Early Clinical Experience in Psychiatry: An analysis of student reflections

doi:10.21203/rs.3.rs-3221314/v1

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Early Clinical Experience in Psychiatry: An analysis of student reflections

https://doi.org/10.21203/rs.3.rs-3221314/v1

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Background

Student experiences have a key role in their choice of Psychiatry as a career. Recently there has been a move to provide early clinical experiences which may vary from a day to a week. The purpose of this study was to describe the student experiences of an early clinical placement in Psychiatry at a medical school in Australia.

Results

A qualitative analysis of student reflections in their longitudinal portfolio was undertaken to elicit student’s perceptions of the placement. Five themes emerged which relate to the placement, patient interactions, consulting style, health systems and the intention to choose psychiatry as a career in future.

Conclusion

Early clinical placements in Psychiatry when designed carefully provide a meaningful learning experience for medical students as well as may lead to subsequent career choice.

Psychiatry

medical students

reflections

qualitative

Clinical placements are an integral component of health professions education. Traditionally these placements are scheduled during the clinical phase in blocks. However, recently early clinical experiences have been included in the curriculum to provide students exposure to patients. An early clinical experience (ECE) is defined as a teaching and learning methodology to provide exposure to patients as early as the first year of medical college in a social or clinical context that enhances learning of health, illness or disease, and the role of the health professional [1]. It also allows students to apply knowledge from the pre-clinical curriculum in the hospital setting [2].

ECE can be offered in a variety of settings. These include inviting patients to the class, sending students to the wards/clinics or through visits to underserved communities and service-based learning opportunities.

In 2014, the University of Western Australia introduced a four-year postgraduate Doctor of Medicine program. Two unique features of this program are early clinical experiences and a longitudinal e-portfolio. The placements were day long starting from the first week of the MD course. These placements were offered in all disciplines including Psychiatry with an objective to familiarise students with the clinical environment. The longitudinal e-portfolio included both mandatory and optional activities. One of the activities within the e-portfolio is a collection of three reflective pieces during the year titled “My learning journey”. Students were required to record significant learning experiences in this activity. A quick scan of reflections during the first formative review of e-portfolios in year one showed that ECE was the subject of at least one reflection. The aim of this study was to explore how medical students feel about the early clinical experience in psychiatry through qualitative analysis of their reflections.

All the reflections were downloaded from the Pebble Pad™ which is the Portfolio Management System used for student portfolios. The reflections related to Psychiatry were separated for analysis and de-identified by one author. Each reflection was allocated a two-digit code to ensure anonymity in analysis. Analysis of these reflections was performed using qualitative content analysis. All reflections were systematically examined to identify emergent themes. In the first stage, five reflections were reviewed and coded independently by each author. Once completed, both authors discussed and categorised the codes into themes to search for relationships among the responses and identify sub-themes. Following this initial exercise, all authors follow the same process for remaining reflections and arranged subsequent review meetings in the following weeks. The purpose of these review meetings was to reach a consensus on themes and sub-themes. The use of three researchers in the process increased the rigour and trustworthiness of the data. Frequencies for each theme was also determined.

In all, there were thirty-three reflections submitted by the students which relate to their first experience in Psychiatry placement. Data saturation was reached after the analysis of eighteen reflections. Yet, we analysed all reflections to ensure that no further theme was emerging.

Five themes are identified in the analysis comprising both positive and negative experiences. These relate to the placement itself, interaction with patients, consulting style, healthcare system and intention to choose psychiatry as a career. (Table 1) Each theme is presented individually with sample comments from the consenting students.

Table 1

Themes and Sub-themes identified in the analysis.
Key Theme	Sub Theme
Experiencing the placements (32%)	Expectations Orientation Group Size Debriefing
Patient interactions (22%)	Diversity Clinical Presentation Establishing the rapport Need for a holistic care
Observing Consultations (22%)	Approach to the interview Interactions with the team Positive attributes Questioning style
Psychiatry as a specialty (16%)	Curiosity Inspiring Confronting Traumatic Questioning themselves
Healthcare systems (8%)	Crowding Resources Safety protocols

Placement Experience

Students had no formal orientation regarding the placement and were unclear of the expectations. They felt unprepared and overwhelmed. It was also mentioned that the number of students (n = 4) in each group affected their experience as they were all asking same questions from an already anxious patient. Consultants were also unaware of the expectations and the level of preparation that students have gone through before coming to the clinics and wards. There were occasions when a consultant asked student to get some forms or to interview the patient. When the student was unable to complete the tasks, the consultant seemed irritated.

I often felt uncomfortable or unsure of which questions were acceptable to ask. I often felt that I just didn't know the right questions to ask and how to cater my questioning to this specific patient.

In other instances, the team has been very welcoming of the new students and allowed them time to settle in through encouragement, orientation and debriefing.

Myself and the other student were quite observant, though this may have been because prior to the interview, we were taught by the registrar that being observant and paying attention to the patient's non-verbal communication is important. We picked up on multiple things that perhaps may seem inconsequential to the casual observer– such as the patient not having changed his clothes since the previous day, or the fact that he was quite distracted during the interview.

Patient interactions

Students acknowledged that patients in psychiatry are very different in clinical presentations. History taking also requires a different approach and for a new student in the medical course it was a daunting experience.

I learnt that taking a history of a mental health condition is complex, time-consuming and extensive. Often to understand the root of the disorder the interviewer must cover the current condition as well as childhood development and years prior to the recognition of the condition.

They also observed that establishing rapport with the patient is of upmost importance and requires an alternative communication style that incorporates respect and empathy. During interactions with the patients, students realised the vulnerability of psychiatric patients.

I realised that xxx was hurting due to his condition and in reality, we (or really the doctor) were the ones who could make the biggest difference to him. xxx was in a particularly vulnerable place given he lacked emotional support.

Another student noted the importance of mental health in the holistic care of the patient.

Visiting this patient really reinforced the fact that treating a patient's mental health is just as important as treating their physical health. The interaction made me consider the role of mental health in all patient interactions, even those patients whose physical concerns may seem to be extremely serious.

Consulting styles

This is the students’ first observation of a consultant interacting with the patients and they used a variety of positive words such as respectful, encouraging, patient, understanding, non-judgmental and observant.

… seeing how the clinician phrased sentences in a manner that was understanding and yet gently prompted the patient back to the issue at hand helped me broaden my communication techniques with patients who have similar mental health issues

I learnt a great deal during the interview. I watched my supervising doctor create an open and non-judgemental environment through posture, eye-contact and appropriate vocal queues.

Students also observed the differences in questioning styles and interaction with other team members.

I noticed that the consultant used layman’s terms while talking to the patient, however he used medical terminology while talking to the nurse who was taking notes.

….the atmosphere was very casual and conversation-like, with light-hearted jokes thrown in, yet the registrar was still able to obtain all the information he needed. This was also a good opportunity to consolidate all the teaching he had done beforehand (i.e. the structure of how a psychiatry interview would go, and the importance of being observant).

Understanding of Health care systems

There were three sub-themes emerged within the reflections i.e. availability of resources, overcrowding and safety protocols. Students had firsthand experience of observing the lack of resources and how it affects the quality of care provided to the patients. They were also questioning the health system, which allows patients to be kept in hospitals for the safety of community against their will.

I remember hearing many times how limited medical resources like inpatient beds are- particularly in psychiatry, where often patients simply can’t function outside of care, or would be dangerous to themselves or others if they were in the general community.

As a result of the unavailability of beds elsewhere in the hospital, patients were being kept in the ED for up to a week.

……both interactions opened my eyes to other issues surrounding the mental health system - the first patient had previously been lost to follow up several times ….

Psychiatry as a specialty

Although it is their first year in the medical course, students are already thinking of psychiatry as a future career. They acknowledge that there is a stigma attached to psychiatry as a specialty but the placement has been an eye-opener which was confronting yet invaluable.

Overall, I found my psychiatric placement inspiring and motivating- it’s definitely a field I see myself working in in the future.

…it began with psychiatry, a specialty I was curious in. It was a memorable experience as I learnt more about psychiatry and also had the opportunity to see the presenting complaints of psychiatric patients.

Early placements offer a valuable learning experience to the students in health professional education [3]. A reflection exercise is a great tool to learn about the experience of students at their institution, while the students practice the skills of critical self-awareness that support the growth of professionalism and empathy [4]. From these reflections, we observed that clinical placement in Psychiatry needs to be carefully designed even if it is of a shorter duration. It is often the first exposure to patients with mental illness, psychiatric wards and mental health services more generally [5]. It is important that students feel welcomed, and consultants are aware of the expectations and level of the students’ knowledge. Students value placements where members of clinical team are welcoming to students. This can be possible if there is an adequate briefing about the objectives of the early clinical placements and that this is the students’ first exposure to the clinical environment. It is also important to arrange opportunities for debriefing during the placements even if the placement is only for a day.

Clerkship studies have found that students feel uncomfortable with patients and the type of patient exposure during the psychiatry term directly relates to student satisfaction [6, 7](Budd et al. 2011; Pai et al. 2012). It is therefore important to select patients that students feel comfortable in talking to and practice some basic communication skills in their first encounter. If it is the outpatient setting where students are only observing the consultations, a debriefing session at the end of the clinic or after each patient may allow students to ask any questions and/or clarification of any ambiguities by the consultant. It is preferred if students are first given a chance to observe interviews to see how patients are approached for history taking and mental state examination. Due to the short time frame, it may be difficult to implement so a short video that prepares students for the placement can be an alternative. This video can be made available through Learning Management System.

One of the interesting observations noted while analysing the reflections was that participating students were already thinking of choosing psychiatry as a specialty. This is very important as it shows that even a short placement can influence the career decision of medical students. This may only be the tip of the iceberg but is an important consideration for a specialty that is trying to recruit more psychiatrists.

Student placements influence the learning and selection of specialty for postgraduate training. With careful planning these may provide enriching experience, which is valuable in specialties like Psychiatry where patients and consulting styles are different from other disciplines. Although the primary objective of this day long placement is only to familiarise students with the clinical environment and practice simple conversations, the analysis of the reflections provides evidence that an early clinical experience is still a great learning experience for students to see what the clinical environment in Psychiatry would be like in future.

One of the limitations of this study may be a small number of reflections analysed and further studies regarding early placements may validate the findings. It is also important to compare the results with findings from other clinical disciplines to see if there are any similarities or differences which are unique to psychiatry.

ECE

Early Clinical Experience

Ethics approval and consent to participate

Ethics approval for the study was received from the UWA Human Research ethics Committee vide reference Number RA/4/1/9143. The data used in this article is from the medical students who consented to participate.

Consent for publication

Not applicable

Availability of data and material

Data will not be shared as it was not included in the Human Research Ethics Application.

Competing interests

The authors declare that they have no competing interests.

Funding

NIL

Author details

¹College of Health Sciences, VinUniversity, Hanoi, Viet Nam.

Acknowledgments

The author is grateful to the students who have consented to participate in the study and all the psychiatry units that allowed students the opportunity to gain first-hand experience of psychiatry as a discipline.

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Brenner A.M., 2011. What medical students say about Psychiatry; Results of a reflection exercise. Acad. Psychiatry. 35(3) 196–198. https://doi.org/10.1176/appi.ap.35.3.196.
Lyons Z, Janca A (2015) Impact of a psychiatry clerkship on stigma, attitudes towards psychiatry, and psychiatry as a career choice. BMC. Med. Educ. 5(34). https://doi.org/10.1186/s12909-015-0307-4
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Early Clinical Experience in Psychiatry: An analysis of student reflections

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Abstract

Background

Methods

Results

Placement Experience

Patient interactions

Consulting styles

Understanding of Health care systems

Psychiatry as a specialty

Discussion

Conclusions

Abbreviations

Declarations

References

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Version 1