Bergen Regional Medical Center / TouroCOM
Medical Student Rotation Manual
Psychiatry Clerkship
2011-2012 Academic Year
Maurizio A. Miglietta, D.O., FACOS
Director of Medical Education
Rachel Cohen
MS-III, Chief Medical Student
Dear Touro Students,
Welcome to the Psychiatry Clerkship at Bergen Regional Medical Center! During the four week
rotation, you will be exposed to the fascinating and dynamic world of Psychiatry. Hopefully, you will
emerge with a new appreciation for the major psychiatric disorders, the struggles patients with these
disorders face in the world, and how the psychiatrists can more effectively address these illnesses. You
will have an opportunity to participate as a member of a treatment team to devise treatment plans based
on a Biopsychosocial Model. You will also acquire new skills in interviewing, which will serve you in
whatever discipline you pursue in the future.
nd
**Report to the Behavioral Health Department, Bldg. 14, 2 Fl., Rm. E223 at 8:00 a.m. on
the first day of your rotation.**
BRMC Medical Student Coordinator
Name: Joel Reed
Location: Bldg. 14, 2nd Floor, Room E223
Phone: 201- 967-4132, Fax: 201-967-4290
Email: jreed@bergenregional.com
What to Bring on First Day
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Please wear your white coat.
Bring an updated resume. Please include your address, phone #, email address & DOB.
Bring a recent color photo of yourself (no larger than 3x5). Please include, name, school &
date of rotation on back of photo.
Expectations on Rotation
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Report and Sign-in, Monday thru Friday, at 8am in Behavioral Health Bldg., Room E222 for
morning presentations with all other medical students.
Sign-out, Monday thru Friday, at 4:15pm in Behavioral Health Bldg, Room E222
Joel will give you weekly assignments for the month. After morning report, find and follow the
Resident in the unit assigned to you that week.
Attend daily afternoon lectures. The medical student schedule is posted in Joel’s office, on the
bulletin board.
o Note= Wednesday is Didactic Day, and medical students are expected to attend all lectures
offered that day (including EBM).
Academic Requirements
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1 Topic or Case Presentation. Each Touro Student is required to present a Psych Topic or
Patient Case during an 8am meeting. **Please ask your Resident Preceptor for assigned dates and
format.**
1 Weekend Call. Each Touro Student is required to rotate in the ER, 9am-1pm or 5pm-9pm.
Please have Resident sign On-Call Form.
1 Weekday Call. Each Touro Student is required to rotate in the ER 5pm-9pm.
Resident Evaluations. Please have each Psych Resident you rotate with sign a Touro Faculty
Evaluation Form. They should all be turned into Joel, who will then coordinate your final
evaluation with Dr. Badr.
Patient Case Log. Please fill out the patient case log you have used on other rotations.
Remember to have each Resident sign for the corresponding cases. Make a copy at the end of your
rotation, and hand in to Joel to help supplement your student file.
Goals & Objectives
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To acquire interviewing skills to obtain pertinent information from patients
in an empathetic, respectful manner.
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To acquire basic understanding and awareness of major classes of
Psychiatric disorders, their evaluation, diagnosis, differential diagnoses,
basic treatment and therapy.
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To learn to provide effective follow-up treatment for non-acute outpatients.
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To make effective referrals for psychiatric consultations.
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To acquire understanding and appreciation for the team approach to patient
care by participating actively in a treatment team .
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To improve skills in communication with other healthcare providers,
including: formal patient presentation, effective documentation, precise
notes and effective treatment plans.
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To acquire understanding of the Mental Health System.
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To gain an understanding for the obstacles and biases psychiatric patients
face in society and the healthcare system
Core Competencies
1. Students will be able to elicit and present a complete psychiatric history and mental status
examination.
2. Students will be able to conduct patient interviews in a manner that facilitates information gathering
and formation of a therapeutic alliance, i.e., demonstrate respect, empathy, responsiveness and concern
regardless of the patient's problems or personal characteristics and be able to use basic strategies for
interviewing disorganized, hostile/resistant, mistrustful, circumstantial, hyperverbal/hypoverbal and
potentially assaultive patients.
3. Student will be able to assess for the presence of general medical illness in psychiatric patients and
determine the extent to which a medical/surgical illness contributes to a patient's psychiatric problem.
4. Students will be familiar with psychiatric terminology and be able to use the five axes of the DSM-IV in
evaluating patients.
5. Students will be able to use and integrate laboratory testing , imaging tests, psychological tests and
consultation appropriately to assist in diagnosis of the patient with neuropsychiatric symptoms.
6. Students will be able to evaluate and begin management of psychiatric emergencies.
7. Students will be able to perform a mini mental status examination of cognitive functioning and
recognize the psychiatric manifestations of organic brain diseases.
8. Students will be familiar with the hypotheses regarding etiology, the epidemiological features, the
common signs and symptoms, the DSM-IV criteria, the differential diagnosis for the following groups of
disorders and be able to formulate a bio-psychosocial treatment plan for each:
a) Schizophrenia b) Mood Disorders c) Anxiety Disorders d) Personality Disorders e) Substance
Use Disorders f) Somatoform and Factitious Disorders g) Dementias & other Cognitive Disorders h) Attention Deficit
Disorders in Children
9. Students will be familiar with basic psychopharmacology, i.e., be able to summarize the indications,
basic mechanisms of action, common side effects and drug interactions of the following classes of
psychotropic medications:
a) Anxiolytics b) Antidepressants c) Antipsychotics d) Mood Stabilizing Agents e) Anticholinergics
f) Stimulants g) Hypnotics h) Cholinesterase Inhibitors
Teaching Methods
Didactic teaching as per schedule (attached) given at orientation, in addition to
formal/informal teaching time by your supervising resident/attending.
Participation in daily morning reports, check-out rounds, unit rounds and case presentations.
Participation in weekly Psychiatric & Medical Grand Rounds and Clinical Case Conferences.
Participation in "on-call" activities. Observation/participation in clinical activities including
direct patient care responsibilities.
Student Evaluations
Your grades will reflect clinical performance during the rotation and will also include evaluation of writeups and your performance in clinical and written examinations at the end of the rotation.
Resources
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Psychiatric Education Library -Located in the heart of
Residency Training, the Psychiatric Education Library receives the
indexed journals in child, adult and geriatric psychiatry with a
vast collection of reference materials. Medical students will also
benefit from the Main Medical Library in Building 6 with
additional reference journals and books.
Computer Room– Located next to Psych Library.
Suggested Readings Introductory Textbook of Psychiatry. Tomb,
Psychiatry (House Officer series). DSM-IV, Pocket Edition. DSM-IV
Casebook, American Psychiatric Association . Kaplan and Sadock,
Pocket Handbook of Clinical Psychiatry. Kaplan and Sadock,
Synopsis of Psychiatry.
CLERKSHIP RESPONSIBILITIES
Inpatient Psychiatric Services
A. Admission of Patients
 Interview patients as resident/attending assigns
 Write complete H & P, Psychiatric Assignment
 Be prepared to give a precise and comprehensive presentation of the patient's case to the
team, and have pertinent data available for the team's review.
B. General Duties on Inpatient Services
 Assist in work-up of new admissions.
 Typically be responsible for following and charting on no more than four patients at a
time.
 You are expected to be available from 8:00 a.m. -5:00 p.m. Monday through Friday. Your
attending may extend these hours as needed to complete work, rounds, etc.
 Talk to your patients -be aware of their status, do Mini Mental State Exam as appropriate.
 Obtain any pertinent new data prior to team rounds (X-rays, labs, EEG results,
neuropsychological or psychological testing, consultation reports, etc.).
 Read ahead so you can develop an understanding of your patient's illness, so you can
participate in a team discussion regarding a reasonable assessment of the patient's status
with respect to diagnosis, management, treatment goals, prognosis and disposition
options.
 Develop an understanding and appreciation for the multi-disciplinary team approach to
patient care, and the role of each team member.
 Always work closely with, and under supervision of, your resident and attending
supervisors.
 Documentation:
o Daily notes on each of your patients should be in S.O.A.P. format (SOAP notes);
may be written before or after rounds, and should include:
o Subjective: What the patient tells you -new complaints or concerns
o Objective: Summary of staff observations since last team rounds, your
observations, notations about sleep/appetite/medication, compliance/problems
with medications/participation in unit activities/use of p.r.n. medications for
sleep, agitation, psychosis, acting out, etc., need for restraints or seclusion,
aggressive behavior, vital signs, Mental Status Examination, including a MMSE
when appropriate to patient's condition. New data: X-rays, labs, psychological or
neuropsychological testing, EEG, information from family, etc.
o Assessment/Plan: Problem list with assessment, rationale for changes in
therapy, treatment goals, plans for disposition. Should include a list of active
psychiatric and medical problems. If you are unsure of the plan, it is acceptable to
write, "Will discuss with attending/supervising resident."
C. Orders on Your Patients
 You are responsible for new and subsequent orders on your patients and having them cosigned by your attending daily. However, you should get verbal approval of your intended
orders for your supervising resident.
D. Off-Service Notes
 List diagnoses, interventions, patient's responses to interventions, prognosis, plans for
disposition, brief summary of hospital course by problem list. This is a courtesy to the
clinician that follows you.
E. Discharge Notes
 At discharge you should write in the chart:
o Admission and D/C dates
o Multiaxial diagnosis ~ Procedures ~ Consultations ~ Disposition ~ Condition at
discharge ~ Diet ~ Activities ~ Medications including: prescriptions written, #
dispensed, # refills ~ Follow-up appointments ~ Any pertinent D/C labs (e.g.
lithium levels, CBC, etc.)
Professional Behavior
Attire
During rotations you will be required to wear your white coats at all times. You are expected to
dress as a professional, which includes collared shirts and ties for men, appropriate dresses or
slacks for women, and no shorts in either case. In addition, both men and women are reminded
that sexually provocative clothing (e.g ., open shirts for men or low-cut dresses/blouses or high
hemlines for women) is inappropriate when working with psychiatric patients.
Physical Safety/Violence
Contrary to common belief, most psychiatric patients present no physical danger to
others; however, some patients may pose a risk. WE DO NOT WANT ANYONE--STUDENT,
RESIDENT, FACULTY, STAFF, OR PATIENT--TO BE INJURED. Thus, it is important that you
follow all safety instructions and that you always be cognizant of safety considerations. Because
psychiatric patients may not think clearly or behave normally, alterations of your usual behavior
with others may be required.
For all of these reasons, please remember that when a faculty member, psychiatric
resident or site staff member asks you to, stop talking about or with a patient, leave the room, or
gives you other specific directions, you need to do so immediately and without question.
Thereafter, you should feel free to ask for an explanation of any directions, which you did not
understand.
There is another important point to be made with respect to physical safety and violence.
If a patient should become violent, it is not your task as a medical student to intervene. Indeed, it
is best that the job of containing a violent patient be left to those who know how to do it: the staff
and hospital security.
Boundary Violations/Professional Boundaries
Mental health professionals have special, specific and very stringent professional and
legal obligations with respect to certain behaviors with mentally ill patients. The concept of
"undue familiarity" or "boundary violations" refers to a mental health professional's obligation to
avoid any sexual activity with his or her patient, no matter how the patient behaves (e.g., no
matter how sexually seductive the patient may be). Similarly, any activity that might be
considered a prelude to sexual activity or other "boundary violations" is proscribed.
Thus, as a physician in general, and in psychiatry in particular, you will need to be careful
not to move from a professional relationship to a friendship with your patients while, at the same
time, remaining human, kind, compassionate, caring and polite. As a helpful reminder, always
carefully consider apparently "benign" requests on the part of patients that may compromise
your professional relationship with them (e.g., no matter what the reason, one should be very
wary of agreeing to meet a patient in a restaurant in the evening). If you are unsure as to
whether certain activity with a patient is within appropriate professional boundaries, then be
sure to first ask your supervisors.
Please note well: a student who engages in any sort of sexual activity with a patient,
"dates" a patient, or otherwise inappropriately associates with a patient outside of the
clinical confines of his/her rotation or site will be immediately dismissed from the clerkship,
will automatically be given a failing grade for the clerkship, and will find himself or herself
before the Psychiatric Education and Review Committee.
Confidentiality
Mental health professionals also have professional and legal obligations with respect to
issues surrounding patient confidentiality. Please remember that psychiatric diagnoses are
typically more "dangerous" and destructive to a patient's work and reputation than are
"medical" diagnoses. You can easily imagine that suffering from congestive heart failure or
diabetes carries nowhere the stigma of being labeled a "schizophrenic" or "manic-depressive".
Furthermore, psychiatric patients often reveal intimate secrets about themselves or their
families, information that could be very destructive if it were to come into the wrong hands.
While all physicians have to pay great attention to issues of confidentiality, this is especially so in
psychiatry.
Thus, while we recognize that you will often discuss your experiences on this clerkship
(just like other clerkships) with friends, spouses and families we expect you to take
extraordinary care in doing so with psychiatric patients. Patient names should never be
discussed and specific details that may inadvertently identify a patient and/or his circumstances
should not be revealed to anyone without specific authorization by your faculty clinical
supervisor.
Furthermore, you are not free to speak with family members, employers or friends of
patients (in person or on the phone) without the explicit permission of the patient. While there
are some exceptions to these rules, such situations in which the physical safety of the patient or
others may be seriously and imminently threatened, the safest course is to be very careful in
speaking about a patient with others. Again, when in doubt, please check with your supervising
resident or faculty member.
Report Dangerous/Risk
If you learn from a patient or others, in the course of your work, that a particular patient
is suicidal, homicidal or otherwise at risk for physical harm to self or others, you should
immediately inform your Attending Psychiatrist, your resident, or appropriate staff members on
site. Similarly, any serious concerns you have about a patient should be so communicated.
Remember that you are a part of a treatment team, and within such teams it is expected that all
relevant and important information will be communicated to other team members.
Professional Respect
The mentally ill are ordinary people like us. All of us know someone who suffers from a
psychiatric disorder, and most of us have had our own personal experience dealing with
adjustment issues, depression, anxiety, substance abuse, and/or other mental illnesses. The
mentally ill are suffering people; they are not "crazies" or "loonies" that are fundamentally
different from those of us currently enjoying better mental health.
Thus, we expect you to treat psychiatric patients as you would want to be treated yourself
if you were in a similar situation--as competent individuals--and show respect, empathy and
compassion. The Golden Rule is just as valid in psychiatry as it is in other aspects of life.
Insensitive, hurtful, thoughtless, demeaning or stigmatizing comments will not be tolerated. And,
in this respect, another important note: patients often hear conversations that take place in
nursing stations; please be careful what you say there.