Dr Miguel’s Experience of securing Core Psychiatry Training

Hi, I’m Miguel, currently a CT1 in Southeast London. I would like to share my experience in securing a Core Training post in Psychiatry. I had an exceptional journey and hopefully this would inspire other IMGs to #ChoosePsychiatry.

Background

I finished medical school in the Philippines on 2016 and completed 1-year internship on 2017. After obtaining my license I worked as an SHO in Internal Medicine in my home country. I had limited experiences in Psychiatry – a 2-week rotation during internship and an elective during medical school but this speciality has always been the field of medicine I am very fascinated about.

Application for Core Training and MSRA

After I passed PLAB1 I had plenty of vacant time to  research on how to enter core training in the UK. During this time, I was made aware that the usual pathway is to join a non-training SHO post first to gain experience and familiarise oneself with the NHS and to improve portfolio. As I was reading the person specification for core training, I realised that I was eligible to apply because of my 1 year internship experience + SHO experience in Internal Medicine. I thought to myself that I might as well try, despite my limited portfolio during that time.

Psychiatry is also one of the specialties that utilises the MSRA to screen core training applicants. And this specialty being a shortage occupation (along with GP) during that time, scoring well (top 10%) in the MSRA would lead to a direct offer of a training job. With that in mind I gathered my documents and had my CREST form signed by my consultant in IM, then flew to the UK to revise for PLAB2.

Whilst preparing for PLAB2, I submitted my application for February 2020 Core Psychiatry recruitment. I was longlisted and received an invitation to sit the MSRA. I scheduled it on the 9th of September 2019.

I sat PLAB2 on 9th August. I had a month to prepare for the MSRA and it was admittedly an extremely tight timeframe when your goal is to score well. So I made a strict schedule of revising for 10-12 hours a day, sometimes more. I did not tour the UK nor fly back home. I stayed in Manchester for another month.

Reading textbooks was out of the question because of the time constraint. I mainly relied on the popular question banks– Emedica and MCQBank. I also used the Arora SRA Clinical audiobook during my rest periods. On the day of the exam, I found the Situational Judgment Test to be more challenging than the Clinical Scenarios.

Getting Core Psychiatry Offer

I was very anxious post-MSRA. I kept on telling myself I had nothing to lose because the exam was free anyway, and it was a good experience for a 2nd try, as I was not keen on pursuing my application without a direct offer because I had limited portfolio.

The surprise came after a few days when I received an email confirming an unconditional offer. Imagine my joy having a job offer even without having gained registration yet.

There were 160 available jobs for February 2020 recruitment. I wanted to train in London because I prefer city life and received good feedback about the quality of training there. Fortunately, I got accepted at the The Maudsley Training Programme, a reputable Psychiatry Training Institution attached to IoPPN, King’s College London. This was because a direct offer would allow one to be ranked ahead of other candidates, increasing the possibility that one gets his/her first choice.

I happily went back home and immediately processed my GMC registration and visa requirements.

Challenges and Start of Training

Despite having already secured a spot for a training job, I started to have internal debate with myself. I realised my pathway was indeed atypical as I had ZERO UK experience. Many people have warned me that the road might be bumpy because of this and it gave me real anxiety. Luckily, I was able to connect with other trainees who provided me with invaluable tips and advice.

I flew to the UK 2 weeks before my official start. I was initially allocated to a community job and I thought it was too premature for me to start with a job in such setting. With the help of my Educational Supervisor, my assignment was changed to an inpatient job when I started. Communication is key.

Unlike acute medical specialties, Psychiatry is rather slow-paced so there is definitely ample room for adjustment if you’re new to it. As a CT1, you are not expected to know everything andmaking any major decisions to patient care is a collaborative process and  seniors will always be there to support you. It really helped that I work alongside a Clinical Supervisor and Specialty Doctor (both IMGs) who were very accommodating. They helped me ease through the intricacies of Psychiatry in the UK – mainly the social, legal and welfare aspects of the practice which were all new to me.

Every day is indeed a learning experience. I would say that after roughly 4 months of working, I have already gained some confidence. Admittedly I still don’t know a lot of things, but rest assured that there is always have a senior to call if in case of doubts. The full-day teaching on Wednesdays is also excellent and is a welcome respite from ward work.

Moving Forward and Advice to Other IMGs

I have recently received news about my next rotations – Old Age inpatient and community CAMHS, both of which were my preference. I also plan to sit Paper A on December 2020.

So is it possible to enter Core Psychiatry Training without prior experience? – Yes! If you’re really passionate about it and you meet the specifications then I see no reason to hold back. Do note the additional requirements on the new CREST form (especially the one about QI projects)..

I have a weak portfolio. – This was me a year ago. Aim to get a direct offer! Psychiatry is starting to become more competitive and scoring well in the SRA would not only let you skip the interviews, but also increase the chance that you secure your top choice! The exam feels daunting but it is achievable with the right preparation and mindset.

Is my pathway the ideal pathway? This depends on the individual. Some would still prefer to get a Trust-grade/non-training SHO job, and that is also perfectly fine. What I did was a leap of faith and I don’t regret it one bit.

Based on my experience so far, I have yet to meet a dismissive Psychiatry consultant or senior doctor. It feels good to be in a kind and supportive environment. This is a very important aspect of training for me. It gives me the optimism that core training would be a less bumpy ride than I imagined.

All the best and #ChoosePsychiatry

Miguel

vecidajm@doctors.org.uk


CESR Journey – by Dr Hal Abdullahi

My CESR Journey – by Dr Hal Abdullahi

On completion of a 5-year psychiatric residency training programme and attainment of fellowship of the West African College of Physicians (Psychiatry), I voyaged to the UK via the MTI scheme and completed the MRCPsych examinations in that time. I subsequently had to choose between higher specialist training in general psychiatry and an offer of a locum consultant psychiatrist job. For largely personal reasons I opted for the latter.

If you think about the Transtheoretical model’s stages of change, then you would better appreciate the phases I went throughto successfully achieve specialist registration via the CESR pathway as I exemplify next;

PRECONTEMPLATION PHASE:

I was pretty comfortable with the thoughts of working as a locum consultant long term and struggled to find a reason to commit to a potentially laborious, bureaucratic and expensive process which would culminate in gaining recognition to do the job I was already doing.

CONTEMPLATION PHASE:

I then started to ponder about my future employability. I came to realize that specialist registration was a pre-requisite for substantive consultant posts in the United Kingdom. I noted that certain opportunities required that one held substantive consultant posts for a period of time. However, there was a barrage of discouraging feedback from CESR predecessors about the tediousness of the process.

DECISION PHASE:

I attended CESR workshops, spoke to a colleague who successfully applied for specialist registration via this route and came to a conclusion that my future self would be thankful to be on the UK specialist register. I knew I had to gather most of the relevant evidence prospectively.

ACTION PHASE:

So, I had to familiarize myself with the GMC’s specialty specific guidance for general psychiatry. I got conversant with the intended learning outcomes as described in “a competency-based curriculum for specialist training” in general psychiatry. I then created a CESR ‘to do list’ made up of evidence I was expected to provide and had to organize them into folders with GMC’s domains of good medical practice in mind as listed below.

Domain 1 – Knowledge, skills and performance

  • CV
  • Primary medical qualification
  • Specialist medical qualification(s)
  • Curriculum or syllabus
  • Specialist registration outside the UK. 
  • Honors and prizes
  • Other relevant qualifications
  • Assessment and appraisals
  • WPBAs – with what would make for a successful ARCP outcome for an ST6 in general psychiatry as a reference point.
  • 360˚ and multi-source feedback – within the past 5 years.
  • Awards and discretionary points letters
  • Personal development plans (PDP)
  • Logbook – You can use the sample table on the specialty specific guidance as a guide to produce a log of clinical activity to help evaluators to understand the type and volume of work you undertake.
  • Consolidation, cumulative data sheets, summary lists and annual caseload statistics – A separate consolidation report is not required in psychiatry.
  • Medical Report – Approximates with case histories.
  • Case Histories – At least 30 case histories. I provided about 35.
  • Referral letters discussing patient handling – At least 25 referral letters.
  • Patient lists
  • Departmental (or trust) workload statistics and annual caseload statistics – Evidence not mandatory for general psychiatry.
  • Rotas, timetables and job plans
  • Portfolios –Cross reference with WPBAs above.
  • Employment letters and contracts of employment – Should match CV.
  • Job descriptions
  • Research papers, grants, patent designs
  • Publications within specialty field
  • Presentations, poster presentations
  • CPD record certificates, certificates of attendance, workshops and at local, national and international meetings or conferences –to cover all aspects of my work and show the breadth of my practice.
  • CPD registration points from RCPsych – CPD log and certificate of good standing.
  • Membership of professional bodies and organizations
  • Teaching timetables
  • Lectures
  • Feedback or evaluation forms from those taught
  • Letters from colleagues
  • Attendance at teaching or appraisal courses –
  • Participation in assessment or appraisal and appointments processes

Domain 2 – Safety and quality

  • Audits undertaken by applicant
  • Reflective diaries
  • Service Improvement and clinical governance meetings
  • Health and safety

Domain 3 – Communication, partnership and teamwork

  • Colleagues
  • Patients
  • Working in multidisciplinary teams
  • Management and leadership experience
  • Chairing meetings and leading projects

Domain 4 – Maintaining trust

  • Honesty and integrity –
  • Equality and human rights (including disability, human rights, race, religion and ethnicity awareness and equal opportunities).
  • Data protection
  • Testimonials and letters from colleagues
  • Thank-you letters, cards from colleagues and patients
  • Complaints and responses to complaints

Apart from authenticated overseas evidence that had to be sent in hardcopies to the GMC, the rest of the application was done online.

MAINTENANCE PHASE:

I benefited immensely from information shared during CESR workshops, networking with others preparing to put forward a CESR application, constructive feedback from colleagues who supervised my workplace-based assessments, support from my past supervisors especially with verification of evidence and the helpful detailed references from referees.Encouragement from mentors/friends as well assupport from my family were crucial when the going got somewhat tough and getting me across the line.

CONCLUSION

It took approximately 2 years from pre-contemplation to a successful outcome which was communicated via an email from my GMC specialist applications adviser. I remember telling my wife about the outcome as we drove home from work and we were both ecstatic as webreathed a sigh of relief! I was so happy I checked the GMC specialist register a few times that day to ‘re-confirm’ the decision.

It was the exception to have a successful decision following a first application so (as a back-up plan) I was gathering further evidence in anticipation of a rejection and with plans to re-apply a second time. Fortunately, re-applying has become unnecessary.      

CESR is definitely doable…

This document will also help you prepare for CESR


Facebook Profile of Dr Abdullahi = https://www.facebook.com/hal.abdul

Audits and Quality Improvement Projects (QIP) in Psychiatry

What is an Audit and what is the difference between an Audit and a QI project?

Healthcare professionals are expected to regularly review their clinical practice against the expected standards. Clinical audits are a part of the quality improvement process where you are comparing your practice with already set guidance. Audits are where you as a junior doctor  as well as seniors can make a huge impact of the running of health services. Audits are a advancement feature of your knowledge and experience.

Quality improvement is a wider term which may include repeated cycles of audits and making sure the recommendations are followed through to make sustainable improvement to the service.

In simple terms:

  • An audit will give you a snapshot of the areas of clinical practice requiring improvement.
  • An audit is usually followed by recommendations and suggestions for improvements.
  • Re-audit will assess the improvements thus completing the audit cycle and this will create a quality improvement project.

How do I generate an Audit idea?

One way to generate an idea is to look at the current guidelines in your area of practice. The most commonly used guidelines in mental health are

NICE Guidelines

These are available for free and readily available online. NICE has published guidelines on various topics related to mental health covering a wide range of conditions. You can read the guidelines related to your area of work and compare your practice with the recommended guidance. 

https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions.

These guidelines are extensive but each of them can be broken down into more specific areas of expected practice to create an audit project.

Maudsley Prescribing Guidelines

These are available in a book format which is updated every few years and can be bought online from Amazon. The Maudsley prescribing guidelines provide extensive guidance on Psychiatric medication and their monitoring.

Local Trust Guidelines

These are readily available via your trust intranet and usually found on the relevant trust intranet website.

These may include:

  • Various trust procedures and policies (like the admission and discharge process, capacity assessments)
  • Prescribing guidance (your trust lead Mental Health pharmacist should be aware of prescribing guidance and are very helpful in gathering your data and offer excellent knowledge with regards to medication enquiries).
  • The Mental Health Act which will include various Sections of mental health act and section 17 leave (your local mental health office will have guidance around various aspects the MHA)

Discussions with local Audit department and senior doctors.

Most NHS trust will have an Audit department already involved in various audits and some trust will have an Audit lead within mental health service. You can discuss your interest in Audits with them and may involve yourself in some already ongoing projects.


Examples of Audits and QIP Projects

These ideas are a rough guide to help your thought process so that you can generate your project idea. Before starting any audit, you must discuss with your seniors and supervisor to gain their permission. Your team members may already have experience and previous experience is always invaluable so never hesitate to ask. There may already be an audit waiting to be carried out.

Audits can be employed in a variety of settings. Listed below are a few such settings.

Psychiatry Inpatient / Ward settings:

Audits on the standard of admission clerking and admission procedures:

When a new patient is admitted to a psychiatry ward. There are some expectations and admission protocols that need to be adhered to. They will naturally, vary between hospitals and trusts but you be able to find your local guidance readily. 

A few pointers

  • Look at the admission protocols and what is expected when a patient is admitted, i.e. a detailed history, a physical examination, bloods and ECGs.
  • After establishing the expected practice, define minimally required standards in the set area. 
  • Pick up a sample of recent admissions, say for example 20-30 patients or a duration of time i.e. 6-12 months.
  • Retrospectively, compare the current practice with set standards.
  • Identify any shortcoming and make suitable recommendations.
  • Share your findings with the stake holders (ward staff, junior and senior doctors)
  • Consider and discuss how the process may be improved.
  • Implement the changes and re-audit with in a suitable time frame.

An example of audit on admission physical health monitoring requirement.

Audits on ward rounds:

Once you have got the hang of ward round you may look back and think this could be done differently or what if we did this instead of that on a ward round so that it could run more efficiently?

There may not be a set of standards of what is expected in a ward round but you can create a quality improvement project by perhaps understanding the perceptions and expectation of the staff involved.

A few pointers could be to

  • Conduct a survey of inpatient nurses and establish their expectations from ward rounds.
  • Conduct a survey of doctors to understand their expectations from ward rounds.
  • Look at the time taken in the ward round and the roles of other professionals involved.
  • Establish the minimum required standards. Are there any minimum standards?
  • Retrospectively, look at previous ward entries and documentation to establish how the process of the ward round could be improved. 
  • Draft your recommendations and share it with your colleagues.

I have seen such project resulting in development of a standard ward round proforma.

An Example

Audits of Medication charts:

Medication involves a large area of our medical practise. You may have heard of significant errors or lack of adequate monitoring in your career so far. You may be thinking how can I improve this? How can my team change our practices to minimize such errors. An audit is an excellent way to tackle these questions. There are several ways to audit medication prescribing.

A few pointers

  • Identify the minimum required standards when prescribing medications.
  • Look at when a new medication was started. Was it documented in the notes and discussed with the patient? Is the duration specified? Does it require follow up and was this done appropriately?
  • Look at the PRN medication charts and check if they are prescribed in accordance with the trust guidelines.  

Audits of Rapid Tranquillisation:

Rapid Tranquillisation refers to the use of medication to manage acute behavioural disturbance in order to reduce the immediate risk of harm to the patient themselves and/or others and to reduce agitation and aggression.

Most NHS Trusts have their set policies and guidance relating to rapid tranquillisation. Your local pharmacist again would be an excellent source of information in this area. Rapid Tranquillisation is mostly used in Psychiatry Intensive Care Unit (PICU) settings or General Adult Psychiatry ward settings.

A few pointers

  • Find local guidelines/ protocols and algorithms.
  • Find the number of cases where rapid tranquillisation was utilised. One way to find cases is to look at incident form data retrospectively. You should be able to find cases where restraint or rapid tranquillisation were used. Is the data following a set guideline?
  • Look at the type of medications initiated and how much was given. Was it in concordance with guidelines?
  • Compare medication use with the trust guidance.
  • Write a report identifying the shortcoming if any.    

Audits on Electroconvulsive Therapy (ECT):

There are several different aspects of ECT which can be audited. The ECT process may involve capacity assessment, the Mental Health Act, cognitive testing, documentation of the progress of mood, documentations of the ECT itself.

Each trust usually has set protocols / guidance which are followed before ECT can be given. Here are NICE ECT guidelines.

https://www.nice.org.uk/guidance/ta59/chapter/1-Guidance

Depending on your local guidelines and service needs, you can audit

  • Whether  the rationale and indications of ECT were discussed and documented.
  • If the patient was involved in the discussion and if not, were the reasons documented
  • If capacity was assessed using the Mental Capacity Act or if a best interest decision was applied.
  • Use of Metal Health Act in relation to the ECT.
  • Documentations of the physical fitness, clinical status.
  • Documentation of the response to ECT.
  • Any recorded adverse effects.
  • If cognitive function was monitored

Audits of Section 17 Leave (MHA) :

Section 17 leave is part of the Mental Health Act and there are local guidelines on how to award Section 17 leave and the documentary standards. Your local trust website or the Mental Health Act office should be able to find you the guidance. The MHA office may also keep the record of section paperwork and Section 17 leave forms.  

  • You can look at the local trust guidelines on Section 17 leave and establish expected standards.
  • Retrospectively look at the number of cases and how the forms were completed and whether escorted or unescorted leave was documented in the patients notes or if a time duration was specified. How often hospital leave was reviewed?
  • Compare the set standards with current practice and identify shortcomings.

Audits of Discharge Summaries:

There are some basic requirements and guidelines locally on the standards of discharge summaries. You can simply look at the excepted standards and compare it retrospectively with the number of discharge summaries recently completed. It may include

  • Diagnosis and ICD 10 codes on discharge summaries
  • Medication list and which medications were initiated stopped and why.
  • Clearly written follow up arrangements and if those were followed through 
  • Time taken to complete the summary and copies sent to the GP

If you like to do a larger Quality Improvement Projects involving the quality of discharge summaries.  You can

  • Start by establishing a mechanism to gather feedback from local GPs on their expectation from discharge summaries.
  • Online or paper surveys can be created and sent to local GPs.
  • Survey the Senior Psychiatrist around their expectation of what should be included on discharge summaries.
  • Look at the already establish standards required for discharge summaries and compare it with the expectations of the GPs and senior Psychiatrists.
  • Audit recent discharge summaries from your department.
  • You can write a report comparing what GPs are expecting and what we are currently sending or differences of expectations of psychiatrist and GPs on the information given in discharge summaries.
  • Draft recommendations to improve standards of the discharge summaries. 

Community team / OPD clinic Audits and QIPs:

Letters sent to the GPs – Audit

Letter sent to GPs from a psychiatry clinics can be audited. You can start this project by establishing expectations of the local GPs on what information they find useful on a clinical letter. For example clear documentation of diagnoses, current medication, changes to medication and follow up arrangements.

  • You can look at the already established standards of clinical letters within your trust or start by a survey of local GPs and Psychiatrists to establishing their expectations from clinic letters.
  • Establish some minimum required standards
  • Compare a cohort of clinic letter sent out in the last few months and compare them with expected standards.

An Example of such Audit.

Audit of Non-attendance of OPD / Did not attend appointment (DNA)    

Non-attendance to psychiatry clinic appointments can have a significant impact on the service delivery and resources. If the DNA rate is high in your department you can create a QIP based around improving psychiatry clinic attendance rate. This would have a high impact on the delivery of your service and help manage resources on a service provision level.

A few pointers

  • Establish the DNA rate of clinics with the help of admin staff. secretaries may have useful information.
  • Study the reasons of the DNAs. Is there s common reason for lack of attendance? any particular geographical area? any particular clinic? is transport an issue? are patients getting letters on time?
  • Study and discuss the methods to improve the clinic attendance.
  • Make recommendations to improve attendance rate using the evidence base.

Systems put in place to send text messages or phone call a few days before the appointment can improve the attendance rate. Many trusts already implement this but other trust may yet to deploy this way of communication.

Physical Health and Metabolic Syndrome monitoring Audit

Certain Mental Health diagnoses and Psychiatry medications are linked with increased risk of metabolic syndrome. Patients with chronic mental health conditions along with long term anti-psychotic medications should be monitored for metabolic syndrome. You may wish to look at this area of mental health.

A few pointers

  • You can start this project by reading guidance on the expected standards of physical health monitoring and metabolic syndrome.
  • Monitoring criteria may include an ECG, HBA1c, weight, waist circumference and lipid profile
  • Find a cohort of patients with chronic mental health conditions and long term use of antipsychotics
  • Study the systems in place to monitor their physical health.
  • Compare current monitoring with the expected standards. 

This is a common audit which I have seen presented in many conferences by junior doctors. You may find yourself in the debate of whose responsibility is to do carry out this monitoring. “Mental health team or the GPs?” Again this in itself can generate a useful QIP!

Audits of Lithium monitoring :

Lithium initiation and monitoring is a frequently audited area. You will find guidance from various sources on monitoring of lithium like NICE, Maudsley prescribing guidelines, and  RCPsych. Most trusts will also have local lithium prescribing and monitoring guidelines and your local pharmacist can help you find them.

It is usually easy to find out how many patients in particular team are on lithium.

  • Establish expected practices and guidelines
  • Collect data retrospectively, on the use of lithium
  • Review how often the lithium levels are done and how often bloods are checked for example U&E, TFTs.
  • Identify shortcoming and make recommendations.

Audits of Clozapine monitoring:

Clozapine is a frequently used medication for the treatment of resistant schizophrenia especially in general adult psychiatry and forensic psychiatry settings. There is usually a central database that will help you identify the  number of patients on clozapine.

You can find clozapine prescribing and monitoring requirement guidelines from NICE, Maudsley Prescribing Guidelines and your local Mental Health Trust Guidelines. Patients on Clozapine also require monitoring of metabolic syndrome markers which you can also use as a standard of an audit.

  • Establish expected standards for clozapine prescription and monitoring
  • Select a cohort of patients on Clozapine
  • Retrospectively look at data comparing current practice with the set standards

High dose (above BNF limit) antipsychotic Audit. 

Some patients require higher doses of antipsychotic medication which are above the BNF recommendations. There may be some trust guidelines on how do we monitor these patients and if they require higher level of physical health monitoring. Some GPs maybe reluctant to prescribe outside BNF guidance and may well prefer to keep the patient monitored under secondary care.

Risperidone and serum Prolactin audit:

Risperidone as an antipsychotic is known to increase the serum prolactin level and increased prolactin levels can make patients symptomatic and have short and long term effects on their bodies.

A few pointers

  • Find local or national guidelines on the monitoring of prolactin in mental health patients
  • Identify patients on risperidone (short or long term) may be with the help of local mental health pharmacist or community team.
  • Audit the current practice with expected standards and identify shortcomings.

Audit the Provision of Psychotherapy:

There is an evidence base and guidelines from NICE regarding the importance of psychological therapies in managing common mental health conditions like anxiety and depression.

You  can re-familiarise yourselves with the NICE depression treatment guidelines here

https://www.nice.org.uk/guidance/cg90/chapter/1-Guidance#stepped-care

However, the provision and availability of psychotherapy varies across the UK.

You can

  • Establish what form of common psychological therapies are recommended for certain mental health conditions by established guidelines.
  • Study what therapies are available locally for your patients and typical waiting times.
  • Make suggestions to how access to psychological therapies could be improved. 

Old Age Psychiatry:

Dementia related Audits and QIPs:

NICE has published detailed guidance on the diagnosis, management and treatment of dementia. Click on the link for current NICE guidance.

https://www.nice.org.uk/guidance/ng97

Different aspects of this guidance can be audited and compared with current practice. The recommendations from this guidance is divided into the following sub-headings.

You could do a quality improvement project in helping to improve the assessment and diagnosis process.

A few pointers may be

  • Look at the process of assessment of cognitive impairment
  • Time taken from first referral to diagnoses
  • Reasons for delay in the process
  • Cognitive testing used and the investigations carried out in the process
  • Identifying the areas causing a delay in the diagnosis process
  • Improve the flow of patients through the service. 

Medications prescribed in Dementia:

  • Study the local prescribing guidance and the expected standards of dementia medication and their monitoring.
  • Review a cohort of cases from the memory clinics retrospectively. 

Here is an example of a service audit on supporting carers in dementia by a junior doctor. 

Driving and Dementia – Audit

Dementia can affect a person’s ability to drive. Assessing if a patient is driving a car at the initial assessment phase is common practice.

Here are DVLA guidance with Dementia and Driving:

https://www.gov.uk/guidance/psychiatric-disorders-assessing-fitness-to-drive#dementia–andor-any-organic-syndrome-affecting-cognitive-functioning

A few pointers may be:

  • A study of issues relating to dementia and driving including the (Driving Vehicles Licensing Agency) DVLA guidance. (LINK)
  • To establish minimal required standards for the assessment.
  • You can study how issues of driving are dealt within the local memory assessment service. 
  • Check notes say for example, if driving status was asked and recorded in notes. This can be done retrospectively.
  • If the patient was driving, what advice was given?

Audits of Inpatients Falls:

Inpatient falls can have a detrimental effect on patients and reduction of inpatient falls is always high on the agenda. A good quality improvement project can be created based on the assessment and reduction of falls. You may look to:

  • Identify fall events using the incident reporting and Datix and incident reporting data.
  • Look at the pattern of falls, location, timing and outcome
  • Study any obvious patterns or particular wards presenting with high number of falls.
  • Study the fall prevention strategies and how they can be implemented on a particular ward.
  • Discuss your findings with the multi-disciplinary team, ward managers and seniors.
  • Draft recommendation on falls prevention.

Here is an example of an inpatient falls prevention project.

A simpler version of an inpatient falls audit may include studying if the falls protocol and local guidance were adhered to following the falls. For example, local guidelines may include a doctor’s review following the fall, a CT head and neuro-observations. 

Audit of the DNACPR ( Do Not Attempt Resuscitation ) Audit:

Most NHS trust will have DNACPR policy in place and DNACPR is used frequently on the dementia assessment wards.

  • Look at the local DNACPR guidance usually available on the Trust intranet online.
  • Retrospectively, check DNACPR decisions if they followed the procedure
  • For example, if they were documented and discussed with the family where appropriate.
  • Identify shortcoming and make recommendations

An example:

Audit of Venous thromboembolism risk management (VTE):

Elderly frail patients may have their mobility compromised putting them at higher risk of VTE. It would be worth familiarising yourselves with the latest NICE for VTE.

https://www.nice.org.uk/guidance/ng89

Most NHS trust will also have internal guidelines to follow on old age psychiatry wards. You may wish to:  

  • Identify a cohort of patients on the old age psychiatry ward at risk of VTE.
  • Identify how the risk of VTE was assessed and how it was documented.
  • What measures and treatments were put in place where risks were identified.
  • Compare the current practice with expected standards and identify shortcomings

An example

Audit of Care home reviews of antipsychotic medication prescription for dementia patients

Regular reviews of anti-psychotic medications prescribed for patients with dementia is advised and long term use of anti-psychotics medications in dementia can be harmful. You can

  • Look at the guidelines around use of antipsychotics in dementia.
  • Standards expected for monitoring and reviews in care homes.
  • Study the current practice and systems put in place for monitoring.
  • Compare the current practice with expected standards.

Audit of the Management of Behavioural and psychological symptoms (BPSDs) of Dementia

Management of BPSDs can be a major challenge on the dementia assessment ward and dementia care homes. Guidelines are available via NICE Dementia guidelines and the Maudsley Prescribing Guidelines around management of such behavioural symptoms of dementia of and these can be used to audit the current practice.

You can

  • Study which guidelines (local or national) are followed locally in the management of BPSDs
  • Look at how BPSDs are recorded in patients’ notes,
  • What non-pharmacological and pharmacological options are available and put in place. 
  • Compare the current practice with the expected standards.

Child and Adolescent Mental Health Services (CAMHS)

Audit of ADHD assessment, medication and monitoring requirements

If you are working with CAMHS, you are likely to encounter ADHD clinics.

NICE has published extensive guidance on the assessment, treatment and monitoring requirements of ADHD medication.

https://www.nice.org.uk/guidance/ng87/chapter/Recommendations#medication

Different aspects of these guidelines can be used to create an audit project depending on the service structure, needs and requirements.

Here are a few examples

Learning Disability (LD) Psychiatry

Audit of Epilepsy management in the LD patients :

Patients with learning disabilities (LD) are more likely to develop epilepsy. Specific NICE guidance is available on how to manage epilepsy in patients with LD. 

https://www.nice.org.uk/guidance/cg137/ifp/chapter/Special-considerations-for-certain-groups#special-considerations-for-people-with-learning-disabilities

  • You can consider looking at the current provision and systems put in place to help and monitor LD patients with epilepsy.
  • Identify standards expected from the mental health services.
  • Identify a cohort of patients and retrospectively look at notes to audit standards

Using STOMP (Stopping over medication of people with a learning disability, autism or both) project to help audit the service:

You can read more about STOMP here

https://www.england.nhs.uk/learning-disabilities/improving-health/stomp/

After identifying service need for this project you can discuss how to approach this subject with the services you are working in.

You can start by looking at the Challenging behaviour and learning disabilities NICE guidelines

https://www.nice.org.uk/guidance/ng11

Study the pattern of anti-psychotic prescriptions and compare it with the guidance provided by NICE. This can create a good audit.

You can take it to the next level and you can develop this project into a QIP with an aim to reduce the prescription of anti-psychotics in LD patients.

Audit of Hospital Passports :

Healthcare or hospital passport is a document with information about patient with LD and their healthcare needs. It may contain useful information, such as their interests, likes, dislikes and preferred method of communication.

You can

  • Audit if hospital passports are used in your service.
  • What information is needed on the passports.
  • If patients have up-to-date information.
  • How often these passports are reviewed and updated.

Psychiatry related Audits if you are working in other medical specialities

Some junior doctors may not be working in psychiatry but interested in applying for Psychiatry training and would like to improve their portfolio by showing they have done a Psychiatry related audit. You can easily do a psychiatry related audit in a general medical setting, surgical ward or the A&E. Here are some ideas:

Audit / QIP on the management of delirium.

NICE has produced comprehensive guidance on the prevention, diagnosis and management of delirium. 

https://www.nice.org.uk/guidance/cg103

Delirium is one of the most common presentations in acutely unwell elderly patients on surgical, medical or A&E. You can

  • Look at how delirium is identified and recorded in notes.
  • The pharmacological and non pharmacological management of delirium
  • What delirium reduction strategies are in place.
  • Staff training in recognising and treating delirium.

Cognitive tests used on the wardsAudit

You will find situations involving elderly patients on medical wards where their memory  and cognition will be questioned such as if the patient has pre-existing dementia or acute confusion with delirium. This is more common in Care of Elderly medical wards.

You can

  • Look at what tools (cognitive tests) are commonly used to assess cognition.
  • Their reliability and validity given the situation. 
  • How deficits in cognition are documented and investigated.

Here is a guide recommending assessment of cognition in different settings.

https://www.alzheimers.org.uk/dementia-professionals/resources-professionals/publications/assessing-cognition-older-people-toolkit

Mental Capacity Assessments and their documentations

Mental Capacity assessments are now part of routine medical work and decision specific capacity assessments and best interest meetings are happening in all medical settings. Most hospitals will have their internal guidance and / or forms relating to capacity assessment and the best interest process.

You can

  • Look at the standards expected from the capacity assessment process.
  • Documentation of the capacity assessment and best interest decisions.
  • Compare the data gathered retrospectively with the expected standards and suggest improvements.

Here are NICE guidance relating to capacity assessment.

https://www.nice.org.uk/guidance/ng108/chapter/Recommendations

Audits of Referral to Psychiatry liaison teams and their outcomes.

Psychiatry liaison teams support medical areas including A&E, medical / surgical wards. The process of referral and expectations may differ depending on where you are working. You can create a quality improvement project based around the interactions of medical and psychiatry teams.

For example:

  • Study the referral process between medical and psychiatry team. Is there a form or phone call involved?
  • Conduct a survey of the staff regarding their expectations of the referral process. Ask mental health staff what they expect at the point of referral and ask medical staff what are their expectations are from the psychiatry teams. 
  • Retrospectively, examine data from past referrals such as the indication for the  referral, what information was provided? The time taken from referral to assessment, what was expected from both teams and what was the outcome?
  • Analysing the data from past referrals and survey of expectations, you may come up with a way to improve communications and referral procedures.  

Management of Behavioural and Psychological symptoms of Dementia (BPSDs) on the medical wards

Behavioural and psychological symptoms of dementia (BPSDs) are common with advancing dementia and you will find patients with establish diagnosis of dementia on the general medical wards presenting with agitation, wandering, and aggression.  

You can use NICE guidance as a tool to help you develop an audit or QIP.

https://www.nice.org.uk/guidance/ng97/chapter/Recommendations#managing-non-cognitive-symptoms

  • Retrospectively, look at how BPSDs were recorded and managed.
  • Compare current practice with NICE guidelines
  • Identify shortcomings and make recommendations. 
  • Retrospectively, look at how BPSDs were recorded and managed.
  • Compare current practice with NICE guidelines
  • Identify shortcomings and make recommendations. 

How and where can I present my Audit / QIP?

As audits are generally part of the service improvement exercise, you should present your findings to the teams and clinicians concerned. Consider the stakeholders who would be interested in knowing about your project. This will generally include the people directly affected by the project. Stake holders may be

  • Junior doctors, middle grade and senior doctors
  • Nursing and other healthcare staff
  • Nursing and healthcare managers

You can present your audit / QIP to:

  • Local Post graduate teaching sessions.
  • Management meetings where stakeholders are present.
  • Quality improvement workshops and audit meetings within your NHS organisations.
  • Local and national conferences as posters.  

Most RCPsych conferences including the Intentional Congress of Psychiatrist accepts quality improvement projects and audits as posters.

How do I include my Audit in my portfolio?

  • Power point slides showcasing the main findings.
  • A short audit report or abstract.
  • Poster of the audit. 

Audit abstract or poster will usually have these headlines

  • Aims and Objectives
  • Background
  • Methods
  • Results
  • Recommendations / Discussions.

Poster designs and templates can be downloaded from the link below. You can make posters in PowerPoint and save them as PDF.

Several other designs are freely available online


Some more examples of completed audits

Further reading:

https://www.rcpsych.ac.uk/improving-care/ccqi/national-clinical-audits


I hope this was helpful – I wish you the very best with your projects.

Developing CV in line with Medical Practises of NHS & UK

IMG doctors commonly ask, how they can improve their CV in line with the requirements of the NHS and make it attractive for the NHS hospitals and UK training system?

IMGs have good clinical exposure from their home countries and usually they can demonstrate clinical skills far more easily but struggle to demonstrate skills in the other areas which are also deemed important in the UK. 

This blog may also help medical students aiming to practice in the UK as it is important to start developing your portfolio early in the career keeping in mind the specialities you are aiming for.

You can break down your profile or portfolio into following sections.

  • Clinical Experience
  • Teaching Experience and Teaching Qualifications
  • Teamwork, Leadership & Management Experience
  • Audit& Service Improvement Projects
  • Courses, Training and Conferences
  • Research Experience
  • Reflective Practice
  • Extracurricular Activities

It is important to look at each of these sections and reflect how you can develop yourself in these areas and how can you gather evidence of your progress.

Clinical Experience

It is important to understand the level of skills required for the particular job or grade you are targeting as it will help you prepare the CV accordingly.

Basic Psychiatry related skills would include:

  • Communications Skills
  • Taking a Psychiatry history
  • Risk Assessment
  • Understanding Psychiatric emergencies and their management.
  • Ability to identify and diagnose common psychiatry conditions  
  • Understanding common Psychiatric medications
  • Use of ECT
  • Some understanding of different subspecialties of Psychiatry

When you apply for Psychiatry training in the UK, you are expected to have achieved the skill levels of a UK equivalentfoundation doctor. A foundation doctor in the UK completes two years of foundation training which is equivalent ofan internship or house job. You can see the level of skills required at this level on the Certificate of Readiness to Enter Specialty Training (CREST) form which you can be downloaded from the link below:

https://www.oriel.nhs.uk/Web/ResourceBank/Edit/MTA3NA%3D%3D

I suggest IMGs to download this CREST form early in their internship in their respective home countries and review all the competences. Try and achieve all the competences whilst working in the home country and gather ongoing evidence of your progress.

The level of clinical skills required for a particular training or non-training job can be seen with the person specification and job description. You can download person specification for training jobs from the HEE (Health Education England) website

https://specialtytraining.hee.nhs.uk/Recruitment/Person-specifications

Documentary evidence of your progress:

There are several ways to document your clinical experience and expertise. You can use

  • Work Place Based Assessments (WPBAs)
  • Log Books 
  • Supervisor Reports
  • Reflections  

Keeping a record of your progress as a junior doctor is good practice and you can create your own logbook or evidence folder.You can download the Psychiatry portfolio framework and some workplace-based assessments forms from this blog post.

https://psychiatry-training.com/2019/01/23/old-style-psychiatry-portfolio/

Electives & Clinical Attachments:

Electives and clinical attachments within the NHS can help you develop a better understanding of the system, gain clinical exposure, network with UK based doctors, find research and audit projects and gain references. 

International medical students can consider doing electives in the UK and qualified doctors can find clinical attachments. Although these experiences can be arranged free of cost and easily, it can cost a fair bit of money to travel and live in the UK for that time period.Bigger cities and especially London are generally very expensive but you can find electives and attachments in rural settings with equally good amount of clinical exposure and relatively much cheaper cost of living and possibly provision of hospital accommodation.  

You can evidence your electives / attachment experience by gathering feedback, a letter to confirm your involvement and reflections on your learning.  

Teaching Experience and Teaching Qualifications

Teaching experience can help you develop your own knowledge, communication skills and demonstrate your commitment to a speciality. Most IMG doctors already have teaching experience with medical students and junior doctors in informal setting but struggle to prove it and place it on their profile.

It is important to gather evidence of your teaching activities. Evidence could be

  • A certificate confirming that you delivered teaching.
  • A letter from senior confirming your teaching activities.
  • Feedback from the students you were teaching.
  • Your reflection on teaching session as in how it went.

It will help if you can get some more details on the teaching environment on the certificate, letter or reflection. Some details like

  • Number of students and their level
  • Setup of session (bedside, lecture, workshop)
  • Learning objectives and outcomes

Many types of feedback forms are freely available on the internet. Teaching feedback form can be downloaded from:

https://www.jrcptb.org.uk/documents/evaluation-form-teaching-and-presentations

https://www.mededcoventry.com/Educators/Feedback-Forms

Please consider teaching beyond the level of medical students and junior doctors. Teaching could be multidisciplinary involving nurses and other health care professionals or even general public. You can set up your own teaching sessions or join already planned teaching activities.

Here is an example of how you can set up teaching session locally.

https://psychiatry-training.com/2018/12/02/setting-up-teaching-sessions-locally/

Formal Teaching Qualifications:

There are teaching courses available which can help you improve your teaching skills like for example the “Teach the Teacher Course”

Here is an example of Effective Teaching Skills (for Clinicians) via Cardiff University.

https://www.cardiff.ac.uk/professional-development/available-training/short-courses/view/effective-teaching-skills-for-clinicians

If you are more interested in an academic career & formal qualifications relating to teaching, you can consider qualification in Medical Education for example:

  • Postgraduate Certificate in Medical Education
  • Postgraduate Diploma in Medical Education
  • Masters in Medical Education.

These courses are available via UK universities for both e-leaning and face to face learning, although very comprehensive, they can be expensive and require a lot of time commitment. 

Here is an example of formal teaching course from the Cardiff University:

https://www.cardiff.ac.uk/study/postgraduate/taught/courses/course/medical-education-msc

Team Work, Leadership & Management Experience

The UK healthcare system expects doctors to be excellent team players with leadership qualities. IMGs are involved in team working, leadership and management activities but may not understand how to evidence their progress. These activities could be in clinical or non-clinical setting.

Team working is about working with other individuals, inspiring them and achieving shared objectives. Leadership is about taking initiative and leading a group of individuals. Think what you could do or have been doing over other doctors or students around you.

Some practical examples I have seen with IMG profiles:

  • Setting up a project to help patients and their relatives.
  • Working together on research or quality improvement projects as group of medical students.
  • Setting up health information initiatives for general public
  • Participating in vaccination drives
  • Gathering donations and distributing them.
  • Arranging blood donations.
  • Working with a various different charity organisations.
  • Team work and leadership in sports activities.

How to evidence these activities:

  • Certificate confirming your participation
  • Letter of recommendations from seniors confirming your role in these activities.
  • Supervisor reports. 

Audit & Service Improvement Projects

Concept of audit can be fairly new for an IMG doctor. It is important to understand the basic principles of the audit and quality improvement in context of the healthcare. This is also the requirement for the new CREST form which is required to enter speciality training.

Quite often IMGs confuse Audits with Research or Surveys and struggle to generate ideas. In short, clinical audit is where you are comparing your current practice with already set standards in order to find the shortcomings and recommend changes to make practice better.

Medical students and junior doctors on placements in general hospital can find several ideas. Few examples from the IMGs

  • Studying the standards of documentations in certain areas of medicine and comparing with what was expected. This could be history taking, medication charts, documentation of physical examination, consent forms and discharge notes.
  • Studying the local prescribing guidelines for certain conditions and comparing it with current practices and identifying shortcomings.

Audits can be presented in portfolio folder with powerpoint slides, a short report and reflection.

You can read more about clinical audit from this resource:

https://www.southampton.ac.uk/sias/resources/howtoseries/howtoclinicalaudit.page

Here is an example of a service improvement project completed in Pakistan.

Here is a service evaluation project completed in Pakistan.

Courses, Training and Conferences

Course, training and conferences can help in showing your progress as a doctor and your interest in a particular speciality. Attendance of a course or a conference can be evidenced by an

  • Attendance certificate.
  • Reflective note on what you learnt.

IMG doctors can find lots of relevant courses, seminars, training and conferences within their home countries.

Some free online learning resources can be found on this blog post. 

https://psychiatry-training.com/2019/01/25/online-cpd-resources/

Within UK, relevant conferences and training events can be found on the relevant Royal college events pages. Like for example

Royal College of Psychiatrist: https://www.rcpsych.ac.uk/events/conferences

If you are doing a clinical attachment within UK or already started working in the NHS, you will find plenty of free and paid courses from within your trust or sometimes with local universities. Most trust websites have a link advertising courses and training events.

Research Experience

Research experience enhances your CV however at junior level it is not an essential requirement for most jobs. You can secure junior level non training or training job in Psychiatry without research experience.

Research experience can be evidenced by:

  • Research papers and their reference
  • Posters made from research projects.
  • Abstracts of your research.  
  • A letter from research supervisor confirming your involvement.

IMGs can struggle to get research experience as not all medical colleges and training schemes abroad provide research orientation, guidance or projects.

If you are interested in conducting or getting involved in research projects. You can start by

  • Studying different methods of research and the hierarchy of research evidence.
  • Start reading some local and international journals.  
  • Developing some basic understanding of critically appraising research projects.
  • Understanding the concept of research ethics and how to get ethical approvals locally.
  • Finding out who is actively involved in research in your institute to see if you can be involved in an already existing project or get someone to supervise you for your own. 

There are several different methods to conduct research and some methods are very time consuming and require a lot of resources. However, conducting research is possible at medical student level by using following methods.

  • Case reports and case series can be written and published
  • Quantitative research (e.g. surveys) or Qualitative research (e.g. interviews) can be conducted, analysed and published.
  • Literature reviews of already existing research.

If you have done any psychiatry related projects, please submit them as posters to conferences locally in your home country or to the Royal College of Psychiatrist (RCPsych) conferences.

Reflective Practice

IMGs may initially struggle to understand the concept of reflective practice. Reflection is a very simple process of documenting your learning and thought process leading to better understanding of certain situation.

You can write some reflections and keep them in your portfolio.

Reflections can be written for:

  • Learning from new clinical cases and challenges.
  • Learning from educational activities and training.
  • Learning from conflict, significant incidents and complaints.

This blog will give you some practical examples of how a reflection is written.

https://psychiatry-training.com/2020/01/11/reflective-practice-examples/

Extracurricular Activities

Hobbies and non- clinical activities play a major part in the personal development of a doctor. Skills we learn outside medicine are transferable to the clinical environments.

For example:

  • Team sports can help you develop your communications, team working skills, leadership style, working under pressure and allow you to motivate others. 
  • Learning and playing music can teach you problem solving, creative thinking, time management and adaptability.
  • Activities like travelling gives you a rich experience of exploring different cultures where you can learn from the diversity and also learn to adopt.
  • Spending time with nature can help you relax better under pressure and can be a form of ensuring wellbeing.
  • Working with a charity will give you the opportunity to develop for team working and management skills. 

It is worth mentioning your hobbies with some details and linking them with the skills required for a clinician.

I have seen several good examples of hobbies showcased in portfolios

  • A young doctor had photos of cakes she likes to make in her portfolio.
  • A doctor who loved travelling had photos of him with various landmarks.
  • Pictures of trophies won in sporting events.
  • Pictures of charity activities and letter confirming their contributions by charity lead.

I wish you the very best in your future careers and I hope this was helpful. Good Luck!

Example of a Mental Health Educational project

A Practical Example of how can you improve your CV and portfolio aiming for Psychiatry Core Training:

Some years ago I met a lady doctor at a conference. She changed her career from O&G to Psychiatry. She had an amazing story to tell.

She was working in O&G for some years and was fed up with no career progression plus workload and thought about exploring Psychiatry. But she had absolutely nothing on her CV, no teaching, no quality improvement, no research experience, no leadership experience and nothing relating to psychiatry.

She started thinking about what can she do in the clinical environment she was working in to improve her portfolio and make it more attractive towards Psychiatry.

This is what she did: 

– Approached the senior midwife responsible for her unit asking if there are any learning needs of staff around mental health. 

– Conducted a survey of midwives and other staff working on the labour ward on their understanding of mental health issues relating to pregnant women, postnatal depression, psychosis and how to assess self-harm risk. 

– Survey results indicated the learning needs of the staff around mental health.

– She conducted a literate review of effective evidence-based training available to O&G staff around the mental health of pregnant women.         

– She then contacted ST doctors working in Psychiatry and teamed up with them to design a 2-hour long workshop based around mental health teaching of O&G staff. She helped in designing and delivering the workshop.  

– Feedback was gathered from the participates of the workshop.

All of this took around 3 months but in that time she has this much on her CV & portfolio. 

– Evidence of quality improvement activity (Pre and post knowledge survey of staff) 

– Evidence of teaching (feedback forms and certificate from the workshop)

– Research experience (Literature review)

– Leadership, teamwork and management experience (designing and delivering training) 

The absolutely brilliant portfolio was ready for the interview stage and she smashed it.  

I use this story to motivate junior doctors and give them a practical example of how you can take initiative in any clinical environment to make a difference and improve your CV + portfolio at the same time.  


Please don’t take this story as against O&G or Psychiatry vs O&G. Every doctor has their own point of view regarding specialities. One speciality is not superior to another. 

Supporting Information on the NHS Jobs Profile.

In the recent months, a good number of IMGs asked me to look at their NHS-Jobs profile. Some IMGs struggle to write supportive information section on the NHS-Jobs profile which could be a deciding factor for their shortlisting.

I am writing this blog based on my experience of reviewing a number of applications and my advice on how to make this section better. This is not the only way to make it better.

Teaching Experience 

A lot of IMGs put routine ward based teaching of medical students in one or two lines in this part. 

I think you can write a lot more in this section. This is the time to describe your passion for teaching, advantages of teaching and qualities of a good teacher. Teaching is a mutually beneficial exercise where the teacher is also learning.  

Read about qualities of a good teacher and how can you relate those skills to yourself. A good teacher is an: 

– Excellent communicator and can engage and entertain the audience. 

– Active listener and responds to student’s learning needs with an adaptable approach. 

– Motivator as they can get best out of their students. 

– Good teachers are lifelong learners themselves.          

 An average / generic statement on this section may say:  

“I have been involved in bedside teaching of medical students during my house job and taught them physical examination skills” 

A better way to write the same thing: 

“During my internship, I was actively involved in the teaching of medical students and I found it was very useful for my personal development as teaching helped in improving my interpersonal and communications skills. I establish a system to understand the individual and unique learning needs of medical students on placement in my ward and tailored my teaching sessions accordingly. I developed some expertise in teaching general physical examination and established techniques to practically demonstrate the techniques. I learnt that developing rapport was key in establishing an effective learning environment.  

I feel teaching on a busy ward based environment helped me develop excellent time management and communication skills along with the added benefit of keeping my own knowledge up to date. I received positive feedback from my students and modified my teaching style based on the feedback. Students found me engaging, approachable with good listening skills and I believe these skills have helped me develop as a clinician. I like to further develop my teaching role whilst working within the (trust you are applying to).” 

If you have done any formal teaching courses, you can mention them here along with what you learnt and how you are applying that to your daily working life. Like for example, if you have done the “Teach the Teacher” course. You can say something like:

“This course has given me insight into different teaching styles and how to improve the engagement of the audience by actively involving them in the teaching sessions. I now use more role-play method in my teaching sessions which my students are finding more beneficial”  

Management of Change

Most IMGs were leaving this section empty in the applications I reviewed. This relates directly to the quality improvement project or an Audit. This is an important area and hot topic for the NHS as in the UK, the doctors are expected to go beyond their routine clinical role and review the systems and practices around them to make things better.

If you have done an audit or quality improvement project. You can write about that in some detail. They are trying to establish if you understand the principles involved in the management of change. 

If you haven’t done a formal audit or quality improvement work. There are still many ways you can write this section from your experience so far. You must have done some quality improvement work during your medical school and as a junior doctor in the home county. 

I can give you several examples of quality improvement work by medical students and house officers I saw while working as a junior doctor in Pakistan. 

“As a house officer whilst working in the department of surgery, I establish a system to link the charity sector originations with patients of poor socio-economic class. Healthcare is not fully funded by the state in Pakistan and as a house officer, I noticed patients were requiring expensive medications which they were unable to afford. There were several charity organisation working locally willing to help out but there was no formal system to identify the patients in need unless the patient themselves approached a charity. As a group of house officers, we studied this issue and establish a system to identify patients with poor socio-economic class who were likely to need financial help at the point of admission and provided them help and support early in their treatment by linking them with relevant charities. Our efforts helped to improve the healthcare outcomes for the patients on the ward”   

“As a 4th-year medical student, I noticed that the blood bank in my local university hospital was struggling to get enough blood donors and was unable to respond to the emergency request of blood units by the clinicians. As a group of six medical students, we studied the reasons for the lack of volunteers for blood donations and we identified some myths associated with blood donations. We designed a health awareness campaign targeting the myths around blood donations and encouraged the university students, local college students and local residents to volunteer for blood donations. We also establish a mobile texting system where donors were sent reminders 4 months after blood donations, encouraging them to return for another visit. We were able to increase blood donations by 25% and we also identified a cohort of donors with rare blood types and established a database.”  

I am sure all of you have been involved in such projects locally in your home countries. Write them down properly.

Research

If you have done the research, well and good. Mention research and also your involvement. They like to know if you understand the process of research itself and its implications. Research is about creating new knowledge. You need to mention the research methods, findings and what you learnt from that process.  

Most junior IMGs do not have formal research experience at the early stages of their careers. Don’t worry about it. Unless this is an academic post with essential research requirement, not having research experience shouldn’t affect you.   

But you can consider doing some small research projects while you are waiting. For most IMGs there is a gap for a number of months between passing PLAB & securing a job. You can easily take up a project like a literature review where you don’t need patients or direct patient data to do research and you can use already published research to create a project.

Literate reviews can help improve your CV while you are waiting. Depending on your speciality, you can find a research oriented senior and ask them to help you with a literature review.  

Let me give you some examples from Psychiatry.

 – Effectiveness of pet therapy in the management of anxiety disorders.

– Treatments for gaming addiction.

– The evidence base around techniques used in cognitive stimulation for patients with cognitive impairment.  

Look at what studies have been done, which methods of research has been used, and what are the results showing. Write a report or an abstract with headings of Aims, Background, Methods, Results and Discussions. Get it checked by one of your seniors.

Remember: Conducting small research project isn’t difficult – Publishing research in a reputed journal is a different ball game.

Other ways to show your research interest:  

– Understanding of basic research methods, online courses.  

– Studying recent journal articles on topics which interest you and writing reflections on what you learnt and how will you apply that to your own practice. 

– Learning to critically appraise research papers and writing the critique. 

Management and Leadership Experience

This is an important section and I see most IMGs are either leaving it empty or writing a few lines in it. We all have to take a leadership roles in our routine clinical or non-clinical work.

Generic examples I have seen in this section

“I was rota coordinator in my previous job and managed 16 doctors” 

“I was the cricket team captain in my medical school” 

To start writing this section, you need to read the qualities of a good leader and relate it to your examples. Leadership is about taking initiative, inspiring people, communication, vision, resilience, problem solving, motivation, ownership, and a lot more. 

Here are some relatively good examples:   

“During my house job I took the lead on rota management which included 16 junior doctors. I took a democratic leadership approach to deal with this challenge and took suggestions and opinions of all doctors involved in the rota. My main aim was effective management of oncall rota ensuring safe health service along with making sure all the doctors were getting a fair share of work and rest. Effective communication and ownership of rota helped me develop a good rapport with all the junior doctors on my ward and we were able to discuss and solve problems as a team. I encouraged culture of openness where rota related issues and workload were discussed freely between the junior doctors and the senior management. This experience has given me an insight into the qualities of a good leader and I like to develop my leadership skills further whilst training in the NHS.” 

“I love playing cricket and I had the honour of captaining my medical school cricket team. As a cricket team captain, I was responsible to lead 11 teammates with different skill sets and capabilities in challenging match situations. I learnt how to motivate my team during times of difficulty, lead by example and earn respect. I also learnt how to maximise the strengths of my team members and how to work around the weaknesses. Cricket gave me the opportunity to work under pressure and adapt to change. As a team, we worked towards achieving a common goal and pushed the boundaries of our skill sets. We also learnt how to deal with failure and use setbacks to motivate ourselves in regrouping with a better strategy. I believe these leadership skills are transferable to my clinical role and cricket has prepared me to take leadership roles in hospital environment.”

Team Working

We all work in teams and we all have a team working experience but unfortunately some of us find it difficult to write it down. In this section, they are trying to check your understanding of team working and its advantages. 

Common generic examples I have seen may have been a few lines like:

” I have been part of a resuscitation team and have done my ALS” 

” I enjoyed working with a team of nurses and other staff on my ward” 

Again, start by reading what is teamwork, why is it important and what are the qualities of a good team and a good team player. 

– Teamwork triggers creativity and a sense of belonging.

– Teamwork makes team members happier and makes them feel safer. 

– Teamwork leads to learning and personal development. 

Relate all this to your own example. Let’s say this example

“During my house job, I was working on a medical ward with a multi-disciplinary team. I feel as a junior member of the team I was given a warm welcome and respect which helped in developing my confidence as a junior doctor. As a team of healthcare staff, we had our defined roles but we encouraged a culture of helping out each other when required and worked towards achieving the common goal of giving our patients the best care possible. I had the opportunity to learn from the senior members of the team and offered my expertise and knowledge to the wider team. I learnt the importance of effective communications, mutual respect and learning from each other as a team. I received positive feedback from my team members and they felt I was approachable and pleasant on interactions. Reflecting on this experience, I feel a good team working environment can help to maximise the potential of junior team members and make them feel safe. I like to further establish my team working skills while working with the (ABC) department of (ABC) hospital.”

You can think of several examples of clinical and non-clinical team working within your scope of work so far and from your personal life. 

Supporting Information:

This section is extremely important, sometimes this may be the main deciding factor on who will get shortlisted given tens of application for a job.

I have seen IMGs copying and pasting all the above sections again in this section and writing long paragraphs with generic statements. I suggest you keep it to 3-5 paragraphs but they must be written very professionally.

This is the section to show:

– Why you are applying for this particular job.

– Why this particular geographical area.

– What skills can you bring to the team.

– How can this job help you develop as a doctor.

You will have to change this section for every job you apply. Generic forms are very obvious to the shortlisting consultants. Show them that you have done your research and are really keen to apply for that particular job.  

Let’s say the job is for A&E in London. You can say things like, 

“I thrive in a busy clinical environment and like dealing with medical emergencies. I am a quick thinker and I have developed a habit of reflecting on every challenging case I encounter. It’s an honour to work on the frontline of the A&E department with a competent multi-disciplinary team and making a real difference to patient`s care. I have the necessary clinical and interpersonal skills required to undertake this job and I have also researched the A&E department of ABC hospital. I found that this hospital provides excellent support to junior doctors and the clinical teams nurture their skills. I believe I can enrich your team with my clinical, team working, teaching and leadership skills and will get supervision and support to develop myself further. 

I would love to live and work in London as I grew up in a metropolitan city, I enjoy the cosmopolitan lifestyle and multicultural environment. I believe working in London will suit my fast-paced lifestyle and London will help me thrive both personally and professionally”

There are geographical areas within the UK with long term shortage of doctors, mostly rural communities. They will go through a huge exercise of advertising and employing doctors but the doctors will find another job within 6 months and move away towards a city. If you are applying in one of these areas, you need to show genuine interest in your supporting information of why you want a job in that area. 

I remember a consultant from West Wales telling me, once they shortlisted and gave a job to a doctor based on his interest in surfing as they knew he was genuinely interested in the beaches of west Wales and it was suitable for his lifestyle and hobbies. They knew he will stay there longer and will not use that job just as a stepping stone.

All the best   


Please Note: I wrote this blog as a reflection of my own experience and i do not claim this to be the best way of filling the NHS Jobs profile. I am sure you can find much better ways.

Reflective Practice – Examples

Important Points to Remember reflections

  • Use a reflection model. For example:
    1. Gibbs’ reflection cycle
    2. Edward de Bono’s six thinking hats
    3. John’s model of structured reflection
    4. Boud, Keogh and Walker’s model
    5. Brenner’s Critical Incident Analysis

Doesn’t matter which one, you can try each and then use the one that suits your personal style better.

  • Read GMC guidance on reflection but most important take home message is to keep the details and descriptions of events short, outlining the case anonymously.
  • Most of the writing should be about what was learnt including what you will do differently e.g. If using the Gibbs’ reflective cycle this will be the analysis and evaluation section.
  • If you’re stuck about what to say about future management, imagine the scenario in a different setting e.g. if you encountered the case out of hours, if had said something differently, if you had tried a different line of treatment etc.
  • Your learning can be:
    • Theory e.g. you learned how to manage a certain problem, you’ve since read certain guidelines.
    • Something you learned about yourself e.g. how to manage your feelings/emotions. It can be something you learned about medical ethics etc.
    • A reflection on your ‘soft’ skills e.g. your leadership skills, team working etc.

Here are few examples of reflections

Example # 1:

Title: Attended a full day GP Update Course (Date – venue)

Reason:

As a GP it is important to continue to renew our knowledge even in areas that we become experts in such as hypertension, asthma and diabetes. Common things are common but medical research is always evolving hence the importance to continue to update our current knowledge base. It was a useful course and new useful guidance is always gained when attending this course.

Reflection:

Amongst many nuggets of knowledge I learned the following:

NSAIDS & Antidepressants- co-prescribing these increases the risk of intracranial haemorrhage (ICH) particularly in the first thirty days. ( BMJ2015;351:h3517) I have always advised patients on short courses of NSAIDS and AD to beware of GI bleeding but had not considered ICH.

The study also suggests that this risk is across the range of antidepressants such as TCAs, SNRIs as well as SSRIs. I will continue to use these with caution. Of course, nothing is straightforward in General Practice. We do not know of the risk beyond 30 days. This risk is also higher in men but surprisingly no increased risk is seen in older people or those with co-morbidities.

Outcome:

Given that we prescribe approximately forty million prescriptions for antidepressants across the UK, we are unaware of patients using NSAIDS over the counter, we have to use caution and advise our patients against such risks.

This has a direct impact on multimorbidity and polypharmacy in primary care.
I have made it clear to patients taking antidepressants about the risks of using NSAIDs. More so, there are a number of patients with depression with chronic pain, these groups are clearly vulnerable to the risks mentioned.
There is a suggestion with NICE guidelines that if an SSRI & NSAID is co-prescribed, gastro protection should be advised.

I have discussed this with our practice pharmacist, as she does the majority of our medication reviews, and made her aware of the risks.
On a personal note, I will be adding gastro protection where possible and advising patients to avoid OTC NSAIDS.
We also discussed the use of NSAIDS which in actual fact cause more deaths than RTA. This has certainly put things into context for me!


Example # 2:

Title: Menopause Masterclass

Activity:

A refresher about menopause and risks/benefit in the current climate.

Reason:

Women are far more self-aware of the menopause and approach the doctor to discuss treatment for the menopause than perhaps decades ago.
As women are also living longer, as is the general population, so comes with it increasing the risk of cardiovascular diseases and other co-morbidities.

Reflection:

It was useful to look at the quality standards that are now in place for HRT. There were several useful websites for information for both health professionals and patients:
British Menopause Society- BMS
Menopause matters.org
M anagemymenopause.co. uk
Also, for younger women with premature ovarian failure the daisynetwork.org.uk< br />

There was useful information on the use of testosterone. I had a peri-menopausal lady who requested testosterone gel to improve her libido. I had no experience in this area so wrote to the HRT clinic, she is now a very happy patient on testosterone gel. As long as the testosterone levels are measured every 3months to ensure that low maintenance doses are continued it is acceptable.

Given that I see a lot of women who often come with an agenda and an expected outcome this seminar was very useful in addressing these issues. HRT can have a lot of expectation for women. Some women are very reluctant to stop taking HRT, it is challenging such as stopping HRT after 5years or more when the risk becomes more concerning that I find challenging. The risk increases in term of CVD, obesity and breast cancer.

I have used the BNF statistics to place this risk into context for women who have been on HRT for many years. On one occasion in a 72year old lady, I stopped HRT much to her consternation. I did refer her to the HRT community clinic where it was restarted. Unfortunately, the risk and responsibility fall on the prescriber and I decline to continue to prescribe in this scenario. This seminar reinforces my practice in such unique case scenarios.

Outcome:

This was a good seminar, given the subject, it validated my current practice and helped me develop a more patient-centred paradigm within our current approach.


Example # 3:

Title: Dermatology update day

Activity:

(Venue) – Evening lectures covering typical skin scenarios commonly seen and dealt with in the primary care setting.

Reason:

The topics discussed on the day were eczema and skin conditions in young children, vulval rashes and psoriasis in the community.
I see a lot of vulval rashes and being contraception lead at my surgery. Also, I have a lot of consultation with women so find that this area needs to be kept up to date.

Reflection:

It was reassuring to know that my management of childhood eczema was in keeping with dermatologist consultant approaches.
The key points to take home were that GPs tend to undertreat eczema rather than over treat. It is reasonable to continue a moderate potent steroid cream as long as it is for a short period and stepped down at the earliest possible.

Outcome:
I will continue to practice as I have been but will take on board certain practices such as treating superimposed infection in eczema for 2weeks and also despite what the instructions are on steroid creams we can apply to broken and infected skin!


Example # 4:

Subject title: Autism Spectrum Disorder (ASD)

What were you reading?:

I read the article ‘Autism in Adults’ published in InnovAiT in June 2017.

Why were you reading this?:

I identified that this is a learning need of mine from a previous reflection on a case I was involved in.

What did you learn?:

I learnt a lot from this very thorough article. I learnt about the terminology currently in use. I did not know that ASD is now an umbrella term that includes Autism and Asperger’s Syndrome. I learnt about the clinical features of Autism, including challenging behaviour, communication difficulties, processing difficulties and rigid/repetitive behaviours. I learnt how to assess patients with suspected ASD. I also learnt how to manage patients with ASD in primary care. The article suggested reasonable adjustments that can be made at a surgery to make healthcare more accessible to people with ASD and it also gave a number of tips regarding communication during consultations.

Reading this article, I was able to reflect further upon a patient I reviewed with ASD who had presented with suicidal ideation. I had found this assessment difficult. I found it difficult to build a rapport with this patient and had a lot of difficulty assessing her level of risk. I identified during the assessment that she was struggling to answer open questions and one of the tips in this article is to ask direct closed questions. It also suggests waiting for a response rather than repeating the question or asking in a different way. This is something that I did whilst trying to assess this patient and may be some of the reason why I failed to do an appropriate, effective assessment on her.

What will you do differently in future?:

In future, I would try to follow some of the communication advice written in this article. That said, another important point raised by the article is that ASD, as the title suggests, is a spectrum. This means that no two patients are the same and while some may respond better to the communication advice provided, others may not. I will therefore keep an open mind and endeavour to adjust my communication technique as I feel appropriate.

What further learning needs did you identify?:

I had already identified that I needed to learn more about ASD. Whilst I now need further practice at managing patients with ASD, this reflection goes some way towards closing this learning cycle.


Example # 5:

Subject title: Urge incontinence

What happened?:

A 41 year old woman presented with a few months history of increasing urge incontinence. She had had one normal vaginal delivery 10 years ago. She reported that she had been consistent with doing regular pelvic floor exercises since the birth of her child. She also reported that she had already tried to cut down on her caffeine intake in an attempt to manage her symptoms. She felt that her symptoms were beginning to have a negative impact on her life and she was beginning to feel reluctant about going out in case of any accidents.

What, if anything, happened subsequently?:

I consulted the NICE CKS guidelines and referred her to the continence team for bladder retraining. I advised her to complete a bladder diary in the meantime.

What did you learn?:

I learnt that I am not confident at managing patients presenting with urinary incontinence. I learnt from the guidelines that it is advisable to refer patients for bladder retraining prior to initiating medication. I would not feel confident at initiating medication at this stage.

I learnt that these symptoms can have a big impact on lots of aspects of someone’s life. This patient is beginning to feel reluctant about going out due to the risk of her being incontinent while she is in public. She was quite tearful as she described how it made her feel even in her own home when she is incontinent in front of family members. She has a young child that she wants to go out with so her symptoms are now beginning to affect their family life. She wishes to lose weight (which would probably benefit her urge incontinence) but is struggling even more with body image and low esteem as a result of these symptoms.

What will you do differently in future?:

In future, I will refer patients for bladder retraining as I did in this case. I will try to be as sensitive as I can when taking a history as I understand that this can be an embarrassing experience for patients.

What further learning needs did you identify?:

I need to learn more about the management of urge incontinence.

How and when will you address these?:

I will undertake some reading on this subject and record what I learn from this in my eportfolio.


Example # 6:

Subject title: Assessing Risk Out of Hours

What happened?:

During an evening shift, along with a member of the Home Treatment Team, I assessed a 22 year old woman who had been referred urgently by her GP due to increasing thoughts of self harm and suicide. She had been referred to the Community Mental Health Services some weeks previously but not yet been assessed. Although she had experienced a number of significant precipitating life events and also disclosed during assessment that she had been sexually abused as a child, there were no specific triggers for the recent deterioration in her mood. She described how over the past 12 months she had been unable to hold down a job or maintain personal relationships. She had fallen out with a number of close friends and been in more than one abusive relationship. She lived with her family and had a very good relationship with her mother. Her mother had accompanied her to the assessment. She also described how she had been arguing with her family and taking out her frustration on them. She felt very guilty about this. Over the past few weeks she had been struggling with insomnia. She had a history of having taken an overdose approximately 6 months prior to this with the intent to end her life and admitted to contemplating doing the same thing again. She had been prescribed medication by her GP for her mood and planned to take an overdose of this.

What, if anything, happened subsequently?:

Following a detailed assessment, myself and the CPN from the Home Treatment Team discussed management options. The options were admission to hospital or discharge home with either follow up from her GP or follow up from the Home Treatment Team. My colleague and I agreed that, although she was relatively high risk for self harm and even possibly suicide, she had a lot of support at home, especially from her mother. We agreed that the best option would be for her to be discharged with follow up from the Home Treatment Team until she felt improved enough to control her thoughts. We discussed the plan with the patient and her mother and asked her to sign a ‘Safety Contract’ that included a plan of action in case she felt like she wanted to act on her thoughts. Both her and her mother were happy with this management plan. We also agreed to give her some night sedation as she was having such difficulty falling asleep. Her mother was to keep these tablets in a safe place.

What did you learn?:

This was an excellent opportunity for me to practice assessing risk of self harm/suicide. I have assessed this risk on my own many times in the Emergency Department and in General Practice and generally err on the side of caution, as evidenced by a previous reflection on this subject. If I had assessed this patient on my own I would have probably admitted her. This time I was working with an experienced colleague and I valued the opportunity to discuss the risk and subsequent management plan with them. Sharing this decision helped alleviate some of the anxiety I sometimes feel when weighing up the risks myself. I feel anxious as I am concerned about the patient’s safety; I would worry about deciding to discharge a patient home who later seriously self harmed or committed suicide. I felt very moved by this patient’s history and she worried me. Having the opportunity to discuss this case gave me more confidence to decide with my colleague that the patient did not need admission.

I also had opportunity to practice completing the WARRN documentation and found this to be a very useful tool to aid our decision making. The WARRN is much like a checklist and can be repetitive but it provided me with a template for considering the level of risk for this patient. There was a lot of detail in this case and the documentation helped to highlight the salient points. I have used checklists in medicine many times and find them very useful. In my experience, not all cases will fit neatly onto a checklist but they are designed so that important points are not missed and all relevant information is recorded.

I learnt more about how to investigate symptoms of auditory hallucinations. The patient reported that she was hearing voices telling her to kill herself. Previously, I would have just documented this in the notes. However, my colleague questioned this further and was able to ascertain that rather than auditory hallucinations, the patient was experiencing ruminating thoughts about suicide and becoming increasingly preoccupied by this. I would not have previously been able to make this distinction.

Working with a member of the Home Treatment Team gave me the opportunity to discuss with him how this team may be able to help this patient (and others). Previously, I did not know that the Home Treatment Team were able to prescribe medication and I had incorrectly thought that they were less available than they are.

What will you do differently in future?:

In future, I would feel more confident about assessing risk of self harm/suicide and deciding on appropriate management plans. In General Practice we do not complete WARRN documentation and doing so would take too much time. However, I would try to think about the risk in the way it is set out in a WARRN to aid my decision making. If I had any doubts or concerns that a patient was at high risk of self harm/suicide, I would again err on the side of caution and, as a GP, would refer patients to secondary care on an urgent basis for further assessment.

Regarding checklists/proformas, I would look to use such tools in my future practice as I feel they play a role in ascertaining the salient points of a case and ensuring all relevant information is recorded. Whilst they do not fit every case, they can also assist in decision making.

What further learning needs did you identify?:

I need to continue to practice assessing risk of self harm/suicide with colleagues and alone. Whilst on this placement, I need to practice using WARRN documentation to become more familiar with the layout.

How and when will you address these?:

I will continue to practice assessing risk and reflecting upon my experiences.


Example # 7:

Subject title: Psoriasis vs Lichen Planus

What were you reading?:

I read information about these two skin conditions from three different resources; Primary Care Dermatology Service, British Association of Dermatologists and DermnetNZ. I also read about differential diagnoses for an itchy rash on the PCDS website.

Why were you reading this?:

I had previously identified this as a learning need when I struggled to diagnose and manage a patient with an extensive itchy rash. I noted that two GPs had subsequently treated the patient for a different condition and realised that I needed to do some reading on these topics.

What did you learn?:

I learnt about Lichen Planus including it’s presentation and management. It can be intensely itchy and is managed with emollients and potent steroids. It usually lasts for two years and as the papules/plaques settle they are replaced by hyperpigmentation. I also learnt about Psoriasis including it’s presentation and management. It presents as symmetrical scaly plaques and is managed with potent steroids, topical vitamin D preparations and coal tar amongst other treatment options. In addition, I learnt about differential diagnoses for an itchy rash, including how to investigate someone with generalised pruritis without rash. I also read about the Dermatology Life Quality Index (DLQI) as a measure for how much a dermatological condition is affecting someone’s life. This would be useful information to consider for referring patients to secondary care.

These are three resources that I regularly use when managing skin conditions. It was interesting to compare the three. Two of these resources are UK based and one is specifically for GPs in the UK. The management advice of each was pretty much identical which was reassuring. I found PCDS had more photographs on their website which is particularly useful when learning dermatology. BAD had lots of useful patient information leaflets which are available for printing.

Reflecting upon the original case, as I read this information I think that lichen planus and psoriasis could quite easily been mistaken for each other. They both present as itchy plaques, have similar triggers and can present with the Koebner phenomenon. Management for each condition is different, however, and given that this woman did not respond to potent topical steroids that could indicate that lichen planus is not the correct diagnosis. Her diagnosis of lichen planus had been made 10 years ago so it is quite possible that this rash is not the same thing. Additionally, back in 2009, she had been treated with diprosalic ointment which is often used in psoriasis to remove scale. After my reading and after reflecting, I think that psoriasis is the more likely diagnosis here and I will be interested to find out what the dermatologist thinks when she is seen in clinic.

What will you do differently in future?:

In future, I will have a better idea of differential diagnoses for patients presentingwith itchy papular skin lesions. I will be better able to differentiate between psoriasis and lichen planus and better able to manage them effectively. I also know which resources I prefer to use with regards to dermatology and would be able to direct patients to information that might be helpful to them, in particular the patient information leaflets on the BAD website.

What further learning needs did you identify?:

This completes my learning cycle.


Example # 8:

Subject title: Management of agitated patients and rapid tranquilisation

What happened?:

During my OOH psychiatry SHO shift, I was asked by a nurse on an adult psychiatric ward to prescribe anxiolytic and antipsychotic medications in order to reduce a patient’s agitation. This health board revert to a rapid tranquilisation policy for these matters.

What, if anything, happened subsequently?:

This patient was extremely agitated and had already cause some (minor) harm to themselves. There was also a risk of harm to staff and patients on the ward due to the severity, nature and unpredictability of the patient’s aggression. To manage this patient, police needed to be called to help de-escalate the situation before any medications could be administered. The patient was transferred to Psychiatric ICU for further management and assessment.

What did you learn?:

This was quite a big learning curve during my first on-call: Firstly, was learning how to manage a patient expressing this degree of aggression and agitation as there was limited we could do safely and legally at this point, which is why the police were called to utilise their different skills for managing these patients. Secondly, utilising the rapid tranquilisation guideline – the nurses were most comfortable/familiar with using Haloperidol and Lorazepam as a combination, however, further reading indicates that Haloperidol and Promethazine are a useful combination because there is some evidence that promethazine can help counter-act potential extra-pyramidal side effects associated with Haloperidol. The negative factor is both have the ability to cause prolonged QTc. Finally, was managing my own feelings because admittedly this was not a situation I had previously had to manage and despite one of the nurses having worked on the ward for 22years, all of the staff were looking at me for answers. Unlike medical or trauma related emergencies, I didn’t have an algorithm like <C>ABCDE to resort to in order to reduce my bandwidth and so having headspace to think in this unfamiliar situation was more difficult but definitely helped by delegating tasks or trying to utilise the team by focusing on priorities e.g. “how do we make this situation safer?” to which the nurses suggested calling the police.
Luckily this patient was on the ward on a section, had the patient been ‘informal’ then this could have added additional ethical and legal complexities but may have resorted in putting the patient on a section 5(2) if appropriate or giving the medication as a one off dose in the patient’s best interests.

What will you do differently in future?:

Our on-calls are off-site i.e. they are based in a different community hospital and we travel to patients or give telephone advice: During my first on-call I had to familiarise myself with everything inc. passwords to unlock doors, finding staff members, finding on-call rooms etc. If I ever have to do on-call shifts like this again, I will ensure I shadow a more experienced colleague/at least see the on-call location before I attend my own on-call to reduce the uncertainty and unfamiliarity. This might help me feel more at ease and give me more headspace e.g. wasting time trying to find paperwork or being locked out of a ward.
With regard to this specific case, it demonstrated a reversal in my relationship with the nurses i.e. throughout the on-call I was relying on the very experienced nurses to help with explaining how various systems worked, where paperwork was and sometimes providing clinical information that added to my assessments of patients. However, in this emergency situation, it was completely expected for me to take charge and tell people what to do. I found this quite interesting, not dissimilar to what can happen on a medical ward but I believe medical training is set toward managing medical emergencies a lot better than emergencies in mental health and so the answers weren’t so readily available to me. I don’t this affected the clinical situation too much but certainly interesting to reflect on. It also strengthened my relationship with the nurses, perhaps because it balanced out me asking them for help prior to this event!
This patient was naïve to antipsychotics and had a normal ECG documented from a previous A&E attendance 3 months prior. It was not appropriate to attempt an ECG for this patient at this point. In terms of choice of anxiolytic, despite evidence showing the use of Promethazine being a useful combination with Haloperidol, I don’t know that I would have used it in this patient due to concomitant risk of prolonged QTc.

What further learning needs did you identify?:

1. I need to learn more about antipsychotics as I am not as familiar prescribing them
2. I need to discuss with my consultant methodology for more focussed prescribing of antipsychotics
3. I need to learn more about MHA and police powers, in particular for managing patients like this

How and when will you address these?:

1. Self directed learning on antipsychotics
2. Discuss with adult psychiatrist in clinic about antipsychotic prescribing esp. PRN doses and combinations
3. Conduct e-learning on MHA and police sections


Example # 9:

Subject title: DNACPR discussion with patient relative

What happened?:

A patient with advanced dementia and multiple co-morbidities was admitted onto the ward and did not have DNACPR form. The patient did not have any close relatives aside from an elderly brother. His brother was invited in for a discussion about discharge and the subject of DNACPR was raised.

What, if anything, happened subsequently?:

DNACPR form was discussed and signed

What did you learn?:

Understanding surrounding DNACPR forms seems variable: In particular I have noticed that having the conversation with a family member who is younger e.g. children of the patient is a lot easier to explain than when discussing it with a spouse or similarly aged relative. I don’t know whether this is because the older generation have less understanding and read less about the forms or whether the decision is more difficult because of their own age and potential frailty. The patient’s brother was very alarmed at the idea that he was discussing this for his younger brother and he kept reiterating his difficulty coming to terms with this. The guidance for DNACPR forms is that they should be discussed with relatives, however, relatives can often understand this to mean that it is THEIR responsibility and decision alone and so can feel reluctant to agree to signing it.

Another aspect that I think is important for patients to understand is that the DNACPR form doesn’t represent stopping all treatment, just not starting CPR in the event of arrest. I explained this to the patient’s brother and he was content with this. It was more difficult to explain the likely outcome of CPR in this patient and patients in general.

What will you do differently in future?:

It was useful to incorporate the discussion of the DNACPR as part of the discharge planning process. I have previously found these conversations more difficult when there is not a ‘way in’ i.e. the patient is not acutely unwell etc. Although I appreciate the guidance is to have a discussion whilst a patient is well as it promotes a healthier understanding, rather than understanding it to be a part of planning a patient’s death but sometimes it is helpful to discuss this when these sort of planning processes are at the front of the relatives mind.

It was clear that the patient’s brother had never heard of DNACPR forms, but when we arranged the meeting, we encouraged him to bring a relative who might help him process the information. He brought his granddaughter, who was a trained GP. Although this was quite daunting for me initially, as I was conscious that another clinician might have their own feelings about how to have this conversation, it was very reassuring for the patient’s brother and so I felt her presence was helpful. She allowed me to explain and then provided reassurance for her grandfather. His main concern was that he didn’t feel, as the patient’s brother, that he was close enough to “sign him off”, I felt it was important to explain the clinician and relatives’ responsibilities in signing DNACPR forms, so that he didn’t have any sense of overburdening of responsibility or feel any guilt.

Relatives and patients have different barriers to discussions and decisions surrounding DNACPR and end of life planning. In this case, I believe I understood these barriers and pre-empted them well e.g. by asking the brother to bring a relative to the meeting. It also acts as a “warning shot” i.e. that more complex or serious discussion is planned, which I think probably helped frame his mindset prior to attending.
For this case, having a relative who understood the process was reassuring in this case but I felt that overall the conversation we had about the form was set at the right level and pace, so had the relative not been medical, they hopefully would have been reassured. If the relatives had not agreed with the process, I would have addressed their specific concerns and barriers, corrected any areas of confusion and explored their expectations. Failing these conversations I think I would have deferred to the consultant and directed the relatives to NHS website resources to further think about the topic and ask them to return to discuss further.

What further learning needs did you identify?:

1) Further experience with DNACPR discussions in different environments
2) Understand palliative care support available in the community inc. for specific needs of certain illnesses e.g. dementia, MND, cancer, MS etc.

How and when will you address these?:

1) Reflect on cases in future placements
2) self directed study


Example # 10:

Subject title: Assessing a patient with Learning Disability

What happened?:

I was asked to assess a 21 year old patient out of hours who had a diagnosis of learning disability, living with his mother who also had a learning disability but less severe. His mother explained that the patient had been leaving the house regularly in order to ‘find friends’, resulting in him hanging around homeless persons and searching out known gang members. The patient had been drinking dregs of alcohol bottles/cans left on the street, smoking cigarette butts and taking unknown drugs offered to him by gangs (but his mother suspected they were making a tally of costs he owed). He also had been steered home by these gang members to ask his mother and family for money for them. The incident preceding this admission involved the police following a fight between 2 known gangs carrying machetes. The patient was found by police visibly upset and confused so was taken home. The patient had been developing psychosis over the preceding months causing him to behave aggressively and fleeing his home spontaneously due to fear of his hallucinations of ‘Freddie’.

What, if anything, happened subsequently?:

The patient was admitted due to concerns surrounding his safety. Initially admitted to an adult ward, with a view for transfer over to the learning disabilities ward.

What did you learn?:

The 2 main learning points of this case were surrounding safeguarding issues and communication.
This patient was extremely vulnerable, despite his age, his communication skills and understanding of the world could not have been more than that of a 4-5year old. The hallucinations he was experiencing seemed to re-enforce this because his fears and hallucinations were of ‘Freddy Kruger’, a monster like character, under his bed or in his wardrobe. Hallucinations are often congruous to the persons’ age, culture and experiences. These hallucinations were scaring him and his response was to run away from them, which his mother was having difficulties managing because of her own LD and his violent behaviours.
This patient was extremely socially isolated – due to his age there were limited services available to him to help him socialise and make friends, therefore he sought out opportunities to meet people and then mistook the manipulative and exploitive behaviour of the gang members he met as acts of friendship. From the history these gang members were evidently exploiting his vulnerability and perhaps even his mother’s. There was limited support given to the mother, aside from the police, who she regularly called to report the patient as a missing person. I found this quite sad; the mother reported that they had been on the ‘list’ for a social worker for 18months and were still waiting for some support. She was anxious that her son wasn’t arrested for his involvement with gang members and possibly drugs.
This consultation required a lot of time: The patient had an obvious processing delay, exacerbated by the sedative medication that he took to manage his psychosis. He had significant poverty of speech and so his mother had to relay a lot of his history, which in itself was not always clear or was missing elements because the mother hadn’t been there. I noticed that the patient had a tendency to agree to things and so I avoided questions with a ‘yes’/’no’ answer, but this was also quite difficult due to the patient’s poverty of speech and general shyness being asked questions by a doctor he had never met. With time, we managed to gain a clear enough picture to be able to understand what had been happening. The patient also had a sister who cared for both the patient and patient’s mother alongside her own young family and so, when it became a more suitable hour, I called her for collateral information and carer’s perspective which was useful.

What will you do differently in future?:

This was a really difficult case, especially for a GP to manage without rapid support and input from community, social support and mental health services. There were so many safeguarding issues for both the patient and mother’s perspective. They are known to be vulnerable characters in the community and on further information gathering, have been targeted and exploited previously by gang members and also fraud perpetrators. Having said that, the patient had not had a social worker since he was a child and was on a waiting list yet to receive allocation, which illustrates a disconnect between child and adult services. The referral to social services had been made 18months prior, I think this case demonstrates the importance of updating referrals to try and expedite them when a situation deteriorates. This would also be a case I would discuss with the practice to try and share ideas on how to manage this case.
A key part of the patient’s perceived problem was that he wanted friends: I think it is easy to overlook the social problems/group them as one big factor that we can’t address easily and then focus on the medical side. I have learned not to underestimate the value of social network groups. Perhaps this patient would have benefitted from being counseled about groups such as ‘mind’ which offer social structures for younger adults.
Finally, for patient’s with LD, it is important to try and give more appointment time for them so they can have the opportunity to explain what has happened and more completely understand what counseling or advice is offered, in addition to being able to explore and come up with solutions together. I cannot imagine that a GP would have been able to assess this patient in a 10 minute consultation.

What further learning needs did you identify?:

1) More understanding and experience managing patients with safeguarding issues
2) More experiencing communicating with patients who have special communication requirements inc. language barriers

How and when will you address these?:

1) Safeguarding e-learning on elfh and other sources
2) Reflect on safeguarding cases in psychiatry, paediatrics and GP placements
3) Attend safeguarding MDT meetings
4) Develop better consultation techniques for patients with LD


Special thanks to my wife and my GP trainees for sharing the examples of reflective practices

Dr Shafiq’s Experience of MRCPsych Exam

Please note this blog was written in Oct 2019. The MRCPsych exam regulations and format may change with time.

HOW I PASSED MRCPSYCH EXAMS IN FIRST ATTEMPT

I did my core training in psychiatry from August 2016 till July 2019 in North east deanery. Just a brief overview about exams in MRCPsych. There are 3 exams:

Continue reading “Dr Shafiq’s Experience of MRCPsych Exam”

Dr Sehrish Shafiq’s Experience of Core Psychiatry Training.

MY JOURNEY IN CORE PSYCHIATRY TRAINING

I did my core training in psychiatry from August 2016 till July 2019 in North east deanery. Just a brief overview about why I chose north east, me and my husband wanted to start training at the same time in August 2016 and he wanted to go into medicine and we were told by our colleagues is that if you apply in north east there is a better chance of you getting the training together in the same deanery and we just did it. At that time, we only worked in NHS for hardly 9-10 months in total.

Continue reading “Dr Sehrish Shafiq’s Experience of Core Psychiatry Training.”
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