Originally published in FuturePsych magazine in 2020
I’m nearing the end of my oncology placement and about to embark on four months as a psychiatry FY2. It’s been some time since I’ve stepped foot on a psychiatric ward, and my medical student placement already seems quite distant. That slight trepidation is starting to creep in, the kind that comes when you try and dredge up facts from your training that are lurking in some obscure corner of your cortex. Clozapine – was it a 5-HT2A agonist, or antagonist? Cotard and Capgras syndromes; which one was which? And what if my patient has neuroleptic malignant syndrome?
After a bit more thought, I have come up with some words of reassurance for both myself and anyone about to start a psychiatry job.
Firstly, it won’t just be you on the ward. Senior help is there for a reason; it won’t be you initiating clozapine, and if you suspected neuroleptic malignant syndrome (which is thankfully rare), you’d be picking up the phone straight away. When it comes to finer points of pharmacokinetics and definitions of rare eponymous disorders, these things may have seemed important in medical school, but in clinical practice they rarely trouble the junior doctor. There are more burning questions pragmatic questions to answer, such as those surrounding admission. While slowly developing this judgement, you will rely on the experience of your seniors and the wider multidisciplinary team. The nurses have seen a hundred juniors come and go, they will know where people slip up, and when you need extra help.
Like obstetrics or paediatrics, psychiatry can seem like its own little world. Yet the reality is that we see patients with mental health problems all the time. Thinking back over my oncology placement there are some fairly striking examples of this; the woman who ended up admitted under section when the pills she bought online plunged her into a manic episode, or the man who planned to end his life before his cancer did. In every patient interaction there is a psychological and emotional component, whether we choose to acknowledge it or not. On oncology I have witnessed every type of stress reaction and coping mechanism. Serious physical health conditions such as cancer will affect the mental health of any individual, regardless of whether we have decided to affix a diagnostic label like depression or adjustment disorder to their medical records when their emotional response crosses some arbitrary line.
Not only are we all, as doctors, engaging with psychiatric illness in every branch of medicine, a lot of the time we are already have the tools to approach distressed patients in a safe and systematic way. Take for instance the patient who had self-harmed on the ward and was describing suicidal ideation. When I sat down for lunch with another doctor, in a confidential space, those events came up in conversation.
“Do you think he was like this before?”
“Like what?”
“Depressed, self-harming. Before the cancer, or do you think it’s a reaction to all of that?”
“Maybe. But he’s also been living alone for a while, which probably doesn’t help.”
“Do you think he’d actually do it though?”
“He told the nurses straight away, I think I’d be more worried if he’d done it secretly. But we definitely need to wait and see what liason say.”
Somewhere in that informal conversation are the bones of that 3×3 grid we learnt in medical school; the biopsychosocial formulation where we look at predisposing, precipitating, and perpetuating factors. And in the latter part of the conversation, the start of a risk assessment.
I’m sure there is much for me to learn on my psychiatry placement, and there will be many times when I feel out of my depth. It is reassuring, however, to know that psychiatry is not a walled-off world to which I will have to become accustomed, but a central part of medicine that all doctors are, sometimes unwittingly, engaging with on a daily basis.
Tom Ronan 