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Feedback and Examination technique

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1 Feedback and Examination technique
Dr Rebeca Martinez and Dr Chris Williams

2 Aims of the attachment The aims of the psychiatry attachment are that by the end of the attachment you can: take a psychiatric history and perform a mental state examination. recognise mental disorders which commonly present in hospital and community settings and describe the features of these disorders. competently assess the severity of these mental disorders and start early management of psychiatric emergencies. be particularly familiar with the role of psychiatry in the general hospital, primary care and community settings.

3 Objectives of the attachment.
Take a comprehensive psychiatric history Be aware of specific aspects of the history which may be relevant to the mental disorder, the age group concerned, and the circumstances of the patient (e.g. relevant physical, social, cultural and ethnic factors). are able to assess the mental state of a patient assess any risk that the patient may pose to themselves or to others are familiar with the features of mental disorders commonly presenting in hospital, primary care, community and psychiatric practice, (e.g. depressive illness, anxiety and related disorders, confusion, alcohol withdrawal schizophrenia) and that you can differentiate these from other conditions including normal and abnormal responses to stress. can assess whether the severity of the mental disorder suggests that emergency treatment is needed (i.e. whether admission or other suitable alternatives are required under the Mental Health Act) and which psychological, social or physical interventions may be needed.

4 Have the attachments covered these?
Range of cases covered? Cases written up in detail? Ward rounds/OPD clinic experience? Visits with CPN’s, OT’s, SW’s and others? What about fact-gaining – reading? Need all of these things by the end of the Psychiatry block – there’s no more psychiatry until finals

5 Feedback: Starting your placement
Welcome: were you met? Were the contact details sufficient? Did you receive the ticklist of suggested learning points? Was this reviewed with you half way through the placement? Did you receive a written weekly timetable? Have you completed and returned the Feedback form to Doreen Lovett? If not please can you do this now

6 Revision (with Finals in Mind)
Need the following information for the exams But also as a doctor – it’s all very relevant

7 Preparing for OSCE’s  You are likely to see a station addressing a common condition: Anxiety/Affective disorders Schizophrenia Alcohol abuse/dependence Dementia Eating disorders OCD Consent issues/MHA (principles) Try to see/assess each of these and read about these conditions

8 OSCE topics History taking skills may ask you to take a basic history from a patient with a mental illness of e.g. anxiety, obsessive-compulsive disorder, depression, memory problems or a drinking problem. Mental State Examination stations will test your ability to elicit symptoms from the MSE such as first rank symptoms of schizophrenia. Communication skills are assessed throughout the OSCE and particularly in stations such as instructing a patient regarding discharge from hospital, consent to ECT or explaining a subject to a patient or to a carer. Examination skills can be tested by getting you to examine a variety of mental state systems (also don’t forget link to the rest of medicine: e.g. cranial nerves, a different part of a neurological examination, blood pressure estimation, fundoscopy etc)

9 OSCE topics Practical skills such as application of ECT electrodes, or introducing how to use a drink diary may be examined. Emergency management stations may centre on the treatment of severe drug side effects such as neuroleptic malignant syndrome or a violent patient. Miscellaneous topics could include data interpretation e.g. analysing blood result or interpreting an ECG or CT / MRI scan.

10 Affective disorders: assessment and management
Basic history taking of depression and hypomania from patient or relative. Postnatal depression assessment. Explaining to a relative the proposed treatment or illness/diagnosis. Psychological treatments of depression. Describing the need for/compliance with or side effects of antidepressants medication. Lithium pharmacology. Essentials of relapse prevention Medication adherence/concordance/side effects of common drugs.

11 Anxiety: assessment and management
Basic anxiety history to determine a diagnosis of anxiety disorder. Aetiology e.g. role of hyperventilation, avoidance and the vicious spiral of anxiety. Psychological Treatments e.g. explain systematic desensitisation or an overview of the CBT approach. Biological Treatments.

12 Capacity Key questions to test capacity
Very poorly answered in last years exams

13 Cognitive assessment and management
Mini Mental State Examination (MMSE). Collateral information from relative on dementia. Assessing functionality of patient with dementia. Cognitive enhancers.

14 Eating Disorders: assessment and management
Basic eating disorder history. Eating Diary (use/rationale). Differentiating between Anorexia and Bulimia Nervosa. Different reversing behaviours (e.g. abuse of thyroxine, exercise, laxatives and insulin).

15 Psychotherapy Explain CBT: essentials of model, key interventions
Explain Psychodynamic Psychotherapy Key elements of problem solving (7 –step plan) Overcoming avoidance – for example in phobias

16 Schizophrenia: assessment and management
Basic history. Explaining to a relative the illness / treatment. Eliciting first rank symptoms. Eliciting other psychotic symptoms e.g. passivity, auditory hallucinations. Starting treatment. Treatment resistance. Extra-pyramidal side effect (EPSE) examination. Explanation of medication/prognosis to a relative

17 Substance Misuse: assessment and management
Basic alcohol history. Basic drug misuse history. Alcohol diaries (use/rationale). Advice on how to reduce consumption. Assessing motivation to stop drinking. Key elements.

18 Suicide /self-harm Basic risk assessment history.

19 Data Analysis Blood results e.g. TFTs, LFTs e.g. in depression/anxiety
Neuroleptic Malignant Syndrome (NMS). Biochemical complications of an eating disorder. Interpret a CT / MRI scan e.g. in dementia Analyse a nursing kardex ( e.g. looking for an drug interactions or dangerous prescriptions).

20 Emergency Management Violent patient. Rapid tranquillisation.
Neuroleptic Malignant Syndrome (NMS). Serotonin syndrome.

21 Some more potential OSCE topics
ECT Explanation of procedure. Gaining consent. Insight Important questions to test insight. Premorbid personality Important questions to determine pre-morbid personality

22 Standardised Differential Diagnosis
Task: In pairs generate Standardised Differential Diagnoses for: Depression Paranoid ideas Alcohol problems Worry Panic/phobias Obsessions/compulsions Confusion

23 Aetiology Q. What would you say here? The three P’s: Predisposing
Precipitating Perpetuating

24 Investigations. “Physical”
Think out in advance appropriate investigations for each condition “These could include ...” Bloods. State which and why. ?EEG/?CT/?Urine drug analysis ?Blood alcohol levels etc. Use common sense. Say what you do in practice.

25 “Social” “Obtain old notes and read them.”
“Speak to a relative, with the patients consent.” “Speak to the ward staff - do they eat/sleep/mix”. “I would consider other sources of information…” (GP/consultant etc.) Specialised reports: OT, social report.

26 “Psychological” “I would admit for a period of assessment”
Psychometric testing Mood rating scales: some now stated as one’s you should know about Thought challenge worksheets Self-monitor: Drinking/Eating/Checking diaries.  Always say why.

27 Prognosis Consider: 1). The classical prognosis of this condition
2). Specific features of this patient which affect it. State your experience, not papers Previous history Response to medication Compliance with treatment/medication. Social supports/ characteristics and strengths of the patient. Degree of intelligence and willingness to work.

28 Structured management plans
Task: Generate structured treatment plans for the treatment of GAD/Panic/Schizophrenia/Depression. 1). Physical. 2). Psychological 3). Social/behavioural.

29 OSCEs in Practice On entering the station
Introduce yourself and in simple terms e.g. as a medical student Describe the task you have been asked to carry out. Interact with the actor / actress not the examiner. Listen to the actor / actress as they have much more information to give if asked the right questions. Communication skills are important in all stations. Don’t write too much and avoid paying attention to the patient as a result. This is likely to irritate the examiner and probably the actor too. Stick to the task asked.

30 Other techniques for the OSCE
Risk assessment issues are prominent in importance. Think of the whole picture (e.g. for a mother with postnatal depression you need to show that you have considered possible risk to the baby as well as to the mother). Remember biological, psychological and social aspects to a case (e.g. in the postnatal depression assessment mentioned above – is the mother able to interact with the child, play and smile at them? What impact might this be having on the child’s development, and the mother’s relationship with the father?). If you run out of time you can always say “at our next meeting we will discuss ….” If you have spare time or run out of questions, reflect whether there are any additional questions you should be asking. You can always summarise back out loud what the patient has said and check you

31 Before entering the Station
Read the vignette carefully, not just one word and jump to conclusions (e.g. see the word “alcohol” and assume it means “alcohol dependent”). Try and determine quickly what the station is trying to assess and what areas you should cover to gain marks. If you run out of time reading the vignette (they can be quite long), make sure you read the task you have to carry out.

32 How to relate to the actors
You need to make sure that you maintain a polite and professional stance in your relationship with the actors. Address them exactly as you would a real patient. Check their name. Avoid jargon. Look for non-verbal clues. Conversation not interrogation. If you make a mistake, apologise and start again (e.g. rephrase jargon into normal language more understandable to the actor / patient). Thank the actor at the end.

33 Feedback and Any Questions

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