We expect that about two thirds of your day should be involved in some sort of patient care: either providing it yourself, or watching someone else do so from whom you can learn. The remaining one third of the day is available to you for reading and pursuing any learning issues that you've identified (a burning question sparked by your work with and observations of patients) or projects you've gotten involved in.  As you'll discover, there's a lot to read and consider. You're expected to do some of this work outside of clinic hours.

Unless other arrangements have been made, start each morning by checking in with your supervisor (Health Psychologist or Attending Psychiatrist) regarding the day's schedule. You will:

• interview patients to help assemble the database used by the Health Psychologist;
• conduct phone follow-ups and "medical sleuth" chart reviews as needed for the Case Coordinators;
• administer health screenings for mental health problems (mood, anxiety, substance use);
• observe ongoing therapy sessions being supervised by an Attending Psychiatrist, via remote video; including discussion of the chart, the therapy, and the case overall, with the attending in person or by speakerphone when you are in a different clinic.
• other tasks as assigned, all of which are selected for their value in your education as well their contribution to the Clinic's patient care.

Maps and Direction
You will have two Maps to guide your learning, a copy of which you should print and carry with you on this rotation.  The Diagnosis Map lays out, by category, most  common mental illnesses.  Likewise, the Medications Map categorizes psychiatric medications (in part simply to help you see all the generic names and trade names side by side, by category). 

As you see patients with a given diagnosis, put a check-mark alongside that diagnosis on your Map. Similarly, when you see a patient being prescribed a new medication you've not encountered before, look it up and compare the PAR you hear the doctor give to the Up-to-Date presentation, or other similar reference (e.g. warnings, contraindications, common side effects, starting dosage and titration),  then put a check-mark alongside that one on your Medication Map. Thus you'll have an ongoing quick reference for what you've seen and what you've not seen yet. One of your colleagues made a table of dosing/side effects/warnings-considerations for each major class and filled that in for specific medications as she went along; consider that. 

After about two weeks on this rotation you should review those Maps with your supervisor to determine which Specialty Services (Inpatient Psychiatric Unit, Child/Adolescent Psychiatry program, or Consult/Liason service at the main hospital) you need to emphasize spending time on to fill out your list as much as possible on this rotation. 

On Specialty Service days, to be arranged as you go through the month, you'll follow the lead of the Attending Psychiatrist for that service. In all settings, we'll be looking for opportunities for you to take the lead in patient interviewing, depending on your skill level and confidence.

At the end of this rotation you should be able to interview patients for basic elements of an Initial Psychiatric Evaluation (HPI, Past Psychiatric History, Psychiatric Family History, Past Medical History, Substance Use, and  Social History); and do so using good reflective listening skills and supportive elements ("good GEW": genuineness, empathy and warmth.) Ask for and expect feedback from your supervisors (including residents) about your skills so that you may improve them as you go. The first couple of times you'll see patients with your supervisor. If you're doing well, you may be invited -- at least in Primary Care --to interview patients on your own, in some cases with televideo supervision.

Rotating Clinics
In order two give you a broad experience in Primary Care Behavioral/Mental Health, and outpatient Psychiatric Services, you will begin your month spending time in each:  three days or more a week in Primary Care, and two half days in one of a variety of Psychiatry Specialty settings, like our inpatient psychiatric hospital. After one to two weeks you and your supervisor will decide, based on your Maps and your interests, how to distribute your time for the rest of your rotation. Options include Specialty Services and emphasizing Primary Care or Psychiatry outpatient work.

You will be given a schedule for the first two weeks as you begin the rotation, indicating the clinic where you'll be expected, on what day, and who your supervisor will be for those days. If in doubt, look for the Health Psychologist at the Primary Care Clinic or the Attending Psychiatrist at Samaritan Mental Health.

Each of these clinics will have a Medical Student Laptop for your use (which may not leave the building. See that it is secure every time you leave. Lose it, buy it). You're welcome to bring your own laptop or tablet and use the guest wireless access in the clinic as well. The MS Laptop will enable you to access Centricity, our medical record; and Aptius, our televideo program. You may use Aptius to watch therapy sessions at Samaritan Mental Health (SMH), whether on site or not (but always check in with the Attending before doing so). If remote, you may call SMH (541 768 5235) and ask to be connected to the Attending who is supervising residents. She or he may put you on a speakerphone while you both listen to a session so that you may ask questions as the therapy proceeds (see below on how you'll later be tested for your grasp of 4 different kinds of psychotherapy, which you'll learn to recognize by observing these sessions).

One-Pagers
At the end of every day, think about the patients whom you saw that day. Pick a diagnosis from your map, based on a patient whom you saw, and take 20-30 minutes to review basics about that diagnosis.  DSM criteria and treatment options are the most important, but you can include things like

• Epidemiology (particularly prevalence)
• Etiology/Pathogenesis (what's the current working understanding of what causes this condition?)
• Differential Diagnosis (what looks similar that you have to rule out or differentiate from?)
• Risk Assessment (how dangerous is this condition? How do you evaluate that, in a given patient?)
• Practical Challenges (what are some of the things that make handling this condition tricky, in practice? How can those be handled? E.g. contraindications, warnings, roadblocks to good outcomes)

Having taught yourself some of these basics (and maybe not so basics), now create a 1-page summary of what you learned. This is for you, not for us. This is to help you pass your Boards. This is to drive this material far enough into your hippocampus that some of it will still be there a year from now. This is to allow you to be creative and follow your nose in terms of what you want to learn. Hopefully the patient whom you saw will make you want to know some or a lot of these things. Use that.

Depending on how busy things are, you and your supervisor may go over some of your 1-pagers but remember, this is for you, not for your evaluation. (Yes, of course it will have an impact on your overall evaluation if you don't follow through on this. But DO NOT go hog-wild here trying to impress. This exercise is for you. Use whatever you think will help make it stick (pictures, diagrams, comparison tables, stars, arrows -- or text). Have some fun and think of that patient.

After you finish your one-pager, circle that diagnosis. We're aiming for circles around all the diagnoses that appear in Bold on your Map; at least a few more circles beyond that. 

Seminars
One half day a week you'll all gather at the Home Office (i.e. Samaritan Mental Health. What, you don't read British murder mysteries?) We'll  review cases you've seen, and thorny questions that arose as you were writing up 1-pagers, and we'll do some psychotherapy exercises to help you work on your skills (easier than you think, perhaps). Some of you may attend these Seminars using televideo equipment, depending on how far away you are. These sessions will be led by Drs. Lindsey and Phelps, and friends -- including current Psychiatry residents and Behavioral Specialists from primary care clinics.

These seminars will give you an opportunity to talk with your MS3 colleagues who are flung about in other clinics.

Required Reading
Aside from a basic guide to Psychiatry such as the Blueprints guide, we have only one required book.  We think it's so important, we'll give you a copy to use on this rotation: Motivational Interviewing, by Stephen Rollnick. Read the whole thing. You should see it happening in interviews you observe, on a daily basis. This skill takes a while to learn, and when you're interviewing patients, you may not have any extra brain bandwidth for working on this (in addition to Good GEW and reflective listening, although as you'll see, those are a significant part of Motivational Interviewing). However, as noted below, the ability to recognize MI is needed for our exam process. 

Specialty Services:  Inpatient Pychiatric Unit, Child/Adolescent Psychiatry program, or Consult/Liason service at the main hospital
You won't be scheduled, at first, to work in these settings. You and your supervisor will determine when and if you can or need to spend a day or more rotating with one of these programs. This will be based primarily on your Diagnosis Map, but also on your interests -- so let your supervisor know if you'd really like to see and work with one of these programs.

How You're Evaluated

• 15-minute exit interview with your primary rotation contact (Psychologist, Attending Psychiatrist), reviewing:
• Maps
• 1-pagers
• Project contributions
• Videotape analysis
• Attending Psychiatrists, Psychologists, and Residents will all observe and comment on Strengths and Room-For-More-Learning areas

Maps: the idea is to see what you've learned. There is no grade attached nor penalties for having uncircled diagnoses or un-checked medications!  But your evaluator will ask you about conditions you've circled, randomly, so don't fudge it. They'll ask you for basics about that condition, the kind of stuff you'd have on your 1-pager. Our expectation, as noted above, is that you'll have circles around the Bold diagnoses, and at least a few more. More is better, obviously. But don't fudge and embarrass yourself, not good. 

One-pagers: your supervisor will look at your collection and pick out 2-3 for review, also random, and based on her/his interests. Bring 'em all.

Projects: if you were involved in any particular Clinic projects, please write a brief (like one page) summary of what you did. This includes passing along any instructions or guides for your MS3 colleagues who follow behind you. You can get a fine grade without doing a large project. But it is a way to feel like you're making a contribution to the Clinics.

Videotape analysis: at the end of the rotation you'll be asked to watch a videotape of a therapy session and note whether you see examples therein of 4 kinds of psychotherapy.  The response form will look like this:

In the recording you observe, there may be not be an example of every one of these therapies. But this exercise is designed to help you really watch closely for these therapies, and ask your supervisors about them, as you're watching therapy sessions (which can seem rather boring at times, but not if you're watching closely for them to appear, and asking your supervisor for help in doing so).

Use the Resources on the Medical Students Home page for further information.