Hard time during Third year help

[charles425]

Hi guys, I need some help.

I'm a new third year on psych consult service. I was asked to preform an observed H&P with an attending on a patient s/p suicide attempt and was super nervous as I've never talked to someone about this sort of thing before. I asked all the residents for their advice on questions to ask about suicide attempts and felt super prepared with the list of questions I had. I felt like I was really connecting with the patient talking about why they felt they needed to harm themselves and was getting a great history. Then, my attending interrupts me, asks a couple questions, and ends the interview after 15 minutes.

Outside of the room, my attending rips me apart on how I didn't do an ROS and had no symptoms to make a diagnosis that we could bill for and was "being a support person not an MD". They basically told me I failed this encounter and needed to do it over again. I totally understand I was taking a long time with the history, but I didn't even have the chance to get to ROS and past med/psych history since my attending interrupted me. Anyways, I understand I need to be quicker with consults and can't take an hour but also it was my first H&P ever and I felt I was doing best by the patient for being someone to talk to for a brief bit before medicalizing everything they were telling me. I ended up crying to the resident that was there to witness the whole thing later, not my finest moment.

Anyone have any similar experiences? Advice to come back swinging on my next try?

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[PugsAndHugs]

I was also shocked when I first observed my psych attendings interact with patients. I always assumed they were supposed to take the longest time with patients and have the most empathy but my experience was very similar to yours.

 

[ConfusedAboutEverything]

If it helps, see hospital psychiatrists as not social workers but as MDs who are trying to stabilize psychiatric urgencies and send patients off with follow up to social workers.

 

[honey0102]

Not psych, but another primary care service. In outpatient, I would take a focused history and do the physical, but sometimes there would be a tiny detail I forgot to ask, as I didn't see it as pertinent-or, I'd think something might be pertinent and would ask it.
My attending would rip me apart, like totally rip me to the ground. Also a beginning M3. Even if I tried to learn from my mistake by asking she yelled at me
Some attendings can just be malignant. It's tragic, really.

 

[OrgoCoop]

You did well here. He just needed X number of ROS and Y number of physical exams documented for billing.

 

[jurassicpark]

This is how you learn. You're taught during pre-clinicals to be empathetic, ask open-ended questions and the whole-shebang. In real world, Attendings and Residents have a very finite number of minutes. As someone mentioned, you're an MD not a social worker. Part of the training (in fact a large part) in third and fourth year is how to concisely get a H&P and pick up on what is or is not relevant. And yes, the all important questions you must get in order to bill. Doesn't matter if you have 10 nobel prizes, if you can't bill you'll starve and no one will get helped.

You'll pick up when to ask those open-ended questions or when to zero in on the kill. When to interrupt the patient and get them back on track. And what specific questions you want to ask for a certain clinical scenario to get to the real story. Memorize that ROS list and get through it fast.

 

[mistafab]

My suggestion is to think about the setting. If you are in the hospital on psych consult liaison s/p suicide attempt, you need to get the details down.

The hospital is not the place to have people pour their hearts out, build life-long therapeutic relationships, and get to the bottom of psych issues. The goal in the hospital is 1. Figure out if someone is going to die 2. Get them stable 3. Get them good follow-up so they can fix the underlying issues outside the hospital. Other common things for C&L is “agitation,” “capacity eval” and “mental status / delirium” so get good at those as well.

The attending on your rotations is not going to be the one to witness you get a full H&P. In the limited time you have with the attending, show them you “get it” and get straight to the meat they care about (depending on the service). On psych, get the HPI, ROS, MSE, and pertinent details. Attendings already assume you can gather the rest of the H&P on your own, so they aren’t there to watch you do that. If you have questions about what they want to watch you do, ASK THEM.

In an attending’s mind, you have spent 5x the amount of time with the patient as they have, so they expect you to know every single detail of the H&P on your patients. But again, they aren’t there to watch you do that. Get help from a resident or upper level med student if you need assistance as to what you should be gathering or doing in your H&P’s on each service.

 

[NickNaylor]

Sounds like you were about par for the course for a student on a consult service.

On the consult services at our hospitals, things are typically quite busy. Some of the attendings simply don't allow for the time necessary for a student to do a full interview, which I see as a failing of the educational responsibility of the attending rather than the student. In fairness to them, though, there may be 3-4 new consults to see in addition to 4-6 follow-ups along with documentation, so there really isn't enough time available to spend an hour per interview. Again, that's not your fault nor does it say anything about your skills, it's just the reality of working on a busy service.

Particularly on a consult service, I would suggest focusing on the following:

- The HPI, especially if a patient is admitted to the hospital following a serious psychiatric event (e.g., suicide attempt). The goal is to obtain a history that you can tell as a story that actually makes sense. You don't need a ton of details here, but enough to get the general picture. For example, a consult may be for "s/p suicide attempt." I would want to know what led to the attempt, what actually happened during the attempt, how they were feeling in the weeks-months prior to the attempt, and how they feel about it now. That's just one example, but the overall goal is the same.

- Psychiatric ROS, essentially screening for common disorders. I include this in the HPI but it's really another framework. At a minimum this would include screening for depression and a history of mania (particularly if a depressive disorder is on the differential), but things like anxiety would also be appropriate to screen for. If you really want to get a detailed history, screening for trauma disorders and eating disorders is also appropriate. Screening for substance use is also important, though I put that under "substance use history" in my own mind. You may want to screen for other things depending on the situation (e.g., memory impairment and ADLs/IADLs if dementia is a potential diagnosis).

- Mental status exam, especially a cognitive screening exam on a consult service. At a minimum ask about orientation, test attention, and test immediate and delayed recall. Do more thorough screens depending on the situation.

And really, that's about it. You need to ask about other things (e.g., PMH, PPH, FH, SH, etc.), but when time is limited, those really are the key things with respect to getting sufficient information to come up with a diagnosis and initial treatment plan.

Students really are at a disadvantage in settings like this because a lot of the skills needed to do a concise interview come with time - it's not something you just "do," but instead you develop the skills to do it over years. You're also at the mercy of the patient. Patients that are long-winded, circumstantial, or want to tell you their whole life story are challenging now matter how good you are at redirecting and refocusing. I'd say that a good goal for a student should be to be able to a reasonably thorough, complete psychiatric evaluation in about 60 minutes assuming that the patient is a "good patient" (cooperative, good historian, able to answer questions directly). In fairness to the attending, it can also be frustrating to sit through a slow interview done by a student that you could do in half the time when you know that you have a ton of other things that you also need to get done that day. As a student, however, that's not your problem.

Keep asking for feedback and try to incorporate that feedback as much as possible. Ask for specifics. See a lot of patients. Those are the only things you can do to improve your skills, and it's not something that's going to happen overnight.