awake at 2am, worrying whether the patients we had discharged with community support would be safe until their next appointment; not satisfied until I was next on shift and could check their electronic records. I felt a huge amount of personal responsibility for the patients I saw and could not help but take this home."
Leaning on others
"For me, I found talking about this was immensely helpful. Our weekly Balint group was a great source of support and each week, a junior doctor had the opportunity to discuss a situation or scenario that had been challenging or upsetting.
These sessions were particularly beneficial for the liaison part of my job – we often discussed patients with emotionally unstable personality disorder, who came to A&E or to the police regularly in emotional crises. I found assessing risk in this patient group extremely difficult, and so it was incredibly valuable to share our experiences and approaches to these situations. Talking about cases also allowed us to revisit the patient history in detail, something which can be difficult during a busy on call shift.
In addition to this, I had excellent support from the consultant team. They were always approachable and expected to be phoned overnight. I never felt like I couldn’t ask for advice – even if it was 3 o’clock in the morning. I also had a weekly supervision session with my consultant and could use this time for portfolio assessments, addressing specific learning needs and for feedback."
"Despite always wanting to be a neurologist, psychiatry is not actually a career I had ever considered – mainly because I had limited undergraduate exposure to the specialty. My placement in the on-call team took me far away from my comfort zone, but was incredibly varied and interesting, with fantastic support from my seniors and peers. I had not realised there were so many different career options within psychiatry, including neuropsychiatry.
So, I am currently applying for both core medicine and core psychiatry training. One thing that may be the deciding factor in my decision to pursue either is the training environment. In medicine, it is easy for trainees to get lost in the system; on some rotations I only ever met my supervisor at the start and end of the job to sign off forms, and I was constantly chasing consultants to fill in portfolio assessments, which felt like a tick box exercise.
In psychiatry, it was very different: I felt like a valued member of the team. The consultants and registrars went out of their way to teach and to provide structured longitudinal feedback throughout the rotation. I also felt that trainee wellbeing was a priority amongst the senior medical and nursing staff and this was a topic that was regularly addressed and focused on.
Whatever path I do end up on, I’m immensely grateful for the experience I had, and how it built up my confidence and resilience to handle more challenging roles (and patients!)."